What Parents and Caregivers Need to Know About the New Pediatric Obesity Guidance

For the first time in 15 years, the American Academy of Pediatrics (AAP) has updated its guidance on obesity in children, recommending a more proactive approach.

According to the Centers for Disease Control and Prevention, nearly 20% of children and adolescents in the United States are obese—meaning that their body mass index (BMI) is at or above the 95th percentile of the CDC growth chart. For children, BMI is an age- and sex-specific measurement using height and weight that helps assess body fat. Children who are obese are at higher risk for physical health issues, including heart disease and type 2 diabetes, as well as mental health issues, such as anxiety and depression.

The new guidance—based on comprehensive reviews of scientific trials and studies—is intended to inform pediatricians and pediatric health care providers about how to care for and evaluate children, and it also helps address societal stigma and bias that may create a barrier to seeking treatment.

For the first time, the AAP is recommending immediate treatment with intensive, family-based lifestyle interventions for any child age 2 years or older with obesity. For adolescents, weight-loss medication is also recommended in addition to intensive lifestyle intervention, and adolescents with severe obesity should be evaluated for metabolic or bariatric surgery.

“The guidance is a major shift,” says Jennifer Woo Baidal, MD, assistant professor of pediatrics at Columbia University Vagelos College of Physicians and Surgeons and a pediatric gastroenterologist at NewYork-Presbyterian Morgan Stanley Children’s Hospital.

“What I am really excited about is that it recommends safe and effective treatments as early as possible, instead of waiting a year or more with a gradual approach. We now have other options that can actually help children have healthy lives.”

Woo Baidal, who is the inaugural director of the Pediatric Obesity Initiative in the Department of Pediatrics at Columbia University, recently spoke about the updated guidance, the key facts to know, and how it will impact children and families.

Why was the guidance updated now?

Obesity has been linked to diseases of every major organ system, as well as mental health problems. The long-term health risks include diabetes, fatty liver disease, cardiovascular disease, high blood pressure, bone problems, and sleep apnea among others.

Over the past four-plus decades, obesity prevalence has steadily increased and, more recently, there has been a concerning rise in severe obesity and widening gaps in racial and ethnic disparities. During COVID, children also became more sedentary and experienced many stressors that can lead to weight gain.

In addition, there have been scientific advancements in the treatment of obesity. It is a medical condition and should be treated as such. So now more than ever, we really need to implement evidence-based practices.

What are some of the key changes in the guidance?

Something that really stood out is the upright acknowledgement of the role of social determinants of health and the stigma surrounding obesity. Obesity is a very complex problem, and one of the big barriers we’ve been facing in making progress is bias. Many people think children can just lose weight on their own, but it’s hard to make changes if there is limited access to affordable, healthy food and exercise. I think the guidance calls this out and gives support and instruction for providers on how to handle those factors.

The guidance also expands the ages for evaluation and treatments. For example, it recommends pediatricians and other clinical providers start obesity evaluation and treatment for children at age 2, instead of 6 years old. Intensive lifestyle interventions—about an hour per week on average with a trained team—should be offered right away when obesity is diagnosed. Weight loss medications to treat obesity can now be offered to children starting at 12 years old. And a big addition is a recommendation for pediatricians to offer a referral for adolescents ages 13 years and older with severe obesity (meaning they have a BMI at or above 120% of the 95th percentile for age and sex) to be evaluated for bariatric surgery.

I want to underscore that intensive lifestyle interventions and use of motivational interviewing—a behavior-change technique—are foundational to successful treatment. In this type of intervention, pediatricians or other clinical providers talk to the patient and family about their needs, their lifestyles, and what is important to them. Based on the assessment, we tailor our treatment plan to prioritize their goals. It is comprehensive, so a healthy lifestyle for the whole family is key to treatments such as medication or surgery to work best for the patient.

Why is body mass index (BMI) used as a measurement?

BMI is a measure of growth based on height and weight. For children and teens of the same age and sex, overweight is defined as a BMI at or above 85% and obesity as a BMI at or above 95%.

BMI is not an extremely specific measure, but we do have really consistent evidence that the BMI cutoffs in the guidelines are a good screening tool for assessing overweight, obesity, and severe obesity. It can help clinicians understand when to progress to recommend intensive lifestyle interventions, weight-loss medications, and metabolic or bariatric surgery in a more timely fashion.

But when I talk to patients, I don’t talk about weight and BMI. I ask about how they are doing and what is going on in their life. Then we talk about what they want to work on and come up with a plan together.

Are treatments like medication and surgery safe for adolescents?

Just in the past year or two, new safe and effective medications have been approved for children who have obesity, and we have an abundance of evidence that metabolic or bariatric surgery should be considered the standard of care for qualifying adolescents who have severe obesity. The idea of surgery can be daunting for families. However, knowledge is power, and seeking a consultation to understand more about what surgery means does not mean a commitment to it.

"For teens with severe obesity who do decide with their families to pursue metabolic or bariatric surgery, they can expect to participate in intensive lifestyle interventions for at least six months. The patient will also undergo a thorough medical evaluation to ensure they have the safest surgery possible. Our adolescent bariatric surgery center has a multidisciplinary team that supports families through this journey and beyond.

There is an abundance of scientific evidence to support these interventions, compared to watchful waiting, which studies show can lead to excessive weight gain and a greater risk for chronic diseases. It is also important to understand that these therapies are recommended together with intensive lifestyle interventions to continually work on healthy behaviors.

Will parents see a difference at an annual checkup?

Pediatricians have always checked weight and height to make sure children are growing in a healthy way, and that will not change. The new guidelines state that offering the most intensive evidence-based intervention available should be the standard of care. If the child is gaining weight more quickly than expected, there may now be an escalated time frame for recommending intensive lifestyle interventions—meaning on average one hour per week—at a younger age. Recommendations to start medications may occur more quickly than in the past. And for adolescents with severe obesity, pediatricians may refer them to bariatric surgery earlier on.

What would you say to parents who are concerned their child is gaining weight too quickly?

No parent or child is at fault. We have evidence to show that placing blame on the individual doesn’t help treat the problem. General health guidance says that everyone should drink plenty of water, eat fruits or vegetables with every meal, avoid processed foods and sugary drinks, get age-appropriate physical activity and play, and limit screen time. But our modern world is complex, and no one is perfect.

I think it can be really stressful. I would remind parents that they should put the oxygen mask on first, take some breaths, and talk to the pediatrician to see if other treatments or evaluations are warranted.