An irreconcilable divide between the American Academy of Pediatrics (AAP) and therapists and groups treating childhood eating disorders highlights the convoluted problem of childhood obesity amid a society where junk foods are cheap and plentiful and nutrition education is scarce.
Opposing Views
The new guidelines from the AAP encourage doctors to treat obese children as young as 12 with pharmaceuticals and bariatric surgery in certain circumstances. The emphasis of the new guidelines is on measurements—body mass index (BMI), blood pressure, and blood glucose. The AAP guidelines say medical interventions are necessary in part because of weight stigma.The guidelines describe obesity as “a common, complex, and often persistent chronic disease associated with serious health and social consequences if not treated.”
Many such groups reject the concept of obesity as a health condition and consider the descriptor word “fat” to be a simple physical characteristic similar to being tall. They back up this view with a selection of studies that refute the links between obesity and different health conditions.
A Complex Interplay
Research shows obesity can contribute to eating disorders even though larger young adults are half as likely to be diagnosed with an eating disorder than their thinner counterparts. Eating disorders, like binge eating, can also contribute to obesity.The AAP’s guidelines acknowledge that “obesity and self-guided dieting place children at high risk for weight fluctuation and disordered eating patterns” but say that “participation in structured, supervised, weight management programs decreases current and future eating disorder symptoms (including bulimic symptoms, emotional eating, binge eating, and drive for thinness) up to six years after treatment.” Relatively few children have access to such programs, a challenge noted in the guidelines.
Meanwhile, children labeled “obese” may struggle emotionally with the diagnosis.
“Individuals who are labeled as ‘obese’ are shamed, stigmatized, and told that their body is diseased; then they are told all of this is their own fault. These new guidelines support this bias.
“To assume that those in larger bodies should accept the health risks associated with weight loss treatment … is evidence of the damaging weight stigma that is pervasive in ‘obesity’ prevention and treatment efforts.”
“Additionally, nutritional and/or behavioral interventions simultaneously addressing weight management and reduction of eating disorder behaviors in individuals with obesity and comorbid eating disorders may be required.”
Weight Stigma in Health Care
Weight stigma does exist and can lead to discrimination, biases, stereotypes, and prejudices about a person’s size. In the health care setting, there’s legitimate concern that a practitioner’s own beliefs about body size will taint the approach they take in diagnosis and treatment of all health concerns.She relayed a story about a woman who complained of severe back pain and saw several providers who all dismissed it as a consequence of her weight. One doctor finally ordered imaging, and it was discovered that her spine was fractured.
The AAP’s statement acknowledges that patients who are overweight and obese are more apt to be victimized, teased, and bullied.
“This experience contributes to binge eating, social isolation, avoidance of health care services, and decreased physical activity, further complicating the health trajectory,” the statement says.
It goes on to encourage providers to use non-stigmatizing language and patients’ preferred terminology in order to strengthen relationships for ongoing care. The body positivity movement often opts for “fat” as a way to describe bigger-bodied people, rather than obese. The AAP recommends that physicians validate children’s emotions like sadness and anger—brought about by their discussions about weight and obesity—while keeping the focus on the child’s health.
The defining disagreement is that CEDO and body positivity movements say BMI and obesity should not be the barometer for disease.
Medical Assumptions?
CEDO’s statement against the guidelines leans on a 2011 Nutrition Journal review that draws on studies that contradict obesity science, as well as picking apart the studies that have led to medical assumptions that assert: BMI significantly raises mortality, overweight people have a lower life expectancy, weight loss is achievable and sustainable, weight loss is associated with less disease and better health, and obesity puts an economic burden on society.In short, the research rejects the findings of other studies that link obesity to any significant health issues.
“It’s not that it’s politically loaded or emotionally charged. It’s that it’s an assumption that we are having a health problem caused by fatness,” Clark said. “We can improve health whether the person loses weight or not. It’s important how we talk about these things.”
The AAP guidelines suggest children should have comorbidities such as Type 2 diabetes, polycystic ovarian syndrome, fatty liver disease, and depression before doctors consider surgery.
Understanding Eating Disorder Physiology
Psychological elements of eating disorders include impaired psychosocial functioning, perfectionism, thin-idealism, negative urgency, and sensitivity to reward and punishment. But eating disorders are increasingly recognized as more than just a mental health disease as they are seven to 12 times more likely to be diagnosed in someone with a family member who’s also had one.“Traditionally recognized as mental illnesses, eating disorders are increasingly appreciated to be biologically-driven … Understanding the role of the gut ecosystem in the pathophysiology of eating disorders will provide critical insights into improving current treatments and developing novel microbiome-based interventions that will benefit patients with eating disorders,” according to the study.
Redefining Health
Clark often encourages those overcoming eating disorders to trust their bodies but falls short of offering dietary recommendations to her clients since she’s not a dietitian.“We’re all born intuitive and emotional eaters,” she said. “Babies eat emotionally. We really demonize emotional eating as a culture.”
Liz Haselmayer, who was treated for bulimia at an in-patient clinic 15 years ago, is concerned the body positivity movement could backfire. Just as popular culture glamorized skinny celebrities during her upbringing, she said celebrating all body sizes without regard for disease amounts to taking one disordered problem and replacing it with another one.
More Than Calories-In, Calories-Out
Haselmayer said caregivers at the eating disorder clinic she attended emphasized weight and calories over food quality and expected her to take nine prescriptions for her disease as she was discharged from the facility.“Nutrition information was terrible. Adults are confused. And I totally used to be wallowing in that confusion,” Haselmayer said. “They didn’t teach me about carbohydrates and how they’re used, or the importance of proteins and fats, or the need to choose satiating real whole foods.”
In addition, she recognizes that anyone with an identity crisis—teens especially—is at risk for an eating disorder. For that reason, Haselmayer is constantly looking for opportunities to emphasize her three daughters’ spiritual values.
“I do my best to build into their self-worth, and identity as a daughter of the King and a member of our family, and to underline and bold it so when society or the enemy offers something … they won’t be susceptible to a poisonous ideology,” she said.
Today’s teens represent a generation that’s growing up among heightened temptations and aggressive marketing with ultra-processed food being the norm at social gatherings. They are primed to mature in a global, yet isolated cultural environment that has emphasized instant gratification over character development.
Clark said her goal with clients is not to get them to eat more of any specific nutrient but to have a more peaceful, connected, and flexible relationship with food. She encourages them to find a health strategy that takes the focus off food.
“It’s a dramatic oversimplification to say, ‘Move more, eat less.’ There’s so much we can do for our health that has nothing to do with food and movement,” Clark said. “As a mother and an eating disorder specialist, it seems wildly unethical to me to be promoting weight loss at a time in life when children should be gaining.”
Copy
