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Growing research has shown that intensive interventions are needed, scientists say. Here is why their advice is changing.
The American Academy of Pediatrics recently issued new guidelines for treating the more than 14 million children and adolescents with obesity in the United States. The recommendations came as a surprise to many parents, and to some experts, as they encourage vigorous behavioral interventions even for very young children, as well as drug treatment or surgery for adolescents.
The guidelines spring from a scientific understanding of obesity that has been evolving for decades. Obesity is a risk factor for a number of disorders, including Type 2 diabetes, high blood pressure, joint and back pain, and several cancers. Treating the problem as early as possible may help prevent a lot of misery.
Here are answers to some questions about pediatric obesity research and why experts are now advising aggressive treatment.
What do the new guidelines say about the causes of obesity?
The A.A.P. recommendations stress that obesity is not just a consequence of poor eating habits and a lack of exercise. Obesity is a chronic disease with many intertwined causes, including genetics.
Researchers now know that obesity is one of the most strongly inherited traits. Studies conducted decades ago showed that identical twins reared apart usually grow up to have similar body shapes and weights. Adopted children tend to have the same shapes and weights as their biological parents.
A genetic predisposition sets the stage for some children to gain weight in an environment in which food — often poor-quality food — is everywhere. And weight gain can become a vicious cycle.
Children and adolescents with obesity often experience teasing and bullying, which, the A.A.P. committee wrote, contribute to “binge eating, social isolation, avoidance of health care services and decreased physical activity, further complicating the health trajectory.”
How do scientists define overweight and obesity?
They are defined by body mass index, a measure of weight and height. (It is an imperfect measure; many muscular athletes, for example, have high B.M.I.s but are in excellent shape.)
Overweight means a B.M.I. at or above the 85th percentile but below the 95th percentile for children and teenagers of the same age and sex. Obesity is a B.M.I. at or above the 95th percentile for children and teenagers of the same age and sex. (The Centers for Disease Control and Prevention offers B.M.I. growth charts here.)
When did pediatric obesity become such a problem?
For scientists, the alarms went off in the 1980s and 1990s. Before then, experts took comfort in data from the 1960s indicating that just 5 percent of children and adolescents had obesity. It just did not seem like a pressing issue.
But national data in the 1980s showed that the rate had doubled. By 2000, it had tripled, and by 2018, quadrupled. As the epidemic began, expert opinions about why it was happening circulated widely, often citing favorite villains like Big Food, too little exercise or a lack of fresh fruits and vegetables. But rigorous evidence was scarce and solutions evasive.
Didn’t anyone try to do intervention studies?
Yes, but results were disappointing. In the 1990s, for example, the National Institutes of Health sponsored two large, rigorous studies. The researchers asked whether weight gain in children could be prevented by intervening in schools by expanding physical education, offering more nutritious cafeteria meals, teaching students about proper eating habits and the need to exercise, and involving parents.
One study, an eight-year, $20 million project sponsored by the National Heart, Lung and Blood Institute, followed 1,704 third graders in 41 elementary schools in the Southwest. Students there were mostly Native Americans, a group at high risk for obesity.
The schools were divided into two groups. Some schools got intensive intervention, while others were left alone. Researchers determined, beginning in fifth grade, whether the children in the intervention schools were weighing less than those in the other schools.
Sadly, they were not, although the students were deeply familiar with the importance of activity and proper nutrition. The children who got intensive treatment also ate less fat, going from 34 percent to 27 percent in the total diet.
“It was not enough to change body weight,” said Benjamin Caballero of the Johns Hopkins Bloomberg School of Public Health, the study’s principal investigator.
Dr. Fatima Cody Stanford, an obesity medicine specialist at Harvard, recalled her own experiences in the 1980s. Children with obesity were sent to a “healthy lifestyle” clinic where they were told to eat healthier food and to exercise more. Often, it did not help.
She recalled a 15-year-old boy who weighed more than 300 pounds. “Maybe he should switch to skim milk, maybe increase his vegetables,” she told his parents. “Oh, he’s working out for half an hour every day? Let’s increase it to an hour.”
That, she said, is how she was taught, and looking back “it breaks my heart.” Dr. Stanford now believes that the advice set up obese children for failure. (She has consulted for companies investigating weight loss drugs.)
What do the guidelines say should be done now?
It’s not that lifestyle interventions cannot work for some. The A.A.P. says that children and adolescents with overweight and obesity should be offered “intensive behavioral and lifestyle treatment,” which is the most effective intervention short of medications and surgery.
The most effective programs involve at least 26 hours of in-person treatment over three to 12 months and include the family. The treatment focuses on nutrition, physical activity and behavior change. The expected result? A decline of one to three points in B.M.I.
But intensive programs are not always available, and insurers often do not pay for them. The A.A.P. advises that doctors instead should “provide the most intensive program possible,” referring families to additional programs to help with food insecurity and to community recreation programs.
The underlying message is one of urgency. In a significant departure from past advice, for example, the A.A.P. recommends that children 12 and older with obesity should be offered treatment with any of the few approved drugs, including newer ones like Wegovy (a brand name for semaglutide) that elicit significant weight loss by suppressing the appetite.
Those 13 and older with severe obesity should be offered bariatric surgery, the academy says. These are drastic (and expensive) interventions for doctors and parents to contemplate, but the authors of the recommendations note that obesity rarely ends without a concerted effort.
Are researchers focusing too much on weight loss?
Although it generally raises the risks of other health problems, many people with obesity remain healthy. Weight loss is not the only route to good health, and one of the perpetual risks of intensive medical intervention is that a child with obesity may come to feel stigmatized.
The conundrum here is that researchers say these children usually are already feeling stigmatized. They are frequently socially isolated, anxious and depressed, and far too often they are made to feel that they are failures who lack the willpower to control their weight. Doing nothing may deepen their isolation, not lessen it.
Will the new recommendations make a difference?
If they are “fully implemented and supported,” the guidelines may lower obesity rates in children, said Dr. Stephen Cook, an obesity specialist at the University of Rochester. But there are no guarantees.
Insurers and the Food and Drug Administration treat obesity differently from other chronic diseases. People with obesity may need drug treatment for a lifetime, for example. But insurers have insisted on paying only for short-term treatments, like six months’ or a year’s worth of medications — if they pay at all.
“If there continues to be no payment for treatment services, health systems will not put resources to delivering this care,” Dr. Cook said. “There will be none to minimal training in medical and professional schools for the next generation of health care providers to address this issue.”
It takes years for doctors to start using new guidelines, noted Dr. Louis Aronne, an obesity medicine specialist at Weill Cornell Medicine in New York. “The ones for adult obesity have never really been adhered to,” he noted. Adults with obesity are already advised to get surgery or drug treatment, but just 2 percent ever do. (Dr. Aronne has consulted for companies looking into weight-loss drugs.)
Researchers hope that at the very least the A.A.P. guidelines will help doctors understand that obesity is a chronic disease that afflicts children and adolescents, and that the old strategy — a kind of watchful waiting, or delayed treatment — won’t help.
The new recommendations may also prod insurers, including Medicaid, to start paying for intensive lifestyle treatment and for medications that these children need.