As a physician, I took an oath to first do no harm. That’s my first order of business. My second order of business is to identify and treat diseases.
The recently released American Academy of Pediatrics (AAP) guidelines, “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity,” published in the February 2023 issue of Pediatrics, focus on achieving weight loss as a primary goal of treatment. Making BMI/weight loss a priority and focusing on “treating” a child’s weight status is antithetical to both of my primary aims as a physician. I do not believe what the medical community categorizes as obesity or overweight are disease states in and of themselves.
In 2013 the American Medical Association made the decision to consider the physical states known as “overweight” and “obesity” diseases. Part of their decision, they say, was to increase research and access to care for these conditions, which are largely driven by a person’s genetics and biological factors they have no control over. However, there is a fundamental flaw in any system that characterizes someone as having a disease based solely on the size of their body. BMI we know is an imperfect data point, as a physical measure calculated using only a person’s height and weight. It does not take into account factors including an individual’s culture, body type, or amount of muscle mass.
People come in a variety of different sizes and shapes and colors naturally. As a medical professional, I cannot tell you if a person has any diseases based on their height and weight alone. We know there are risks associated with developing certain medical conditions that occur more commonly in people who live in larger bodies, but these medical illnesses themselves have markers in the form of abnormal blood tests (ex. high fasting blood glucose, elevated hemoglobin A1c, high blood pressure, high cholesterol, or elevated liver enzymes). If those disease markers aren’t there, I would not treat someone for a disease they did not yet have and might not ever have. Yet, the new Clinical Practice Guidelines (CPG) recommend doing just that, and doing so aggressively. The guidelines endorse treating children and adolescents who live in larger bodies as if they have a disease even without any indication of such based on blood tests or other medical tests.
They go further to say the focus of treatment should be on weight loss, and endorse aggressive treatment of these children and adolescents with weight loss medications and even bariatric surgery. There is precious little long term outcome studies on the health (including mental health) of these children 10 or 20 years out. We know that once people stop using the newer weight loss medications (called GLP-1 agonists) they gain back weight that was lost. In essence the guidelines suggest starting these medications with no clear data or guidance on when to ever end them.
What we do know from robust data is that dieting is one of the most significant risk factors for developing eating disorders (which people in larger bodies already have increased risk for). When parents diet or talk about weight to their kids, the risk increases further. We do know that people living in larger bodies, especially children and adolescents, face weight stigma and bullying regularly because of how they look. This takes a tremendous toll on the self esteem, mental health, academic and social functioning of the children and adolescents who are subjected to it. We know that weight stigma increases disordered eating, including binge eating. The data on these points is clear.
Kids today face overwhelming social pressures exacerbated by social media, all of which in America centers on the thin ideal. We currently have a child and adolescent mental health crisis that worsened significantly during the pandemic, with rates of inpatient hospitalizations for suicidal ideation and eating disorders reaching record highs.
The guidelines put out by AAP mention mental health. They mention screening for eating disorders, which medical students receive little to no training in. Expecting a pediatrician to detect an eating disorder (unless it’s quite advanced) is like expecting a psychiatrist to screen for a rare dermatological condition (you’d want to see a dermatologist for that). They mention the risks of bullying and weight stigma. But none of these mentioned areas are centered or prioritized in the guidelines. The known risks of focusing on weight and weight loss as primary markers of health are not discussed. The unknown risks of launching into a long course of pharmacotherapy are minimized. The new guidelines directly contradict the 2016 paper written by the AAP on “obesity” and eating disorders, which explicitly states that the focus should NOT be on weight or weight talk but on health and indicators of health like blood glucose, lipid profile, bone health, exercise, increasing fresh vegetables in dietary intake, etc.
Seven years later, the definition of health for America’s youth has been distilled largely down to BMI. I know we can do better than this. I shudder to think about the long term consequences of widespread adoption of the AAP guidelines on the mental health and long term physical health of the high risk children that this guideline specifically targets. There are ways to achieve health that are healthy, affirming and sustainable. There are quick fixes (weight loss shots or surgeries) that fail to address the needs of the person as a whole, in a culturally attuned way, and these quick fixes rarely, in my experience, equate to long term health. The staggering gaps in health equity and systemic issues need to be aggressively addressed, including the real problem of worsened health status in the growing number of kids living with violence in their communities, unequal access to fresh foods, increases in child and adolescent (and parental) mental health and substance use disorders, unequal access to good healthcare, and the food environment. AND the ever-growing social pressure to lose weight and be thin.
Dr. Kim Dennis was featured on PBS NewsHour to discuss the AAP’s new clinical guidelines. Many eating disorder specialists disagree with them. Watch Dr. Dennis’ response:
