Understand the Underlying Causes, Challenges of Treating Obesity

Obesity is not the patient's fault, according to Claudia Fox, MD, MPh, an associate professor of pediatrics at the University of Minnesota Medical School in Minneapolis. In an interview with Pharmacy Times, Fox suggested that obesity is really just when the body cannot appropriately regulate an individual’s energy stores.

Child on a scale | Image credit: Protsenko Dmitriy - stock.adobe.com

“Any [individual] who carries extra weight does so because their body doesn’t have the proper energy regulatory system to keep it in check,” Fox said. “The reason why it is not working correctly varies from [patient] to [patient].”

According to Fox, the main determinant of obesity is the patient’s genetics, but many factors can contribute to obesity, including stress, which can be caused by such factors as food insecurity, depression, racial discrimination, and more.

Findings from a study published in the Journal of Family Medicine and Primary Care show that environmental factors, lifestyle factors, and cultural factors play pivotal roles in obesity. The investigators noted that pediatric obesity can affect a child’s health, social and emotional well-being, and self-esteem and is associated with poorer academic performance and lower quality of life.¹

TREATMENTS FOR CHILDHOOD OBESITY

To combat obesity as a chronic illness, the American Academy of Pediatrics (AAP) has published guidelines for the treatment of children and adolescents with obesity. The guidelines recommend treatments that include motivational interviewing, intensive health behavior and lifestyle treatment (IHBLT), use of pharmacotherapy, and in some cases, pediatric metabolic and bariatric surgery.²

Although evidence supports these treatments, concerns have been raised about the long-term effects of more intense treatments as well as the mental health impacts of these therapies on children.

“The guideline takes a big step in labeling obesity as a disease, [but] it was already heading in that direction to be labeled as a disease,” Jennifer Salvon, RPh, a clinical pharmacist and an adjunct professor at University of Connecticut School of Pharmacy in Storrs, said in an interview with Pharmacy Times. “Some [individuals] feel that labeling it as a disease, meaning it’s not just your fault, is going to help [patients] not feel the stigma of being obese.”

However, she emphasized that others contend that diagnosing obesity as a disease could increase the prevalence of eating disorders.

One intense treatment that has raised concerns has been IHBLT, defined by the guidelines² as a “foundational approach to achieve body mass reduction or the attenuation of excessive weight gain in children.” It involves frequent and intense visits to help sustain healthier eating and physical activity habits, according to the guidelines. IHBLT requires 26 hours or more of face-to-face and family-based interventions.²

Salvon said the goal of IHBLT is to involve the whole family, with an emphasis on lifestyle changes instead of body mass index or weight.

One appeal of IHBLT is that evidence shows similarities between IHBLT and treatments used for disordered eating, including how IHBLT promotes healthy food consumption, physical activity for enjoyment, and self-care focused on self-esteem and self-concept.²

There are, however, limitations associated with IHBLT, including the number of providers who are trained for these treatments, patients’ access to transportation, and social determinants of health factors. Salvon added that she believes there is a fine line between making lifestyle changes and having the child be too self-aware of their nutritional patterns.

“I think it’s a fine balance that it would take a really skilled interviewer to fine-tune to make sure [the children don’t become hyperaware] because…in a lot of [patients with obesity], there is that disordered eating anyway, and so they may become hyperaware of what they’re eating,” Salvon said. “When we talk about childhood obesity, I mean, it is a problem. Almost 20 million children are obese in the United States, but then there’s also those [who] are hyperaware and not eating or [are] bulimic.... To me, it’s a whole spectrum of eating disorders.”

Salvon added that obesity is an issue needing continued attention, especially because children who are obese could grow up to develop other medical issues, such as type 1 diabetes, high cholesterol, hypertension, and arthritis.

In addition to motivational interviewing and IHBLT, which are more about behavioral and lifestyle changes, there are pharmacotherapy and surgical treatments to address childhood obesity.²

For surgical interventions, Fox noted that the eligibility criteria are based primarily on body mass index and the presence of weight-related comorbidities. There is also no age limit or age recommendation in the AAP guidelines.² Fox said this is because evidence shows that obesity can impact a child’s growth and pubertal development, so a surgical intervention may be used to help them maintain normal growth and development.

Salvon has some concerns with surgical interventions, particularly surgery that is performed too young.

“I get worried that parents may want to do it quickly because they just want their kid to fit in or be thin [because] it takes time and effort [with other interventions],” Salvon said. “I think sometimes [individuals] in our society are looking for a quick fix.”

Salvon added that the follow-up and adherence necessary after the surgery might not be a good fit for younger children. In addition, following bariatric surgery, it takes time to adjust to the lower amount of food that can be consumed, and she said this could affect someone who is still growing because they are not going to absorb the amount of vitamins and minerals that their body might need.

Pharmaceutical interventions are another key topic in the AAP guidelines. Antiobesity medications (AOMs) have been proven to be effective, with evidence to support their use in children 12 years and older.²

Fox said that medical professionals should weigh the risks and benefits for every intervention. She noted that children with severe obesity are more likely to have severe comorbidities, including type 2 diabetes, sleep apnea, hypertension, fatty liver disease, and serious mental illnesses like depression, anxiety, and eating disorders.

She added that injectable AOMs have been associated with adverse events, including gastrointestinal issues, but these adverse events are typically minimal when the medication is appropriately titrated and proper adjustments are made to eating behavior and dietary patterns. However, Fox said, the long-term use of these medications is still unknown, especially for children.

“It’s also likely that an individual is probably not going to be on the same medication for 40 years, or even 20 years for that matter,” Fox said. “We have to balance that with the definite knowledge of ‘Wow, my patient in front of me, this 12-year-old kid who already has fatty liver disease with cirrhosis…might not even make it to 20 years later because of their obesity.’”

Fox emphasized that treatment approaches truly depend on the individual and that physicians should be evaluating use of these medications on an individual basis, considering the risks and benefits associated with them.

Parents should also be encouraged to have conversations with their children about nutrition, health, and maintaining a healthy lifestyle, whether or not that includes AOMs. Although these medications can benefit patients when used correctly, Salvon noted that the prominence of semaglutide (Ozempic) in pop culture, the media, and social media plays into unhealthy perceptions of such medications.

“There was an article about Kim Kardashian, [who] took semaglutide and lost a bunch of weight to fit in Marilyn Monroe’s dress,” Salvon said. “That’s not good for young [children] to see.”

Salvon added that media coverage definitely contributes to the use of injectable AOMs as well as to the proper or improper use of them. She said she believes this has the most profound effect on middle school–aged children but that teenagers and parents might also turn to injectable AOMs before trying lifestyle changes when looking for a “quick fix” to obesity.

WHAT’S BEST FOR THE PATIENT?

Obesity does not have a one-size-fits-all solution, nor are the solutions black-and-white. Both Fox and Salvon emphasized that the risks and benefits of all interventions should be carefully considered and individualized to meet patient needs.

“The bottom line is that [an individual] with obesity is not just a thin person who ate too much,” Fox said. “That’s not what obesity is.”

Reference

1. Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS. Childhood obesity: causes and consequences. J Family Med Prim Care. 2015;4(2):187-192. doi:10.4103/2249-4863.154628
2. Hampl SE, Hassink SG, Skinner AC, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics. 2023;151(2):e2022060640. doi:10.1542/peds.2022-060640