The New Obesity Guidelines for Kids are Horrifying, Registered Dietitian Says
Trigger warning:use of the word Obesity as part of the AAP guidelines
The American Academy of Pediatrics (AAP for short) has released a new set of guidelines in an effort to combat what they refer to as the “obesity epidemic” in children and adolescents.
The release of these guidelines has sparked controversy among dietitians and healthcare providers across the nation. Parents and caregivers everywhere are questioning whether these guidelines are more harmful to children than they are helpful. To understand how these guidelines may impact your and/or children you have in your life, it is necessary to understand exactly what the guidelines are recommending and the implications of this advice.
AAP Guidelines for Childhood Obesity - What are they?
The AAP guidelines for childhood obesity were released in February of 2023 in an effort to “evaluate and treat children with overweight and obesity related health concerns”. The AAP released these guidelines as a guiding tool for pediatric clinicians to use in order to treat children classified according to body-mass-index (BMI) as obese.
The guidelines can be broken down into three sections:
Intensive Health Behavior and Lifestyle Treatment (IHBLT)
Authors of these guidelines are recommending behavior and lifestyle interventions to manage weight in children as young as two years old. This includes motivational interviewing and behavioral change, nutrition, and physical activity support. Authors explicitly state in the executive summary that although IHBLT is “challenging to deliver” and “not universally available”, it should still be used to treat obesity in children.
Use of Weight Loss Pharmacotherapy
In cases of more severe obesity and risk of comorbidities, authors of these guidelines are recommending that clinicians use weight loss pharmacotherapy alongside IHBLT treatment.
Weight loss pharmacotherapy is the use of medications to promote or induce weight loss. The guidelines state that in children aged 12 years or older with severe obesity, clinicians should prescribe medication to cause weight loss. Some medications that the guidelines highlight include: metformin, orlistat, liraglutide, and topiramate.
Weight Loss Surgery
The guidelines recommend to physicians referrals for metabolic or bariatric surgery for children 13 years or older with cases of severe obesity.
Bariatric (also known as weight-loss) surgeries involve physically manipulating the structure of the digestive system as a means to lose weight. Some of these surgeries involve reducing the size of the stomach, which limits how much you can eat. Or, the surgeries can also bypass certain parts of the digestive system, limiting how much of the nutrients are absorbed from the foods you eat. In some cases, bariatric surgery can involve both.
With a closer look at these guidelines, its authors, and their inevitable impact on children nation-wide, people are beginning a much-needed discussion on the ethicalities of weight stigma in healthcare.
How have guidelines from the AAP changed from the past to now?
In 2016, the AAP released a publication titled “Preventing Obesity and Eating Disorders in Adolescents.” This paper aimed to highlight the importance in recognizing the role that weight-based language and medical treatment have on the development of eating disorders.
The paper identified factors that can put children at risk for developing eating disorders including dieting, weight talk, weight teasing, and body image. The AAP establishes dieting and caloric restriction as a risk factor for weight gain and increased risk of binge eating. The paper also admits the negative impacts of weight-talk and says that, “Parents who had conversations about weight had adolescents who were more likely to engage in dieting, unhealthy weight-control behaviors, and binge eating.” (1)
So how do they differ? The old AAP guidelines strongly advised against weight-centered comments and conversations among children, while the new guidelines base the entirety of clinical diagnoses in question on one factor: weight.
The old guidelines even make note of the fragile nature of a child’s perceived body image, stating that, “Weight issues can be a topic of sensitivity and therefore can be time consuming.”
In knowing this, there is cause for concern and confusion. The AAP states that they know the harm of weight stigma, and weight-based talk on children's body image and eating behaviors and in the same breath recommends that clinicians make recommendations that do exactly what they’re advising against.
When there is such a drastic shift for guidelines such as these, and seeing that their stance was different in the past, it’s important to take a look at who made the decisions about these guidelines and if they had any conflicts of interest.
Conflicts of interest for those that made AAP childhood obesity guidelines:
The guidelines fail to disclose multiple conflicts of interest including:
7 of the 14 authors are medical doctors who have profited from pharmaceutical companies
21 of the authors have careers based on “body-size-as-a-disease” paradigm
None of these financial profits were included in the “conflicts of interest” section of the guidelines. For example, one of these authors has profited upwards of $50,000 from pharmaceutical companies in promotion of products.
Additionally, of the 20+ authors that contributed to these guidelines, not one of the authors’ careers operate on a basis of weight-neutral care. These guidelines perpetuate the same beliefs that profit their marketed services.
It should also be noted that of the 20+ authors, there is not a single credentialed dietitian contributor.Doctors receive minimal education on nutrition care and support in their time at medical school. Dietitians devote their entire educational careers to understanding metabolism and nutrition needs.
How are the AAP guidelines rooted in weight stigma and bias?
These guidelines propose drastic blanket solutions to children that have unique lifestyles, resources, and needs. Additionally, the AAP guidelines are advising that clinicians use BMI to identify whether a child qualifies for the treatment mentioned above. However, BMI is not a reliable measurement of health/wellbeing in adults, and especially not in children. Up until early adulthood, children and adolescents are still growing, developing, and changing. This is why when working with children, dietitians use growth charts and not BMI. BMI in children (and adults) does not account for:
Metabolic health
Pubescent development
Growth chart changes or consistencies
Muscle mass
Genetic differences
BMI is a height-to-weight ratio used to produce a number that’s intended to indicate risk of poor health. The BMI scale was never intended to be used for health reasons. In addition to this, children are constantly growing, developing, and changing. BMI is not a reliable means to diagnose children with serious metabolic issues, and should not be the guiding measure for such drastic interventions.
In adult populations, there is significant research that shows metabolic disorders and chronic conditions that are typically attributed to body size, such as diabetes, heart disease, and stroke, are actually a result of weight-cycling. This fluctuation of weight causes more metabolic stress on the body. For children, the health impact of putting this kind of metabolic stress on a child’s growing body puts them at greater risk for the development of metabolic disorders, higher risk of gaining more weight, and higher risk of developing an eating disorder.
Additionally, the guidelines refer to obesity as an “epidemic”, which is defined as “a widespread occurrence of an infectious disease…” They use this as evidence for the need to adjust guidelines and create interventions. Comparing a person’s body size to an “infectious disease” displays the deeply rooted weight stigma and anti-fatness that these AAP guidelines are rooted in. The guidelines are teaching clinicians that children, who have a growing body, should limit their food intake, take weight loss drugs and possibly go under the knife purely because of their body size.
Why are the AAP guidelines harmful to children?
These guidelines and their weight bias pose an immense risk to children and adolescents. Not only do they not take into account that body diversity is a normal part of being a human, they are recommending a blanket type, one-size-fits-all treatment instead of looking at individual child or adolescent needs. Each child is different, and each child deserves to be treated so.
Secondly, these guidelines propose intensive health behavior and lifestyle treatment, recommending care from multiple providers including therapists, pediatricians, dietitians, pharmacists, and surgeons all while requiring parental involvement to be at an all-time high. Bariatric surgery requires a strict life-time adherence to a diet and exercise regimen - a regimen that would be life altering for a 13 year old. Similarly, pharmacotherapy requires intensive follow-up appointments that will require children to miss school and parents to miss work.
In this way, the guidelines fail to acknowledge how unfeasible it is to expect children of low socioeconomic status to have access to these services. There are many children for whom these “interventions” would be recommended that have low socioeconomic status, often experiencing food insecurity, poverty, and inadequate health care. To encourage the new AAP guidelines is to ignore a much bigger problem at hand: poverty, access to food, access to safe places to move, and other social determinants of health.
Thirdly, and very important to us as eating disorder dietitians at Bravespace Nutrition in Seattle, WA, these guidelines put children and adolescents at GREAT risk for the development of eating disorders.
Research supports that children are aware of their body image as young as age three. Countless research articles report that eating disorders are more likely to develop in childhood and adolescence. Even more studies show the impact of weight stigma on disordered eating behaviors. Prioritizing weight-talk and weight-consciousness at such a young age is detrimental to a child’s self-efficacy, self-perception, and overall mental health. By encouraging these clinical guidelines, we are contributing to children feeling unworthy, unaccepted, and unloved by their families and by the world. Eating disorders are the second deadliest mental illness, and our children deserve more than the weight bias and body judgment these AAP guidelines perpetuate.
Fourthly, the medications listed as weight-loss pharmacotherapy are backed by minimal research. These are just a few of the medications listed in the weight loss pharmacotherapy section of the AAP guidelines and here is their recommend for children:
Metformin - a drug typically used for diabetes but has not been approved for weight-loss
Orlistat - a medication backed by only 2 research studies (one with 25 total participants, 7 of which dropped out due to severe side effects, and another that showed total weight regain while still on the medication
Liraglutide - a diabetes medication that also showed overall total weight gain
Topiramate - a medication initially meant to treat migraines and seizures but has an additional side effect of reduced appetite (a pathophsyiological mechanism scientists still haven’t identified) and evidence of cognitive slowing in children
Here’s the truth: Children don’t need weight loss interventions, diets, weight loss surgery or drugs. Children don’t need doctors telling them there is something wrong with their body. Some children have fat bodies and others have thin bodies, and everything in between. We need to stop pathologizing fatness, especially in children, and start getting at the root of what a child might be struggling with such as access to food, access to healthcare, access to safe places to move, and access to a better quality of life. Health is not a body size and we at Bravespace Nutrition fundamentally reject these new guidelines.
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Do you feel concerned about your child or teens body size and not quite sure what to do? Curious to learn more about these AAP guidelines?
At Bravespace Nutrition, our Health At Every Size, eating disorder Dietitians want to help and support you in healing your or your child’s relationship to food and body. We offer nutrition therapy to people ages 16+ and coaching to parents that wants to support their kids in food and body image challenges. We specialize in eating disorders, disordered eating, intuitive eating and body image concerns. Reach out to us to schedule a discovery call today!
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