Am I Failing if My Kid Eats In Front of the TV?
Plus: We're at the crossroads of science and social justice, but keep making the wrong turn.
But When Do We Start Rejecting The Premise.
Last week, JAMA published an essay titled: “Childhood Obesity at the Crossroads of Science and Social Justice.” And friends, I almost got excited.
The piece is by David Ludwig, MD, PhD, a professor at Harvard Medical School who co-directs the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital and Jens Juul Holst, MD, DMSc, who is a professor of medical physiology at the University of Copenhagen and a scientific director for the Novo Nordisk Foundation Center for Basic Metabolic Research.
So: Two prominent ob*sity researchers, one of whom also writes diet books and consults for pharmaceutical companies, and one of whom is funded by the makers of Ozempic and Wegovy. But still! They used the phrase “social justice” in the headline! Could it be that the field of ob*sity research is evolving in the right direction at long last?
Spoiler: It could not.
The piece does not argue that a social justice approach to childhood ob*sity would be to stop putting kids on diets. The authors do not acknowledge the evidence that social determinants of health like poverty, food insecurity, healthcare access, and experiences of chronic oppression have a bigger impact on children’s long-term health outcomes than their BMI.
Instead, they begin with a mild tsk-tsking of the American Academy of Pediatrics’ new clinical guidelines. But Ludwig and Holst are concerned not with the guidelines’ emphasis on weight loss for children, but with the “relatively little specific attention” the guidelines pay to which type of diet produces the most weight loss for children. They argue that a “low-glycemic load diet” might work just as well as weight loss drugs,1 if only they could get some more research funding to do better studies, and like, really prove it this time.
They sure would need different studies to prove this, because current research on keto and other low-glycemic diets shows they don’t work any better than any other diet. As Ludwig and Holst note themselves, “Meta-analyses of clinical trials show only a modest advantage in weight loss for low- vs high-carbohydrate diets.” This is to say, they work a little bit in the short-term, but not in the long-term. But Ludwig and Holst then optimistically cite two individual studies reporting more dramatic results for low-glycemic load diets. Alas, the first followed subjects for only six months, so we know nothing about how sustainable that diet turned out to be, whether kids regained their weight loss over the next year, or how that experience of dieting contributed to their long-term disordered eating risk. And the second study followed only 262 patients and did not randomize subjects to the diet they followed. We could keep putting more and more kids on “high intensity diet interventions” in the hopes of documenting that they really do lose a lot of weight this time. Or we could ask: What the hell are we doing?
The paper also tries to thread a weird needle by purporting to critique weight loss drugs (including those made by a company that funds both of these authors) but also really doesn’t want to critique weight loss drugs (because they are made by a company that funds both of these authors). Our “justified excitement” about Wegovy and its relations, they write, “should not lead to deprioritizing development of nonpharmacologic interventions aimed at the root causes of the epidemic.” In other words: Drugs are great but let’s not forget about diets! You’ll still need your diets because these drugs don’t seem to work as well if you’re not also dieting, and they also don’t seem to work anyway after two years, as Lisa DuBreuil reports in this excellent Twitter thread.
You’ll also need your diets because, Holst and Ludwig admit, “rapid weight gain occurs” if you stop taking your weight loss drugs. And btw, probably you should stop taking them eventually, they add, because “we cannot yet know the potential risks of long-term treatment, begun in adolescence, with this or any drug that modulates fundamental metabolic pathways.”
The authors then bring us back to the social justice of it all by noticing that weight loss drugs are actually super expensive: “At $1400 per month, GLP-1 RA treatment of all adolescents with obesity in the US would cost approximately $100 billion annually.” Diets, on the other hand, are cheap(er than that, anyway, if we control for GOOP, I guess?). The authors conclude: “To advance science and social justice, we must also better fund research into new dietary treatments and overcome obstacles to reimbursement for the intensive behavioral interventions considered necessary by the AAP guideline.” Because continuing to research—and market—diets makes the unsustainable pursuit of thinness accessible to the masses. Not all heroes, etc.
What this paper never does, of course, is question the premise. Ludwig and Holst take for granted that BMI is a useful barometer of health, even though data shows that it’s particularly unhelpful when when used in kids. They take for granted that childhood obesity is a disease, rather than investigating why we’ve chosen to pathologize kids’ bodies, a question I explore in Chapter 1 of FAT TALK, which you can read or listen to here:
…When we talk about the impossibility of raising a happy, fat child, we’re ignoring the why: It’s not their bodies causing these kids to have higher rates of anxiety, depression, and disordered eating behaviors. Even when high weight does play a role in health issues, it’s often a corresponding symptom, a constellation point in a larger galaxy of concerns. The real danger to a child in a larger body is how we treat them for having that body. Fat kids are harmed by the world, including, too often, their own families. And our culture was repulsed by fat children long before we considered ourselves amid an epidemic of them.
Ludwig and Holst, like virtually everyone working in obesity research today, take for granted that making kids thinner is the best way to promote their health, despite strong evidence to the contrary. Framing the necessity of diets as a social justice issue ignores everything we know about social determinants of health, which operate quite separately from body size. Kids at high risk for metabolic health issues don’t need weight loss; they need enough to eat, access to healthcare, safer schools and neighborhoods, and to not live with the chronic oppression of anti-fatness and other forms of bias.
It is not enough for ob*sity researchers to say, “Yes, weight stigma is so real and harmful and we need to be so much nicer while we figure out how to make everyone thin.” They cannot borrow fat liberation rhetoric about social justice without looking up the definition of the term. And as long as they stay focused on the best way to change people’s body size, and use that as a proxy for changing people’s health, they will continue to underserve and harm.
You Asked: Can My Toddler Eat Dinner In Front Of The TV?
Q: My partner and I have gotten into the habit of letting our 2-year-old watch TV during meals/snacks. She is very active and it is hard to get her to sit still long enough to eat much. Without TV, she’ll take a few bites and then want to go play, but quickly melts down into tantrums that seem to be because she’s hungry?
I guess I’m looking for any tips/ reassurance that this is okay. I work as a registered dietitian and I’m having a hard time separating what actually works for feeding my child versus what I was taught “should” be done.
To answer this, I’m going to first point you to this piece of brilliance by
. Jenny is a fantastic cookbook author, who literally wrote the book on family dinner and her number one rule for making it happen is: If you have a kid under age three, don’t bother.