Guidelines for Kids With Obesity

Douglas Lunsford’s son Samuel has struggled with obesity all his life.

Just before turning 14, Samuel, now 25, took part in a program at Ohio-based Nationwide Children’s Hospital’s Center for Healthy Weight and Nutrition. The program consisted of twice-weekly meetings with a nutritionist, including lessons in food portion size, what food does within the body, what foods can be used to supplement other foods, and similar topics, as well as physical exercise. 

Although the program was designed for youngsters with weight problems, Lunsford also took part. 

“They would exercise us and work us out,” he said.

Father and son did the program together for 2 years. Since then, Lunsford has advocated for youngsters with obesity. 

“Samuel’s struggle spurred us into action,” he said. 

Eventually, Lunsford helped create the American Academy of Pediatrics’ recently released Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. 

Helping Create Change

According to Sandra Hassink, MD, co-author of the guideline and vice chair of the Clinical Practice Guideline Subcommittee on Obesity, the goal was to “help patients make changes in lifestyle, behaviors, or environment in a sustainable way and also to involve families in decision-making at every step of the way.”

The guideline recommends comprehensive obesity treatment that may include nutritional support, exercise, behavioral therapy, medication, and metabolic and bariatric surgery.

Ideally, a child would receive intense behavioral and lifestyle treatment, although this approach isn’t always available and might be challenging to deliver. The most effective treatments include at least 26 hours of face-to-face, family-based treatments, consisting of many different components and lasting 3 to 12 months.

The guideline suggests that doctors offer adolescents 12 and older medication to assist in weight loss, along with health, behavior, and lifestyle treatment, and that teens who have severe obesity should consider metabolic and bariatric surgery as they continue intense health behavior and lifestyle treatment. 

“We’re living at a time where we’ve watched obesity affect our children and adult population for 4 decades and, along with the risk of obesity, we’ve watched a rise in obesity, we’re seen increases in illness that go along with obesity, such as type 2 diabetes, lipid diseases like high cholesterol, and nonalcoholic fatty liver disease,” Hassink said.

She explains that as people gain weight, the cells in adipose (fatty) tissues start to malfunction and produce inflammatory chemicals that cause these illnesses. 

“So having extra adipose tissue is a risk,” she said. “As pediatricians, we measure body mass index [BMI] — which is calculated based on height and weight — as a way of seeing whether the child could be at risk for developing these dysfunctioning cells. If so, we screen them for prediabetes, lipid disease, or liver disease and other obesity-related comorbidities.”

In addition, “we’re concerned about the mental health of children with obesity because of the weight bias in our culture,” says Hassink. “A child gets stigmatized, and this takes the form of bullying and teasing, and leads to low self-esteem, depression, and anxiety. So we know we have a host of physical problems we need to look out for, as well as the emotional and psychological effects of how our culture views things.”

Are Parents Ready for the New Approach?

A new report from Harmony Healthcare IT, a data management firm that works with health data, looked at how parents regard their children’s obesity. The company surveyed more than 1,000 parents and found that one-tenth of respondents had children who were overweight or obese and over a quarter (26%) worry about their child’s weight.

Nearly 40% of parents would consider weight loss medication for their child if the child became obese at age 12, and about 16% would consider weight loss surgery. But most parents would not consider this surgery until their child was an average age of 15 rather than the AAP’s recommended age of 13.

Lunsford said that his son considered surgery and medication but was “never comfortable” with these approaches. 

This isn’t unusual, Hassink said. “Not every parent will think the same way, and their view will be based on their experience and what’s going on with their child.”

The guideline wasn’t designed to encourage every child to try medication or have surgery, she said. 

“But parents now know that there are potentially helpful choices here that we didn’t have years ago, and those can be discussed with the child’s pediatrician.”

Challenges to Keeping Healthy

It’s tough to stay healthy and not develop obesity in our modern environment, Hassink said. 

“There’s a lot of processed food, a lot of sugar in our foods, a lot of sedentary behavior, and a decrease in physical activity. In many communities, it’s hard for people to get healthy foods.”

Lunsford said that when his son was in his late teens and would go out with friends, they typically went to fast-food restaurants. 

“Sam would say ‘yes’ to these foods, although he knew they weren’t good for him, because he wanted to be like everyone else,” he said.

Harmony Health IT’s survey found that many parents say it is a struggle to get kids to eat healthy foods and get enough sleep. Although almost all respondents (83%) said they try to prepare healthy, home-cooked meals, 39% eat fast food at least once a week, mostly because parents are too tired to cook. 

Hassink said the COVID-19 pandemic also played a role.

“We knew that COVID would be hard for kids with obesity, and there might be weight gain because of the extra sedentary time and fewer sporting activities, and there was a high cost of food to families who are already economically strapped,” she said. 

In general, family support is essential, Hassink said. “Obesity treatment requires that the family be involved. The family is living in the same nutritional and activity environment as their child. Everyone has to be on board.”

Talking to Kids About Food and Weight

The survey found that many parents struggle to talk about food and weight with their children. The AAP guideline notes that involving a health care professional can help. 

“If a parent or caregiver is concerned about a child’s weight, he or she can take the child to their pediatrician,” Hassink said. “The first thing the pediatrician will do is ask about the child’s overall health, review the family history — because obesity tends to run in families — and see if other conditions, like diabetes, also run in the family.” 

The pediatrician will do a physical examination that includes BMI and, if it’s high, other tests looking at blood sugar, lipids, and liver function may be performed. 

Ideally, the child will be prescribed intense lifestyle and behavioral treatment that will take the child’s and family’s nutrition into account, as well as physical activity and the amount of sleep the child is getting, which is sometimes tied to weight gain. If the child has disordered eating, such as binge eating disorder, they can be evaluated and treated for that.

Each child is seen as an individual with a particular set of needs. “One size doesn’t fit all,” Hassink said. 

Providing Emotional Support for Children with Obesity 

Pediatricians can assess the child’s mental, emotional, and social well-being. “Children who are bullied or teased may need help working through that. Children experiencing depression may need treatment,” Hassink said.

Lunsford said Samuel was fortunate in that he rarely got taunted. 

“Part of the reason is that although weight was an issue, he never allowed his weight to define him,” he said. “He was always an extroverted kind of kid, athletic, very outgoing and friendly, and being overweight was never part of his identity.” 

Lunsford encourages parents whose children are teased or bullied to create a “no-judgment” zone at home. 

“Let your kids know that their parents love them for who they are,” he said. “Emphasize that weight is a ‘number’ and health is a ‘lifestyle.’ Try to highlight the good things in their lives and encourage them to be as active as they can in the things that interest them.”


Douglas Lunsford, Chatham, OH. 

American Academy of Pediatrics: “American Academy of Pediatrics Issues Its First Comprehensive Guideline on Evaluating, Treating Children and Adolescents With Obesity.”

Pediatrics: “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity.”

Sandra Hassink, MD, vice chair, Clinical Practice Guideline Subcommittee on Obesity, American Academy of Pediatrics.

Harmony Healthcare IT: “[Report] How Parents Struggle with Keeping Kids Healthy in 2023.”

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