The guidance has been met with a lot of backlash—and rightfully so. Here’s the latest.
On January 9th of this year, the American Academy of Pediatricians (AAP) published their “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity.” With this guidance, the AAP is advising doctors and other providers that the “monitoring” and “watchful waiting” approaches are no longer valid. In a sad but unsurprising shift from the previous recommendations, the focus with the new guidance is unabashedly on weight (instead of health—which encompasses both the social determinants of health and mental health as foundational).
The new recommendations call for a more aggressive approach to larger-bodied children through proactive intervention via behavior modification, medications and bariatric surgery based solely on weight status (whether or not the child’s has any medical problems like hypertension, high cholesterol or prediabetes).
As a psychiatrist who focuses on eating disorders and trauma, I believe these new AAP guidelines—though well meaning—are stigmatizing, largely inaccessible, and unsustainable, for the great majority of Americans. More than any of that, these guidelines miss the whole point of doctoring. First, do no harm. Next, treat disease.
The harm of weight stigma and the primary focus on weight loss (rather than health engagement) pervades modern American culture. For the last 30 years, the medical establishment has focused on weight loss and BMI. Now we are doubling down and including children in this failed effort that has led us to worsening rates of diabetes, hypertension, and cardiovascular disease.
The misguided war on our children
The AAP guidelines, like the rest of medicine in America, take prioritizes thinness over health. Considering a person’s weight class alone as a disease is a fundamental flaw in how we practice medicine today, and a primary reason our current methods fail. Any guidelines that boil health down to BMI and solutions down to weight loss are doomed to fail.
They also may end up doing more harm than good because of the eating disorder risks associated with dieting and the impact of trauma of weight on kids, whose concept of self is still developing. Imagine from a kid’s perspective trying to understand your medical doctor telling you that you have a disease based on how you look. On the playground we call that bullying and expel the kids that engage in it. In the pediatric clinic we consider it “preventive care”?
Interestingly, in its 2016 guidelines on obesity, the AAP specifically and explicitly called for pediatricians and parents to avoid the “weight talk” and weight focus. The 2023 guidelines now emphasize the very thing the former recommendations said to avoid.
The gaping hole
The biggest miss with these guidelines is the lack of attention to mental health, trauma, eating disorder screening and social determinants of health. Food is a decent anesthetic for kids who are lacking in basic developmental needs (safety, nurturance, structure, consistency, attention). Food insecurity and the food environment are largely skimmed over in these guidelines.
It’s a lot quicker and easier to say to a parent and child, “you have a ‘disease’ called ‘your body is too big,’ but I can give you a once-a-week shot to make you lose weight (for at least as long as you stay on it for the price of $1,200 a month)” than it is to sit down with a kid and family to discuss what barriers may be to family meals that include fruits and vegetables and regular family activity/movement. Or to discuss what might be driving emotional eating and lack of regular movement/exercise.
My overall take on these guidelines
These AAP recommendations are well-intentioned, helpful in some aspects, and shine a bright light on an area of great concern: the physical health of our children. But pediatricians and their PCP counterparts are in a losing battle for the actual health of Americans, because we are focused on the wrong things.
For example, the guidelines use BMI as the be-all and end-all for measuring health, at the expense of many other more accurate markers such as blood pressure, cholesterol levels, blood glucose, mental health, level of engagement with exercise.
Also, how are children supposed to reach that BMI target, i.e., the almighty marker of good health? By losing weight. Sometimes a lot of it. Through radical interventions if necessary. But what about the increased levels of adolescent and young adult eating disorders triggered by weight stigma and dieting?
Because we’re focusing on the wrong thing (weight), we neglect key factors that will have a much more profound and sustainable health impact: the social determinants of health and the mental health of kids. People with trauma, depression, anxiety, and addiction have a difficult time taking care of themselves. They don’t have energy to make meals, eat intentionally, or engage in pleasurable movement. A surgery won’t fix that. A once-a-week shot (originally created for people with diabetes but now given to healthy people with higher BMIs) won’t fix that.
Further thoughts on BMI, behavior management, and medication and surgery recommendations
Body mass index: It’s problematic to make assumptions of health based on weight/BMI alone. In fact it’s irrelevant other than we know there are increased risks of developing certain medical and mental illnesses (like eating disorders and depression) at higher BMIs.
Meanwhile, as night follows day, these guidelines with their weight-loss focus will cause a spike in eating disorders among fat-shamed and weight-stigmatized children and adolescents, and these conditions will follow them into adulthood. There is robust research showing that a history of dieting is the number one risk factor for developing an eating disorder, with weight stigma and “the thin ideal” following close behind.
Many adolescents and young adults I treat for eating disorders and who live in larger bodies had doctors tell them as kids that their body is unhealthy or somehow broken because of their size. They were also told they needed to exercise more and eat less than “normal” kids. Those received messages are compounded by living in a society where: (1) thin equates to health, privilege, and power; and (2) they are subjected to awful bullying in school and sometimes by their families because of their size (causing weight stigma-related trauma).
Intensive health behavior and lifestyle treatment (IHBLT): Because the therapy normally lasts from 3 to 12 months, dropout rates are very high. Accessibility is a huge problem, especially in socioeconomically disadvantaged communities where parents don’t have the time or means to get their child to three hours of therapy every week. I could have the most potent and powerful medication that cures diabetes, but it doesn’t work if a person can’t get it or can’t sustain taking it regularly.
Medication and surgery recommendations: We don’t yet know if some of these new and powerful weight-loss medications (Wegovy, Ozempic, etc.) carry any risk of misuse, as some of them are quite new even for the adult market. But we do know from other weight loss medications that these drugs are often misused by people with eating disorders.
We also have little long-term impact data on health—including mental health—for kids or adolescents who have started on these medications. And what happens longer-term when a child stops the medications? Or are they supposed to take them forever? Will young people develop a tolerance for them, requiring higher doses? What must a kid think about their body if a doctor gives them a medication every week to shrink it?
The AAP guidelines say little about the dangers of using these medications particularly if there are no actual illness such as prediabetes, high blood pressure, or high cholesterol present. What about the mental health impact of telling a child at the age of five or six that they are sick (they have a “disease”) because of their body size, and they need to take medication for it. As a physician I can’t tell you if a person is healthy or unhealthy simply by looking at their height and weight. Health comes in all sizes. As does sickness.
As for referring certain kids 13+ years old for bariatric surgery, my main concern again is that there is very little data on the long-term physical and mental health effects of this drastic and expensive procedure when performed on young people. Of the studies we do have, some are concerning. One of the studies used to support the new AAP guidelines looked at 81 severely obese Swedish teenagers ages 13 to 18 who had bariatric surgery and were followed up for five years. Though average weight loss was significant, and cardiovascular health other health markers also improved, 20 test subjects (25 percent) ended up requiring follow-up surgery because of complications from the original procedure. 58 subjects (72 percent) showed some type of nutritional deficiency at the five-year follow-up. No mental health screens were listed as having been done.
Advice for parents
Focus on your child’s health (including mental health) not on their weight.
The great majority of the time, our bodies will take care of themselves when we take care of ourselves. Our weight will get to whatever is healthy for us (not for a BMI chart) when we take care of our pain, including emotional pain, loneliness, trauma, and when we have access to safe spaces, food security, family meals and variety in what we eat.
Another suggestion? Become an advocate. We need to fight against the insanity of a medical system that is hell bent on repeating a failed experiment regarding the adult “obesity epidemic”—but now with kids. Are we going to get different results with this same focus on weight and weight loss medications when it didn’t work for adults? What are we missing? A focus on systemic change, evaluation of the food environment, consideration of food addiction as a valid clinical entity, and healing the toxic internalized weight stigma that pervades our culture.
A good conversation to have with your pediatrician
I fully support parents who tell their child’s pediatrician to focus on their child’s health, and whether the child has indications of known conditions such as prediabetes, diabetes, high cholesterol, high blood pressure, liver disease and joint problems. Note: The American Medical Association decided in 2013 that obesity and overweight are diseases in and of themselves. This remains controversial, but it has now become standard dogma, which worsens the problem. If considering obesity a disease and prescribing diets, pills, and surgery actually worked, we wouldn’t still have rising rates of obesity, diabetes, heart disease, and eating disorders.
So yes, you are within your rights to ask your pediatrician to keep the focus off your child’s weight and BMI. Ask the pediatrician to screen your child for size-related trauma or stigma, depression, anxiety, and eating disorders.
If your pediatrician wants to start your otherwise healthy child on a weight-loss drug, tell them you want a referral to a child mental health professional first. That person will be better equipped to screen for eating disorder risk and risk of depression.
Also, ask your pediatrician what the end game is. When do you stop the medication? What happens then? What are the medical risks of medications or bariatric surgery? How many studies have looked at health outcomes ten years after this intervention? Or five? What about mental health outcomes?
This will help you make an informed decision. (Also, keep in mind your own weight bias!)
Final thought: As a doctor I took an oath to first do no harm. In my opinion, the new AAP guidelines risk doing substantial harm at worst, and at best not working long-term for many children.
This article was previously posted at Psychology Today: https://www.psychologytoday.com/us/blog/live-free/202302/a-critical-look-at-new-guidelines-for-kids-with-higher-bmis