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AAP: Global commission’s new obesity criteria could have unintended consequences for children

January 15, 2025
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A new definition and diagnostic criteria for clinical obesity from a global commission of experts does not translate well to children and adolescents, according to experts at the AAP. 

The commission of 58 people representing multiple medical specialties and countries “sought to define clinical obesity and identify objective and pragmatic criteria for its diagnosis,” according to a consensus statement published Jan. 14 in The Lancet Diabetes & Endocrinology. It recommends against using body mass index (BMI) as the sole determinant of obesity and suggests classifications of clinical obesity and preclinical obesity. 

The commission defines clinical obesity as a chronic illness that can be diagnosed when a patient meets two criteria:  

  • an excess of body fat confirmed by both BMI and either waist measurement or direct fat measurement; and  
  • symptoms of ongoing dysfunction of organ systems and limitations to the patient’s ability to move and/or perform basic activities of daily living.  

Preclinical obesity, the commission said, is “essentially a physical phenotype, characterised by excess adiposity” but bereft of major symptoms of organ dysfunction. 

Sarah C. Armstrong, M.D., FAAP, immediate past chair of the AAP Section on Obesity, commended the commission’s efforts and recognizes the challenges of using BMI alone to diagnose obesity, but she and her colleagues are concerned about how its recommendations apply to children and adolescents. 

“We recommend that pediatric clinicians continue to follow recommendations for screening, evaluation and treatment of pediatric obesity as outlined in the evidence-based 2023 AAP Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity (CPG),” said Sandra G. Hassink, M.D., FAAP, medical director of the AAP Institute for Healthy Childhood Weight. 

The commission’s requirement of two or more measures of adiposity to diagnose obesity does not address a child’s growth or the role of BMI percentiles and there are no currently validated normative ranges for the confirmatory (i.e. waist circumference) measures in children. 

The commission also outlined 13 diagnostic criteria for children and adolescents that signal organ dysfunction as a product of obesity. These include vision loss and headaches due to intercranial pressure; hyperglycemia or glucose intolerance paired with high triglycerides, high LDL cholesterol or low HDL cholesterol; apnea and hypopnea during sleep; and raised arterial blood pressure. 

 "We have concerns about some specific items missing in these criteria that are relevant to pediatrics such as genetics, precocious puberty, and mental health,” Dr. Armstrong said. “In addition, we have concerns about some of the selected criteria and their application and relevance across the age span, particularly young children.” 

Furthermore, the commission does not specify any age criteria for which these criteria apply. 

 Broad application of the diagnostic criteria outlined by the commission could have an unintended consequence: Many children with obesity will not meet the criteria for clinical obesity and thus may be denied care at a time when early screening and intervention could help prevent chronic illness in adulthood. 

“Most of the listed cardio-metabolic conditions will not occur prior to age 9 or won’t be identified because current guidelines recommend initiating screening at puberty onset,” Dr. Armstrong said. “If young children do not meet one of these criteria and are classified as ‘preclinical,’ we have significant concern that payers will use this new definition to deny coverage for obesity care.” 

The AAP CPG was created to “further advance the equitable care of children and adolescents with this chronic disease,” according to its introduction. It also recognizes the “genetic, physiologic, socioeconomic and environmental contributors” to obesity. 

 “The CPG delivers clear and actionable evidence-based clinical recommendations for pediatric health care providers, which consider the context of the whole child, includes the family in personalized and tailored decision-making and emphasizes the need for timely and effective treatment,” Dr. Hassink said.

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