The American Academy of Pediatrics (AAP) has drawn fire for issuing new recommendations designed to reduce childhood obesity. The AAP's critics are deeply confused.
Childhood obesity is a growing problem in the US. More than 1-in-5 American children (22 percent) are obese, a startling increase from just five percent in the 1970s that could generate some truly tragic public health consequences if the problem isn’t solved in short order. “Obesity can harm nearly every system in a child’s body,” according to an analysis conducted by the Harvard School of Public Health (HSPH). And more relevant to our concerns here, HSPH adds that
“… Youth who are overweight or obese have substantially higher odds of remaining overweight or obese into adulthood, increasing their risk of disease and disability later in life.”
For these reasons, experts are eager to get a handle on childhood obesity. The American Academy of Pediatrics (AAP) in January released a detailed guidance highlighting “the urgency of providing immediate, intensive obesity treatment to each patient as soon as they receive the diagnosis of obesity.” The group also noted that interventions for obesity should address “nutrition, physical activity, and health behavior change using evidence-based targets for weight reduction and health promotion.”
As a parent and someone who struggled with obesity throughout my adolescent and young-adult years, this renewed focus on diagnosing and treating patients early strikes me as commonsense, science-based health care.
But not everybody agrees. Echoing a coalition of eating disorder treatment specialists, NPR reported on February 15 that the Academy’s new guidance wrongly focuses on BMI and weight, as opposed to health, and “minimizes the risk of disordered eating and could perpetuate deep-rooted, damaging stigmas.”
Eating disorders are serious conditions that shouldn’t be downplayed, but aggressively treating obesity for what it is—a critical threat to public health—doesn’t stigmatize anybody, nor does it keep us from addressing disordered eating.
The “weight-not-health” trope
It’s become acceptable in recent years to divorce obesity from its health consequences. Urging overweight people to slim down isn’t about helping them lead healthier lives, the argument goes, it’s about reinforcing a socially constructed stigma against fatness, which does severe damage to the emotional well-being of obese people. As a result, doctors have been lectured to mind their language and focus on health, not size.
Critics of the AAP’s guidance are working from the same confused playbook. “Since experiencing weight discrimination is associated with internalized weight stigma and poor mental health outcomes,” the Academy for Eating Disorders warned, “we are concerned that an explicit focus on weight loss could have iatrogenic effects on some individuals …”
This complaint falls flat for two reasons. First, doctors focus on weight when treating obesity because it is an important determinant of health. The bigger someone gets, the more likely they are to develop heart disease, stroke, diabetes and other conditions caused in part by excess weight gain. Conversely, losing weight significantly reduces the same risks. These aren’t mere associations, either. Overeating causes fat accumulation, which causes inflammation and ultimately contributes to all those nasty outcomes listed above.
This information should be communicated to patients respectfully—but it absolutely must be communicated. And that leads us to our second point. The AAP dedicated an entire section of its guidance to “health equity considerations,” which outlined specific recommendations to help pediatricians reduce weight stigma and bias in clinical settings. These included sensible suggestions like recognizing the genetic and environmental contributors to obesity, as well as
“having appropriately sized office furniture, using appropriate capacity medical equipment, ensuring that aesthetic and/or instructional images posted in the office are inclusive, and avoiding stigmatizing language.”
This borders on patronizing, quite frankly, but it also illustrates that the AAP has bent over backwards to address weight stigma. The guidance authors even used the same emotive language—“internalized weight bias”—as their opposition. My minor criticisms aside, the AAP struck a reasonable balance by acknowledging the risks of obesity while stressing that health care providers should treat overweight patients with respect.
The real reason for the backlash
Despite a valiant attempt to conform with the accepted social justice wisdom, the AAP landed in hot water because it didn’t shy away from one crucial fact: individual obese patients (with the help of their parents in this case) can and should take steps to lose weight. The Academy for Eating Disorders said as much in its press release:
… the AAP Guideline recommends many individual-level changes (e.g., pharmacological treatment, bariatric surgery) rather than structural changes (e.g., changes in food policy, amelioration of food insecurity, reduction of stigma), which may reinforce the blaming and shaming of individuals in higher-weight bodies [my emphasis].
These so-called “structural changes” do not work. More than 50 clinical studies conducted over the last decade in multiple countries have examined any and every population-level intervention you can think of. None of this research has yielded impressive results. Even the scientists who performed those studies have said so.
In contrast, the AAP’s individual-level recommendations can work quite well. As I’ve written previously, research has found that individuals can lose weight and keep it off by monitoring their caloric intake and body weight and exercising regularly. Planning meals and choosing the right diet can also improve the results people see. The UK’s National Health Service put it well: "there's no reason why most people cannot lose weight," despite the influence of genes and "poor eating habits learned during childhood [my emphasis]."
The AAP deserves credit for telling that same truth, even if it offends the tastemakers who wrongly believe they can police everybody’s language.