Nearly 20% of all children in the US have what’s considered to be a high body mass index, the measure that practitioners use to determine whether a person has obesity. New draft guidelines released Tuesday by the US Preventive Services Task Force say that doctors should step in to help these children better manage their weight so they can be healthy.
In the draft guidelines, the task force — a group of independent experts whose recommendations guide doctors’ decisions and influence insurance coverage — recommends that pediatricians refer children 6 and older who have obesity to comprehensive, intensive behavioral interventions based on what it describes as “moderate certainty” that such interventions can provide a “moderate net benefit.” The interventions did not pose any harm.
But the task force’s draft recommendations do not include weight loss medications or surgery, although it has looked at some research on those interventions. The American Academy of Pediatrics, which updated its own guidelines to manage patients with obesity earlier this year, recommends both options for some patients.
And some doctors that treat pediatric patients with obesity said using behavioral interventions only may be difficult for doctors to provide and difficult for families to access, given the extent of the time commitment.
What’s in the proposed guidelines
A high BMI for children is defined a little differently than it is for adults. For adults, a BMI of 30 or higher is within the obesity range. A child with obesity is defined as one who is at or above the 95th percentile of kids of their age and gender, based on US Centers for Disease Control and Prevention growth charts. For example, a 10-year-old boy who weighs 102 pounds and is 4 feet 6 inches would have a BMI of 22.9. That would put him in the 95th percentile and suggest that he has obesity.
Based on evidence from 50 randomized controlled trials that showed weight loss in children, the task force found, intensive behavioral interventions would need to involve the child and their parent in at least 26 hours of help from a health professional a year.
Interventions could include supervised physical activity sessions, group sessions and individual counseling that teaches children and their parents healthy eating, safe options for exercise, lessons on how to read food labels, behavior change techniques, goal setting, and ways to monitor diet and physical activity.
The more time children had in physical activity sessions and contact with experts, the research showed, the more weight they lost.
The emphasis on intervention, as opposed to just screening for obesity, will be a shift in thinking for some providers.
“The feeling initially was that children would grow out of it, and that has been demonstrated to be false,” said Dr. Ilene Fennoy, who as a professor of pediatrics works with children and their parents to help them reach a healthier weight at Columbia University Medical Center. She was not involved with the new draft guidelines.
Weight can fluctuate as children grow, particularly before a growth spurt, she said, but the more severe the level of obesity, the less likely they are to grow out of it.
“If anything, it causes early puberty, and with early puberty, their bones reach maturity early, and therefore they’re not able to grow anymore,” she said. “They’re past that.”
Obesity is one of the most common pediatric chronic diseases, and it can lead to a lifetime of other health problems, including those involving mental health.
Many pediatricians say they are seeing children with obesity-related health problems that used to be associated more with adults, like type 2 diabetes, heart disease and high blood pressure.
Obesity is also one of the most common reasons that children and teens are bullied at school, research shows.
Guidelines take different approaches
Unlike guidelines from the American Association of Pediatrics that came out earlier this year, these new draft guidelines focus only on kids with obesity and don’t encourage interventions for children in the overweight category.
“Of course, all of us should do our best to achieve and maintain a normal healthy weight, but in this case, the evidence was specifically strong in the area of these really high BMI categories,” said Dr. John Ruiz, a member of the US Preventive Services Task Force and a professor of clinical psychology at the University of Arizona. “The task force guidelines are evidence-based, and we have to respect that and maintain that for our guidelines.”
The guidelines also differ from the American Association of Pediatrics’ in that they focus on lifestyle interventions only. Surgery, the task force says, is considered “outside the scope of the primary care setting” and is not recommended in these guidelines.
The task force also examined studies including the weight loss drugs liraglutide, semaglutide, orlistat, and phentermine and topiramate. In most trials, the medications were associated with larger BMI reductions than with a placebo. But there wasn’t enough evidence to determine what effects they could have in the long term, Ruiz said.
“There’s really just such a dearth of evidence right now,” he said. “For that reason, the task force is calling for more data.”
In practice, Columbia’s Fennoy says, there are few pediatricians who offer an intensive 26 hours of lifestyle intervention services. “We have demonstrated that our lifestyle interventions do work, but they’re dose-dependent,” she said. “We don’t have a lot of access to these programs for our patients.”
Clinics focused on weight loss would also have a hard time offering that much help, said Dr. Susma Shanti Vaidya, a pediatrician who runs the weight loss clinic at Children’s National Hospital in Washington.
“We can’t even offer that intensity of care in the ideal program at Children’s because we have so many people that we want to see, and parents really are not able to come back every two weeks,” she said.
Although lifestyle changes are the foundation of everything the clinic does, she said, they alone are not always enough.
For years, that’s been a point of frustration for her patients and for her practice, but she said things have started to improve with the introduction of weight loss drugs.
The new guidelines may not be able to recommend them, but she says the drugs work and radically improve some patients’ chances of reaching a healthy weight.
“The FDA approval of some of these medications has really been a game-changer,” Shanti Vaidya said. “It changes people’s lives.”
Her clinic also offers surgery, which she says has been effective, even if it’s also been left out of these guidelines.
What happens next
The guidelines are not final and are only a draft. They will be available online for public comment for four weeks. After a review of the comments and possible revisions, the task force will take a vote on whether to adopt them.
New guidelines would replace recommendations from 2017 that leaned more toward screening for high BMI, as opposed to emphasizing how important it is for doctors to intervene.
Because the task force guidelines typically influence what approaches or drugs insurance will cover, going without a recommendation for weight loss drugs means it could be a while before all children would have access to them.
Just 16 states offer access to anti-obesity medications through Medicaid, said Dr. Justin Ryder, a pediatric obesity researcher with Stanley Manne Children’s Research Institute at Ann & Robert H. Lurie Children’s Hospital of Chicago.
Ryder, who wasn’t involved with the draft guidelines, said it is important that research continue on what is effective at helping children maintain a healthy weight.
“The millions of kids that have obesity really deserve treatments that work,” he said. “Those treatments could be medications. Those treatments could be behavioral management, and those treatments could be surgery.”
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