Building H #76: Ozempic Nation 2
The American Academy of Pediatrics issued new guidelines last month for the treatment of children with obesity. The guidelines are aggressive and represent a significant escalation from previous recommendations. Catherine Pearson offers a good summary of both the recommendations and the context in her story in the New York Times. The Times also features the guidelines in an episode of The Daily, with veteran health reporter Gina Kolata.
The guidelines call for intervention, through referrals to intensive health behavior and lifestyle treatment (IHBLT), for all children aged six and up with overweight or obesity and the consideration of such referrals for children as young as two, depending on the circumstances. IHLBT is essentially lifestyle and behavior counseling around nutrition and physical activity. The key to IHLBT, the AAP notes, is the intensity of the dose and they recommend a program of 26 hours, delivered face-to-face over a 3-to-12 month period. The AAP recommends that physicians consider weight-loss medication, as an adjunct to IHBLT, for children 12 and over. And for children 13 and over, with severe cases of obesity, the AAP guidelines call for the referral for evaluation of bariatric surgery.
These guidelines are … a lot. Even the first-line IHBLT counseling is a major family commitment and its availability (it’s often confined to academic medical centers and specialty practices) will be far less than the demand if the guidelines are followed. Starting ongoing medication at age 12 let alone surgery at ages as low as 13 are daunting prospects.
AAP did not make these recommendations lightly. They are an indication of the seriousness of the issue in our times. The authors cite the astonishing prevalence of obesity – 19% in children 2-19, a tripling since 1965 – and the fact that it rises with age. According to one model, if 2017 obesity trends hold, 57% of children currently aged 2-19 will be living with obesity by the time they reach 35. (The numbers are far worse for children of low-income and children who are Black or Hispanic.) It’s here, it’s not going away – and, for children living with the condition, the consequences to their physical and mental health, can be devastating. Add to that the pain and other consequences that result from the social stigmatization that can tragically follow one living with the condition.
The guidelines have sparked quite a backlash, based on a wide array of legitimate concerns. Virginia Sole-Smith covers several in her opinion piece, “Why the New Obesity Guidelines for Kids Terrify Me.” Sole-Smith notes the inadequacy of BMI as an individual-level screening tool, the emphasis on weight loss as reinforcing anti-fat bias, the potential for resulting eating disorders and the side effects of both weight-loss drugs and bariatric surgery. Her piece and others highlight the complex, almost paradoxical relationship between medicalization and stigma: the medicalization, which is designed to reduce the prevalence of obesity, can, by signaling the seriousness of the condition, increase the stigmatization of the condition.
This moment, when intensive treatment is recommended for a third of all children in the US, is a good time for reckoning. Implicit in the AAP’s recommendations is the conclusion that obesity is very difficult to prevent at a population level. The report describes the complexity of the issue, noting influences such as food marketing, underresourced communities, fast food proximity, lack of access to safe places to play, screen time, racism, sleep inadequacy, genetic and epigenetic effects, and psychosocial stress. But it also states simply and clearly,
“[A]s the environment has become increasingly obesogenic, access to evidence-based treatment has become even more crucial.”
We are here, because with few exceptions, we have shied away from the harder, more complex work that is needed to shift the environment. We are once again relying on a downstream, medical approach to bail us out, even as we agonize over the consequences of doing so. Given the situation, it would be unconscionable not to take some downstream action, but it is never too late to re-imagine environments for people that wouldn’t earn the tag “obesogenic.”
Obesity is a challenging and complex issue and we’d love to hear your thoughts on it. We’re opening up comments on this edition of the newsletter over on our website. Please join the conversation by adding your comments below.
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