The current and long-term health of 14.4 million children and adolescents is affected by obesity in the USA. [1]. International reports suggest that the global prevalence of pediatric obesity has tripled over the past 30 years, [2] a trend that likely accelerated during the COVID pandemic [3].
In response to the growing concern among health providers of the alarming rise of obesity among children and adolescents, the American Academy of Pediatrics has published a clinical practice guideline (CPG) for the evaluation and management of children and adolescents with overweight and obesity [1]. The guideline emphasizes that managing pediatric obesity requires support for both children and their families.
The guideline provides 13 “Key Action Statements” and 11 “Consensus Recommendations for the Evaluation and Treatment of Children and Adolescents with Overweight and Obesity.” Generally, a most excellent approach. However, I have some serious reservations about certain aspects of this paper.
While it is an accepted fact that the primary prevention of obesity in children is an essential public health issue [4], this guideline does not address it.
As far as the highly touted Key Action Statements go, here is “KAS 9: Pediatricians and other PHCPs should treat overweight (BMI ≥85th percentile to <95th percentile) and obesity (BMI ≥95th percentile) in children and adolescents following the principles of the medical home and the chronic care model, using a family-centered and non-stigmatizing approach that acknowledges obesity’s biologic, social, and structural drivers”. [1].
Polished and shining with virtue. However, is this advice useful to the majority of practicing doctors? Don’t they already approach their patients regardless of age or sex in this manner?
The Action Statement on drugs reads, “KAS 12: Pediatricians and other PHCPs should offer adolescents 12 years and older with obesity (BMI ≥95th percentile) weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.” [1].
On page 128 of the 155-page paper, discussing medications, we find this sage advice: “Weight loss medications require the same oversight and expertise in management as other medications used in pediatric care.” [1]. Really? And I thought they were candy.
Let’s get real. Obesity can lead to a host of medical problems, including diabetes, liver disease, heart disease, cancers, sleep apnea, and increased mortality. This is a serious condition. Therefore, prevention and treatment, especially early on, are paramount. The new weight loss drugs can be miraculous in the short term, but are not a panacea.
It seems to me that you can gain and retain weight in two ways. You put more calories into a normally functioning body than you put out. That’s psychological. It often has the hallmarks of an addiction. Or, you have a normal caloric intake, but you retain more than you put out. That’s physical. In other words, your body does not metabolize the food you ingest properly.
Conditions such as hypothyroidism, Cushing’s Disease, diabetes, insomnia, sleep apnea, and common medications such as antipsychotics, antidepressants, epilepsy drugs, and beta-blockers (for high blood pressure), which can lead to weight gain, will, of course, be managed accordingly.
If you are going to treat a child, or an adult for that matter, for obesity, it is essential to know whether the weight gain is psychological or biological in origin. Often, one leads to the other when both need to be addressed.
Many studies show that a considerable number of children and adolescents who are obese use food as a maladaptive coping mechanism in response to experiences of childhood trauma [6]. Therefore, health care professionals, whenever possible, should see the child or adolescent by themselves at least a few times and inquire carefully about a history of physical, sexual, or emotional abuse, neglect, parental arguing or violence, separation, or untimely death of a parent.
Bullying may be another issue that a child may hesitate to talk about in the presence of a parent [5]. Depression or treatment for depression with antidepressant drugs may be a contributing factor in weight gain [6]. Obviously, all the above produce additional stress on both child and parent that exacerbates the problem.
We don’t know the contributions genetics makes to obesity. What we do know is that if either parent or both parents are obese, a discussion with them about their lifestyle is indicated. Do they dine as a family and talk to each other, or do they eat separately while watching TV? What kinds of food do they eat? How often do they eat out, and if so, where? Parents are role models for their children. If you are a parent, keep in mind that you need to practice what you preach.
All the pediatricians I spoke to agreed that sustainable weight loss involves a balanced approach, including increasing their healthful food consumption, participation in physical activity for enjoyment and self-care reasons, improvement in self-esteem and self-concept, stress management, and adequate sleep. They hardly ever prescribe Ozempic and similar drugs because of rare but serious side effects, a lack of long-term studies in children, and because most children don’t like the prospect of “weekly needles.”
The clinical practice guidelines emphasize that “Obesity in children and adolescents is a complex, multifactorial, and treatable disease” [1]. Certainly, obesity can lead to increased morbidity and mortality, but so can many other habits or activities like smoking, drinking, or driving a car. Obesity, as I see it, is neither a moral failing nor a disease but rather a multifactorial psychosomatic condition that must be approached with empathy and support free of preconceived notions, keeping in mind that more attention to early prevention would decrease the need for treatment later.
This article is an abridged version of a post originally published on May 30, 2025, in The Globe and Mail.
