Q&A: Maybe Kids Don’t Need to Lose Weight

Feb. 22, 2023 — After the American Academy of Pediatrics’ new guidelines for treating obese kids came out, I wrote “What Parents Should Know” for WebMD. It included insights from several experts and two moms of overweight children. The guidelines have proven controversial due to the recommendations of medication and bariatric surgery for older kids — but also because a growing number of people question whether telling a child to lose weight is ever a good idea. 

One of the most prominent voices reaching parents about kids and weight belongs to Virginia Sole-Smith. A journalist and creator of a newsletter and podcast focused on fatphobia, diet culture, and parenting called Burnt Toast, she’s also the author of a forthcoming book on the subject. Fat Talk: Parenting in the Age of Diet Culture will be published in April. I spoke with her about the AAP guidelines and how to parent a fat — or thin — child in our seemingly inescapable diet culture.

This interview has been edited for length and clarity.

Q: This is probably due to my own history as a fat kid, but when I read the new AAP guidelines, they struck me as thoughtful and empathetic, though the idea of medicating or operating on teens made me uneasy. But you point out that encouraging weight loss in the first place is likely to cause more problems than it solves.

A: We don’t have a ton of evidence that high body weight itself is the problem. There are reasons to be concerned about weight-linked health conditions, but pathologizing body size brings with it a whole other set of complications. When you do that, you start telling kids their bodies are problems to solve, you start focusing on food in ways that can raise their risk for disordered eating and eating disorders. There’s a whole ripple effect to this that the guidelines aren’t reckoning with. 

Underpinning this whole conversation is anti-fat bias. We live in a culture that believes fat bodies are less valuable, less lovable, and less attractive than thin bodies. Our whole world is built to celebrate and welcome thin bodies and push out larger ones. This is just another way we’re doing that.

Q: People may wonder why the AAP would put out guidelines that might be harmful for kids since this is an organization that clearly cares about children’s health. 

A: It’s really tricky. Officially, in their paper, they say, “We have no financial disclosures to reveal, everything’s on the up and up.” But the AAP itself receives donations from pharmaceutical companies, including Novo Nordisk, which is the manufacturer of two of the biggest weight loss drugs. A lot of the authors on this paper have received research funds, speaking fees, consulting fees, etc., or they’re employed by centers that do bariatric surgery. That doesn’t need to get disclosed because it’s just their job. They’re considered an expert because of it, but they’re financially entangled with weight loss being a thing we push for. (Editor’s note: WebMD reached out to the AAP for comment. This is their reply: The AAP has a strict conflict-of-interest disclosure policy and process for all authors of policy statements, clinical reports and clinical practice guidelines. The authors include medical experts with a wide range of perspectives, medical specialties and professional experiences, including some who have conducted research on weight and obesity and others who have devoted their careers to this aspect of medicine. Their knowledge and expertise was important in the development of these evidence-based guidelines. The guidelines also underwent an extensive peer-review process among many other groups of pediatricians and pediatric specialists, and ultimately were approved by the AAP Board of Directors.)

Q: Is trying to lose weight always bad? The moms I interviewed for that article, both of whom use the new injectable weight loss drugs, said they found it reassuring to have a medical solution to their weight problems. It removed a lot of the shame to know it was a physiological thing. And doctors point out that if your child had diabetes you wouldn’t hesitate to give them drugs. So why is this different?

A: Why is because body size in and of itself isn’t a medical condition. Doctors have pathologized it and made obesity a diagnosis, but there’s a lot of evidence to suggest it shouldn’t be. So it’s not the same as giving your kid an inhaler for asthma or insulin for diabetes. That’s what I want — I want doctors to medicate the actual medical conditions. 

The moms you spoke to are being told over and over that their kid’s body is a problem, and they are to blame. Parents in general, but moms especially, get so much judgment if they have a fat kid. And if you’re a fat parent with a fat kid, doubly so. They’re being told if you don’t get this problem under control, your child will have lifelong health consequences. Your child will be bullied. Your child will be unpopular, unlovable, less employable, and so on. All of that is driven by bias. That’s not medical. 

I empathize with parents — they’re terrified for their kids so making kids smaller feels like the answer. But when we choose that, we reinforce anti-fat bias and we make it more powerful. And we say to these kids, yup, the bullies are right, your body is the problem, you are the problem. We need to change you. We don’t need to change this whole system.

Q: The AAP guidelines say that the treatments they’re recommending statistically don’t lead to eating disorders. You argue that in reality, they do. 

A: Eating disorders are really underdiagnosed in fat people because we assume they only happen to thin white girls. But we know they happen to people of every age, every gender, every race. There’s a lot of evidence to show that fat folks, by the time they do get treated, are much sicker because doctors have been reinforcing that disordered behavior along the way. They’re so happy to see weight loss, they don’t question how the loss was achieved. But you absolutely can have an eating disorder, you can be experiencing the physical complications of eating disorders, the heart issues, the fainting, all of that, in a larger body. You don’t have to be emaciated to deserve treatment.

As for the AAP saying these programs don’t cause eating disorders, the research they used to determine that didn’t follow kids long enough. Often studies only follow people for 1 to 2 years. If you put a 10-year-old on a diet and follow them until they’re 11 or 12, that eating disorder may not onset until age 14 or 15. 

And then when they did check for eating disorder symptoms, they looked for things like binge eating, overeating, purging. They looked for the symptoms they expect fat people to show, but they did not look for restriction, skipping meals, cutting out food groups, because No. 1, they don’t think fat people do that, and No. 2, that is exactly what they’re teaching the kids to do: to restrict. 

Q: There are diseases with clear correlations to excess weight. I was just diagnosed with arthritis in my hip, and I suspect it has to do with the fact that I was 100 pounds overweight for years. How should we be talking about that?

A: We often rush to say weight is legitimately an issue without investigating. Might a thin person with the same habits have the same risk for the condition? Just focusing on making body size smaller won’t necessarily affect whatever lifestyle factors are at play. 

There’s also the fact that people in larger bodies receive significantly worse medical care, so a thin person reporting symptoms might get treatment faster than a fat person. I remember interviewing a weight-inclusive doctor, and I asked about knee issues. I’m fat and I have knee problems. And she said, “I have knee problems, too. I get physical therapy, I’ve gotten surgery, I’ve been prescribed all these different treatments.” But fat people get told to lose weight to take pressure off your knees. They don’t get referrals to physical therapy and things that might help these issues. The bias becomes a self-fulfilling prophecy.

Of course, there are conditions where weight may play a causal role. I’m not disputing that. I don’t think anyone is disputing that. What we’re disputing is treating fat people like it’s their fault — if only they’d had more willpower, they wouldn’t be in this situation. Denying them care in a punitive way. That’s the harder thing for the medical community to wrap their heads around. Even if you’re fat and unhealthy, your body is still worthy of dignity and respect and health care. 

The last piece is that sustainable weight loss doesn’t work most of the time. Dieting has a huge failure rate. Medications and surgery may be starting to change that, but they come with significant side effects. The surgery is going to be lifelong, and the medication you have to stay on for life to sustain the weight loss. You’re looking at a lifetime of consequences.

Q: Let’s talk about the more positive side of things. In your book, you write about fat positivity and how to instill it, telling your child, “Your body is never the problem.” What does a kid get out of hearing that?

A: It’s not the doctor’s fault, but doctors always see bodies as problems to solve — why is this symptom or behavior happening? For a kid sitting under the microscope, what a gross feeling that is, knowing someone has to invest time and money into fixing them. And with weight, it reinforces this whole larger bias. 

But you can’t necessarily control what the doctor says in an appointment. You can ask not to discuss BMI or weight, you can try to set boundaries, but you can’t guarantee how the conversation will go. The only thing you can control is what your child hears you say. If you say to the doctor, “I don’t view their body as a problem,” at least your child comes away with the knowledge that my body is safe in my home, with my family. My parents don’t see me this way. It feels like an important foundation that so many fat kids don’t get. 

Q: What about parents of thin kids? What should they be doing?

A: I really want parents of thin kids to be talking about this, for two reasons. One, thin kids aren’t immune to the harms of anti-fat bias. Not every thin kid will grow up to be a thin adult. I say this as a former thin kid who’s a fat adult. It’s really important that thinness not be so interwoven with their identity, that if they can’t maintain that thinness, they feel like they’re failing.

Thing two is, parents of thin kids need to talk about anti-fat bias the same way parents of white kids need to talk about racism. If we don’t have these hard conversations, if we don’t teach our kids to name and unlearn this bias, the rest of the culture is going to teach them instead. 

It’s not that I want parents to try to keep their kids in a fat-positive bubble with no exposure to diet culture. I want parents to be naming these things, to be learning alongside their kids, to be having conversations so that we can help kids develop critical thinking skills. Then they can start to point out diet culture to us, they can say, “Hey, this is a really messed up way to talk about bodies in this TV show or this book I’m reading or this person I’m following on TikTok.” That is going to do more to buffer kids against these influences because we’re giving them the option to disagree with it. We’re giving them the option to think about going a different way. 

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New Guidelines for Kids With Obesity: What Parents Should Know

Jan. 13, 2023 — The American Academy of Pediatrics last week issued their first new guidelines in 15 years for evaluating and treating kids and adolescents with overweight or obesity. 

If you only saw the headlines, you might think that when a youngster is a few pounds overweight, their pediatrician will prescribe a weight loss drug or bariatric surgery. The reality is much less alarming. The guidelines take a deep dive into evidence-based treatments at various levels.

“It’s a misunderstanding, it’s being sensationalized,” says Lori Fishman, PsyD, a child psychologist who specializes in pediatric weight management. “There’s so much more to the process. It’ll be a small percentage of kids who’ll even qualify for these treatments.” 

Treating the Whole Child

Before writing the guidelines, the AAP’s Subcommittee on Obesity spent years analyzing and synthesizing information from nearly 400 studies. 

“We now have more information than ever that supports that obesity is a chronic, complex disease that requires a whole-child approach,” says Sarah Hampl, MD, one of two lead authors of the guidelines. “And many kids will not outgrow it, so it’s important to identify children with obesity early and offer them evidence-based treatments.”

In the new guidelines, treatment of overweight and obesity doesn’t mean putting a kid on a diet and expecting their parents to manage it. Instead, multi-pronged approaches might include nutrition support, physical activity specialists, behavioral therapy, medications for adolescents 12 and up, and surgery for teenagers with severe obesity. 

Before starting any of these evidence-based treatments, the guidelines remind pediatricians to consider each child’s individual circumstances — their living situation, their access to healthy food, and more.

“As pediatricians, we ought to be especially mindful of the influences that child and family are surrounded by,” Hampl says. “We should help guide them, whether it’s to local resources for healthy food or support for a child who’s being bullied.”

Because obesity is often stigmatized, the pediatricians’ group also included guidance for pediatricians to help them examine their own biases. It calls on them to acknowledge the myriad genetic and environmental factors that contribute to obesity and treat children and their parents with respect and sensitivity.

The Rise of Childhood Obesity

For kids 2-18, obesity is defined as having a BMI at or above the 95th percentile for a child’s age and sex. Rates of pediatric obesity have more than tripled since the 1960s, from 5% to nearly 20%. Just last month, the CDC released updated growth charts to take into account how many more children and adolescents now have severe obesity, well beyond the 95th percentile. By 2018, more than 4.5 million kids qualified, but the old charts didn’t go high enough.

If these trends continue, researchers estimate that 57% of children aged 2 to 19 will have obesity by the time they hit 35. And the pandemic has only made things worse.

“It’s about much more than what we eat and drink or how physically active we are,” Hampl says. Risk factors for obesity include genetics, socioeconomics, race and ethnicity, government policies, a child’s environment, neighborhood, and school, and even their exposure to unhealthy food marketing. Because each child is so different, these factors combine in unique ways.

You can see an example of the variability in Jill’s family. She’s a New Jersey mom with two teenage sons. For privacy reasons, we’re using only her first name. 

“I have two children who I raised the same way, who were offered the same foods, and yet one weighs 80 pounds more than the other,” she says. “My 16-year-old is happy to choose fruit over a cookie. He’s able to stop, to not eat another bite. The 14-year-old will eat cookies until they’re gone.”

No More Watch and Wait

The last set of guidelines, from 2007, called for pediatricians to monitor kids with obesity via “watchful waiting.” It would give children a chance to outgrow their excess pounds before being treated. Research conducted since then shows that’s not effective. 

“The risk of watching and waiting, in my experience, is that a 10-pound-overweight child a year later might be 30 pounds overweight,” says Fishman. “That’s a lot harder to tackle.”

In the new guidelines, the AAP stresses the urgency of treating children with overweight and obesity as soon as it’s diagnosed. Instead of hoping a growth spurt might take care of the problem, pediatricians should move quickly, “at the highest level of intensity appropriate for and available to the child.”

By guiding children and their families to adopt healthier habits early, it may help to reduce some of the weight-related health issues that have also increased in the last few decades. Just within the 21st century, diabetes rates for children and teenagers have skyrocketed — between 2001 and 2017, the number of kids with type 2 went up an astonishing 95%.

“Now we understand the consequences of untreated obesity, especially severe obesity,” says Mary Ellen Vajravelu, MD, a doctor-scientist at the Center for Pediatric Research in Obesity and Metabolism in Pittsburgh. “That includes type 2 diabetes, fatty liver disease, high blood pressure, high cholesterol. It’s important to treat obesity in childhood to avoid the complications we’re seeing in young adults.”

Also important: Reversing the trend while a child is young can help them avoid the emotional impact of growing up with obesity. 

“I saw the recommendations and thought, ‘How different would my life have been for the past 35 years if they had treated my obesity when I was a child?” says Heather, the mother of a 10-year-old in Florida. She’s been carrying shame and limiting herself since childhood, for instance by avoiding activities where her size might prove embarrassing. “For kids who are struggling, I think it’ll be life-changing.”

What the Guidelines Really Say

In a world where fat-shaming is rampant, parents often want to protect their children by encouraging them to lose weight — but parental pressure adds another layer of bad feelings. The AAP advises against putting a child on a diet or restricting their access to food without professional help. Guidelines recommend that pediatricians:

  • Treat obesity as a chronic disease. That calls for long-term care strategies and ongoing monitoring.
  • Implement a model known as the “medical home.” It takes treatment beyond the exam room to shape behavior and lifestyle changes. Pediatricians should build partnerships with families in their care and serve as a care coordinator, working with a team that may include obesity treatment specialists, dietitians, psychologists, nurses, exercise specialists, and social workers.
  • Use a patient-centered counseling style called motivational interviewing. Rather than a doctor prescribing changes for a child’s family to figure out, the process guides families to identify which behaviors to adjust based on their own priorities and goals — that might mean cutting back on sugary drinks or walking together after dinner. Research has shown it takes less than 5 hours of motivational interviewing with a pediatrician or dietitian to help bring down BMI.
  • Opt for an approach called intensive health behavior and lifestyle treatment (IHBLT) whenever feasible. As the name suggests, it’s an intense treatment that calls for at least 26 hours of face-to-face, family counseling on nutrition and exercise over a period of 3 to 12 months. More sessions produce larger reductions in BMI, with 52 hours or more over the same duration having the greatest impact. Unfortunately this treatment program isn’t available everywhere, and for many families the time and financial demands put it out of reach.
  • Offer approved weight loss drugs to adolescents 12 years and older who have obesity. Medication should always be used together with nutrition and exercise therapies.
  • Refer adolescents 13 and up with severe obesity for possible weight loss surgery. That referral should be to a surgical center with experience in working with adolescents and their families, where the teen would undergo a thorough screening process.

Medication and Surgery

Those last two recommendations have garnered most of the headlines, and it’s understandable. Medicating a child — or performing an operation that would permanently change their body — might seem extreme. But the research shows that for children with obesity and severe obesity, these treatments work.

“This isn’t for a kid who’s a little overweight,” says Fishman. “It’s obesity that’s limiting this child’s ability to function. When we face something this disabling, we want to attack it from every direction we can.”

Right now, only a handful of medications are approved to treat obesity in adolescents. Some are taken orally, while others, like the recently approved Wegovy, are injected. 

Jill, the New Jersey mom, is using Wegovy herself. 

“The fact that I’ve had success with it makes me more comfortable about approaching it as an option for my son,” she says. “And ultimately, it’s his choice. If he wants to see if he can just do things differently first, we’ll try that. A nutritionist’s guidance will be part of this for him regardless, so he can understand what’s involved. It’s not like he’ll get the shot and all of a sudden magic happens.”

Losing weight with medication can help remove some of the shame that often comes with obesity. Heather, the Florida mom, is also using an injectable drug.

“It’s all the morality stuff like, if you had more self-control, if you worked harder and really tried, if you just made the choice,” she says. “This pulls all the morality out of it. Obesity is a medical condition. It’s so clear. In the same way I take thyroxin because my thyroid doesn’t work well, this makes my insulin receptors work properly.”

For kids 13 and older with severe obesity — a BMI over 35, or 120% of the 95th percentile for age and sex — metabolic or bariatric surgery may be recommended. Of course, surgery is much more invasive than medication, with a greater risk of complications. The guidelines acknowledge this and stress the need for thorough screening before proceeding.

“The pediatrician would refer a child for evaluation. They wouldn’t say, ‘You definitely need to have surgery,’” Hampl says. “They’d say, ‘As your pediatrician, I feel that you would benefit from a comprehensive evaluation at a pediatric bariatric surgical center.’ These types of centers do a very thorough pre-op evaluation over at least 6 months, and then careful monitoring is done for years afterward.”

Weight loss surgery for adolescents does have certain drawbacks. Any surgery has the risk of complications, and some surgical patients do gain back a significant amount of weight. Some research suggests that adolescents who have the surgery are more likely to have alcohol problems later in life.

Even with those risks, for some teens surgery may prove life-saving.

“We know much more about the complications of obesity in adults, we know those are devastating,” says Hampl. “If we can prevent heart attacks, stroke, sleep apnea, diabetes, and other really serious medical complications, that in itself is a huge benefit to the person’s health.”

The Question of Equity

The guidelines point out that obesity has inequities baked into the condition. Risk factors increase depending on your economic status and your race. Access to treatment is lopsided. Some of the most effective treatments, like intensive health behavior and lifestyle treatment, aren’t available everywhere. Providers may not be in-network or even accept insurance. 

If the family of a child with overweight can’t access effective programs to help them build healthy habits, the child’s odds for developing obesity grow. As they get older and their BMI reaches the level of obesity or severe obesity, treatments like medication and surgery become an option. But they’re even more costly, which leaves many families with no help at all.

That’s why the guidelines also include policy recommendations aimed at covering comprehensive obesity prevention, evaluation, and treatment. They call attention to the ways unhealthy food is marketed, the effects of limited resources on a community, how socioeconomic and immigration status factor in, and the challenges posed by food insecurity.

“We hope the guidelines will serve as impetus to help improve access to care for all children with obesity,” Hampl says. “That includes everything from infrastructure and policy to systems change as well.”

For parents who struggle to help their children with overweight and obesity, having such an authoritative resource can pave the way to getting real help.

“It’s good that they issued these guidelines. I’m hoping, for my son and all the kids out there who are struggling, that it will help to have it recognized as something worthy of clinical, medical management,” Jill says. “It’s validating.” 

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