For the first time, The American Academy of Pediatrics (AAP) has created a clinical practice guideline on treating childhood obesity. The medical association recommends a proactive—and what some may consider aggressive—stance in treating the condition, saying that kids with obesity should be offered more intensive treatment options earlier that focus on the “whole child” and which may include nutrition and behavior therapy, weight loss drugs and even surgery for some.

The group is moving away from the “watchful waiting” approach that typically calls for delayed treatment when it comes to childhood obesity, which, after a comprehensive literature review, AAP says has no evidence behind it. 

“Waiting doesn’t work,” said Dr. Ihuoma Eneli, a co-author of the guidelines, to CBS News. “What we see is a continuation of weight gain and the likelihood that they’ll have [obesity] in adulthood.” 

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Instead, AAP is advising pediatricians to “offer treatment options early and at the highest available intensity,” which should include at least 26 hours of an intensive nutrition and lifestyle behavior program for the entire family and, when warranted, may include drug treatments in kids over 12 and, in some cases, surgery for kids over 13. 

Defined by AAP as a body mass index (BMI) at or above the 95th percentile for age and sex, childhood obesity is estimated to affect 14.4 million children and teens in the US. The new guidelines were created by a multidisciplinary group of experts in various fields, along with primary care providers and a family representative.

“The goal is to help patients make changes in lifestyle, behaviors or environment in a way that is sustainable and involves families in decision-making at every step of the way,” says Sandra Hassink, MD, an author of the guideline and vice chair of the Clinical Practice Guideline Subcommittee on Obesity, in a press release.

That said, treating obesity is not only complicated, but a complex social issue shrouded in stigma.

Obesity isn’t a lifestyle problem

The guidelines reflect a sea change in clinical thinking: that childhood overweight and obesity are not a result of a person’s lifestyle choices, but rather from social determinants of health (SDoH), environmental and genetic influences that impact children and families. 

They aim to erase the inaccurate picture of obesity as “a personal problem, maybe a failure of the person’s diligence,” said Dr. Sandra Hassink, medical director for the AAP Institute for Healthy Childhood weight, and a co-author of the guidelines, to CBS News.

Driving home this point to pediatric practitioners can only help, given the fact that doctors and clinicians have historically been–and remain—forces responsible for weight bias and stigma around obesity and overweight. “[Pediatricians and other pediatric healthcare providers] first need to uncover and address their own attitudes regarding children with obesity,” write the guideline authors, who go so far as to outline “supportive, nonstigmatizing communication strategies” for doctors to use to guide discussions about obesity with children, teens and families, in order to help reduce weight bias.

Related: ‘Don’t weigh me’ cards help empower patients at the doctor’s office

But the implications of telling kids—who are still growing and developing—that they need to change their body size, regardless of how the message is delivered, could have lasting negative consequences, as several eating disorder therapists attest

“Research shows that a history of dieting, body dissatisfaction and weight stigma are risk factors for eating disorders, particularly the earlier in life all of these things start,” Courtney Crisp, PsyD, an eating disorders therapist and researcher, shares with Motherly.

Treating childhood obesity is complex

According to established research, childhood obesity is understood to be a contributing factor to chronic health issues later in life, such as diabetes, high blood pressure, heart disease and liver conditions, in addition to having social and economic consequences.

Which is why the guidelines assert that “identification and treatment should begin as early as possible and continue longitudinally through childhood, adolescence, and young adulthood, with transition into adult care.”

It’s a tricky needle to thread, especially for families with young children, who may be concerned about assigning an obesity diagnosis from a young age and the long-term effects of doing so. 

Related: Eating disorders and tic disorders have increased dramatically among teen girls as a result of the pandemic, say CDC and AAP

Additionally, childhood obesity has been notoriously hard to treat, namely because the causes behind the condition are multifactorial, comprising everything from genetics, family dietary preferences, school environment, access to fresh food and policy factors like food marketing, just to list a few. For this reason, rudimentary recommendations on diet and exercise often don’t work because so many SDoH and systemic factors are at play. 

“Individuals exposed to adversity can have alterations in immunologic, metabolic, and epigenetic processes that increase risk for obesity by altering energy regulation,” write the guideline authors. They highlight that obesity does not affect all population groups equally. 

“These influences tend to be more prevalent among children who have experienced negative environmental and SDoHs, such as racism.” 

AAP childhood obesity guidelines promote intensive, family-centered therapy

AAP recommends at least three months (and up to 12) of intensive in-person coaching on nutrition, physical activity and behavior changes and lifestyle treatment for the family as a whole, starting for kids age 6 and older, but which may be used for kids as young as 2. Of course, this type of treatment is time-consuming, challenging to deliver and not widely available, which the group acknowledges. 

In addition to this intensive therapy, weight loss drugs or surgery may be considered for kids on an individual basis who may require additional support, according to AAP. But they’re not meant to be used on their own—they should always be included as part of a broader therapy plan. 

It’s hard not to worry about the long-term repercussions of those options. Some experts fear that the focus on bariatric surgery and weight loss medication in kids may be premature, given that kids still have years of growth ahead of them. Or they worry that those interventions may be used as a quick fix or bandaid by some practitioners when it’s the larger systemic problems that need rectifying for real change to occur. 

Though one class of injectable weight loss drugs, semaglutides, have been shown to be effective in promoting BMI reduction in kids and teens (the drug Wegovy was just approved by the FDA last month for kids age 12 and up), it’s important to note that placing kids and teens on these drugs not only opens them up to side effects like gallstones, but may mean they’ll need to stay on the medication for years to come—or risk gaining the weight back. Where will that leave kids then?

Insurance is also unlikely to cover the costs of the drugs, which can be around $1,300 per month, making accessibility an issue.

New guidelines focus on proactive treatment, but not prevention

The new clinical practice guidelines don’t touch on obesity prevention, saying that’s a subject for a forthcoming policy statement. The main takeaway? Essentially, not to delay treatment for childhood obesity, noting that a proactive approach incorporating the whole family is the best measure. 

Yet others worry that taking such a proactive approach could raise the risk of eating disorder development in kids. But the literature doesn’t support this theory, the guideline authors state. “Structured and professionally run pediatric obesity treatment is associated with reduced eating disorder prevalence, risk, and symptoms.” 

Related: 7 ways to help your kids form a healthy relationship with food

The structure and underlying principles of the intensive therapy program outlined “share multiple similarities with eating disorder programs. These include a focus on increasing healthful food consumption, participating in physical activity for enjoyment and self-care reasons, and improving overall self-esteem and self-concept,” authors write. 

Intuitive eating counselors assert that it comes down to the fact that these health-promoting behaviors, while helpful, should be uncoupled from the message to change one’s body size. That’s a key part in reducing weight stigma and body dissatisfaction.  

Ultimately, the guidelines provide access to more comprehensive tools and proven treatments for those who want them—and go well beyond fraught diet and exercise recommendations. 

“Weight is a sensitive topic for most of us, and children and teens are especially aware of the harsh and unfair stigma that comes with being affected by it,” said Sarah Hampl, MD, chair of the Clinical Practice Guideline Subcommittee on Obesity, in a press release

“Our kids need the medical support, understanding and resources we can provide within a treatment plan that involves the whole family,” said Dr. Hampl.