It’s a scene you might expect taking your child to a doctor’s office. You fill out some forms and enter a room. Then temperature, blood pressure, height, weight, and a quick chat with the doctor before you head out. But what if the next time you went to see your pediatrician, you didn’t just leave with a sticker — but diet pills

It’s a fear that many parents have expressed in the wake of the American Academy of Pediatrics releasing its first major guideline on treating childhood obesity in almost 15 years. The 70-plus-page document, published earlier this month, completely revamped the current best practices for pediatricians treating obesity — using dozens of methodologies and a detailed emphasis on the “socioecological, environmental, and genetic influences” that can increase a child’s risk of obesity. But it’s a small suggestion on the fourth page that has sparked a firestorm over the best way to treat childhood obesity: giving kids as young as 14 weight loss meds or surgery. 

Most physicians celebrated the new guidelines as a welcome step in preventing adult obesity. But the Academy has received major backlash over the suggestion that children should be allowed such intense medical intervention while their bodies are still growing. On social media, hundreds of parents and mental health professionals have expressed concern about the long-term mental and physical effects of such treatments and the capability of providers to consistently provide a detailed level of care across the board. Rolling Stone spoke to experts who say the guidelines will allow pediatricians to talk to their patients about obesity without stigma, but other mental health advocates say the new guidelines will target childhood obesity at the expense of kids’ future well-being. 

“These guidelines take the first step to message that obesity should be considered a chronic disease”

Doctors have defended the guidelines for their focus on destigmatizing obesity and encouraging care that addresses lack of access to nutrition, emotional support, systemic challenges, and genetics more than dropping pounds. Dr. Raquel Hernandez, the director of the Center for Pediatric Health Equity Research at Johns Hopkins All Children’s Hospital, calls the new guidelines a “long overdue” start in addressing stigma and past inequities in obesity treatment.

“These guidelines take the first step to message that obesity should be considered a chronic disease and that pediatricians should take the same approach that they take for other common conditions like asthma and diabetes,” she tells Rolling Stone. “The choice of treatments, medications, and surgery are options. And a lot of people are getting caught up on the medication and surgery but if you read the guidelines, that is only for kids who meet certain criteria.” 

According to Dr. Edith Bracho-Sanchez, a pediatrician at New York-Presbyterian and Columbia University Irving Medical Center, previous guidelines told pediatricians to adopt a “watch and wait” method when caring for children with obesity, which limited potentially helpful interventions. Now, she says, the new instructions encourage pediatricians to directly address chronic health issues in a comprehensive and sensitive way.

“They’re really offering a number of options, one of which is weight loss medication and surgery. But I think some of the coverage has focused on that out of context and the big picture has been missed,” Sanchez says. “It’s scary for parents out of context to be told that they’re gonna go to the doctor and their child’s gonna be put on medication and sent to have surgery.”

A large portion of the backlash has centered around the idea that kids who need time to grow, or are simply just bigger, will be pushed to take weight loss medications — and potentially develop eating disorders when handled poorly. In the United States, clinical practice guidelines are used as a general way for physicians to agree on a standard of care, so while the new additions from the Academy of Pediatrics recommend the most helpful ways to speak to kids about weight, they do nothing to enforce them. 

“There has to be a multi-level approach here,” Dr. Hernandez says. “Training around patient-centered language and things like weight bias. Those are things that, unfortunately, are not offered in pediatric residency, even though I pull my hair out to try to do that across the country. This is not something that the best provider in the clinic is going to be able to do overnight. So, accessible training for providers needs to be forthcoming and married to these guidelines.”

Another concern is that the new guidelines use outdated methods like Body Mass Index (BMI) to determine which children need intervention. BMI, which is calculated by dividing a person’s weight by their height, has been criticized in medical circles for its inability to accurately take into account physical outliers, says Dr. Mitchell A. Lazar, director of the Institute for Diabetes, Obesity, and Metabolism at the University of Pennsylvania. 

“People who are highly muscular can end up having a high BMI based on this weight measurement,” he says.  “But to defend it, I would say it’s relatively simple to do and it’s certainly a lot less expensive than if you did a sophisticated MRI test.”

But the biggest sticking point in the guidelines remains the medical intervention aspect. While the guidelines are clear that pills and surgery aren’t necessary for most children, they do advocate for weight-loss medications or bariatric surgeries like gastric sleeve or bypass in severe cases. While post-surgery risks can be minimized, they aren’t non-existent. And even the Academy acknowledges that a major risk of gastric bypass can leave a person unable to absorb nutrients correctly or dependent on years of medical follow-ups. However, Dr. Hernandez says that in cases where a child is in need of such treatment, telling children to use diet and exercise to alleviate weight gain caused by genetics or imbalances does them a disservice. And for kids who don’t need medicine or surgery, the guidelines encourage doctors to deemphasize the number on the scale and focus on general health goals. 

“You can see in the guidelines, there’s no emphasis on having that number of a scale change as the immediate goal,” Hernandez adds. “In fact, for so many kids, our first goals are something called non-scale victories, which can mean: ‘You have more energy, you feel better about yourself. Great job. Let’s keep going.’ The myth I think that’s going to come up is that this is going to cause an eating disorder. In my opinion, that myth has landed us exactly in this epidemic, because we can’t talk about it.”

“Behavior modifications or weight loss programs for children come at a really high cost”

But according to several mental health experts, pediatricians talking about weight is exactly the problem. Shira Rosenbluth, a licensed clinical social worker focused on eating disorder recovery, says that even pediatricians with the best intentions can send struggling kids into a mental health spiral by discussing a need to lose weight or get healthier. And put in the hands of the wrong doctor, Rosenbluth calls harm “inevitable.”

“As a therapist, I think probably half of my current caseload right now are clients that were triggered by their pediatrician,” she tells Rolling Stone. “Behavior modifications or weight loss programs for children come at a really high cost. The majority of pediatricians don’t know how to look out for disordered eating. And [kids] show up in my office six months to a year later in really scary shape.” 

Christine Byrne, a dietitian who specializes in eating disorders, tells Rolling Stone that the new guidelines might put added pressure on parents to see their child’s changing weight as an illness that needs immediate attention. But for those concerned about their children potentially receiving the detrimental mixed messaging about body image, Byrne says parents should be more proactive about advocating for their children — even if it means going against the medical advice in front of them. 

“I’m kind of still shocked by it, but I think this will further the need for parents advocate for their own kid and say ‘Do not talk to my kid about weight or BMI or weight loss drugs or weight loss surgery or anything like that,’” Byrne says. 

According to every expert who spoke to Rolling Stone, the Academy’s new direction proves how we talk about childhood obesity is evolving. But changes considered progress by the medical community have continued to bump against society’s slowly growing critique of fatphobia and diet culture. And while the Academy’s guidelines suggest moving the focus away from pounds, it tells pediatricians to determine candidates for surgery and medicine using proportional benchmarks — meaning for some kids, it will still come down to the number on the scale. 

“I think this is an affront to body autonomy in a way, saying if you’re at a certain weight, the recommendation is that you must change your body,” Byrne says. “Even giving everyone the benefit of the doubt, I think when parents hear from a pediatrician ‘Your kid should go on a weight loss drug,” they’re gonna want to do what’s right to make sure their kid is healthy. But to hold everyone to the same standard when everyone develops at different times… It’s just such an oversimplification.”

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