There's a lot of talk going around about AAP's recent release of their clinical practice guideline for addressing childhood obesity. It's a long document... 100 pages long. And it's centered around a topic that drives a lot of emotion for a lot of people. There's a lot to unravel there.
As pediatric dietitians, we work regularly with parents of children living in larger bodies. They often come to us because their pediatrician expressed concern about their child's growth or weight, they feel concerned, their child is beginning to express concern about their body size, and so forth. There is so much emotion driving these visits because, as parents, we all want our children to be as physically and emotionally healthy as possible.
Our style as pediatric dietitians centers around balance. We work with families to help them raise healthy children regardless of size. As a society, we have some work to do to promote wellness for all of our children, not just those at the top of the growth charts. While we recognize that carrying excess body fat can impact a child's physical and emotional well-being, we also know that every child deserves to feel safe and accepted in their own skin. It's a very challenging balancing act and many families just aren't sure how to strike that balance, so they look to medical professionals to help guide them. The AAP clinical practice guideline was written to standardize care for children living in larger bodies. Unfortunately, as child nutritionists, we are feeling disappointed and frustrated by them, and here's why...
BMI as a measuring tool for health
Is BMI a tool for measuring body size? Yes. Is it a reliable tool for measuring a child's (or adult's) overall health? No. It's well established that BMI is an outdated tool that no longer represents our current population. Additionally, it creates a large amount of stigma around the terms "overweight" and "obesity". Labeling a child as either can create a lot of shame and body dissatisfaction and communicates to that child "there is something wrong with your body".
What we also know is that BMI is not a direct indicator of health. A person living in a larger body can be healthy and those living in average or smaller bodies can be unhealthy. Body size does not determine health. While it's true that excess body fat can be linked to health conditions such as high blood pressure, high cholesterol, and diabetes, this isn't always the case. When we are looking at a child's overall health, we need to be looking at how their body is performing, not how small or large it is, and tailoring care accordingly.
Growth charts are often misinterpreted
We can't tell you how many times parents have come to us concerned by their child's size on the growth chart. Maybe they are on the smaller side. Maybe they are on the larger side. Doesn't matter. Parents struggle with this. I've been there myself as a mom to an infant that struggled with growth and dipped down below the 3rd percentile. The anxiety surrounding her growth consumed me.
So we always want to start by helping parents understand what their child's growth chart actually tells us.
Growth charts help us understand a child's growth pattern.
The number on the chart simply tells us how many children are smaller and larger than our own. So a child who is growing at the 75th percentile is larger than 75 percent of children his own age and smaller than 25 percent of children his own age.
Typically a child whose BMI dips below the 5th percentile is considered underweight while a child who exceeds the 85th percentile is considered overweight. Everything in between is considered "healthy weight" by medical professionals.
What is more important than your child's percentile is their trend. Have they always been around that percentile and are staying on their own growth curve? AND can we reasonably assume that they are meeting their genetic potential (their size compared to mom and dad)? If so, that's fantastic!
If they are making drastic shifts on the charts and have jumped up or dropped down significantly, then we want to take a deeper look into why their growth may be slowing or accelerating.
For example, a child who is at the 95th percentile, but has been there all their life is likely a healthy child that happens to live in a larger body. Comparatively, a child who was at the 50th percentile for years and then suddenly climbed to the 95th percentile may need some help finding the root cause of the shift.
Interventions that cost families a lot of time and money aren't reasonable or sustainable
The new AAP guideline recommends intensive health and behavioral lifestyle treatment for children as young as 2 years old. These are in-person programs that last for months. This is a huge burden for families that don't have the time or the money to commit to this type of extensive program.
Additionally, we know that directly involving children in weight management programs can decrease self-esteem, increase risk of disordered eating, and cause long-term emotional damage. In our private practice, we work with parents directly to assess a child's overall health and make lifestyle recommendations accordingly. We teach parents what it means to raise a child with a whole-body health perspective. In other words, we take the focus off food and look at the bigger picture (nutrition, physical activity, sleep, emotional well-being, and more). Our children don't need to be burdened with this. What they need is a lot of love and some healthy boundaries to set them up for success.
In our practice, we work with families to find a schedule that fits their busy lifestyle. We almost always meet via telehealth so that parents can maximize their time and avoid travel to yet another appointment. We work with insurance providers, provide discounted rates, and accept HSA and FSA to reduce the financial burden for these families. In our experience, families just don't have the time or money for months of intensive treatment.
Pharmaceutical and surgical interventions carry risks
We recognize that each family is different, and some families may choose to go the pharmaceutical or surgical route to reduce their child's weight. There are many factors to consider when making this decision. For example: how is my child's weight impacting their health, their quality of life, their emotional well-being, etc. For some families, pharmaceutical or surgical interventions may feel like the best fit for their child once all of the risks and benefits are weighed. For us, at this time, we believe research is lacking in this area. We want to see more research evaluating long-term success and potential risks with these types of interventions. Perhaps, in years to come, we will know more. For now, we will continue to help families identify what is right for them and support them through their journey.
In summary...
There's a lot of work left to do. And there are tens of millions of children in the U.S. alone who are depending on us to figure it out. We don't have all the answers. None of us do. We appreciate the efforts that are being made, and we aren't sure how these clinical guidelines will evolve over time. What we do know is that we're going to keep doing what we are doing: educating and supporting as many families as we can, so that they can raise healthy, happy children regardless of body size.
If you're interested in learning more about our work, we offer free discovery calls and are more than happy to chat with you one-on-one.
And if you'd like to take a look at the (summarized) document yourself, you can view it right here!