Early interventions are best for kids with obesity. Expert discusses new clinical guidelines

One-fifth of U.S. kids have obesity, and many have related conditions such as high blood pressure, type 2 diabetes and high cholesterol. Last week, the American Academy of Pediatrics released the first new clinical guidance in 15 years for treating obesity and overweight in children. We spoke with UCSF experts about their takeaways on the guidance.

What is new and noteworthy in these guidelines?

Beck: Previous guidance was three-step: the primary care provider starts by counseling on diet and physical activity changes and sees how it goes, then steps up to a detailed nutrition plan if needed, then recommends an intensive lifestyle program if needed. The new advice is to go right to that intensive program and aim for 26 hours of provider contact over 3–12 months. The challenge, and the guidelines say this, is that there are far too few programs like this.

Schillinger: What also stuck out to me was the very comprehensive way the guidelines outlined how obesity is driven by multiple factors beyond an individual's choice, such as lack of access to healthy food and physical activity environments. And how clinicians need to accommodate and adapt their approach to the realities that families face.

Recent media coverage emphasized guidance about medications and surgery. Was there a big change there?

Beck: Since the last recommendations, we have a lot more data on the safety and outcomes of bariatric surgery in adolescents with severe obesity. It's very compelling, and the impact that we see with surgery compared to lifestyle intervention or even medication is huge. We've seen advances in medication as well, including Wegovy resulting in 16% weight loss. Again, there is no lifestyle intervention that can touch that.

Should more children go straight to medication or surgery because it's so effective?

Beck: First of all, as a general rule, medication shouldn't start until at least age 12, and it's age 13 for surgery. And that is for adolescents with severe obesity who have already attempted lifestyle changes but who are continuing to gain weight, or whose comorbidities aren't resolving.

Tinajero-Deck: Medications and surgery are not a magic bullet; you need to make those other lifestyle changes too or the weight will come back. At the same time, there are children in their early teens who are morbidly obese and really sick, and they shouldn't have to wait to get healthy. They need access to surgery, and that can be hard to get, especially for patients on Medi-Cal.

What advice do you give parents of children with obesity?

Beck: Support your child emotionally and ask if they are being bullied, since anxiety and depression are common with obesity. Make the home food environment as healthy as you can: no sugary beverages, fewer processed foods, smaller portion sizes. Do physical activity together as a family. Praise your child when they engage in healthy behaviors. Don't comment on your child's weight or allow others to do so and avoid commenting on your own weight. Focus on health—explain that the changes you are making are for health reasons (not weight).

What obstacles do families, especially vulnerable populations, face in making changes around food and activity?

Tinajero-Deck: I met this wonderful grandmother who said, "I know what you are going to tell me to do. Before you start, I want you to tell me if you can help me find and pay for all the healthy food I need in my refrigerator at the end of the day. Will you help me find the time to cook it, and to get these children to eat it? Will you help me secure a safe place outside for these kids to play, because someone died of a gunshot in that park across the street last week?" That summed up a lot of it.

Schillinger: It is the high cost of health foods and the low cost of ultra-processed and junk foods, and predatory marketing to children, especially children of color. It's the way junk food is concentrated in areas that are already under-resourced and the healthy food is elsewhere. It is a legal environment that makes it impossible to regulate junk food industries. Because obesity, at its core, is a societal problem that has become medicalized.

For patients, what can clinicians do to make the lifestyle part of the guidelines more attainable?

Beck: Make it easier to participate. Many parents work, so my clinic's hours start at 4 p.m., and we offer physical activity on Monday evenings and Saturday mornings to increase participation. Also, we keep on top of community programs and provide support and case management to connect families to physical activity programs and food resources. We also partner with other organizations that serve children, such as SF Parks and Rec.

Tinajero-Deck: At our clinic, we hold a weekly food pharmacy where we get healthy food from the county food bank and give it to patients. One model that was successful in Seattle was a physician literally led an after-school program where kids would come every day, learn about healthy eating and do activities. On a national level, we need something like Head Start, but for after-school programs focused on health.