President's Message, January 2023
Mary Ann Rigas, MD, FAAP
Dear Fellow PA AAP Member,
I saw one of my favorite patients in the office this week. I first met Max as an active three-year-old child running around the exam room. At the time, his BMI was 98% for age, and his mom reported that Max had food on his mind all the time. Over the intervening 12 years, Max’s BMI increased steadily, and now that he is 15, has reached 129% of the 95% for age. Max loves football, but he also loves video games, and, especially, food. Max’s blood pressure has been in the stage I hypertension range for the past year, his fasting glucose and hemoglobin A1C are in the prediabetes range, and a recent sleep study confirmed sleep apnea.
Each year, I counsel Max and his mom on the importance of healthy food and beverage choices, as well as regular exercise. Despite this counseling, Max’s BMI has continued to increase year after year, and I have felt powerless to help. Max’s mom has reported that he is obsessed with food, and that she has a hard time saying “no” to him when he begs her for more. Mom herself was overweight as a child; she knows how it feels to be bullied about her weight and does not want to make Max feel bad about himself or his body.
We used to think that we could treat childhood obesity by matching calories in with calories out, allowing a few extra calories for growth. We assumed that obesity was the result of decisions that a child or family made, and that it was a lifestyle issue that could be reversed through diet and exercise. In Pennsylvania, our school nurses measure children’s BMI each year and send letters home to parents, advising them to consult their children’s health care providers if their BMI is over 85% for age.
During a plenary session at AAP’s National Conference and Exhibition this past fall, Dr. Joseph Skelton challenged us to change our way of thinking about childhood obesity. Rather than regarding obesity as a lifestyle choice, Dr. Skelton proposed that we regard obesity as a multi-causal disease with many negative health consequences that deserves to be treated in the same way that we treat other serious diseases. He also encouraged us to promote self-acceptance in our patients regardless of their weight, and to acknowledge our own explicit and implicit biases towards our overweight patients as the first step in eliminating weight-based discrimination in our practice of pediatrics.
During his session, Dr. Skelton reviewed the growing body of evidence demonstrating that childhood obesity is a complex chronic condition that is strongly influenced by genetics, physiology, and one’s environment, including the social determinants of health. He pointed out that genetic control of weight ranges from 40% up to as high as 80% in some severely obese children. He described short- and long-term feedback mechanisms that occur when someone loses weight to drive their weight back to what it was before the weight loss, including a decrease in energy expenditure related to loss of muscle mass and an increased drive to consume more calories. Finally, Dr. Skelton pointed out that environmental factors such as food insecurity, food deserts, and the need to rely heavily on cars for transportation can contribute significantly to the chance that a child becomes obese.
This past week, the AAP released its first clinical practice guideline on the evaluation and treatment of pediatric obesity (Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity | Pediatrics | American Academy of Pediatrics (aap.org). It highlights evidence-based approaches that pediatricians can use to treat children safely and effectively. The evaluation section emphasizes taking a “whole child” approach using supportive, non-stigmatizing communication strategies to guide discussions about obesity with children, adolescents, and families. In addition to obtaining a thorough medical history and performing a complete physical exam, the guideline recommends assessment of social determinants of health, mental health, disordered eating, and readiness for change.
What struck me as most game-changing about the clinical guideline was its recommendation to treat obesity early and intensively. For years, I have encouraged my overweight patients and families to make lifestyle changes, but in most cases, I do not see weight decreasing for these patients from year to year. The new clinical practice guideline for obesity states explicitly that there is no evidence to support a watchful waiting approach. Instead, we should use motivational interviewing and a focus on the outcome of improved health rather than weight loss to steer our patients and families into intensive health behavior and lifestyle treatment programs if available. We can also refer them to whatever resources are available locally, including registered dietitian nutritionists, behavioral health and exercise professionals, and community programs. Reassuringly, the evidence shows that participation in structured, behaviorally-based programs is protective against the development of disordered eating, in contrast to self-dieting, which increases the risk of eating disorders. In addition, we should become educated on the indications for and prescription of new and promising weight loss medications and refer adolescents with severe obesity for metabolic and bariatric surgery.
Finally, the guideline reminds us that treating obesity includes treating its comorbidities, recognizing that these comorbidities play a significant role in the long-term health and wellbeing of our patients. Studies have shown that people with obesity do not receive the same medical care as people without obesity, and it is our job to change that. As for Max, I could choose to refer him to specialists for treatment of his hypertension, sleep apnea, and prediabetes. Alternatively, I could opt to become educated on how to treat these conditions and prescribe weight loss medications myself to make treatment more accessible to him and my other patients with obesity.
Change is always hard, especially for those of us who practice far from the support of academic medical centers, but these changes have the potential to drastically improve the health and wellbeing of so many of our patients, to whom we owe our very best efforts!
Sincerely,
I saw one of my favorite patients in the office this week. I first met Max as an active three-year-old child running around the exam room. At the time, his BMI was 98% for age, and his mom reported that Max had food on his mind all the time. Over the intervening 12 years, Max’s BMI increased steadily, and now that he is 15, has reached 129% of the 95% for age. Max loves football, but he also loves video games, and, especially, food. Max’s blood pressure has been in the stage I hypertension range for the past year, his fasting glucose and hemoglobin A1C are in the prediabetes range, and a recent sleep study confirmed sleep apnea.
Each year, I counsel Max and his mom on the importance of healthy food and beverage choices, as well as regular exercise. Despite this counseling, Max’s BMI has continued to increase year after year, and I have felt powerless to help. Max’s mom has reported that he is obsessed with food, and that she has a hard time saying “no” to him when he begs her for more. Mom herself was overweight as a child; she knows how it feels to be bullied about her weight and does not want to make Max feel bad about himself or his body.
We used to think that we could treat childhood obesity by matching calories in with calories out, allowing a few extra calories for growth. We assumed that obesity was the result of decisions that a child or family made, and that it was a lifestyle issue that could be reversed through diet and exercise. In Pennsylvania, our school nurses measure children’s BMI each year and send letters home to parents, advising them to consult their children’s health care providers if their BMI is over 85% for age.
During a plenary session at AAP’s National Conference and Exhibition this past fall, Dr. Joseph Skelton challenged us to change our way of thinking about childhood obesity. Rather than regarding obesity as a lifestyle choice, Dr. Skelton proposed that we regard obesity as a multi-causal disease with many negative health consequences that deserves to be treated in the same way that we treat other serious diseases. He also encouraged us to promote self-acceptance in our patients regardless of their weight, and to acknowledge our own explicit and implicit biases towards our overweight patients as the first step in eliminating weight-based discrimination in our practice of pediatrics.
During his session, Dr. Skelton reviewed the growing body of evidence demonstrating that childhood obesity is a complex chronic condition that is strongly influenced by genetics, physiology, and one’s environment, including the social determinants of health. He pointed out that genetic control of weight ranges from 40% up to as high as 80% in some severely obese children. He described short- and long-term feedback mechanisms that occur when someone loses weight to drive their weight back to what it was before the weight loss, including a decrease in energy expenditure related to loss of muscle mass and an increased drive to consume more calories. Finally, Dr. Skelton pointed out that environmental factors such as food insecurity, food deserts, and the need to rely heavily on cars for transportation can contribute significantly to the chance that a child becomes obese.
This past week, the AAP released its first clinical practice guideline on the evaluation and treatment of pediatric obesity (Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity | Pediatrics | American Academy of Pediatrics (aap.org). It highlights evidence-based approaches that pediatricians can use to treat children safely and effectively. The evaluation section emphasizes taking a “whole child” approach using supportive, non-stigmatizing communication strategies to guide discussions about obesity with children, adolescents, and families. In addition to obtaining a thorough medical history and performing a complete physical exam, the guideline recommends assessment of social determinants of health, mental health, disordered eating, and readiness for change.
What struck me as most game-changing about the clinical guideline was its recommendation to treat obesity early and intensively. For years, I have encouraged my overweight patients and families to make lifestyle changes, but in most cases, I do not see weight decreasing for these patients from year to year. The new clinical practice guideline for obesity states explicitly that there is no evidence to support a watchful waiting approach. Instead, we should use motivational interviewing and a focus on the outcome of improved health rather than weight loss to steer our patients and families into intensive health behavior and lifestyle treatment programs if available. We can also refer them to whatever resources are available locally, including registered dietitian nutritionists, behavioral health and exercise professionals, and community programs. Reassuringly, the evidence shows that participation in structured, behaviorally-based programs is protective against the development of disordered eating, in contrast to self-dieting, which increases the risk of eating disorders. In addition, we should become educated on the indications for and prescription of new and promising weight loss medications and refer adolescents with severe obesity for metabolic and bariatric surgery.
Finally, the guideline reminds us that treating obesity includes treating its comorbidities, recognizing that these comorbidities play a significant role in the long-term health and wellbeing of our patients. Studies have shown that people with obesity do not receive the same medical care as people without obesity, and it is our job to change that. As for Max, I could choose to refer him to specialists for treatment of his hypertension, sleep apnea, and prediabetes. Alternatively, I could opt to become educated on how to treat these conditions and prescribe weight loss medications myself to make treatment more accessible to him and my other patients with obesity.
Change is always hard, especially for those of us who practice far from the support of academic medical centers, but these changes have the potential to drastically improve the health and wellbeing of so many of our patients, to whom we owe our very best efforts!
Sincerely,
Mary Ann Rigas, MD, FAAP
President 2022-2024
President 2022-2024