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 It appears the guidelines were not peer reviewed by a diverse array of professionals such as Registered Dietitians and Eating Disorder Specialists.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
References:
https://publications.aap.org/pediatrics/article/doi/10.1542/peds.2022-060640/190443/Clinical-Pr actice-Guideline-for-the-Evaluation-and?autologincheck=redirected
https://www.aap.org/en/news-room/news-releases/aap/2022/american-academy-of-pediatrics-is sues-its-first-comprehensive-guideline-on-evaluating-treating-children-and-adolescents-with-obe sity/
https://www.pbs.org/newshour/show/new-guidelines-to-treat-childhood-obesity-suggest-more-dr astic-interventions
https://www.npr.org/2023/01/09/1147828006/childhood-obesity-requires-early-aggressive-treatm ent-new-guidelines-say
https://www.healthline.com/health-news/childhood-obesity-new-guidelines-recommend-surgerynutrition-therapy
https://www.nbcnews.com/health/kids-health/new-guidelines-treating-childhood-obesity-includemedications-surgery-rcna64651
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