This past January, the American Academy of Pediatrics (AAP) released its first comprehensive guidelines for evaluating and treating children and adolescents with “obesity.” These guidelines recommend: (1) referring “obese” or “overweight” children as young as two years old to intensive health behavior and lifestyle treatment programs, (2) prescribing weight-loss medications to “obese” children ages twelve and up, and (3) referring children over thirteen with “severe obesity” to a bariatric surgery center.  

These recommendations are ethically problematic for several reasons. These reasons have a central feature in common: they challenge the AAP’s self-proclaimed aim of reducing threats to children’s current and future health. Despite these concerns, many of which are mentioned in the guidelines, the subcommittee members still believe “treatment can be successful” and should be pursued in certain cases. This indicates that the Academy believes the risks that obesity poses to health outweigh the risks associated with these ethical concerns. 

1. Implicit Biases Among Healthcare Providers

These guidelines are primarily intended to advise pediatricians and other primary healthcare providers (PHCP) on what actions to take if their patients are overweight or obese. Doctors, however, are susceptible, like the rest of us, to biases and human error. Weight bias is particularly common among doctors, even those specializing in nutrition or obesity. Doctors who simply give standard medical advice for weight loss are often unintentionally complicit in contributing to weight stigma. If education does not improve weight bias, how are doctors expected to provide appropriate advice or treatment to children who are in most need of help? 

There is also the problem of how this bias negatively affects the quality of care that overweight patients receive. For instance, overweight patients often get misdiagnosed or undiagnosed due to PHCP assumptions about the cause of their patient’s ailment and their behaviors. It is presumed that any ailments in larger bodies are caused by obesity, which itself results from poor diet and a lack of exercise. These assumptions often lead to prolonged suffering related not only to the ailment that brought them to the doctor’s office in the first place but also the physical and psychological harm associated with weight stigma. 

2. The Effects of Weight Stigma on Health

Assumptions about obesity (e.g., a body that is “obese” is diseased) and people who have it (e.g., they don’t eat healthy and/or exercise enough) run rampant and result in stigmatization (e.g., obese people are lazy, untrustworthy, lack self-discipline, etc.). Weight stigma is known to contribute significantly to psychological stress because it further contributes to the shame and self-blame that many children in larger bodies experience. Unfortunately, the reality is that children in larger bodies experience weight stigma at a very young age and has been shown to have significant negative effects on a child’s school performance. While peers may more explicitly tease and bully children in larger bodies, teachers also have negative perceptions of these children (e.g., as lazy, untidy). So, not only does stigma have an emotional and physical influence on children, but it negatively affects their ability to succeed. 

Though some believe that fat shaming would aid efforts to reduce the prevalence of obesity, research has shown that shame actually increases the likelihood of unhealthy eating behaviors (e.g., binge eating, food restriction), avoidance of physical activity, and poorer outcomes in weight loss treatment. For example, shame often leads to yo-yo dieting and disordered relationships with food and exercise, both of which often result in weight gain and poor health. The growing rate at which children are developing eating disorders must be weighed when deliberating about how to improve children’s health. 

3. The Myth of Long-Term Intentional Weight-Loss

Even modest weight loss has been associated with significant improvements in cardiovascular health. However, this information must be weighed against studies that suggest efforts to lose weight via changes in diet and exercise routines rarely result in long-term weight loss, and that such efforts actually predict weight gain and may negatively affect health and well-being. This information holds true for pediatric obesity interventions. 

One question that should be asked is whether these improvements in cardiovascular health that are trying to be achieved through weight-loss can be achieved through reducing the prevalence of weight stigma instead.

4. Parental Blame

Behavioral models of obesity in children have focused mostly on the social environment of the family. It is common for people to criticize parents of overweight or obese children because “obesity” is presumably a sign of negligent parents who are unconcerned about their children’s well-being. These types of assumptions have led to cases where children are taken from their parents and placed in foster care. 

Mothers, in particular, receive the most criticism for their children’s weight. Pregnant mothers are being held to higher standards of responsibility for their children’s body size by being pressured to breastfeed, eat/exercise in a particular way, and avoid gaining too much weight while pregnant. Yet there are numerous problems with “mother blaming”, ignoring the role that food insecurity and the stress of poverty plays in obesity. This complication with mother blaming demonstrates why individual solutions are not what’s called for but rather, societal changes.

What can be implied from the AAP’s recommendations is that the risks of obesity outweigh the risks associated with weight stigma and the shame, blame, anxiety/depression, eating disorders, etc. that often accompany weight-related biases and stigma. Moreover, the risks associated with weight stigma should be taken even if intentional weight loss is rarely maintained. Despite the fact that “there is still so much we have yet to discover” about obesity, the AAP still clings to the idea that “obesity treatment can be successful,” and this chance of success is enough to justify harmful recommendations. However, if the medical community continues to frame obesity as a preventable or curable health risk and expects people to take such extreme measures to avoid it, public health will not improve, and we will become increasingly less tolerant of larger bodies.

Kayla R. Mehl is a Ph.D. Candidate at the University of Washington.