New guidelines on child obesity advise less watch and wait, more urgent and early intervention

Young child eating vegetables at a table.

Q&A with Kate Bauer

Associate Professor of Nutritional Sciences

February 8, 2023

In its first guidelines on childhood obesity in 15 years, the American Academy of Pediatrics is advising urgent and early treatment interventions, including medications and surgery at younger ages, rather than relying on wait-and-see treatments.

More than 14.4 million U.S. children and teens are at risk of serious short and long-term health concerns such as cardiovascular disease, diabetes and behavioral health issues, if untreated, according to the AAP.

Kate Bauer, associate professor of Nutritional Sciences at the University of Michigan School of Public Health, is an expert on causes of and reactions to childhood obesity, especially in marginalized communities.

What are your thoughts on the new guidelines and how they might change how pediatricians, families, society respond to obesity in childhood?

I appreciate that the task of developing clinical guidelines was massive; the American Academy of Pediatrics was previously relying on 15-year-old guidelines regarding how to approach obesity with children and families. 

I also want to recognize that the guidelines first and foremost emphasize how body size is dependent on a complex interaction of social, economic, behavioral and genetic factors, and that systemic racism and weight discrimination, which are pervasive in our culture, are harmful to our children's health. 

However, I do believe that the guidelines will have unintended negative effects on health care providers, families and society. Just a few of my specific concerns are:

  • The guidelines support screening, diagnosing and treating children based on body size, not behavior or mental or physical health. The guidelines themselves note that some children with higher BMIs will have positive relationships with food and activity, and have no medical indication that intervention is needed. Yet, the guidelines recommend that all children older than 5 with BMIs over the 85th percentile (which is relatively low and common) receive intensive treatment. This treatment is time consuming, expensive, can be upsetting to families and may increase stigma against children, rather than decrease it.
  • Language matters. While the guidelines emphasize the importance of reducing weight stigma, they themselves are stigmatizing. Throughout the guidelines, terms including, "abnormal weight" and "suffering from overweight and obesity" are used. I feel that the authorship group did not interrogate their own ideas about language well enough.
  • General practice pediatricians should not be responsible for providing children pharmacotherapy for higher weight. There are serious medical and emotional implications of starting children on medication to alter their weight. Most pediatricians do not have the proper training to approach this topic with families or to adequately make clinical decisions and monitor. I have seen individuals who have distressing relationships with food benefit from making informed decisions about medication with the support of intensively trained health care providers. All children deserve this level of care.
  • Nearly everyone in our society (or perhaps just everyone), holds harmful, weight-biased beliefs. Pediatricians are not immune to this, individuals with higher weight themselves are not immune to this and parents of heavier children are not immune to this. These guidelines will not change that and will not turn a biased health care provider into someone who can engage in nonstigmatizing care. 

The guidelines discuss increased risks for children affected by socioeconomic inequities and structural racism. Is this something pediatricians and health care are equipped to address?

No. The health care system is an important component of connecting families to resources. However, the reality is that our current social safety net is just a Band-Aid and an insufficient one at best. For example, health care providers are increasingly screening patients for food insecurity and then, ideally, will support families enrolling in our federal food assistance programs and accessing food banks.

These programs though don't erase the reality that working parents, especially women and Black and Brown parents, are not provided a living wage; that our current food stamp benefits aren't enough for families to make it through the month; and that housing, education and health care costs are putting many families in irrecoverable debt. 

How does nutritional insecurity—access to healthy foods—come into play in childhood obesity? How can pediatricians support families with children affected by food insecurity?

Not having consistent access to healthy food during childhood can have persistent impacts on individuals' health and relationship with food, which can manifest as obesity later in life. When you're unsure where your next meal is coming from, or more generally, are stressed or scared, you're more likely to eat beyond the point of fullness or eat comforting foods, which tend to be very calorically dense. It is a perfectly rational response to a distressing situation.

As I noted, there are things that pediatricians can do to improve families' nutrition security—they can make sure that families are enrolled in the financial and food assistance programs that they are eligible for, or they could help them problem solve how to overcome other barriers to healthy food access, such as transportation. These are important, yet for most families, not sufficient to make sure that families consistently have enough healthy food. 

You've explored the tendency for society to blame parents, to shame them and their children for body weight. Does this guidance for pediatricians help shift that unfair and inaccurate viewpoint? 

No. I was quite dismayed to see in the guidelines the common sentiment that parents are not aware of their children's weight status and that this is a problem that pediatricians need to correct. The vast majority of this belief comes from the fact that on surveys, a certain percentage of parents of children with higher BMIs do not circle the "correct" weight status. Honestly, this is completely ridiculous. 

Who cares if parents do not identify their children using the same terms as a researcher would? Perhaps parents are hesitant to circle the phase that maybe describes their children's weight status because society deems "overweight" children as lazy or stupid? And ultimately, there is no evidence that parents who do accurately select their child's weight status engage in healthier parenting practices.

More broadly, most parents of heavier children have been discriminated against because of their children's weight. They are told by their family that they are bad parents, that they don't have control of their children. They are asked by pediatricians, "What are you feeding them?" Given that the recommended treatment for children with higher BMIs is intensive family-based counseling, there is no reason to believe that pediatricians will be any less likely to see parents as responsible than they already do.

What do you see as the key takeaway for families concerned about a child who is overweight?

Focus on supporting your child's mental health and healthy behaviors—spend your energy exposing your child to new foods and tastes, talk about paying attention to how our bodies feel when eating, encourage movement because it is fun, identify whether certain types of screen time and social media build us up or put us down. 

Find ways to connect with your child and be a trusted resource, especially if they're encountering bullying or feel down on themselves. Listen more than talk. Do not encourage quick fixes or restrictive approaches to weight loss—they will backfire. Be your child's advocate. If you don't like the way their health care provider is supporting healthy eating, activity or body size, try to find someone new.

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