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Courtesy of Duke Healthy Lifestyles and Bull City Fit Program

AAP’s first clinical practice guideline on obesity advises early, intensive care that focuses on ‘whole child’

January 9, 2023
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The AAP’s first clinical practice guideline (CPG) on the evaluation and treatment of pediatric obesity highlights evidence-based approaches that pediatricians can use to treat children and adolescents effectively and safely.

Obesity is one of the most common chronic diseases facing children and adolescents. More than 14.4 million U.S. youths are affected by obesity, which is associated with significant early and late medical and emotional health consequences.

Release of the CPG and related documents follows an extensive literature review and development process that produced 13 key action statements and 11 consensus recommendations.

The documents, Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity, and an executive summary are available at https://doi.org/10.1542/peds.2022-060640 and  https://doi.org/10.1542/peds.2022-060641. They will be published in the February issue of Pediatrics along with two technical reports: Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions (https://publications.aap.org/pediatrics/article/doi/10.1542/peds.2022-060642/190447) and Part II: Comorbidities (https://publications.aap.org/pediatrics/article/doi/10.1542/peds.2022-060643/190446). 

Complex, chronic disease

The CPG reflects a “whole child” approach. Sections on risk factors and evaluation acknowledge the multiple influences that can lead to excess weight and influence treatment efforts. In addition to individual and familial risk factors, broader structural and contextual inequities not only contribute to obesity risk but also impede treatment success.

The likelihood that a child or adolescent with obesity will become an adult with obesity is significant. Therefore, a life course approach is recommended, including early detection and longitudinal treatment in the medical home with ongoing monitoring for emergence and worsening of comorbidities.

Comprehensive evaluation

The evaluation section includes supportive, nonstigmatizing communication strategies to guide discussions about obesity with children, adolescents and families. The section also details a recommended initial approach that includes a thorough medical, medication and social history, screening for social determinants of health, assessment of mental health, detection of disordered eating concerns and determination of readiness for change as well as physical examination.

Age-based guidance is given for initial evaluation of common comorbidities such as disorders of glucose metabolism, dyslipidemias and elevated liver enzymes. Recommendations for follow-up evaluation and initial management of these and many other comorbidities also are provided with the recognition that treating obesity is treating its comorbidities.

Treat early, intensively

Evidence supports that obesity treatment is safe and effective. There is no evidence for a watchful waiting approach; therefore, pediatricians and other pediatric health care professionals (PHCPs) should offer treatment options early and at the highest available intensity. The CPG recommends using principles of the medical home and the chronic care model with a motivational interviewing approach.

Intensive health behavior and lifestyle treatment (IHBLT) is a foundational evidence-based strategy for children ages 6 years and older, with nutrition, physical activity and behavioral change support. At least 26 hours of family-based, face-to-face, multicomponent treatment over three to 12 months is associated with clinically significant health outcomes. The evidence for this treatment modality in children ages 2-5 years is more limited. Regardless of age, the greater the number of contact hours, the greater the treatment effect.

When an IHBLT program is not available, pediatricians and other PHCPs should provide the most intensive program possible, partnering with registered dietitian nutritionists, behavioral health and exercise professionals, and community programs.

Weight loss pharmacotherapy is a newer and promising treatment strategy. It is recommended as an adjunct to IHBLT in adolescents who need additional treatment and may be indicated in younger children with severe obesity and comorbidities. Medication mechanisms of action, indications and potential adverse effects are discussed.

Adolescents with severe obesity should be offered referral for evaluation for metabolic and bariatric surgery to a local or regional comprehensive, multidisciplinary pediatric metabolic and bariatric surgery center. Both laparoscopic Roux-en-Y gastric bypass and vertical sleeve gastrectomy result in significant and sustained weight loss as well as improvements and/or resolution of comorbidities.

The same intensive health behavior and lifestyle treatment, pharmacotherapy and surgical options should be offered to children and youths with special health care needs and their families, although creative, individualized modifications may be needed.

Many tenets from the systems of care approach can benefit those with overweight and obesity and their families, including provision of evidence-based care in a medical home, family partnerships, respect for cultural and other salient values, and planning for care transitions.

Extensive review

In 2017, the AAP Institute for Healthy Childhood Weight supported by the Centers for Disease Control and Prevention convened a committee of multidisciplinary experts led by epidemiologist Asheley Skinner, Ph.D., to probe two key questions to guide the literature review: 1) What are effective clinic-based treatments for obesity? 2) What is the risk of comorbidities among children with obesity?

The committee screened 16,000 abstracts and reviewed 1,642 full-text articles representing 382 studies before creating two technical reports, which formed the background for the CPG.

The AAP Council on Quality Improvement and Patient Safety convened a writing subcommittee with representation from multiple disciplines and a parent representative.

In 2019, the writing committee began to create a comprehensive CPG to guide evaluation and care of children and adolescents with obesity using a whole child approach. The aim was to recognize obesity’s multifactorial etiologies and offer as much practical guidance as possible for pediatricians and other PHCPs.

Evidence from the technical reports was updated and supplemented with evidence-based guidance from national professional societies to enhance actionability of recommendations. The CPG then underwent a thorough review.

Policy changes needed at multiple levels

The CPG outlines policy strategies aimed at making obesity treatment accessible for all children and adolescents with overweight and obesity, including the following:

  • Create supportive payment and public health policies that cover comprehensive obesity prevention, evaluation and treatment.
  • Address structural racism drivers of disparities in obesity and obesity-related comorbidities.
  • Develop partnerships with public health, community and health care organizations and their members aimed at increasing access to evidence-based treatment programs and community resources addressing social determinants of health.
  • Implement clinical decision supports through electronic health records at the practice and provider levels, which will facilitate best practices for managing children and adolescents with obesity.
  • Advocate for medical and other health professions schools, training programs, boards and professional societies to improve obesity-related education and training opportunities for both practicing providers and in preprofessional schools and residency/fellowship programs.

Drs. Hampl and Hassink are lead authors of the CPG. Dr. Hampl was chair and Dr. Hassink vice chair of the writing subcommittee. In addition, Dr. Hassink is medical director of the AAP Institute for Healthy Childhood Weight.

Resources

Implementation resources developed by the AAP Institute for Healthy Childhood Weight (https://bit.ly/39uvJqm) include an algorithm for the key action statements, clinical decision support tools, coding references, quality improvement opportunities and tools, self-paced continuing medical education modules, multimedia resources and parent education, www.aap.org/obesitycpg.

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