The war on obesity, or “ob*sity,” has picked up steam—and the targets are getting younger. (Note: I use an asterisk when referring to the term “obese” to reflect discomfort with the term as, historically, it has been inherently stigmatizing—i.e., “the war against obesity.”)
As you may have heard, the American Academy of Pediatrics (AAP) released new clinical guidelines for the care of higher-weight children. The 100-page document is full of deeply concerning recommendations, including suggesting “Intensive Health Behavior and Lifestyle Training” for higher-weight children as young as age two and with surgery and drug interventions advised starting at age 13.
The guidelines require dissection and challenge along a number of fronts. For a start, let’s look at weight stigma, which is among the drivers of AAP recommendations.
Discourse about health that focuses primarily on body weight is referred to as the weight-centered health paradigm (WCHP). Essentially, the basic tenets of WCHP include the idea that people can control their body weight through diet and physical activity and that achieving an “optimal” [reduced] body weight will lead to improved health.
Critics of WCHP assert that focusing on body weight as a method of improving health is ineffective and, ultimately, harmful. Critics contend that the proposed direct tie between health and body weight is scientifically inaccurate and that the prevailing attitudes and beliefs associated with the WCHP marginalize and oppress individuals based on their size alone.
Recently, critical analysis of WCHP has picked up with an effort to shift the paradigm away from body size toward more general markers of health and well-being such as the nutritional quality of one’s diet, physical activity practices, and also medical criteria like cholesterol, blood pressure, etc. Since 1988, when the National Institutes of Health (NIH) declared ob*sity to be a “complex multifactorial chronic disease,”many health experts have expressed concerns about referring to a person’s body size as a “disease.” The association between size and disease feeds into a long history of stigma and discrimination towards individuals in larger bodies.
Given the complex history of ob*sity, when the American Academy of Pediatrics (AAP) released new clinical practice guidelines1 to treat children from ages 2 to 18 who classify as ob*se—meaning they have a body mass index, or BMI, at or above the 95th percentile for their age and sex, according to CDC growth charts—alarm bells sounded for many healthcare providers, mental health professionals, patients, families, advocates and beyond.
Most people who fall into the category of ob*se have suffered teasing, bullying, and other negative consequences of weight stigma throughout their lives. Children and teenagers are at heightened risk of bullying both in person and in the digital environments that dominate younger generations. Sadly, we know that internalized stigma increases vulnerability to a range of difficulties, including depressive symptoms, low self-esteem, suicidal ideation, inferior social and academic outcomes, disordered eating behaviors, reduced physical activity, substance use, and weight gain.
Our global obsession with being thin at any cost and popular misconceptions about weight and health can poison our relationships, including those relationships with our medical providers. “Physicians are not immune to societal weight bias that is prevalent in our culture,” Rebecca Puhl, a professor and the deputy director of the Rudd Center for Food Policy and Health at the University of Connecticut, said in conversation with The New York Times. “Weight bias is rarely, if ever, addressed in medical school training.”
Weight stigma, discrimination, and inequitable access to care are pervasive issues in healthcare settings across the globe. A recent study found that approximately two-thirds of 12,996 adult participants residing in Australia, Canada, France, Germany, the U.K., and the U.S. had experienced weight stigma from a doctor. Invariably, we know that negative experiences in routine medical care can lead to delay or avoidance of critical help until medical issues worsen or become life-threatening.
Despite the prevailing stigma, compelling research tells us that an individual’s BMI is a measurement of their size, not necessarily their health. It is possible for someone to be above average weight and healthy, just as it is possible for someone to be thin and sick.
This is one of the reasons why many health experts are calling for the medical community to reconsider its stance on “treating” ob*sity. Weight loss is a common recommendation, even though extensive research tells us that weight loss is almost always followed by weight regain (in 95 percent of cases). Weight cycling—losing and gaining weight repeatedly—is common among dieters and is known to stress the body and worsen health outcomes in the long run. A recent review of the scientific literature proposed that increased physical activity and cardiorespiratory fitness are more effective than weight loss at keeping a person healthy and prolonging their life.
Rather than relying on the BMI alone, many experts recommend looking at more clear and meaningful measures of health. Blood pressure, heart rate, inflammation, body temperature, ability to breathe easily, and glucose levels are all better indicators of how healthy a person is regardless of their body size. And the absence of illness or disability has a more meaningful impact on someone’s life than whether they see a certain number when they step on the scale.
For children and teenagers especially, the focus on BMI is misleading as their bodies are still developing and undergoing many changes as a natural result of puberty. Unfortunately, medical providers and other concerned adults may be so intent on the child’s weight that they may overlook the complicated genetic, environmental, and socioeconomic factors that are more urgently affecting their health. For instance, a sudden drop or gain in weight is concerning not because of the number itself but because it can be a red flag for many serious medical and mental health conditions.
As an eating disorder treatment professional, I see the damage of weight stigma firsthand each and every day. The work of eating disorder treatment is often about undoing years of harmful messaging. In many cases, the most traumatic messaging came directly from medical professionals under the guise that losing weight would improve health in the long term. I’ve heard countless stories from patients, noting the “beginning” of their ED journey taking place in the pediatrician’s office, with a recommendation to “watch” or lose weight.
The AAP needs to revisit their guidelines, incorporating feedback from experts, advocates, and individuals with lived experience in larger bodies. Our medical community has the ethical responsibility to “do no harm”; promoting a lifetime of dieting behavior in our children goes against the ethics of the medical profession. It’s time for a do-over.
1 Hampl, S.E., Hassink, S.G., Skinner, A.C., et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics. 2023;151(2): e2022060640
2 Kyle, T.K., Dhurandhar, E.J., & Allison, D.B. Regarding Obesity as a Disease: Evolving Policies and Their Implications. Endocrinol Metab Clin North Am. 2016 Sep; 45(3):511-20. doi: 10.1016/j.ecl.2016.04.004. PMID: 27519127; PMCID: PMC4988332.
3 O’Hara, Lily & Taylor, Jane. (2010). Don’t Diet: Adverse Effects of the Weight Centered Health Paradigm. 10.1007/978-1-60327-571-2_28.
4 Puhl, R.M., Lessard, L.M. Weight Stigma in Youth: Prevalence, Consequences, and Considerations for Clinical Practice. Curr Obes Rep 9, 402–411 (2020). https://doi.org/10.1007/s13679-020-00408-8.
5 Pearson, C. (2023, January 20). New Guidelines Underscore How Complicated Childhood Obesity Is for Patients and Providers. The New York Times. https://www.nytimes.com/2023/01/20/well/family/childhood-obesity-guidel….
6 Puhl, R.M., Lessard, L.M., Himmelstein, M.S., & Foster G.D. (2021). The roles of experienced and internalized weight stigma in healthcare experiences: Perspectives of adults engaged in weight management across six countries. PLOS ONE, 16(6): e0251566. https://doi.org/10.1371/journal.pone.0251566.
7 Gaessar, G.A., & Angaddi, S.S. (2021). Obesity treatment: Weight loss versus increasing fitness and physical activity for reducing health risks. iScience, 24(10). https://doi.org/10.1016/j.isci.2021.102995.