One step forward and two steps back: the New Obesity Guidelines in the US
In late January 2023, the American Academy of Pediatrics (AAP) released new recommendations for treating children with obesity. The guidelines, involving drastic interventions for overweight children as young as two years old, have been critiqued for their aggressiveness. Today, we’ll outline the successes and downfalls of these guidelines, and what they mean for children in the US.
A complex new perspective
You’re probably no stranger to the nature versus nurture debate. For decades, scientists have been trying to establish the role of diet, exercise and psychosocial factors on what is arguably America’s most pressing health issue. An important aspect of the new guidelines is the call for a paradigm shift in how we think about obesity. That is, personal choices don’t always make or break your weight.
The researchers highlight the role of genetics, or the traits that get passed down to children from their parents. Perhaps a child has a mutation in the KSR2 gene, discovered by researchers to control hunger and metabolism levels (1). Some estimates say there are dozens of genes that directly impact an individual’s appetite and food preferences (2).
With the addition of the genome to their policies, the AAP has modernised the understanding of weight to include social, lifestyle, and biological factors—an outstanding win for scientists and policy makers who have urged the acknowledgment of how multi-factorial our health truly is.
Suggested therapies in the report
The AAP suggests children aged 2 and over identified as overweight receive intensive lifestyle and behavioural treatment for a total of 26 hours or more, with a team of clinicians from various disciplines (3). They suggest obese adolescents aged 12 and older are prescribed a weight loss drug, in tandem with lifestyle therapies (3). Finally, adolescents aged 13 and up may be recommended to undergo bariatric surgery(3), a procedure in which the stomach size is reduced by 80% (4).
Determining whether a child qualifies as obese, and will be recommended any of these treatments by their doctor, largely relies on Body Mass Index (BMI) as an indicator (3).
My perspective: BMI or bust is outdated
An initial glance at the AAP’s suggested course of action is, without a doubt, intense. Many sing its praises at the hope of treating obesity, what has in recent decades been defined as a chronic disease, as early and as quickly as possible. I, for one, question how a simple measurement of BMI can be informative enough for any clinician to warrant a child in need of extreme intervention of this degree.
Despite the fact that BMI is still commonly used in doctor’s offices, it doesn’t account for muscle mass or bone mass (5). It also can’t tell us the distribution of fat in a patient’s body (5). Depending on an adolescent’s level of pubertal development compared to the average for their age, knowing this might make all the difference. Overall, BMI is an outdated marker of weight, and continuing to use it may lead patients to treatments they don’t need.
The guidelines reinforce the false notion that everyone who weighs more must be unhealthy. People labelled as overweight are often the target of bullying, and I believe the intense scrutiny these guidelines place on children’s weights will only further encourage these behaviours. Of the patients who experienced weight stigma in a study of 14 000 people, two thirds were targets of bias from doctors themselves (6). Further, pushing children to stop certain behaviours in hopes of curbing obesity often leads to disordered eating, and gaining even more weight (7).
Won’t this approach prevent heart disease and diabetes?
Proponents of strict guidelines to prevent and treat obesity often cite health risks associated with high body fat as requiring significant attention. Data overwhelmingly shows that people identified as obese have significantly higher risk of type 2 diabetes and heart disease (8). One of the drug therapies recommended by the new guidelines, GLP-1 agonists, do show promising effects in some patients, with 6.1 to 17.4% mean weight loss in patients without diabetes (9). However, they should not be the only recommended therapy, as many physicians report lack of blood glucose control, severe nausea, and no weight loss effects with use of the drug (10).
In terms of our broader understanding of treating chronic diseases like type 2 diabetes, prevention is not so simply accomplished. A report from Science explains that 10% of the US population has an obese BMI, but are also metabolically healthy (11). There’s also 8% of the US population who have a “normal” BMI, but are metabolically unhealthy, with a higher risk of diabetes and heart disease (11). The data repeatedly points to the fact that thin people can be unhealthy, and “overweight” people can be healthy–it’s more complicated than how you look.
The new AAP guidelines take an important step forward for the world of chronic disease: they acknowledge the role of genetics, and subsequently, the lack of control of our weight in many instances. At the same time, they push the longstanding narrative that “overweight people are automatically unhealthy,” without room for a middle ground or grey area. This demonstrates the need for consulting a wide range of clinicians and mental health professionals with diverse specialties, in order to grasp the true complexity behind the health of children labelled as obese.
- Pearce LR, Atanassova N, Banton MC, Bottomley B, van der Klaauw AA, Revelli J-P, et al. KSR2 mutations are associated with obesity, insulin resistance, and impaired cellular fuel oxidation. Cell [Internet]. 2013 [cited 2023];155(4):765–77. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3898740/
- Office of Genomics and Precision Public Health, Office of Science (OS). Genes and obesity [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2013 [cited 2023]. Available from: https://www.cdc.gov/genomics/resources/diseases/obesity/obesedit.htm
- Hampl SE, Hassink SG, Skinner AC, Armstrong SC, Barlow SE, Bolling CF, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics [Internet]. 2023 [cited 2023];151(2). Available from: https://doi.org/10.1542/peds.2022-060640
- Public Education Committee, ASMBS. Bariatric surgery procedures: ASMBS [Internet]. American Society for Metabolic and Bariatric Surgery. 2021 [cited 2023]. Available from: https://asmbs.org/patients/bariatric-surgery-procedures
- Centers for Disease Control and Prevention. Body mass index: considerations for practitioners. Available from: https://stacks.cdc.gov/view/cdc/25368
- Puhl RM, Lessard LM, Himmelstein MS, Foster GD. The roles of experienced and internalized weight stigma in healthcare experiences: Perspectives of adults engaged in weight management across six countries. PLOS ONE. 2021;16(6). Available from: https://doi.org/10.1371/journal.pone.0251566
- Sole-smith V. Why the New Obesity Guidelines for Kids Terrify Me [Internet]. The New York Times. The New York Times; 2023 [cited 2023Feb28]. Available from: https://www.nytimes.com/2023/01/26/opinion/aap-obesity-guidelines-bmi-wegovy-ozempic.html
- Abdullah A, Peeters A, de Courten M, Stoelwinder J. The magnitude of association between overweight and obesity and the risk of diabetes: A meta-analysis of prospective cohort studies. Diabetes Research and Clinical Practice. 2010;89(3):309–19. Available from: https://doi.org/10.1016/j.diabres.2010.04.012
- Jensterle M, Rizzo M, Haluzík M, Janež A. Efficacy of GLP-1 RA approved for weight management in patients with or without diabetes: A narrative review. Advances in Therapy. 2022;39(6):2452–67. Available from: https://doi.org/10.1007/s12325-022-02153-x
- Sikirica M, Martin A, Wood R, Leith A, Piercy J, Higgins V. Reasons for discontinuation of GLP1 receptor agonists: Data from a real-world cross-sectional survey of physicians and their patients with type 2 diabetes. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2017;Volume 10:403–12. Available from: https://doi.org/10.2147/DMSO.S141235
- Ahima RS, Lazar MA. The health risk of obesity—Better Metrics Imperative. Science. 2013;341(6148):856–8. https://doi.org/10.1126/science.1241244