New pediatric guidelines aim to treat obesity without stigma. Critics say they’ll make bias worse.

From the time Alexandra Slick was little, she knew that when she went to the doctor’s office, at least one person was probably going to tell her that she needed to lose weight.

She remembers sitting in an examination room as a middle schooler, watching her mother cry as a nurse practitioner asked her if she wanted her daughter to die. At that point, while Slick’s weight was considered obese by the body mass index, she already had been dieting for about four years and practiced karate every week.

“It used to be that if I had a doctor’s appointment in the day, I wouldn’t eat or drink anything until I had gone to the doctor — whether or not that appointment was at 10 a.m. or if that appointment was at 3 p.m.,” she said. “I just wanted to be as small as I could going into the doctor’s office.”

When Slick, a 31-year-old Baltimore resident, heard about the American Academy of Pediatrics’ new guidelines for treating childhood and adolescent obesity, she shuddered.

The guidelines, released in January by the country’s leading pediatricians group, advise primary care doctors to offer families a variety of treatments early for childhood obesity. “Watchful waiting” to see if children with obesity developed into average weight adults — the group’s previous recommendation — would no longer cut it.

The guidelines became an immediate subject of controversy, triggering backlash from nutritionists, eating disorder clinicians and people like Slick, who know what it’s like to live in a larger body.

They worry a focus on weight loss will trigger or worsen disordered eating in children with larger bodies, exacerbate weight stigma in doctor’s offices and lead physicians to overlook the diets and exercise routines of children whose weights are — according to the body mass index — average or low.

Especially controversial was a guideline that doctors consider prescribing weight loss drugs to children as young as 12 and referring 13-year-olds to be evaluated for weight loss surgery.

The guidelines use the body mass index, or BMI, a measure calculated from a patient’s weight and height. While controversial, BMI remains widely used by physicians to determine whether a patients’ weight is healthy.

Supporters of the guidelines say surgical treatment options wouldn’t be offered in isolation. The recommendations also emphasize the need for ongoing lifestyle and behavioral treatments, such as proper nutrition and physical activity.

“This is nothing that pediatricians can or should force on families,” said Dr. Sarah Hampl, a lead author of the guidelines and a pediatrician in Kansas City, Missouri.

Research dating back decades has documented weight stigma among medical professionals. Primary care physicians may be less likely to show empathy, concern and understanding to patients whose bodies the doctors consider overweight or obese, while such patients have reported being mis-diagnosed and may even avoid going to a doctor.

The American Academy of Pediatrics’ guidelines explicitly recognize the role weight stigma historically has played in medical care.

At Kennedy Krieger Institute’s Weight Management Program, patients work with their doctors to create unique treatment plans, said Dr. Anton Dietzen, a pediatric physiatrist with the institute’s Fit and Healthy Clinic.

“Every one of these cases is so different,” Dietzen said. “There are so many complex biopsychosocial issues going on — a lot of multigenerational households, and parents working two jobs, and issues of food insecurity, and patients who are eating two of their three meals a day at school.”

But no matter the circumstance, Dietzen said, it’s important to offer early and intensive treatment for childhood obesity.

The condition is a chronic disease, and its effects pile up over time, he said. The longer a child’s weight is elevated, the more likely it is they’ll develop serious diseases like cardiovascular health problems and Type 2 diabetes, he said.

Colleen Schreyer, an assistant professor at the Johns Hopkins School of Medicine who serves as the director of clinical research for the Johns Hopkins Eating Disorders program, has complicated feelings about the guidelines.

“I see the need for treatment of obesity,” Schreyer said. “I also think we need to be thoughtful about how we implement those treatment interventions to prevent the onset of disordered eating.”

Some researchers say people whose weights are considered obese by the BMI can still be healthy. But Schreyer said patients with a BMI above 30 are more likely to have conditions such as high blood pressure, elevated cholesterol levels, chronic pain and limited mobility.

Schreyer said bariatric surgery can alleviate some of those conditions. She said before adolescents undergo surgery at Johns Hopkins, they receive six months of a behavioral weight loss intervention and meet for six months with a psychologist to identify and treat mental health concerns such as eating disorders, depression and anxiety. Hopkins offers the surgery to adolescents as young as 16.

The guidelines recommend that doctors consider referring children to be evaluated for the surgery if their weight is 120% above the 95th percentile, according to the BMI. Schreyer said her typical adolescent patient weighs well above the 99th percentile for BMI — some around 400 pounds — and typically have other medical issues like high blood pressure and limited mobility.

Deborah Kauffmann is a nutrition counselor who practices a non-dieting approach to weight management and is the former director of nutrition services at The Center for Eating Disorders in Towson. She said the BMI is an inaccurate measure of health.

“Many people are born with a high number of fat cells and that doesn’t determine health,” Kauffmann said. “Even if the BMI did account for body composition, it would still be pretty meaningless and not be an indicator for your health in any way.”

Dietzen said BMI is a useful tool when it comes to screening patients for potential weight management intervention, but doesn’t capture the complete picture.

“Just like anything in medicine, you have to look at the individual and not the numbers,” he said.

Kauffmann strongly objected to the guidelines’ suggestion of considering weight loss surgery consultation for teenagers as young as 13. She said bariatric surgery comes with short and long-term complications, which she’s seen in patients she’s worked with after surgery who have digestive and nutritional issues.

Schreyer defended weight loss surgery as a long-term solution. One option involves removing up to 80% of a patient’s stomach, allowing them to feel full after eating significantly less food.

“We know that 95% of people who start a behavioral weight loss intervention will regain the majority of their weight,” Schreyer said. “Around 60-65% of patients who undergo bariatric surgery keep their weight off five to 10 years later.”

A bigger issue with the guidelines, Kauffman said, is that they treat obesity alone as an elevated health risk. Instead, Kauffman said, physicians need to pay attention to sudden, drastic weight loss or gain, which could be indicative of issues such as eating disorders or insulin resistance.

“To assume that a child isn’t healthy because of a higher weight is just wrong,” Kauffmann said. “There’s no way around it — scientifically and morally, it’s wrong.”

Jane Zeltser, the practice manager for the Eating Recovery Center’s east region, said weight loss surgery is like “butchering” children “just so they can fit a mold of looking a certain way.”

Still, Zeltser, 38, said that when she was a teenager struggling with an eating disorder, she would have jumped at the suggestion.

“I would have done anything and everything to make myself smaller,” Zeltser said.

At 4 years old, Zeltser immigrated with her family from what is now Kyiv, Ukraine. She said that while she couldn’t control her secondhand clothing or her accent, she could reject her hometown foods that set her apart from other students.

By the time she got to high school, that restriction morphed with a desire to occupy a smaller body, leading Zeltser to take weight loss pills. She experienced worrying symptoms: an elevated heart rate, insomnia, headaches and even hallucinations.

But because Zeltser never fell into the “underweight” category, help was hard to come by, especially from Zeltser’s pediatrician.

“He would say, ‘Well, you’re in the 75th percentile. So actually maybe you could stand to lose some weight,’” Zeltser said. “I was hospitalized because of the effects of these diet pills on my body.”

According to the National Association of Anorexia Nervosa and Associated Disorders, fewer than 6% of people with eating disorders are medically diagnosed as underweight.

Hampl said the American Academy of Pediatrics is working with eating disorder organizations to develop better tools to help doctors check their patients for the warnings signs of disordered eating, regardless of their weight.

Research shows that kids who try to lose weight through fad diets are more likely to have an eating disorder, Hampl said. But kids who have a caring medical provider trying to help them “achieve a healthier weight” through a structured program are less likely to develop such disorders, she added.

“There’s really no benefit in trying to pit the eating disorders community against the weight management community. That’s really counterproductive,” Hampl said. “Both of these issues are highly stigmatized. They’re often interrelated.”

Schreyer said that, in her experience, obesity specialists are not primarily interested in making their patients skinnier.

But Zeltser said her pediatrician constantly told her to eat less.

“He fueled my eating disorder,” Zeltser said.

Zeltser said she was sick to her stomach when she read the pediatricians’ new guidelines.

“Children should be able to be children. And I feel like these guidelines are taking away from their childhood,” Zeltser said. “I didn’t even have a childhood because of my eating disorder.”