A Dietetics Perspective of the New AAP Guidelines for Treatment of Children with Obesity

 Written By: Katelyn Gasperlin; SLU Dietetic Intern

The New Guidelines 

On January 9th, 2023 the American Academy of Pediatrics released its first comprehensive guidance on obesity treatment in 15 years and its first clinical practice guideline (CPG) outlining evidence-based evaluation and treatment of children and adolescents with overweight and obesity. The AAP states that “comprehensive obesity treatment may include nutrition support, physical activity treatment, behavioral therapy, pharmacotherapy, and metabolic and bariatric surgery”. Recommendations include that physicians offer adolescents ages 12 years and older with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment. Another recommendation states that teens aged 13 and older with severe obesity (BMI ≥120% of the 95th percentile for age and sex) should be evaluated for metabolic and bariatric surgery. 

In the full report, the AAP recognizes the importance of the RDN’s role by saying, “[RDN’s] may be the most widely available specialist with whom pediatricians and other PHCPs can work to provide more intensive behavioral intervention”. However, dietitian referral is not mentioned in the summary and there are no authors with an RD/RDN certification listed, nor are there mental health professionals or eating disorder specialists listed. Additionally, the guidelines do not mention a nutrition assessment prior to making weight loss recommendations. It appears the guidelines were not peer reviewed by a diverse array of professionals such as Registered Dietitians and Eating Disorder Specialists. 

Dr. Sandra Hassink, the director of the AAP's Institute for Healthy Childhood Weight, in an interview with PBS stressed the emphasis of the intense health and lifestyle behavioral therapy, which she states is at the core of obesity treatment with pharmacology and bariatric surgery as adjunct therapies. Indeed, the AAP did say that intensive health behavior and lifestyle treatment (IHBLT) is the most effective known behavioral treatment for child obesity. However, they immediately follow that up with the numerous challenges to deliver this treatment and mention the scarcity of these treatment programs. 

It is important to note that these guidelines do not address the prevention of obesity. The AAP stated that this will be addressed in a forthcoming policy statement. 

Pushback from Professionals 

In the hours, days, and weeks following the publication of these new guidelines, healthcare professionals from a variety of backgrounds came forth to voice their concerns. These concerns include, but are not limited to: the use of BMI which is not an accurate measurement of health, the disordered eating and eating disorders that will emerge from putting children through weight loss treatment, the harm this could wreak on important childhood growth,and the unknown long term consequences and effects of these recommendations. 

Jessica Setnick, @understandingnutrition on Instagram, calls the AAP guidelines, “Embarrassing. Hypocritical. Indefensible”. She goes on to explain the inaccuracies, the outdated science, and the bad medicine in these guidelines. Setnick criticizes the guidelines for assuming shrinking a child’s body will improve their health. 

Arthur Caplan, PhD, a bioethicist at the NYU Grossman School of Medicine in New York, described medication and surgery as just “Band-Aids in a society that can’t figure out what to really do to protect the interests of its kids.” 

Brian Castrucci, the head of the de Beaumont Foundation, a nonprofit involved in public health, told the Washington Post that it’s “unfortunate” the authors “focus on what individual patients need to do, instead of the policies and environments that can produce better health.” 

Strong Opposition from the Eating Disorder Community 

Many RDN’s and eating disorder specialists strongly suggest these recommendations will undoubtedly bring harm to children including increased eating disorder prevalence. The Collaborative of Eating Disorder Organizations (CEDO) strongly opposes these new guidelines and states that the guidelines may exacerbate eating disorders, increase medical weight stigma, and are not in the best interest of children. Most recently, The Academy for Eating Disorders (AED) has issued a statement urging the AAP to “revise their Guideline with input from key stakeholders including eating disorder professionals and individuals/families with lived experience in higher-weight bodies”. 

I asked Abigail Frech, MS, RDN, LDN, CPT, a Registered Dietitian working at an eating disorder treatment center, what her opinions are on the guidelines. She expressed that they seem to promote eating disorders and disordered eating. She also notes that promoting weight loss surgeries and diets can lead to nutrient deficiencies and complications with growth and development. As we all know, childhood and adolescence is an enormous period of growth, not just physically, but also mentally, neurologically, and hormonally. Putting all that on top of weight loss surgeries that already pose huge risks for adults, Frech states that “even suggesting that for children is just so dangerous”. Furthermore, Frech suggests that the guidelines are harmful since they are prioritizing “small”, possibly malnourished bodies, over bigger, healthy bodies. 

In the guidelines, the AAP states, “Evidence-based treatment delivered by trained health care professionals with active parent or caregiver involvement has no evidence of harm and can result in less disordered eating”. Anti-diet psychologist and eating disorder specialist, Alexis Conason, used Instagram (@theantidietplan) as a space to voice her opinion that the ‘research’ they used to back up this claim is biased and irrelevant. One reference used comes from an article with three authors who are either consultants or employees of Weight Watchers or Novo Nordisk. I confirmed by locating the potential conflict of interest which states that one author, M. I. Cardel, is an employee at WW International, Inc and has served as a consultant for Novo Nordisk, while another, R. L. Pearl, received grant funding from WW International, Inc and has served as a consultant for WW International, Inc and Novo Nordisk. The second and third articles referenced do not look specifically at eating disorders. Additionally, Conason criticizes the AAP for disregarding all the research that consistently identifies dieting and intentional weight loss as predictors for eating disorders. 

Is there a Silver Lining? 

One bright side to these new guidelines is that it has people talking about childhood obesity and recognizing the complexities of it and the need to provide effective care. 

I believe the AAP guidelines have potential for an important step in the right direction to decreasing the prevalence of childhood obesity and related health problems that can arise. That being said, I think the AAP failed in their approach. First off, their focus on weight and BMI as the measurement tool of that is flawed. I want to note that having a body of a certain size is not the same as having a health condition, and weight does not give an accurate picture of one’s health. Their guidelines could have been stronger and better grounded had they enlisted the help of Registered Dietitians, Eating Disorder Specialists, and a wide array of other important healthcare professionals. The overwhelming negative response to these guidelines demonstrate the lack of support from these professions. Occurrences like this remind us of the need for interprofessional health care and (in my biased opinion) respect for the dietetic field. Furthermore, the guidelines and especially the AAP’s News Release on these guidelines too strongly recommend the use of drugs and surgeries even though they state that IHBLT is the most effective treatment for childhood obesity. As a future RD, I am not ready to recommend weight loss pharmaceutical therapy or weight loss surgery to any child or adolescent because the risk of unknown long term complications both physically and mentally is just too high. It’s dangerous to be recommending this to kids, who are in immensely important periods of growth. 

Just as important to me as the treatment is the prevention of childhood obesity. I look forward to reading what the AAP releases for the prevention of childhood obesity and hopefully seeing a position paper from the Academy of Nutrition and Dietetics. 

What Other Dietitians Are Saying 

The Up-Beet Dietitians Podcast Episode 85: A Dietitian’s Take on the 2023 AAP Childhood Ob*sity Guidelines 

Anticipated Food Trend of 2023: Comfort Foods

 Written By: Olga Goumas; SLU Dietetic Intern 

Food trends strike us every year, and we see them go viral on social media such as Tik Tok and Instagram. Many of us might be familiar with the pink sauce, butter boards, and baked oats that took over our pages over the past year. With the new year comes new trends, right? Comfort foods are rumored to be one of the top food trends of 2023. While they are listed as a "new" trend, they are nothing new to us. Comfort foods provide nostalgia or sentimental for someone. These can be childhood favorites, foods from a particular time, or something that makes you feel good after eating. We all have that one that comes to mind.  

 

Food trends seem sudden; one day, it's unheard of, and the next, it's groundbreaking news, so how do we anticipate a trend like comfort food? A food characteristic that has been around for everyone, it's not new! Let's take a deeper look into this.  

 

Who Predicted This? 

 

Several outlets have their own lists of predicted food trends for 2023. The content and rankings vary, but comfort foods consistently made the top 10. This variance is expected since it is a prediction, so these sources make their best-educated guess based on previous consumer trends. The most credible forecast comes from the National Restaurant Association (NRA). The NRA partnered with the American Culinary Federation (ACF) and Technomic to conduct the 17th annual What's Hot survey. More than 500 professionals from the ACF and chefs associated with these programs gave their input on the menu trends for 2023. Listed #2 on their "macro trends," or significant shifts in consumer behavior, is comfort foods, and #4 on their "hot trends for 2023." From the restaurant, food, and beverage market research of 2023, comfort foods were ranked as #3 for 2023 culinary trends.   

 

How Did This Manifest?  

 

As post-pandemic life emerges, and ambiguities are still high, people look for comfort as they visit restaurants or bond with others over food. Reflecting on previous years also results in longing for nostalgia, which could mean consumers making their own interpretations or revisiting food spots. A survey by Farm Rich from 2020 found that 69% of respondents said they consume more comfort food and will continue to consume the same amount post-pandemic. Stresses are still high from the pandemic, and Americans have flocked to comfort foods, reports Forbes. Comfort food sales in the first two months of 2022 were higher than in the same 2019 period. This is reflective that consumers still desire a feel-good sensation from their foods post-pandemic, and their buying power shows it's from comfort foods. 

 

What is Happening to Comfort Foods? 

 

The NRA predicts that consumers will be interested in menus offering comfort foods but with a global or signature twist. So far, what has already been seen on Tik Tok and Instagram is that people are adding a twist to their favorite foods. They're elevating their comfort food favorites such as combining two favorites (i.e., buffalo chicken mac 'cheese) or incorporating globally inspired flavors (i.e., Thai chili wings, birria bao buns). The NRA also noted that "comfort foods and healthier items continue to trend in a classic face-off; consumers are loathe to part with either option." In 2022, it was noticed that consumers are balancing craved comfort foods with health-conscious options. Their meals' nutritional value has been improved by incorporating plant-based alternatives or lower fat/calorie substitutions into traditional recipes. People are enjoying the foundation of their favorite comfort foods but are adapting them and making them their own!  

 

Everyone has a different take on comfort food, but it typically involves nostalgia and what is craved when stressed. Trends support that this widely anticipated trend will be apparent this year, but we will have to wait and see!  

3 New Year’s Resolutions to Help You Reach and Sustain Your Health Goals and Build a Better Relationship with Food and Your Body

 Written by: Morgan Farida; SLU Dietetic Intern

As we enter the new year, it is natural for us to reflect on the previous year and create goals to better ourselves in whatever way feels necessary for our own personal growth and well-being. It is common for people to create “new year’s resolutions” or daily habits to reach the goals that they set for themselves. With that being said, it is easy to assume that many of us may be reflecting on the various ways we can improve our health and wellness. However, often these resolutions can be centered around diet and weight loss, which can lead to restrictive dieting or excessive exercise. These can lead to a disordered relationship with our bodies and food, because when these fail, as restriction with food and excessive exercise tend to do, we often feel an overwhelming sense of guilt and shame. 

 

Below are just a few new year’s resolutions you can practice in 2023 that will help you reach your health and wellness goals and build a better relationship with food and your body while leaving diet culture in 2022. 

 

1. 1. Practice Intuitive Eating 

Intuitive eating is an evidence-based approach to eating that promotes developing a positive relationship with food, your body, and yourself. A study in the Journal of the Academy of Nutrition and Dietetics found that there was a positive relationship between intuitive eating and positive psychological status, higher self-esteem and body appreciation, and satisfaction with life, as well as an inverse relationship between intuitive eating and eating disorder symptomatology, body surveillance/shame, and body mass index (Carraça, Eliana V., et al., 2018). 

 

To put it simply, intuitive eating is honoring your hunger and respecting your fullness and involves listening to your body’s hunger and fullness cues and eating in response to them, without restriction or guilt. It is an intuition that every individual is born with and a practice that most individuals need to re-learn due to the disordered habits they develop as they grow. However, diet culture and the cycle of dieting make this practice very difficult for most, and like any practice, it is most effective to start slowly and work your way toward being an intuitive eater. One book I highly recommend that talks about the aspects of intuitive eating and provides an in-depth guide for navigating through reaching your intuitive eating goals is Intuitive Eating: A Revolutionary Anti-Diet Approach by registered dietitians Evelyn Tribole and Elyse Resch. 

 

2. 2. Practice intentional movement for at least 30 minutes a day 

Repeat after me: I do not need to participate in intense exercise and go to the gym every single day to reach my health and wellness goals. For some, this type of exercise is very enjoyable and realistic and is a common practice in their life. While for others this type of exercise is draining, hard to maintain, and unenjoyable. It is no secret that movement is essential for optimal overall well-being as research has proven daily movement, regardless of intensity, reduces the risk of chronic diseases and improves mental health. However, movement looks different for each and every individual, and that is completely okay. That is why it is imperative that one creates a personalized regimen that is enjoyable to them and meets their own personal needs, as opposed to following what works for someone else.  

 

Intentional movement is another important aspect of maintaining a healthy lifestyle: instead of focusing on weight loss or making your body look a certain way, the goal is to move in a way that is enjoyable and feels good for your body and mind. This can include activities such as walking your dog, yoga, or hiking, rather than traditional exercise programs that can be overly restrictive and lead to burnout if you do not enjoy them. Intentional movement also relates to intuitive eating as seen in the study mentioned above. Research has shown that being more active with the goal of losing weight or controlling your weight is correlated with a disordered relationship with food and your body. This in turn leads to more restrictive eating patterns which disturb one’s ability to rely on their own hunger and satiety cues (Carraça, Eliana V., et al., 2018). On the contrary, it has been proven that when one is more active with the purpose of improving their overall mental and physical health, it naturally leads to a healthier relationship with food (Carraça, Eliana V., et al., 2018). That is because when your goal is to be healthier as opposed to “looking better”, you are naturally inclined to have healthier, more nutrient-dense, eating habits.  

 

3. Prioritize sleep and mental health 

It is no secret that there is a direct correlation between sleep and mental health. But where does diet fit in? Research taken from the Journal of the Academy of Nutrition and Dietetics has shown that making modifications to one’s diet is a natural way to improve sleep quality and vice versa (Wilson, Katherine, et al., 2022). This study depicts how the amount and type of carbohydrates and fats in one’s diet can affect sleep quality positively or negatively.  For example, complex carbohydrates and healthy fats cause improved sleep quality. In addition, diets high in fiber and protein improve sleep quality (Wilson, Katherine, et al., 2022). Just as diet has effect on sleep, sleep has an effect on diet and lifestyle. The amount and quality of sleep one gets can relate to the quality of one’s diet and food cravings. With further research, it is predicted that there will be further findings that will allow us to understand more in-depth the correlation between diet and sleep quality.   

 

In conclusion, when it comes to New Year’s resolutions, it is important to focus on building a better relationship with food and our bodies, rather than solely focusing on weight loss or dieting. By practicing intuitive eating, intentional movement, and prioritizing sleep and mental health, we can set ourselves up for success and achieve our health goals in a sustainable and enjoyable way. Remember, progress is not linear, and it is okay to take steps back, but keep going and be kind to yourself. Let’s start the new year off on the right foot by breaking free from diet culture’s harmful practices and focus on overall health and well-being.