New AAP Childhood Obesity Clinical Practice Guidelines Have Implications for Medicaid

Background

In January 2023, the American Academy of Pediatrics (AAP) released new clinical practice guidelines on the evaluation and treatment of children with obesity. The new guidance, AAP’s first such update in 15 years, reflects a major change in clinical perspective on obesity: The AAP reframes obesity as a chronic disease—rather than a result of personal choices—carrying significant short- and long-term implications for children’s health, and highlights the importance of addressing it through early and intensive treatment.

The new guidance accompanies a broader, national increase in the focus on nutrition and health. In September 2022, the Biden-Harris Administration released their National Strategy on Hunger, Nutrition, and Health and hosted the first White House Conference on the topic in more than 50 years. Many related initiatives have since taken root at the federal, state and community levels. ^{1, 2, 3} This work aims to address a growing epidemic, with nearly 1 in 5 children affected by obesity in the United States,⁴ a figure that has nearly quadrupled since the 1970s.⁵

The following article reviews the new AAP guidance, its implications for pediatric clinical practice, and the associated impacts on coverage and care delivery for children enrolled in Medicaid.

Issues Addressed in the AAP Guidance

Childhood obesity is defined as a body mass index (BMI) at or above the 95th percentile for children and teens of the same age and sex, and overweight is defined as a BMI at or above the 85th percentile.⁶ The condition can have significant, lifelong implications for health. Obesity contributes to numerous health conditions throughout the life span, including high blood pressure, high cholesterol, type 2 diabetes, asthma, sleep apnea and joint problems.⁷ Children with obesity are shown to have more specialist and emergency room visits and higher prescription drug costs than those who do not have obesity.⁸ And evidence overwhelmingly indicates childhood obesity carries into adulthood;⁹ children and adolescents with obesity may be more than five times as likely to have obesity as adults as are their counterparts without obesity.¹⁰

The AAP guidance indicates a few key recommendations for the treatment of childhood obesity:

1. Destigmatization of weight and obesity. The AAP highlights the significant stigma surrounding childhood and adolescent obesity. In addition to contributing to eating disorders and behaviors such as decreased physical activity, this stigma can also lead to avoidance of medical care. The AAP recommends clinicians uncover and address their own bias regarding children with obesity and work to reduce weight stigma and bias in the clinical setting. Proposed approaches include the use of person-first language (e.g., “child with obesity” rather than “obese child”) and sensitivity in discussing weight with patients (e.g., focusing discussion on the child’s health rather than the child’s weight).¹¹
2. A more proactive approach to referrals. The AAP emphasizes the safety and effectiveness of current obesity treatments and lack of evidence supporting delays in treatment. The updated guidance indicates that rather than put off discussion of treatment due to stigma concerns, delay more intensive treatment in order to try counseling first, or wait for a child’s obesity to become severe, clinicians should refer children to intensive treatment programs as early as possible.¹²
3. Early, intensive treatment. The AAP guidelines specifically recommend children with obesity and their families receive intensive health behavior and lifestyle treatment (IHBLT). Such programs involve at least 26 hours of face-to-face, family-based treatment over the course of three to 12 months for children ages 6 and older and address nutrition, physical activity and behavior change. Care teams often involve community health workers, nutritionists, exercise physiologists, physical therapists and social workers who coordinate with pediatricians and other primary health care providers. For children with severe obesity, defined as a BMI of 120 percent of the 95th percentile of the same age and sex, the new AAP guidelines recommend referral for treatments such as weight loss pharmacotherapy as early as 12 years old and metabolic or bariatric surgery starting at age 13.¹³
4. Attention to the role of structural and socioeconomic factors in children’s risk for obesity. The AAP guidance highlights that, in addition to individual and familial risk factors, a number of structural and socioeconomic factors contribute to children’s obesity risk. Lower socioeconomic status, systemic racism and discrimination, exposure to toxic stress and adverse childhood experiences, and lack of access to healthy foods and opportunities for physical activity have been associated with higher obesity risk by adolescence.¹⁴ Such factors can also hinder treatment success, with children and families in under-resourced communities lacking access to available and affordable options for obesity treatment.

Criticisms of the AAP Guidance

While many providers, medical associations, and children’s health and nutrition advocates welcomed the guidance, the new guidelines have garnered some controversy among children’s health experts. Key concerns that have been cited include:

1. Lack of availability of IHBLT programs nationwide. Some critics have argued that IHBLT programs, the primary treatment option recommended by the AAP, remain rare nationwide. Program availability and differences in access based on demographic factors are not well understood, though most programs are located in cities and academic medical centers.¹⁵ Even where these intensive programs are available, many families may lack the time and finances needed to see them through to completion.¹⁶
2. Potential harm of interventions involving weight loss pharmacotherapy and surgery. For adolescents with severe obesity, the new guidance recommends evaluation for treatment interventions such as pharmacotherapy or metabolic or bariatric surgery.¹⁷ Some adolescent health experts have argued against performing surgery so early, citing long-term impacts on lifestyle, including the necessity of following strict, lifelong nutrition requirements. In addition, critics noted that the use of pharmacotherapy treatments for obesity in children remains relatively new.¹⁸
3. Risk of early weight discussion contributing to disordered eating. Despite the AAP’s emphasis on the importance of destigmatizing obesity, some pediatricians and adolescent medicine specialists have raised concerns that these conversations may contribute to development of other serious medical conditions related to disordered eating. Particularly when treatment options may be difficult to access or unsuccessful, critics argue such discussions may have negative implications for children’s relationships with food and their bodies for years to come.¹⁹

Focus on Nutrition and Health at the Federal and State Levels

Even before the release of the new AAP guidelines, a number of national efforts were already underway in response to the Biden-Harris Administration’s National Strategy on Hunger, Nutrition, and Health. In November 2022, the U.S. Department of Agriculture (USDA) announced it would invest over $59 million in incentive programs to support projects aimed at improving dietary health from the community level to the national level.²⁰ The same month, the AAP announced a partnership with No Kid Hungry’s Share Our Strength campaign to improve pediatric screening for food insecurity.^{21, 22}

States are initiating new work in this area as well. To support one of the key pillars of the National Strategy—the integration of nutrition and health—the Biden-Harris Administration committed to expanding access to “food-as-medicine” interventions for individuals enrolled in Medicaid, as well as nutrition and obesity counseling.²³ A number of state Medicaid programs have already aligned with this strategy; last fall, the Centers for Medicare & Medicaid Services (CMS) approved Section 1115 demonstrations in Arkansas, Massachusetts and Oregon to cover specified Health-Related Social Needs (HRSN) services, including nutritional assistance and medically tailored meals. California’s Medicaid program similarly began offering medically tailored meals to eligible enrollees last year as one of the state’s Community Supports services,²⁴ and North Carolina launched food support and meal delivery services in spring of 2022 as part of its Healthy Opportunities Pilots.²⁵

State Spotlights: Massachusetts and North Carolina

Massachusetts’ innovative demonstration enables the state to provide a robust package of nutrition supports as HRSN services:

• Nutrition counseling and education, including on preparing healthy meals
• Coverage of up to three medically tailored meals per day for up to six months, including delivery
• Six months of food prescriptions, such as fruit and vegetable prescriptions and protein boxes
• Provision of cooking supplies to support meal preparation, such as refrigerators, utensils, pots and pans
• Transportation to nutrition-related HRSN supports, as needed

Massachusetts may provide additional meal supports for households with children or pregnant individuals identified as having special health needs (such as a behavioral health or complex physical health need requiring improvement or support) and risk factors (such as nutritional deficiency or nutritional imbalance due to food insecurity).^{26, 27}

North Carolina’s demonstration allows the state to provide a suite of food support and meal delivery services. In addition to funding such services as nutrition counseling and education, provision of “healthy food boxes” and targeted meal delivery, North Carolina also offers services specifically relevant to children and adolescents. These include assistance with:

• Applications for the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants and Children (WIC)
• Identification of and access to school-based food programs
• Location of and referral to food banks or community-based summer and after-school food programs

What the New AAP Guidance Means for Medicaid

The new AAP guidelines highlight the importance of destigmatizing weight in pediatric clinical settings, paying attention to structural factors in children’s obesity risk, and initiating early and intensive obesity treatment. This guidance carries implications for care delivery as well as service coverage for childhood obesity treatment under Medicaid.

Currently, children enrolled in Medicaid have access to all services deemed medically necessary to address their obesity through the federal entitlement Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). These services may include BMI screening, nutrition education, prescription medication or surgery—anything that is medically necessary to care for the child, regardless of whether the service is covered in the Medicaid State Plan. In addition, under the Affordable Care Act (ACA), preventive screening and counseling services for obesity are covered nationwide, as is coverage of intensive lifestyle treatment for childhood, with no cost-sharing.²⁸ However, the AAP indicates there is a gap between this policy and actual practice.²⁹

Under the new AAP guidance, pediatricians and other primary care providers may soon deem more intensive treatments to be medically necessary for more patients. As a result, Medicaid may need to cover an increasing number of childhood obesity treatments covered through EPSDT—including pharmacological and surgical interventions.

Conclusion

States can take a number of actions to address childhood obesity early and reduce the need for medication and surgery. Medicaid programs can use the new AAP guidance to improve quality of care related to referral for and delivery of obesity treatment, particularly within vulnerable populations. They can ensure more holistic coverage of sub-specialists (e.g., registered dieticians) and leverage Section 1115 waiver authority to offer HRSN services that support the availability of and access to IHBLT programs for children and their families.³⁰ Medicaid programs can also work to improve underserved communities’ access to nutrition and physical activity resources to curb children’s and adolescents’ development of obesity and support better health outcomes for children and families in the long term.

_{^1. CMS. U.S. Health and Human Services (HHS) Approves Groundbreaking Medicaid Initiatives in Massachusetts and Oregon. Available here.}

_{^2. USDA. USDA Invests More Than $59M to Improve Dietary Health and Nutrition Security. November 2022. Available here.}

_{^3. Held, L. Medicaid Is a New Tool to Expand Healthy Food Access. Civil Eats. December 2022. Available here.}

_{^4. Centers for Disease Control and Prevention (CDC). Childhood Obesity Facts. May 2022. Available here.}

_{^5. Harvard T.H. Chan School of Public Health. Obesity Prevention Source: Child Obesity. Available here.}

_{^6. Hampl, S.E. et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. AAP. January 2023. Available here.}

_{^7. CDC. Childhood Obesity Facts. May 2022. Available here.}

_{^8. Wilfley, D.E. et al. Improving Access and Systems of Care for Evidence-Based Childhood Obesity Treatment: Conference Key Findings and Next Steps. Obesity. January 2017. Available here.}

_{^9. McCarthy, C. More than half of today’s children will be obese adults. Harvard Health Publishing: Harvard Medical School. December 2017. Available here.}

_{^10. Simmonds, M. et al. Predicting Adult Obesity from Childhood Obesity: A Systematic Review and Meta-Analysis. Obesity Reviews. December 2015. Available here.}

_{^11. Hampl, S. and Hassink, S. AAP’s First Clinical Practice Guideline on Obesity Advises Early, Intensive Care that Focuses on ‘Whole Child’. AAP News. January 2023. Available here.}

_{^12.Hampl, S. and Hassink, S. AAP’s First Clinical Practice Guideline on Obesity Advises Early, Intensive Care that Focuses on ‘Whole Child’. AAP News. January 2023. Available here.}

_{^13. Radde, K. New Childhood Obesity Guidance Raises Worries Over the Risk of Eating Disorders. NPR. February 2023. Available here.}

_{^14. Hampl, S.E. et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. AAP. January 2023. Available here.}

_{^15. Hampl, S.E. et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. AAP. January 2023. Available here.}

_{^16. Pearson, C. New Guidelines Underscore How Complicated Childhood Obesity Is for Patients and Providers. New York Times. January 2023. Available here.}

_{^17. Radde, K. New Childhood Obesity Guidance Raises Worries Over the Risk of Eating Disorders. NPR. February 2023. Available here.}

_{^18. Pearson, C. New Guidelines Underscore How Complicated Childhood Obesity Is for Patients and Providers. New York Times. January 2023. Available here.}

_{^19. Pearson, C. New Guidelines Underscore How Complicated Childhood Obesity Is for Patients and Providers. New York Times. January 2023. Available here.}

_{^20. USDA. USDA Invests More Than $59M to Improve Dietary Health and Nutrition Security. November 2022. Available here.}

_{^21. No Kid Hungry. RELEASE: No Kid Hungry and American Academy of Pediatrics Expand Partnership to Address Food Insecurity. December 2022. Available here.}

_{^22. Held, L. Medicaid Is a New Tool to Expand Healthy Food Access. Civil Eats. December 2022. Available here.}

_{^23. The White House. Biden-Harris Administration National Strategy on Hunger, Nutrition, and Health. September 2022. Available here.}

_{^24. California Department of Health Care Services. Medi-Cal Community Supports, or In Lieu of Services (ILOS), Policy Guide. January 2023. Available here.}

_{^25. NCDHHS. Healthy Opportunities Pilots. March 2023. Available here.}

_{^26. CMS. MassHealth Medicaid and CHIP Section 1115 Demonstration. November 2022. Available here.}

_{^27. CMS. HHS Approves Groundbreaking Medicaid Initiatives in Massachusetts and Oregon. October 2022. Available here.}

_{^28. This coverage mandate is due to the treatment’s “B” grade from the U.S. Preventive Services Task Force (USPSTF). The USPSTF is authorized by the U.S. Congress to assign grades to treatment options based on existing evidence, and health plans are mandated under the ADA to cover treatments with “A” and “B” grades with no cost-sharing.}

_{^29. Hampl, S.E. et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. AAP. January 2023. Available here.}

_{^30. Wilfley, D.E. et al. Improving Access and Systems of Care for Evidence-Based Childhood Obesity Treatment: Conference Key Findings and Next Steps. Obesity. January 2017. Available here.}