I’ve lost track of how many people—including my younger sister—have told me their eating disorder started with something their pediatrician said.
As a pediatrician, a psychiatrist, and a child and adolescent psychiatrist in training; a person whose sister and friends have been diagnosed with eating disorders; and someone in recovery from one myself, many things scare me about the new American Academy of Pediatrics (AAP) Obesity Guidelines, released on January 9, 2023, which recommend that physicians consider weight loss pharmacotherapy for children as young as 12 and metabolic bariatric surgery for adolescents as young as 13. The sparse discussion of eating disorders is near the top of that list.
The three leading causes of death among the adolescent age group are accidents, homicide, and suicide. We have gone to great lengths to decrease the rate of unintentional injuries—creating seat belt laws, airbags, smoke detectors, helmets, etc. The same cannot be said for homicide and suicide, for which we should be doing everything in our power to mitigate the risk. Instead, I argue, the AAP is creating guidelines with the high potential to increase the risk of death by suicide.
How the AAP Guidelines Might Impact Suicide Risk
The potential of these guidelines to increase suicide risk is multifactorial. The first is a direct cause: One study, published in January of this year, found that bariatric surgery increases the risk of suicide, especially in the youngest patients.
The second cause is indirect. By promoting fatphobia, these guidelines are likely to increase the risk of adolescents developing eating disorders.
Outside of the opioid epidemic, eating disorders are the most fatal of all mental illnesses, with mortality rates up to 10 times higher for females 15 to 24 years old. It has been estimated that 1 out of every 5 people with anorexia will die from complications of their eating disorder within 20 years, and only 30 to 40 percent of patients ever fully recover.
Strikingly, eating disorders increase the risk of suicide; individuals with anorexia are 18 times more likely to die by suicide, and individuals with bulimia are 7 times more likely to die by suicide compared to gender- and age-matched peers. Eating disorders represent a lethality that far outweighs that of obesity, and at a much younger age.
The AAP guidelines fail to mention that the risk factors for developing an eating disorder are closely related to those for developing obesity. For people with a genetic predisposition to develop an eating disorder, a single diet can set off a lifelong struggle with mental illness. Just as not everyone who starts drinking will develop a substance use disorder, not everyone who goes on a diet will develop an eating disorder. But some will.
Fatphobia at the Doctor’s Office
As a doctor, my greatest fear is inadvertently causing irreparable harm to a patient’s life. And in and of itself, weight focus at the doctor's office increases fatphobia. My sister, along with many others, cites her pediatrician's statements about her “being overweight” as triggering a lifelong struggle with anorexia.
What’s more, our focus on obesity relies on antiquated systems. BMI was never intended to be used as a measurement for health, and our current growth charts are based on data from the 1960s through the early 1990s. Are these outdated measurements truly the best measure of health?
Weight can be a helpful data point, but it needs to be evaluated in the context of overall health. Are we targeting obesity as a chronic disease, or are we simply causing psychological distress by telling children their bodies “aren’t right”? It is not fair for pediatricians to hold that burden of inadvertent harm, especially when they are simply following the algorithms laid out for them.
Despite being generally well-intentioned, pediatricians are overworked, among the lowest-paid specialties, and forced to see many patients daily, requiring short visits. This restricts the time that pediatricians can spend counseling families. Thus, the well-intentioned pediatrician, following the algorithm laid out by the American Academy of Pediatrics, may inadvertently light the match for someone's eating disorder.
These guidelines may treat weight, at least temporarily, but do they treat health? The guidelines highlight the fact that obesity-related diseases, such as diabetes and cardiovascular disease, can be improved upon with lifestyle changes and weight loss as justification for the treatment of weight.
However, they do not mention the medical complications of eating disorders, which are numerous and far exceed the medical complications of obesity. As a physician, I would have much preferred my sister to have a possible future risk of diabetes and cardiovascular disease than an illness that put her in the hospital at age 16 with heart problems.
Of all the recommendations the AAP outlined, I argue that the request for evaluation for bariatric surgery is the most misguided. It was based on minimal data, and there have not been any long-term studies on the physical and psychological effects of bariatric surgery in childhood.
Can a thirteen-year-old truly consent to the lifelong undernourishment caused by such a radical procedure? Can they consent to the increased risk of suicide? While it is great to minimize the risk of potential future disease, it cannot be at the cost of premature death. A key factor in helping our children grow into healthy adults is making sure they live long enough to become one.
As a physician, a friend, a family member, and a survivor, I ask the AAP: Is weight loss worth this risk? Are we focusing on health, or inadvertently shaming children? Is the potential to increase the odds of suicide, already one of the top three causes of death in the adolescent age group, worth the risk?
Including weight loss pharmacology and bariatric surgery in the AAP obesity guidelines is premature, irresponsible, and dangerous. The dangers of these guidelines increasing suicidality and perpetuating eating disorders are much greater than the risks associated with being overweight or obese.
Opinions expressed are solely my own and do not express the views or opinions of my employer.
If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.