Evidence-Based Management of Pediatric Obesity: Highlights of the New AAP Clinical Practice Guideline

Column Author: Lauren Fay, MD | Internal Medicine-Pediatrics PGY-2

Column Editor: Kathleen Berg, MD, FAAP | Hospitalist - Pediatrics; Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Recently the prevalence of pediatric overweight and obesity in the United States has plateaued around 30%; however, the prevalence of “severe obesity” (BMI >35 kg/m² or 120% of the 95th percentile) has continued to rise.¹ Since 2007, the American Academy of Pediatrics (AAP) has recommended a stepwise approach to managing pediatric obesity: prevention, structured weight management, comprehensive multidisciplinary intervention and tertiary care intervention.² Building on this approach, the AAP released a valuable new clinical practice guideline (CPG) for primary health care providers in January 2023 that integrates the most up-to-date evidence to guide obesity screening, treatment and referral.³

When diagnosing overweight or obesity, it is crucial for providers to recognize their own weight biases, empathetically discuss the problem with the patient and caregiver, and help the patient and family set appropriate expectations. For adolescents in particular, studies have shown that avoiding weight-centric language and asserting that thinness does not equate to health can greatly improve engagement and health outcomes.^4,5

Importantly, the CPG emphasizes that treating obesity is multifactorial. As an essential part of management, it encourages evaluating and addressing social determinants of health, psychosocial health, sleep and obesogenic medications. Notable obesogenic medications include glucocorticoids, antiepileptics, and antipsychotics including risperidone and olanzapine.³ The CPG provides the following laboratory, nutritional and physical activity recommendations:

Laboratory Recommendations:

• All children ages 9-11: one-time fasting lipid panel
• Age 2+ with BMI >85th percentile: fasting lipid panel (repeat screening every two years if normal or monitor every six to 12 months if abnormal)
• Adolescents 10+ with BMI >95th percentile: fasting lipid panel PLUS hemoglobin A1c and transaminases depending on risk factors for diabetes or non-alcoholic fatty liver disease (e.g., family history, signs of insulin resistance, obesogenic medications, central adiposity)
  

Nutritional Recommendations:

• Low-glycemic diet for pre-diabetes/diabetes diagnosis or risk factors
• Dietary Approaches to Stop Hypertension (DASH) diet for hypertension diagnosis or risk factors
• Replace calorie-dense with nutrient-dense foods
• Focus on healthy habits such as food preparation skills and meal planning over dieting/restricting calories
• Address barriers to nutritious eating such as food scarcity or psychiatric conditions
• Refer patients to resources such as Choose My Plate (MyPlate.gov) and “5-2-1-0” rule
• Connect patients with registered dietician nutritionists whenever able

Physical Activity Recommendations:

• 60 minutes of moderate to vigorous activity daily
• Include both aerobic and non-aerobic as well as weight-bearing activities as appropriate for the patient’s age and ability
• Emphasize participation in physical activity for the benefits of enjoyment and self-concept rather than changes in weight/body shape
• Limit sedentary screen time
  

For maximal success, lifestyle interventions should be prompt, longitudinal, family-based, empathetic and non-stigmatizing. They should include components of motivational interviewing and promote self-management. Given that face-to-face time with patients is limited in the primary care setting, referral to a multidisciplinary treatment program is often best practice. Within Children Mercy Kansas City, the PHIT (Promoting Health in Teens and Kids) Clinic fulfills this role. Similar programs may also be available through schools, local Parks and Recreation, YMCA, Boys and Girls Clubs of America, and other organizations. Any transportation, health insurance or language barriers should be taken into consideration when considering the best program for the patient.

Medications may be an additional treatment option for patients age 12+ who are failed by traditional lifestyle and nutritional interventions alone. Primary care providers can often appropriately initiate and manage these medications with proper education, but they may also refer to metabolic or bariatric specialists.³ 

Finally, for patients age 12+ with BMI > 40 kg/m², or BMI > 35 kg/m² plus at least one comorbid condition, bariatric surgery can lead to durable weight loss and possibly reverse comorbid conditions well into adulthood. Patients should be referred early when considering surgery, even if only for more in-depth discussion of risks and benefits while trialing other treatment modalities.³ 

References: 

1. Kumar S, Kelly AS. Review of childhood obesity: from epidemiology, etiology, and comorbidities to clinical assessment and treatment. Mayo Clin Proc. 2017;92(2):251-265. doi:10.1016/j.mayocp.2016.09.017
2. Spear BA, Barlow SE, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120 Suppl 4:S254-S288. doi:10.1542/peds.2007-2329F
3. Hampl SE, Hassink SG, Skinner AC, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics. 2023;151(2):e2022060640. doi:10.1542/peds.2022-060640
4. Raffoul A, Williams L. Integrating Health at Every Size principles into adolescent care. Curr Opin Pediatr. 2021;33(4):361-367. doi:10.1097/MOP.0000000000001023
5. Palad CJ, Yarlagadda S, Stanford FC. Weight stigma and its impact on paediatric care. Curr Opin Endocrinol Diabetes Obes. 2019;26(1):19-24. doi:10.1097/MED.0000000000000453