The Need for Increasing Pediatric Obesity Advocacy

We believe KJ Kemper raises essential points in the article Obesity in Children and Youth: Public Health Emergency? Or opportunity for research, education, and advocacy.¹ Indeed, public policies geared towards addressing obesogenic environments may help in terms of obesity prevention and treatment.² Part of these policies should address issues with food distribution inequality, as this has contributed to both the obesity epidemic and rising food insecurity in the U.S.^3-4 Further, addressing climate change is vital to our future, and there appear to be bidirectional associations between adiposity and global warming.^5-6

We want to raise a few points in response. First, we do not call for pediatric obesity to be declared a U.S. public health emergency at this time. We believe arguments favoring such a declaration (i.e., obesity is a burgeoning disease epidemic, public health emergencies have helped in the past) may not currently exceed those opposing it (i.e., resource allocation concerns, potential negative impacts on autonomy, weight bias, and stigmatization).⁷ We believe that considering these arguments may offer additional insights into more effectively addressing this epidemic.⁷

The focus should not primarily be on changing individual and family behaviors.¹ As pointed out, individual behaviors, including dietary choices, exercise, and sedentary screen time, do not occur in a vacuum.¹ In concordance with pediatric obesity treatment guidelines, there is a need to address these issues; however, at the individual level, obesity is primarily driven by underlying biological and genetic factors.^2,8-9 Specifically, per The Obesity Society’s Position Statement on Obesity as a Disease: Obesity is a multi-causal chronic disease recognized across the life-span resulting from long-term positive energy balance with development of excess adiposity that over time leads to structural abnormalities, physiological derangements, and functional impairments…As with other chronic diseases, obesity is distinguished by multiple phenotypes, clinical presentations, and treatment responses.¹⁰ We believe treatment should be individual- and family-based, addressing individual-level underlying biological processes and critical external factors. An excessive focus on changing individual behaviors may inadvertently add to weight stigmatization more than it may improve health.¹¹

Concern was also raised that attempts at treating obesity with anti-obesity medications (AOMs) and bariatric surgery may encourage dependence on expensive treatments (in the diagnose and dispense model of care in which physician income is tied to a reimbursement system that rewards repeated brief visits for chronic conditions that never fully resolve).¹ Behaviors contributing to obesity are manifestations centrally driven by biological factors that are largely beyond an individual’s control, including increased appetite, low satiety, and hyperactive craving/reward pathways.¹² Effective treatment works to disrupt these pathophysiological processes and restore homeostasis to the energy regulatory system.^13-14 Further, around half of physicians do not receive compensation based on personal productivity, and of those who do, nearly 75% receive less than half their income from this.¹⁵ Indeed, high costs may be preventing some interventions, including some AOMs and metabolic/bariatric surgery, from being cost-effective, additionally creating access and equity issues^16-18 That said, in time, with improved insurance coverage, more long-term outcome data and market competition, weighed against exorbitant and rising costs of obesity and its associated complications, these options and others may ultimately prove cost-effective.^17,19-20

One action that could be taken under a pediatric obesity public health emergency is to mandate that Medicare and public assistance programs provide comprehensive coverage for obesity treatment, including provider/dietician visits, AOMs, and metabolic/bariatric surgery, as appropriate. As stated in The Obesity Society Position Statement on Patient Autonomy, patients and clinicians should engage in a shared-decision making to select and pursue optimal obesity care, and every person with obesity should have access to the entire scope of evidence-based care, including access to multi-modal treatment approaches.²¹ Policymakers should continue working with manufacturers and other stakeholders to reduce obesity-related treatment costs. Doing so may reduce inequalities and make all evidence-based treatment options available to everyone to meet their health goals.²¹

Finally, while we believe that addressing public-health-related social determinants of health (SDoH) is vital, it should not preclude offering a comprehensive care approach to children and youth currently living with obesity. In the U.S., it is estimated that obesity presently affects nearly 20% of children and adolescents, with severe obesity (defined as body mass index ≥1.2 times the 95^th percentile and/or BMI ≥35 kg/m²) at record high prevalence.^22-23 This disease is associated with substantial morbidity and mortality, and it has been estimated that 85% of adolescents with severe obesity already have ≥1 cardiovascular risk factor.^2,24 Like the pathophysiology of obesity, SoDH are chronic and complex, and fully addressing these will take substantial time, resources, and effort. Waiting for SDoH to be fully addressed before offering comprehensive and shared decision-making-based treatment will not help the individual presenting for care today. Efforts to treat obesity and address SDoH should be made in concert, which may be easier to attain through a pediatric obesity public health emergency declaration.

Overall, we believe that the most essential first step towards more effectively addressing the pediatric obesity epidemic is to increase advocacy to empower youth and families living with this disease.⁷ One of the first actions geared towards mitigating weight bias and obesity-related stigma is the use of person-first and person-first language (i.e., “person with obesity” rather than “obese person”) in overweight and obesity advocacy, practice, research, and education.²⁵ A better recognition by providers, policymakers, and the public around the fact that obesity is a genetically and biologically driven disease, rather than a personal choice or failure, should lessen “blame the victim” mentalities and open further conversations around developing and implementing more successful public health policies to prevent and treat this disease.