A Pediatrician's Take on the New Childhood Obesity Guidelines

I’ve lost track of how many people have told me their eating disorder started with something their pediatrician said, including my younger sister. As a pediatrician, a psychiatrist, and a child and adolescent psychiatrist in training; a person whose sister and friends have been diagnosed with these deadly illnesses; and as someone in recovery from an eating disorder myself, many things scare me about the new American Academy of Pediatrics (AAP) Obesity Guidelines. The sparse discussion of eating disorders is at the top of that list. For anyone who hasn’t read them, these guidelines recommend weight loss pharmacotherapy to children as young as 12 and metabolic bariatric surgery to adolescents as young as 13.

As a doctor, my greatest fear is causing inadvertent harm that could destroy someone’s life. In and of itself, weight focus at the doctor’s office increases fatphobia. This focus on obesity increases the stress on numbers, using antiquated systems. BMI was never intended to be used as a measurement for health, and our current growth charts are based on data from the 1960s through the early 1990s. Are these outdated measurements truly the best measure of health? Weight can be a helpful data point, but it needs to be evaluated in the context of overall health. Are we targeting obesity as a chronic disease, or are we simply causing psychological distress by telling children their bodies “aren’t right”?

The guidelines fail to mention that the risk factors for developing an eating disorder are the same as those for developing obesity. For people with a genetic predisposition to develop an eating disorder, a single diet can set off a lifelong struggle with mental illness. Just as not everyone who starts drinking will develop a substance use disorder, not everyone who goes on a diet will develop an eating disorder. But many people will.

My sister cites her pediatrician’s statement about her “being overweight” as triggering a lifelong struggle with anorexia. Outside of the opioid epidemic, eating disorders are the most fatal of all mental illnesses, with mortality rates up to 10 times higher for females 15 – 24 years old.

It has been estimated that one in five people with anorexia will die from complications of their eating disorder within 20 years, and only 30 – 40% of patients fully recover. Eating disorders represent a lethality that far outweighs that of obesity, and at a much younger age. It is not fair for pediatricians to hold that burden of inadvertent harm, especially when they are simply following the algorithms laid out for them.

These guidelines may treat weight, at least temporarily, but do they treat health? The guidelines highlight the fact that obesity-related diseases, such as diabetes and cardiovascular disease, can be improved upon with lifestyle changes and weight loss as justification for the treatment of weight. However, it does not mention the medical complications of eating disorders, which are numerous and far exceed the medical complications of obesity. As a physician, I would have much preferred my sister to have a possible future risk of diabetes and cardiovascular disease than an illness that put her in the hospital at age 16 with heart problems.

Of all the recommendations the AAP outlined, the request for evaluation for bariatric surgery is the most misguided. It was based on minimal data, and there have not been any long-term studies on the physical and psychological effects of bariatric surgery in childhood. Can a 13-year-old truly consent to the lifelong undernourishment caused by such a radical procedure? Prominent figures in the recovery community have cited countless patient reports of harm and none of success. Most notably, a study published on Jan 25, 2023, reports that bariatric surgery increases the risk of suicide, specifically in the youngest patients.

As a physician, a friend, a family member, and a survivor, I ask the AAP: is weight loss worth this risk? Are we focusing on health, or inadvertently shaming children? Including weight loss pharmacology and bariatric surgery in the AAP obesity guidelines is premature, irresponsible, and dangerous. The dangers of these guidelines encouraging eating disorders are much greater than the risks associated with being overweight or obese.

Sincerely,
Danielle Burton, MD
Pediatrics/Adult Psychiatry/Child and Adolescent Psychiatry
Opinions expressed are solely my own and do not express the views or opinions of my employer.