AAP Guidelines: ‘Watchful Waiting’ No Longer the Right Call for Child Obesity

In contrast to previous recommendations, pediatricians and other pediatric healthcare providers are advised to provide “immediate, intensive obesity treatment to each patient” as soon as they receive a diagnosis, according to new guidance from the American Academy of Pediatrics (AAP).

The guidance, published in Pediatrics, marks the AAP’s first clinical practice guideline outlining evidence-based evaluation and treatment for children and adolescents with overweight (defined as a body mass index [BMI] at or above the 85th percentile and below the 95th percentile) or obesity (defined as a BMI at or above the 95th percentile), though the organization previously published recommendations on prevention and treatment in 2007.

“This is one of the most important messages that differentiates our current clinical practice guidelines from the prior recommendations, and that is to say 15 years of data have taught us that ‘watchful waiting’ only leads to greater increase in child BMI, accumulation of comorbidities, and more challenges in trying to reverse some of this,” author Sarah Armstrong, MD, co-director of the Duke Center for Childhood Obesity Research in Durham, North Carolina, told MedPage Today.

In a number of key action statements, the guideline authors state that pediatricians and other providers should refer children ages 6 years and older — and potentially those ages 2 to 5 years — with overweight or obesity to intensive health behavior and lifestyle treatment.

Additionally, healthcare providers should offer weight-loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment to adolescents ages 12 and older, Armstrong and colleagues noted. They should also offer referrals for evaluation for metabolic and bariatric surgery to adolescents ages 13 and older with severe obesity (BMI ≥35 or 120% of the 95th percentile for age and sex, whichever is lower).

“The timing is particularly good right now as we’ve seen sort of a wave of approvals of new medications and indications for bariatric surgery and other treatment,” Armstrong said.

Overall, she said the message is clear that “we have treatments that are effective [and] shown to be safe,” and the new guidance is meant to help clinicians determine the most appropriate treatment for each individual child.

Accordingly, other key action statements detailed in the guidance include that pediatricians and other providers should regularly screen all children ages 2 years and up for obesity, and they should evaluate children and adolescents with overweight and obesity for related comorbidities by using a comprehensive patient history, mental and behavioral health screening, social determinants of health, physical examination, and diagnostic studies.

Further statements included that healthcare providers should treat children and adolescents for overweight/obesity and comorbidities concurrently, and in accordance with the principles of the chronic care model, using a family-centered and non-stigmatizing approach that acknowledges the biological, social, and structural drivers of obesity.

In addition, providers should use motivational interviewing to engage patients and families in treating overweight and obesity.

The key action statements are based on a comprehensive evidence review of controlled and comparative-effectiveness studies, as well as longitudinal and epidemiologic studies, Armstrong and colleagues said. The AAP published accompanying technical reports detailing the evidence review, including one focused on interventions and another on comorbidities.

Though the new guidance does not address prevention of obesity, the AAP noted that the topic will be addressed in a forthcoming policy statement.

As for implementation of the guidance, Armstrong acknowledged that there “most certainly will be hesitancy” when it comes to adopting early interventions or treatments, noting three primary reasons for this.

“One key driver is unfamiliarity with treatment options and how to access them,” she said. “Most of the treatment options would require new learning for more clinicians, and in some cases, new partnerships.”

That may involve new partnerships within the community, learning about the intensity of lifestyle treatment and how to prescribe and manage medication alongside such treatment, and determining where high-quality bariatric surgery programs are available, she explained.

“The hope is that the clinical practice guidelines will drive that change,” Armstrong said. “Many of these services don’t exist today.”

She also pointed to payment barriers to treatment options that exacerbate disparities. Policy recommendations regarding reimbursement by public and private payers will be important in ensuring that all children have access to evidence-based treatment options, she added.

Finally, there remains “ongoing weight bias and stigma among the public, and in particular, among healthcare providers, with the misconception that obesity is a personal failing or matter of willpower, or ultimately a fault of the child and parent,” Armstrong said.

However, that is simply not the case, she noted, pointing out that obesity needs to be treated via the same model as other chronic diseases, accounting for remissions, relapses, monitoring, and ongoing care.