Same Anti-Fatness, Different Look: An Analysis of the "Ob*sity Bill of Rights"

Upon first learning of the existence of the “Ob*sity Bill of Rights,” it may be tempting to look upon it as a tool for addressing anti-fatness in healthcare settings. While the packaging is pretty, though, what’s inside isn’t nearly as appealing. I’ve put together an analysis of the contents of the bill, and though this isn’t a complete list, it will hopefully draw attention to some of the document’s glaring issues.

It is very important for me to acknowledge my thin privilege - the ways I do not and never will understand the impact of this bill on fat folks. 

1. It’s Pathologizing

The use of the O-word in the title indicates, right away, that fatness and fat bodies are viewed as a problem to be eradicated. At this point in time, we have mountains of data to support the fact that the correlation between fatness and health problems is overwhelmingly due to the real-life impacts of anti-fat oppression, rather than fat itself as something inherently harmful. With all the research and data available, it is irresponsible at best – and, in many cases, medically negligent – to pathologize fatness as a problem that needs to be solved. This only perpetuates the very anti-fat narratives that threaten the well-being of fat patients in the first place. 

Fat people have insisted, for quite a while, that the word “ob*sity” is a slur that pathologizes and problematizes plus-size bodies. A movement that claims to respect and care for fat patients while using a word identified as a slur by fat communities is obviously not listening to the very people it purports to advocate for.

Additionally, the preamble dangerously perpetuates the idea of fatness being unequivocally harmful, stating that “400,000 people are estimated to die every year from ob*sity.” This language is misleading and entirely inaccurate: a tired assumption that if deaths from conditions such as diabetes and heart disease occur in patients who happen to be fat, their fatness must be the cause. Such assumptions do nothing but further the very narratives about fatness that are so often used to discredit and dehumanize fat people.

2. It Doesn’t Challenge Assumptions Rooted in Anti-Fatness, Instead Passing Them Off as “Information”

The bill states that patients have the right to  “accurate, trusted information in culturally appropriate and easily understandable language that explains obesity as a complex chronic disease requiring personalized treatment” (emphasis added). While it’s indisputable that patients should absolutely have the right to information, what happens when the information they are given – information being taken for granted as tried-and-true fact – is deeply rooted in anti-fatness and, by extension, eugenics, ableism, and white supremacy? Under the guise of informing patients, this item encourages healthcare professionals to coerce fat patients into problematizing their own bodies–a coercion that can be so strong, it can lead patients to agree to certain treatments under duress. Claiming that fatness is a disease requiring treatment leaves fat patients without a voice with which to refuse the pathologization of their bodies. 

3. It Makes False Claims About “Safe & Effective” Weight Loss Treatments

We know by now that intentional weight loss methods simply do not work; the vast majority of those who pursue intentional weight loss regain this weight, and then some, within a few years. Thus, the “safe and effective” treatments mentioned in the bill do not actually exist. This is misleading at best.

It’s important to note that many fat people have spent much of their lives engaging with diets, exercise regimens, and various forms of restriction/starvation in an attempt to make their bodies smaller. For some, these attempts began as early as childhood. We know, though, that when the body is exhausted and depleted in pursuit of the thin ideal, the opposite happens over time. I once worked with a fat adult patient who had engaged in food restriction patterns since elementary school, leading to decades of weight cycling that resulted in a higher weight set point with each cycle. When she realized this, she had an outburst during one of our sessions, exclaiming, “So I anorexiced myself to ob*sity?!” Her experience is not at all uncommon, and it points to the flaws of the claims of “safe and effective” weight loss treatments made by the bill of rights.

4. It Insists On Using Person-First Language “As a Sign of Respect”

While many are taught that person-first language is the most respectful way to talk about marginalized identities, an overwhelming amount of people with those identities, including fat people, caution against its use. A colleague and fat liberation advocate explains it as such:

“For me, person-first language inappropriately distances my fat identity from the reality of my day-to-day life. Referring to me as a 'person with fatness' gives the inaccurate idea that the size of my body isn’t a major part of my identity. It wouldn’t have to be, in a world that didn’t actively hate fat people, but unfortunately that’s not the world we live in. I identify myself as a ‘fat person’ because my fatness is always the first thing people notice about me, and because anti-fat oppression is unequivocally the thing that makes my life the hardest.”

5. It Perpetuates the Eugenicist Notion that Fat People Should Not Exist

We all know what the authors of this bill mean when they refer to “ob*sity treatment:” the eradication of fat bodies. It is this mentality that contributes to poor body image and eating disorders: when we identify certain bodies as “wrong,” people will go to great lengths to avoid looking like them, causing themselves great harm, and sometimes even dying, in the process.

Additionally, it maintains a false binary between ”good fat people” (that is, fat people who spend their lives trying not to be fat) and “bad fat people” (those who do not “obey” societal standards by constantly trying to take up less space). The fat patients described in the bill are all the former: the ones who accept their ob*sity diagnosis and obediently seek “treatment” for the alleged wrongness of their body in an attempt to make it smaller. Perpetuation of this binary unequivocally causes harm – particularly to the "bad" fat people who choose not to pursue intentional weight loss – making anti-fat discrimination in healthcare settings far more likely for these patients, who are often slapped with labels such as "non-compliant" that can cause insurance companies to restrict their access to many different types of care.  

6. It Entirely Misses the Real Problem with Anti-Fatness in Healthcare

Nowhere in this bill are any conditions mentioned that aren’t correlated with fatness; yet, this is what so many people in large bodies struggle with. I hear horror stories from people about going to the doctor for an earache and being lectured about weight loss. The same colleague who I quoted about person-first language spent decades of their life with chronic pain that was blamed on their fatness. It wasn’t until age 38 that they were finally diagnosed with a progressive disability – a disability that, due to lack of treatment, has severely impacted their ability to stand and walk. Their diagnosis could have come so much sooner, and their mobility could have been preserved, if doctors had been able to look beyond their fatness and actually evaluate their symptoms, the way they would for a thin patient.

These problems are so common, nearly every fat patient can tell you a similar story–yet the bill of rights doesn’t even mention them. Instead, everything it advocates for has to do with fat people receiving treatment so that they can somehow magically not be fat anymore. It doesn’t address anti-fatness within healthcare – instead, it perpetuates it.

Make no mistake: while the Ob*sity Bill of Rights may appear to have the interests of fat patients in mind, it essentially only functions as yet another tool of anti-fat oppression. Rather than attempting to pathologize fatness and “treat” fat people out of existence, those whose care practices are truly rooted in freedom from oppression would do well to take the bill with a heaping tablespoon of salt and treat their patients like diverse human beings instead of walking, talking diagnoses.

Losing More Than Just Weight: Ozempic, Wegovy, and the Harms They Can - and Will - Create

By now, you’ve all likely heard much of the buzz surrounding the drugs Ozempic, Wegovy, and others like them, which are now being widely prescribed for weight loss. I’ve been deeply troubled by this for quite some time, and recently I watched a webinar from the Center for Body Trust, titled "Let's Talk About Weight Loss Injectables," with in-depth dialogues surrounding these issues. Today I am offering a very condensed synopsis of some of the points in the webinar and how they support my criticisms of these medications as tools for weight loss. I highly recommend watching the webinar, which is still available for purchase on a sliding scale if you would like to dive deeper.

A big thank you to Hilary Kinavey and Dana Sturtevant of the Center for Body Trust, as well as panelists Sirius Bonner, Ragen Chastain, Lisa DuBreuil, and Marianne McCormick.

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1. These are diabetes drugs - not weight loss drugs. The dosages at which they are prescribed  in order to have the intended effect on weight are obscene: double, even triple, what is recommended for diabetes. There are virtually no long-term studies at these dosages, which means we don’t even really know whether it’s safe or not three, five, or ten years down the line – a major issue, considering many will be taking these drugs for the rest of their lives.

Even if there were no health risks - even if there’d been decades worth of thorough testing and research to suggest these dosages are perfectly safe - the issue still stands that these drugs are intended for diabetes, and that the uptick in demand for the purposes of weight loss means that diabetic people who rely on these medications to stay alive now struggle to access them. Some diabetics report unsolicited pressure from healthcare providers to increase their dosage for the “added benefit” of weight loss. Further, a look at the history of the greedy pharmaceutical giants behind these drugs - namely, Eli Lilly and Novo Nordisk - shows us that when demand goes up, so does price, making them even harder to get for those who truly need them.

2. The decision to take these drugs is not an informed one. Even if doctors are giving their patients all the available information and people are using these medications willingly and as directed, the fact remains that anti-fatness is the reason they are being prescribed for weight loss in the first place. Using these drugs in this way is inherently skewed in favor of weight stigma and thus cannot be considered an objective and informed decision. The harmful impacts of anti-fatness are very real and deeply impact the lives of fat people, and any decisions made under the heavy burden of weight stigma can only be considered as having been made under duress.

Additionally, most people are told they will need to keep using these drugs for life in order to keep their weight off. Studies are showing, however, that weight regain is highly probable after prolonged use, even when still taking the drug. When this happens, other medications are likely to be added into the mix, bringing with them a whole new slew of side effects. The data is unmistakable: cessation of these drugs will cause the weight to come back, making the maintenance of any kind of weight loss (if even possible) an ever-complicating life sentence - which is likely not what patients are aware they’re signing up for.

3. The use of these drugs for weight loss is rooted in weight stigma and anti-fatness. Developers and proponents of Ozempic, Wegovy, and their ilk aren’t shy about stating their intentions to eradicate fatness. In order to accept that fatness should be eradicated, of course, we must first believe that fat people should not exist. This is the crux of anti-fatness: the idea that there is a certain point at which bodies stop being acceptable. In order to champion weight-loss injectables, one must believe that to be true.

Moreover, as I have heard pointed out by NAAFA’s Tigress Osborn, fatness as something that can be medicated away only opens the floodgates for increasing discrimination and oppression against those who choose not to, or cannot, take these drugs. Weight stigma already kills. Fatness is already largely seen as a choice in mainstream diet culture. These problems, in a world where fatness can be eradicated with medication, will only increase in severity.

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These are only three of the many, many reasons that I, and so many other care providers, sense inherent danger in the current iteration of the weight loss drug boom. We’ve seen this before; many have likened it to the opioid epidemic and the lack of caution that was exercised leading up to it. This scenario may be even more chilling, in fact, given who is most likely to be harmed. While the opioid epidemic was very clearly a massive problem, medical professionals and society at large will likely not show the same readiness to admit their mistake when it comes to weight loss injectables, for one simple reason: in a society of anti-fatness, we don’t care when fat people die. Instead, we justify it by blaming their weight - the very thing they were so desperate to address in the first place. It’s a downward - and deadly - spiral that both fuels and feeds off of anti-fatness and weight stigma.

Instead of trying to eradicate fatness and fat people, healthcare providers need to focus on eradicating bias. This is the underlying message of the webinar mentioned above, which I highly recommend purchasing if you are able. I am not an affiliate of the webinar, and I do not receive any compensation for referrals - I just believe deeply in its message and feel everyone should see it!

Lastly, I’m hosting an online overview training on March 29: “Eating Disorders Treatment: Applying a Social Justice Lens for Healing and Liberation.” It’s intended to provide a foundational understanding for care providers of the ways in which oppressive systems not only perpetuate eating disorders but also inform the way they are diagnosed and treated and thus disproportionately harm marginalized patients. For more information and to register, click here.

Brilliance? I'm Not Sure: Barbie, Body Image, and Legacy

We need to talk about Barbie.

This statement may feel fairly redundant. After all, it seems as though there are few places in which people aren’t talking about Barbie, and for good reason: the film has blown all expectations out of the water to become Warner Brothers’ highest-grossing global release in history. That in and of itself is quite the feat, particularly because of the film’s femme-forward storyline, direction, and cast. 

The movie certainly gives us much to discuss, and it does quite a lot of things really well. It’s a visually intoxicating tale of self-discovery, power, and persistence that’s laden with clever critiques of patriarchy – much of which are as hilarious as they are potent. What’s not to love? I laughed A LOT during the film. Watching Barbie in a body that is so glorified by impossible beauty standards was unsettling. Yet I just sat with it as there was so much in the film.

*Please note: spoilers ahead!*

A scene towards the beginning of the movie shows Barbie arriving at a middle school and having a brief and fairly contentious experience with an outspoken young woman, Sasha, and her group of friends. As someone who grew up knee-deep in Barbies and diet culture, I was thrilled when Sasha points out Barbie’s less-than-rosy legacy. “You’ve been making women feel bad about themselves since you were invented,” she bristles. “You represent everything wrong with our culture. Sexualized capitalism. Unrealistic physical ideals.” 

This accusation is certainly one that millions can get behind, and I’m sure I wasn’t the only one breathing a sigh of relief when the elephant in the room finally got roped into the conversation. I was disappointed, however, that the discussion about Barbie’s complicity within diet culture didn’t continue – at least, not in a particularly potent way. The mentions of it here and there throughout the rest of the film felt like crumbs we were being thrown and came nowhere near to doing the topic justice.

I suppose I’d been expecting – or at the very least, hoping for – a storyline that included Barbie taking accountability for her unfortunate legacy of impossible beauty standards. Sadly, though the film addressed important topics, this one felt like more of an aside.

I also felt uncomfortable later on,when America Ferrera’s character snaps the Barbies out of their subservient role with a powerful speech – one that’s been circulating all over the internet for weeks. It was awesome watching each Barbie realizing how they have been manipulated, and it did a lot to represent the way we so often fall prey to gaslighting from cultures of oppression. I loved the strong speech and have enjoyed seeing it come up again and again online. What I had to grapple with, however, was the fact that America Ferrera – who offered so much for challenging beauty standards in Real Women Have Curves and Ugly Betty – had lost so much weight that I did not recognize her. Further, what I found during an online search for America Ferrera was page after page of…her weight loss strategies. 

It’s important to note that I do not fault Ferrera for the desire to lose weight. How can anyone work in the context of Hollywood without falling prey to unrealistic beauty standards and body ideals at every turn? Ferrera isn’t to blame here – but the industry that does so much to create, perpetuate, and uphold these standards very much is. I get so frustrated with the entertainment industry: all the power it holds to influence societal norms, yet it takes none of the responsibility for doing so when those norms cause such devastating harm.

All that said, I walked out of the theater feeling conflicted: I was thrilled and amused at the creative critique of patriarchal culture I’d just seen, yet I was holding disappointment as well. 

Author and activist Virgie Tovar observes that “the film’s core conflict feels off, or at least askew. If the new Barbie movie is about addressing and righting past wrongs - and I think it is - the central plotline doesn’t tackle the right one, the big one. When it comes to Barbie, it’s not toxic masculinity that needs to be reckoned with. It’s Barbie’s long-time correlation with negative body image and lower self-esteem in girls.” Virgie does an incredible job of addressing why this movie is not the utopia it’s being made out to be – see her article here: https://www.forbes.com/sites/virgietovar/2023/07/28/theres-a-body-image-sized-hole-in-the-new-barbie-movie/amp/?fbclid=IwAR0Q_hnTPI35AdwTEF4qecWMnnraNbklc8qwAQGq_ZmwQNZG3Eg_z8py6pY

This fair and honest review of the film by Tabitha St. Bernard-Jacobs echoes a lot of my own feelings about it, particularly that of representation. Given Barbie’s ties to harmful beauty standards, one couldn’t be blamed for hoping a wide range of body types would be represented in the film. Sadly, this wasn’t the case: while two plus-size Barbies were included, played by Nicola Coughan and Sharon Rooney, they were given supporting roles and did not have any particular prominence in the film. As St. Bernard Jacobs notes in the review: “If we only get supporting roles, is it really representation?” 

Additionally, this review critiques the film from an intersectional and abolitionist perspective, offering strong points about the white feminism and desirability politics inherent to it, all of which are deeply entwined with patriarchy itself and could have been addressed in more impactful ways. I realize it would be impossible to address the entire structure of patriarchy, as well as its many intricate intersections with various systems of oppression, in two hours – and, I think acknowledging those limitations could have improved the Barbie experience for me, as well as for countless viewers with marginalized identities everywhere.

The Path to Wellness Isn't 10,000 Steps Long

The Origin of a Myth, and How it Perpetuates Harm 

It’s the default goal on a Fitbit or an Apple Watch. It’s recommended by official health and wellness authorities worldwide. At this point in time, the target of 10,000 steps per day has been burned into the collective consciousness, taken for granted as a given if one wants to attain good health. I remember working in Health Education over 15 years ago with such a focus on 10K steps and pedometers. We created promotions, health information, campaigns and even had team contests. 

When we question that target, however, we find a whole lot of information that doesn’t exactly support this widely known “fact.” This newsletter is focused on the myth of 10K steps, as I was inspired after I listened to Aubrey Gordon and Michael Hobbes explain in a recent episode of their excellent podcast Maintenance Phase. Their 10K podcast is just brimming with research facts, history, information illustrating the deep political roots of 10K steps. So I just want to focus on a few facts I took away from their super fabulous podcast episode (btw, every episode is just super fabulous):

• 10,000 is an entirely arbitrary figure in terms of fitness and health. The number itself was chosen by a group of Japanese researchers in the 1960s who determined that if the average Japanese person increased their steps to 10,000 a day, they would lose a certain amount of weight each year. These calculations, however, were based on the “calories in, calories out” model, which has since been thoroughly debunked, effectively turning their research into junk science. Moreover, it is absolutely worth mentioning that this fascination with step count was born out of a desire to make people thinner – not healthier. It is deeply rooted in anti-fatness.
• 10,000 was also chosen because the Japanese written language of 10,000 looked “good”. It was a “cool” symbol. Again, where is the focus on health?
• Citing an interest in children's health, McDonald’s released the Go-Active Happy Meal, which included pedometers for kids, in 2004 - the same year the film "Supersize Me” came out. Coincidence? Not really: McDonald’s sales plummeted after the movie and the Go-Active Happy Meals were a way to increase profits during an era that demonized fast food. So this Happy Meal was about profit, not health, despite their claims.
• Additionally, given that all our bodies and experiences are unique, it doesn’t take a whole lot of thought to realize how deeply meaningless this standard of health is. Research has shown that different bodies respond to different forms of movement in different ways – findings which only become more varied as differences in age are taken into account.¹  And while it is, for the most part, true that the human body benefits from movement in general, to suggest that 10,000 steps is the ideal for achieving health is ableist, on top of everything else. Many people with chronic pain, invisible illness, or other disabilities might be unable to achieve the 10,000-step mark. If this is our goalpost for what it means to be well, it implies that anyone who cannot meet the goal (or who chooses not to meet it) is unwell: an assumption that is simply not true.
• Happiness and enjoyment are components of wellness, too, and interestingly, as Gordon and Hobbes point out, emerging data shows that measuring the output of tasks can inhibit the enjoyment of said task. Simply put, people who track their steps may actually find less pleasure in their movement than people who do not keep track. Something definitive we know about human behavior: if we enjoy doing something, chances are good we will continue to do it. Therefore, if tracking our steps makes movement feel less like fun and more like a chore, we’re less likely to continue to do it with consistency–making striving for a certain step count something that could actually counteract our well-being in the long run.

On a final note, because this is so important: health has no moral value. A human being is worthy of respect and care, regardless of the status of their health. It might be tempting to read this post and walk away with the knowledge that the step count we should strive for is, simply, one that supports our health and well-being. While that’s not untrue, I want to offer a caution against the well-meaning but ultimately harmful caveat of “...as long as you’re healthy.” Why? Because in this day and age (and stage of neoliberal capitalism), health is a privilege. It should be a right–but it’s certainly not treated like one. Countless people in the United States and across the world do not have the resources to attain health. In the U.S. alone, many people cannot afford adequate healthcare even with health insurance coverage; additionally, those living under U.S. food apartheid (in places often referred to as “food deserts”) often lack access to meals that meet their nutritional needs. For other people, physical health may simply not be a priority–and that’s okay, too. The point is: no one owes their health to anyone else.

For a deep dive into the origin and history of step counting, listen to “The 10,000 Steps Myth” on Maintenance Phase!

¹ Paluch, Amanda E et al. “Daily steps and all-cause mortality: a meta-analysis of 15 international cohorts.” The Lancet. Public health vol. 7,3 (2022): e219-e228. doi:10.1016/S2468-2667(21)00302-9

The Whale, Brendan Fraser, and Fat Representation: How Tired, Uncreative, and Harmful Tropes Perpetuate Eating Disorders

Several weeks ago, I happened to see the speech Brendan Fraser gave after winning an Academy Award for his latest film, The Whale. Having heard some concerning reports about the film itself, I’d decided against seeing it, but even Fraser’s acceptance speech was peppered with whale references. I was outraged, and as it turns out, I wasn’t the only one: Ragen Chastain of Dances With Fat tweeted that “Brendan Fraser making whale metaphors (jokes, really) while accepting an Oscar for cosplaying a fatter person in a film written and directed by thin people that rests on grotesque weight stigma, ableism, homophobia, and stereotypes is the end of my support for him.” Regardless of your feelings about the actor himself, there’s little doubt that The Whale leans on a stereotypical – and incredibly harmful – trope: that fat is the worst thing a person can be.

It is, of course, entirely possible for a person to exist in a fat body and still experience love, happiness, joy, fulfillment, health, and connection. Yet, looking at movies like The Whale, is it any wonder that so few people realize this is true? Representation of fat folks, particularly those on the larger end of the spectrum, is almost always limited to narratives like this, with fat people being portrayed as sad stories, wells of unrealized potential, or cautionary tales. Where are the movies about fat people experiencing elation, being promoted, falling in love, or living long and happy lives? 

This lack of representation only feeds into the idea that fatness is inherently bad–a paradigm which drives body dysmorphia and harmful patterns of disordered eating. For all the patients I’ve been able to help in my practice, there are others who make the choice to cease treatment, due solely to a fear of their body becoming larger as a result of recovery. These are people who are fully aware that their eating disorder is on the path to killing them, and do not pursue healing out of a fear of becoming fat. And yet their fear is real and their feared consequences are a reality. These moments are heartbreaking. There is pain in their voices: deep sadness, utter weariness. They know the decision they are making, the position they are putting their health in, and the dangerous consequences. But oppressive systems are insidious and oh-so-strong, and fatphobia is no exception. Patients tell me time and time again that our eating disorders clinic is the only space that supports their right for food liberation and nourishment and a weight restored body.

We won’t see an end, or even a reduction, in disordered eating behaviors until we, as a society, stop demonizing and dehumanizing fat people. In many ways, fatphobic discrimination and weight bias are still entirely socially accepted, even in a culture which is (far too slowly) moving toward curbing discrimination for other marginalized groups. For example, it is legal in 49 states to fire a person for being fat. Despite the very real consequences of, and casualties resulting from, fatphobia and weight stigma, body size is not considered a protected class, the way race, gender, and sexual orientation are, to name a few. The very fact that this is the case points to how socially, and even legally, sanctioned fatphobia is–and why so many people are so afraid of gaining weight.

The movement toward fat liberation is full of incredible people offering a wealth of resources for unpacking and untangling our own internalized fatphobia. Check out the following folks for (much, much) more information! 

Da’Shaun Harrison

• Website: https://dashaunharrison.com 
• Book: Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness

Aubrey Gordon

• Book: “You Just Need to Lose Weight” and 19 Other Myths About Fat People
• Podcast: Maintenance Phase

Sonya Renee Taylor

• Website: https://www.sonyareneetaylor.com 
• Book: The Body is Not an Apology

Ragen Chastain

• Website: https://danceswithfat.org
• Twitter: @danceswithfat

Lindley Ashline

• Website: https://bodyliberationphotos.com
• Twitter: @lindleyashline

Sonalee Rashatwar

• Website: https://www.sonaleer.com
• Instagram: @thefatsextherapist

Asher Larmie

• Website: https://www.fatdoctor.co.uk
• Podcast: The Fat Doctor

An Eating Disorder Specialist’s Response to the 2023 Guidelines from American Academy of Pediatrics

If you're reading this post, you are likely well aware of the new pediatric guidelines released by the American Academy of Pediatrics at the beginning of this year. There is much to sift through here, and I’ve been engaging in a lot of conversation with other care professionals who specialize in eating disorder treatment and health justice. To say we are concerned is a massive understatement, and it’s important that people know why.

I thought I’d share a summary of some of the reasons why professionals like myself are so vehemently opposed to these updated guidelines. There is a lot of complexity inherent in this topic, so I’ve broken things down into a list form to address the concerns I have about the harm the AAP is perpetuating with this guidance.

1. The guidelines are structured around the BMI scale, which is a tool capable of telling us absolutely nothing about the health and well-being of a person’s body. 

We know this, and have known it for decades. Still, the AAP insists on using it as a measurement to determine which bodies are diseased and in need of intervention, and which ones are not. This alone should be enough to discredit their guidelines. Further, little attention is given to the racist origins of the BMI and fatphobia. A statement from ASDAH sums this issue up neatly: “Despite several sections discussing the prevalence of higher BMIs among Black and brown people, the connection between racism and fatphobia was completely excluded from the guidelines as well as from their analysis and interpretation of the research. Fatphobia was born out of eugenicist and racist ideas. These racist ideas are then upheld systemically through tools like the BMI and recommendations such as these. This history and how it shaped research and current medical practice is missing entirely from the AAP’s recommendations. Its omission allows for the continuation of harmful, racist, and fatphobic practices.”  

2. The guidelines stress a focus on “non-stigmatizing” care - which, in this context, is impossible. 

The pathologizing of fatness, which is achieved here by classifying o*esity as a disease that must be eradicated, sends the message to children that their bodies are wrong and unacceptable–a determination which, again, is made on body size alone and not on any real measure of wellness. The very nature of this is fatphobic and stigmatizing; it is impossible to attempt to eradicate something (in this case, fatness) without sending the message that it is negative and should not exist. Keep in mind, too, that anti-fat bias is woven into the fabric of the U.S. healthcare system, and that most care providers operate from within an inherently stigmatizing paradigm and are unequipped and unprepared to provide “non-stigmatizing” care. 

3. The guidelines encourage dieting behaviors in patients as young as two years old. (Don’t be fooled by the “lifestyle change” terminology they’ve used: food restriction originating in a desire to make one’s body smaller is a diet, no matter what language one utilizes to describe it.) 

The AAP states that, because these “lifestyle” behaviors share much in common with eating disorder treatment programs, they carry virtually no associated risk of eating disorders. Consider, though, that most eating disorder treatment programs are not incredibly effective at helping patients heal: only 40-50% of those who have undergone treatment for an eating disorder remain in long-term remission.¹ Additionally, adolescent girls who engage in extreme dieting behaviors are up to 18 times as likely to develop eating disorders,² making the AAP’s risk-free claims sound dubious, indeed.

4. The guidelines recommend pharmacotherapy for children as young as eight and weight-loss surgery for children starting at thirteen years old. 

This is, frankly, appalling; given the lack of data available on pediatric pharmacological and surgical interventions, there is little reason to proclaim these treatment methods will not harm patients in the long-term. Keep in mind, too, that these recommendations are made in cases of what the AAP refers to as “severe o*esity”–which, again, is measured by BMI and has nothing to do with the health of the human as a whole. These recommendations may very well see providers performing surgery on perfectly healthy children.

5. Per the guidelines, all these recommendations are made on the grounds that “severe obesity is a harbinger of the establishment and cumulative progression of numerous related comorbidities, diminished long-term health status, and shortened life expectancy.” 

I’m incredibly concerned, however, at the exclusion of alternative explanations for the correlation between weight and health–explanations that are entirely plausible and factor in realities such as medical weight stigma, which keeps many in larger bodies from accessing quality care. To ignore these realities is to actively perpetuate harm.

6. The guidelines prescribe weight loss as a “solution” to the weight stigma that harms children and adolescents in larger bodies.

This posits that those who are harmed by weight stigma and anti-fat bias are at least in part to blame for the harm they receive. Putting the onus on solving oppressive environments on those who are directly oppressed by them only perpetuates harm and does nothing to address it.

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I’ll stop here, though there is still more to unpack, but I hope this has helped explain and clarify the alarm that so many care providers–particularly those of us specializing in eating disorder treatment–have expressed. For more excellent information, I strongly recommend reading the statements from the Association for Size Diversity and Health (ASDAH) and the Center for Body Trust, as well as thoughts and reflections from these incredible folks: 

Serious Issues with the AAP Guidelines

Letter to Parents and Caregivers

Letter to a Pediatrician

Dear Kids, The AAP Got It Wrong

Sources:

¹ McAleavey K. Ten years of treating eating disorders: what have we learned? A personal perspective on the application of 12-step and wellness programs. Adv Mind Body Med. 2008 Summer;23(2):18-26. PMID: 20664141.

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