Angles on the Guidelines

Eating disorder dietician Christine Byrne offers this perspective:

I don’t use the terms “overweight” or “obese” in my practice because they pathologize body size and stigmatize people in larger bodies, and because they’re based on body mass index, or BMI, which has racist origins and is a poor measure of health.

She only uses the words when discussing their presence and significance in the collection of treatment guidelines newly issued by the American Academy of Pediatrics.

Byrne points out the noticeable contrast between the new recommendations and those published back in 2016. At that time, the advice was to not put adolescents on weight-loss diets, either with or without pharmaceutical aids. Professionals were urged to emphasize positive body image and healthful everyday habits, and the guidance then did not even mention surgery.

She notes a lot of Americans, including many of her colleagues in the eating disorder field, are outraged by the new guidelines, which cannot help but have “an extremely negative impact on kids’ relationships with food and their bodies.” It is felt that eating disorders will multiply. Of course, not all troubled teens will become anorectic, but some will.

Byrne conceded that in the new guidelines, eating disorder screening is mentioned:

[P]ediatricians are told to ask about “unhealthy practices to lose weight,” inducing meal skipping, using diet pills or laxatives, or inducing vomiting. But eating disorder providers say this is totally inadequate in reducing eating disorder risk, since telling a kid or teenager to lose weight could inherently increase their risk of disordered eating behaviors, body image distress, and, potentially, an eating disorder.

A lot of people deplore the idea that, even when a young person does not appear to experience any health issues, doctors are being told to recommend weight loss. On the other hand, the family doctor is only one voice among many that assail the ears and spirits of vulnerable teens. Thanks to the ubiquitous presence of the internet in everyone’s pockets, it is easy for a young person to take lessons from peers who are experts in the arts of laxative use, voluntary vomiting, and worse.

Many professionals consulted by Byrne agree in their concern that eating disorders are…

[…] known to increase the risk of anxiety, depression, suicidality, substance use disorders, premature death, and serious issues at work, school, and in relationships. They can also have a negative impact on heart, bone, brain, digestive, and hormone health.

Obviously, nobody needs any of this.

Your responses and feedback are welcome!

Source: “The New Obesity Guidelines for Kids Are Appalling,” Self.com, 02/02/23
Image by Tanvir Alam/CC BY 2.0

Guidelines Backlash, the Biggies — Access and Cost, Part 3

Among others heard from on the subject is bioethicist Arthur Caplan who has called obesity one of the biggest moral challenges that contemporary America is up against. He describes both medication and surgery as “Band-Aids” in the sense of being alleged answers that provide the illusion of doing something, but which really do not accomplish much, and in fact, may even worsen the underlying problem.

Brian Castrucci, who heads a nonprofit foundation, has publicly said that more progress needs to be made, instead, with “the policies and environments that can produce better health.” Another concerned professional interviewed by Christopher Curley is pediatric endocrinologist Dr. Sissi Emperatriz Cossio:

If [patients] do not have health insurance, the costs are too high, and if they do, a great deal of paperwork is required to get the procedures approved. As with many maladies that doctors treat, the insurance approval and payment hurdles are among the chief sources of disparity of care quality between wealthier and poorer communities.

As with most issues in the USA, race and ethnicity enter into the controversy. Curley also reported that studies show how obese minority children “vastly underutilize available treatments, from drugs to counseling to surgery, because of these financial and logistical barriers. He quoted the executive report that accompanied the new guidelines:

Targeted policies are needed to purposefully address the structural racism in our society that drives the alarming and persistent disparities in childhood obesity and obesity-related comorbidities.

The AAP guidelines document itself says,

Inequalities in poverty, unemployment, and homeownership attributable to structural racism have been linked to increased obesity rates. Racism experienced in everyday life has also been associated with increased obesity prevalence. Youth with overweight and obesity have been found to be at increased risk… In adults, studies have found positive associations between self-reported discrimination and waist circumference, visceral adiposity, and BMI in both non-Latino and Latino populations.

Fatima Cody Stanford told a journalist…

[…] studies show that Black girls and boys are less likely to get treatment, compared with children of other races, despite having higher rates of the disease. Even those covered by Medicaid are less likely to be treated. “We find biases in who gets referred. If you don’t get the diagnosis, you don’t get the treatment,” she said.

Your responses and feedback are welcome!

Source: “Aggressive treatment guidelines for childhood obesity getting backlash,” WashingtonPost.com, 01/20/23
Source: “Criticism Emerges Over New AAP Guidelines for Childhood Obesity,” Healthline.com, 01/20/23
Source: “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity,” AAP.org, February 2023
Image by Got Credit/CC BY 2.0

Guidelines Backlash, the Biggies — Access and Cost, Part 2

Becoming too enthusiastic about weight-loss pharmaceuticals or surgery, or even about intensive therapy, could cost a ton of money — which may not be forthcoming from the sources that the most hopeful proponents look to for funding.

Some optimists have suggested that the new recommendations in the AAP guidelines might incentivize insurers, including the government through Medicaid, to willingly open their wallets and pour out payments. Other professionals are not so sanguine in their expectations, like Dr. Katy Miller, who works with teenagers experiencing eating disorders. She says,

We are proposing treatment strategies that are expensive and even in the best circumstances are often unsuccessful. How can we ask someone to diet when we’re not addressing things like poverty, food scarcity and housing instability?

Journalist Sara Monetta met with a mother of three who was enthused about her healthy cooking support group (a YMCA project.) This mom believed in healthy eating and plenty of exercise, and lamented the lack of sports programs and other exercise opportunities for children. She would consider weight-loss drugs or surgery “only if I had tried everything.”

On the question of expenses for any of the options, a Washington Post article said this:

Insurance can be tricky to navigate. Doctors say bariatric surgery for those who are severely obese is usually covered. But only a few states mandate reimbursement for medication and behavioral treatments under Medicaid and private plans vary in their coverage.

Apparently, an anti-obesity bill was introduced to Congress 10 years ago that would have provided coverage under Medicaid, not only for prescription drugs, but also for profound and extensive behavioral therapy. But introduction was as far as the acquaintance went. There was no second date.

More angles

Jason Wachob of MindBodyGreen.com wrote about the relative short-term and long-term costs, predicting that…

[…] pharmaceuticals and surgeries will dwarf the costs of changing school curriculums to reflect our dire need to get our kids and our future generations thriving… what would be required for an overhaul of our education system…

He then went on to suggest some audacious policy changes:

What if we subsidized vegetables, fruits, and nutrient-dense animal products, instead of just corn and soy?

Journalist Ariana Eunjung Cha noted the probability of unequal access to treatment, and added another concern, namely, “worry that earlier medical interventions may create more fat-shaming of vulnerable children.” Meanwhile, other critics have other reasons to object, chiefly because they believe that making this sort of help too easy to get will encourage children to persist in their poor lifestyle choices, i.e. eating too much. Cha wrote,

People on both sides express uneasiness about the potential long-term consequences of putting millions of children on drugs or under the knife, instead of doing more to prevent the condition in the first place.

Your responses and feedback are welcome!

Source: New US childhood obesity guidelines criticised by families,” BBC.com, 01/29/23
Source: “What you need to know about the new childhood obesity guidelines,” WashingtonPost.com, 01/20/23
Source: “The New AAP Childhood Obesity Guidelines Are Setting Kids Up To Fail,” MindBodyGreen.com, 01/17/23
Source: “Aggressive treatment guidelines for childhood obesity getting backlash,” WashingtonPost.com, 01/20/23
Image by Pictures of money/CC BY 2.0

Guidelines Backlash, the Biggies — Access and Cost, Part 1

As previously mentioned, intensive health behavior lifestyle treatment (IHBLT) is on record as the best evidence-based treatment to prevent or reverse childhood obesity. Claire McCarthy, M.D., wrote,

This involves face-to-face, family-based, multidisciplinary counseling on nutrition and physical activity, preferably based in your community and connected to community resources. To make a difference, it should involve at least 26 hours over at least three to 12 months. These programs, unfortunately, are not easily available to most families.

There is, obviously, the expense. The staff of an adequately equipped pediatric obesity facility needs to include “pediatricians, endocrinologists, hepatologists, surgeons, social workers, psychologists, fitness experts and nutritionists.”

Such opulent medical centers exist mostly in large cities, and they are sought out by so many hundreds or thousands of patients that the wait time for an appointment can be quite long. The keeping of appointments may involve parents missing work, as well as expenses for travel, parking, eating, and maybe even staying overnight. For many families, this is not an enterprise that can be undertaken lightly.

Deep pockets required

Dr. Jessica Madden specializes in pediatrics, neonatology, and lactation, and has a strong interest in childhood obesity. Christopher Curley wrote of her,

She noted that interventions such as IHBLT require a significant time commitment… One major barrier to implementing IHBLT is the cost. Who is expected to pay for the cost of these programs? Are they (or will they be) covered by insurance, grants, or are families expected to cover the cost?

Aside from figuring out the logistics, and meeting the cost of transportation and the like, there is the issue of motivation. Attending 26 therapy hours over three to 12 months is a project that requires real persistence. So why not choose medication instead? It is no wonder that handing out pills simply seems more efficient and pragmatic. Dr. Nazrat Mirza, a co-author of the new AAP guidelines, told journalist Sara Monetta:

Just like asthma, just like hypertension… In hypertension you would tell somebody to cut salt, but then the blood pressure is still high, so you’re still going to give them medication.

Your responses and feedback are welcome!

Source: “New pediatric guidelines on obesity in children and teens,” Harvard.edu, 01/24/23
Source: “Criticism Emerges Over New AAP Guidelines for Childhood Obesity,” Healthline.com, 01/20/23
Source: “New US childhood obesity guidelines criticised by families,” BBC.com, 01/29/23
Image by Pictures of Money/CC BY 2.0

AAP Guidelines and Backlash, Part 9

When people praise the new AAP guidelines they often say, “Effective treatment, in the form of drugs or surgery, is available. So, why not opt for one of those methods?” Of similar mind is pediatric surgeon Ann O’Connor of the San Antonio Children’s Hospital, who is quoted as saying, “One of the things we know for sure is that as children with obesity get older, they get bigger and bigger and sicker and sicker, and their medical problems get worse.”

Among other possible outcomes of waiting, there is lifelong chronic illness. Endocrinologist Grace Kim (Seattle Children’s Hospital) warns that while it may take a decade for an adult to progress from prediabetes to diabetes, this can happen to a child in as short a time as two years.

Journalist Christopher Curley has pointed out that an increasing number of professionals now have a fundamentally different view of obesity, tending more to regard it as “a chronic, refractory, relapsing disease,” meaning that a wait-and-see approach cannot be satisfactory.

Uncomfortable truths

Dr. Jennifer Woo Baidal of Columbia University reminds us that bias is one of the prominent factors that prevent progress, especially when bias refuses to recognize that obesity is a very complex problem. This is true of professionals and laypersons alike. Dr. Baidal told the press:

Many people think children can just lose weight on their own, but it’s hard to make changes if there is limited access to affordable, healthy food and exercise. I think the guidance calls this out and gives support and instruction for providers on how to handle those factors.

Writer Catherine Pearson quoted Prof. Rebecca Puhl, deputy director of the Rudd Center for Food Policy and Health at the University of Connecticut, who said, “Physicians are not immune to societal weight bias that is prevalent in our culture… Weight bias is rarely, if ever, addressed in medical school training.”

Jason Wachob of MindBodyGreen.com writes that he is not against surgery or medication, but suggests that before considering either of those routes, the medical team should be totally convinced that the less intrusive possibilities for lifestyle modification have been exhausted. He mentions a thing that some find strange, that the AAP’s new recommendations were released before the same institution’s statement on obesity prevention, and adds:

While we need to act urgently to treat the mounting childhood obesity epidemic in this country, I think the order of these two publications is telling. The medical system is taking drastic measures to “treat” the signs of an issue before fully considering its root cause.

Wachob quotes family medicine physician Bindiya Gandhi, M.D., who reiterates that before considering bariatric surgery on pediatric patients, many other interventions can and should be utilized. According to this worldview, particular attention should be paid to eliminating sugar and hyper-processed foods, and to encouraging a meaningful amount of physical activity.

Also quoted is family physician Madiha Saeed, M.D., who confirms what has been known or suspected all along: “I was taught no nutrition and almost no lifestyle strategies to aid my patient care.” Dr. Saeed believes that more resources should be devoted to weight management education, and characterizes the new recommendations as “horrifying.”

Your responses and feedback are welcome!

Source: “Criticism Emerges Over New AAP Guidelines for Childhood Obesity,” Healthline.com, 01/20/23
Source: “What Parents and Caregivers Need to Know,” NYP.org, undated
Source: “New Guidelines Underscore How Complicated Childhood Obesity Is for Patients and Providers,” NYTimes.com, 01/20/23
Source: “The New AAP Childhood Obesity Guidelines Are Setting Kids Up To Fail,” MindBodyGreen.com, 01/17/23
Image by Jernej Furman/CC BY 2.0

AAP Guidelines and Backlash, Part 8

The previous post discussed the major changes that are meant to be implemented in the treatment of childhood obesity, and which the American Academy of Pediatrics will encourage, going forward. Yet, there is more to the story, and an apparent enthusiasm in some quarters for further policy adjustments. Concerning the standard by which obesity is measured, the individual’s Body Mass Index, problems have been evident for quite some time.

Very close to the date when the AAP released its controversial new guidelines to prevent and cure childhood obesity, the Centers for Disease Control released updated growth charts. Reporting for media giant CNN, journalists Jamie Gumbrecht and Jacqueline Howard explained that those charts are…

[…] standardized tools used by health care providers to track growth from infancy through adolescence. But as obesity and severe obesity became more prevalent in the past 40 years… the charts hadn’t kept up. The newly extended percentiles incorporate more recent data and provide a way to monitor and visualize very high body mass index values.

Apparently, the extended growth charts will be used by providers who treat severely obese children, but meanwhile, the previous child and adolescent charts will not change. Has anyone interviewed a mathematician about whether the basic formulae are solid? As journalist Catherine Pearson has pointed out, reliance on the Body Mass Index standard is increasingly problematic as a measure of metabolic health, relying as it does on arbitrary number scores alone.

Not getting the message?

Are some healthcare providers misinterpreting the new guidelines, willfully or unwittingly? Are some members of the public spreading misleading or ignorant commentaries just to be contrary? Who knows? Users of social sites like Facebook and Twitter have noticed some of their fellow communicators complaining that the AAP guidance ignores the vast harm done by junk food. Another wrinkle that health professionals have noticed is the layperson’s tendency to blur the line between extra poundage and morbid obesity, which complicates the debate even more.

Time is not on our side

Regarding the previously endorsed “watchful waiting” philosophy, more and more experts point out that we do not have all the time in the world, because once obesity has taken hold of a person, the window for potential reversal is a narrow one. A typical warning comes from obesity specialist Matt Haemer of Children’s Hospital, Colorado. He mentions that despite good-faith efforts to make positive lifestyle changes, 80 to 90 percent of child obesity cases persist into adulthood.

(To be continued…)

Your responses and feedback are welcome!

Source: “Updated obesity treatment guidelines for children and teens include medications, surgery for some young people,” CNN.com, 01/11/23
Source: “New Guidelines Underscore How Complicated Childhood Obesity Is for Patients and Providers,” NYTimes.com, 01/20/23
Source: “Aggressive treatment guidelines for childhood obesity getting backlash,” WashingtonPost.com, 01/20/23
Image by Bilal Lashari/CC BY 2.0

AAP Guidelines and Backlash, Part 7

As the previous post mentioned, although many parents and health practitioners prefer working with the diet plus exercise method of controlling childhood obesity, official policies will now support that model to a much lesser extent.

As Gina Kolata reported for The New York Times, some major research projects have been less than encouraging. Back in the 1990s, the National Institutes of Health sponsored two very sizable and careful studies. Could weight gain in children be prevented at school, through the expansion of physical education programs? How about cafeteria meals designed to be more nutritious?

What if students were taught more intensively about good eating and lots of exercise? What if parents were also brought into the picture? Kolata writes,

One study, an eight-year, $20 million project sponsored by the National Heart, Lung and Blood Institute, followed 1,704 third graders in 41 elementary schools in the Southwest… Some schools got intensive intervention, while others were left alone.

In the intervention schools, students changed their eating habits to include slightly less fat, but not much else happened. The investigators had to regretfully declare that body weights had not noticeably shrunk. However, there still is no universal agreement on the failure of diet and exercise. Kolata’s article also included some paragraphs that cast a shadow over the controversial new AAP proposals:

It takes years for doctors to start using new guidelines, noted Dr. Louis Aronne, an obesity medicine specialist at Weill Cornell Medicine in New York. “The ones for adult obesity have never really been adhered to,” he noted. “Adults with obesity are already advised to get surgery or drug treatment, but just 2 percent ever do.”

For The Washington Post, Ariana Eunjung Cha listed the three most important new guideline concepts that the public is meant to grasp:

1. Obesity is a chronic medical condition, not primarily a consequence of lifestyle choices.
2. Medications are a tool that can be used in children 12 and older in a safe manner. Bariatric surgery can also be considered for severe obesity in children 13 and older.
3. More must be done to ensure access to treatments for all children who need them.

Many health professionals and laypersons would prefer to stick with emphasizing healthy eating and increased exercise, ideas which although now relegated to an inferior position, are not entirely abandoned. The new guidelines still include them in the preferred method of first resort, known as Intensive Health Behavior Lifestyle Treatment, or IHBLT.

As summarized by Claire McCarthy, M.D.:

This involves face-to-face, family-based, multidisciplinary counseling on nutrition and physical activity, preferably based in your community and connected to community resources. To make a difference, it should involve at least 26 hours over at least three to 12 months.

This will be discussed further.

(To be continued…)

Your responses and feedback are welcome!

Source: “Why Experts Are Urging Swifter Treatment for Children With Obesity,” NYTimes.com, 01/27/23
Source: “What you need to know about the new childhood obesity guidelines,” WashingtonPost.com, 01/20/23
Source: “New pediatric guidelines on obesity in children and teens,” Harvard.edu, 01/24/23
Image by U.S. Dept of Agriculture/Public Domain

AAP Guidelines and Backlash, Part 6

Childhood Obesity News has discussed many of the infamous co-morbidities associated with child obesity. The truly alarming news is that they currently occur at much younger ages.

To counter that trend, every once in a while there is a major development. The National Institutes of Health designated obesity as a chronic illness in 1998. In 2013, the American Medical Association deemed obesity a disease. In 2007, the American Academy of Pediatrics issued a set of prevention and treatment guidelines, which were only updated last month.

For journalists, it is easy to summarize the updates, as Nina Shapiro has done:

The emphasis on the new guidelines is earlier intervention for children with obesity, with recommendations for children ages 6 to 12 years (and even younger in some situations) to receive behavior and lifestyle treatment. Children over age 12 years can be considered for pharmacotherapy in addition to behavioral therapy. And children ages 13 years and over whose BMI is 120% above the 95th percentile may be candidates for bariatric surgery.

The recent mini-revolution has attracted attention and criticism. The information in that medium-sized paragraph has lit fires all over the place. It is now feared that clinicians may tend to become too aggressive in the use of pharmaceuticals and surgery. Having researched the reactions of professionals from nutritionists to pediatricians, Shapiro wrote:

They emphasize that the focus should first and foremost be on increased education on the risks of high-sugar, highly processed foods. They state that increased physical activity, stress management and better education should obviate the need for medications or surgery. Unfortunately, we are not seeing improvements in these arenas; in fact, children are more sedentary and are eating less healthfully than in years past.

In some quarters, the perceived abandonment of the diet plus exercise paradigm is seen as not just giving up too easily, but actually courting failure. There is anxiety among parents who fear that the new suggestions will make people think the diet plus exercise approach should be forgotten.

For example, BBC News journalist Sara Monetta interviewed a mother who was distressed to learn that her 14-year-old daughter’s school planned to end Physical Education classes, during which young people get actual exercise, and replace them with a standard classroom health course. In contrast, young Jaelynn had taken part in a YMCA summer camp that included plenty of outdoor activity, and lost 12 pounds in three months. This also improved the chronic kidney disease from which she had suffered since childhood.

But people are being discouraged from this kind of optimistic thinking. The studies have been conducted, and the news has not been good.

(To be continued…)

Your responses and feedback are welcome!

Source: “New Guidelines On Childhood Obesity Are Met With Some Resistance,” Forbes.com, 01/17/23
Source: “New US childhood obesity guidelines criticised by families,” BBC.com, 01/29/23
Image by Mohd Fazlin Mohd Effendy Ooi/CC BY 2.0

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