If you’re reading this post, you are likely well aware of the new pediatric guidelines released by the American Academy of Pediatrics at the beginning of this year. There is much to sift through here, and I’ve been engaging in a lot of conversation with other care professionals who specialize in eating disorder treatment and health justice. To say we are concerned is a massive understatement, and it’s important that people know why.
I thought I’d share a summary of some of the reasons why professionals like myself are so vehemently opposed to these updated guidelines. There is a lot of complexity inherent in this topic, so I’ve broken things down into a list form to address the concerns I have about the harm the AAP is perpetuating with this guidance.
1. The guidelines are structured around the BMI scale, which is a tool capable of telling us absolutely nothing about the health and well-being of a person’s body.
We know this, and have known it for decades. Still, the AAP insists on using it as a measurement to determine which bodies are diseased and in need of intervention, and which ones are not. This alone should be enough to discredit their guidelines. Further, little attention is given to the racist origins of the BMI and fatphobia. A statement from ASDAH sums this issue up neatly: “Despite several sections discussing the prevalence of higher BMIs among Black and brown people, the connection between racism and fatphobia was completely excluded from the guidelines as well as from their analysis and interpretation of the research. Fatphobia was born out of eugenicist and racist ideas. These racist ideas are then upheld systemically through tools like the BMI and recommendations such as these. This history and how it shaped research and current medical practice is missing entirely from the AAP’s recommendations. Its omission allows for the continuation of harmful, racist, and fatphobic practices.”
2. The guidelines stress a focus on “non-stigmatizing” care – which, in this context, is impossible.
The pathologizing of fatness, which is achieved here by classifying o*esity as a disease that must be eradicated, sends the message to children that their bodies are wrong and unacceptable–a determination which, again, is made on body size alone and not on any real measure of wellness. The very nature of this is fatphobic and stigmatizing; it is impossible to attempt to eradicate something (in this case, fatness) without sending the message that it is negative and should not exist. Keep in mind, too, that anti-fat bias is woven into the fabric of the U.S. healthcare system, and that most care providers operate from within an inherently stigmatizing paradigm and are unequipped and unprepared to provide “non-stigmatizing” care.
3. The guidelines encourage dieting behaviors in patients as young as two years old. (Don’t be fooled by the “lifestyle change” terminology they’ve used: food restriction originating in a desire to make one’s body smaller is a diet, no matter what language one utilizes to describe it.)
The AAP states that, because these “lifestyle” behaviors share much in common with eating disorder treatment programs, they carry virtually no associated risk of eating disorders. Consider, though, that most eating disorder treatment programs are not incredibly effective at helping patients heal: only 40-50% of those who have undergone treatment for an eating disorder remain in long-term remission.1 Additionally, adolescent girls who engage in extreme dieting behaviors are up to 18 times as likely to develop eating disorders,2 making the AAP’s risk-free claims sound dubious, indeed.
4. The guidelines recommend pharmacotherapy for children as young as eight and weight-loss surgery for children starting at thirteen years old.
This is, frankly, appalling; given the lack of data available on pediatric pharmacological and surgical interventions, there is little reason to proclaim these treatment methods will not harm patients in the long-term. Keep in mind, too, that these recommendations are made in cases of what the AAP refers to as “severe o*esity”–which, again, is measured by BMI and has nothing to do with the health of the human as a whole. These recommendations may very well see providers performing surgery on perfectly healthy children.
5. Per the guidelines, all these recommendations are made on the grounds that “severe obesity is a harbinger of the establishment and cumulative progression of numerous related comorbidities, diminished long-term health status, and shortened life expectancy.”
I’m incredibly concerned, however, at the exclusion of alternative explanations for the correlation between weight and health–explanations that are entirely plausible and factor in realities such as medical weight stigma, which keeps many in larger bodies from accessing quality care. To ignore these realities is to actively perpetuate harm.
6. The guidelines prescribe weight loss as a “solution” to the weight stigma that harms children and adolescents in larger bodies.
This posits that those who are harmed by weight stigma and anti-fat bias are at least in part to blame for the harm they receive. Putting the onus on solving oppressive environments on those who are directly oppressed by them only perpetuates harm and does nothing to address it.
I’ll stop here, though there is still more to unpack, but I hope this has helped explain and clarify the alarm that so many care providers–particularly those of us specializing in eating disorder treatment–have expressed. For more excellent information, I strongly recommend reading the statements from the Association for Size Diversity and Health (ASDAH) and the Center for Body Trust, as well as thoughts and reflections from these incredible folks:
1 McAleavey K. Ten years of treating eating disorders: what have we learned? A personal perspective on the application of 12-step and wellness programs. Adv Mind Body Med. 2008 Summer;23(2):18-26. PMID: 20664141.
2 Patton, G. C., Selzer, R., Coffey, C., Carlin, J. B., & Wolfe, R. (1999). Onset of adolescent eating disorders: population based cohort study over 3 years. BMJ (Clinical research ed.), 318(7186), 765–768. https://doi.org/10.1136/bmj.318.7186.765