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Whispering Back at the AAP

A dietitian’s response to the American Academy of Pediatrics 2023 clinical practice guidelines on childhood obesity

By Natalie Loschiavo RDN, LDN, Owner of Balanced Nutrition LLC and Mother

January 13, 2023

I’ve spent the past two days reacting to the new guidelines released this week by the American Academy of Pediatrics. When I first saw the headlines, I threw up my figurative hands and texted my beloved staff to tell them “I quit.” You see, my colleagues and I spend our days sitting with individuals suffering with the long-term physical and emotional consequences of weight-loss interventions that were imposed on them in childhood.

After being reminded that “now is not the time to quit,” I began, instead, to think.

I thought of a client who has shared vivid memories of anxiously attending Weight Watchers meetings with their mother at the ripe old age of nine. Surrounded by adults who swapped tips on how to eat the fewest “points,” they recalled feelings of confusion not only by why people were eating “points,” but also why they, as a child, were there in the first place. “I didn’t even know I was fat. Or that it was bad to be fat. I didn’t even know I was bad because I was fat until those meetings,” they explained.

I thought of another client who before the onset of puberty was gifted with a scale in her basket on Easter Sunday. That scale would come to be her most valued accessory through adolescence and young adulthood--toted to sleepovers, on vacations, and even to her first admission to residential treatment for her debilitating eating disorder (and then soon discarded by her treatment team).

I thought of my various clients who, as consenting adults, underwent surgical weight loss procedures only to find out decades later that their issues were not caused nor solved by weight changes. Most of them do not regret their personal and well-thought-out decisions to have surgery. As adults, with fully developed prefrontal cortexes, they had the ability to think and reason critically when making this life-altering decision. They understood everything that was presented to them by their surgeons and clinicians. Despite that, to this day, they admittedly aren’t sure if they would make the same decision again knowing what they know now. Additionally, they often report feelings of frustration and resentment that their doctors didn’t thoroughly explain or disclose the long-term outcomes and side effects of surgery.

Finally, I thought of my son, now 12 months old, who is a happy, growing baby with no understanding of weight, BMI or health markers. He’s a big boy, blowing past the 90th percentile on CDC growth charts. At his last pediatrician visit, I was shown his BMI on the growth curve and told “you don’t really need to worry about this yet.” But now I wonder, is that true?

To clarify this last point. I’m not ever going to worry about my son’s BMI (or body mass index). Primarily because BMI has more inherent flaws than the Titanic, but I’ll save that for another writing.

However, I don’t agree with his pediatrician when she said, “you don’t really need to worry about this yet.” Because after the recent guidelines released by the American Academy of Pediatrics (or AAP), it looks like I do, in fact, need to start worrying about this. I need to start worrying that my baby could be assessed against this metric in the coming years and recommended by his trusted doctors to engage in intensive weight management efforts should he end up with a “high BMI” by the age of two…two. Even worse, he may be offered diet drugs or even surgery as an option by the age of 12. If I don’t need to “really worry about this yet,” then when?!

As I continued to think of what these recommendations might mean for my son, our children, I went from thoughtful to enraged. How could we do this to our children? How could we recommend such extreme measures based on such poor research and evidence? How could we act so irresponsibly with the wellbeing of our babies at stake.

The universe must have known I needed to pause for a moment before I voiced my outrage because I woke up this morning with laryngitis. So, even if I wanted to scream from the mountaintops in fury, my only option was a quiet whisper. This reminded me of something my father once said, “people are forced to listen more closely when you whisper than when you yell.”

So, this is my whisper.

I took the day to read and review the full AAP guidelines. They’re long, detailed, and extensive. I reviewed the research and literature that was referenced, as well--equally long.

I must admit, the guidelines in their entirety are more nuanced and inclusive than I had originally assumed based on the summaries and headlines seen on news forums. And they did address some of the concerns that were being shouted about on social media platforms. They briefly acknowledge issues such as race, socioeconomic status, adverse childhood experiences, abilities, special needs, weight stigma, oppression, etc. in their discussion of the complex nature of the “disease of obesity.”

In greater detail they outline the extensive (and expensive!) assessment tools and interventions that are recommended to holistically aid children and families in what is termed “IHBLT” or Intensive Health Behavior Lifestyle Treatment for “obesity.” And to be honest, most of the interventions outlined weren’t terrible. In truth, I can get on board with a lot of them. That said, I’m wondering who is providing or paying for these interventions? And who’s paying for parents to reduce their working hours to allow them time to support such efforts? And who is buying the safe houses, in the safe neighborhoods, with the fresh grocery stores within walking distance? They didn’t have answers for these or other similar questions. They did, however, acknowledge how important it is for providers to be sensitive to these barriers. I appreciate that, but sensitivity is not a solution.

As I continued to read, I wondered a bit more. “Who else is reading this whole thing?” I happened to be sick today, without a voice or the ability to hear out of my left ear. So, I had some extra time. But outside of my fellow cold-sufferers, how many parents and practitioners are reading the guidelines in their entirety? How many, instead, are reading the headlines and listening to the sound bites-- You know, the ones that read “Updated obesity treatment guidelines for children and teens including medications, surgery for some young people” (CNN)?

The guidelines also contained an important section that reviewed the validity assessments of the studies and research used to formulate the guidelines. Below are a few points that I found interesting. These are taken directly from the guidelines (Sections D, E, F from content point #2, Approach)

· "Randomized trials were given a quality assessment using the Cochrane Risk of Bias tool. The Subcommittee decided not to limit studies based on the study quality, because many of them did not reach “high-quality” status (ie, at low risk of bias for most or all domains in the Cochrane Risk of Bias Assessment) using any of the tools."

· "Because of small numbers, the Subcommittee combined randomized and nonrandomized surgical studies. Brief treatment descriptions and BMI-related outcome data were extracted from these, but the Cochrane Risk of Bias tool was not used because these were observational designs."

I am not going to pretend to be an expert in clinical research. For that reason, I welcome further input from anyone more qualified than I. But from what I gather, the validity of much the research used to help create these new “obesity guidelines” for our kids is quite lacking. And I get it! It’s science. It’s medicine. Its human metabolism combined with social, environmental, behavioral, psychological, genetic, and biological components. It is nearly impossible to study such a complex human experience and even more-so to collect real “evidence.”

I ask then, why are we framing these recommendations as “evidenced-based?” Some individuals may be willing to accept interventions that are insufficient in long term outcome studies. Others are likely willing to accept recommendations based on studies whose quality assessment demonstrates a balance of benefit to harm.

But are we being clear about this with our patients? Are we even clear about this within our own clinical understanding? Do we know what the true outcomes are? The consequences? The risks? The costs (financial and otherwise)?

I realize that chronic disease is life-altering. I realize that interventions for diabetes and hypertension are costly. I realize that children with obese BMI’s are at risk of discrimination and oppression and maybe even chronic disease. I do recognize and agree that there is a problem. I also believe it’s our responsibility to find a long-term solution for our children.

However, not only do we not have a reliable solution, we also don’t fully understand the problem yet. And we must stop feigning that we do! What we do know is that the problem is bigger than what we eat and how we exercise. To that end, so must the interventions be.

While many of the interventions proposed by the AAP appear well-meaning and comprehensive. They are equally unrealistic for the vast majority of the people they are intended to serve. And some of the recommendations will surely be considered barbaric and abusive when studied by generations to come. Namely, the recommended use of poorly studied medications and irreversible surgical procedures for our children with high BMIs. My reaction to those recommendations…. those are hard to put into a whisper.

The reality is this. When large organizations like the AAP create guidelines such as these, I’m certain they take great care in the entire process. In fact, it was evident in much of the article contents as they were detailed, thorough, and addressed various important points including mental health and eating disorders. But in today’s world, no one is reading the fine print. They’re reading the headlines and watching the Reels. And the message they’re receiving from the AAP is a dangerous one-- one that endorses strong drugs and risky surgeries for our growing children. We don’t yet know the consequences of all of this. Likewise, I don’t know what exactly my son will be faced with. But I do know that it’s time to “worry.” And it’s time to whisper as loud as we can to protect our children.

About the Author:

Natalie Loschiavo is a registered and licensed dietitian in Pennsylvania and Delaware. She owns a private practice outside of Philadelphia that specializes in working with individuals with eating disorders in addition to many other nutrition-related conditions. Natalie has provided medical nutrition therapy for children, adolescents, adults and families for well over a decade and sits on the board as a medical liaison for the Southwest Philadelphia chapter of the International Association of Eating Disorder Professionals. In addition to her professional career, Natalie is the mother to her 12 month old son, Lincoln, and lives in the suburbs of Philadelphia with her family.

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