advocacy

Association for Size Diversity and Health Statement Re: Academy of American Pediatrics Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity

February 9, 2023

We firmly and unequivocally oppose the Academy of American Pediatrics’ Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Ob*sity. Not only do the guidelines fall short of adequate scientific rigor in interpreting the research base, they worsen medical fatphobia and ultimately degrade the quality of healthcare for fat children, teens, and their families.

It is abundantly clear that the authors of this paper have failed to adequately address their own fatphobia and weight bias and thus are unqualified to author this paper. In failing to do so, they have produced a biased set of recommendations. Worse, they claim to incorporate “non-stigmatising care” and the social determinants of health to improve health equity for Black and brown young people. By co-opting this language, they are putting those most harmed by the medical system at greater risk. There is no non-stigmatizing care in the name of obesity prevention or treatment. This is especially true for children and adolescents who rely on parents, guardians, and healthcare providers for safe and appropriate care.

The ways in which the weight bias of the authors infiltrates the guidelines are many. They include:

• Omitting any discussion on the racist origins of fatphobia and the BMI. Despite several sections discussing the prevalence of higher BMIs among Black and brown people, the connection between racism and fatphobia was completely excluded from the guidelines as well as from their analysis and interpretation of the research. Fatphobia was born out of eugenicist and racist ideas.¹ These racist ideas are then upheld systemically through tools like the BMI and recommendations such as these. This history and how it shaped research and current medical practice is missing entirely from the AAP’s recommendations. Its omission allows for the continuation of harmful, racist, and fatphobic practices.
• Underestimating the impact of weight bias and stigma on health and health outcomes. Not only do they spend a whopping ⅓ of a page on this topic, they fail to recognize it as a risk in nearly every Key Action Statement. More importantly, none of their Key Action Statements call for addressing provider weight bias or systemic racism and fatphobia in the healthcare system. Writing guidelines that acknowledge the social determinants of health and then go on to recommend solely individual solutions worsen care, access to care, and the wellbeing of those most impacted by medical fatphobia while scapegoating fat children and their families for any ailments they develop.
• Failing to consider key ethical considerations underpinning the recommendations. Fat people, and especially fat children, are not responsible for the medical fatphobia of our care providers. Medical providers have an ethical imperative to address their individual weight bias and the systemic barriers affecting fat people in the healthcare system. Fat people, including fat children and adolescents, do not have an ethical imperative to lose weight and participating in pursuing weight loss should never be a requirement to access safe, effective, and non-stigmatizing care.
• Using hyperbolic and sensationalized language. This kind of rhetoric has shown again and again to worsen weight bias in general and in healthcare especially.^2-4 With 68% of the largest fat people avoiding healthcare, the focus in improving the health of fat people must be on creating equitable systems of care.⁵
• Failing to consider alternative and plausible explanations for the correlation between health and weight. The authors double down on weight-biased assumptions with ignorant and harmful interpretations of the research base, often citing studies that were not actually testing the claims they make in their recommendations.
  • For example, on page 2, they open the introduction with the claim that being in a larger body is affecting the current and long-term health of fat children. They cite two articles that measure the prevalence of ob*sity, not whether it causes or is even correlated with disease.
  • The authors frequently cite other recommendation guidelines which are similarly biased instead of original research articles to support their claims and recommendations.
• Repeated conflation of correlation and causation. This should have been stamped out in the first year of grad school. Weight bias allows for this conflation to go unchecked and recommendations based on the inappropriate assumption of causation from the correlation of weight and certain health conditions results in biased and harmful recommendations. It ignores the (very plausible) possibility of reverse causation which is not considered once within their 100-page guidelines.

The guideline’s authors must first address their weight bias before continuing to conduct research or lead development of guidelines related to weight and health. Future research and recommendations by the AAP and all organizations aiming to lead recommendations about health and weight should be held accountable to the public for their weight bias. In addition to specialized training to dismantle racist and fatphobic ideas they hold, authors should take weight bias assessments and make their results known alongside any research or recommendations published.

The AAP’s Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Ob*sity reflect the historical commitment of western and white-centric healthcare to kill all deemed ‘other.’ We call for the AAP to rescind these guidelines in light of the reality that they violate the primary directive of healthcare providers to first do no harm. Our children and adolescents deserve better.

Association for Size Diversity and Health