Unpacking the New AAP Obesity Guidelines

When, in early 2023, the American Academy of Pediatrics (AAP) released updated guidelines for the care of children with obesity, new recommendations for the use of weight-loss medications and surgery were the focus of widespread media attention — and some controversy.

But these medications represent an important new tool: one that should add to, not replace, other options for managing obesity, notes Cleveland Clinic pediatric endocrinologist Roy Kim, MD. He said providers should consider medication in the larger context of the guidelines as a whole, an extensive document that covers a wide range of interventions and puts a new emphasis on lifestyle and systemic risk factors that contribute to obesity.

“On the one hand there’s been a lot of excitement and a well-founded sense of optimism about the available treatments,” he says. “If there is controversy, I think it’s the idea that all children with obesity should be on medicines or getting surgery. But that is not what the guidelines say.”

It’s the first time the AAP’s obesity guidelines have been changed since 2007, and Dr. Kim calls the update “really overdue.” Along with discussing surgery and medication, the guidelines summarize lifestyle changes and interventions, and highlight the importance of primary care physicians in coordinating obesity care with multiple other providers for their young patients.

“The field is becoming very specialized, with more and more to know, and it can be a challenge for extremely busy primary care providers who are being called upon to have a greater role in the management of this condition,” he says.

Lifestyle interventions still come first

Dr. Kim notes that, historically, there have been few options for safe and effective medications to treat obesity in any age group. Recent drugs have been shown to be effective, with a good safety profile, and are now approved for use in adolescents as young as 12 for patients with a BMI in the 95th percentile.

“Adolescents who take these medicines, like adults, can really experience significant weight loss that far exceeds what we can usually see with lifestyle alone,” he says.

Lifestyle changes, including working with a dietitian and engaging in fun, physical activity remain the first-line interventions for weight loss in children. “Medications and surgery are further down the list” and should be considered for young patients who aren’t responding to regular interventions, he says.

An emphasis on obesity risk factors

Notably, the updated guidelines put new and greater emphasis on obesity risk factors. These include not just historically accepted risk factors like sugary drinks, sedentary activities, sleep issues and mental health but also societal and systemic issues that contribute to obesity disparities, such as access to grocery stores with healthy food and safe outdoor spaces to play, healthcare and insurance access, obesity related stigma in social and healthcare settings, and inequities in outcomes related to social, economic, racial and ethnic differences.

“These are added dimensions that are important to recognize,” he says. “As healthcare providers, we have to be intentional about assessing these issues and addressing them to the extent that’s possible.”

Best practices for prescribing

The new guidelines state that weight-loss medication should be considered in cases of severe obesity, or when the patient is not responding to other interventions. Dr. Kim says that providers should first screen patients for other factors that may be affecting their weight, such as lifestyle issues, or other medications that may promote weight gain, and address those issues first.

But if other interventions haven’t worked, medication can be another tool.

“These are kids and teenagers who might have been repeatedly engaged in weight management programs and have really tried and given a diligent effort to lose weight,” he says. “In that situation, they can benefit tremendously by adding a medication and continuing those healthy lifestyle practices.” Relying on medication alone, and not following up with regular visits, is “really discouraged,” he adds.

Once medication is prescribed, it’s likely the patient will need to continue taking it for many years, or even their whole life. “We regard obesity as a chronic disease,” he says.

“It’s not just an issue of willpower. We think some people are hardwired by their genetics and the environment to have this condition. And just like we wouldn’t stop somebody’s blood pressure medicine after a few years, it’s not reasonable to think that for most people we could stop these anti-obesity medicines after only a short period of time.”