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Opinion The Checkup With Dr. Wen: The new guidelines for childhood obesity are crucial

(Patrick Sison/AP)
9 min

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This month, the American Academy of Pediatrics (AAP) revised its guidelines on childhood obesity to fundamentally shift how we treat the condition. Instead of monitoring and watchful waiting, the nation’s leading pediatrician group is recommending early and proactive treatment. This change is overdue and crucial.

Children with obesity are four times more likely to develop Type 2 diabetes and twice as likely to die from heart disease. They are also at increased risk of hypertension, depression and early arthritis. Treatment exists, and early diagnosis and intervention can prevent these adverse outcomes.

In the United States, more than 14 million children — nearly 1 in 5 of those under 18 — have obesity. Obesity itself is a considered a chronic disease and is the second-leading cause of preventable death after tobacco use. It’s also a major risk factor that predisposes individuals to a large array of other serious health problems.

According to the AAP’s extensive review of existing research, the most effective initial intervention is intense behavioral modification to change nutrition, physical activity and other lifestyle factors. This is recommended for children 6 years and older considered to be overweight (defined as body mass index between 85th and 94th percentile) or to have obesity (BMI at or above 95th percentile). In some cases, intervention could begin for families with kids as young as 2 years old.

The next step beyond behavioral modification is medical treatment. For the first time, AAP is recommending doctors to consider weight-loss medications for adolescents 12 and above with obesity. Those 13 and above with severe obesity might be evaluated for bariatric surgery.

The guidelines acknowledge that obesity is complex and that there are many contributing factors, including genetics, socioeconomic resources and food environments that facilitate unhealthy diets with sugary sodas and ultra-processed food. Regardless of the cause, however, the end result is a disease that has staggering consequences.

The guidelines are not without controversy. Some are concerned they could increase stigma and “fat-shaming.” To be sure, pediatricians must approach children and families with empathy and sensitivity. According to the AAP, research shows that when administered by trained professionals with active family involvement, behavioral interventions have “no evidence of harm and can result in less disordered eating.”

In my view, medicalizing obesity is key to reducing stigma. If obesity is seen solely as choice, then patients are blamed for their illness.

On the other hand, if it is seen as the consequence of multiple factors for which a combination of lifestyle modification and medical treatments are needed, obesity can be regarded just as we do other chronic illnesses such as diabetes or heart disease. The AAP guidance reinforces this point and emphasizes the importance of insurance coverage for obesity treatment. Insurance plans often restrict such coverage to patients unless they are also being treated for another disease. That needs to change.

This leads me to my only significant criticism of the AAP guidelines, which is that they will be difficult to implement on a population level. The recommended behavioral modifications demands considerable time with patients. The most effective treatments requiring 26 or more hours of face-to-face contact with a multidisciplinary team of providers over a three- to 12-month period.

That’s a huge time commitment for parents and other caregivers who are working full-time jobs, and that’s assuming they are able to obtain this type of multi-specialty treatment and have it paid for by their insurance.

It’s unrealistic to expect that this gold-standard care will become widely available anytime soon. And many families might struggle with the recommendations because they lack access to affordable healthy food and safe places to exercise. The obesity epidemic is a societal crisis that requires major policy changes.

Still, I think the AAP’s new stance is a much-needed reminder of the lifelong consequences of obesity and the need to address it in childhood. As with other chronic diseases, the message should be unequivocal: Don’t wait to start managing a serious medical condition when there is evidence-based and effective treatment.

Ask Dr. Wen

Newsletter subscribers are invited to submit questions to Dr. Wen. Not a subscriber yet? Click here to sign up.

“I’m a healthy 44-year-old woman who has never had covid, and I’m wondering what my odds are of getting it this year (or ever?). I’m a high school teacher, so I have 60 to 95 students through my classroom per day, but I wear a surgical mask at all times and don’t eat lunch with others. I also mask in other public places such as the grocery store. I’m up to date on all my vaccinations. Many of my students over the past year and a half of in-person school have been sick with covid, but weekly testing shows that I haven’t been infected. My brother’s wife and three kids all had covid last year, but he never got it. Is it possible that he and I are immune? Or am I just cautious and lucky?” — Meredith from California

There are some people who have not contracted covid-19 because they have taken many precautions. There are others who may have a genetic marker that makes them more immune to the coronavirus. Then there are those aren’t aware that they have had covid.

This last group is probably the largest. A recent study from the Centers for Disease Control and Prevention found that about 44 percent of people who think they never had covid actually did. Perhaps they remained asymptomatic or their symptoms were very mild. It’s also possible that a rapid antigen or PCR test missed their diagnosis if they took it before they had a sufficient viral load.

If you want to find out whether you have contracted covid, you could consider taking a specific antibody test. The SARS-CoV-2 nucleocapsid antibody test will specifically look for prior infection. The test does not detect antibodies produced by the vaccines. You can ask your health-care provider to order it (it’s available at standard laboratories such as Quest and Labcorp).

“My wife and I are over 70 and have had all the vaccines and boosters, including the bivalent. We also have never tested positive for covid. We attend live theater performances three or four times per week and are grateful that the theaters have reopened. Most of the larger theaters require patrons to be masked while in the theater. Recently, we were at one of the smaller houses. They do not require masking any more, and when we sat down, we found we were surrounded by unmasked patrons. Indeed, almost all of the patrons were unmasked. There were no seats we could have switched to where we would have been somewhat distanced or surrounded by masked patrons. Although we were wearing KN95 masks, we decided to leave before the play started because of concerns about the lack of masking. Were we overreacting?” — Tom from Maryland

If your KN95 masks fit you well and you keep it on the entire time during the performance, the risk of contracting covid-19 is very low. Health-care workers treating covid patients are wearing masks like yours and are able to protect themselves that way, even when in close proximity with individuals who have high viral loads and are actively shedding virus.

That said, other factors can reduce risk, too, including going to a theater that is larger, with better spacing and good ventilation. And if other patrons are wearing high-quality masks, that reduces your risk.

“We have a 9-year-old son. No one in our household has any underlying medical condition of note. Given it’s important for kids to develop immunity through exposure to various viruses out in the world, unless and until there is an elevated presence of covid in our area, we have decided it is generally better for our son not to wear a mask when out and about. What are your thoughts?” – Mark from NY

I am doing the same as you with my children, ages 5 and 2. For nearly two years, they rarely had runny noses or coughs because of masks, distancing and other mitigation measures that kept covid and other viruses are bay. Then, after they went back to school without masks in September, they’ve had several rounds of viral infections.

This was the norm before covid and will be going forward, too. For us, and probably for most parents, it’s not a long-term strategy to shield our kids against all viruses.

The Post has also compiled Q&As from my previous newsletters. You can read them here.

What I’m reading

A large study in Portugal, published in Lancet Infectious Diseases, provides further reassurance that hybrid immunity conveys strong protection against covid. Researchers examined a national registry with more than 9.3 million vaccinated people ages 12 years and older. Those with prior infection as well as vaccination were 90 percent protected against reinfection. This fell to about 70 percent after five months and appeared to stabilize at around 65 percent at eight months. This level of protection was between three to four times higher compared to individuals who were vaccinated but had not contracted covid.

Pfizer’s bivalent vaccine is effective in children 5- to 11-years old, according to a new South Korean study in JAMA Pediatrics. Researchers evaluated vaccine effectiveness during the time of omicron dominance, and found that protection with the Pfizer vaccine was 58 percent after 15 days, 50 percent after 31 days and 41 percent after 61 days. Importantly, there was 100 percent protection against critical illness for 90 days.

A study in JAMA Health Forum shows that the expansion of mental health services via telemedicine more than offset the reduction of in-person care during the first year of the pandemic. In 2020, the use of in-person services declined by more than 50 percent. But telehealth utilization climbed 16- to 20-fold, with the highest increase among those presenting for anxiety disorders. This study underscores the huge unmet need for mental health care pre-covid and the potential of telemedicine to expand access.