This month, the American Academy of Pediatrics released its first comprehensive guidelines for evaluating and treating children and adolescents with obesity. The paper, co-written by 21 prominent doctors, health researchers and obesity experts, advises health care providers that they may refer children as young as 2 years old to “intensive health behavior and lifestyle treatment” programs if they have a body mass index in the overweight or obese range. For children ages 12 and up with an obese B.M.I., doctors are encouraged to prescribe weight-loss medications and to offer those over age 13 with severe obesity a referral to a bariatric surgery center.
The paper’s authors see this new guidance as a brave leap forward in the fight against childhood obesity, which they frame as a “complex and often persistent disease” requiring early and aggressive treatment.
But the guidelines are rooted in a premise that should have been rejected long ago: that weight loss is the best path to health and happiness.
The academy’s guidelines are the latest sally in the war on obesity that health care providers, public health officials and the general public have waged to shrink our bodies for over 40 years. The approach hasn’t worked; Americans, including kids, are not getting thinner.
Instead, we face an epidemic of anti-fat bias, which results in the stigmatization of fat people in schools, workplaces, doctor’s offices and other public spaces. In a study of almost 14,000 people enrolled in behavioral weight management programs across six countries, researchers found that over half of the participants had experienced weight stigma, with more than two-thirds of those encountering it doing so from doctors.
In dozens of interviews with families I heard about doctors shaming low-income moms for buying dollar store ramen noodles instead of pricier fresh vegetables. I talked to teenagers who were gaining weight while dealing with depression or anxiety and whose doctors told them to cut carbs. Families described doctors who rushed conversations, grabbed bellies or made jokes about kids’ bodies.
The guidelines acknowledge that experiences of “weight stigma, victimization, teasing and bullying” are major challenges faced by kids in larger bodies that contribute to disordered eating and worse mental health outcomes. Some health care providers, they note, are biased against fat patients in ways that compromise the quality of care and contribute to more severe illness and even death.
And yet by framing the new guidelines around the best ways to pursue and achieve weight loss for kids, the academy reinforces that bias. It relies heavily on B.M.I. as an indicator of health status, even though mounting evidence reveals its limits. B.M.I. may be less reliable when used in kids because it doesn’t consider a child’s muscle mass or level of pubertal development, both of which influence body composition.
Significant weight shifts in children can signal an underlying health condition like diabetes or an eating disorder, or food insecurity. (Some kids are also just genetically predisposed to be bigger.) But our weight-based medical model trains doctors to see “normalizing” a child’s B.M.I. as the priority rather than to view that number as one data point to be curious about. That leads providers and patients to focus on weight loss in the hopes thinness will fix everything else. But approaches to childhood health that focus on behavioral changes explicitly for weight control “rarely result in health improvement or sustainable weight loss and are instead associated with disordered eating and greater weight gain,” as a 2020 editorial in JAMA Pediatrics put it.
The American Academy of Pediatrics argues that its recommended “intensive health behavior and lifestyle treatment” program is different from the diets that we’ve long known can raise kids’ risk for eating disorders. A three-year study on almost 2,000 kids published in 1999 by Australian researchers found that teenage girls who dieted “at a severe level” were 18 times more likely to develop eating disorders than those who did not, and that even moderate dieters were at five times greater risk than non-dieting peers. (Subsequent studies have reaffirmed the link between dieting and eating disorders.)
We also know that a vast majority of efforts to deliver durable weight loss through lifestyle changes often fail in all age groups. This may be why the academy has added new tools to doctors’ arsenal, including bariatric surgery and weight-loss drugs. One drug, Wegovy, the brand name for semaglutide, was recently approved by the Food and Drug Administration for ages 12 and up. The pediatrician group says such strategies can help kids who have weight-linked health complications, like Type 2 diabetes and nonalcoholic fatty liver disease.
But it’s worth noting that Wegovy and other medications can come with side effects like diarrhea and vomiting, and long-term use of these drugs is not well studied in children. Meanwhile, one study used to support the academy’s guidance on bariatric surgery involved 81 Swedish teenagers; while cardiovascular health and other illnesses improved, 25 percent of the patients required additional surgery to resolve complications from the first procedure or from the rapid weight loss, and 72 percent reported nutritional deficiencies. Other research shows that bariatric surgery is associated with an increased risk for alcoholism and suicide.
What should the obesity guidelines say instead? Stop classifying kids and their health by body size altogether. This would involve a paradigm shift to weight-inclusive approaches, which see weight change as a possible symptom of, or a contributing factor toward, a larger health concern or struggle. These approaches focus providers on addressing that issue rather than managing weight loss. This means looking less at the number on the scale and talking more to families about their health priorities and challenges. Can they add healthy foods rather than restrict calories? Can they find ways to move their bodies that they enjoy? It also means avoiding stigmatizing discussions of weight and prescriptions of weight loss.
One weight-inclusive approach known as Health at Every Size has shown promising results in adults: a 2020 meta-analysis of 10 randomized control studies found that it showed similar efficacy to approaches aimed at weight loss in terms of physical health gains and a greater improvement in eating disorder outcomes. And a 2021 evidence review on the approach for adolescents concluded, “The benefits of HAES interventions on eating behavior and psychological well-being more broadly outweigh the potential risks of weight-focused care.”
We cannot solve anti-fat bias by making fat kids thin. Our current approach only teaches them that trusted adults believe the bullies are right — that a fat body is just a problem to solve. That’s not where the conversation about anyone’s health should begin.
Virginia Sole-Smith is the author of the forthcoming book “Fat Talk: Parenting in the Age of Diet Culture.” She also writes Burnt Toast, a newsletter about anti-fat bias and diet culture.
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