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Aggressive treatment guidelines for childhood obesity getting backlash

But experts say that the old approach of ‘watchful waiting’ often failed and that many children developed lifelong health issues

Adolescents participate in physical education at Nitschmann Middle School in Bethlehem, Pa., in 2020. (Katherine Frey/The Washington Post)

Within hours of the release of new treatment guidelines for childhood obesity last week, Mary Savoye’s inbox began to fill up with haranguing emails.

The American Academy of Pediatrics guidelines, based on decades of scientific research, including hers at Yale New Haven Children’s Hospital, call for early and aggressive treatment, instead of “watchful waiting.” They urge intensive therapy for children as young as 6, weight loss drugs for those as young as 12 and surgery for teens as young as 13.

Savoye had been hopeful the information would help drive home the reality of obesity as a chronic medical condition, rather than just a consequence of lifestyle choices. Instead, she found her work caught up in the latest culture-war front over fat.

Critics on the left have raised concerns about unequal access to treatment, which insurance does not always cover, and worry that earlier medical interventions may create more fat-shaming of vulnerable children. Conservative commentators have suggested that the guidelines offer an easy out for poor lifestyle choices. People on both sides express uneasiness about the potential long-term consequences of putting millions of children on drugs or under the knife, instead of doing more to prevent the condition in the first place.

“Turning to surgery and pills is quintessentially American,” said Arthur Caplan, a bioethicist at the NYU Grossman School of Medicine who said he struggles with weight himself. Caplan called obesity “one of the biggest moral challenges” our society faces but described medication and surgery as just “Band-Aids in a society that can’t figure out what to really do to protect the interests of its kids.”

What you need to know about the new childhood obesity guidelines

Brian Castrucci, head of the de Beaumont Foundation, a nonprofit involved in public health, also has concerns. He said it’s “unfortunate” that the guidelines’ authors “focus on what individual patients need to do, instead of the policies and environments that can produce better health.”

But he said the same people who have spread misinformation about the coronavirus, vaccines and masking are twisting the debate over obesity — creating confusion that endangers children by preventing families from making informed decisions based on facts.

In recent days, for instance, Twitter and Facebook have been rife with false suggestions that the guidelines ignore the harms of junk food. In fact, they continue to recommend lifestyle modifications, in addition to the consideration of medication or surgery.

Commentators also took issue with how the guidelines had a section about obesity being associated with “racism experienced in everyday life.” Numerous studies have shown the link between structural racism and weight — such as how stores in poor, minority areas tend to stock more highly processed foods and fewer fruits and vegetables, as well as the lack of access to suitable outdoor areas to exercise and fewer youth sports programs in some communities.

“This is all part of the erosion and attack on science,” Castrucci said, “and now that attack is starting to move beyond covid.”

Savoye acknowledges that there is legitimate debate about the right approach to combating a problem that has root causes related to food marketing, the environment, genetics, racism, access to insurance, and many other aspects of science and society. But she said that when she saw some of the misleading commentary, “actually, I got angry.”

“I thought, ‘Oh, my gosh. It was ignorance,’” she said. “They took one or two pieces of the truth and changed it.”

Childhood obesity has been recognized as one of the nation’s greatest public health challenges, with rates tripling over the past three decades. The Centers for Disease Control and Prevention estimates that about 1 in 5 children and adolescents are affected. That’s about 14.7 million children, or almost 20 percent of all those ages 2 to 19.

Savoye said many people do not understand that there is a narrow window in which doctors can intervene to prevent a child from developing severe, lifelong health issues related to excess weight. At the obesity clinic at Yale New Haven, where she is associate director, she has seen 10-year-olds with fatty liver disease as well as 12- and 13-year-olds with diabetes related to their obesity whose conditions could be prevented with medications or surgery.

“Childhood obesity is not simple,” Savoye said. “People think you just need to teach people to stop eating so much. But it’s so much more complex than that.”

The war over fat

The last time the American Academy of Pediatrics weighed in on obesity, in 2007, it was not even recognized as a medical condition. Since then, there has been a change in public attitudes about the different shapes and sizes that people come in, with catchphrases such as body positivity, fat acceptance and fat pride becoming popular.

Lululemon, the athleisure pioneer famous for its $100-plus yoga pants, has begun regularly featuring plus-size models. When Taylor Swift recently chose to label her demon “FAT” in a video for her song “anti-hero,” fans protested and she edited the word out. In October, Disney released its first movie featuring a plus-size heroine, a ballerina, struggling with body image.

But at the same time, there has been a blurring of the difference between carrying a few extra pounds and being morbidly overweight — and the big potential health consequences of the latter. Obesity has been associated with heart attacks, stroke, high cholesterol, Type 2 diabetes and musculoskeletal disorders, among other conditions — all of which can lead to early death or disability.

Some argue that minimizing those potential health consequences to promote self-acceptance is simply wrong.

Obesity is defined as excessive fat accumulation that presents a risk to health. A body mass index (BMI) over 30 — that is, a person’s weight in kilograms divided by the square of height in meters — is considered obese. Using that measure and adjusting for the conversion to pounds and feet, an adult man who is 5-foot-9 would be considered at a healthy weight between 125 to 168 pounds, overweight at 169 to 202 pounds, and obese at 203 pounds or more, according to the CDC.

The type of excess weight can create havoc on all sorts of body systems, and children are especially vulnerable given their rate of growth and the swirl of hormones during adolescence.

Grace Kim, an endocrinologist at Seattle Children’s Hospital, explained that for obese adults, it can take a decade or longer to progress from prediabetes to diabetes. In children, that can happen as quickly as two years, she said. Diabetes is a condition involving how the body processes sugar that can destroy the heart, kidney, nerves and vision.

“If you are a kid who was diagnosed at 13, that means that by the time you are in your 20s, you may already be experiencing complications. And that is scary,” Kim said.

Shane Stephenson, a public school teacher in New Haven, Conn., said his health problems are a testament to why more aggressive approaches are necessary. He said he first saw a specialist at 15, but the prescribed dietary changes and physical activity did not help him shed weight.

“They did not want me to go to medication right away,” he said. He remembers having to leave class early in high school, as he struggled to make it down the hall, and seeing the nurse constantly to get his blood pressure taken.

By the time he was 19, he was 5-foot-9 and 338 pounds, with Type 2 diabetes. A little over a year ago, at age 20, he finally started Ozempic, part of a new generation of drugs found to be remarkably effective for weight loss, and has lost over 100 pounds. While most of his bloodwork has bounced back to healthy levels, he has noticed numbness and tingling in his extremities, which his doctors worry is a sign of permanent damage from diabetes.

“When I was losing weight, I was like, ‘The war is over.’ Well, the war is not won completely,” he said.

Treating obesity

With the recognition of obesity as a complex disease with many causes, there has been a proliferation of multidisciplinary pediatric centers around the country. They often include endocrinologists, hepatologists, surgeons, social workers, psychologists, fitness experts, nutritionists and more.

The old approach, which was in place until early this week, involved a focus on healthy lifestyle behavioral training. But Matt Haemer, an obesity specialist at Children’s Hospital Colorado, said that the data shows this did not work and that 80 to 90 percent of cases persisted until adulthood.

“There were real medical harms and quality-of-life harms for something we could effectively treat,” he said.

“One of the things we know for sure is that as children with obesity get older, they get bigger and bigger and sicker and sicker, and their medical problems get worse,” agreed Ann O’Connor, a surgeon at the Children’s Hospital of San Antonio.

Weight-loss surgery is now much simpler and safer than it once was. It typically involves a procedure called a sleeve gastrectomy, in which a small incision is made to remove about 85 percent of the stomach, reducing how much food a person needs to feel full. Patients usually spend one or two days in the hospital.

Physicians and public health experts say the new guidelines are just part of a larger conversation that needs to take place about how to combat obesity. Many worry a lot about equitable access to the treatments, with insurance coverage a major question.

Medicaid in most states will cover surgery for obesity, but coverage varies for medications, which can cost $1,000 to $1,300 a month, and for behavioral interventions that the guidelines say should encompass 26 hours of therapy within a year. Private insurers are also hit or miss when it comes to reimbursement.

Fatima Cody Stanford, a physician at Massachusetts General Hospital specializing in obesity and associate professor at Harvard Medical School, said there are a lot of social determinants of health, such as housing security and food security, that need to be addressed as well.

Stanford said studies show that Black girls and boys are less likely to get treatment than children of other races, despite having higher rates of the disease. Even those covered by Medicaid are less likely to be treated.

“We find biases in who gets referred. If you don’t get the diagnosis, you don’t get the treatment,” she said.

Susan Woolford, a child obesity expert and pediatrician at the University of Michigan’s C.S. Mott Children’s Hospital, said that while she’s pleased with the guidelines, she agrees there is much more to do.

“We can all, as a society, realize we have a role to play in reducing the stigma around childhood obesity and helping to change many of the factors that lead to excess weight so that we can help this generation of young people grow up with better health,” she said.

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