Laseanya Darby has dropped more than 45 pounds in three months. The Owings Mills resident is exercising, eating right and feeling good. At age 20, Darby’s only regret is that she couldn’t have had bariatric surgery sooner.
“I didn’t feel like a normal child,” Darby said. “People would say, ’Look at her, she’s so big.’ I wasn’t healthy. If I’d been offered surgery as a teenager I would have considered it because when you’re younger everything is easier.”
Leading pediatricians are starting to agree.
The childhood obesity rate has tripled in the past three decades to 14.4 million, or 1 in 6 kids, and the American Academy of Pediatrics issued guidance in January eschewing traditional “watchful waiting” and calling for earlier intervention.
That includes weight loss medications for those as young as age 12 and surgery at age 13.
The most aggressive measures are not for kids likely to thin out as they grow, or a first step for anyone. And pediatricians say they still believe in behavioral changes, as well as approaches that avoid stigmatizing families and children for their shape.
The idea is to treat children gaining so much weight so fast they already are showing signs of diabetes, high blood pressure and other potentially devastating conditions.
Pediatricians say they strive to involve all family members, avoid words like “diet,” “weight” or “exercise” in favor of healthy eating and being active, and set realistic goals.
“Our kids need the medical support, understanding and resources we can provide within a treatment plan that involves the whole family,” said Dr. Sarah Hampl, a lead author of the guidelines, in a statement when they were released.
What stops doctors and families from intervening sooner
Achieving the goals, however, is far easier said than done. Medical providers say challenges include access to healthy food, safe places for activities, costs and their own ability to deliver results.
The guidelines don’t come with training for primary care doctors on using medications or when to turn to surgery, which both come with side effects and long-term commitments.
“Doctors, of course, want to follow the guidelines, but the tricky thing is actually implementing them in real life,” said Dr. John Irwin, a pediatrician at MedStar Harbor Hospital in South Baltimore.
“What should we do, and what can we do, with insurance and other barriers families face?” he said. “It’ll be hard to implement them, though it doesn’t mean they shouldn’t be done.”
He said primary care doctors have limited time with patients, and weight gain can result from a complex tangle of medical, genetic, environmental and cultural issues. Specialty programs, like the one at Mt. Washington Pediatric Hospital that treated Darby, fill up fast.
Just defining obesity can also be tricky, as the standard calculation using body mass index, a combination of height and weight, is widely considered an oversimplification, but there’s not an accepted alternative. Obesity is a step above overweight on BMI tables.
Still, providers believe earlier intervention is essential to preserve kids’ health and mental well-being, said Jill Morgan, a pediatric clinical pharmacy specialist who works in a University of Maryland gastroenterology practice seeing children ages 3 and older.
She said about 20% of overweight and obese children are pre-diabetic and at risk of damage to their hearts, blood vessels and other organs. Kids like Darby have coped with poor self-image, bullying and inability to participate in activities.
First steps can be simple, like replacing weight-inducing medications or eliminating fruit juice, often a primary and underappreciated culprit. But usually, they are long-term and fraught, like overhauling whole meals and incorporating regular activity.
“The guidelines very much stress the use of behavioral change,” said Morgan, also a professor and chair of Maryland’s Department of Practice, Sciences and Health Outcomes Research. “But kids don’t go grocery shopping, so you can’t just be talking to the child.”
Doctors have long been using medications, often “off-label,” or when approved for older people or other uses. Expected to gain in use are new drugs appearing more effective, like Ozempic and Wegovy, approved for kids ages 12 and older who weigh at least 132 pounds. Medications, however, are usually needed long-term and can cause stomach issues.
They also can cost $1,000 a month out-of-pocket, said Dr. Stephanie Green, a pediatric endocrinologist at Johns Hopkins Children’s Center and Kennedy Krieger Institute. She and colleagues are pushing Medicaid, the government health program for low-income residents, to cover the drugs.
“We should be starting medications early and giving guidance on how to do that,” she said. “We need to mobilize general pediatricians on this because watchful waiting doesn’t work.”
Surgery, she said, is still limited at Hopkins to those ages 16 and older.
Treating obesity as a chronic disease
Still, medication and surgery don’t work on their own. She and Dr. Anton Dietzen, co-director of Kennedy Krieger’s Fit and Healthy Clinic, involve a team of experts, including nutritionists, behaviorists, endocrinologists and others to tailor programs to patients.
They map out healthy meals and how to achieve them without creating negative food associations or seeming so judgmental or aggressive families reject them. They add physical therapy and other activity, and promote good sleeping habits.
They suggest things like nixing extra meals and snacks and reducing portion sizes and unhealthy choices. They also call for reduced screen time, especially at bedtime, and the addition of activities that generate extra steps and are fun, like dancing, even for 10 minutes.
“Obesity is a chronic disease that can wax and wane,” Green said. “We have access to some of the most effective medications we’ve ever had, but it’s a big decision for families. ... Lifestyle changes can be more impactful.”
Michelle Demeule-Hayes, director of Mt. Washington’s Weigh Smart Program, said starting at younger ages helps because “habits are less engrained.” The average age and weight of patients there is 12 and 200 pounds. Darby started at age 7.
“We were seeing heavy children at 5, and their doctors didn’t know what to do with them,” she said. “It’s the nature of health care; they see patients for 15 or 20 minutes, and that’s not enough time.”
Demeule-Hayes said her program has evolved over time to focus on positive language and developing realistic expectations. The program also addresses access to food by, for example, passing out packs of healthy food through schools that kids can take home.
She said programs still must turn to other tools when necessary; the program recently referred a 16-year-old weighing 400 pounds for surgery.
“They [other options] can’t be off the table,” she said.
Darby and her mother, Rana Young, welcomed both the push for positive language and solid plans for achievable goals — and knowing when more is needed.
Young said doctors couldn’t explain why Darby began gaining weight quickly after infancy. They found no medical reason and blamed genetics because she and her husband were overweight, though Darby’s siblings were not.
By age 4 or 5 Darby was over 100 pounds. They ditched high-calorie drinks and junk food and found ways to be active. They dutifully participated in Mt. Washington’s programs. Darby had constant support from family.
At age 12, she was over 200 pounds, needed surgery on her leg due to weight complications and told doctors she didn’t like her body because she was bigger than her peers.
At 18 and over 450 pounds, doctors finally recommended surgery, but she was scared. Her mother, a constant companion and supporter, got bariatric surgery first.
Mother and daughter now eat small, healthy meals, walk three miles daily in their tree-lined Owings Mills neighborhood and enjoy watching their shapes change. They have registered big improvements in their blood pressure and cholesterol. Young’s diabetes is no longer detectable.
Darby said she’s looking forward to the future and plans to become a certified nursing assistant.
“I’d tell everyone to get help early on so you can get on with your life,” she said. “We’re grateful where we are today, but earlier would have been better.”
This article has been updated to correct the name of Mount Washington Pediatric Hospital's weight-management program. It is called Weigh Smart.