Wait! There is more to weigh in the conversation about weight.

We live with constant and extreme pressure to change our bodies.  This year, however, has seen not just the typical grifters seeking to profit off of insecurity, but the medical community has joined in as well.

On January 9^th of this year the American Academy of Pediatrics (AAP) put out new guidelines for the “Evaluation and Treatment of Children and Adolescents with Obesity.”¹ In these guidelines the AAP recommends children as young as 2 years old be given “intensive health behavior and lifestyle treatment” programs.¹ They recommend weight loss medication for children as young as 12 and weight loss surgery for children as young as 13. As Virginia Sole-Smith states, “The paper’s authors see this new guidance as a brave leap forward in the fight against childhood obesity, which they frame as a “complex and often persistent disease” requiring early and aggressive treatment. But the guidelines are rooted in a premise that should have been rejected long ago: that weight loss is the best path to health and happiness.”²

Then on January 25^th a study was published by Adams, et al that outlines better health outcomes for people who participate in bariatric surgery.

My local news outlet, KSL, covered the new study in an article that made it sound like anyone living in a large body would be foolish to opt out of such a lifesaving surgery.³ However, I would like to propose that there is more nuance to this topic than is being presented.

For decades we have heard about “The War on Obesity” and have likely given it little critical thought. There is a growing Fat Activist movement that opposes both the word “obese” and the fact that we are warring against bodies that have always existed. The movement is fighting for the dignity and rights of all people: fat people, disabled people, black people, people of color, trans people, and LGBTQIA+ people. The word “obese” is seen as a slur. For that reason, I will use the terms fat (as reclaimed by this movement as a neutral body descriptor) or large bodied unless specifically addressing research.

What is almost never discussed when we talk about size is the nuance and reasons why someone may be in a larger body. We maintain that if someone had enough willpower they could change their size.

Recently, Heather Hogan, a senior editor of Autostraddle responded to a reader’s question with the following,

“While I’m hearing that you’ve encouraged your girlfriend to eat healthier and go to the gym, I’m not hearing anything about the zillion other factors that go into determining a person’s weight. Like genetics, age, hormones, family history, metabolism, mental health, stress, social pressure, medications, her relationship to her past traumas or abuses or neglects, her history with food and exercise, the messages she internalized about those things growing up, whether or not she’s a perfectionist, what demands are on her life and time and body outside of “diet and exercise,” what her financial situation is, whether or not she has any food aversions or sensitivities, how the pandemic has affected her. I could go on and on. I could ask a billion more questions about your girlfriend. Because a person’s weight is almost never about their willpower to eat vegetables and sweat it out on a stationary bike; it’s a tangled, mangled knot of physical, mental, financial, emotional, and social factors that is almost impossible to unravel.”⁴

The topic of body size and health is complex. Yet, we tend to look down our noses at those who cannot achieve thinness, never stopping to consider if our assumptions are accurate or even helpful.

Other writers who are much more talented and knowledgeable than I am have written at length on why measures such as the BMI are flawed. They have written about the racist origins of weight stigma. They have addressed why size alone is a poor measurement of our health.

As a clinical nutritionist who specializes in helping people with eating disorders, I understand that the decision to have weight loss surgery is complex. I do not seek to judge or condemn anyone for the decisions they have made to survive in a world that was not made for those of us in large bodies. I have listened to people explain that in order to get proper medical treatment for matters unrelated to their size they were pressured to get weight loss surgery before other treatment would be offered. While there may be a time and a place for extreme weight interventions, I’d like to add a little nuance to this conversation.

I want to share a handful of stories today in the hopes that you may understand that offering weight loss advice or assuming all people who refuse bariatric surgery are ignorant is perpetuating harm. Aubrey Gordon recently wrote in her excellent book “You Just Need to Lose Weight” and 19 Other Myths About Fat People, “researchers have long known that facts don’t change our position on social issues—human stories do.”⁵

Meet Jake:

Jake sits in my office after a recent doctor’s visit. I send all my clients to their primary care physicians to get basic blood work once we start working together. It helps me understand their nutritional status.

Jake explains that he told the doctor he was working with a nutritionist for his eating disorder and that we needed some basic lab values to make sure he was safe to continue outpatient care. Jake is in a larger body.

The doctor agreed to the lab values. Addressed some other medical concerns that Jake brought up, and then told him that next time they could discuss weight loss medication.

As Jake and I discuss this experience he explains to me that he never brought up his weight with the doctor. He didn’t want to discuss it as it wasn’t related to his present concerns. In fact, because of his history with an eating disorder, discussing weight makes it much harder for him to recover.

Jake has Atypical Anorexia. Which meets all the same criteria as a diagnosis of Anorexia Nervosa, but with the distinction that he is not in an underweight body. The word, “atypical” is misleading. Less than 6% of people who are diagnosed with an eating disorder are underweight.⁶

Jake’s eating disorder started when he was 7 year’s old after a doctor told him he was bigger than other kids his age. He started restricting food more and more. Jake recalls that nearly every time he visited a doctor as a kid he was told he needed to eat less. During his teen years Jake was eating less than a full meal each day. Yet, pressure from family, friends, and his doctors continued. He felt humiliated with every visit to the doctor as the doctor repeatedly told him he needed to eat less.

I asked Jake during one of our sessions, “did any of your doctors ever ask you what you were actually eating?” He responds, “no. They just told me to eat less.” All through his teen years he was consuming less food than a toddler needs to grow and develop.

The sad reality for many eating disorder sufferers is that even when they speak up and share how little they eat they are not believed. People in large bodies are often dismissed when they seek help or share their lived experiences.

“Leslie Schilling, MS, RDN, CED-S […] took to Twitter on January 11 to share her thoughts: “in my twenty+ years as a registered dietitian/nutrition therapist, I have NEVER met an adult that found weight loss interventions/advice from their childhood pediatrician helpful. It almost always results in harm, also known as eating disorder.”⁷

My experience as a clinician mirrors that of Schillings. My clients often tell stories of how humiliating and traumatizing it was to go the pediatrician knowing they would be blamed for something out of their control.

Meet Suzie

During my first conversation with Suzie she explained to me that she had recently been to see her doctor to help her manage some medications. The doctor ran some routine labs and found that Suzie’s cholesterol was elevated slightly. She explained to me that during that conversation the doctor advised her to seriously reduce her calorie intake. She told the doctor she had a history of anorexia nervosa. Yet the doctor continued to insist she needed to engage in calorie restriction, leading her to believe if she did not she would soon die of a heart attack. She was in her early 20s at the time.

By the time we started working together she had fully relapsed into her eating disorder. From her perspective, the doctor didn’t consider her at risk for an eating disorder since she was in an average sized body. It has taken her nearly 2 years of hard work to get to an almost stable place with her mental health.

The recommendations by the AAP and by Adams, et al. fails to mention how these interventions impact mental health. “There is considerable evidence that the focus on weight and weight loss is linked to diminished health.”⁸  This is, in part, attributed to the impact on mental health.

Dieting evolves into an eating disorder for 1 in 4 dieters.⁹ Even for those who do not progress to an eating disorder, many will continue to struggle with a disordered relationship with food and their body for years, seriously impacting quality of life.

What the Adams, et.al.  study and the recommendations by the AAP fail to acknowledge is that often people in larger bodies have been dieting and trying to lose weight for long periods of time. The outcome has been increased weight. Studies show that the most likely outcome of intentional weight loss attempts is weight gain for up to 95% of the population.¹⁰

 This history with dieting has led many to have eating disorders and other complicated mental health issues. Eating disorders are the second deadliest mental health illness, second only to opioid addiction.¹¹

Meet Amanda

Bariatric surgery is often presented as the solution to all of the problems faced by fat people. Amanda thought that would be the case for her only to find that was very inaccurate. Amanda had an eating disorder prior to her surgery. She had undergone treatment multiple times and found treatment very biased towards people in large bodies. She often felt isolated and that her recovery was tainted by unhelpful messages about her size.

Despite not being in recovered from her eating disorder, Amanda got approved for bariatric surgery. After surgery she experienced some modest weight loss and quite a few negative side-effects such as dumping syndrome (a condition where the body quickly eliminates anything ingested). When Amanda spoke with her physician after the surgery they checked to make sure nothing had gone wrong with the surgical site. When all of the tests came back normal Amanda was told she was the problem.

Amanda cries in my office as she explains that she feels her medical team has written her off as a failure. She feels that because she didn’t lose the amount of weight they hoped for she is being blamed, and is no longer welcome to seek medical care from her medical team.

Meanwhile, her eating disorder is once again wreaking havoc on her mental and physical health, because what she really needed treatment for wasn’t her weight, it was her eating disorder all along. In addition, she is experiencing trouble with substance abuse post surgery. This is a common, yet rarely talked about, side-effect of bariatric surgery.

The Adams, et al study and the AAP recommendations mention that weight is nuanced and influenced by a myriad of things. Not the least of which is trauma. This small sample of stories clearly illustrates that trauma is happening not just out in public, but among our healthcare providers.

I recognize that not all physicians cause harm and that those who do may be unaware and really are doing their best. Yet, it is a nearly universal experience among fat people to be shamed, denied care, and/or treated poorly at their physician’s office.

Weight stigma is briefly mentioned in the AAP recommendations, but their solution isn’t to address the stigma, it is to put the responsibility back on the stigmatized person by demanding they lose weight and offering treatments that are known to have dangerous consequences.

LaMotte writes, “ One alarming finding [in a recent study] was a 2.4% increase in deaths by suicide, primarily among people who had bariatric surgery between the ages of 18 and 34.”³

Please explain how lowering the age to 13 is going to help children when we know that rates of suicide go up the younger the surgery is performed. Additionally, the rates of eating disorders are on the rise since the Covid-19 pandemic.¹² With a 100% increase in hospitalizations of adolescents with eating disorders.¹³

It is important to note, the researchers of the Adams, et al study did not look into how weight stigma impacts the outcomes of people in large bodies. It is possible that people who have had bariatric surgery are able to access medical care that people who chose not to engage in a surgery with known dangerous side-effects cannot get access to.

It is difficult to know what the actual health outcomes of fat people are because we do not live in a world where fat people get the same medical care. Additionally, fat people face prejudice and stigma no matter where they are. They may get removed from airplanes because a thin person complains and may or may not receive a refund. They may not be able to find seating in public places. They are always the butt of jokes and are portrayed as unintelligent and lazy in the media. Fat people are unable to get jobs or are paid less than thin coworkers for the same work. Fat people are often yelled at while going about normal daily activities. They are treated poorly in nearly all situations. It is impossible to know if health outcomes for those who have bariatric surgery are better because of the surgery, or better because they escape the intense stress and trauma that weight stigma causes.

Based on this and the actual lived experience of fat people it is clear that weight loss, particularly by invasive means, is not a clear cut option and may only reduce health risks by reducing the stigma faced by those who opt for surgery.

There are actual consequences of the surgery, not the least of which is malnutrition. The AAP recommending these extreme interventions when children’s bodies are developing and at their greatest need for nutrients is a blatant example that we prize size over health.

In addition, the AAP guidelines reinforce weight bias by outlining the best ways for children and adolescents to achieve weight loss. In response to these harmful guidelines CEDO (Collaborative of Eating Disorders Organizations) wrote, “To assume that those in larger bodies should accept the health risks associated with weight loss treatment (i.e., GLP-1 agonists and/or surgery) is evidence of the damaging weight stigma that is pervasive in “obesity” prevention and treatment efforts.”¹³

I join my voice to the hundreds of eating disorder professionals in pointing out that weight loss at the expense of mental and possibly physical health is not worth the risk.

“We stand firmly against the new [AAP guidelines]. The statements made throughout these guidelines are problematic at best, and at worst, put American children and adolescents at serious risk for developing eating disorders, disordered eating, and other mental and physical health issues.”¹⁴

It may be tempting to excuse all the nay-sayers when you consider that the AAP recommendations were made by doctors. People with substantial training.

“Weight-inclusive researcher and activist Regan Chastain also reacted to the guidelines. In one article, she focused on “red flags” related to conflicts of interest: ‘…you might not guess that, of the 14 authors who are medical doctors, eight have taken money from companies that are developing or sell weight loss products that either directly benefit, or may benefit from these recommendations either through the development of a new drug, or approval of an existing drug for adolescents.’”7

In my work as a clinical nutritionist I have sat with so many clients who have been directly harmed by weight stigma that started in a doctor’s office, and I would like to propose that asking people to continue weight loss attempts and to do so by more extreme measures is causing harm and is not the answer. Putting this same pressure on younger and younger children will lead to devastating consequences. If we want to help fat people have better health outcomes, we need to address the weight stigma that is endemic in every facet of our lives.

Addressing Weight Stigma

It is important that we each do our own individual work to address our own prejudices. We have all grown up in a culture that worships the thin ideal; therefore, we all need to unlearn our prejudices toward fat people. Here are some practical tips to help you address your own weight bias.

1. If you feel the need to comment on what someone is eating or to share your diet tips with another person…don’t.
2. Stop complimenting weight loss. It sends a clear message that we only value one thing about a person…their weight.
3. Stop commenting on other people’s bodies in general. Even off-hand comments you think may be harmless may be causing harm to the listener.
4. Ensure you have size inclusive furniture in public spaces and offices. This includes chairs without arm rests and pieces of furniture meant to hold all sizes of bodies.
5. If you hear comments being made about someone or to someone intervene on that person’s behalf.
6. Offer to accompany fat friend’s to medical appointments. Having another person in the room (particularly a person who has thin privilege) can help the outcomes of the appointment.
7. Believe your fat friends when they tell you about their experiences that have caused them harm. Validate them. Do not try to justify the actions that caused them harm.
8. Do some reading to unpack your own biases. Below are some excellent resources to do just that.
   1. “You Just Need To Lose Weight” and 19 Other Myths About Fat People by Aubrey Gordon
   2. What We Don’t Talk About When We Talk About Fat by Aubrey Gordon
   3. Fearing the Black Body: The Racial Origins of Fatphobia by Sabrina Strings
   4. Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness by Da’Shaun L. Harrison
   5. Heavy: An American Memoir by Kiese Laymon
   6. More resources at: https://therepproject.org/fat-activism-information-resources/

These are small steps that can gradually move us closer to a kinder world. Our current solutions to weight bias ask the people being stigmatized and mistreated to change so we don’t have to be cruel anymore. However, size is much less in our control than we have been led to believe. Rather than blaming the victims, we can all make small changes to our own behavior to help victims feel safe, receive appropriate medical care, and get fair treatment. People deserve dignity and respect. No matter what their body looks like.

References:

1. Hampl S, Hassink S, Skinner A, et al. “Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents With Obesity.” Pediatrics. Vol 151; 2 (2023). https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the-Evaluation-and?autologincheck=redirected

2. Sole-Smith, Virgina. “Why the New Obesity Guidelines for Kids Terrify Me.” ProQuest (2023): doi:2769530341.

3. LaMotte, Sandra. “Weight-loss sugery extends lives, Utah study finds.” January 28, 2023; https://www.ksl.com/article/50567262/weight-loss-surgery-extends-lives-utah-study-finds

4. Hogan, Healther. “You Need Help: You Fat-Shamed Your Beautiful Girlfriend.” Autostraddle; January 17, 2023. https://www.autostraddle.com/you-fat-shamed-your-beautiful-girlfriend/?fbclid=IwAR0y2pY-lcXJZ_n5DUzB63nhC9lGfSRZIN1wltptfc0BpC9mo-OmO_jJ4bs

5. Gordon, Aubrey. “You Just Need To Lose Weight” and 19 Other Myths About Fat People. Boston, MA, Beacon Press, 2023.

6. Flament, M., Henderson, K., Buchholz, A., Obeid, N., Nguyen, H., Birmingham, M., Goldfield, G. (2015). Weight Status and DSM-5 Diagnoses of Eating Disorders in Adolescents From the Community. Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 54, Issue 5, 403-411. https://www.jaacap.org/article/S0890-8567(15)00076-3/fulltext#relatedArticles

7. Young, Caroline. “As an Eating Disorder Counselor, I Fear the AAP Guidelines on Childhood ‘Obesity’ Will Cause Major Harm.” Good Housekeeping, January 28, 2023. https://www.goodhousekeeping.com/health/a42620426/aap-obesity-guidelines-2023/

8. Tylka, Tracy L et al. “The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss.” Journal of obesity vol. 2014 (2014): 983495. doi:10.1155/2014/983495

9. Brooks S, Severson A.How to Raise an Intuitive Eater. New York, NY, St. Martin’s Essentials, 2022.

10. Tribole E, Resch E. The Intuitive Eating Workbook. Oakland, CA, New Harbinger Publication, Inc., 2017.

11. Reynolds K, Reese J, Lucrezia S. “Eating Disorder Facts.” Johns Hopkins All Children’s Hospital. https://www.hopkinsallchildrens.org/Services/Pediatric-and-Adolescent-Medicine/Adolescent-and-Young-Adult-Specialty-Clinic/Eating-Disorders/Eating-Disorder-Facts

12. 12. Gao Y, Bagheri N, Furuya-Kanamori L. Has the COVID-19 pandemic lockdown worsened eating disorders symptoms among patients with eating disorders? A systematic review. Z Gesundh Wiss. 2022;30(11):2743-2752. doi: 10.1007/s10389-022-01704-4. Epub 2022 Mar 29. PMID: 35369670; PMCID: PMC8961480.

13. Otto AK, Jary JM, Sturza J, Miller CA, Prohaska N, Bravender T, Van Huysse J. Medical Admissions Among Adolescents With Eating Disorders During the COVID-19 Pandemic. Pediatrics. 2021 Oct;148(4):e2021052201. doi: 10.1542/peds.2021-052201. Epub 2021 Jul 8. Erratum in: Pediatrics. 2022 Jan 1;149(1): PMID: 34244452.

14. Collaborative of Eating Disorder Organizations. “Response to American Academy of Pediatrics’ Guidelines.” CEDO. January 13, 2023.https://cedo.my.canva.site