Understand the Underlying Causes, Challenges of Treating Obesity

Obesity is not the patient’s fault, according to Claudia Fox, MD, MPh, a professor of pediatrics at the University of Minnesota Medical School in Minneapolis. In an interview with Pharmacy Times, Fox stated that obesity actually occurs when the body can’t properly regulate a person’s energy stores.

“Every [individual] the extra pounds do it because their bodies don’t have the proper energy regulation systems to keep it off,” says Fox. “The reasons why it’s not working properly vary from [patient] to [patient].”

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

Findings from a study published in Journal of Family Medicine and Primary Care demonstrated that environmental factors, lifestyle factors, and cultural factors play an important role in obesity. The researchers note that childhood obesity can affect children’s health, social and emotional well-being, and self-esteem and is associated with worse academic performance and lower quality of life.¹

TREATMENT FOR CHILD OBESITY

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

While evidence supports these treatments, there are concerns about the long-term effects of more intense treatments as well as the mental health impact of these therapies on children.

“The guidelines take a major step in labeling obesity as a disease, [but] it is already heading in that direction of being labeled as a disease,” Jennifer Salvon, RPh, a clinical pharmacist and assistant professor at the University of Connecticut School of Pharmacy at Storrs, said in an interview with Pharmacy Time. “A number of [individuals] feeling that labeling it as a disease, meaning it’s not just your fault, will help [patients] don’t feel the stigma of being fat.

However, he stressed that others argue that diagnosing obesity as a disease could increase the prevalence of eating disorders.

One intensive treatment that is causing concern is IHBLT, which is defined by guidelines² as “a basic approach to achieving reduction of body mass or attenuation of excessive weight gain in children.” This involves frequent and intense visits to help maintain healthier eating and physical activity habits, according to the guidelines. IHBLT requires 26 hours or more of face-to-face, family-based intervention.²

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

One of the attractions of IHBLT is that evidence points to similarities between IHBLT and treatments used for eating disorders, including how IHBLT promotes healthy eating, physical activity for pleasure, and self-care focused on self-esteem and self-concept.²

However, there are limitations associated with IHBLT, including the number of providers trained in this care, access to patient transport, and social determinants of health factors. Salvon adds that he believes there is a fine line between making lifestyle changes and making children too aware of their nutritional patterns.

“I think it’s a fine balance that it takes a very skilled interviewer to perfect to be sure [the children don’t become hyperaware] because… in many ways [patients with obesity], there is an eating disorder after all, so they may become very conscious of what they eat,” says Salvon. “When we talk about childhood obesity, I mean, it’s a problem. Nearly 20 million children are obese in the United States, but some are obese [who] is hyperaware and does not eat or [are] bulimia…. For me, it’s the whole spectrum of eating disorders.”

Salvon added, obesity is a problem that needs continued attention, especially because children who are obese can grow up to develop other medical problems, such as type 1 diabetes, high cholesterol, hypertension, and arthritis.

In addition to motivational interviews and IHBLT which are more about behavior and lifestyle changes, there are pharmacotherapy and surgical treatments for childhood obesity.²

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

Salvon had some concerns with surgical intervention, particularly one that was performed too young.

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

Salvon adds that the follow-up and compliance required after surgery may not be suitable for younger children. Also, after bariatric surgery, it takes time to adjust to the smaller amount of food one can eat, and he says this can affect someone who is still growing by not absorbing the amount of vitamins and minerals his body needs. may need.

Pharmaceutical interventions are another major topic in the AAP guidelines. Antiobesity drugs (AOMs) have been shown to be effective, with evidence supporting their use in children aged 12 years and older.²

Fox says that medical professionals must weigh the risks and benefits of each intervention. He notes that children with severe obesity are more likely to have severe co-morbidities, including type 2 diabetes, sleep apnea, hypertension, fatty liver disease, and serious mental illnesses such as depression, anxiety, and eating disorders.

He adds that injectable AOM has been associated with side effects, including gastrointestinal problems, but these side effects are usually minimal when the drug is properly titrated and appropriate adjustments are made to eating behavior and dietary patterns. However, Fox said, the long-term use of these drugs is still unknown, especially for children.

“It’s also likely that someone isn’t going to be on the same drug for 40 years, or even 20 years for that matter,” Fox said. “We have to balance that with the definitive knowledge of ‘Wow, my patient in front of me, these 12 year olds who already have fatty liver disease with cirrhosis… maybe not even 20 years later because of their obesity. .’”

Fox emphasizes that the treatment approach is truly individual and that doctors should evaluate the use of these drugs on an individual basis, taking into account the risks and benefits associated with them.

Parents should also be encouraged to talk with their children about nutrition, health and maintaining a healthy lifestyle, whether or not that includes AOM. While these drugs can benefit patients when used properly, Salvon noted that semaglutide (Ozempic)’s prominence in pop culture, the media, and social media play a role in the unhealthy perception of the drugs.

“There’s an article about Kim Kardashian, [who] took semaglutide and lost a lot of weight to fit into a Marilyn Monroe dress,” says Salvon. “It’s not good for young people [children] to see.”

Salvon added that media coverage must have contributed to the use of injectable AOM as well as its proper or inappropriate use. He said he believed it had the most profound effects on middle-school-aged children but that teens and parents might also turn to injectable AOM before trying lifestyle changes when looking for a “quick fix” for obesity.

WHAT IS BEST FOR THE PATIENT?

Obesity does not have a one-size-fits-all solution, nor is it a black-and-white solution. Both Fox and Salvon emphasize that the risks and benefits of all interventions must be carefully considered and tailored to the needs of the patient.

“The bottom line is that [an individual] with obesity it’s not just skinny people who eat too much,” says Fox. “It’s not obesity.”

Reference

1. Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS. Obesity in children: 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 guidelines for the evaluation and treatment of children and adolescents with obesity. Pediatrics. 2023;151(2):e2022060640. doi:10.1542/peds.2022-060640