I recently watched “An Oprah Special: Shame, Blame and the Weight Loss Revolution” because my mother-in-law recommended that I check it out. As a pediatrician who has practiced in mostly outpatient primary care for nearly a decade, I have thought deeply about – and at times struggled very much – with how to speak to children and their families about growth, particularly, about weight.
That night, I watched Oprah interview Maggie Ervie, a 15-year-old girl who struggled with obesity until she began taking the medication Victosa (a GLP-1 agonist that was an early predecessor of Ozempic and Wegovy) before undergoing bariatric surgery. Her weight-loss journey had previously been detailed in an excellent article by Lisa Miller in “The Cut”, published online in December 2023, titled “An American Girlhood in the Ozempic Era” – and has fuelled much, great, discussion about the AAP recommendations surrounding childhood obesity.
Sitting across from Oprah on a couch next to her daughter, Maggie’s mother Erika described how life-changing these medical treatments had been for her daughter: “It was like a butterfly coming out of a cocoon.” Not only did she witness a surge in her daughter’s self-esteem, but Maggie’s labs, which had previously shown fatty liver disease and prediabetes, completely normalized for the first time just two years after the surgery. While she remained confident in her family’s decisions regarding Maggie’s treatment, Erika also tearfully reflected on how much she had struggled with the decision to take such drastic steps on Maggie’s behalf: “How do I teach her to love herself exactly as she is right now – and still support her desire to be in a different body?”
The American Academy of Pediatrics released new guidelines or recommendations in February 2023 around obesity in children and adolescents – how we think about it, its risk factors (which include things like genetics and poverty), and what modern interventions can and should be made available to those who suffer from it. The authors acknowledge that Body Mass Index, or BMI – while frequently used to approximate excess body fat because it is easy and inexpensive to measure and track in the outpatient setting – has its limitations. Furthermore, they recognize that, “Weight-related discussions can be uncomfortable for clinicians who want to avoid stigmatizing children because of their shape or size.”
And indeed, I AM sensitive to this when I see children in my office. I always start a review of the growth curves at check-ups by pulling up their height curves first, saying “Let’s see how tall you got!” I then go on to explain that most kids should gain weight as they get taller, and we talk about making sure that their growth is “picking a curve and following it” as well as how “bodies come in all shapes and sizes.” We talk about eating lots of different types of energy (food) and moving our bodies to keep them strong.
And why am I so careful with my use of language and cautious to “raise the alarm” at times, especially if a child is not truly overweight or obese? Because I have had both patients and their parents tell me that their previous healthcare provider made the child concerned they were “fat,” or tipped them into overly restricting calories or exercising excessively. I do, of course, try to stay curious about whether the child or the family is already struggling physically, mentally, or socially because of their weight. And for those children who do fall into the categories of overweight or obese – I often recommend checking bloodwork and talking with a Nutritionist as a first step. We are very lucky to have pediatric weight management clinics based out of nationally recognized children’s hospitals within driving distance, which can be utilized when symptoms are more severe and initial attempts at lifestyle modification do not help.
And now, we have even more tools at our disposal to help combat childhood obesity than ever before, in the form of medications and surgery. However, the data is lacking for long-term outcomes when we are talking about the use of weight-loss medications in children as young as 12-years-old, and bariatric surgery for teenagers 13-years-and-up. Frankly, I have mixed feelings about such drastic intervention on a child so young, with the major long-term consequences of surgery being balanced against the known complications of chronic severe obesity. For most weight loss medications, children would have to plan to be on them for life, as they are likely to gain the weight back once they stop taking them.
But, as with every medical advancement, these interventions are new (at least when applied to this age group), and I’m still learning. It will take a while for us as pediatricians to get comfortable with these interventions which, for Maggie, seem to have changed the course of her life for the better. I would never want to withhold options from a patient who could benefit as greatly as she has. In the meantime, all we can do is center the patient and their caregivers in the discussion, listening to their concerns and partnering with them as we set children up for a lifetime of strength, resiliency, and health.
