Are drugs or surgery the answer for your child's obesity? New guidelines raise hope, concern

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Nine-year-old Brayden Coronado is tormented by insatiable hunger.

And it's not his fault.

His parents, Raul and Jennifer Coronado of Mason City, Iowa, struggle to keep him out of the kitchen cupboards as he forages for any food he can find. They can't keep anything sweet in the house, whether it be cookies, juice or ice cream.

A rare genetic disease known as POMC deficiency that often leads to obesity in young children makes it almost impossible for Brayden, who is developmentally delayed, to really feel full. And though his parents offer him healthy alternatives and encourage plenty of exercise, it's a constant battle to try to manage his weight.

“You tell him, ‘No you can’t have this, you’ve already eaten’ and it just triggers the swearing and the slamming cupboards," Jennifer Coronado said. "It's tough."

The family has been working to get approval for an injectable medication that could help, but doctors and insurance companies have been reluctant to use more aggressive medical treatments for children struggling with obesity.

That may be changing.

In recent weeks, a leading medical group has begun advising doctors to treat obesity in children earlier and more aggressively, including using treatment options such as weight loss medication and bariatric surgery.

The new guidelines from the American Academy of Pediatrics establish a new, proactive roadmap for obesity treatment with recommendations that providers focus on treating obesity head-on.

It's an acknowledgment that America is losing the battle against childhood obesity, and the traditional "wait-and-see" approach isn't working for many kids.

"Sometimes when kids are really struggling, when obesity is really severe, they do need more tools," said Dr. Vanessa Curtis, a pediatric endocrinologist at the University of Iowa Hospitals and Clinics who is treating Brayden.

But some child advocates and eating-disorder specialists find the new guidelines particularly disturbing and worry they will feed into America's body-image bias, further damaging kids who may already feel bad about how they look.

Dr. Sara Schwatken, a Fort Dodge, Iowa-based psychologist who deals with eating disorders, said she was "horrified" at the guidelines' characterization of weight as a chronic disorder, saying it stigmatizes weight gain in a way that could lead to lasting harm for children.

"Is it really about health, or is it about weight bias and fat phobia?" she asked.

Still, for families like the Coronados, the guidelines may open treatment options that have been out of reach.

Currently, many families struggle to get insurance coverage for drugs that can help treat obesity in children. Some medications can cost families up to $1,600 a month, Curtis said.

"If we’re really going to optimize this area, we need insurance companies to recognize the importance of these drugs," Curtis said.

The Coronados' medical providers recommended an injectable medication that would help suppress Brayden's appetite, but it costs about $4,000 a shot, Raul Coronado said. Medicaid denied their coverage, claiming the medication was only cosmetic.

“He would really thrive from that shot, but the insurance company won’t pay for it," Raul Coronado said.

And that reticence has been reflected in the medical profession's historic views on child obesity. Doctors are starting to understand that for some children, the problem won't go away on its own.

"Obesity is a chronic medical condition, and it's actually the most common pediatric chronic disease," said Dr. Jennifer Groos, a Des Moines, Iowa-based pediatrician who is on the American Academy of Pediatrics' committee on obesity.

"It's not something that we necessarily cure. The goal is to preserve and maintain health, and that approach is much more successful."

What's in the new childhood obesity guidelines?

The new guidelines urge medical health providers to consider treatment options "at the highest level of intensity" appropriate for the patient.

For children 6 and older — and in some cases, as young as 2 — providers should offer months of in-person behavior and lifestyle treatment, which includes coaching on nutrition and physical activity, the guidelines recommend.

If intensive therapy is not enough for adolescents 12 and older, weight loss medications should be considered.

Kids 13 and older with severe obesity should be evaluated for weight-loss surgery.

This more aggressive approach is also a necessary move, medical providers say, particularly as they've seen a troubling increase in children and adolescents with obesity, which is associated with other lifelong chronic conditions.

The U.S. Centers for Disease Control and Prevention defines obesity in a child as having a body mass index, or BMI, at or above the 95^th percentile for children and teens of the same age and sex.

Nationwide, 14.7 million children and adolescents are affected by obesity, a rate that had increased in the past decade, studies from the CDC has found.

Since the pandemic, the CDC found rates of obesity among young Americans rose from 19% before the pandemic to about 22% by 2020.

Children with a higher body mass index, or BMI, are more likely to experience other chronic medical conditions, such as diabetes or cardiovascular disease. They can also have a higher risk for orthopedic complications, such as joint pain.

BMI calculator:Is your child obese?

In addition, they have a greater likelihood of developing diseases such as type 2 diabetes; non-alcoholic steatohepatitis, a liver dysfunction; and cardiovascular disease, said Dr. Jennifer Paisley, an Indiana-based physician and a member of the Obesity Medicine Association's national pediatric committee.

"Children with obesity don't just outgrow their disease, they become adults with obesity," Paisley said.

Why are health officials taking this new approach?

The American Academy of Pediatrics' new recommendations are the first update to clinical guidelines on the topic in 15 years.

According to Groos, it was long awaited. She said there's strong evidence of how effective treatment options, including drugs and surgery, can be for addressing obesity in young patients.

Groos said she and other providers have been turning to pharmacology and surgery for their young patients for some time, but with the new guidelines in hand, it will likely help other primary care providers feel good about these treatments.

"The goal is that more of these programs for intensive health behavior and lifestyle treatment become available because they're not available in many areas of our state," Groos said. "That's something that we're using these guidelines for, to advocate for expansion and coverage by payers, expansion for accessibility and support for building these programs that we know are effective to be able to help all of these kids and families attain really optimal health."

The medical group says in its guidelines that "the lack of payment by insurers remains a major barrier to childhood obesity treatment," and creates a major barrier for families to obtain laboratory testing, attend multiple doctors visits and otherwise complete treatment programs.

"Families are doing the best with what they have, but if they’re on a budget, they can only do so much," Curtis said.

Some providers raising alarms over risk of eating disorders

The new guidelines note that "obesity is a complex chronic disease" and a number of factors can contribute to obesity beyond an individual's behavior, such as genetic predispositions.

The guidance also highlights other significant factors that lead to a higher risk of obesity, including racism, food insecurity and socioeconomic status.

"This is a chronic medical disease just like asthma, and we want to be able to present our patients with the best practices around it," Groos said. "When there's bias and stigma associated with it, it's more difficult to gain access to the services that individuals need."

The medical group notes that children who live with obesity often face unfair stigma, even from doctors who treat them.

However, when structured, supervised weight management programs are delivered by trained health care professionals, they say, the risk for current and future eating disorder symptoms decrease.

Even so, the national Collaborative of Eating Disorders Organizations has strongly denounced the new clinical guidelines, in particular the recommendations to consider bariatric surgery and drug interventions for children.

"The statements made throughout these guidelines are problematic at best, and at worst, put American children and adolescents at serious risk for developing eating disorders, disordered eating and other mental and physical health issues," the group wrote.

Holly Paulsen, a dietician, said she sees many adult patients who are still struggling with eating disorders they developed because they were encouraged to lose weight as children.

"I have had patients who reported (that) when they were children, their parents would lock up the food from them," she said. "I have had two new clients this week who independently told me they were sent to Weight Watchers under the age of 10. That was the start of their journey with eating disorders and disordered eating and a lifetime of weight cycling."

But for families such as the Coronados, the new guidelines may open the opportunity for treatment options they hope could change their son's life.

"Maybe someday," Jennifer Coronado said, adding that Curtis, "gave us this number for a clinical trial to see if there's something, but there's no guarantees."

Michaela Ramm covers health care for the Des Moines Register. She can be reached at mramm@registermedia.com, at (319) 339-7354 or on Twitter at @Michaela_Ramm.