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Counting calories should not be the focus of weight-loss strategies for children with obesity, according to an expert who said pediatricians need to change the way they discuss weight with their patients.

During an October 9 plenary session of the American Academy of Pediatrics (AAP) 2022 National Conference, Joseph A. Skelton, MD, nitroglycerin high blood pressure professor of pediatrics at Wake Forest University School of Medicine, Winston-Salem, North Carolina, said pediatricians should recognize the behavioral, physical, environmental, and genetic factors that contribute to obesity. For instance, food deserts are on the rise, and they undermine the ability of parents to feed their children healthy meals. In addition, more children are less physically active.

“Obesity is a lot more complex than calories in, calories out,” Skelton said. “We choose to treat issues of obesity as personal responsibility ― ‘you did this to yourself’ ― but when you look at how we move around and live our lives, our food systems, our policies, the social and environmental changes have caused shifts in our behavior.”

According to Skelton, bias against children with obesity can harm their self-image and weaken their motivations for losing weight. In addition, doctors may change how they deliver care on the basis of stereotypes regarding obese children. These stereotypes are often reinforced in media portrayals, Skelton said.

“When children or when adults who have excess weight or obesity are portrayed, they are portrayed typically in a negative fashion,” Skelton said. “There’s increasing evidence that weight bias and weight discrimination are increasing the morbidity we see in patients who develop obesity.”

For many children with obesity, visits to the pediatrician often center on weight, regardless of the reason for the appointment. Weight stigma and bias on the part of healthcare providers can increase stress, as well as adverse health outcomes in children, according to a 2019 study. Skelton recommended that pediatricians listen to their patients’ concerns and make a personalized care plan.

Skelton said doctors can pull from projects such as Health at Every Size, which offers templates for personalized health plans for children with obesity. It has a heavy focus on a weight-neutral approach to pediatric health.

“There are various ways to manage weight in a healthy and safe way,” Skelton said.

Evidence-based methods of treating obesity include focusing on health and healthy behaviors rather than weight and using the body mass index as a screening tool for further conversations about overall health, rather than as an indicator of health based on weight.

Skelton also encouraged pediatricians to be on the alert for indicators of disordered eating, which can include dieting, teasing, or talking excessively about weight at home and can involve reading misinformation about dieting online.

“Your job is to educate people on the dangers of following unscientific information online,” Skelton said. “We can address issues of weight health in a way that is patient-centered and is very safe, without unintended consequences.” Brooke Sweeney, MD, professor of internal medicine and pediatrics at University of Missouri–Kansas City School of Medicine, Kansas City, Missouri, said problems with weight bias in society and in clinical practice can lead to false assumptions about people who have obesity.

“It’s normal to gain adipose, or fat tissue, at different times in life, during puberty or pregnancy, and some people normally gain more weight than others,” Sweeney said.

The body will try to maintain a weight set point. That set point is influenced by many factors, such as genetics, environment, and lifestyle.

“When you lose weight, your body tries to get you back to the set point, decreasing energy expenditure and increasing hunger and reward pathways,” she said. “We have gained so much knowledge though research to better understand the pathophysiology of obesity, and we are making good progress on improving advanced treatments for increased weight in children.”

Skelton reports no relevant financial relationships.

American Academy of Pediatrics (AAP) 2022 National Conference: Plenary session. Presented October 9, 2022.

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