In January, the American Academy of Pediatrics (AAP) released its first obesity guidance for children and adolescents in 15 years. The AAP’s recommendations are almost entirely focused on weight-related interventions, including aggressive weight loss strategies for children as young as age 2. The new obesity guidelines have come under fire, particularly from mental health and eating disorder experts who say the recommendations put an already vulnerable population at higher risk of disordered eating.

What the AAP obesity guidelines recommend

The first sections of the guidelines acknowledge that weight and overall health are complex and determined by multiple genetic, behavioral, and socioeconomic factors. The authors note that body mass index (BMI) is a flawed health metric that doesn’t account for normal variations in muscle mass, body composition, and bone density or race and sex-related differences. The guidance also acknowledges that children at higher weights face stigma, bullying, and social isolation and are at higher risk of developing eating disorders. Research shows that weight-focused approaches don’t promote weight loss or improve overall health. Instead, they lead to an unhealthy cycle of dieting and weight fluctuations and an increased risk of disordered eating.

The consideration given to these issues makes the AAP’s recommendations all the more surprising. In addition to guidelines for health care providers to evaluate and diagnose obesity in children and adolescents, the guidance makes the following recommendations for children with higher BMIs:

  • Children should receive comprehensive, “non-stigmatizing” weight loss treatment monitored by trained health care professionals with involvement from parents to reduce the risk of disordered eating.
  • Children ages 6 and up should receive at least 26 in-person hours—over a period of three to 12 months—of intensive health behavior and lifestyle treatment (IHBLT), supervised weight loss programs that focus on exercise, nutrition, developing healthy habits, and a supportive home environment. The programs require significant participation from families and are recommended for children as young as age 2.
  • Children ages 12 and up who are classified as “obese” should be offered weight loss drugs, such as metformin, in addition to IHBLT. 
  • Children ages 13 and up who are classified as “severely obese” should be offered weight loss surgery.

The obesity guidelines notes that dieting and other attempts to lose weight without support and supervision negatively impact children’s mental and physical health. Even with supervision, health strategies that focus primarily on weight loss are linked to lower self-esteem, internalized weight stigma, self-isolation, and disordered eating habits that can result in severe, long-lasting health effects. The recommended behavioral weight loss treatments show modest weight loss (between 3.5 and 18 pounds per year in the most intensive programs) that can be maintained in the short term without significant increases in disordered eating behaviors like binging. 

Criticism of the updated guidelines

Unlike the AAP’s past obesity guidelines, which directly addressed mental health and discouraged dieting and medical interventions for children with higher weights, the new guidelines focus on weight and BMI to the exclusion of almost all else. 

“It is very concerning to me that even though the American Academy of Pediatrics acknowledges health as multifactorial, these weight loss guidelines are based solely on weight and BMI,” says Christine Byrne, a registered dietitian who promotes a weight-inclusive approach to health. 

It’s unclear what has changed to warrant such a dramatic shift in recommendations from the AAP, which acknowledges some of BMI’s shortcomings but describes it as “the most appropriate clinical tool to … make the clinical diagnosis of overweight or obesity.” The guidelines state that “there is more evidence than ever” that obesity in children can be safely and effectively treated. But they fail to address that a major risk of “treating” obesity is triggering disordered eating. More than one-fifth of children globally engage in disordered eating behaviors, and children with higher weights are more at risk than other children. Past research also shows a link between dieting and focus on weight and disordered eating in children. Yet the AAP guidelines do not include clear recommendations for eating disorder screening.

Although research analyzing behavioral weight loss programs has found a decreased risk of mental health impacts compared to self-guided diets, the risks still exist. And with little long-term analysis of the programs in children, we have no way of knowing what the mental health outcomes will be for the patients these programs are being recommended to. The recommended programs are not widely available, making the option inaccessible to the vast majority of families. The degree of family involvement may also contribute to the programs’ dropout rates, which are as high as 60 percent among low-income families. 

Given what we know about how weight- and BMI-focused care impacts children and adolescents’ mental health, the guidelines’ focus on BMI is particularly troubling. BMI on its own is not a marker for health, so why is it being used as the definitive metric by which all children’s health is measured? 

The goal of these guidelines is weight loss, first and foremost, with all other outcomes secondary. The idea that care with the ultimate goal of weight loss can be provided in a “non-stigmatizing” way also raises questions. Doctors, including pediatricians, receive little training in weight-inclusive health care. This has resulted in patients of all ages with higher weights reporting discriminatory treatment and subpar care, leading many to avoid seeking medical care. The AAP guidelines could make that worse.

At the heart of the debate over the guidelines is the question of what is most important in pediatric care: weight or health. Are children considered healthy if they weigh less but develop disordered eating from trying to lose weight or maintain weight loss? Are children considered healthy if their BMI is lower but they have severe anxiety about every pound that their developing bodies gain or lose? 

“Weight neutrality is so important for kids and teens because their bodies, identities, and sense of self are still forming,” Byrne says. “Pathologizing their weight is going to have a huge impact on their mental and maybe even their physical health.”