2023 AAP Clinical Practice Guidelines for Child Obesity: A Weight-Neutral Perspective

By Ellyn Satter, MS, MSSW, Dietitian and Family Therapist; Carol Danaher, RDN, MPH; Keira Oseroff, MSW, LCSW, CEDS; Cristen Harris, PhD, RDN, CD, CEDS, CSSD, ACSM-CEP, FAND; Jennifer Harris, RDN, LD, CEDRD-S;  Rebeca Hernández, MS, LD; Peggy Crum, MA, RDN

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In arriving at the Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity, we recognize AAP’s mission to “accelerate progress in prevention and treatment of obesity for all children.”  We also recognize the pressure on the work group to arrive at a standard of care.¹

While we share AAP’s concern, we prefer to understand the problem in a way that it can be solved.

We have found weight-loss intervention to be destructive

As a group of clinicians specialized in child nutrition, we cannot endorse AAP’s recommendations for early diagnosis and intervention and use of weight-loss drugs and bariatric surgery in children as young as 13 years. We speak from our experience of doing weight-loss intervention. We gave it up because it didn’t work and because it made both our patients and us feel defeated, demoralized, and dishonest. Despite their best efforts, our patients could not lose weight and keep it off. It made them miserable to try, contributed to their feeling stigmatized because of their weight, and their so-called “failure” acted as a barrier to their seeking needed medical attention. Despite our best efforts, we could not help them achieve and maintain weight loss, and continuing the struggle was heart-rending and tedious. Trying to change a child’s weight was even worse. Collaborating with parents to impose food restriction on children drove children to sneak, hide, hoard, and prevaricate to get enough to eat. Children rarely lost weight, but they always felt ashamed of their hunger and ashamed of not being able to please their parents. In most cases children gained weight when their food was restricted. But even if the child’s weight stabilized or decreased, the child and family were left with negative feelings and distortions precipitated by the regimen.²

The dieting and weight histories of patients who had been on the receiving end of weight-loss regimens were just as persuasive. Those patients had been nutritionally traumatized.³ Adolescents and adults whose weight had been an issue from early on presented to us as conflicted, anxious, and guilt-ridden about their eating, hating their bodies, and having great difficulty doing self-care. They could no longer diet, they didn’t know how to eat, and their weights were unstable. The greater the number of “helpers” and the more extreme the methods, the worse the outcome.

The literature does not support weight-loss intervention

We did an independent review of the literature and, based on our findings, set aside our weight-loss agenda.

There is no increased risk for “large” infants during early childhood. We found that most unusually heavy infants slimmed down by age seven years, and that most children who went on to have a high BMI were not unusually heavy as infants.⁴ Infants who ate often and grew rapidly tended to be weaned earlier from the breast. Those same infants were taller and had higher lean body mass at 7-8 years but were not fatter.⁵

Children grow predictably based on their genetic endowment. In 7978 two- to 15-year-old parent-child pairs, thinness (<18.5 BMI) reflected parent thinness.⁶ In 20,554 parent-child pairs, child fatness from age 3 to 17 years reflected parent mating combinations.⁷ Longitudinal study of 7625 3-15 y/o Dutch, Turkish, Moroccan and South Asian living in the Netherlands showed Turkish children to have the highest and south Asian children to have the lowest BMI z-scores at every age.⁸

Claims about the health consequences of child obesity/overweight are exaggerated. In nine year-olds studied 50 years later, there was no excess adult health risk from childhood or teenage “overweight.”⁹ In 9 to 23-year-old males studied 35-40 years later, those who stayed overweight since childhood showed no greater adult levels of fasting blood sugar, serum cholesterol, beta-lipoprotein, blood pressure, or cardiovascular renal disease. Children who were underweight and those who became overweight as adults showed more-distorted metabolic parameters.¹⁰ In a meta analysis of 37 studies, childhood “obesity” was associated with moderately increased risks of adult “obesity”-related morbidity, but the increase in risk was not large enough for childhood BMI to be a good predictor of the incidence of adult morbidities. The majority of adult “obesity”-related morbidity occurred in adults who were of “healthy” weight in childhood.¹¹

Weight loss impairs mental health and nutritional and status. Young Swedish “obese” adults who had undergone obesity treatment as children and adolescents had a 3 times higher risk of all-cause mortality in early adulthood compared with a population-based control group. Most deaths were from suicide and self-harm.¹² Children on weight-loss interventions lost bone mass.¹³ Parenthetically, mineral content is higher in “obese” children than in “normal weight” peers.¹⁴ While we couldn’t find studies on child weight loss and lean body mass, adults who lost weight with or without endurance exercise lost lean body mass.¹⁵

Weight-loss intervention does not work. In a review of 15 articles of adequate scientific rigor abstracted from 369 inadequate studies, only multidisciplinary child weight interventions, 36 to 98 contact hours, had significant BMI change: +0.1 to -1.7.¹⁶ In a more recent review of 59/450 trials, only multidisciplinary child weight interventions, 52 to 114 contact hours showed absolute reductions in BMI z score of 0.20 (- 2 to 4 lb or -1 to 2 Kg).¹⁷

Diagnosing “obesity/overweight” is obesogenic. Children gain more weight over time when parents perceive their child’s weight as too high. Two-year-old children from the Netherlands whose parents identified their child as “overweight” had a higher BMIz at 5 years and were more likely to maintain this higher weight at age 10 years.¹⁸ 3557 four-year-old Australian children perceived by their parents as “overweight” as opposed to “about the right weight” had a greater increase in BMI between four and 13 years old. This finding did not depend on the actual weight of the child.¹⁹ Parents who worried about their child’s weight and saw their young child as being food-preoccupied were likely to restrict.²⁰ Restriction made children food-preoccupied, prone to eat more when they got a chance, and fatter, not thinner.^21-23

Do excellent feeding and then trust the child to grow

Instead of diagnosis and conventional intervention in the form of dietary restriction, we recommend doing an excellent job with feeding from birth following the practices outlined below. Those practices are operationalized by the Satter Division of Responsibility in Feeding (sDOR).^24-26

• Accept children’s consistent BMI at any level as appropriate for them, even if it is above the 85th or even the 95th percentile.²⁷
• Support children in following their consistent growth trajectory: growing up to have bodies that are consistent with their genetic predispositions for food intake, activity, and growth.^6-8
• Join with parents in supporting/teaching positive feeding dynamics: healthful practices that support parent leadership in providing structure and routines in family life.²⁸
• Support neutral food exposure food to allow children to learn to eat and enjoy a variety of food.^{29, 30}
• Respect children’s considerable regulatory abilities to guide how much they eat.³¹
• Support children in discovering joyful activity that is right for them.³²
• Investigate weight/growth that diverges from a consistent pattern and do feeding-dynamics-based treatment.³³
• Support children in accepting their and others’ genetic endowment with respect to growth^{7, 8, 34} and being all they can be, whatever their weight.³⁵

Summary

We agree with AAP that regularly assessing children’s growth is important. However, we recommend supporting children’s consistent growth by teaching parents to do an excellent job with feeding. sDOR guides parents in taking appropriate leadership with feeding and giving children appropriate autonomy with eating, without attempting to influence food selection or energy regulation. An essential part of teaching sDOR is helping parents to understand their child’s typical patterns of eating and growing. When parents follow sDOR, children have lower nutritional risk,³⁶ and clinical observation shows that their weight acceleration levels off. With the recent validation of sDOR.2-6y,^{24, 36, 37} we can now test those clinical observations.