Aggressive obesity guidelines sparks life-saving conversations

By Dr. Dyan Hes

This January, the American Academy of Pediatrics (AAP) made headlines for aggressive updates it made to its obesity guidelines from 15 years prior. The new suggestions include earlier obesity evaluations for kids as young as two, medication for those 12 and above and bariatric surgery for teenagers 13 and older. The guidance also highlights the benefits of behavioral and lifestyle therapy which would optimally consist of 26 hours of in-person sessions a year addressing diet and exercise. As a pediatrician who specializes in obesity, these past few months have been filled with meaningful conversations with caregivers who deemed the proposals too drastic. I understand and share some of their concerns but while these proposals are not perfect, they are a step in the right direction toward healthier kids.

Since the 1970s, childhood obesity rates have tripled in the United States. The condition is linked to many life-threatening diseases including diabetes, heart disease, stroke, and even some cancers. Due to these dire consequences, I support the need for earlier evaluations like the ones highlighted in the updated guidance. The sooner we can step in to curb harmful behavior and institute positive lifestyle practices, like a healthy eating and exercise, the more likely we are to reverse the troubling trends we are seeing. I applaud the AAP’s intent to instill healthy values in our nation’s children, but I believe 26 hours of therapy are unrealistic goals for guardians and health care providers alike.

More controversially however, is the use of medicinal and surgical options on severely obese kids as young as 12. Unlike most pediatricians or even pediatric obesity medicine doctors, I have been prescribing drugs to treat weight loss for over 20 years as long as I’ve exhausted traditional weight-loss methods. As a specialist, I could not sit by and watch patients continue to gain weight and become sick with comorbidities knowing weight loss drugs were safe and effective. In March, for example, I prescribed medications to a 12-year-old girl with morbid obesity who suffered from severe asthma and sleep apnea. By June, she had lost weight and had already noticed a dramatic drop in her asthma pump usage and in her sleep apnea.

Medicating patients, however, comes with an unforeseen problem which, once again, reveals some of the unrealistic aspects of these proposals. While they may suggest drugs and surgery for some children, insurance does not cover it unless the patient has severe comorbidities. Many patients who should be eligible for these treatments do not meet these strict criteria and would then be expected to pay out of pocket for medications that cost upwards of $1,300 a month.

In addition to medications, I have managed many patients as young as 12 who have had gastric sleeve surgery or gastric bypass surgery. These surgeries, reserved for patients with life-threatening cases, are performed in conjunction with extensive testing and pre and postoperative care where experts carefully monitor the patient’s nutrition and exercise. The last patient that I referred to a bariatric surgeon was a 13-year-old with morbid obesity. She was prediabetic and suffered from debilitating physical ailments including high blood pressure, high cholesterol, urinary incontinence, recurring urinary tract infections, asthma, joint pain, and constipation. These symptoms also took a mental toll, causing severe depression and anxiety. Due to this long list of illnesses linked to her weight, she was taking a cocktail of medications to manage her health. Within a month after the surgery, she was weaned off all her medications and by her one-year check-up, she was significantly lighter.

I can’t overstate the impact these changes have made on her life which was dictated by a rigorous medicine schedule. She was able to able to shop and wear clothes like her classmates. Her renewed confidence helped her rejoin the cheerleading team and she even had a boyfriend the last time I saw her! These procedures help kids be kids and allow them to fit in which, at that age, seems like the most important thing in the world. While we perform these procedures with a medical goal in mind, the mental and social impacts are overwhelmingly beneficial. I am so glad, that two decades later, the evidence-based medicine that we have been waiting for supports the treatments that I have been giving.

The AAP’s guidance is not perfect, but it is addressing a growing concern and starting a very difficult conversation that must be done carefully as to not send harmful messages to young, impressionable children. We all know the health risks associated with obesity, but irresponsible conversations can lead to mental health issues including eating disorders and body dysmorphia.

These guidelines stress the importance of therapy centered around a healthy lifestyle and while the aforementioned 26 hour-long appointments are unrealistic, there is something there to strive for. There needs to be more specialized training in dealing with childhood obesity so these guidelines can be more easily enforced. Primary care physicians – who are already stretched thin -- should be urged to refer patients to these specialists more often so that kids can get the critical care they need. I sincerely hope the conversations sparked by the AAP guidelines lead to positive change where kids can live healthier and more fulfilling lives.

Dyan Hes, MD, is board certified pediatrician at Northwell Lenox Hill Hospital. She is a diplomate of the American Board of Obesity Medicine (ABOM) and served as a director of the ABOM for eight years.