Commentary From the AAP Section on Obesity

Commentary From the AAP Section on Obesity

The Section on Obesity started as a provisional section in 2010 under the leadership of Stephen Pont (TX) and Christopher Bolling (KY), after they submitted an emergency resolution at the 2009 American Academy of Pediatrics (AAP) Leadership Forum. Although submitted at the 11^th hour, it became the #2 priority that year. The section galvanized multiple child obesity initiatives including AAP’s “Be Our Voice” advocacy training, NACHRI (Children’s Hospital Association) “Focus on a Fitter Future,” and emerging research on obesity prevention and treatment. The section became permanent in 2013, and currently has more than 500 active members, a dedicated educational at NCE, and an annual CME course. The section executive committee has published 4 books, authored 7 statements/reports, co-authored 3 obesity-related statements/reports, provided input to dozens of publications, and in 2023 published the first Clinical Practice Guideline for the Evaluation and Treatment of Child and Adolescent Obesity.

First Quarter Century (1948-1973)

Foundations of Pediatric Obesity Research Among Children of African Descent

Matthew Haemer, MD, MPH, FAAP¹; Fatima Cody Stanford, MD, MPH, MPA, MBA, FAAP, FACP, FAHA, FAMWA, FTOS²

Affiliations: ¹Associate Professor, Department of Pediatrics/Section of Nutrition, University of Colorado Anschutz Medical Campus; ²Associate Professor of Medicine and Pediatrics, Harvard Medical School

Highlighted Article From Pediatrics

Verghese KP, Scott RB, Teixeira G, Ferguson AD. Studies in growth and development: XII. Physical growth of North American negro children. Pediatrics. 1969;44 (2):243-247

We selected the article “Physical Growth of North American Negro Children” as relevant to childhood obesity because its authors sought to publish the first growth reference relevant to Black children in the United States. Published decades before the onset of the obesity epidemic, it highlights the need to measure outcomes across racial and ethnic groups to detect and rectify health disparities. The article begins: “Authoritative studies of physical growth of North American Caucasian children are readily available; however, there are surprisingly few published studies on the growth patterns of North American Negro children in the United States…”¹ We chose to highlight this article for the following reasons: it highlights past inequities in public health surveillance and the authors’ efforts to draw attention to the importance of measuring the growth of Black children living at low income (a population excluded from much prior research on child growth and development), because its authors represent pioneering Black pediatrician-researchers, and because it is also an example of how race was viewed incorrectly as a biological construct in the segregated United States.

This was one of the first publications that focused on the growth of Black children in the United States throughout the pediatric age range. This early attempt to draw equal attention to the growth of Black children in families with low income laid the groundwork for measuring growth-related health disparities among populations of color in the United States. Our nation has a long history of failing to measure inequity, a necessary precursor for efforts to resolve health inequities, captured by Peter Drucker’s truism, “You can't improve what you don’t measure.” By doing the hard work to measure and report on a population of Black children from low-income communities often ignored by previous research and national health policies, the authors fostered the creation of future generations to identify and to work against growth-related health disparities, including childhood obesity that would disparately affect future generations of Black children growing up in poverty.

We selected this article, in part, to highlight the careers of pioneering Black pediatric researchers and the critical contributions of Howard University as a historically Black college and university (HBCU). The lead author, a future American Academy of Allergy, Asthma & Immunology member, graduated from medical school in India. He was a junior faculty member at Howard and a former trainee of his Howard faculty co-authors. Dr. Scott, whose career studying sickle cell disease focused on alleviating a tremendous health disparity for Black Americans, was one of the first two Black members of the American Academy of Pediatrics (AAP) (admitted on re-application after first being denied based on his race) and the first Black physician to become a member of the American Pediatric Society and the Society for Pediatric Research. Gertrude Teixeira (m. Hunter), MD, 1926 – 2006, was professor and chair of community health and family practice and served as national director of health services for Head Start and administrator of the US Public Health Service for New England. Angella Dorothea Ferguson (born February 15, 1925) is the last living author who developed the blood test commonly used to detect sickle cell at birth. She was professor and former vice president for health affairs at Howard University. We highlight these extraordinary individuals’ careers and the mission of their institutions to serve and speak up for the needs of African Americans and those living in poverty. Freedmen’s Hospital, now Howard University Hospital (HUH), opened in 1862 as the first hospital to provide medical treatment denied elsewhere to enslaved persons freed during the Civil War. HUH is now the nation’s only teaching hospital of an HBCU and carries on this legacy as one of the most comprehensive healthcare facilities in the Washington, DC, metropolitan area.

We also selected this article because it exemplifies how race was historically framed as a biological construct in the segregated United States. While seeking to identify possible disparities in growth, the authors stated their work in the then-prevailing, now debunked, notion that race was more than a social construct. Unfortunately, “race” has been commonly used to describe research participants and population. There are significant limitations when we classify research participants by race, and there have been efforts to abandon this practice. Race, a social construct, should not be utilized to explain biological phenomena. Still, comprehensive frameworks that account for ethnicity should be utilized in conjunction with acknowledgment of the role of social determinants of health in the outcomes of minoritized and marginalized groups.¹

Reference

1. Duggan CP, Kurpad A, Stanford FC, Sunguya B, Wells JC. Race, ethnicity, and racism in the nutrition literature: an update for 2020. Am J Clin Nutr. 2020;112(6):1409-1414; doi: 10.1093/ajcn/nqaa341

Second Quarter Century (1973-1998)

Understanding Social and Environment Contributors of Pediatric Obesity: Breaking the Obesity and Hunger Paradox

Kofi D. Essel, MD, MPH, FAAP¹, Joani L. Jack, MD, FAAP²

Affiliations: ¹Assistant Professor of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC; ²Assistant Professor, University of Tennessee College of Medicine

Highlighted Article From Pediatrics

Dietz WH. Does hunger cause obesity? Pediatrics. 1995;95(5):766-767

We selected the case report “Does Hunger Cause Obesity?” as relevant to childhood obesity because it became one of the first published case reports from a prominent author linking the condition of food insecurity with the disease of obesity. In fact, the construct at the time was that obesity and hunger were “paradoxical.” This case report highlights a 7-year-old African-American girl with obesity, acanthosis nigricans, and a strong family history of obesity who presented to a weight management clinic in Boston. The family experienced many social needs, including food hardship, and was supported by federal nutrition and cash assistance programs throughout the month. In addition, clinicians became aware that strategies to maximize nutrition could not be maintained by the family due to financial constraints. This led to cycles of the girl consuming higher fat foods during periods of availability in an effort to compensate for periods of food deprivation during the financial hardship. The discussion highlighted a theoretical causation between hunger and obesity with either the increased consumption of fat content due to food hardship or the body developing obesity as an adaptive response to temporary periods of food hardship cycles.

Although the description of obesity and hunger as paradoxical made sense at the time, they are no longer viewed as contradictory. The USDA defines food insecurity as the limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire acceptable foods in socially acceptable ways. This terminology for food insecurity took root in 1990 after a seminal report completed by the Life Sciences Research Office of the Federation of American Societies for Experimental Biology brought clarity to its definitions. Households with children are considered to be at higher risk for food insecurity, and these risks are amplified in racial/ethnic minoritized households as a result of years of systemic injustices directed toward these communities.

In June 2013, the American Medical Association began recognizing obesity as a disease. According to the Obesity Medical Association, obesity is a “chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences.” According to the AAP, obesity is a “medical diagnosis with real health consequences” that should be taken seriously. Families that experience food insecurity often have financial hardships that trigger a series of events, including an adjustment of the foods purchased and consumed. These increased stressors are often associated with a higher consumption of foods higher in fat and sugar that are often ultraprocessed. Although these changes in diet may lead to rapid weight gain and, thereby, obesity, it is important to remember that calories can never and should never tell the whole story for obesity in children. It is important to recognize the chronic and generational stress of food and financial hardship, often exacerbated by the inadequacy of federal programs to support families with social needs, such as food insecurity. Data indicate that families with children using programs such as the Supplemental Nutrition Assistance Program use >50% of monthly benefits by day 7 of receipt, highlighting their inadequacy over the long term. These and other chronic stressors are now understood to exert a physiological impact on weight regulation and the disease of obesity.

This key case report was among the first to draw an important association between food insecurity and obesity, before the physiology of hunger, stress response, and the disease of obesity were well understood. A strong collection of studies and a larger body of literature on adverse childhood experiences clearly outline an overall mixed association between obesity and food insecurity. Additional studies with improved study designs are warranted in this field. Whether or not a direct correlation has been established, it is important to understand the roots and breadth of the problem in order to provide meaningful interventions to prevent obesity and help families who experience food insecurity and/or have children with obesity.

The seminal case report reminds us that “consideration of the family environment is essential to establish the most appropriate focus for counseling.” Although it is no longer necessary to consider the coexistence of obesity and hunger as a paradox, this case report highlights the importance of addressing both of these conditions simultaneously and emphasizes the inability of dissociating social needs from the health outcomes of children and families.

Third Quarter Century (1998-Present)

Prevention, Assessment, and Treatment of Pediatric Overweight and Obesity: Then and Now

Claudia K. Fox, MD¹

Affiliation: ¹Associate Professor of Pediatrics, University of Minnesota Medical School

Acknowledgment

Assisted by: Sarah E. Barlow, Professor of Pediatrics, University of Texas Southwestern Medical Center

Highlighted Articles From Pediatrics

• Barlow SE, Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4): S164-S192
• Hampi Se, Hassink SG, Skinner AC, et al. Executive summary: clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics. 2023;151(2):e2022060641

One of the most influential papers published in Pediatrics since 1998 was the 2007 Expert Recommendations on the Prevention, Assessment and Treatment of Child and Adolescent Overweight and Obesity.¹

Where We Were

By 2007, the prevalence of pediatric obesity had risen so that obesity affected 1 in 6 children, and obesity and overweight together affected 1 in 4 children. At the time, pediatricians had little guidance about how to address this issue on their own.² Updated growth charts, published in 2000, included body mass index (BMI) percentile growth curves, an improvement over the weight-for-height curves.³ However, electronic health records were just emerging, and most practices first had to calculate BMI (with BMI wheels or pocket calculators!) and then plot BMI by hand on paper growth charts. Screening with BMI percentiles took some effort. Despite the high prevalence of pediatric obesity, the US Preventive Services Task Force 2005 systematic review concluded that not enough evidence existed on effective treatment to justify recommending for or against screening of BMI in children.⁴ (It would be another 5 years before a clear, evidence-based recommendation to screen and treat obesity was published.⁵) Against this backdrop, a committee comprised of representatives from 10 professional organizations was convened to develop recommendations for the assessment, prevention, and treatment of obesity in children and adolescents. These representatives formed 3 writing groups composed of clinicians and researchers, one for each section, and reviewed the literature, though not systematically. Despite the fact that most studies were cross-sectional or correlational, the committee bravely made recommendations. Probably most distinctive was the concept of the 4 stages of progressively intensive obesity treatment. The description of each stage included not only the components but also the location of delivery, the suggested deliverer(s) of that treatment, the frequency of visits, and a recommendation to offer each stage serially, including describing the desired duration and outcome of a trial before escalation. This approach resonated widely with pediatricians and was broadly cited, including in the National Institute of Health Request for Applications and the White House Task Force on Childhood Obesity 2010.⁶

In our view, the stages were appealing because they addressed an implementation problem, even though there were no peer-reviewed publications that evaluated the efficacy of offering staged therapy. Although primary care providers could not do everything, clearly they could do something. With a large proportion of their patients affected, they had to be involved in identifying and addressing obesity, but they also were unable to deliver the high-intensity care needed by some of their patients. The 4 stages presented a conceptual model of a coordinated healthcare system with shared responsibility for this epidemic condition.

Where We Are Now

In the interim since 2007, strong evidence has accumulated about effective treatments. This evidence includes the efficacy of multicomponent, moderate-to-high intensity lifestyle and behavior programs for achieving modest BMI change, as well as the safety and efficacy of anti-obesity medications that are FDA approved for children ≥12 years of age^7,8 and metabolic and bariatric surgery⁹ for youth. Unfortunately, the proportion of children and adolescents with severe obesity¹⁰ has only increased in the face of continued barriers to sustained support for and access to treatment of this chronic condition. The AAP has released a clinical practice guideline on the assessment and treatment of child and adolescent obesity that emerged from a systematic review and rating of the evidence, a process in contrast to the expert consensus statement that preceded it.¹¹ We are hopeful that this guideline will help spur changes within healthcare and public health to allow for practical implementation of effective treatment.

References

1. Barlow SE, Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4): S164-S192
2. Ogden CL, Carroll MD, Fryar CD, Flegal Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics; 2015
3. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: Methods and development. National Center for Health Statistics. Vital Health Stat. 2002;11(246). Available at https://www.cdc.gov/nchs/data/series/sr_11/sr11_246.pdf
4. US Preventive Services Task Force. Screening and interventions for overweight in children and adolescents: recommendation statement. 2005;116(1):205-209
5. US Preventive Services Task Force. Screening for obesity in children and adolescents: recommendation statement Pe 2010;125(2):361–367
6. White House Task Force on Childhood Obesity. Solving the Problem of Childhood Obesity within a Generation: White House Task Force on Childhood Obesity Report to the President. Available at https://letsmove.obamawhitehouse.archives.gov/sites/letsmove.gov/files/TaskForce_on_Childhood_Obesity_May2010_FullReport.pdf
7. Kelly AS, Auerbach P, Barrientos-Perez M, et al. A randomized, controlled trial of liraglutide for adolescents with obesity. N Engl J Med. 2020;382(22):2117-2128; doi: 10.1056/NEJMoa1916038
8. Kelly AS, Bensignor MO, Hsia DS, et al. Phentermine/topiramate for the treatment of adolescent obesity. NEJM Evid. 2022;1(6): 1056/evidoa2200014
9. Armstrong SC, Bolling CF, Michalsky MP, Reichard KW; Section on Obesity, Section on Surgery. Pediatric metabolic and bariatric surgery: evidence, barriers, and best practices. 2019;144(6):e20193223; doi: 10.1542/peds.2019-3223
10. Skinner AC, Ravanbakht SN, Skelton JA, Perrin EM, Armstrong SC. Prevalence of obesity and severe obesity in US children, 1999-2016. 2018;141(3):e20173459; doi: 10.1542/peds.2017-3459. Erratum in: Pediatrics. 2018;142(3)
11. Hampi Se, Hassink SG, Skinner AC, et al. Executive summary: clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. 2023;151(2):e2022060641

Figure 1. Example of wheel used to calculate BMI without a calculator.

Figure 2. Timeline of key events leading up to 2007 Expert Committee Recommendations.