AAP childhood obesity guidelines on surgery, treatment draw scrutiny – USA TODAY

Faith Anne Heeren vividly remembers the day she first became aware of her weight.
It was first grade. Nurses came to her North Carolina private school to practice taking vitals, which included weighing in front of the entire class.
Heeren watched from the back of a single-file line as each one of her classmates stepped up onto the scale. After it was her turn, she suddenly she felt a hand grab her arm and yank her out of the classroom.
“They took me to a private room and told me if I didn’t focus on my weight that I was putting myself at risk for all these health issues,” said Heeren, now 25 and living in Gainesville, Florida. “They sent me home to my parents after having this traumatic experience where my weight was being used against me.”
For the next 10 years, her mother took her to countless providers to seek help but they were always met with variations of the “eat less, move more” response. Eventually at age 15, Heeren became one of the first teens to undergo weight loss surgery. 
Last week, the American Academy of Pediatrics issued its first comprehensive guidance for evaluating and treating childhood obesity, recommending early and proactive treatment for children as young as 2. The new guidance suggests doctors may prescribe weight loss drugs to kids 12 and older who have obesity and may refer teens 13 and older with severe obesity for weight loss surgery, though situations may vary.
“There is no evidence that ‘watchful waiting’ or delayed treatment is appropriate for children with obesity,” said Dr. Sandra Hassink, co-author of the guideline and medical director for the AAP Institute for Healthy Childhood Weight, in a statement.
While the procedure changed Heeren’s life, the guidance has drawn scrutiny from advocates and other experts who say it contributes to weight stigma and could fuel disordered eating. They also criticize the guidelines because there is no long-term data for how weight loss drugs and surgery affects children and teens. 
While the American Medical Association acknowledges obesity as a disease, many fat-acceptance advocates argue excess weight is not a disease on its own. 
“Fat is not nearly as unhealthy as it has been portrayed to be by the mainstream medical establishment,” said Tigress Osborn, board chair of the National Association to Advance Fat Acceptance. “There is good reason to ask lots of questions about the motivations of industries and institutions to continue to maintain the narrative that fat is deadly.”
More than 14.4 million children and teens in the United States are affected by obesity, according to the AAP. 
Young people with obesity have a body mass index – a measure of body size based on a calculation of height and weight that meets or exceeds the 95th percentile for kids of the same age and gender. Kids have severe obesity when they reach or exceed that level by 120%. 
The AAP guideline dedicates a section to weight bias and stigma, urging providers to address and reduce their own biases before discussing treatment options with patients and families. 
“We know that excess body weight can be associated with health conditions, which we have an obligation to identify and manage,” said Dr. Sarah Armstrong, section chair on obesity for the AAP who helped author the new guideline. “At the same time, we don’t want to stigmatize children and their parents for what is essentially a medical condition.”
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Health experts argue classifying obesity as a disease helps reduce stigma that excess weight is a personal, moral failing. But even after the AMA officially designated obesity as a disease in 2013, a study found about two-thirds of Americans report experiencing weight stigma from doctors.
People with higher internalized weight bias also reported greater health care avoidance, lower frequency of obtaining routine checkups, and lower quality of health care, according to the 2021 report published in the peer-reviewed journal PLOS One.
Although the data only reflects adults, Osborn argues calling obesity a disease is stigmatizing and the new guidelines put kids at risk for experiencing weight bias. Weight bias is “negative attitudes, beliefs, judgements, stereotypes, and discriminatory actions” aimed at people due to their weight, according to the Obesity Action Coalition. 
“There’s no way that this advice doesn’t further stigmatize fat kids,” she said. “Having a national organization be like, ‘hey, fat kids are an even bigger problem than we thought they were,’ does not lessen stigma for children.”
Ragen Chastain, a board-certified patient advocate and medical researcher in Los Angeles, received calls from parents who were worried about how the guidelines would affect their children who have excess weight.
“A lot of panic, a lot of fear,” said Chastain, who also authors a blog called “Dances with Fat.” “They were put through this as kids and they know how much it harmed them and are terrified it’s going to happen to their kids.” 
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Despite getting weight loss surgery at a young age, Heeren said she still experiences instances of weight bias at the doctor’s office. Although her high blood pressure and insulin resistance has gone away, providers still press on what she’s doing to manage her weight. 
She believes more education on obesity and related treatments – especially in medical schools and clinical settings – will help combat weight bias and stigma.
“I’ve never been something that’s socially accepted as thin and I still have to love my body and appreciate my body for what is and what it does for me,” Heeren said. “My treatment actually led me to feeling most comfortable in my body.”
In the new guideline, the AAP acknowledges “adolescents with obesity may engage in unhealthy practices to lose weight,” and refers readers to previous guidelines to prevent, identify and manage disordered eating. Eating disorder experts played a role in shaping the guidelines, according to AAP’s Committee on Adolescence, which authored the academy’s eating disorders guidance. The guideline also provides resources to screen for disordered eating among teens and children with obesity.
But some argue AAP guidance for children as young as 2 years old may ruin their relationship with food and exercise without giving them a chance to develop intuitive eating skills.
“These guidelines set up a recipe for eating disorders to flourish,” said Alexis Conason, psychologist, certified eating disorder specialist and author of the “Diet Free Revolution.”
“When we take kids in larger bodies … and we tell them in the medical profession that there is something wrong with their body, it can set kids on a lifetime path of difficulty around food and disordered eating,” she said. 
Research suggests young adults with excess weight are more likely to have an eating disorder diagnosis or report disordered eating behaviors, such as binge eating, vomiting, skipping meals or using laxatives, according to a 2018 study published in the Journal of General Internal Medicine. 
“There’s a huge concern that teaching kids to use foods and movement as a way to manipulate their body is how eating disorders start,” Chastain said. “Not every diet leads to an eating disorder, but every eating disorder starts with a diet.”
Other research shows supervised treatment for obesity may decrease the risk of disordered eating or developing an eating disorder.
Heeren recalls how her own problematic relationship with food manifested after a lack of clinical guidance. Her mother looked to health care providers for help but was told to “stop feeding her daughter cookies at dinner.” 
“My mom spent a lot of time and energy looking for resources, trying to figure out how to make foods without added sugars,” Heeren said. “We were monitoring it but without any kind of clinical help.”
Advocates argue the AAP shouldn’t make recommendations that include weight loss drugs and surgery that don’t have more than three to five years of follow-up data in children and adolescents. It’s impossible to know the long-term impacts of these weight loss interventions, especially in young children, Chastain said. 
Last fall, pharmaceutical company Novo Nordisk announced results of its latest clinical trial assessing the effectiveness of their weight loss drug semaglutide, sold under the brand name Wegovy. Results showed adolescents who got a weekly injection of the drug lost an average of 14.7% of their starting body weight, while those who got a placebo gained 2.7% of their initial weight. Health experts say patients who take other medications on the market typically lose an average of 5% to 12% of their body weight.
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However, researchers stopped reporting results at 68 weeks. Like other weight loss methods, Chastain said most of the participants will likely experience weight regain.
She’s worried this could lead to harmful weight recycling, where people lose and regain dangerous amounts weight repeatedly. Regaining weight after medical interventions may also deter people from seeking care out of shame for not keeping the weight off, she argues, leading to worse health outcomes.
“We’re allowing them to make this decision with little long-term data and those who aren’t successes are often blamed for their poor experiences,” Chastain said. “They stop reporting and accessing care because they’re ashamed they haven’t had the desired outcome.”
Weight loss surgery has a few more of years of data. In teens between 13 and 19 with severe obesity, researchers saw improvements in weight, cardiometabolic health, and weight-related quality of life three years after the procedure, according to a 2016 study published in the New England Journal of Medicine.
“There are many things we don’t know about what happens when we treat individuals for years and years, potentially decades upon decades, with these medications, but years and years and decades and decades of obesity has known consequences,” said Dr. Margaret Stefater-Richards, pediatric endocrinologist at Boston Children’s Hospital adolescent weight loss surgery program. 
Experts say when left untreated, obesity can cause serious short and long-term health problems, including cardiovascular diseases, diabetes and depression.
At about 10 years after the procedure, Heeren hasn’t experienced any long-term effects from her bariatric surgery. Although she has reported some weight regain, she says obesity is a chronic condition that requires care even after bariatric surgery. 
“It can be exhausting being a person living with obesity,” she said. “It never really goes away.”
Follow Adrianna Rodriguez on Twitter: @AdriannaUSAT. 
Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.


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