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Should childhood obesity be treated with drugs or surgery? What is obesity and how common is it? The terms overweight and obese are often used interchangeably, however, a medical definition of overweight is being in the top 15% of body mass index (BMI), and obese is being in the top 5%. BMI is calculated as weight in kilograms divided by height in meters squared. Obesity is a serious and increasingly common health problem for children and adolescents. In the late 1970s, 5% of U.S. pre-school age children 2-5 years of age were obese, by the year 2000 that proportion had increased to more than 10%. During the same period, obesity among adolescents aged 12-19, increased from 5% to 18%. In 2017-2020, 19.7% of U.S. children and adolescents aged 2 to 19 years were found to be obese as defined by being at or above the 95th percentile of BMI. Why does it matter? What causes obesity? Can childhood obesity be prevented or cured? Since the main cause of childhood obesity is an unhealthy lifestyle, intensive lifestyle therapy (ILT) is the first intervention recommended. Based on a recent review of evidence, the US Preventive Services Task Force (USPSTF) recommends that clinicians provide or refer children and adolescents aged 6 years or older with a high BMI (≥95th percentile for age and sex) to comprehensive, intensive behavioral interventions because they can promote weight loss in children and teens. However, since evidence shows that weight patterns develop early in life, there could be a benefit from starting interventions earlier than age 6 years. Intensive behavioral interventions need to involve the family (parents and children), include supervised physical activity sessions, information and advice about healthy eating and reading food labels, dietary monitoring, supervised physical activity, and help with self-monitoring and goal setting. To be effective these interventions often need to be intensive, long term and delivered by experts such as pediatricians, exercise physiologists, physical therapists, dietitians, psychologists, social workers, and behavioral health specialists. Higher-intensity behavioral interventions (at least 26 contact hours over 3 to 12 months and up to 1 year) are better than less intense interventions for promoting weight loss. The inclusion of physical activity sessions during behavioral intervention studies is associated with significantly greater reductions in BMI. A challenge for parents is that that insurance and other payers, public health agencies, and medical care institutions have not done enough to make these treatments widely available. Should overweight or obese children use drugs or surgery to lose weight? The USPSTF found that weight loss medications can help those with high BMI to lose weight with loss of about 5% and 10% of baseline weight or BMI. Several such drugs are approved by the FDA for use by children aged 12 or older: orlistat, liraglutide, semaglutide, and phentermine combined with topiramate. However, these drugs are not commonly prescribed for children and teens. They cause gastrointestinal side effects in up to 65% of users. Side effects are usually mild (e.g., nausea, diarrhea) and serious adverse events are rare. The drugs are also expensive and when discontinued weight often rebounds back toward previous levels. In 2023, the American Academy of Pediatrics (AAP) recommended: “Pediatricians and other pediatric health care providers should offer adolescents 12 years and older with obesity (BMI 95th percentile) weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.” However, the USPSTF concluded that the totality of evidence was not adequate to allow them to make a recommendation about use of GLP-1 drugs because information on possible harms from long-term use by children and teens was inadequate. The USPSTF did not review evidence for bariatric surgery, but it remains another important treatment for children and adolescents with severe obesity. The AAP recommends that clinicians identify adolescent bariatric centers nearby and offer referral for patients who meet eligibility criteria, to support patient education, autonomy, and shared decision making. This approach is supported by several professional recommendations, based on high-quality longitudinal safety A full consideration of the effects of bariatric surgery should be considered prior to any decision to undergo the procedure. In addition to the short-term risks and side effects of surgery, there are significant long-term problems. In addition to requiring a lifetime abnormal eating pattern of small meals they include:
Conclusion Since the main cause of obesity among both children and adults is an unhealthy lifestyle, the starting place for prevention and cure is intensive lifestyle therapy (ILT). The typical American diet is not healthy. It contains too much saturated fat, red meat, refined grains, sodium (salt), added sugars, processed food, and too many calories. Americans don’t eat enough fruit, vegetables, and whole unprocessed or minimally processed plant-based foods. Our unhealthy diet is an important reason that high blood cholesterol, elevated blood pressure, and obesity are common among children in the U.S. Most nutrition experts agree that a healthy diet eliminates all trans-fats, minimizes red meat and saturated fats, is low in sodium, added sugars and products made from refined grains, and avoids excess calories. There is also a consensus that a healthy pattern of nutrition includes high levels of consumption of whole unprocessed or minimally processed plant-based foods: legumes (legumes are beans, peas, lentils and more than 100 other edible plant foods), whole grains, fruits, and vegetables. These whole, mainly plant foods, provide high-quality carbohydrates and fiber. Highly processed foods high in fat sugar and salt and kid favorite foods such as pizza and hamburgers should not be on the menu. The other key element if the prevention and reversal of overweight and obesity is physical activity. Some structured community recreational programs for children have demonstrated efficacy and potential for weight loss maintenance. Among a group of adults who successfully lost weight and kept it off an hour a day of exercise was needed to keep from regaining weight. According to authors Kharofa, Crimmins, and Shah, writing in the Journal of the American Medical Association: “The time to prevent and intervene on childhood obesity is now, and the need to start with ILT is clear. However, it is critical to continue to optimize interventions for each patient. For many patients, ILT alone may not be enough to prevent serious outcomes. In these instances, pharmacotherapy and/or bariatric surgery may need to be considered to improve health outcomes in youth with obesity.” A higher priority and increased investments at the local, state, and federal levels is needed to provide the resources to make screening and effective behavioral interventions equitably available to all children and adolescents with obesity. A synergistic combination of effective clinical care, as recommended by the USPSTF, and public policy interventions is critically needed to turn the tide on childhood obesity. References:
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