Rising rates of child and adolescent obesity continue to be a growing concern for physicians and other health professionals. This alarming trend affects physical health and contributes to long-term emotional and psychological challenges for children and teenagers. That is why immediate interventions are needed to address the root causes of obesity and promote healthier futures for children.
About 14.7 million people 2–19 years old in the U.S. have obesity, and there are inequities that affects history marginalized racial and ethnic groups. Obesity also affects children in families that are economically or socially marginalized. And each year, obesity costs the U.S. more than $1 billion in health spending, according to the Centers for Disease Control and Prevention. In policy first adopted in 2013 and updated last year, the AMA recognized “obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.”
For children and adolescents 6 years or older with a body mass index (BMI) in the 95th percentile, the U.S. Preventive Services Task Force (USPSTF) recommendation goes beyond just screening for obesity. Instead, the task force recommends that physicians provide or refer children and adolescents with obesity to intensive behavioral programs that can promote weight loss. These programs should offer guidance on healthy eating, safe exercising and understanding food labels. In policy adopted in 2023, the AMA acknowledges that the use of BMI alone is an imperfect clinical measure.
The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.
In this installment, Stanley W. Spinner, MD, a pediatrician and chief medical officer at Texas Children’s Pediatrics in Houston, discusses what to know about childhood obesity.
Texas Children’s Pediatrics is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Genetics plays a role in obesity
“Obesity really is a disease. It’s not just due to a bad lifestyle, although that can certainly contribute and aggravate it,” Dr. Spinner said. “We see a lot of factors such as the food that our kids are getting—fast foods and ultraprocessed foods—and people aren’t at home to cook meals that are a lot healthier and less fattening than years ago. So, some of that certainly contributes to obesity.”
“There’s also a lot of stress for our kids, more so than before, and stress adds to it. Stress affects certain hormones that can add to weight gain and higher insulin levels,” he said, adding that “we have known for quite a long time that environment plays a role. What we’ve been realizing more recently is that genetics is a significant part of that.”
“We can see kids or people who can consume a lot more calories without gaining weight or gaining body fat based on their genetics,” Dr. Spinner said. “Some people are going to inherit healthier genes for certain things, and some people can be a lot less healthy in their lifestyle or their diet but not have obesity.”
Meanwhile, “others have to work at it because of the genetics,” he added, noting “we still have a lot more to learn about it, but we’re definitely seeing that genetics plays a significant role in obesity.”
“It is similar to cholesterol. If you have familial high cholesterol, you’re not going to fix it by just cutting cholesterol out of your diet,” Dr. Spinner said. “That can lead to the conversation about medications.”
Obesity has long-term consequences
“When I was a young physician, obesity was an adult disease exclusively. Now it’s a pediatric disease too, and type 2 diabetes is a significant long-term consequence of obesity,” Dr. Spinner said, noting that “insulin resistance then leads to type 2 diabetes, which leads to a whole host of multi-organ problems such as kidney disease, heart disease and liver disease.”
“We see a lot of liver disease secondary to obesity, and that’s why we measure liver function in kids,” he added. “As we see abnormalities, we try to be more aggressive in managing that, because once you start messing up your liver, it’s hard to fix, and there are many consequences.”
“Diabetes, high blood pressure and heart disease are things that we used to just think about in adults, but now we see them in pediatric patients due to the fact that they had this problem as a child,” Dr. Spinner noted.
Early diagnosis is key
“The effects of high insulin levels or potentially high sugar levels with obesity don’t just wait until you’re older for it to suddenly start,” Dr. Spinner said. “It’s kind of like when you have high blood pressure. The longer you have it, the more damage it’s going to cause.”
That is why “we recognize that if you start targeting kids at an earlier age, it’s easier to modify their lifestyle when they’re younger than it is once they’re teenagers and they’re really hard to control for anybody,” he said. “So, doing interventions at an early age is very important.”
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Height and weight are tracked
“Our goal at every visit is [to measure] height and weight, which automatically generates a BMI calculation for our staff,” Dr. Spinner said. “If there is a BMI in the 85th or 95th percentile, our providers are taught to take note of that and help the family understand what that concern is and what we want to do from a standpoint of lifestyle changes to help change that direction so that their BMI will start to hopefully slow down, or even not continue increasing, and what the risks are.”
“When we see a 95th percentile BMI, we have built into our electronic medical record a warning, or what we call a best practice alert, especially for our adolescent patients, where we talk a little bit more about what that means, what the concerns are and the risk for prediabetes leading to type 2 diabetes,” he explained.
Follow-up appointments are vital
“One of the most important things that we’ve started to focus on more recently is follow-up appointments,” Dr. Spinner said. “We really try to get these kids back in the office depending on the circumstances.”
“It may be within a few weeks or it may be two or three months, but we really try to get these kids to come back, see what progress we’re making, decide what else we need to do and if we need to be more aggressive if we’re not starting to see some changes early on,” he added.
Focus on eating healthy, not diets
A lot of the treatment for obesity will focus on “lifestyle changes. It’s not going on a diet; it’s eating the right foods,” Dr. Spinner said. “We’ve known for a long time that that when people go on a diet, once they get off the diet, weight gain comes back. So, it’s learning to eat healthy.”
For example, “instead of having fried foods, have foods that are not fried. Instead of having a lot of processed foods, cut back on that, so that becomes the norm moving forward,” he said, emphasizing that “when we talk about lifestyle changes, it’s eating healthier choices of food so that you don’t have to think about it. You don’t have to count calories.”
Help kids be more active
When it comes to physical activity, it’s about “being active, getting away from the TV or the screen time and spending more time being outside when weather allows for it or even indoor activities that can allow for more getting your heart pumping,” Dr. Spinner said. That is “because you are going to increase your metabolic rate when you’re active, which helps us process those calories in a healthier way.”
As for how long children should be active, “it will depend on their age. There’s not one standard, but 30 to 60 minutes has been considered that golden rule to try to find that much time in a day to be active,” he said. “That can be indoor, outdoor, cardio type versus running around.”
“Some may need more than that, but 30 to 60 minutes is considered the gold standard,” Dr. Spinner reiterated.
Include the whole family
Children shouldn’t go at this alone, though. Instead, include the entire family in the process because “it’s like trying to tell teenagers to stop smoking when the parents are smoking. It isn’t going to fix it,” Dr. Spinner said. “The family, the parents, have to set the example. They have to show the same healthy lifestyle, the same healthy eating.”
“You can’t give your kid broccoli while you’re eating a hamburger. It doesn’t work,” he said. “Even if the family doesn’t have obesity, if it is just the child, they still have to work as a unit because that’s what the child is going to learn from.”
Medications may be an option
The USPSTF found inadequate evidence on the benefits of medications for weight loss in children and adolescents due to a small number of studies and limited evidence on long-term treatment harms.. However, the American Academy of Pediatrics (AAP) advises that physicians consider the use of such medications for children and adolescents 12 years or older based on the medications’ indications and risks and benefits, recommending that be accompanied by health behavior and lifestyle treatments.
“There’s always more caution with kids because medications are always going to have potential side effects, especially when you’re talking about long-term use,” Dr. Spinner said. “That is why the AAP came out with recommendations to consider the use of medications in kids or adolescents.”
“As pediatricians, we’re not usually the first to jump on a bandwagon to use new medications. We want to be comfortable with them,” he said. “Children 12 or older, if they are above the 95th percentile for BMI—for a 12-year-old male of average height, 95% BMI would be around 115 pounds—that’s when you can start to think about it.
“In some cases, if you feel comfortable that a family is doing whatever they’re going to be able to do outside of that and it’s still not working, those are the times to start thinking about medication” Dr. Spinner added, noting that the use of medication will depend on the individual patient.
Don’t feel ashamed
“Body image certainly is a problem, and it’s really complicated because we want to help our families recognize it, to face it, to deal with it,” Dr. Spinner said. “But it does cause a lot of anxiety, especially for our adolescents because we don’t want them to feel bad about their body image.
“We want to talk about this in a positive way, that obesity is a disease. It’s a medical issue. It’s not that you’re eating too much and you’re lazy,” he added. “We do have a lot of adolescents who have been negatively impacted by this and the negative body image concerns can lead to eating disorders.”
“A lot of parents get very upset about it and don’t want to address it, so we walk a very thin line between addressing it in a healthy way—which is important for the child—without making them feel bad about themselves,” Dr. Spinner said. “There’s no easy way to do that, but we want you to live a long, healthy life, and these conditions are shortening your life at the risk for your lifespan.”
