Why we won’t be prescribing to the new American Academy of Pediatrics Guidelines

We want to share a critical message with you that is something that will affect so many folks – especially families and children.

I’ll be honest, I am so frustrated with some of our progress in so many aspects of how we, as a people, live.

Here we are in February 2023, and this month we have Eating Disorder Awareness week, Black History month, and next week is Heart Health month…

These are things that we need to focus on every day, not just at certain times of the year. But our ever-changing world makes this so challenging to do with all the roadblocks that pop up in our path.

One of these roadblocks is the new guidelines that the American Academy of Pediatrics recently released that are setting us back decades in the fight against diets, diet culture, and raising children who turn into adults who are finally at peace with food and their body image.

In the guidelines released titled, “Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents With Obesity,”(1) they recommend that:

• Higher weight kids, ages 2 and up, be referred for “intensive health behavior and lifestyle treatment”
• Kids over 12 can be offered weight loss medications (i.e., injectables like Ozempic, and Wegovy)
• Kids over 13 can be referred for bariatric surgery

In my professional journey as a Registered Dietitian over the past 40 years, I have caused unintentional harm. But I have learned from these actions, as have many colleagues all over the world.

Yes, in the past, I have prescribed weight loss; More than 20 years ago, I ran an intensive “weight management” program called “ShapeDown” with a psychologist. The program was intended to treat “overweight and obesity” in kids and teens. Pediatricians referred young patients if their BMI charts indicated they were either “at risk” of becoming “overweight” or actually were considered to be “overweight” or “obese” by BMI standards.

As predicted, some of the kids and teens I had worked with when they were younger ultimately developed disordered eating and eating disorders; the constant emphasis on looks and body weight, as well as the trauma of weekly weighing, contributed to this problem.

So, eventually, I stopped. I stopped pushing weight loss. I stopped weighing my clients unless it was a medical necessity.

I started looking at my clients as whole, embodied people, who just happened to come in all different shapes and sizes.

Here are our serious concerns about the AAP guidelines for the Evaluation and Treatment of Children and Adolescents With Obesity:

1. The Guidelines did NOT involve adolescent medicine doctors or eating disorder specialists.

These guidelines are a stark contrast to those put out in 2016 by a committee that included adolescent doctors and eating disorder specialists.(1) They discouraged dieting, skipping meals, and diet pills and instead “encouraged and supported the implementation of healthful eating and physical activity that can be maintained on an ongoing basis.” They recognized the need to promote a positive body image among adolescents and discouraged body dissatisfaction as a reason for dieting.

2. The Guidelines, that include conflicts of interest, were written by experts with ties to the pharmaceutical and bariatric surgery industry.(2)

Conflicts of interest abound, as the “obesity” experts have ties to the industry, including Novo Nordisk, the company which makes both Ozempic and Wegovy, two brand names of injectable medications used for diabetes and off-label for weight loss. Of the fourteen authors who are medical doctors, at least seven have taken money from companies that are developing or selling weight loss products that either directly benefits or may benefit from these recommendations either through the development of a new drug, or approval of an existing drug for adolescents. There are authors who run pediatric weight loss clinics, authors who run pediatric weight loss surgery programs, and authors who are employed as pediatric weight management specialists.(3)

3. BMI is an inaccurate, outdated, and racist measurement of physical health and body size that leads to WEIGHT STIGMA.

The person who dreamed up the BMI in the mid-1800s, Adolphe Quetele, was a Belgian Astronomer and NOT a medical doctor. He explicitly stated that the BMI could not, and should not, be used to indicate the level of fatness of an individual.

The BMI was never meant to be used as an assessment tool for individuals but was created as an arcane mathematical concept having nothing to do with actual health markers. (4) Today, we now know that the words “Obesity and Overweight” do terrible harm to individuals. They pathologize people with larger bodies, creating a climate of weight stigma that causes people to want to make their bodies smaller – a dangerous prospect since diets often lead to disordered eating and eating disorders. There are normal variations in weight seen in populations, where some people come in smaller, and some in larger, bodies.

4. The timing of these new guidelines may have a grave impact on the mental health of adolescents, most importantly at-risk youth still impacted by a global pandemic.

During the pandemic, eating disorders skyrocketed in adolescents with waiting lists at most eating disorder treatment programs(5). Between social isolation, school shutdowns, separation from friends and families, and uncertainty about the future, there has been an increase in disordered eating and eating disorders, including “emotional” eating, anorexia nervosa, bulimia, binge eating disorder, as well as restrictive dieting and increased body image dissatisfaction. More kids than ever have been hospitalized with eating disorders as well as other mental health concerns.(6)

And who will be impacted the most by these dreadful guidelines? The same population who was impacted most by the COVID pandemic – communities of color.

According to a recent article in the Seattle Times, “It gets even worse for kids who aren’t white. The AAP guidelines state 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 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 is 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.”(7)

According to Galen Hope, an eating disorder treatment center,” the guidelines demonstrate no understanding of the psychological and physical dangers of weight stigma (8). There is no understanding of how devastating and deadly eating disorders can be, how prevalent they are, how they impact children at extraordinarily young ages, and how the constant, unrelenting pressure to lose weight is one of the major risk factors for the development of one. There is a lack of emphasis on alternatives, such as the value incorporating health-promoting behaviors that are separate and unrelated to the outcome of manipulating one’s size and shape, as viable means of promoting both physical and psychological health in children. There is no acknowledgment that weight gain is a natural and expected component of adolescence.

5. Weight loss through medication and/or bariatric surgery has serious short short-term as well as long-term negative implications.

Weighing kids, teens, or adults weekly, in an effort to create a calorie deficit, backfires gloriously! Our bodies are not calculators, and our metabolisms are far more nuanced than just moving more and eating less to create weight loss.

Growing children who take weight loss drugs or undergo bariatric surgery are at high risk for dietary deficiencies, including iron, calcium, and vitamin D, due to changes in their diet and absorption of nutrients. Implications on bone mineral density, hormone regulation, nutrient deficiencies, heart muscle development, puberty/sexual development, and serious emotional and psychological issues, including body image concerns, depression, and anxiety must be taken into account. Bariatric surgery carries a risk of complications, including serious infection, bleeding, hernias, and even death.

In summary, according to the Academy of Eating Disorders (AED): “We are concerned that the 2023 AAP Guideline – which represents a major shift in perspective from the AAP’s previous 2016 recommendations – has the potential for iatrogenic effects. In line with the Hippocratic oath of first, do no harm, the AED urges the AAP to revise their Guideline with input from key stakeholders including eating disorder professionals and individuals/families with lived experience in higher-weight bodies.”(9)

As eating disorder professionals, we know there is a better approach, and it is weight-neutral.

Now we encourage and teach our clients within their individual capacities to motivate them toward positive self-image and self-care, enjoyable exercise choices, mental well-being, and a diverse diet regardless of body weight.

If you or anyone you know wants and needs help from clinicians who will take an approach to food and body image with a weight-inclusive approach, please reach out. We can help you and your family and friends in a way that honors our oath to “Do no harm,” unlike these guidelines.

Book a time to talk with me, and we can determine what help you need and the best way to get that help.

You can also learn more about ways to positively impact your children in these articles on our website:

What is an “Almond Mom?”
10 Tips to Help Your Child Develop a Healthy Relationship with Food

References:

1. https://publications.aap.org/pediatrics/collection/523/Clinical-Practice-Guidelines
2. https://publications.aap.org/pediatrics/article/138/3/e20161649/52684/Preventing-Obesity-and-Eating-Disorders
3. https://weightandhealthcare.substack.com/p/special-edition-dangerous-new-american?publication_id=534306&isFreemail=true
4.  https://ab.co/3kWnCsl
5. https://publications.aap.org/aapnews/news/16552
6. https://www.contemporarypediatrics.com/view/eating-disorder-admissions-increased-during-covid-19-pandemic
7. https://www.seattletimes.com/life/wellness/what-do-new-pediatric-obesity-guidelines-really-mean-for-kids/
8. https://galenhope.com/mental-health-blog/our-response-to-the-newly-released-clinical-practice-guideline-for-the-evaluation-and-treatment-of-children-and-adolescents-with-oity-from-the-american-academy-of-pediatrics/
9. https://www.newswise.com/articles/the-academy-for-eating-disorders-releases-a-statement-on-the-recent-american-academy-of-pediatrics-clinical-practice-guideline-for-weight-related-care-first-do-no-harm