The American Academy of Pediatrics (AAP) updated guideline on obesity evaluation and treatment in children and teens has been hotly debated since it was released in early January 2023.1 Groups such as The Obesity Society and Obesity Action Coalition support the recommendations while others such as the Collaborative of Eating Disorders Organizations (CEDO) and the Eating Recovery Center say the recommendations on bariatric surgery and antiobesity medications put children at risk for developing eating disorders, disordered eating, and other mental and physical health issues.2,3
The updated AAP guideline, the latest in 15 years, includes new recommendations that emphasize an intensive and comprehensive approach to care of children affected by obesity such as assessing risk factors, evaluating for comorbidities, and offering treatment options using shared decision-making with the child and family. The AAP has moved away from a watchful waiting approach to see if children outgrow obesity to now recommending that treatment options be offered early and at the highest intensity available. The guidelines recommend 4 treatment options:
- Motivational interviewing
- Intensive health behavior and lifestyle intervention
- Antiobesity medications
- Metabolic and bariatric surgery used alone or in combination with other treatment modalities
“Obesity is a chronic disease that requires treatment across the lifespan, including for children. As with other chronic diseases like asthma, hypertension, and diabetes, we need a range of treatment options depending on the patient, and for obesity, that includes lifestyle modifications, medications, and surgery,” said Daniel S. Hsia, MD, a member of The Obesity Society’s Pediatric Obesity Treatment Task Force and associate professor, Pennington Biomedical Research Center in Baton Rouge, La.
The AAP also recommends the following guides on how to evaluate children and teens for obesity:
- Comprehensive obesity treatment may include nutrition support, physical activity treatment, behavioral therapy, pharmacotherapy, and metabolic and bariatric surgery.
- Intensive health behavior and lifestyle treatment, while challenging to deliver and not universally available, is the most effective known behavioral treatment for childhood obesity. The most effective treatments include 26 or more hours of face-to-face, family-based, multicomponent treatment over a 3- to 12-month period.
- Evidence-based treatment delivered by trained health care professionals with active parent or caregiver involvement has no evidence of harm and can result in less disordered eating.
- Physicians should offer adolescents ages 12 years and older with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.
- Teens aged 13 years and older with severe obesity (BMI ≥120% of the 95th percentile for age and sex) should be evaluated for metabolic and bariatric surgery.
Four antiobesity medications are now approved for treatment in adolescents 12 years and older: orlistat, liraglutide, phentermine/topiramate ER, and semaglutide. Phentermine is also approved for adolescents older than age 16 years. Setmelanotide is approved for children age 6 and older who have Barde-Biedl syndrome, a genetic disease that causes obesity.
The AAP and the American Society for Metabolic and Bariatric Surgery Pediatric Committee found metabolic and bariatric surgery is safe and effective in adolescents. Given the higher risk of adult obesity that develops in childhood, metabolic and bariatric surgery should not be withheld from adolescents when severe comorbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist, according to a statement from The Obesity Society.
“The medical costs of obesity on children, families, and our society as a whole are well-documented and require urgent action,” said Sarah Hampl, MD, a lead author of the AAP guideline. “This is a complex issue, but there are multiple ways we can take steps to intervene now and help children and teens build the foundation for a long, healthy life.”
Eating Disorder Groups Oppose the Guidelines
CEDO strongly opposes the new AAP guidelines particularly the recommendations on use of bariatric surgery and pharmacotherapy for children and adolescents with obesity.4,5
“The statements made throughout these guidelines are problematic at best, and at worst, put American children and adolescents at serious risk for developing eating disorders, disordered eating, and other mental and physical health issues,” CEDO wrote in a letter to the AAP.
The Eating Recovery Center in Denver, Colorado, launched a petition calling on the AAP to reconsider and rewrite the guidelines. A chief complaint is that the guideline includes minimal guidance about screening for, or treatment of, disordered eating. Also, the Center said that the recommendations “perpetuate harmful weight stigma and move us further away from achieving universal weight-inclusive care.”6
“We urge the AAP to work with us and other pediatric experts in weight-inclusive care and eating disorders to reconsider and rewrite these guidelines to include more appropriate screening and support for the safety and wellbeing of our children and adolescents,” said Anne Marie O’Melia, MD, chief medical officer and chief clinical officer at Eating Recovery Center.6
The Academy for Eating Disorders echoed these statements. The academy’s 3 primary concerns with the AAP guideline are the minimal reference to eating disorder screening and treatment referral, that pediatricians are not well trained in approaching the topic of weight with sensitivity, and the lack of long-term efficacy and safety data on the obesity medications and surgical interventions recommended for children.7
CEDO stated that the long-term effects of newer obesity medications such as glucagon-like peptide-1 (GLP-1) receptor agonists are not well studied. Research does not support the assessment that the negative side effects of weight loss treatment outweigh the risks of obesity in children, and the negative health consequences of obesity such as type 2 diabetes and heart disease are not linked to increased mortality rates in teens, according to CEDO.
“To assume that those in larger bodies should accept the health risks associated with weight loss treatment (ie, GLP-1 agonists and/or surgery) is evidence of the damaging weight stigma that is pervasive in ‘obesity’ prevention and treatment efforts,” CEDO noted.
CEDO noted data showing that youth who use over-the-counter (OTC) diet pills have a 6-fold higher risk for being diagnosed with an eating disorder in the next 3 years compared with nonusers and that 25% of the more than 23,000 emergency department visits each year related to use of dietary supplements involved weight-loss supplements. “The likelihood of abuse is great, and based on the experience with dietary supplements and medications for weight loss in the past, these guidelines will contribute to an increase in eating disorders,” the group wrote.
Additionally, CEDO believes adolescents do not have the emotional or cognitive capacity to handle the complex life-long medical, nutritional, and lifestyle changes (eg, restrictive eating behaviors) required with bariatric surgery. They noted a high rate of binge eating disorder among adults presenting for weight loss surgery and that treating these disorders after surgery is problematic.
We will report back on what Clinical Advisor readers think of the recommendations.
1. American Academy of Pediatrics. American Academy of Pediatrics issues its first comprehensive guideline on evaluating, treating children and adolescents with obesity. AAP press release. Accessed January 31, 2023. https://www.aap.org/en/news-room/news-releases/aap/2022/american-academy-of-pediatrics-issues-its-first-comprehensive-guideline-on-evaluating-treating-children-and-adolescents-with-obesity/
2. Obesity-focused Organizations Issue Statement in Support of New AAP Clinical Guideline on Childhood Obesity. The Obesity Society and Obesity Action Coalition; January 13, 2023. Accessed January 31, 2023. https://www.prnewswire.com/news-releases/obesity-focused-organizations-issue-statement-in-support-of-new-aap-clinical-guideline-on-childhood-obesity-301720942.html?tc=eml_cleartime
3. Opposing new clinical guidelines from the American Academy of Pediatrics. Collaborative of Eating Disorders Organizations; January 13, 2023. Accessed January 31, 2023. https://www.theprojectheal.org/blog/opposing-new-clinical-guidelines-from-the-american-academy-of-pediatrics
4. Sarwer DB, Cohn NI, Gibbons LM, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg. 2004;14(9):1148-1156. doi:10.1381/0960892042386922
5. Tess BH, Maximiano-Ferrerir L, Pajecki D, Wang YP. Bariatric surgery and binge eating disorder: should surgeons care about it? A literature review of prevalence and assessment tools. Arq Gastroenterol. 2019;56(1):55-60. doi:10.1590/S0004-2803.201900000-10
6. O’Melia AM. Our Response to the American Academy of Pediatrics Guidelines on care for kids in larger bodies. February 7, 2023. Accessed February 9, 2023. https://www.eatingrecoverycenter.com/blog/aap-response
7. The Academy for Eating Disorders releases a statement on the recent American Academy of Pediatrics clinical practice guideline for weight-related care: first, do no harm. Academy for Eating Disorders. January 26, 2023. Accessed February 8, 2023. https://www.newswise.com/articles/the-academy-for-eating-disorders-releases-a-statement-on-the-recent-american-academy-of-pediatrics-clinical-practice-guideline-for-weight-related-care-first-do-no-harm