New U.S. guideline addresses management of pediatric overweight and obesity

The American Academy of Pediatrics (AAP) has issued its first clinical practice guideline on the evidence-based evaluation and treatment of children and adolescents with overweight and obesity. The guideline does not cover obesity prevention, which is set to be addressed in a future AAP statement. The AAP hopes this guideline will advance the equitable care of children and adolescents with this chronic disease.1 The AAP notes obesity has long been stigmatized as being a consequence of personal choices, when, in fact, it has complex genetic, physiologic, socioeconomic and environmental contributors. In 1998, the U.S. National Institutes of Health aimed to counter misperceptions about obesity and its causes by designating obesity as a chronic disease. In 2013 the American Medical Association followed suit and recognized obesity as a complex chronic disease that requires medical attention.1 The new 100-page AAP guideline acknowledges that obesity is a chronic disease with escalating effects over time. Identification and treatment should begin as early as possible and continue throughout childhood, adolescence and into adulthood.1 Key topics addressed in the guideline: Epidemiology of childhood and adolescent obesity (prevalence, impact of obesity) Diagnosis and measurement of obesity (use of body mass index [BMI] for screening and diagnosis; clinical utility of BMI; communicating BMI and weight status to children and parents) Risk factors for child and adolescent overweight and obesity (policy factors; neighborhood and community factors; family and home environment factors; individual factors) Evaluation of children with overweight or obesity (medical/social history; assessing readiness to change; lab evaluation) Comorbidities of pediatric overweight and obesity (lab evaluation; concurrent treatment of obesity and obesity-related comorbidities; specific guidelines for initial evaluation for comorbidities). Comorbidities include dyslipidemia, prediabetes and diabetes, hypertension, nonalcoholic fatty liver disease, obstructive sleep apnea, polycystic ovarian syndrome, depression, orthopedic comorbidities, idiopathic intracranial hypertension). Treatment of child and adolescent overweight and obesity (obesity is a chronic disease; evidence-based treatment reduces risks for disordered eating; motivational interviewing; intensive health behaviour and lifestyle treatment; when intensive programs are not available; specific health behaviour recommendations; self-management; treatment considerations for children with special healthcare needs) Pharmacotherapy. Intensive health behaviour and lifestyle treatment has the largest body of evidence for effectiveness, but it is important to consider pharmacotherapy for children and adolescents who require an additional treatment option to manage their obesity. This is particularly true for children with more immediate and life-threatening comorbidities, those who are older, and those affected by more severe obesity. Weight loss pharmacotherapy should be offered to adolescents 12 years of age or older with obesity (BMI ≥ 95th percentile), and may be offered to children ages eight through 11 years with obesity. Medications should be used as an adjunct to health behaviour and lifestyle treatment, with medication choice based on medication indications, risks and benefits. Pediatric metabolic and bariatric surgery. Pediatricians and other healthcare professionals should offer referral for adolescents 13 years or older with severe obesity for evaluation for metabolic and bariatric surgery. Systems of care for children with overweight and obesity Evidence gaps and future research directions.1 Guideline highlights Algorithm for screening, diagnosis, evaluation and treatment of children and adolescents with obesity Appendix 1 (issued as a supplement to the guideline) provides an overall algorithm for screening, diagnosis, evaluation and treatment of children and adolescents with obesity.2 Recommendations and action statements A separate executive summary of the guideline tabulates the key action statements and consensus recommendations for the evaluation and treatment of children and adolescents with overweight and obesity.3 Medication-induced weight gain Certain medications may be associated with weight gain, including glucocorticoids, sulfonylureas, insulin, thiazolidinediones, antipsychotics, tricyclic antidepressants and antiepileptic drugs. Second-generation antipsychotics (risperidone, clozapine, quetiapine, aripiprazole) can lead to rapid weight gain and comorbidities such as prediabetes, diabetes and dyslipidemia. The guideline includes a table (Table 3) of some commonly prescribed obesogenic medications in children and adolescents, along with suggested nonobesogenic alternatives.1 Pharmacotherapies The majority of studies in children (≥ 12 years of age) have evaluated the efficacy of metformin either alone (16 randomized, 7 observational) or in combination with other medications (7 randomized). Other studies have evaluated orlistat (2 randomized), exenatide (2 randomized), or other medications with only one study each (phentermine, mixed carotenoids, topiramate, ephedrine, recombinant human growth hormone). The guideline also discusses high-quality evidence for newer agents—setmelanotide (currently under Health Canada priority review for treatment of obesity in Bardet-Biedl syndrome), liraglutide, and the combination of phentermine and topiramate).1 Summary Obesity in children and adolescents is a complex, multifactorial and treatable disease. Management must take the child’s health status, family system, community context and resources for treatment into consideration to create the best evidence-based treatment plan for each child. Comorbidities should be treated concurrently with overweight or obesity. The guideline supports early treatment at the highest level of intensity appropriate for and available to the child.1 References 1. Hampl SE, Hassink SG, Skinner AC, et al; American Academy of Pediatrics. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics 2023;151(2):e2022060640. (accessed February 6, 2023). 2. Appendix 1. Algorithm for screening, diagnosis, evaluation, and treatment of children and adolescents with obesity. (accessed February 6, 2023). 3. Hampl SE, Hassink SG, Skinner AC, et al; American Academy of Pediatrics. Executive summary: clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics 2023;151(2):e2022060641. (accessed February 6, 2023).

New U.S. guideline addresses management of pediatric overweight and obesity

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