The American Academy of Pediatrics (AAP) finally released guidelines to tackle obesity in children instead of continuing its “watchful waiting” policy.
This is not the first time AAP vocalized its support for weight loss surgery on children. It’s just the first time the group put it in guidelines. AAP adapted its policy statement in 2019 to these guidelines.
The guidelines include common sense approaches but also push parents and doctors not to wait regarding medicine and surgery:
“Weight is a sensitive topic for most of us, and children and teens are especially aware of the harsh and unfair stigma that comes with being affected by it,” said Sarah Hampl, MD, a lead author of the guideline, created by a multidisciplinary group of experts in various fields, along with primary care providers and a family representative.“Research tells us that we need to take a close look at families — where they live, their access to nutritious food, health care and opportunities for physical activity–as well as other factors that are associated with health, quality-of- life outcomes and risks. Our kids need the medical support, understanding and resources we can provide within a treatment plan that involves the whole family,” said Dr. Hampl, chair of the Clinical Practice Guideline Subcommittee on Obesity.
The guidelines have a discussion on “structural racism” because, of course, it does. This information is important because it comes into play when talking about the surgery:
Racism as an SDoH [social determinants of health] has been defined as a “system of structuring opportunity and assigning value based on the social interpretation of how one looks (race) that unfairly disadvantages some individuals and communities (and) unfairly advantages other individuals and communities…” that “impacts the health status of children, adolescents, emerging adults and their families.”Inequalities in poverty, unemployment, and homeownership attributable to structural racism have been linked to increased obesity rates. Racism experienced in everyday life has also been associated with increased obesity prevalence. Youth with overweight and obesity have been found to be at increased risk not only for weight-based harassment but also for sexual harassment and harassment based on race and ethnicity, socioeconomic status (SES), and gender. In adults, studies have found positive associations between self-reported discrimination and waist circumference, visceral adiposity, and BMI in both non-Latino and Latino populations.
I’m glad that, overall, AAP emphasizes intensive health behavior and lifestyle treatment (IHBLT). But it also encourages using the medicine for kids between 8 and 11, ages before puberty and full development. How many kids have shed that “baby fat” people talk about by age 8? When you hit puberty, you grow, and the weight usually evens out.
AAP lists eight medications.
Metformin is for patients 10 and older. AAP mentions it is not a weight loss drug, and the FDA hasn’t approved it for “prediabetes, PCOS, and prevention of weight gain when used with atypical antipsychotic medications.”
AAP also lists Phentermine and topiramate, taken as a combination medication, but is only approved for adults trying to lose weight.
Then there’s the push for surgery for those with “severe forms of pediatric obesity (ie, ≥class 2 obesity; BMI ≥ 35 kg/m2, or 120% of the 95th percentile for age and sex, whichever is lower).” I do not see a minimum age requirement in this section except that the FDA approved laparoscopic surgery for people 18 and older. And yet (emphasis mine):
These studies suggest that weight loss surgery is safe and effective for pediatric patients in comprehensive metabolic and bariatric surgery settings that have experience working with youth and their families. Laparoscopic Roux-en-Y gastric bypass and vertical sleeve gastrectomy are both commonly performed in the pediatric age group and result in significant and sustained weight loss, accompanied by improvements and/or resolution of numerous related comorbid conditions.Laparoscopic adjustable gastric band procedures, approved by the FDA only for patients 18 years and older, have declined in use in both adults and youth because of worse long-term effects as well as higher-than-expected complication rates.Similar to the adult experience, an expanding body of data shows that pediatric bariatric patients also experience durable reduction in BMI, as well as significant improvement and/or complete amelioration of several obesity-related comorbid conditions. These include HTN, T2DM, dyslipidemia, cardiovascular disease risk factors, and weight-related quality of life.
But age is not the only requirement. The AAP recommends that doctors look at the child’s surroundings:
Age is not the sole determinant of eligibility for metabolic and bariatric surgery. The pediatrician or other PHCP should take into account the patient’s physical and psychosocial needs. Evaluation for metabolic and bariatric surgery should include a holistic view of the patient and family, including individual and social risk factors. Families should be fully informed of the benefits and risks of metabolic and bariatric surgery, and their preferences are paramount. As highlighted in a recent AAP policy statement, the decision to continue care with a pediatrician or pediatric medical or surgical subspecialist should be made solely by the patient (and the family, as appropriate).
So instead of working it out with eating less and moving more, the kid should immediately have surgery?
we’re not the only ones who have reservations about the jump to use medicine and surgery on our children. The Associated Press spoke to a few doctors:
“It’s not that I’m against the medications,” said Dr. Robert Lustig, a longtime specialist in pediatric endocrinology at the University of California, San Francisco. “I’m against the willy-nilly use of those medications without addressing the cause of the problem.”Lustig said children must be evaluated individually to understand all of the factors that contribute to obesity. He has long blamed too much sugar for the rise in obesity. He urges a sharp focus on diet, particularly ultraprocessed foods that are high in sugar and low in fiber.Dr. Stephanie Byrne, a pediatrician at Cedars Sinai Medical Center in Los Angeles, said she’d like more research about the drug’s efficacy in a more diverse group of children and about potential long-term effects before she begins prescribing it regularly.“I would want to see it be used on a little more consistent basis,” she said. “And I would have to have that patient come in pretty frequently to be monitored.”At the same time, she welcomed the group’s new emphasis on prompt, intensive treatment for obesity in kids.“I definitely think this is a realization that diet and exercise is not going to do it for a number of teens who are struggling with this – maybe the majority,” she said.
Here is a report in 2019 about the policy statement:
CLICK HERE FOR FULL VERSION OF THIS STORY