AAP Guidelines and Backlash, Part 5

New York Times journalist Catherine Pearson wrote,

The American Academy of Pediatrics released new guidance last week about how to evaluate and treat children who are overweight or obese, issuing a 73-page document that argues obesity should no longer be stigmatized as simply the result of personal choices…

… Which kind of oversimplifies matters. Up to this moment in time, theoreticians and researchers have suggested over 100 possible causes of obesity, ranging from genetics to gut microbes to air pollution to electronic screens. Harvard’s Dr. Claire McCarthy set out some pertinent statistics:

Hovering around 5% in 1963 to 1965, rates of obesity had more than tripled to 19% by 2017 to 2019. Early data suggest childhood obesity rates continued climbing during the pandemic. If these trends continue, 57% of children currently ages 2 to 19 will have obesity as adults in 2050.

She makes the point that obesity is typically stigmatized as a personal choice issue, or if not precisely “choice,” at least a matter of individual responsibility, which is a hard sell when a baby pops out of the womb weighing 16 pounds. But as time goes on and evidence piles up, it may not be just bad eating habits, low-quality food, or lack of exercise. The factors that contribute to childhood obesity include genetic, physiologic, socio-economic, and environmental, among many other possibly more peripheral factors.

And each one is complicated. For instance,

Prenatal factors, such as maternal weight gain or gestational diabetes, increase risk before a child is even born. We are just beginning to understand genetic factors, many of which can be further affected by the child’s environment. There are ways that systemic racism and deeply embedded socioeconomic factors play a role.

At any rate, the AAP invested a lot of verbal energy in preparing the nation for its bombshell recommendations — drugs and bariatric surgery for teens and even children. The reaction to these two concepts has been clamorous. In the case of acceptable drugs, one is said to have helped adolescents reduce their Body Mass Index number by around 15%.

Another is said to age the face at the top of a newly-slimmed body, reminiscent of a quip attributed to Zsa Zsa Gabor: “After a certain age, a woman has to choose between her face and her fanny.” More will be said about these and other suggested pharmaceuticals. Among many other loud voices are those which insist that the pharmaceutical research to date is nowhere close to adequate.

Also, it seems that many professionals and members of the public have misunderstood the AAP’s intention, which is to recommend drugs and surgery as extreme measures to be taken only after serious lifestyle intervention has been tried. The organization has also acknowledged that some prejudice and stigmatization, unfortunately, come from doctors and other medical professionals. There is a belief that using gentler language will help, for instance not saying “obese child” but instead, “child with obesity.”

Maybe; maybe not. Pearson quotes adolescent medicine specialist Dr. Jason Nagata:

He has worked on studies showing that disordered eating behaviors like fasting or vomiting are common in children with obesity. Even if parents and doctors are careful to use person-first language and focus discussions on health, not weight, a child may only hear “you’re telling me I’m too fat, I need to lose weight,” he cautioned.

Your responses and feedback are welcome!

Source: “New Guidelines Underscore How Complicated Childhood Obesity Is for Patients and Providers,” NYTimes.com, 01/20/23
Source: “New pediatric guidelines on obesity in children and teens.” harvard.edu, 01/24/23
Image by Howard Lake/CC BY-SA 2.0

AAP Guidelines and Backlash, Part 4

In the past few weeks the new anti-obesity guidelines issued by the American Academy of Pediatrics, revised for the first time in 15 years, have caused quite a flurry. Previous posts have discussed some of the angles, but the worst is yet to come.

Background: Contrary to long-held hopes, young people rarely “outgrow” childhood obesity, but rather just bring it along into their adolescence, where it coexists with such typical problems as skin eruptions, sexual anxiety, and academic challenges. Then, they simply carry the excess weight into adulthood, along with a whole array of new physical, social and emotional issues.

One doctor’s view

Dr. Sarah Armstrong is the AAP’s obesity section chairperson, as well as a Duke University professor of pediatrics. We have already referenced some of the information that journalist Caroline Kee obtained by interviewing her, and there is more to say. Dr. Armstrong recommends a “whole child” approach and believes that parents and healthcare professionals should no longer wait for the situation to worsen because the overwhelming odds are that both obesity and co-morbidities will increase over time. With longevity, every problem becomes more difficult to treat.

Starting at age six, the at-risk child should receive at least a year of intensive treatment, including face-to-face counseling and lifestyle modification training. If no progress is made, patients in their teens, or approaching their teens — or even younger — might reasonably be prescribed one of six weight-loss medications that have been deemed safe. Even then, pharmaceuticals should not be expected to take the place of lifestyle modifications. Whichever drug is chosen should be used simultaneously with the cultivation of good everyday, real-life habits.

Reinforcement

Also quoted is pediatrician Dr. Sarah Hampl, another co-author of the revised guidelines:

The evidence suggests that you should treat children as early as obesity is identified and with the highest available intensity of treatment that is appropriate, given their age and the severity of their obesity. Different risk factors influence a child’s weight, (including) things we can’t control, such as genetics.

But that is not all. After intensive case evaluation, weight-loss surgery is now seen as acceptable for individuals as young as 13. It took a 73-page report to introduce these new recommendations, which have been met with reactions ranging from disbelief to outrage. The AAP tried to soften the concepts and show them as reasonable and in many cases necessary.

New York Times journalist Catherine Pearson wrote that the organization…

[…] argues obesity should no longer be stigmatized as simply the result of personal choices, but understood as a complex disease with short- and long-term health implications… [T]here is no evidence to support delaying treatment for children with obesity in the hope that they will outgrow it.

This is very caring, but do others, including experts and parents, have more to say about all these ideas? You bet they do!

(To be continued…)

Your responses and feedback are welcome!

Source: “New AAP childhood obesity guidance includes medication, surgery: What parents should know,” Today.com, 01/11/23
Source: “New Guidelines Underscore How Complicated Childhood Obesity Is for Patients and Providers,” NYTimes.com, 01/20/23
Image by Toho Scope/CC BY-SA 2.0

AAP Guidelines and Backlash, Part 3

The previous post left off with Dr. Nicole McLean speaking of how pediatricians and other healthcare providers need to avoid stigmatizing language when talking with parents and children. Along with language, racial disparity is an enormous area of concern.

The first, having to do with the tone and precise phrasing of weight-related discussions, is very much under the control of individual practitioners. The second is of course partly controllable by health care providers, but the influence they can exert is quite small when stacked up against an imposing historical background and a societal mindset that often seems to be intractable.

We also mentioned how talk therapy has not been particularly effective, which is not totally due to the choice of language. Yet at present, a formula that includes a lot of talk seems to be the best thing on offer. For The New York Times, Catherine Pearson reported on what has been described as “the most effective behavioral treatment for children with obesity who are six and older,” which is enrollment into an intensive program concentrating on health behavior and lifestyle treatment.

Such programs are found in community hospitals, specialized obesity treatment clinics, and medical centers connected with universities. The specialists involved include, naturally, nutritionists, along with social workers and exercise physiologists. The ideal course of treatment must include at least 26 hours of in-person counseling with the whole family.

The fly in this ointment is that such programs are scarce, and even if they are available, few families have the resources to devote that much time, or to organize the travel arrangements. There was even a question about whether to include this item in the AAP recommendations at all, since it was felt that the majority of families would not be able to find an appropriate program or manage the logistics of attendance.

On the other hand, it is the organization’s responsibility to recommend whatever seems to be the best course of action. Dr. Sarah Hampl of Children’s Mercy Hospital is quoted as saying, “We have to lead with the evidence, because that is what we were charged to do.”

Journalist Caroline Kee interviewed and quoted Dr. Sarah Armstrong of the American Academy of Pediatrics:

“Childhood obesity has been continuing to increase almost in all age groups, races/ethnicities and sexes for the past 30 years.” Existing racial and ethnic disparities in obesity prevalence have also widened over time, and the pandemic was like a “magnifying lens” on these trends, she adds. “We saw greater year-to-year increases in the prevalence of obesity for all children during the pandemic years than we had in the previous 20 years combined.

Your responses and feedback are welcome!

Source: “Children with obesity should get proactive treatment,” 6abc.com, 01/10/23
Source: “New Guidelines Underscore How Complicated Childhood Obesity Is for Patients and Providers,” NYTimes.com, 01/20/23
Source: “New AAP childhood obesity guidance includes medication, surgery: What parents should know.” Today.com, 01/11/23
Image by Quinn Dombrowski/CC BY-SA 2.0

AAP Guidelines and Backlash, Part 2

This post is continued from the previous one. American Academy of Pediatrics Guidelines co-author Dr. Sarah Hampl, a pediatrician and weight management specialist, said, “Our kids need the medical support, understanding and resources we can provide within a treatment plan that involves the whole family.”

And that in itself is a problem. In the area of behavior “modeling,” previously known as setting a good example, not much progress seems to have been made in the past decades. Even in families where a good example is set, a very harmful condition known as Oppositional Defiant Disorder tends to crop up. In other words, anything that parents demonstrate or suggest is impossibly lame, and not to be adopted under any circumstances, just because some kids enjoy saying “No” more than anything.

An article written by Dr. Nicole McLean says,

Overweight means having BMI 85% greater than others their age and gender, while obese children are at or above 95%. BMI is an imperfect tool…

By this logic, in theory, the criterion of normalcy can continue to spiral upward toward infinity. If a child weighs 300 pounds, that’s okay as long as 15% of the other children are even heavier. Aside from the obvious problems like not being able to find cool clothes or fit into a classroom desk, obese children are at higher risk for all kinds of physical and psychological ailments like sleep apnea, heart disease, type 2 diabetes, hypertension, high cholesterol, fatty liver disease, arthritis, depression, and social malfunction.

Meanwhile, the AAP casts a rosy, optimistic glow over its recommendations:

All services for children and teens should also be carried out in a way that is mindful of patients’ culture and language preference, the guidelines say. By working with families to identify personal beliefs, risk factors, and challenges, pediatricians can provide a personalized plan for treatment.

Dr. McLean also wrote,

The new AAP guidelines call on pediatricians and other health care providers to avoid stigmatizing language when discussing weight with patients. The organization is also calling for policy changes that could help reduce racial disparities in childhood obesity, including improving access to healthy foods and treatments for groups at greatest risk.

In the actual world, where parents face increasingly difficult challenges to just keep their children housed and fed, how often does this ideal service scenario line up with reality? Some doubters speak of the expense and scarce availability of the type and duration of treatment that is recommended.

Some say that even under the best circumstances, talk therapy, especially in a family setting, is not spectacularly successful. The next post will go into more detail about the specifics. And no matter what, young people are setting out on a rough road, in challenging relationships with bodies that experience the increasing risk of serious medical conditions with every day that passes.

(To be continued…)

Your responses and feedback are welcome!

Source: “Children with obesity should get proactive treatment,” 6abc.com, 01/10/23
Image by GollyGforce/CC BY 2.0

AAP Guidelines and Backlash, Part 1

This year began with news that many felt was shocking and even scandalous. After a 15-year pause, the American Academy of Pediatrics issued a new set of childhood obesity guidelines. “Watchful waiting,” or giving children time to outgrow obesity, is not doing the trick. As Kaitlyn Radde reported for National Public Radio, “The group is now advising pediatricians to ‘offer treatment options early and at the highest available intensity’.” To some, those words have an ominous ring.

The new guidelines were authored by, among others, the vice chair of the AAP’s Clinical Practice Guideline Subcommittee on Obesity, Dr. Sandra Hassink. For children age six and older, but in extreme cases for those as young as two, the journalist wrote:

The most effective interventions require upwards of 26 hours over three to 12 months of intense, in-person behavior and lifestyle treatment from health care providers. Such treatment includes coaching on nutrition, physical activity and changes in behavior, such as role modeling by parents.

The preference is for those conversations to be couched in the “motivational interviewing” technique. This is where the clinician asks open-ended questions to try and understand the different family members’ perspectives. It is not difficult to imagine this leading to privacy issues, religious issues, distrust of governmental authority, and other undesirable reactions, but presumably, avoiding this is part of the training that professionals receive. On the other hand, one school of thought tends to believe that many patients and families will improve spontaneously, because the mere knowledge that someone cares and takes an interest, is beneficial.

A heavy schedule

All of this is, as the saying goes, “a lot,” especially for families with limited means. Even though the majority of Americans want to believe that COVID-19 and its numerous variants are in the rear-view mirror, those nasty critters are very much with us. People are still sick, and people are still unemployed, and some are both. If they have the time for these interventions, they don’t have the money — and vice-versa.

Those whose lives were least changed by the pandemic are the extremely disadvantaged, who did not use to have cars or childcare options or an extra dime to spare, and they still don’t. Seemingly ordinary amenities like well-child checkups are luxuries far beyond their means. But the recommendations for obesity abatement do not end with expensive and time-consuming appointments. Radde describes the next steps:

After this intensive therapy, weight loss drugs should be considered for adolescents as young as 12, the AAP says, while teens 13 and older with severe obesity should be evaluated for weight loss surgery.

But then, for young teens, the situation becomes even more problematic, because getting the recommended weekly injection of a drug called Wegovy is dicey, “due to recent shortages and insurance companies declining to cover it.”

Currently in the United States, more than 14 million children, or one in five humans in that age group, are officially obese. With regard to the objections that some critics have voiced, the organization also says that…

[C]hildhood obesity is a disease with genetic, social and environmental factors — not something caused by individual choices — and that it shouldn’t be stigmatized by health care providers.

(To be continued…)

Your responses and feedback are welcome!

Source: “Childhood obesity requires early, aggressive treatment, new guidelines say,” NPR.org, 01/09/23
Source: “Children with obesity should get proactive treatment,” 6abc.com, 01/10/23
Image by franchise opportunities/CC BY-SA 2.0

Intuitive Eating, Part 3

From the two previous posts we might have guessed that few medical professionals in the obesity field are on board with Intuitive Eating, but in this mixed-up world of today, that could always change.

Not surprisingly, Elyse Resch, one of the Intuitive Eating pioneers had, in her 30s, alternated between self-starvation and binging. Journalist Michelle Ruiz quoted her:

“I would try not to eat lunch, and in the afternoon, I couldn’t take it anymore and I’d eat something and then feel so guilty that I’d broken my ‘willpower,’” Ms. Resch said, adding that controlling her food had been an escape from her strained first marriage.

That is an interesting fact. In a troubled relationship, the most affected partner does not know whether to fight, flee, surrender, or lie down and die. So this sounds like displacement behavior, something to drain off excess brain energy. Ruiz also says,

Intuitive eating practitioners work on their own or with a dietitian; there are 2,000 certified intuitive eating counselors across 40 countries.

For followers of this philosophy, success seems largely to depend on a person’s ability to tune in to their own body’s signals of both hunger and satiation. This is not a widely-shared talent, especially among people who enjoy alcohol before, during, or after their meals. One negative experience is related by Adina Kish, a woman in her early 20s who gave it her best shot for a year and a half. Ruiz writes,

Trying intuitive eating for 18 months between 2020 and 2021 led her to “essentially binge eating,” Ms. Kish said, summarizing her resulting mentality as, “I should be able to eat anything, so I’m going to eat everything.” For some, intuitive eating amounts to an oversimplification — an ineffective response to the complex ways so many people relate to food.

At Michigan Medicine, Andrew Kraftson bears the long title of clinical associate professor of metabolism, endocrinology and diabetes, along with being director of the weight navigation program. In his view, the body is not always a reliable advisor regarding what should be fed into it, because “there is hormonal, neurobiological and metabolic dysregulation that can happen.”

Furthermore, a seemingly small weight change can bring about disproportionate benefits. For instance, for people in a pre-diabetic state, “if they lose 5 percent to 7 percent of their weight, they reduce their chance of developing full-blown diabetes by 60 percent.” People with hypertension and sleep apnea can also benefit greatly from seemingly small reductions.

Ms. Ruiz also spoke with a registered dietitian nutritionist, Liz Brinkman, who also became certified as an intuitive eating counselor. But over time, she has come to feel that its principles are based on some unstated assumptions about people that are not often true; for example, that they are “adequately resourced with time, money, and a sense of agency.” Sadly, these qualities apply to a quite small and inordinately privileged sub-group of humanity.

Many other professionals, including Dr. Pretlow, wish that people would “Honor your body” and “Honor your health,” but do not mean the same thing by it that the Intuitive Eating proponents do.

Your responses and feedback are welcome!

Source: “They Rejected Diet Culture 30 Years Ago. Then They Went Mainstream,” NYTimes.com, 01/18/23
Source: “10 Principles of Intuitive Eating,” IntuitiveEating.org, undated
Image by Fernando de Sousa/CC BY-SA 2.0

No Name-Calling, Please!

The illustration expresses an emotion felt by many overweight people. Some who are not even obese, but just a bit hefty, are very sensitive about public taunts. Today is the last day of this year’s National No Name-Calling Week. The exact dates change annually, but everywhere and all the time, people are called names and subjected to many sorts of bullying, for far too many reasons. Not surprisingly, Childhood Obesity News concentrates on the plight of obese children.

What should not even need to be stated, is that every week ought to be devoid of name-calling, fat-shaming, teasing, bullying, and the entire spectrum of behavior that involves making someone feel “less than” for being “more than.”

In 2004, the Week was founded by students and teachers, of kindergarten through the senior year of high school, with the goal of ending bullying and name-calling. Parents can help too, by looking up the how-to-take-action ideas.

Dr. Erica Lee, a psychologist at Boston Children’s Hospital, talks about the impact that childhood obesity can have on a child’s mental and overall health:

Weight and physical attractiveness are pretty strongly linked here in America and there’s a lot of negative stigma around being overweight or obese… This means there’s a lot of pressure and often negative attention on kids who are overweight or don’t fit that typical mold.

For any child, she recommends conversation about healthy habits. For those already experiencing weight problems,

Try to shift the conversation away from appearance or comparison to other people. Rather than focusing on a child’s weight or appearance, try to teach kids things like engaging in regular exercise and trying to have a relatively balanced diet… You can try to link it to whatever their goals are. If kids talk about wanting to be taller or doing better in school, you can explain to them that they need to eat lots of fruits and vegetables, and exercise.

Regularly acknowledge that their feelings are real. Try to avoid making any negative comments about your own weight or other people’s weight, and help your kids build strong self-esteem that has absolutely nothing at all to do with their appearance.

But objections to perceived fatphobia can go too far, as shown by an anonymous social media entry by a mother who took a group of children to a trampoline park. To use the equipment, a person had to weigh in at less than 250 pounds. This woman was livid with rage at being excluded, and warned her readers, “Thin privilege is a real thing! Stop saying it doesn’t exist!”

Perhaps, but the laws of physics do exist, despite our feelings about them. If a trampoline (or Ferris wheel seat, or bicycle, or pogo stick) is determined by its manufacturer to be unsafe for anyone above a certain weight, shouldn’t we all just relax and be grateful that regulations are in place to guarantee that we are warned about such safety hazards?

Your responses and feedback are welcome!

Source: “National No Name-Calling Week,” OK2bMe.ca, undated
Source: “No Name-Calling Week Activity Guide,” UnitedWayBroward.org, undated
Source: “Mass. psychologist on emotional impact on childhood obesity,” WCVB.com, 01/09/23
Image: Public Domain