When I first started taking care of children and adolescents as a pediatrician in the late 1980s, obesity in childhood was rarely seen as a medical issue. Many colleagues wondered why I was interested in kids with obesity and why they would need a doctor’s help. A common misperception — which exists to this day — saw obesity as something that can be “fixed” if only the patient would “eat less and exercise more.” Culturally, individuals with obesity have been blamed for their condition, since relatively few experts understood how obesity changes some of the body’s essential systems. Metabolism and energy regulation, the immune system, even the way genes are expressed in the cells, are all altered when someone has obesity.
For me, however, the toll obesity was taking on my patients was alarming. Every time I walked into clinic I encountered diseases stemming from obesity that I never expected to see in kids: A 9-year-old with severe sleep apnea who had to wear a breathing mask at night; a 12-year-old with obesity-related liver disease that if unchecked could result in a liver transplant; another 12-year-old who needed emergency surgery to pin his hips due to an obesity-related hip injury called slipped capital femoral epiphysis. Kids and adolescents were also suffering from bullying and teasing, low self-esteem and at times, depression. One teenager burst into tears when I asked her what she planned to do after graduation. She desperately wanted to join the police force but was terrified she would not be able to meet the physical entrance requirements for this profession. Another patient felt she couldn’t go to her prom because she would never be able to find a prom dress in her size. I heard these stories every day.
Today, we have an abundance of evidence that obesity is a chronic and complex disease with lifelong health ramifications. And the good news is that we know that obesity is treatable with early and intensive intervention.
New guidelines by the American Academy of Pediatrics for the first time provide physicians with an extensive road map of options for families that are now available and that have evidence proving their effectiveness. These guidelines do not replace the need to take preventive actions to avoid overweight and obesity, such as eating nutritious food and staying physically active, or the work we must all do collectively to address the environmental causes of obesity including food and economic insecurity, racism and adverse childhood experiences. That work must be done. But this is not an either/or scenario. Both are needed — and for those who live with obesity right now, these guidelines are lifesaving news.
To better help these children, we recommend physicians develop an individualized treatment plan that is centered on the whole child. This means taking into consideration the unique health status of the child in the context of their family, community, and the environment in which they live. This evaluation is critical: Understanding a child’s unique physical, mental and emotional health coupled with an in-depth look at social structures and environmental factors that place the child or adolescent at risk for obesity is key to developing an individualized plan.
Research has shown that intensive health behavior and lifestyle treatment that educates and supports families in nutrition, physical activity, and behavior changes is effective in improving weight status and related health issues like diabetes and hypertension, as well as promoting long term health. This intervention is connected and coordinated in the pediatric medical home and can be supported by community programs and other pediatric health care professionals such as registered dietitians, behavioral health and exercise specialists. There is evidence that obesity drug treatment and metabolic and bariatric surgery can be effective for adolescents who meet the criteria for these therapies, as an addition to health behavior and lifestyle treatment. Patients, their families and physicians should spend time carefully considering these treatment options and how they may impact their health and trajectory of their lives.
Some are concerned about how this approach will impact children and adolescents who are prone to eating disorders. As physicians and parents, we know firsthand the trauma that so many with obesity have experienced, and we understand the concerns. Both obesity and eating disorders are serious and often stigmatized health conditions that require compassionate and comprehensive care. After examining the research, we found that evidence-based obesity treatment that is structured, supervised, non-stigmatizing and family-centered does not cause eating disorders or result in harm to the patient. In fact, structured, supervised weight management programs actually decrease current and future eating disorder symptoms.
It is time to recognize obesity in childhood and adolescence for the complex chronic disease that it is. This means that treatment should begin upon diagnosis and be available and accessible for all children and adolescents with obesity. There is no room for weight bias or stigma in our thinking about obesity as a society. To blame a child and family for obesity makes no more sense than blaming a child for having asthma. As physicians, we now have evidence-based treatment options to offer and allow us to partner with patients and families to improve their physical, mental and emotional well-being. Most of all, we believe acting early to treat obesity, with understanding and compassion. will instill hope in our patients.
