We are a grassroots advocacy organization of medical students across the country, focused on making health care more equitable for patients in larger bodies. We join the physicians, eating disorder professionals, and community members who raise concerns regarding the AAP’s most recent clinical guidelines, “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity.”
The new AAP guidelines are based on science that grossly misrepresents the complex relationship between weight and health. BMI is a flawed tool for assessing patient health and has become a default means of classifying bodies as “healthy” or “unhealthy.” The evidence remains elusive as to whether increased BMI alone is causative of increased morbidity and mortality. This outdated tool does not consider genetic, ethnic, and epigenetic variation or significant factors like poverty, racism, trauma, environment, chronic stress, and weight stigma, all of which negatively affect health outcomes in and of themselves.
There is strong evidence that the current interventions we prescribe for weight loss cause more harm than good. Restrictive diets have been shown to be unsuccessful in the long term for the purpose of reducing body weight and often result in weight cycling, which has been shown to increase rates of morbidity and mortality. Though most studies focus on the adult population, there should be concern about the health implications for children, who would experience weight cycling and potential lifelong malabsorptive states at a younger age, and for a longer duration.
Weight loss medications, including the praised GLP1 agonists, are also not without harm, causing significant side effects in a large percentage of patients. Weight loss from these medications has not been shown to last more than two years, and once the drug is discontinued, patients’ weights fluctuate back upward as hormone levels equilibrate. Given existing shortages of these medications for patients who are using them to manage T2DM, issues of long-term accessibility must also be more realistically considered.
Weight loss surgeries take healthy, functioning organs and put them into a permanent disease state by reducing digestive hormone production, absorption of nutrients, and result in frequent complications. As a result, patients are forced into behaviors that mimic eating disorders in preparation for invasive surgery and then for the rest of their lives to maintain the weight loss and adjust to their modified organs. These surgeries have been shown to cause harmful health outcomes and side effects in adult patient populations and require lifelong supplementation of vitamins and minerals to maintain proper levels. If we recommend these life-altering surgeries that come with a constellation of health risks for vulnerable youth as young as 13, we as medical providers are acting in direct opposition to our duty to “do no harm.” We cannot ask adolescents, who lack the ability to fully consent and manage their bodily autonomy, to risk their lives and well-being in an attempt to make their bodies smaller.
Furthermore, dieting and poor self-image are known risk factors for the development of eating disorders among children and adolescents. The AAP guidelines intensify the focus on BMI and weight loss as measures of overall health and further stigmatize the bodies of children whose environments are likely already rampant with weight bias. As a result of these guidelines, children will learn that their bodies are a pathology rather than a variation on the normal spectrum of body shapes and sizes. They will view weight gain, a normal and expected process during the dramatic period of growth in adolescence, as a personal failure, which may irrevocably harm their sense of self-worth.
For these reasons, we respectfully ask AAP to rescind and reconsider these guidelines. For decades, medical guidelines have been weight-centric with a single message at heart: being fat is bad. We understand it is difficult to step away from this paradigm, which substitutes weight as a primary measure of health and instead consider the myriad of factors that impact body size. Society is saturated with dual messages that higher body weight is a risk factor for chronic diseases and that every larger body has a skinny one inside, waiting to emerge.
We have reviewed literature that establishes the validity of a size-inclusive approach to medicine which supports patients to define their health by measures other than their weight. Recent systematic reviews have shown that cardiovascular fitness, rather than BMI, is the strongest predictor of a long and healthy life, and weight cycling is strongly associated with an increased risk of developing diabetes and cardiovascular disease and higher cardiovascular and all-cause mortality.
We believe it is in the best interest of our current and future patients to modify the recommendations and hope the AAP will, after reviewing this data.
Jessica Mui is a medical student.