What do new pediatric ‘obesity’ guidelines really mean for kids?

On Nutrition

Last month, the American Academy of Pediatrics released its clinical guidelines for “the evaluation and treatment of children and adolescents with obesity.” The recommendations include weight management (“intensive health behavior and lifestyle treatment”) for children as young as age 2, weight loss drugs for kids as young as 12 and bariatric surgery for those as young as 13.

On the surface, the guidelines look evidence-based and even sensitive, allotting significant space to discussion of health disparities and inequities caused by poverty, racism, weight stigma (anti-fatness) and other forms of systemic oppression. But below the surface, something darker emerges. And not just because many of the guideline authors have received money from pharmaceutical companies who manufacture weight loss drugs, or because some of these companies give money directly to the AAP.

Let’s start with the shaky foundation the guidelines stand on. In 2013, the American Medical Association designated “obesity” as a disease, going against the recommendations of its own Council on Science and Public Health. The council said that while “obesity” is associated with many health problems (note: association doesn’t prove cause-and-effect) and may increase the risk of some of those problems, designating it as a disease wouldn’t necessarily improve health. They pointed out that the tool used to measure “obesity,” body mass index, is “an indirect and imperfect measure of body fatness,” so not an accurate diagnostic tool.

Here’s where the council was psychic: They were concerned that fat people with healthy nutrition and lifestyle habits may still be pressured to receive weight loss drugs or surgery, and that widespread recognition of “obesity” as a disease would result in a greater push to develop, and get insurance reimbursement for, those drugs and those surgeries. Cha-ching. (I use “fat” as a neutral descriptor, like short or tall.)

Despite repeatedly stating that “obesity” is associated with other health problems, the guidelines echo years of fearmongering public health campaigns with strong statements implying that “obesity” causes disease. When I traced these claims to the cited research studies (and to some studies cited by those studies) I found a string of unsupported opinions, associations and assumptions that if fat people are more likely to, say, develop high blood pressure, it’s because they are fat. (How then to explain thin people who get high blood pressure?)

The guideline authors recommend weight loss even for healthy fat kids, noting that many won’t lose weight, that those who do will likely lose only 1% to 3% of their starting weight, and that there’s “limited” evidence about the viability of long-term weight loss. They write, “The natural course of obesity across the life span is characterized by responses to treatment and relapse when treatment ends.” In other words, weight cycling, which itself can harm health.

So putting children on supervised diets and indoctrinating them into the idea of “good” foods and “bad” foods because their bodies are “diseased” may only result in, say, 1 to 3 pounds of weight loss for a 100-pound child? And they’ll probably gain the weight back (relapsing), so they’ll go on another diet (treatment) and be set up for years — or a lifetime — of yo-yo dieting, body shame and possibly an eating disorder.

The “evidence” to support use of weight loss drugs or bariatric surgery isn’t any better. The cited gastric bypass studies only looked at a total of 161 adolescents, followed them up for a maximum of “5+ years,” and noted weight regain, nutritional deficiencies and need for additional surgery in many cases. Several drugs are recommended (some “off label”), but the cited studies involving adolescents were plagued by a significant risk of side effects, minimal weight loss (sometimes none) and weight regain.

It gets even worse for kids who aren’t white. The authors write about the need to address “the structural racism in our society that drives the alarming and persistent disparities in childhood obesity and obesity related comorbidities.” That’s a bit tone deaf in a country where Black people are shot for being Black while walking, sleeping, driving, playing, etc. Reducing any child’s body to a risk factor is stigmatizing, but when you’re talking about Black, brown, Indigenous and other children of color, it’s racist. Pressuring these families to make their children’s bodies comply with the wishes of a predominantly white medical establishment is not health equity. “Educating” families about nutrition and physical activity can’t overcome the structural forces that affect food choices and activity levels in marginalized communities. Their health, and even their lives, will still be at risk because of those structural forces and the color of their skin.

Poverty, racism and weight stigma contribute to health disparities and inequities that have direct effects on health, regardless of body size. The guidelines tell pediatricians they need to “understand” these things, but then prescribe weight loss as the “solution.” Increasing access to adequate food, to nutritious food, to safe places to play and be active are all good, important things — for all kids of all sizes.

The guideline authors write that “pediatricians and other [primary health care providers] have been — and remain — a source of weight bias. They first need to uncover and address their own attitudes regarding children with obesity.” That sounds promising, but there’s no plan, no talk of real solutions, and no accountability to do better.

Can parents of fat children — who may be fat themselves — really make an “informed choice” in an anti-fat medical system in an anti-fat society? Even parents from marginalized groups who may feel historical pressure to comply? Even when the supposed benefits of weight loss diets, drugs and surgeries may be oversold, and the risks undersold? Health problems that happen in fat people happen in thin people, too, and those health problems can be treated directly. Making weight the scapegoat and pressuring families to pursue weight loss for their children leads to health care avoidance, and that helps no one.