A Pediatrician’s Response to the AAP Guidelines on the Treatment of Pediatric Obesity

Written by: Emily Russo, MS, RD, CDN

The American Academy of Pediatrics recently published its first ever set of guidelines for the treatment of obesity in children, and the recommendations have received a lot of media attention – both good and bad. We asked local pediatrician, Dr. Pia Fenimore, how she felt about the document (over 100 pages!), and she graciously shared her insight!

The American Academy of Pediatrics recently published its first ever set of guidelines for the treatment of obesity in children, and the recommendations have received a lot of media attention – both good and bad. We asked local pediatrician, Dr. Pia Fenimore, how she felt about the document (over 100 pages!), and she graciously shared her insight.

There has been significant media attention, including public criticism of the inaugural guidelines for pediatric obesity. Many have likely seen the news coverage, and those who subscribe to our local newspaper may have read an article authored by area pediatrician, Dr. Pia Fenimore. She outlined the purpose of the guidelines and the impact they will likely have on an individual and community-wide level. 

I felt compelled to further explore with her the more critical side of the guidelines, and I appreciate the time and thought Dr. Fenimore took in addressing these questions and concerns (noted in bold below). There are certainly no easy answers, and no right way to approach every situation or every patient, but asking the hard questions tends to deepen our understanding of more complex issues.

As always, we welcome your questions in the comments section below, and I am also happy to share my insight as a dietitian. We approach these issues from different life perspectives, and perspective frames how we interpret things. This will certainly be an ongoing conversation, and we hope you will be a part of it!

The first AAP guidelines for the treatment of obesity in children have received both good and bad media attention. Read more to find out why!

How often do pediatricians consult the AAP guidelines generally in daily practice? 
Mostly we use guidelines when it comes to specific disease entities such as asthma, jaundice or bronchiolitis.  The simple act of putting out guidelines for pediatric obesity is a good move on AAP’s part because it ends the misconception that obesity is simply a behavioral problem and moves it strictly into the disease category.  

Why have these guidelines garnered so much attention?
Well probably the major reason is that there is a small part of the guidelines that support the further research and ultimately use of medication and surgery to address this problem.  

But I hope they are also getting attention because of the way they very firmly pointed out that the pediatric obesity “epidemic” is a medical problem predominantly caused by poverty (with undercurrents of racism, stigma, and lack of pediatric advocacy).  

Will these new guidelines be impacting day-to-day treatment of patients? If so, how?
Unlikely that it will impact day to day since some of the basic recommendations are already in place (monitor balance between growth and weight gain starting at age 2, account for family history, use family centered care, screen for co-morbidities etc).  Where we are all hoping it makes impact is in the advocacy realm, in the bias/stigma arena, and in the support for future treatments area as well.

How will the guidelines shape policy change going forward, specifically in relation to issues of food insecurity and under-resourced communities?
These guidelines can be used in many ways to shape decisions that affect under resourced communities.  Since awareness is always the first step towards change this hopefully will empower pediatricians, lawmakers etc. to take steps towards making real changes on food sourcing, green space, school nutrition, etc.

How is BMI used to determine intervention (low, normal, or obese), and what interventions are recommended based on it?
Most of us use BMI as only one consideration of the health of the child as a whole.  Many things can affect BMI and it is not a perfect measure so we always take into consideration growth rate, nutrition, exercise, conditioning, and family history. 

What does it mean to have a non-stigmatizing conversation about weight with children and/or their families?
First and foremost it means having the conversation when they are ready to have it, and in a place, with a person that they want to have it with.  It means coming at it from an overall health and wellness approach, a prevention approach, and an understanding of the obstacles, many beyond control, that are blocking change.

Is there a downside to promoting intentional weight loss, or slowed growth, in children? 
Weight loss can be a result of interventions but should never be the promotional part of the goal… it should focus on health.  Growth to me is the balance between linear height and muscle/adipose/bone gain, promoting that balance with a compassion and sensitivity to all its challenges is not wrong.

The guidelines suggest one of the strategies in the treatment of eating disorders (using CBT) is a good model for obesity care – why is that?
Some might argue that the document speaks out of both sides of its mouth with this recommendation by spending so much time saying this is a medical problem but then recommending behavioral interventions such as CBT.  But I think it requires deeper thinking.

Part of the disease of obesity is that the person loses the ability to self regulate based on body cues such as satiety, etc.  This loss is a physiological one with genetics playing a role, but it is also behavioral rooted in food insecurity.  Cognitive Behavioral Therapy teaches us to be aware of our body and our brain and the way the two interact.  This can help a person to actually feel the benefits of proper nutrition both physically and mentally.

The guidelines support intensive counseling programs for children with obesity (26+ hours over a few months to a year), using research studies that show a modest improvement of 1% to 3% BMI percentile decline. Is 1-3% impactful (that’s like going from a BMI of 40 to 39)? If not, what is the goal? And are programs like this accessible and available in the community?While 1-3% seems low if you have achieved improvement in other health (physical and mental) aspects then it is worth it.  Furthermore, intensive counseling really is needed since so many kids with overweight or obesity are also dealing with depression, anxiety, or other mental health disorders it goes without saying that we need to give them that support.  

Counseling also has been shown to be effective in decreasing the effects of ACEs (adverse childhood events) which are shown to coincide with pediatric obesity so I do not think, despite low BMI changes, that you can go wrong by making counseling part of the treatment approach.

Accessible in the community… NO they are not.  And they are certainly not accessible in the underserved community.  This is everywhere, not specifically our community.  And that is the most frustrating thing about the guidelines. The main treatment approach: a multi discipline team of counseling, education, dietitian, and food/housing/community support is sometimes available piecemeal but it is up to the pediatrician and the parents to coordinate it and find it.

At what point should bariatric surgery be recommended for a child?
My personal opinion is that as a child nears adulthood there is a certain time when you see obesity cross into serious health problems such as pre diabetes, arthritis, apnea, hypertension, etc.  

When other interventions have failed to slow down the progression of these co-morbidities then medication and surgery should be considered.  Will there come a time that we may consider them even earlier than that (such as before those things happen…) … maybe… but I do not think we have the knowledge or resources yet for that.

Novo Nordisk just announced Wegovy lowered their safety age range from 18 to 12 years old (which will increase profits by billions), several other pharma are major donors to the AAP itself, and almost all of the writers of these guidelines are involved with Novo, so what kind of impact does this conflict of interest have on the new guidelines?
Pediatricians as a whole have a legacy of being protected and immune to pharma bias.  We have never been and certainly are not now for sale on any issue.  Medication is a very very small part of the guidelines and all potential medications are given equal voice (and by voice I mean the guidelines summarize current research, practice, and availability).  

Safety age ranges are lowered based on research and need: not profit.   Pediatricians do not prescribe medications as proliferatively as adult physicians, we never treat our patients as mini adults, and we always look for the safest alternative to addressing a medical need, I do not expect that this will change that.


💛 Thank you to Dr. Pia Fenimore for sharing her responses to these questions. I know we both hope this will spark conversation and dialogue around these issues, because it’s all about collaboration for best patient care. 



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