New childhood obesity guidance raises worries over the risk of eating disorders

Eating disorder treatment specialists are sounding the alarm over new guidance from the American Academy of Pediatrics advising doctors to treat obesity earlier and more aggressively, which they say could lead to eating disorders.

They say it focuses on weight loss and BMI rather than health, minimizes the risk of disordered eating and could perpetuate deep-rooted, damaging stigmas.

"We run the risk of doing significant harm to kids who are 6 or 8 by telling them that they have a disease" — obesity — "simply based on their weight status," says Dr. Kim Dennis, a certified eating disorder specialist and co-founder of SunCloud Health, a treatment center for eating disorders and other mental health issues.

Eating disorders among children and adolescents rose dramatically during the pandemic, and the risk of developing an eating disorder is higher among patients who've been diagnosed as overweight or obese and patients who've engaged in dieting.

A new study in the journal JAMA Pediatrics found that one in five kids have disordered eating behaviors — meaning behaviors that characterize eating disorders but don't rise to the level of a clinical diagnosis, like strict calorie restriction or overexercising. That proportion is significantly higher among girls and kids with a higher BMI, the researchers found.

Researchers wrote that larger adolescents are "the population that appears to experience symptoms of disordered eating most frequently."

But supporters say the updated guidance will help destigmatize obesity precisely because it treats it as a disease – like cancer or COVID – that requires medical intervention and isn't the patient's fault.

Supervised obesity treatment programs like the one the AAP recommends "are associated with lower risk of disordered eating," says Dr. Sarah Hampl, an author of the new guidelines and a pediatrician at Children's Mercy Kansas City. That risk rises "when youth try to do it on their own," she says.

What does the guidance recommend?

Americans' average weight has been rising dramatically for years, and so have the diseases linked to extra weight, like heart and liver diseases and diabetes, lending a sense of urgency for the AAP to encourage earlier action to stave off more serious health issues down the road.

The primary recommendation in the new guidance is intensive health behavior and lifestyle therapy, which entails coaching on nutrition, exercise and behavioral changes like role modeling by parents. Ideally, patients would receive at least 26 hours of in-person treatment over several months.

Supporters of the new guidance acknowledge that it will be a while before this type of intensive therapy is widely available, though there currently are other, more accessible alternatives, Hampl says. As well, many people's insurance won't cover it, and it's a significant time commitment. These barriers are even higher for racially and socioeconomically disadvantaged families.

In addition to therapy, the AAP now says doctors should offer weight loss drugs to adolescents diagnosed with obesity at age 12 or older and should evaluate teens who are 13 and older with severe obesity for bariatric surgery. Severe obesity is defined as a BMI of 120% of the 95th percentile, or roughly the 99th percentile, for age and sex.

Though its use has come under fire, the BMI percentile remains "the most recognized indicator to diagnose obesity" and prompts other evaluations to determine treatment, Hampl says.

Why are eating disorder specialists concerned?

Several eating disorder treatment and advocacy organizations have released statements opposing the guidelines and urging the AAP to reconsider or revise them.

Many eating disorder specialists don't believe that obesity should be classified as a disease in the first place because it puts an explicit and misguided focus on weight rather than health. That opens the door to reinforcing weight stigma and preventing patients from receiving proper care.

While a person's BMI can tell doctors what risks a patient is more likely to have, "that's a different matter altogether than saying, 'This is your BMI. You have a disease,'" says Dennis, the eating disorder specialist.

Medical schools generally provide little training on how to identify and treat eating disorders, meaning pediatricians may not be able to identify an eating disorder until it's advanced — especially in larger patients, Dennis says.

Heavier patients who've lost a potentially dangerous amount of weight go to a pediatrician, Dennis says, and "they're told, 'Amazing. Whatever you're doing, keep doing it.'"

Those factors, plus the trauma of weight stigma, make recovery even more challenging for those patients, Dennis and others say.

Doctors should treat problems that are linked to unhealthy weight gain and habits, but the focus needs to be on treating specific health issues, not on weight and weight loss, Dennis says.

The specialists NPR spoke to were particularly concerned about the new recommendations for weight loss drugs and surgery, given the limited data on the long-term effects of both for children and adolescents and the potential for these treatments to disrupt patients' relationship to food.

For instance, when adult patients stop taking the class of weight loss drugs recommended in the guidelines, they often gain the weight back, which means kids might be on the medication for the rest of their lives.

They also said there's a risk — thought to be rare, but likely underreported — of disordered eating after bariatric surgery.

Monika Ostroff is executive director of the Multi-Service Eating Disorders Association, a treatment and advocacy center, and an eating disorders specialist. She and others have treated patients who developed eating disorders after bariatric surgery, some of whom had the surgery as teenagers.

Bariatric surgery "completely changes the way that you can nourish your body," Ostroff says. It dramatically restricts the types and amount of food and drinks patients can have and changes everything down to the speed at which they need to chew. The patients Ostroff treated weren't prepared for those changes, she says, leading to physical complications after surgery and eating disorders down the line.

But for children with severe obesity, bariatric surgery is reliably effective and can reverse the condition's life-threatening effects: diabetes, hypertension and liver disease, obesity specialists say.

"The effective treatments for severe obesity in adolescents are really just one: That is bariatric surgery," Dr. Thomas Inge, a lead scientist on a multiyear National Institutes of Health study tracking young bariatric patients, said in 2021. At the time he spoke to NPR, he was a director of adolescent bariatric surgery at Children's Hospital Colorado and has since moved to Lurie Children's Hospital in Chicago.

How the AAP is trying to address these concerns

Hampl says the authors of the guidance understand and share concerns about heavier patients' risk of developing eating disorders — which is why the new guidance emphasizes that screening and evaluation for disordered eating should take place not just at the beginning but throughout treatment.

The guidelines acknowledge obesity has complex causes outside a person's control, including genetic, environmental and socioeconomic factors. Despite that, patients in larger bodies face harsh, unfair stigma from those — including many doctors — who believe obesity is an individual's choice.

Hampl says the AAP has written resources about how to use non-stigmatizing language with patients and is working with external organizations to ensure that guidance reaches pediatricians nationwide. She recommends the University of Connecticut Rudd Center as a good place for doctors and parents alike to find tools to talk about obesity "in a health-focused, not weight-focused, way."

Some children are diagnosed as overweight or obese and are otherwise healthy, but more often than not, patients have at least one health problem related to their extra weight, "whether it be medical or psychosocial or emotional," Hampl says. Weight loss can help improve those complications, which could otherwise worsen over time.

What's next? And what can parents do?

The AAP plans to work with the Academy for Eating Disorders and the National Eating Disorders Association to develop more resources and training on evaluating patients for disordered eating. An AAP clinical report on preventing both obesity and eating disorders is undergoing a scheduled revision, hopefully for release within the next year, and AED and NEDA will serve as reviewing organizations.

"We all care deeply about the well-being of children and adolescents and are eager to work together," Hampl said in an email.

For now, parents still have to navigate conversations with their kids and make decisions about their health. So what can you do?

Experts agree the goal is to make kids healthy, not skinny. Dieting and weight talk — comments about weight and weight loss, no matter who they're directed toward — are associated with higher risk of both obesity and eating disorders, and they can assign moral value to food, so try to avoid them.

Small, positive changes — think introducing vegetables and movement that children enjoy — can improve a child's individual health risks regardless of whether there is weight loss, says Dennis of SunCloud Health. Steps like eating meals together as a family can reduce the risk of both eating disorders and obesity.

In short: focusing on your child's whole health, including mental health, is the best strategy for trying to avoid serious problems down the road.

Being healthy happens "at a whole range of sizes," Dennis says.