San Francisco health educator Heidi Galleni hears a lot of diet talk among preteens at her school. Children as young as 11 comment on one another’s bodies and agonize over what to eat out of the school lunch.
She overhears kids cruelly telling one another to “eat a salad." One day, she said, a student confided that their mother put them on a diet because of what their doctor said.
“I have a tiny little seventh-grader worried about what kind of diet they should be on, because they can pinch a centimeter of skin,” said Galleni, who teaches at Roosevelt Middle School. “We need to stop hurting our kids with our obsession about size. It’s not helping anybody.”
Some educators and parents worry the situation will get worse under new childhood obesity guidelines released last month. The American Academy of Pediatrics (AAP) now advises early and aggressive interventions such as intensive behavioral treatment for kids as young as 6, weight loss drugs for kids as young as 12 and surgery for kids as young as 13.
For adults like Galleni who can already see the effects of body-shaming, the advice was terrifying.
Health journalist Virginia Sole-Smith found it “really, really maddening” that the guidelines’ authors acknowledged the social determinants and stigma of obesity, but concluded that medication was the answer, anyway.
“We know that doctors are already causing a ton of harm,” said Sole-Smith, a parent and author of the forthcoming book, Fat Talk: Parenting in the Age of Diet Culture. “Seeing the guidelines codify that as a strategy is extremely disheartening and discouraging. You just perpetrated the stigma.”
From parents, Sole-Smith hears a lot of anger and questions about what this means for their kids. Elsewhere, she hears old “anti-fat rhetoric,” like pinning blame on laziness.
The guidelines discuss the broader factors that go into obesity: genetics, poverty and food scarcity, discrimination or stigma, family turmoil and loss. It also noted how doctors can have weight bias, and must address their own attitudes toward obesity.
Because of negative health outcomes as children turn into adults, the AAP looked at a wide range of options, meant to be tapped on a patient-by-patient basis with informed consent from caregivers.
“We are well aware kids are coming to us carrying this burden of weight bias and stigma,” said Dr. Sandra Hassink, an author of the guidelines and director of the AAP Institute for Healthy Childhood Weight. “That’s why these guidelines are out there. We have to have robust treatment efforts with robust prevention efforts.”
Educating physicians on all the nuances is a whole other leg of the work, Hassink added. Forthcoming AAP guidelines for preventing childhood obesity will come at a later date.
Anti-diet culture advocates like Sole-Smith point to the Health at Every Size approach, which avoids focusing on weight but can nonetheless make behavioral and physiological improvements in a patient. They also criticize the use of Body Mass Index (BMI), which doesn’t account for bone density, muscles or fat distribution.
Taking weight out of the school setting could also do wonders for self-image and well-being, while helping downplay bullying. Students often comment on the food people eat, especially if the kids are a bigger size, and may pick up on adults talking about the new diet they are on, Galleni added. Instead of fitness tests, for example, school should grade students in physical education based on improving abilities.
A small survey of about 40 fifth-graders at SF’s Cesar Chavez Elementary School last year found that 93% of them hadn’t been weighed at school and 42% of them felt uncomfortable getting on scale. While 93% said you could be fat and healthy, 40% had a negative reaction to the word “fat.” Just 63% felt comfortable with their weight.
Meghann Hayes, a resource specialist at Cesar Chavez Elementary, surveyed the fifth-graders to get a sense of the impacts of BMI and weighing students at school.
“Maybe this is what happens when our kids are not weighed: They can form their own opinions about things,” Hayes said. “Being a second-grader or first-grader and having an adult say something disparaging about your weight, that’s really heartbreaking and can have long-lasting effects.”
Dr. Jason Nagata—a pediatrician with the University of California San Francisco who also cares for teenagers with eating disorders—is keenly aware of how weight stigma affects teenagers. For one thing, he said disordered eating is more common in youth who are overweight or obese.
But he does think the guidelines are a step in the right direction. Encouraging regular follow-ups, in particular, is an important reminder for physicians, he said. Doctors may see children one year later having lost excess weight through dangerous methods like food restriction, purging or laxatives—which he said could backfire in the long run and should also be warned against from the get-go.
“I’ve seen where it can go awry,” Nagata said. “It’s a very delicate balance that providers have to address when dealing with these sensitive topics. Eating disorders affect people of all sizes and weights. As we’re treating obesity, we need to be aware of the stigma and discrimination people with larger bodies experience.”
While Nagata sees the limitations of BMI, he says it’s a quick and easy way to assess obesity and predict poor health down the line. Other methods like X-rays or imaging are better, but may not be practical or cost-effective.
Another issue with BMI is that definitions for obesity are based on binary genders, making it hard to assess health of trans or nonbinary youth. Trans or nonbinary youth are particularly affected by weight and body-image issues, he added.
Starting from age 11, eighth-grader Amelie Serang noticed having body-image issues and has friends who have grappled with it, too. The San Francisco teenager now looks out for body-positive messages when on the internet that raise awareness about the unhealthy conditioning of diet culture—but the images of certain beauty standards can still make it through her self-imposed filters.
“Anyone that you want to have a good opinion of you, the messages you get from them shapes how you can see certain topics,” Serang said. “It’s in my brain sometimes, that I want to have a slimmer waist or look a certain way. It’s not healthy to make sure I look a certain way to feel pretty.”
Critics of the guidelines say children—who may turn into adults grappling with body-image issues—ultimately should not feel a burden from their weight. She advises focusing on building healthy behaviors, like limiting sugar and offering more fruits and vegetables with meals.
“People feel completely entitled to comment on the size of other peoples’ bodies,” Galleni said. “You can build healthy habits without ever talking about size. We can’t teach all these things without excluding and marginalizing bodies that don’t fit on a chart.”