In January, the American Academy of Pediatrics (AAP) put out a press release announcing the organization’s latest guidelines on evaluating and treating childhood obesity—its first update to these guidelines in 15 years. The new recommendations include interventions for children as young as 2 years old as well as treatments for older kids, which include pharmaceutical regimens and in some cases, even bariatric surgery.
Like millions of other parents, I am a millennial who grew up in a world heavily influenced by toxic diet culture. Low-rise jeans and tight-fitting tops that were cropped just enough to show a peek of a bare midriff were the style. Striving for a thigh gap was totally normal, if not encouraged, and exercise was always a means of losing weight—never something you did for your health and well-being. By the time I was 20, I could proudly rattle off the number of calories in all of my favorite foods and tell you exactly how long I’d have to run on the treadmill to burn off a slice of pizza. The unhealthy obsession with weight and my restrictive eating habits lasted for nearly two decades, destroying my self-esteem (and I never did achieve that thigh gap).
Now that I’m a mom, I will do anything in my power to prevent my two daughters from developing a dysfunctional relationship with food and physical activity. So when these latest guidelines by the AAP were released, I immediately went into protective mode—and quite frankly, I was triggered and disheartened.
The AAP is a group of trusted pediatric experts who are devoted to ensuring our children receive the best care possible. So, I initially questioned how they could overlook the mental health struggles and disordered eating behaviors that are a direct result of diet culture. How could they ignore all of the progress we’ve made as a society when it comes to body positivity and acceptance and suggest such extreme measures for managing children’s weight?
We spoke to experts to help make sense of these new guidelines. But first, let’s take a look at what the report had to say about childhood obesity.
What Are the New Guidelines?
There is a lot of information to sort through in the 73-page official report. The press release provides a summary highlighting some of the included recommendations:
- More than 14.4 million children and teens in the U.S. are living with obesity.
- There is no evidence that a “wait and see” approach is appropriate for obesity.
- The report categorizes “overweight” as a child with a body mass index (BMI) above the 85th percentile and below the 95th percentile for their age and sex.
- The report categorizes “obese” as a child with a BMI at the 95th percentile or higher for their age and sex.
- Evidence-based recommendations in the guidelines start for children as young as 2 years old (suggested interventions vary by age).
- Evidence-based treatment delivered by a trained health care provider with active parent/caregiver involvement has no evidence of harm and can result in less disordered eating. (The full report emphasizes that parents and pediatricians should be mindful of how an obesity diagnosis is conveyed to a child to avoid harmful effects.)
- Recommendations for comprehensive obesity treatment may include nutrition support, exercise, behavioral therapy, pharmacotherapy, and metabolic and bariatric surgery.
- For patients 12 years and older, providers should offer weight loss pharmacotherapy as an adjunct to health behavior and lifestyle treatment.
- Teens 13 years and older with a BMI of 120% or more of the 95th percentile for age and sex should be evaluated for metabolic and bariatric surgery.
In addition to the recommendations for evaluating and treating obesity, the report also acknowledges some of the challenges that may stand in the way of these guidelines, such as accessibility and affordability for some of the interventions and programs. The report also does not address any prevention measures pediatricians can take, though the AAP says a policy statement on prevention is “forthcoming.”
In the meantime, we connected with experts in the field to gain greater insight into pediatric obesity and the newly proposed guidelines for treating children: Psychiatrist Kimberly Dennis, MD, CEDS is the chief medical officer, CEO, and co-founder of SunCloud Health where she treats adolescents with addiction (including food addiction) and eating disorders in the Chicago area. Angela Fitch, MD, FACP, FOMA, Dipl, ABOM, is the co-founder and chief medical officer of knownwell, a weight-inclusive health care provider offering metabolic health services, primary care, nutrition counseling, and behavioral health services to patients of all sizes. She is also the president of the Obesity Medicine Association, and board certified in internal medicine, pediatrics, and obesity. Lastly, Marian Tanofsky-Kraff, PhD, is a professor in the department of medical and clinical psychology, director of the developmental research laboratory on eating and weight behaviors, and research director of the military cardiovascular outcomes research program at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Physical Health Considerations
Whatever your feelings may be about diet culture—whether you’ve embraced it, you’re indifferent to it, or it scares you—we can’t ignore that obesity is a serious problem in the U.S. that is accompanied by major, long-term health issues.
“Left untreated, obesity has been shown to reduce life expectancy by eight to 10 years for children,” says Dr. Fitch. “There is also a high risk of developing other chronic diseases such as diabetes, kidney failure, high blood pressure, and cardiovascular disease.”
Indisputably, anything that causes such health complications, especially in children, should be treated by a health care provider, even if what causes such complications is obesity. But what do the AAP’s treatment recommendations look like in real life? And are there areas of concern with any of them?
Intensive Health Behavior and Lifestyle Treatment
One of the AAP’s recommendations is intensive health behavior and lifestyle treatment (IHBLT), an approach that recognizes each child’s individual needs and aims to address those needs (both of the child and the family as a whole) holistically. According to the organization, this method of treatment is safe and effective in treating young people with obesity. These programs can be effective, but they also require parents to invest quite a bit of time, as kids will get services from several specialists including community health educators, dieticians, and exercise specialists. Additionally, depending on a family’s insurance coverage, these programs may also require a large financial investment.
Dr. Dennis notes that research on the long-term effectiveness of these programs is lacking and that the focus of many studies is primarily on the physical aspects of treatment, not mental health.
“We don’t have much at all in the way of long-term outcome studies in kids [who participate in IHBLT]. The studies that exist typically look at physical markers of body size and weight, and maybe some mental health screens for self-esteem or depression—no eating disorder screens. Also, the measures are only conducted at the beginning and end of the intensive treatment, which is usually anywhere from a 3- to 12-month course, and dropout rates are very high.”
Body Mass Index
Body mass index (BMI) has long been a tool health care providers use to measure a person’s health based on their weight. It’s calculated based on a person’s height, weight, and sex, but it lacks nuance. For instance, someone who is shorter than average and is a muscle builder in amazing physical health may fall into the obese category because of their weight, or someone who is rapidly losing weight due to an undiagnosed internal disease may fall into the normal BMI range.
Still, while BMI is flawed, there has to be something providers can use as a baseline to help them determine if they need to look closer at someone’s health.
“BMI is useful for understanding the population as a whole—not the individual,” says Dr. Tanofsky-Kraff, adding, “measures of adiposity (obesity) and laboratory values are much more accurate assessments of health.”
Dr. Fitch agrees, and explains, “[BMI] is a diagnostic tool, and then based on that data combined with a physical exam, lab values, and other vital signs [providers] make a diagnostic of obesity. The BMI isn’t meant to be the definitive diagnosis, but it is a good ‘risk stratification’ tool that helps us understand if intervention (lifestyle changes, medication, and surgery) are warranted.”
She goes on to say, “Ideally, in the future, we will have more effective tools (we have them now in our specialty obesity treatment centers) such as body composition testing to determine if a person has excess body fat that is adversely affecting their health.”
For many of us, when we hear “prescription weight management medications” we instantly think “diet pills,” which is why we might find these AAP guidelines for children 12 years and older so unnerving. But, Dr. Fitch explains that using medication (under the care and guidance of a health care provider) to help treat obesity is no different than using prescription drugs to treat any other disease.
“The use of the term ‘diet pills’ is what needs to change in our society. This is stigmatizing and a biased look at a disease process. These are not ‘diet pills,’ but effective pharmaceutical agents that treat a disease process … Using medication combined with healthful lifestyle choices is more effective than healthful behavior change alone. Only about 5% of people are able to lose 20% of their weight with lifestyle changes alone. With medication, 40% of people are able to lose 20% of their weight.”
That being said, it’s important for parents of a child with obesity to try lifestyle changes before jumping right to medication, according to Dr. Tanofsky-Kraff. “The first line of treatment should always be intensive family based health behavior and lifestyle treatment by a trained professional who conveys that the body size is due to genetic, metabolic, and hormonal influences, and environmental factors that predispose some persons to larger bodies.”
If lifestyle changes don’t prove to be successful, that’s when she says medication may be the right option. “Among those [patients] who are not responsive, due to their biology or other circumstances, these medications can have important medical benefits.”
Dr. Tanofsky-Kraff notes, however, that we need more research on the long-term outcome of these medications, so parents should carefully consider whether or not this is the best approach for their child.
Dr. Dennis agrees and notes that in addition to not knowing the long-term effects of many of these pharmaceuticals, we also don’t know what medications carry the risk of addiction. And there are still mental health aspects to consider for children who start on these medications at a young age.
If a teen is considered to have severe obesity once they reach 13 years old, the AAP guidelines recommend surgical treatment. Whether it’s for ear tubes, a heart condition, or appendectomy, no parent wants to put their child through surgery, but just like all of these procedures may be necessary to a child’s health, metabolic and bariatric surgeries are often just as important for the children who need them.
“We use surgery much [as] we do for other diseases when it is needed to produce a better [health] outcome in the long run,” explains Dr. Fitch, “Obesity is a chronic, serious, and treatable disease, and when the severity of the disease necessitates a surgical intervention, then we recommend that treatment because it has been shown to produce the best long-term outcome.”
Mental Health Considerations
While the new AAP guidelines thoroughly address the physical health of a child with obesity, there doesn’t seem to be as much concern for the psychological repercussions of these treatment recommendations.
“Clinically, as a psychiatrist that focuses on eating disorders and trauma, many adolescents and young adults who live in larger bodies that I treat who now have disordered eating, bulimia, atypical anorexia, or binge eating disorder have been to doctors [when they were kids] who told them their body is unhealthy or broken because of their size, and that they need to exercise more and eat less than ‘normal’ kids,” explains Dr. Dennis. “This is compounded by living in a society where thin equates to health, privilege, and power, and [these patients] are subject to awful bullying in school and sometimes in their families because of their size, resulting in weight stigma-related trauma.”
Dr. Fitch echoes Dr. Dennis’ concerns about bullying but argues that avoiding this trauma is why parents should seek treatment for a child with obesity. “[Children with obesity are at] a higher risk of bullying, and therefore isolation and depression,” she says. “The bias and stigma associated with the disease of obesity make the child and the parents feel like the disease is their ‘fault’ and that they should ‘fix’ it on their own. This blame and shame approach promotes worsening mental health and can lead to chronic unsuccessful attempts at ‘dieting’ (due to the biology of the disease of obesity) and promote worsening body image and dysfunctional eating behaviors.”
As for how obesity treatment, specifically, affects a child’s mental health, Dr. Tanofsky-Kraff says, “There is no research to support the notion that supervised intensive health behavior and lifestyle treatment—by a trained professional—promotes disordered eating. If anything, the research shows they sometimes reduce disordered eating. By contrast, strict, fad, extreme, unsupervised diets pose a serious risk for eating disorders in susceptible people.”
Dr. Tanofsky-Kraff also says it’s important that parents and providers put as much emphasis on monitoring a patient’s mental health throughout the treatment process as they do their physical health. “Screen for eating disorders prior to and throughout weight management efforts,” she advises, “arguably, we need to regularly screen for eating disorders in primary care, the same way we do for other concerns.”
In the full report, the AAP acknowledges that many of the recommended treatment options will be difficult for families to manage, especially lower-income families. It also draws attention to factors that contribute to childhood obesity inequities, such as food insecurity, marketing of less nutritional foods, and structural racism.
Childhood obesity disproportionately affects those in low-income families. One study found that children of low-income parents are twice as likely to have higher BMI scores than children of higher-income families. This inequity becomes even more pronounced when you factor in new recommended treatments, which often require significant financial and time investments from parents.
“[Treatment] accessibility is a huge problem,” says Dr. Dennis, “This particularly impacts kids from BIPOC (Black, Indigenous, and people of color) and lower socioeconomic status communities whose parents don’t have the time or means to get themselves and their kids anywhere from three to nine hours of therapy per week.” She also notes that many of these parents have multiple kids to care for and they often work multiple jobs.
Dr. Fitch shares these concerns and explains that this is why Medicaid and the health exchange should cover effective treatment programs. As the AAP noted in the guidelines, the “wait and see” approach doesn’t benefit children with obesity, so the sooner these patients have access to intervention, the better their outcome will likely be.
“Unfortunately, only 11 states have anti-obesity medications on the formulary, and none of the health exchange plans include this treatment either. We are advocating to change this because diseases should not be excluded [from health insurance coverage], and the exclusion comes from an old feeling that obesity is the fault of the patient versus a disease warranting comprehensive chronic care,” says Dr. Fitch.
For many families affected by childhood obesity, whether or not these new recommendations are too aggressive is irrelevant. This guidance is simply focused on a symptom of a much larger systemic problem that needs to be fixed in order to truly address the problem of childhood obesity in the U.S. But, we need to acknowledge that this is not the job of the AAP; their job is to advise us on the best ways to care for our children’s health.
I must admit, after speaking with our experts and hearing their perspectives on the AAP’s new guidelines, I felt relieved. It’s important to remember that these guidelines are generalized and that a good pediatrician will treat your child like the individual they are. Also keep in mind that you have a say in your child’s treatment plan as well, so if you’re uncomfortable giving your child prescription medications or surgery, ask for more information and seek a second opinion (if you’re financially able).
And, of course, even with these new guidelines in place, take comfort in knowing that we can still advocate for body positivity and health at any size and do our part to stop weight stigma. It doesn’t have to be one or the other.