Medication and surgery are among new recommendations for treating childhood obesity. One Triad doctor explains.

GREENSBORO, N.C. (WGHP) – To combat the increasingly troublesome epidemic of childhood obesity, the American Academy of Pediatrics recently issued what it called its first guidelines to help physicians treat and stymie a trend that threatens not only the mortality of young people but their outcomes as adults.

The academy in announcing its plan said that there are more than 14.4 million children and teens who are overweight, which leads not only to cardiovascular disease – think heart problems – but also type 2 diabetes.

The report defines a person as overweight who has a body mass index (or BMI) at or above “the 95th percentile for children and teens of the same age and sex.”

And the problem is significant across the nation but also in North Carolina, where data suggest that the rate of incidence tracks the national average and surpasses most states.

As of 2021, using data compiled by the Robert Wood Johnson Foundation, North Carolina’s incidence of childhood obesity between the ages of 10 and 17 was 16.1%, which ranked 18th among the states and Washington, D.C., and was higher than the national rate of about 15.5%.

About that same time, America’s Health Rankings, which does annual research about various health and wellness issues in cities, counties and states, found that, during the pandemic period of 2019-2020, North Carolina’s incidence of childhood obesity was 33.9%, which surpassed the national average (32.1%) and was a peak for data collected between 2016 and 2021.

Otherwise, the state’s average has been a match for the nation’s, and in fact, it declined slightly by 2021 so that both registered 33.5%. By comparison, Wyoming is the healthiest state (at 24.3%), and Mississippi is the least healthy (41.4%).

But know this: The Centers for Disease Control and Prevention two years ago, in January 2021, reported that the prevalence of childhood obesity between the ages of 2 and 19 had more than tripled between 1963 and 2018.

A CDC graphic showing the growth in childhood obesity. (CDC)

America’s Health Rankings cited four groups most affected by these trends:

Non-Hispanic Black and Hispanic youth compared with non-Hispanic white and Asians.

School-aged children 6-19 compared to those ages 2-5.

Children who live in lower-income households.

Children whose parents are less educated.

The new recommendations

The question – and the reason the AAP has taken this step – is how physicians should respond to this problem, which is caused by an absence of healthy eating and physical activity but also influenced by social relationships and even advertisers who sell products that contribute to the problem.

“There is no evidence that ‘watchful waiting’ or delayed treatment is appropriate for children with obesity,” Dr. Sandra Hassink, an author of the guideline and vice chair of the Clinical Practice Guideline Subcommittee on Obesity, said in the release about the new standards. “The goal is to help patients make changes in lifestyle, behaviors or environment in a way that is sustainable and involves families in decision-making at every step of the way.”

The guidelines issued by the AAP do not address preventing obesity – the organization promises a report on that at a later date – but they suggest the role of pediatricians or family doctors who oversee care for a child who meets the definition of being obese.

They define comprehensive treatment that could include requirements for nutrition, physical activity, behavioral therapy, pharmaceuticals and even surgery. Specifically:

Face-to-face interaction that includes intensive health behavior and lifestyle treatment. This could be 26 or more hours of face-to-face, family-based treatment during a 3-to-12-month period.

Working with parents and caregivers on helping avoid “disordered eating.”

Potentially prescribing for children 12 and older medications that help with weight loss, using a variety of behavior and lifestyle issues as guidance.

Evaluating teens (13 and older) with a BMI of at least 125% or in the 95th percentile for their age/sex for metabolic surgery – that’s sometimes called a “stomach staple” – and bariatric surgery, which is also known as a “gastric bypass.”

A Triad doctor offers insights

To understand the breadth and practicality of these recommendations, WGHP reached out to experts in the Piedmont Triad. Novant Health offered insights from Dr. Soren Johnson, a pediatrics specialist for the past decade who practices in Winston-Salem. Johnson also did an earlier Q&A that you can watch here.

Cone Health in Greensboro has not provided a doctor to respond to these same questions. Johnson’s answers are offered essential verbatim, with light editing for style and clarity.

How big of an issue do you see childhood obesity in the Piedmont Triad?

DR. SOREN JOHNSON: “Trends in the Triad generally mirror nationwide trends. Obesity is a massive problem, and rates continue to rise annually in toddlers, schoolchildren, and teens.”  

Aren’t children typically monitored for weight gain up until they are ready for preschool?

JOHNSON: “Yes, pediatricians monitor height and weight at every well-child check-in from infants through to adulthood.”

What about genetic obesity? Do any of these approaches have the potential to address weight gain caused by something other than lifestyle?

JOHNSON: “A very small percentage of children with obesity have an underlying genetic cause. Some of the newer medicines for obesity have been specifically developed to help individuals with a mutation of the leptin gene, for example. There are a few other genetic conditions that have been discovered to contribute, but for 99% of kids with obesity there is no identifiable genetic cause.” 

What is your immediate reaction to the idea of prescribing “diet pills” for children who have not reached puberty?

JOHNSON: “There’s not really a category of medicines considered ‘diet pills,’ so I’d recommend avoiding that term. Medications are not recommended for anyone as a first-line treatment. The first steps are to try to address the contributing factors through lifestyle changes. There are more medication options for those ages 12 or more, and only a few for those for less than 12 years old. Mechanism of action for most of the available options doesn’t really affect pubertal development, so I don’t think sexual developmental stage is really pertinent to most decisions about when to consider medication treatment or not. That being said, it’s going to be a decision that needs consideration and discussion on a case-by-case basis with the child and the parents. It’s more a question of what has the family tried already, what’s working and what’s not, and at least now we have more options to consider using if what we’ve tried has been unsuccessful.” 

What about weight loss surgery for teenagers? Is that too young? And would that be too drastic and costly to be realistically considered?

JOHNSON: “Again, I have to reiterate that surgery is never a first-line treatment. The data for successful outcomes from bariatric surgery in adolescents is quite strong. However, surgery comes with additional risk and requires a very committed family and patient. As for cost, the up-front costs of bariatric surgery are high, but it can be cost-effective in the long run if that patient avoids the medical consequences of chronic obesity: heart disease, type 2 diabetes, obstructive sleep apnea, hypertension, etc.”

Does hands-on intervention by a pediatrician for as much as 26 hours over a year represent an achievable plan?

JOHNSON: “The intensive multidisciplinary treatment programs referenced in the guidelines are only available at some medical centers. We are fortunate to have Brenner Fit at Wake Forest/Atrium available in our community. CoreLife also serves some adolescents in our community. These programs are the most successful intervention available, but simply aren’t available for everyone. Also, they require a huge time commitment from the family. So it’s simply not going to be an option for families with transportation challenges, parents with demanding work schedules, lack of insurance coverage, among other barriers. Not surprisingly, some of these factors may contribute to the risk of obesity to begin with.” 

Isn’t it unreasonable to expect that health insurance would help pay for such significant treatment that some might view as elective?

JOHNSON: “That’s a question that can’t be answered over email concisely. There’s no right or wrong answer, and it’s going to be a matter of opinion. How do you define ‘unreasonable’? Does reasonable = cost-effective? I’m certain most people don’t “electively” choose to have obesity, particularly children. Show me a first-grader who ‘electively’ wants to be the subject of ridicule for being obese. I’m not suggesting personal motivation has no role. But the longer we as a society continue to focus on assigning blame, the longer it takes us to move on to a more effective analysis.

“It’s more important to ask, ‘What works to make it better?’ and ‘How can we prevent it?’ not ‘whose fault is it.’ The guidelines are designed to help providers make effective medical decisions for individual patients. But until our community/country/world addresses the underlying causes of obesity, population rates [among the obese] will rise.”