The Academy for Eating Disorders (AED) has issued a statement on the American Academy of Pediatrics’ (AAP) 2023 “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity”1 (hereafter referred to as “AAP Guideline”).
The mission of the AED is to advance eating disorder prevention, education, treatment, and research by expanding the global community of committed professionals. We are concerned that the 2023 AAP Guideline—which represents a major shift in perspective from the AAP’s previous 2016 recommendations2—has the potential for iatrogenic effects. In line with the Hippocratic oath of first, do no harm, the AED urges the AAP to revise their Guideline with input from key stakeholders including eating disorder professionals and individuals/families with lived experience in higher-weight bodies.
We have three primary concerns:
First, the AAP Guideline makes only minimal reference to eating disorder screening and treatment referral. Eating disorders are potentially lethal illnesses that occur across the weight spectrum and individuals of higher weight are at especially high risk.3 Early detection and treatment of eating disorders is a vital component of successful recovery,4 and the AAP Guideline includes a very limited plan for identifying new and emerging cases. Further, although the AAP guideline mentions screening, it offers no clear course of action for healthcare providers to take if an eating disorder is suspected or identified.
Second, although pediatricians are advised to approach the topic of weight with sensitivity, we are concerned that traditional medical training minimally equips healthcare providers with these skills. Since experiencing weight discrimination is associated with internalized weight stigma and poor mental health outcomes,5 we are concerned that an explicit focus on weight loss could have iatrogenic effects on some individuals, and given limited data on eating disorder risk factors,6 it will be difficult to predict which ones. Further, despite positioning weight-related health within a broader framework of social determinants, the AAP Guideline recommends many individual-level changes (e.g., pharmacological treatment, bariatric surgery) rather than structural changes (e.g., changes in food policy, amelioration of food insecurity, reduction of stigma), which may reinforce the blaming and shaming of individuals in higher-weight bodies.7
Finally, we have concerns about the long-term efficacy and safety profile of medications being recommended for children as young as eight years old, and surgical interventions being recommended for adolescents as young as 13. Long-term outcomes data on the recommended pharmacological interventions are limited in pediatric populations. Moreover, there is evidence that eating disorders can and do emerge after weight-loss surgery.8,9 Lastly, we wonder about the independence of the AAP recommendations given the financial reliance on pharmaceutical companies that is often required to investigate medication efficacy.
Overall, the AED strongly suggests that the AAP Guidelines be revised with input from key stakeholders including eating disorder professionals and individuals/families with lived experience in higher-weight bodies to incorporate more fully eating disorder screening and referral; mitigation of weight stigma in the pediatric setting; and the limited data on efficacy and side effects of pharmacological and surgical interventions in youth.
