New and Controversial Guidelines from the American Academy of Pediatrics
Any parent that’s taken their child to the pediatrician eagerly awaits news of their progress on a growth chart. Are they growing appropriately? When does the percentile on the chart become a concern for their health? Most clinicians use body mass index (BMI), but with the new American Academy of Pediatrics (AAP) guidelines, what they may advise using this information could be concerning.
You can calculate BMI using a person’s height and weight. An adult BMI of 25 to 29.9 is considered overweight, while a BMI above 30 is in the obese category.
In children aged 2 to 19, a percentile is used to diagnose obesity. Those with a BMI in the 85th to 94th percentile for their age and sex are considered overweight while a BMI over the 95th percentile is considered obese.
Over 14 million US kids are impacted by obesity, making it one of the most common chronic diseases in children. The AAP suggested initial guidelines for the prevention and treatment of obesity in 2007. New clinical guidelines have recently been released, and the AAP claims the recommendations are based on several years of evidence-based research.
Obesity is a complex problem that includes genetic, socioeconomic, biological, and environmental factors. Adult conditions such as arthritis, cancer, diabetes, heart disease, liver disease, and sleep disorders are associated with obesity and are being seen in younger populations, which is why the AAP states their emphasis is on earlier treatment.
In obese children aged 6 to 12, behavior and lifestyle treatment are advised. Drug therapy may be considered along with behavioral therapy in those over 12 years of age. Bariatric surgery is an option for adolescents 13 and up who have a BMI that is 120% over the 95th percentile.
The new AAP guidelines were decided on using research on the medical, psychological, and social impacts of childhood obesity. The AAP recognized that the negative way weight concerns are handled in children needs to be quelled, while the chronic illnesses related to obesity should be approached in more sensitive, positive ways.
Look at any TikTok video or Instagram post. “Thinfluencers” and advocates for weight loss are everywhere, leading to more weight bias, fat-shaming, and eating disorders.
Clinicians, including many pediatricians and dietitians, are worried that the AAP guidelines have gone too far, especially when it comes to suggestions of weight loss medications and surgeries in kids who may be just past the age of puberty.
Children recognize their physical differences. Negative reinforcement of their body size may impact their self-image, self-esteem, and overall sense of well-being. Dietitians are particularly concerned about the risk of eating disorders.
Registered Dietitian Jessica Setnick, an eating disorder specialist, speaker, and owner of www.JessicaSetnick.com notes,
“All kids need access to food, movement, love, fresh air… the things that help them grow and develop. All kids, not just big ones. […] We know for a fact that focusing on weight loss harms kids’ mental and physical health. […] In communicating with a child’s doctor about weight, parents may ask, ‘Do you have a concern about my child’s health that’s unrelated to their weight? If so, I’d like to hear your recommendations. If your concern is only for their size, that’s not an issue I’m willing to discuss.’”
Certified Eating Disorder Dietitian, Laurie Dunham, MS, RD, CEDS-S, LD of Laurie Dunham Nutrition agrees.
“These guidelines recommend intentional weight loss using some extreme & invasive measures. Aside from the fact that restriction of food intake in growing bodies will negatively impact normal growth and development, excessive focus on eating and exercise (or medication & surgery) at a young age, can lead a child to believe their body is wrong and that they must work to fix it.
Eating disorder specialists work with kids who have been put on diets all the time (and adults that were once these kids) because it's almost always in their history. Dieting is a known risk factor for eating disorders. The guidelines stigmatize kids in larger bodies. Internalized weight stigma can severely compromise psychosocial well-being leading to more problems in a child or adolescent's life.
If parents have questions about their child's weight, I recommend asking the doctor about it privately, without the child in the room. Many parents don't realize that weight alone doesn't tell healthcare providers, or anyone, much of anything. If parents would like nutrition education or a comprehensive evaluation of their child's eating habits, they can ask for a referral to a weight-inclusive (emphasizing non-weight-based markers of health) dietitian or an eating disorder specialist who can expertly and thoroughly assess behaviors to better determine what, if any, changes should be considered.”
As children have become less active, technology use has increased, and intake of sugar-laden drinks has gone up, obesity is not surprising. Access to more nutritious food, parent education, physical activity programs, and stress management may be more appropriate strategies than setting up children for a lifetime of weight cycling and risk for eating disorders.
Below are tips for parents of children that are concerned about their child’s weight:
Ask for a referral to a weight-inclusive dietitian for an evaluation and plan of care.
Do NOT put your child on a calorie-restricted or any other restrictive diet such as low-carb.
Reduce technology use in your home. Children mimic their parents’ behaviors.
Do not use food as a reward or restrict food as punishment.
Encourage physical activity as a family and not as a weight loss method.
Do not bully or force children to lose weight.
Limit foods and beverages high in sugar.
Encourage balanced meals and moderation.
Lisa Andrews, MEd, RD, LD
References:
2. de Valle MK, Wade TD. Targeting the link between social media and eating disorder risk: A randomized controlled pilot study. Int J Eat Disord. 2022 Aug;55(8):1066-1078. doi: 10.1002/eat.23756. Epub 2022 Jun 16. PMID: 35708162.
