New pediatric guidelines on childhood obesity are a massive problem
And why it's important for more than just kids
In January, the American Academy of Pediatrics (AAP) released new guidelines for the “Evaluation and Treatment of Children and Adolescents with Obesity.” These guidelines got some splashy headlines — both positive and negative — but the mainstream media conversation about them has been pretty superficial. This is a massive disservice for a health guideline that will affect one-third of American children.
There is so much to grapple with in the new AAP guidelines that it is hard to be concise. So I’m not going to untangle everything here. Instead, I am going to focus on what I think are the largest flaws in the new approach and will point you to other articles if you are interested in going deeper.
For better or worse…
The AAP’s stated goal is to make obesity treatments such as weight loss drugs (e.g. Ozempic and Wegovy), and bariatric surgery more accessible to children and adolescents. The AAP acknowledges that there is a stigma against obesity1 in the medical profession and helpfully points out that too many doctors think obesity is a failure of willpower instead of a complex and multifactorial condition. The AAP undoubtedly thinks it is doing the right thing by offering surgery and drugs to fix that, but the new guidelines suffer from fundamental flaws that are going to end up causing harm.
First, the treatments offered are prohibitively expensive and aren’t covered by Medicaid/insurance;
Second, the overall approach focuses on weight loss above all else and applies to millions of healthy children;
And third, the guidelines do not offer a way to opt out of weight loss approaches.
Weight loss surgery, pharmacology, and “lifestyle” programs
There has been backlash to the idea of children undergoing bariatric surgery, which is irreversible and has lifelong consequences (including malnutrition, dumping syndrome, adrenal failure, serious GI issues, depression, and eating disorders). There are also significant concerns about weight loss pharmacology for children related to both the well-known short-term side effects (nausea, diarrhea, vomiting, constipation, and stomach pain) and the unknown long-term consequences for children since these drugs are intended to be used indefinitely (weight is regained when the medication is stopped). Everyone has the right to choose what to do with their bodies, but that choice should be well-informed. When the AAP and the mainstream media gloss over the downsides of these treatments, it raises questions about whether pediatricians have enough information to give informed advice and whether families are in a position to make informed decisions.
But these concerns are going to be mainly hypothetical for most people. The AAP explicitly acknowledges that the treatments they are urging aren’t widely accessible due to the cost, especially for weight loss drugs. The new wonder drug on the market is semaglutide (sold under the names Ozempic and Wegovy), costs around $1000/month, and is not covered by insurance or Medicaid. This drug is meant to be taken indefinitely, for a rolling annual cost of more than $12,000. Because obesity correlates to lower socioeconomic status, it should be obvious that this solution is only an illusion for most. 2
Even the non-pharma weight loss programs recommended by the AAP, (called Intensive Health Behaviour and LifestyleTreatment (IHBLT) programs), present similar barriers around practicality and accessibility. These programs are extremely time-consuming (26+ hours of in-person counseling), involve the entire family, and aren’t covered by Medicaid or insurance. The drop-out rate is over 50%, which of course wasn’t factored into the “success rate” touted by the guidelines. Even the AAP notes the many barriers to accessing these programs:
There are known limitations for families to access and participate in IHBLT… [including] the relative scarcity and distribution of such treatment programs and pediatricians or other pediatric health care providers with experience and/or training in pediatric obesity treatment, family transportation challenges, loss of school or work time to attend multiple recurring appointments during what are typically working hours, [Social Determinants of Health3], competing health issues for children or family members, and mismatched expectations between the family (who may expect significant weight loss) and pediatricians or other pediatric health care providers.
Right… So this is another illusory solution. The AAP’s only plan for filling in these gaps is for the pediatrician to use “community resources,” which is undefined or give weight loss support themselves. There is no mention here of the fact that family doctors rarely receive any formal training in weight loss, nutrition, obesity, eating disorders or psychology in medical school. It essentially means: just put these kids on diets any way you can.
And here is the kicker. The title of the guidelines might lead one to believe that this applies only to the most severe cases of childhood obesity. In fact, the recommendation for weight loss and weight loss programs applies to all children over 5 whose BMI is in the obese and overweight categories. There is no explanation or evidence for why the AAP is sweeping in millions of children with zero health concerns. And yet, as discussed below, the AAP knows full well that they are putting these children at risk.
Ignoring their own advice
This sweeping decision is a complete reversal from the AAP’s prior guidance on “Preventing Obesity and Eating Disorders in Adolescents” published in 2016. That report, relying on extensive evidence that dieting is a risk factor for both weight gain and eating disorders, recommended that pediatricians:
Discourage dieting, skipping of meals, or the use of diet pills; instead, encourage and support the implementation of healthy eating and physical activity behaviors that can be maintained on an ongoing basis. The focus should be on healthy living and healthy habits rather than on weight.
This new 2023 guidance insists that Intensive Health Lifestyle Treatment programs (IHBLTs) don’t create the same issues because they are “comprehensive” and “high-intensity.” First, the studies cited in the recommendations simply don’t support that position.4 Second, most kids won’t be connected to an IHBLT but will just be getting non-comprehensive and low-intensity support from their pediatrician. This brings us back to square one, with pediatricians continuing to rely on the failed approach of ad-hoc dieting.
Overreliance on weight and BMI
The AAP guidelines compound this problem by relying entirely on Body Mass Index (BMI) to diagnose overweight and obesity without regard to any other factors. The BMI is a simplistic and quick calculation that, according to the CDC, is only meant to be used as a screening tool and never as the sole basis for a diagnosis.5 And yet this is EXACTLY what the AAP is doing.
The BMI was originally developed in the 19th century by a Belgian mathematician to analyze the distribution of body size at a population level. It was never intended for meaningful use on individuals or in healthcare. It is known to be less reliable for BIPOC, children, the elderly, athletes, and pregnant women.6 In fact, the CDC warns that BMI is particularly unreliable when assessing children who fall into the overweight category because of the development of muscle mass during adolescence and puberty.7
It is really extraordinary to use an unsuitable metric to tell one-third of American children that their body is a problem and that they need to fix.8 This is without regard to individual factors. It is without regard to health status. And it is in willful ignorance of the evidence cited in its own reports that diets are harmful. Lastly, it is without explanation. Why is the AAP doing this?
The suspicion of many critics is that the AAP isn’t really driven by health outcomes but by fighting fatness. The AAP makes a big deal out of defining obesity as a multifactorial disease rather than a choice. They think the harm of weight stigma is in telling a person in a large body that it's their fault. But they are blind to the harm of pathologizing body size. While this might be helpful to someone trying to get insurance coverage, it is built on a toxic premise that a body type is a disease state.9 The fact that a larger body has associated risks for some conditions, doesn’t make that body type a disease. Just like my gender and my age aren’t diseases even though they put me at higher risk for plenty of health conditions.
There must be some way out of here
So what is a parent to do when they want to opt out? The AAP is silent here. The guidelines do not even acknowledge that someone might want to opt out even though millions of these kids are perfectly healthy. The AAP guidelines do not discuss Health At Every Size® or weight-inclusive approaches to health10, nor did they include pediatricians with that expertise in their panel.11
Repeatedly, the AAP seems to think that weight loss will remedy the various social factors that contribute to negative health outcomes. For example, the guidelines extensively explore Social Determinants of Health (SDoHs) such as poverty, food insecurity, unstable households, unsafe neighborhoods, lack of access to resources, racism, immigration status, and other social inequities. But the recommendations don’t address these root causes in any way. In the end, they seem to think (without citing any evidence) that lifestyle interventions can make an individual resilient to their environment. Or that weight loss drugs fix the effects of poverty? It’s really a weak attempt at solving systemic problems with individual solutions.
In another astonishing contortion of logic, the AAP discusses weight-related teasing and bullying as contributing factors to “binge eating, social isolation, avoidance of health care services, and decreased physical activity.” Yet they do nothing to address these issues other than recommend diets for the victims of bullying.
Virginia Sole-Smith, journalist and author of the upcoming book Fat Talk: Parenting in the Age of Diet Culture, put it this way in the New York Times Opinion Section:
We cannot solve anti-fat bias by making fat kids thin. Our current approach only teaches them that trusted adults believe the bullies are right — that a fat body is just a problem to solve. That’s not where the conversation about anyone’s health should begin.
The AAP’s guidelines, which state and restate that children should lose weight by any means necessary, are clearly going to reinforce the bias that society has against people with larger bodies. Before, their size might have been mischaracterized as the consequence of lifestyle choices. Now, people may accept that obesity has many causes but are allowed to believe that continuing to live in a larger body is the consequence of a bad healthcare choice (ie not finding a way to make these treatments work for them).
We obviously don’t solve racism by changing skin color, sexism by changing gender, or agism by stopping time. Yet this flawed thinking that our weight is completely within our control leads many to think that dieting is the solution to anti-fat bias. This is obviously nonsense.
We make people healthier by focusing on health, not on weight. Humanity has always included bodies of all shapes and sizes. We need to start making room for all of them in society and make authentic healthcare available at every size
If you made it this far and you still have questions, let me recommend further reading from some terrific writers:
How To Talk to Your Kids About Weight in Light of the New American Academy of Pediatrics Obesity Guideline. This is a really terrific guide on talking to your kids about weight and practical tips for dealing with your pediatrician. One thing I really appreciated in this article is that the author also addresses talking to kids of any size about weight.
Virginia Sole-Smith, quoted above, has written extensively about weight bias and parenting. Her op-ed above is paywalled, but she also wrote about the guidelines in her Substack newsletter
. If you are a parent interested in the topic, please dig through her archives. She is a treasure.A first-person account of encountering weight bias in the pediatrician’s office: Life In A Plus-Size Body Is Complicated — Especially For Kids
If you are curious about anti-fat bias in medicine, I encourage you to read As Coronavirus Rages, We Need to Talk About Medical Anti-Fat Bias by Aubrey Gordon. Doctors’ lack of training in medical school about nutrition, obesity, or disordered eating leads to blind spots that cause real harm in practice. I also recommend Gordon’s podcast Maintenance Phase and her most recent book “You Just Need to Lose Weight”: And 19 Other Myths About Fat People.
Weight stigma refers to the negative characteristics that might be projected onto someone because of their weight or size. These might include laziness, lack of willpower, being unsuccessful, unintelligent, and unattractive. One study cited by the AAP states “more than one-half of health care providers attribute overweight and obesity to a lack of willpower, reinforcing negative stereotypes and dissuading people with obesity across the globe from seeking medical care.”
Indeed, the wealthy have been quick on the uptake, including Elon Musk, who tweeted about Wegovy to his 116M followers about it. Chelsea Handler told a podcast that her “anti-aging doctor just hands [Ozempic] out to anybody.” And the NYT has a super disturbing article about the demand for facelifts to fix “Ozempic face.” That one really did my head in.
“SDoHs are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. SDoHs can be grouped into 5 domains: economic stability, education access and quality, neighborhood and built environment, and social and community context.” AAP Guidelines p6.
The first study cited “summarize[s] current, practical advice for rendering trauma-informed care across varied medical settings.” The second study cited found that “[s]tructured, professionally run pediatric obesity treatment is not associated with an increased risk of depression or anxiety… .” As for the third study, Patient-Centered Care for Obesity: How Health Care Providers Can Treat Obesity While Actively Addressing Weight Stigma and Eating Disorder Risk, I just wish the AAP had read it. It does say that althought IHBLTs can lead to disordered eating, they generally improve disordered eating behaviors because “these treatments focus on improving overall health rather than weight loss alone.” The authors’ final call to action states: “Respect for a diversity of body shapes and sizes by health care providers and society at large is needed and, for those seeking obesity treatment, conversations with health care providers should emphasize overall health rather than weight alone.”
Body Mass Index: Considerations for Practitioners, located at https://www.cdc.gov/obesity/downloads/bmiforpactitioners.pdf
How useful is the body mass index (BMI)?, June 22, 2020, by Robert H. Shmerling, Harvard Health Publishing.
Body Mass Index: Considerations for Practitioners, located at https://www.cdc.gov/obesity/downloads/bmiforpactitioners.pdf
According to the CDC: From 2017-2020, 16.1% (12.2M) of children and adolescents aged 2-9 were overweight and 19.3% (14.7M) have obesity.
In another logical Mobius strip, the AAP leaves us without a definition of success. It seems that the only way to get out of this trap is to reduce your BMI to the “normal” category. But the most successful of these weight loss programs produced reductions of between two and seven points, which may not even change an individual’s BMI category. One study notes that many people are discouraged about making the effort if it won’t get them into a “healthy BMI.” The obvious answer to this is to educate them on the limitations of BMI and to avoid using it as a determinant of health.
A weight-inclusive approach views “health and well-being as multifaceted while directing efforts toward improving health access and reducing weight stigma”. Weight-normative approaches emphasize “weight and weight loss when defining health and well-being.” The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss, Tylka, et. al. (2014)
Linda Fleetwood (AKA: Kincer) I have lived in 7 countries for 13 years, visited all the continents and been a drug detail-person. I so agree with you that drugs and surgery don't belong in weight management, at any age!
For me it is knowing the truth about nutrition and supplements, and understanding inflammation; how it can cause debilitating health issues, if Not addressed. I wish that my knowledge today, I had 10 years ago as I could have lessened my severe degenerative disc disease. I am blessed that a local Nutritionist with her PHD spent sometime with me!
Kate keep getting your message heard!! Your knowledge and point of view will be a game-charger as it is so easy to follow and understand :-)
Thank you for this comprehensive and interesting piece on what has become a major problem in our society. I am absolutely horrified at the APA promotion of bariatric Rx's and/or surgery for children. This will no solve the problem!