While the United States Preventative Services Taskforce (USPSTF) made a positive change in dropping “obesity” and “overweight” from their recommendation, the primary focus is still on weight (BMI) and the main outcome is weight loss. Weight stigma we know from robust data causes profound harm to people living in larger bodies, and there’s no way to say to a family or a kid, “I’m recommending a form of intensive behavior and lifestyle therapy based on your child’s BMI…” without adding to weight stigma and causing harm. It doesn’t matter what tone of voice you use, or what words you put around it, or any other way you try to be sensitive about the topic. The focus always needs to be on health as defined by the patient and family, looking at actual conditions known to harm health, which would include high blood pressure, high cholesterol, high fasting blood glucose, and DEPRESSION, PTSD, ANXIETY, EATING DISORDERS, etc.
The preamble to this recommendation states, “The USPSTF is committed to helping reverse the negative impacts of systemic and structural racism, gender-based discrimination, bias, and other sources of health inequities, and their effects on health, throughout its work.”
Despite the USPSTF‘s stated commitment to reversing the impact of systemic racism, they fail to acknowledge that BMI is an outdated and inherently racist tool, created by a white man for use in white men (for insurance risk purposes) and applied to other racial groups without data specific to those racial groups (such as Black Americans, Hispanic Americans, Native Americans, Asian Americans). It is a tool that perpetuates weight stigma and systemic racism in medicine and disproportionately harms marginalized children.
Another positive in the recommendation was the acknowledgment of potential harms outweighing benefits of weight loss medication for children (which the American Academy of Pediatrics supported in their latest recommendations) as well as the dangerous lack of any long-term data for children on those medications. The recommendation by USPSTF also acknowledges the data supporting their recommendation in this article (intensive behavioral and lifestyle interventions) has no long term data.
One of the most problematic pieces of the recommendation was its BMI-based recommendation for a therapy that many people don’t have access to. Intensive health behavior and lifestyle therapy (IHBLT) requires 26 hours minimum of contact over the course of a year. Many working parents with limited resources and more than one child to care for, even if they had access to such a therapy, would not practically be able to avail themselves of it. This puts both pediatricians who are trying to help and parents in quite a bind. Even those who are able to get to the therapy don’t always have providers of it geographically close to them.
In summary, any intervention for children that is based on the child’s size and that implicitly or explicitly focuses on weight loss as a goal adds to weight stigma. This must be acknowledged explicitly in the recommendation as a harm. Families deserve informed consent, and behavioral therapies come with their own set of potential “side effects.” Further, data to support recommendations from USPSTF needs to include more research that centers mental health outcomes and long term outcomes, especially for children. Finally, recommended interventions must be accessible to those they are intended to serve. We are facing massive burnout in medicine, with a medical workforce ill-equipped to identify eating disorder risk factors and ill-equipped to manage the explosion of mental health crisis facing our nation’s youth. A decade from now, if we continue to head in the current direction, that crisis will be exponentially worse.
Any of you who care about this issue and treat patients who have been harmed by weight stigma, please speak up. The full recommendation is currently available online and open for comments using the following link.: https://www.uspreventiveservicestaskforce.org/uspstf/high-bmi-children-adolescents-interventions-draft-evidence-review
Kim Dennis, MD
CMO, SunCloud Health