Tackling Texas Childhood Obesity with Evidence-Based Policies

Introduction

Childhood obesity is an epidemic with major short- and long-term effects on the health of Texans and the state’s economy. Despite Texas having passed several laws to address the burdens of this disease since 2000, the percentage of Texans who are obese, including children, continues to grow. In recent times, national medical organizations have updated their clinical guidelines, detailing new medications and procedures with the potential to make a substantial impact on childhood obesity. This brief outlines a modern policy approach to childhood obesity — incorporating advances made over the last decade and providing policy options and recommendations. With a renewed, evidence-based approach, Texas can turn the tide against the increasing problem of childhood obesity.

A Growing Issue

In 2020, one-fifth of children in Texas between the ages of 10–17 met criteria for obesity, a figure 4% higher than the national average. Periodic state assessments show that this rate will likely continue to worsen. Amongst 4th graders, the percentage rose from 24% in 2009 to 27% in 2017. Further, in Texas, Hispanic and African American children have nearly twice the rate of obesity compared to non-Hispanic white children.

Figure 1 — Trends in Obesity in Children and Adolescents: United States, 1963–2018

Comorbidities and Cost

As children become more obese, they begin developing comorbidities such as diabetes, hypertension, depression, and asthma. There are indications of an association between childhood obesity and mental health disorders. Depending on its severity, obesity can significantly reduce life expectancy, potentially shortening lifespan by five to 20 years.

Obesity and its subsequent comorbidities also lead to greatly increased health care costs. One study found that obesity added $307 per capita in annual total medical costs per child and if that child had to be hospitalized, there would be an increase of $2,848 per hospitalization compared to a child of normal weight. Another study estimated that a child with obesity will have anywhere from $12,000 to $19,000 more in lifetime medical costs than a child with a normal weight. Across the country, the estimated annual cost of obesity among children in 2019 was $1.3 billion.

Legislation

Over the years, Texas has attempted to address childhood obesity with legislation, implementing multiple recommendations to improve nutrition and exercise in schools, starting with SB 19 in 2001 — later extended to middle school students in 2003 by SB 42. Despite these efforts, childhood obesity has continued to rise in Texas. Fortunately, treatments and guidelines have also evolved and in 2023 the American Academy of Pediatrics (AAP) released guidelines on the most recent evidence on the treatment of childhood obesity.

Medication

Medications, including newer classes such as glucagon-like peptide-1 (GLP-1) agonists (marketed as Wegovy or Ozempic), are a promising new tool available to pediatricians. Randomized controlled trials have shown a decrease in body mass index (BMI) of 5% over one year for liraglutide, a weekly injectable medication that is FDA approved for children 12 and older. Despite these results and FDA approval, only 10 states cover anti-obesity medication through their Medicaid programs: Texas is not one of them.

Surgery for Severe Obesity

Specific and clear consideration is needed for a growing cohort of children who, given the severity of their obesity and inability of medications to improve their risk of comorbid conditions, may require additional treatment. Metabolic and bariatric surgery (MBS) refers to several effective surgical procedures performed on the gastrointestinal tract to promote weight loss. 

A study comparing bariatric surgery to medication therapy in children with type 2 diabetes mellitus and severe obesity showed that the risk of a cardiovascular disease continued to rise in children receiving medical therapy only. In contrast, those who underwent bariatric surgery were able to significantly reduce this risk. This risk reduction persisted five years after surgery, and other studies have shown that bariatric surgery in adolescents can more effectively reduce or eliminate comorbidities such as diabetes and hypertension compared to surgery as adults.

The next sections offer policy options for consideration by the Texas legislature and policy recommendations aimed at more immediate action.

Policy Options

Direct the Texas Department of Health and Human Services to investigate the fiscal implications, as well as health risks and benefits, of including anti-obesity medication and bariatric surgery in Texas Children’s Medicaid and Children’s Health Insurance Program (CHIP) coverage for consideration at the next legislative session.

Key Points:

• Advantage — An evaluation of any policy suggestion is vital to proper implementation. This approach could help provide more information to advocate for these policy changes with lawmakers. 
• Disadvantage — This alternative lengthens the amount of time to implementation of effective policy, which is undesirable given the growing childhood obesity rates in Texas.

Implement an excise tax on sugar-sweetened beverages and eliminate the tax deduction for companies headquartered in Texas that advertise unhealthy food to children, as defined by USDA guidelines.

Key Points:

• Given that nearly 60% of Texas’ 11th graders consume a sugar-sweetened beverage daily, the state has room to improve its childhood and adolescent obesity prevention efforts.
• Elimination of tax deductions for companies that advertise unhealthy foods is recommended by the American Academy of Pediatrics (AAP) guidelines.
• While these interventions would have the added benefit of increasing tax revenue, they may be politically unpopular.
• Since changes like these take time to implement and change behaviors, their ability to provide a direct, immediate, and effective impact is limited.

Policy Recommendations

Direct state and third-party vendors of Texas Children’s Medicaid and CHIP to cover anti-obesity medications for children over 12, including GLP-1 agonists, per FDA approval and AAP clinical guidelines.

Key Points:

• These medications have been shown to be an effective part of a multimodal approach to obesity.
• Medicaid can lead in setting coverage standards for the insurance industry.
• While coverage may initially be costly, the long-term reduction in healthcare utilization and associated savings must also be considered.

Direct state and third-party vendors of Texas Children’s Medicaid and CHIP to cover bariatric surgery for children over 12 with class 2 obesity and comorbidities or class 3 obesity alone, per AAP clinical guidelines.

Key Points:

• Severe obesity includes class 2 and 3 obesity. Class 2 obesity is defined as BMI 120% to 140% of the 95th percentile or a BMI between 35 kg to 39.9 kg/m2. Class 3 obesity is defined as over 140% of the 95th percentile or BMI over 40 kg/m2.
• For these children, the severity of their condition means that lifestyle changes and medications are not enough; bariatric surgery is the primary intervention that can assist them.
• Because this procedure is expensive, a cost analysis should be considered before implementation.
• Insurance coverage for bariatric surgery is imperative for any modern approach to addressing the childhood obesity epidemic.

Conclusion

The rapid development of weight-loss aiding medications and surgeries has changed the landscape in the fight against childhood obesity. The efficacy and safety of these interventions is sufficient to warrant a change in national guidelines. To fully leverage the benefits of these advances, our state’s policies must evolve to effectively tackle the growing challenge of childhood obesity, ensuring a healthier and more prosperous future for all Texans.

This material may be quoted or reproduced without prior permission, provided appropriate credit is given to the author and Rice University’s Baker Institute for Public Policy. The views expressed herein are those of the individual author(s), and do not necessarily represent the views of Rice University’s Baker Institute for Public Policy.