Guidelines, Quibbles and Quirks — Part 5

Some things never change. There is very little likelihood that the United States will ever adopt the metric system for general use. Blue jeans will always be in style. And probably, the Body Mass Index will continue to be how the establishment decides whether or not a human is fat.

The BMI standard has always been controversial. Dr. Danielle P. Burton recently called it an antiquated system and explained,

BMI was never intended to be used as a measurement for health, and our current growth charts are based on data from the 1960s through the early 1990s. Are these outdated measurements truly the best measure of health?

A widely-held position is that obesity should not be determined by a lone data point, but by an array of them. Most things in life are on a spectrum, and ideal body weight is no exception. Gyms are full of living proof there is no exact cutoff point between fitness and the shame of being unacceptably big. A desperate need is felt for the culture to at least admit the possibility that size diversity and health could co-exist. When surgery is recommended, especially for kids, there is a hunger for evaluations that include the patient’s mental health status.

Stirring the pot

Meanwhile, policies uttered by the American Academy of Pediatrics at the beginning of this year focused intense attention on BMI once again. One expert who reacted is Dr. Kim Dennis, co-founder and medical officer at SunCloud Health, who says,

I think we do more harm than good when we […] say, ‘Based on the fact that your BMI is, you know, 28 or 30, you have a disease. By pushing people to get into this normal weight range, we’re only causing eating disorder behaviors.

It is no wonder that the recent news has been met with questions, concern, and outrage from practitioners and parents alike. Childhood Obesity News explored the concept of iatrogenesis. Many critics have mentioned ways in which the ideas could be dangerous for kids:

[T]he AAP released guidelines that recommend actions that are known top risk factors for eating disorders with almost no reference to how discussing weight and BMI can increase eating disorder risk. It is not helpful to reduce the number of children with obesity if they are driven toward the top risk factors for the second most deadly mental health illness.

Speaking on behalf of the grassroots advocacy organization Medical Students for Size Inclusivity, Jessica Mui noted that by focusing on the “flawed tool” of BMI, the AAP guidelines “are based on science that grossly misrepresents the complex relationship between weight and health.” To insist that weight loss is the chief measure of health is to “further stigmatize the bodies of children whose environments are likely already rampant with weight bias.” Mui adds,

The evidence remains elusive as to whether increased BMI alone is causative of increased morbidity and mortality. This outdated tool does not consider genetic, ethnic, and epigenetic variation or significant factors like poverty, racism, trauma, environment, chronic stress, and weight stigma, all of which negatively affect health outcomes in and of themselves.

When surgery is considered, a high BMI is what is known in logic as a necessary condition, but not a sufficient condition. In other words, a big number signifies that a person is obese enough to be medically qualified for bariatric surgery, but that alone is not enough. In making the recommendation, weight is just one factor, and needs to be regarded in the context of total health.

Your responses and feedback are welcome!

Source: “The Hidden Danger in the AAP’s New Obesity Guidelines,”, 03/04/23
Source: “Eating disorder specialists ‘horrified’ by child obesity guidelines,”, 03/07/23
Source: “The AAP’s new childhood obesity guidelines are dangerous. Here’s what to do,”, 03/01/23
Source: “Size-inclusive medicine: a response to AAP’s guidelines for the treatment of children and adolescents with obesity,”, 03/01/23
Image by Ambuj Saxena/CC BY 2.0

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About Dr. Robert A. Pretlow

Dr. Robert A. Pretlow is a pediatrician and childhood obesity specialist. He has been researching and spreading awareness on the childhood obesity epidemic in the US for more than a decade.
You can contact Dr. Pretlow at:


Dr. Pretlow’s invited presentation at the American Society of Animal Science 2020 Conference
What’s Causing Obesity in Companion Animals and What Can We Do About It

Dr. Pretlow’s invited presentation at the World Obesity Federation 2019 Conference:
Food/Eating Addiction and the Displacement Mechanism

Dr. Pretlow’s Multi-Center Clinical Trial Kick-off Speech 2018:
Obesity: Tackling the Root Cause

Dr. Pretlow’s 2017 Workshop on
Treatment of Obesity Using the Addiction Model

Dr. Pretlow’s invited presentation for
TEC and UNC 2016

Dr. Pretlow’s invited presentation at the 2015 Obesity Summit in London, UK.

Dr. Pretlow’s invited keynote at the 2014 European Childhood Obesity Group Congress in Salzburg, Austria.

Dr. Pretlow’s presentation at the 2013 European Congress on Obesity in Liverpool, UK.

Dr. Pretlow’s presentation at the 2011 International Conference on Childhood Obesity in Lisbon, Portugal.

Dr. Pretlow’s presentation at the 2010 Uniting Against Childhood Obesity Conference in Houston, TX.

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