The Human Cost of Anti-Fat Bias

Diving deeper into new American Academy of Pediatric guidelines on treating ob*sity.

Photo by supersizer via Getty Images

Last Thursday, the New York Times ran my essay on the new American Academy of Pediatrics guidance about ob*sity. This is a story I started working on my first day back in the office after winter break, because as soon as I saw the report, I knew: We need to have a giant conversation about the disconnect between how the medical establishment thinks about fat kids and what fat kids and their families actually want, need, and deserve. 

And that conversation started happening, right away, with fat liberation activists doing the best and most important work. Ragen Chastain immediately devoted three issues of her Weight and Healthcare Substack to an exhaustive analysis of the AAP’s financial conflicts, issues with their research, and a deep dive into one of their most egregious claims — that pediatric weight management programs decrease eating disorders. (Spoiler: Only if you think fat kids restricting calories or taking diet pills is probably/always a reasonably good idea! I also appreciated Alexis Conason’s analysis of that last part.) Many other folks spoke out on social media. (We’ll hear more from them in a minute.) 

Of course, I immediately wanted to have the conversation here, on Burnt Toast, with all of you. And we were able to start that on Friday. But I’ve felt weird about my relative silence here over the previous three weeks because I was focused on helping to make the conversation happen first in a mainstream media outlet. I went that route both because that’s my particular set of skills and because this is a moment where we need to do more than preach to the choir. We need to start challenging people who haven’t yet wrapped their heads around concepts like anti-fat bias and diet culture. This part is brutal. (I am logged out of Twitter as I write this!) But it’s necessary if we’re going to make change. 

So, I spent the past three weeks writing and rewriting the piece, as the conversation shifted and my editors and I changed our minds about where we should focus my argument. They ultimately wanted a fairly straightforward explanation of what anti-fat bias is, and why guidelines focused on pediatric weight loss perpetuates it, so that’s what I wrote. I’m happy with the piece and I think it’s a useful entry point for folks new to the conversation. But there is so much more to this story that didn’t fit into that word count. 

Today we’re going to get into the rest of it. 

Why Did the AAP Do This? 

The new guidelines represent a significant shift from the AAP’s previous policy of “watchful waiting,” and pretty directly contradicts the advice they gave healthcare providers in a 2016 position paper to avoid stigmatizing conversations about weight and weight loss. The guideline authors say this change was driven, at least in part, by recent data showing how American kids’ rate of weight gain increased during the first two years of the Covid-19 pandemic. They interpret this as evidence that “watchful waiting” has failed.

The way kids’ bodies have changed in the past 3 years may be a byproduct of living through the stress and trauma of a global pandemic. The way kids’ bodies have changed generation to generation over the past 40 years of our “childhood obesity epidemic” may tell a more complicated story about the impact of racism, poverty, and other social inequities on health, while also revealing how our 40-year public health focus on making people lose weight has backfired rather spectacularly. And some kids just are (and always were) genetically predisposed to be bigger. But none of these realities are changed or improved by trying to make kids today smaller. 

And there’s another, much clearer motivation for the AAP to publish these guidelines, making these recommendations, right now: Less than a month ago, the pharmaceutical manufacturer Novo Nordisk announced that the FDA had lowered the age eligible for their injectable weight loss drug Wegovy from 18 to 12. The company has estimated that Wegovy could earn $3.72 billion in sales by 2025. Adding the 22 percent of American kids aged 12 to 19 who have a BMI in the ob*se range to their potential customer base is certainly one way to get there. 

The American Academy of Pediatrics asserts that the authors of their new guidelines received no external funding and disclosed only one active financial relationship. Yet many of the authors listed make their living, at least in part, by performing bariatric surgeries or working for medical weight loss clinics. Several have received research grants, paid speaking opportunities and consulting fees from Novo Nordisk, Astra Zeneca, and other pharmaceutical companies. But it wouldn’t matter even if these individual researchers had no such industry ties. Novo Nordisk and several other pharmaceutical companies are major donors to the AAP itself. The weight loss industry (both pharmaceutical companies and diet and fitness brands) has been shaping scientific research on weight and health in order to profit off our “war on obesity” for decades.  

We saw this in 1998, when the National Institutes of Health’s task force lowered the BMI’s cut-off points for each weight category, a math equation that moved 29 million Americans previously classified as “normal” or “overweight” into the overweight and obese categories. The NIH made this decision despite mounting evidence that the BMI was a deeply flawed barometer of health and that the relationship between weight and health is far more nuanced than we’ve been led to believe. And in the years around the NIH’s decision, the FDA approved several weight loss drugs (Redux in 1996, Meridia in 1997, Xenical and Alli in 1999), all aggressively hyped and in need of a market. Both Redux and Meridia were later recalled due to concerns about their potential to cause heart damage. This war has never been about health. 

Questioning The Premise

One thing I realized, yet again, while sifting through the evidence cited in the AAP guidelines: Everything we think we know about kids, weight and health is rooted in our culture’s pervasive anti-fat bias. It’s always the X factor in obesity research. Many of the biggest, and most oft-cited studies on weight and health were funded directly by the companies that stand to profit when we decide to start a new diet or take a weight loss drug. And anti-fat bias drives a premise never questioned in obesity science: That fatness is a disease and that every fat person would be happier and healthier if they could only become thin.

Shira Rose @theshirarose

I was put on a diet at age 10 in the name of health. The result of that seemingly benign diet was a 20+ year eating disorder that almost killed me. Pushing weight loss on kids is the opposite of health. But no one cares because thinness above all else is our culture’s religion.

This ignores decades of research documenting the very real health risks of such treatments; I summarized some of that evidence in the NYT essay, but there’s plenty more both in the clinical research and in the lived experiences of fat people. “I was put on a diet at age 10 in the name of health,” tweeted my friend Shira Rosenbluth, an eating disorder therapist. “The result of that seemingly benign diet was a 20+ year eating disorder that almost killed me. Pushing weight loss on kids is the opposite of health.” 

whitneytrotter.rd

A post shared by Whitney Trotter RD -(she/her) (@whitneytrotter.rd)

Whitney Trotter, RD pointed out that the kids most at risk from these guidelines are Black, brown and otherwise marginalized children who are already facing multiple forms of bias every time they enter a healthcare setting. “It is always your right to decline weight loss surgery [and] weight loss medication discussion with your child’s pediatrician,” wrote fat activist and influencer Mia O’Malley. “But for some of us this may not feel safe and for some, it may not be safe.” Her post offers excellent language for parents wondering how to advocate in these moments.   

Journalist and essayist Meg St-Esprit wrote about her own experience with bariatric surgery for Romper in response to the AAP guidelines. (CW for discussion of numbers and intentional weight loss.)

“The painful surgery that I chose to undergo as a 34-year-old woman is something I cannot ever imagine a child navigating. I couldn’t finish a cheese stick in one sitting for nearly a year. Sometimes, five years later, I still vomit from a bite of food that gets “stuck” in the small opening my surgeon created.

There are some positive things that came out of the surgery for me. I had few complications. The herniated discs that prevented me from lifting my children healed with less stress on them. […] I am a success story, according to my doctor. It was still a brutal process.

The new AAP announcement has caused me to think critically about my body’s journey. And one thing I know for certain: Losing weight doesn’t undo the trauma of diet culture. It doesn’t for adults, and it certainly won’t for kids.”

And Evette Dionne, author of the excellent new book Weightless, wrote about the realities of life on weight loss drugs for BuzzFeed: 

Of course, there’s a catch 22: Once you stop taking the medication, most people regain the weight they’ve lost. In that way, these medications are no different than any other diet — and they come with even more dire side effects. As Dr. Caroline Apovian, co-director of the Weight Management and Wellness Center at Brigham and Women’s Hospital in Boston, told 60 Minutes, side effects can range from nausea, vomiting, and diarrhea to pancreatitis. There are also other side effects that haven’t been studied: Mila Clarke, who began taking Ozempic for latent autoimmune diabetes in 2021, told the Cut that she began having cardiac symptoms within a week of taking Ozempic. “I could feel my heart beating out of my chest,” she said. “It was hard to breathe. I was woken up in the middle of the night from these heart palpitations. And I just could not take it anymore.”

Ozempic and Wegovy are getting the most attention right now because their aggressive marketing for weight loss (especially to post-partum moms and please see Doree Shafrir’s excellent take on this) may have contributed to medication shortages that risk the lives of diabetics who need these drugs to manage their disease. But they aren’t the only drugs on the AAP’s list. Also now recommended for kids 12 and up is phentermine, a relative of amphetamine, that pharmaceutical companies used to combine with the appetite suppressant fenfluramine to be a weight loss silver bullet until patients began to report cardiac complications and several died. Writes Dionne: “...the deadly fen-phen fiasco revealed a lot about how the FDA thinks about ob*sity and the weight-loss medications prescribed to treat it.” Aubrey Gordon shared her own experiences of taking fen-phen as a fat teenager during our recent conversation, and what it’s like to “live as a ticking time bomb,” wondering if she has yet to face the full consequences of the drug, prescribed to her by adults she was supposed to be able to trust with her health. 

Not All Doctors? 

After publishing Thursday’s piece, I immediately started to hear from many “weight-inclusive” healthcare providers who have been doing the work to unlearn their biases and change their approach. These doctors are worried that the new guidelines will make their work even more difficult, because they can now be critiqued for not following established protocols and even find themselves more open to litigation or malpractice charges. I’m worried too; but also, always, encouraged to hear from these folks and hope we can keep discussing how they can advocate with the AAP to make change, and how the rest of us can support them.

I’m also hearing, sadly much more frequently, from doctors eager to tell me just how sick their fat patients are, and how they need drugs, surgery and diets to save lives. So I want to be clear: Many, maybe even most, of the doctors and researchers supporting these guidelines are concerned about health. They just haven’t reckoned with how much their own bias impedes that goal. And they aren’t looking at how their single-minded focus on weight loss disrupts the trust and communication that should be the bedrock of all provider-patient relationships. 

When healthcare providers deal with kids in bigger bodies, their well-documented anti-fat bias is always present in the exam room. This creates a vicious cycle: Fat patients are more likely to “doctor shop,” and less likely to seek care or follow a doctor’s instructions because they expect to be stigmatized and shamed. And healthcare providers perceive patients who skip appointments or don’t follow through with referrals as unmotivated and noncompliant, which adds to their reluctance to care for such patients. A 2016 survey of nurses and support staff at an urban pediatric hospital found that those who cared for patients in larger bodies were more likely to believe that body weight is controllable, a common misconception that then leads providers to blame patients who “fail” to control their weight. 

One of the most disturbing aspects of the new guidance is that we can see weight-centric providers like these co-opting the rhetoric of weight stigma research to justify their work. The guidelines note, for example, that it’s important for doctors to screen all patients for eating disorders and monitor patients following their protocols for dangerous amounts of weight loss. The authors also devote significant space to exploring how social determinants of health, including the experiences of racism and weight stigma, can contribute to a child’s body size and health status. 

But while it is progress for a major medical organization to acknowledge that weight stigma exists and causes harm, the AAP fails to see how they are continuing to perpetuate this bias with their own recommendations. A weight-focused definition of health ignores the natural diversity of kids’ bodies and growth patterns. But most fundamentally, it doesn’t see fat kids as whole people, as equally entitled to the full range of emotions and experiences as thin kids. Too many pediatricians who see kids with high BMIs in their exam rooms don’t need to be told to prescribe weight loss because it’s what they’re already doing—and families live with the consequences. Pediatricians need to untangle health and body size and to value the mental health and well-being of kids just as much as their physical health. They need to look for ways to encourage kids to love moving their bodies because that is innately health-promoting regardless of whether it impacts BMI. And they need comprehensive anti-bias training to help them recognize how their own fatphobia prevents them from seeing a fat patient as anything other than a problem to solve. 

But none of that makes the weight loss industry any money. So instead, we get guidelines like these. And for fat kids everywhere, the doctor’s office becomes an even more fraught and dangerous place.