HJNO Jul/Aug 2023

CHILDHOOD OBESITY 34 JUL / AUG 2023 I  HEALTHCARE JOURNAL OF NEW ORLEANS   statements and resources focused on pre- vention and continues to actively update this to the most recent scientific evidence. The new CPG on child obesity treatment were developed specifically for the 14 mil- lion children and adolescents who already have obesity and the projected millions more to develop obesity in this genera- tion. For these children, prevention alone is insufficient to achieve clinically meaning- ful, sustainable weight loss. One major concern about the weight loss med and surgery recommendations for youth is that they guarantee weight loss but not good nutrition. Just because someone drops weight by eating less doesn’t mean they are getting the nourishment they need for optimal health. Are we really creating lasting change and good health if we are not also making modifications in quality rather than quantity of diet? Yes, healthy nutrition is a key element to healthy weight. Indeed, the CPG empha- sizes that medication and surgery should be accompanied by IHBLT. The clinical trials on medication and surgery included dietary and behavioral counseling. Medication and surgery should not be offered without IHBLT, according to the scientific evidence and the guidelines. We should set up kids for success by helping families change their environment and build skills to help them succeed, and paramount to this is healthy nutritional intake. What compelling research has been done on gastric bypass surgery in youth and the long-term effects as these patients age? Please refer to the following evidence summarized in the CPG: “Correspond- ing analyses related to the use of various surgical weight loss procedures in pediat- ric populations have been primarily estab- lished in the last 20 to 30 years. Large con- temporary and well-designed prospective observational studies have compared adolescent cohorts undergoing bariatric surgical treatment versus intensive obesity treatment or nonsurgical controls. These studies suggest that weight loss surgery is safe and effective for pediatric patients in comprehensive metabolic and bariatric surgery settings that have experience work- ing with youth and their families. Laparo- scopic Roux-en-Y gastric bypass and verti- cal sleeve gastrectomy are both commonly performed in the pediatric age group and result in significant and sustained weight loss, accompanied by improvements and/ or resolution of numerous related comor- bid conditions. 732 Laparoscopic adjustable gastric band procedures, approved by the FDA only for patients 18 years and older, have declined in use in both adults and youth because of worse long-term effects as well as higher-than-expected complica- tion rates.” 647,652,654,655,706,732–736,739–744 Has there been any long-term research on the effects of weight loss drugs on children? Should providers be completely comfortable recommending weight loss drugs vs IHBLT? The CPG does not promote the use of weight loss medication as a monotherapy; rather, it is to be used in conjunction with IHBLT, not as a stand-alone treatment. There should never be a “weight loss drug versus IHBLT” conversation with a patient — the guidelines make it clear that IHBLT is to be offered to all children and adoles- cents with obesity, and the tertiary options like medication and surgery are added on to the IHBLT. Some of these trial results such as sema- glutide have just come out in the last few months, whereas other medications have been around for years if not decades. Because of this, there are varying lengths of follow-ups, but FDA-regulated drugs will continue to be monitored through phase 4 trials. The CPG provides the references and study descriptions that underly the key action statements, and providers can review these to understand the time course of the trials. Ultimately, the provider works with the family to select the treatment options based on what is available and right for that patient. How would you respond to the critique that claims the CPG is too weight- focused, rather than health-focused? Obesity is a medical diagnosis accord- ing to the American Medical Association and several other medical organizations, and there are ICD codes specific to obesity. Obesity is weight exceeding what is recom- mended for a patient’s height (for adults this is their BMI, for children their BMI percen- tile indexed for age and sex). Weight is an important marker of health and underlies several other serious and often life-threat- ening or life-shortening diseases. Weight and health go hand in hand. Families’ and patients’ goals need to be considered — many families are looking for improvements in self-esteem, quality of life, the ability to run a mile or join a sports team, how to eat healthier, etc. These outcomes can be just as, if not more, important to fam- ilies than weight and are considered in the IHBLT programs that were included in the CPG technical reports. The amount of time needed for counseling/coaching behavior modifications has been stated as an obstacle in achieving weight loss. Popping a pill or taking a shot may be perceived as quicker and easier … but hasn’t research shown that if the patient stops taking the weight loss pill, the cravings return, and the patients return to their premedicated weight? Wouldn’t logic dictate that IHBLT would be so much better long- term than a pharmacological or surgical solution? IHBLT is the cornerstone of obesity treat- ment, as theAAPCPG emphasizes. Ethically, healthcare providers (and insurance com- panies, policymakers, healthcare adminis- trators) should make more evidence-based treatment options available to patients and providers. Some families may prefer IHBLT and may not pursue medications or surgery.