The American Academy of Pediatrics (AAP) on Monday published new guidance in Pediatrics advising pediatricians and pediatric healthcare providers to provide "immediate, intensive obesity treatment to each patient" as soon as they are diagnosed.
For the first time in 15 years, AAP on Monday released updated guidelines on childhood obesity—a move that comes as childhood obesity rates have continued to climb in the United States.
Under the new guidance, AAP suggests that intensive behavioral and lifestyle adjustments should be implemented to address childhood obesity. The group also recommended anti-obesity medications and surgery for the first time.
"We now have evidence that obesity therapy is effective. There is treatment, and now is the time to recognize that obesity is a chronic disease and should be addressed as we address other chronic diseases," said Sandra Hassink, medical director of the AAP Institute for Healthy Childhood Weight and co-author of the new guidelines.
According to AAP, children ages 6 and older—and some children aged 2 to 5— with obesity should work with providers to implement changes to their behavior and lifestyle. In addition to lifestyle changes, the group recommends anti-obesity drugs and weight-loss surgery for older children who have been diagnosed with obesity.
Currently, four drugs are approved for obesity treatment in adolescents ages 12 and up, including Orlistat, Saxenda, Qsymia, and Wegovy. One drug, phentermine, is approved for individuals ages 16 and older, and another drug, setmelanotide, has been approved for children ages 6 and older who have Barde-Biedl syndrome, a genetic disease that leads to obesity.
The guidelines also recommend discussing weight-loss surgery for individuals ages 13 and up with severe obesity.
"The sooner the better for many things," said Joan Han, a professor and chief of the Division of Pediatric Endocrinology and Diabetes at Mount Sinai Kravis Children's Hospital. "There is research that shows that getting bariatric surgery sooner can reverse health issues like Type 2 diabetes and high blood pressure, which is why surgery should be considered for pediatric patients."
"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," said co-author Sarah Armstrong, who serves as co-director of the Duke Center for Childhood Obesity Research. (Radde, NPR, 1/9; McLean/Manier, ABC News, 1/9; Sullivan, NBC News, 1/9; Aleccia, Associated Press, 1/9; Henderson, MedPage Today, 1/9)
By Gabriela Marmolejos and Gina Lohr
Recent criticism of AAP's pharmacotherapy recommendations points to the pervasive stigmatization of obesity treatment. Concerns that widespread use of weight loss medications among children and adolescents "could lead physicians to overlook the root causes of an individual's condition" demonstrate prevalent misconceptions and lack of education on evidence-based obesity diagnosis and treatment.
As mentioned in a recent Advisory Board blog post, these medications are only indicated for use in combination with behavioral and lifestyle treatment as part of a comprehensive obesity treatment plan. AAP recommends clinicians consider prescribing these therapies among children 12 years and older with specific indications such as those with "immediate and life-threatening comorbidities." As with any medication, some clinicians may inappropriately prescribe them off-label. But should that preclude all children and adolescents with obesity from accessing an evidence-based treatment option? For most medications, the answer is no. Health leaders should use these conversations as a catalyst for improving broader clinician education on formally diagnosing obesity and delivering effective obesity counseling.
These guideline changes also reflect the dramatic growth in weight loss drug usage. Specifically, the use of glucagon-like-peptide-1 (GLP-1) receptor agonists such as semaglutide and tirzepatide. The number of patients taking these drugs has skyrocketed and now the market is facing a shortage (at least of semaglutide).
Additionally, employers and plan sponsors are faced with the difficult decision of determining whether and how they'll cover these drugs. Plans are wrestling with whether these drugs should be elective or essential medications, and there are cost and access implications associated with either choice.
If these drugs are covered, costs for these medications ($900-$1350 monthly per patient) will add up quickly given the large eligible population. If plans choose to cover these drugs, it will likely raise near-term health insurance costs for everyone. But without health plan coverage, there are serious inequities—some patients, who can afford to do so, are paying for these drugs out-of-pocket while others who may benefit cannot access these medications.
The other consideration for health plans is the promise of lowering long-term costs due to complications from obesity-related diseases such as diabetes and cardiovascular disease—though definitive analysis on cost savings has yet to be completed.
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