New AAP Childhood Obesity Clinical Practice Guideline

Column Author: Sarah Hampl, MD | Pediatrics, Weight Management Pediatrician; Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

On Jan. 9, the American Academy of Pediatrics (AAP) published a clinical practice guideline (CPG) for the evaluation and treatment of children and adolescents with obesity.¹ It is the AAP’s first CPG on this topic and replaces the 2007 Expert Committee Recommendations. The CPG does not discuss treatment in children under age 2 or prevention of obesity, which will be covered in an upcoming policy statement from the AAP Section on Obesity. 

Obesity is a complex chronic disease that requires a comprehensive, whole child approach. The causes of obesity are not limited to individual or family factors, such as genetics, nutrition and physical activity. They also involve multiple, complex situations in the wider environment that can lead to obesity. Examples include unjust food systems and economic factors, which can make it hard for some families to access or afford healthy food choices; unsafe physical environments, which can limit opportunities for physical activity, exercise and active play; and sources of toxic stress such as exposure to racism. Toxic stress can affect the hormones that regulate weight, among other health effects. We also know that weight bias and stigma is pervasive and harmful and can be a barrier to treatment. Longitudinal evaluation of children with obesity includes these factors and is a core component of care.

Obesity treatment is safe and effective. Watchful waiting is not indicated. We are fortunate that now more evidence-based tools than ever before are available for primary care providers to create a comprehensive whole child treatment plan. Participation in a structured weight management program decreases the risk of disordered eating in children with obesity.

The AAP recommends that treatment begin early and at the highest available intensity. There is strong evidence that family-based intensive lifestyle and behavioral treatment works. This treatment goes beyond standard nutrition and physical activity advice to include processes of behavior change and skill-building and opportunities to practice healthy behaviors. For caregivers, this treatment also includes parenting skills, role modeling and consistent reinforcement techniques. Programs may include different specialists, like registered dietitians, and behavioral health and exercise specialists, and can take place within health care settings or community-based organizations, while the medical home monitors patient progress. The most effective treatments provide at least 26 hours of face-to-face intervention over three to 12 months.  

Medications for weight loss are Food and Drug Administration (FDA)-approved for children ages 12 and older, in conjunction with intensive health behavior and lifestyle treatment, and are effective and usually well tolerated. These medications help children feel less hungry, and include topiramate/phentermine, liraglutide and semaglutide. Orlistat, which blocks some dietary fat absorption, is also FDA-approved for youth 12 and older, but gastrointestinal side effects often limit its use. Studies are ongoing, but initial data indicates that adolescents may need long-term use of medication to prevent weight regain. 

Metabolic and bariatric surgery is also an evidence-based option for some children with obesity, as it is also effective in treating obesity and decreasing or eliminating comorbidities. The CPG recommends that primary care providers refer adolescents with severe obesity for evaluation to a comprehensive pediatric center with a multidisciplinary team. 

The recommended treatments and insurer coverage of these treatments are not universally available. The AAP Institute for Healthy Childhood Weight is working with state chapters, national insurer groups and others to improve access to care. 

Education and implementation resources have been created to facilitate adoption and integration of these recommendations into clinical practice, and more resources are in development. Please explore the CPG, executive summary, algorithm, technical reports and other resources at www.aap.org/obesitycpg. To learn more about how to implement the new guidelines into your practice, consider joining the Show-Me Telehealth Network’s Pediatric Weight Management ECHO, which meets from 12 to 1 p.m. on the second and fourth Wednesday of each month.

Have questions about the CPG or resources? Feel free to contact me at shampl@cmh.edu. The Link may feature a follow-up article with FAQs in the next few months.  

Reference: 

1. Hampl SE, Hassink SG, Skinner AC, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Published online January 9, 2023. Pediatrics. 2023;e2022060640. PMID: 36622115. doi:10.1542/peds.2022-060640