Earlier this month, as fellow eating disorder providers and I worked with clients and patients to navigate the annual new year dieting messages, the American Academy of Pediatrics (AAP) released new guidelines for children and adolescents with obesity*.
In addition to the more measured and refreshing suggestions, such as encouraging clinical opportunities to “screen and address the social, economic, educational, environmental and personal-capital needs of the children with obesity and their families,” the report was littered with egregious recommendations. Here are some of the worst:
Offering teens ages 12 and older obesity weight loss medications.
Advising that teens ages 13 and older with severe obesity, which they define using Body Mass Index (BMI), be assessed for weight loss surgeries.
Proposing that nutrition support, behavioral therapy and exercise guidance aimed at weight loss starting as early as two years old.
News of the new guidelines came to me through a speedy social media uproar of health providers and activists. Among them was fellow eating disorder dietitian Leslie Schilling, MS, RDN, CED-S, who took to Twitter on January 11 to share her thoughts: "In my twenty+ years as a registered dietitian/nutrition therapist, I have NEVER met an adult that found weight loss interventions/advice from their childhood pediatrician helpful. It almost always results in harm, also known as an eating disorder."
Weight-inclusive researcher and activist Regan Chastain also reacted to the guidelines. In one article, she focused on "red flags" related to conflicts of interest: "...you might not guess that, of the 14 authors who are medical doctors, eight have taken money from companies that are developing or sell weight loss products that either directly benefit, or may benefit from these recommendations either through the development of a new drug, or approval of an existing drug for adolescents."
On the other hand, The Obesity Society (TOS), a nonprofit organization focusing on "obesity treatment and prevention" and the Obesity Action Coalition (OAC) had a different take, outlined in a joint press release "More than 14 million children and adolescents are impacted by obesity, according to the AAP,” the release stated. “Despite the complexity of the disease, TOS and OAC are confident that the new AAP clinical guidelines will help steer pediatric obesity physicians to develop the best, comprehensive evidence-based treatment plans for their patients."
Additionally, pediatric gastroenterologist Rebecca Winderman, MD posted a video on Twitter on January 19 supporting the guidelines, including the use of medication to treat children with obesity. "This is a step in the right direction," she says.
Why I Can’t Support the AAP Guidelines
As an eating disorder dietitian and nutrition counselor, I have sat with countless clients replaying traumatizing experiences with their pediatricians who told them their bodies were problems to be solved. The majority of my clients recall those moments in their trusted doctors' offices as the beginning of their first diets, and the start of a fraught relationship with food and body. Some say those experiences kicked off their life-threatening eating disorders.
According to the National Association of Anorexia Nervosa & Associated Disorders (ANAD), eating disorders are the second deadliest mental illness behind opioid addiction and research shows a 100% increase in teen hospitalization for eating disorders since the start of COVID-19.
*As a weight-inclusive eating disorder provider who does not typically use stigmatizing and pathologizing language such as “overweight” or “obese,” please note I use such terms in this article when I am quoting or paraphrasing language used in the AAP’s guidelines.
Ironically, "these guidelines acknowledge that disordered eating may develop in the setting of behavioral weight loss interventions," says Anna Tanner, MD, FAAP, FSAHM, CEDS-S, Vice President of Child and Adolescent Medicine for Veritas Collaborative and The Emily Program. "This risk is so high that the authors recommend, 'Pediatricians should evaluate patients before, during, and after intensive behavioral intervention for the presence of disordered eating as well as for greater than expected weight change.'"
Dr. Tanner points out that a 2016 clinical report from the AAP, which is referenced in the new guidelines, cautioned that teens might use unhealthy behaviors to try to lose weight. The report included recommendations for pediatricians to focus on positive body image and healthy lifestyle habits, discourage dieting and focusing on weight, and encourage families not to talk about weight.
Plus, Dr. Tanner says, the long-term science isn't there to support safe use of AAP's suggested pharmacotherapies or bariatric surgery in kids. "Older patients who have had bariatric surgery face a risk of gastrointestinal (GI) complications and micronutrient deficiencies," she says. "We do not know how these types of problems might affect children aged 13 and older who still have significant growth and development ahead of them."
Aside from disrupting gastrointestinal absorption and growth processes, bariatric surgery comes with rigid post-op rules that many, especially children, may have difficulty following, says, Stefani Sassos, MS, RDN, CDN, Nutrition Director for the Good Housekeeping Institute. "Bariatric surgery is an incredibly intense and serious operation that requires strict dietary practices which can be unbelievably difficult to maintain," she says.
And the recommendations to start weight loss-focused nutrition regimes for toddlers, kids and teens put healthy growth and development into question.
"Nutrition and growth are closely tied. Although many people think of growth stopping after the pubertal growth spurt, significant bone and brain development continues until the late teens and into the early twenties," Dr. Tanner says. "Research shows that lack of appropriate weight gain in normally developing children and adolescents may lead to slowing and cessation of linear height gain and impede normal development of brain and bone."
Dr. Tanner notes the above medical complications are irreversible and seen in kids and teens with restrictive eating disorders. "No data is cited in [the AAP guidelines] that patients who restrict their diet to achieve recommended weight loss are immune to these significant medical concerns," she says.
Of course, there are other concerns with weight-loss focused nutrition interventions for kids, including impeding their connections to their bodies, and relationships with food and their bodies.
"Children are growing and developing at these young ages and restrictive feeding can not only negatively impact growth but also interfere with a child’s natural ability to listen to their hunger and fullness cues," Sassos says. "The rigidity and restriction may also backfire and contribute to disordered eating behaviors and a poor relationship with food as the child grows."
The AAP uses BMI percentages to determine weight loss interventions, which both Sassos and Dr. Tanner agree is questionable. "BMI itself does not take into account many important factors including muscle mass, bone density, racial differences and more," says Sassos.
"Providers should be encouraged to take a more nuanced approach to assessing growth and development and not rely on one calculated number – the BMI," Dr. Tanner adds.
Weight Stigma In a Doctor’s Office Starts Young
Discrimination against people because of their shape or size in healthcare settings continues to be a major public health issue. It can lower quality of care and even prevent people from going to the doctor at all. Research also supports weight stigma can in fact lead to weight gain and poor overall health.
"When patients experience weight stigma in a healthcare setting, they may suffer from increased rates of depression, anxiety, poor body image and social isolation," Dr. Tanner says. "Providers who care for patients with eating disorders are concerned that these recommendations may promote weight stigma and increase the risk of eating disorders and weight cycling."
Dr. Tanner points out that the AAP acknowledges that pediatricians are a source of weight bias and recommend they work to unearth and confront their attitudes regarding weight.
“We do not know which kids and adolescents are most vulnerable to the development of an eating disorder," Dr. Tanner says. "Providers and families must remember that eating disorders are serious mental illnesses with significant morbidity."
In a press release responding to the guidelines, The National Alliance for Eating Disorders says AAP acknowledges that genetics, racism, poverty, cultural differences and environmental contributors are factors in obesity, yet recommend behavior change for weight loss, which "further contributes to the misconception that 'obesity' is based on individual choices" and puts into question whether or not AAP truly cares about weight bias.
How Families Can Navigate the New Guidelines
Dr. Tanner stresses that families need to work with their pediatricians to find the best approach for their children. "It is clearly stated in the guidelines that parents can tell their pediatrician if they do not want to discuss these topics in front of their child," she says. "Conversations should focus on health-promoting behaviors."
Specifically, Sassos recommends adopting habits like structured family mealtimes focusing on balance and satisfaction and incorporating movement into fun family time. "Minimizing screen time and getting our children accustomed to the naturally slow pace of everyday life also plays a major role here," she says. "The intervention focus needs to be on promoting healthy lifestyle habits that are sustainable, realistic, attainable and accessible."
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