Weight Inclusive Nutrition and Dietetics (WIND) is a community of weight-inclusive providers that focuses on providing education, supporting our membership, and maintaining a nationwide referral network. Our aim is to educate, support research and serve social justice movements in both healthcare and fat-liberation spaces. We are writing in response to the Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity that was published in January 2023. We want to raise our concerns regarding fundamental flaws in the guideline. The intention of this letter is to highlight the areas of the guideline that may cause harm and negative health consequences. In alignment with our community’s mission to educate and support, we hope to raise awareness on why it is important for these guidelines to transition to a weight-neutral approach which is defined as viewing “health and well-being as multifaceted and focuses efforts towards improving health access and reducing weight stigma rather than focusing on weight loss” [1].
While the stated intentions of the guideline is to improve the long-term health of children and adolescents, we fear the emphasis placed on body weight will perpetuate another epidemic of health issues, namely disordered eating and eating disorders. We believe that providing due diligence in order to establish an evidence-based treatment guideline should also include risk factors for eating disorders in this patient population. Children who are diagnosed as obese are at an increased risk for developing an eating disorder during adolescence [2].
“Growing up a larger kid I have a very concrete memory of my doctor telling my mom that I was obese. From there my mom, very well meaning, enrolled me in soccer and told me it was because the doctor said I was overweight. This continued as I started to believe that if I could play enough sports and change my body enough I would be good and nobody would make fun of me again. Needless to say I struggled with orthorexia and body image issues through high school and college and am still working through the effects at 28.”
Adolescents diagnosed with both obesity and an eating disorder are more likely to continue to gain weight. Focusing on one epidemic related to body size (obesity) impacts the prevalence of another (eating disorders). There is another way to elevate the health of children and adolescents in our country. But first, we believe it is important to highlight that the size of one’s body is not a chronic disease [3].
Within the clinical practice guideline, you state that “childhood obesity results from a multifactorial set of socio ecological, environmental, and genetic influences that act on children and families. Individuals exposed to adversity can have alterations in immunologic, metabolic and epigenetic processes that increase risk for obesity by altering energy regulations.[4]” We absolutely agree that a variety of factors, including but not limited to family history, genetics, race or ethnicity, age, sex, eating and physical activity habits, location, routine, culture, sleep, medical conditions, medications, trauma, and stress impact the size of one’s body [5]. Even after stating this, the clinical practice guideline goes on to focus on only eating & physical activity habits. Simply focusing on these two factors with the expectation that body size will change is putting an unnecessary and ineffective emphasis on those particular factors [6]. The expectation that focusing on eating and physical activity habits alone in an effort to obtain a smaller body places blame on the individual. Body size is classified as “overweight” or “obese” by body mass index (BMI) classifications without acknowledging all additional factors that impact body size, and overall health [3]. Chronic diseases develop in individuals of all body shapes and sizes. Continuing to emphasize body size as a precursor for chronic disease has potentially fatal consequences, the most important of which is how it contributes to weight stigma, disordered eating and eating disorders.
“When I was 15, my pediatrician warned me that I should be careful not to gain more weight and that I should consider weighing myself at least monthly to monitor myself. At the time my BMI was 20.4 and I struggled with what I can now see was likely undiagnosed body dysmorphia which caused extreme anxiety about my body. Even without the extremes of recommending bariatric surgery or weight loss drugs to minors, even something as "minor" as telling a teenage girl to "watch her weight" can have long lasting consequences. I attribute interactions like this one to the development/perpetuation of my disordered eating & preoccupation with thinness.”
The connection between weight stigma—defined as “the social devaluation and denigration of a person because of their excess body weight” [7]—and disordered eating cannot be overlooked. As we mentioned previously, the current clinical guideline perpetuates weight stigma and weight bias. The harm caused by weight stigma is documented extensively in research. Children and adolescents who experience weight stigma are at a greater risk of disordered eating behaviors [8]. The clinical guideline advocates for several methods of weight loss and/or weight control for children and adolescents in the name of health promotion; however, it is well documented that the single greatest predictor of eating disorder development is previous weight loss attempts [9]. Thus, no healthcare provider can recommend weight loss interventions to children and adolescents without the potential to cause significant harm, including putting the child at risk of engaging in such behaviors as binging, purging, and food restriction [9]. Children and adolescents who are told they have excess weight experience symptoms of disordered eating more frequently [10]. Children might misinterpret healthy eating/weight messaging which could lead to dangerous behaviors [11]. Disordered eating risk increases as children enter early adolescence due to stressors like body changes and the desire to fit in [11]. Adolescents are also more likely to engage in unhealthy behaviors like skipping meals in an effort to “eat healthier” which increases the risk of developing an eating disorder [10].
“My doctor prescribed my first diet when I was 6.5 years old, I never reached the “ideal” bmc weight, I developed an ED (atypical anorexia which at first the pediatrician did not believe because my weight was average) at 13, at 16 I almost became bold for the hair loss I was having due to my caloric restrictions, there were days I did not eat at all, I'm 34 yo-yo dieting ever since and still struggle with my weight and my ED, I can't see myself in the mirror without crying.”
Eating disorders pose a significant threat to a person’s mental health and physical well-being and are considered to be a public health crisis [12]. Disordered eating and eating disorders can place a person at risk for several complications, including “osteoporosis, cardiovascular, endocrine, gastrointestinal, and skeletal disorders, dental problems, nutritional deficiencies, obesity, psychiatric disorders, and substance use” [11]. Restricting food intake has also been shown to increase the risk of weight cycling. Weight cycling is defined as a pattern of repeated periods of weight loss and regain, and is associated with an increased risk of both heart attack and stroke [13].
“My mom started me on weight watchers when I was 12. By 13, the trainers at the gym knew me well. I spent my preteen and teen years thinking constantly about food - how many points or calories I had left, when I would be “allowed” to eat next, what I would eat next - rather than learning to listen to my body and honour my hunger signals. Even restricting like this, weight loss was slow for me and every week I didn’t lose a pound during the public weigh in, I felt ashamed, and regretted that extra apple or piece of toast. 1200-1400 cal/day diets were packaged as healthy weight loss and only led to weight cycling and a preoccupation with food.”
We come together as a community of healthcare providers, educators, researchers, and advocates for weight-inclusive care to voice our concerns and propose an alternate approach. We urge you, the American Academy of Pediatrics, to consider the impact your clinical practice guideline has on the perpetuation of weight stigma, increasing risks of disordered eating, and eating disorders for generations to come. It is critical that your clinical guideline panel include registered dietitians who have experience in treating clients with both disordered eating and eating disorders from a weight-inclusive and health at every size (HAES®) approach. It is essential for the well-being and safety of the children and adolescents in our country that the clinical guideline is revised to shift to a weight-neutral approach [1].
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Italicized text was submitted by WIND members who have lived experience as a child & adolescent who received feedback regarding their weight or body size.
REFERENCES:
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[2] Tsekoura E, Kostopoulou E, Fouzas S, Souris E, Gkentzi D, et al. The association between obesity and the risk for development of eating disorders - A large-scale epidemiological study. ERMPS 2021;25:6051-6056.
[3] Katz DL. Perspective: Obesity is not a disease. Nature 2014;508:S57.
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[5] Factors Affecting Weight & Health. NIDDK 2018. https://www.niddk.nih.gov/health-information/weight-management/adult-overweight-obesity/factors-affecting-weight-health/ (accessed June 19, 2023).
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[12] Puhl RM, Neumark-Sztrainer D, Austin SB, Luedicke J, King KM. Setting policy prioritizes to address eating disorder and weight stigma views from the field of eating disorders and the US general public. BMC Public Health 2014;14:524.
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