On January 9 of this year, the American Academy of Pediatricians (AAP) published their "Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity." With this guidance, the AAP is advising doctors and other providers that the "monitoring" and "watchful waiting" approaches are no longer valid.
In a stark shift from previous recommendations, the focus of the new guidance is unabashedly on weight loss and body mass index (BMI) instead of health. The new recommendations call for a more aggressive approach to weight loss, including the use of weight loss medications like the GLP-1 agonists for adolescents based solely on weight status -- regardless of whether the child has any medical problems like hypertension, liver disease, high cholesterol, or diabetes/prediabetes. This continued emphasis on weight reflects a doubling down on the same approach that hasn't improved health outcomes over the last 20 years; instead, we now have worsening rates of diabetes, hypertension, and cardiovascular disease.
We seem to believe that by applying a weight-focused approach to health more aggressively, with a new class of weight loss drugs, and on younger patients, we will get different results.
As a psychiatrist who specializes in eating disorders, I find the new AAP treatment recommendations -- though well meaning -- to be stigmatizing, inaccessible for most families, and unsustainable. Even more concerning is the substantial potential for harm by adding to weight stigma, worsening already historically high rates of adolescent eating disorders and negatively impacting mental health. The guidelines sidestep a guiding principle in the practice of medicine: First, do no harm.
A Misguided Approach to Health
There is a longstanding belief in medicine and American culture alike that thin equals healthy. Guidelines that boil health down to BMI and treatment down to weight loss are short-sited and ineffective at best and harmful at worst. In its 2016 guidelines on obesity, the AAP explicitly called for pediatricians and parents to avoid the "weight talk" and weight focus. This was prior to the GLP-1 agonist boom. Fast forward to 2023, and the guidelines instead emphasize focusing on weight. The AAP recommendations are well-intentioned, seek to provide guidance to a taxed pediatric workforce on the front lines of the growing adolescent mental health crisis, and shine a bright light on an area of great concern: the physical health of our children. But with the guidelines promoting such a limited focus on weight, pediatricians and their primary care counterparts are in a losing battle for the actual health of Americans.
BMI as a primary tool to define health is a sloppy measure when compared to markers such as blood pressure, cholesterol levels, blood glucose, mental health, level of exercise, or even waist to hip ratio for individual patients. The guidelines promote weight loss as our primary intervention for all patients deemed "at risk," and measure treatment success by amount of weight lost. But what about the adolescent and young adult eating disorders that can be triggered by weight stigma and dieting?
Impact on Mental Health and Eating Disorders
My biggest issue with current approaches to "obesity" as a public health problem is the lack of attention to mental health, trauma, weight stigma, eating disorder screening, and social determinants of health. Food is a decent anesthetic for kids who are lacking in basic developmental needs (safety, nurturance, structure, consistency, attention). Food insecurity and the food environment are largely skimmed over in these guidelines. The role of the food industry and wide availability of ultra-processed foods with addiction potential is neglected. The impact of social media, the weight loss industry, diet culture, and big pharma goes largely unchecked.
The role of mental health and eating disorder prevention is relegated to a small section of the lengthy guidelines. Any set of practice guidelines for pediatric primary care that fails to fully integrate mental health is at best incomplete.
We have little long-term impact data on health -- including mental health -- for kids or adolescents who have started on GLP-1 weight loss medications. What must a kid think about their body if a doctor gives them a medication every week to shrink it? What does that do to their identity? What if they have been stable on their growth curve since birth, have no medical problems, exercise, eat a variety of foods, and have parents in larger bodies with no medical problems?
What about the mental health impact of telling a 12-year-old child that they have a "disease" because of their body size, and they need to take medication for it. Health comes in all sizes. The data substantiates this, with up to 30% of patients considered "obese" by BMI category having normal metabolic health, and conversely up to 30% of people with "normal" BMI having at least one metabolic disorder. When we focus on and lead with weight, we stand to do harm. And because most of us have received little to no formal or in-depth training on eating disorders and mental illness, we don't even realize how we might do harm.
Adolescent eating disorder rates are at an all-time high, with inpatient admission rates doubling during the pandemic. And more attention is finally being paid to the fact that people with eating disorders don't always "look" as we expect -- many people in larger bodies may be starving themselves, or engaging in other harmful eating behaviors, such as binge eating or purging. Adolescents are experiencing a mental health crisis, with rates of despair and suicidal ideation continuing to rise, particularly for girls. We know that social media algorithms specifically target teens looking to lose weight in ways that are detrimental to their physical and mental health. Data from the eating disorder literature shows that one of the biggest risk factors for young people to develop an eating disorder is dieting behavior -- even when that is recommended by their doctor. Add to this the buzz about the GLP-1 medications and the ensuing social media storm, and we just keep adding more fuel to the flames of the adolescent mental health crisis.
Recommendations
Amidst the buzz of GLP-1 drugs and their efficacy for weight loss, can we stand back and consider the impact of pharmaceutical companies on present day medical care, policymaking, public health goal setting, and medical education? Can we step back, look at the "war on obesity" over the last 2 decades, in the context of new treatment guidelines from AAP, and consider that perhaps our approach is fundamentally flawed, especially in the present-day adolescent mental health crisis? Can we focus on long-term health instead of quick "health," with little sustainability?
These are the questions that stand to make a difference for the millions of American adolescents who are counting on us to help them. We can fundamentally change course by changing our practice: 1) personalize medical care, 2) deprioritize weight as a measure of health, 3) take a holistic approach to health, 4) risk stratify -- identify and resource adolescents at risk of developing eating disorders, depression, and anxiety, and 5) focus on sustainable and accessible health. We must change direction; the road we're headed down will only make things worse.
Kim Dennis, MD, is a psychiatrist and certified eating disorder specialist. She is co-founder of SunCloud Health, a treatment center for eating disorders and other mental health issues.