What to do about children with obesity?
New American Academy of Pediatrics guidelines reflect an uncomfortable truth.
For the first time in a generation, the American Academy of Pediatrics yesterday issued new childhood obesity guidelines that will certainly make a lot of people uncomfortable. Instead of “watchful waiting”, the academy urged clinicians to consider obesity medication or bariatric surgery in eligible children 12 and older. In other words, doctors should use their clinical judgement to act early and aggressively in their littlest patients rather than waiting for kids with obesity to become adults with obesity. Here’s AAP’s algorithm for screening patients, via Dr. Angela Fitch:
The move has been met with applause but also a good measure of alarm: that rather than addressing the root causes of childhood obesity – the catastrophic food- and built- environment we subject children to – clinicians are now being urged to drug and operate on kids. The point is valid, but it ignores a key question: what to do about all the young people who are struggling right now, in an environment that isn’t changing fast enough?
I’ve spent a lot of time reporting on the treatment of childhood obesity, even before the recent advent of the effective GLP1-based obesity drugs (such as semaglutide and tirzepatide), when bariatric surgery was the most effective, and under-used, path to significant, enduring weight loss. I became interested in the question of how to treat kids with obesity after learning about a movement in medicine to advocate for surgery in young people. As more and more evidence piled up of bariatric surgery’s effectiveness and health benefits, the movement was becoming mainstream, and I wanted to understand this argument.
Admittedly, I went into the stories thinking surgery was an extreme response to America’s national eating disorder and felt disturbed about the prospect of cutting kids open in an effort to address what is clearly an environmental problem. (As I wrote in the Times last month, our genes didn’t’ change in the last half century, when obesity rates exploded; our environment did.)
But then I had the pleasure of reporting on an exceptionally bright teenager before and after bariatric surgery. And my views changed. Following her for a year, I saw how the operation altered her eating habits – and her life. She lost a lot of weight, for the first time ever, and her modified anatomy smoothed a strained relationship with food. Post-surgery, she found it much easier to eat less and mealtimes were no longer stressful.
We’ve been in touch on and off in the years since, and last I heard, she got married, and pursued her dream of becoming a nurse. Five years ago, she had told me health work might not be possible for her because her weight made it difficult to walk. Now, she will contribute to society in a way she may not have been able to without the surgery.
Her experience mirrored the research I read on teen bariatric surgery. As I summarized for Vox:
Bariatric surgery patients live longer, and have a lower risk of cancer and lower rate of Type 2 diabetes. People who get the surgery also weigh significantly less, on average, compared to adults with obesity who don’t get the operation. The most common forms of bariatric surgery in America today, the gastric sleeve and gastric bypass, help people lose about 30 percent of their bodyweight and keep it off. That’s why Medicaid now covers the procedure in 46 states, as do national health systems in countries as diverse as Canada, Brazil, and Israel.
Several compelling longer-term studies have also shown that teens reap similar benefits as adults. Intervening with surgery earlier in life seems to help young people with obesity not only lose weight and resolve their chronic health woes — like diabetes and high cholesterol — but even prevent these conditions from developing in the first place.
Those bariatric surgery stories and studies revealed to me an important nuance: the treatment of obesity in individuals who presently have the condition should be considered separately from questions about prevention and obesity’s environmental causes. The new guidelines reflect a similar truth. They’re targeted at clinicians, focused on delivering the best medical care to patients, not at governments looking to prevent obesity in societies. And right now, the best medical care is surgery and medication, however uncomfortable that might make some people.
Certainly, in the best-case scenario, policymakers would immediately and radically address the root causes of childhood obesity, for example, by curtailing children’s exposure to junk food and making it easier for them to be active and eat healthfully. But until that happens, there are a lot of young people out there, like Jewel, who want and need help right now. A few years ago, bariatric surgery was the most effective option. Today, patients also have medications at their disposal (if they can afford them, of course).
I still would not wish an operation or even a drug on any child. Instead, I wish they never had to suffer in the first place. But I also understand that not everybody is that lucky. A lot of people are already struggling, and medical intervention might be their only way out.
That’s all for now. Thanks again for reading and as always, feel free to reach out any time.
All the best,
Julia
Ps. You can contact me here, or through my Twitter @juliaoftoronto, Mastodon @juliaoftoronto@masto.ai or Facebook profiles.