Feb. 22, 2023 -- After the American Academy of Pediatrics’ new guidelines for treating obese kids came out, I wrote “What Parents Should Know” for WebMD. It included insights from several experts and two moms of overweight children. The guidelines have proven controversial due to the recommendations of medication and bariatric surgery for older kids -- but also because a growing number of people question whether telling a child to lose weight is ever a good idea.
One of the most prominent voices reaching parents about kids and weight belongs to Virginia Sole-Smith. A journalist and creator of a newsletter and podcast focused on fatphobia, diet culture, and parenting called Burnt Toast, she’s also the author of a forthcoming book on the subject. Fat Talk: Parenting in the Age of Diet Culture will be published in April. I spoke with her about the AAP guidelines and how to parent a fat -- or thin -- child in our seemingly inescapable diet culture.
This interview has been edited for length and clarity.
Q: This is probably due to my own history as a fat kid, but when I read the new AAP guidelines, they struck me as thoughtful and empathetic, though the idea of medicating or operating on teens made me uneasy. But you point out that encouraging weight loss in the first place is likely to cause more problems than it solves.
A: We don’t have a ton of evidence that high body weight itself is the problem. There are reasons to be concerned about weight-linked health conditions, but pathologizing body size brings with it a whole other set of complications. When you do that, you start telling kids their bodies are problems to solve, you start focusing on food in ways that can raise their risk for disordered eating and eating disorders. There’s a whole ripple effect to this that the guidelines aren’t reckoning with.
Underpinning this whole conversation is anti-fat bias. We live in a culture that believes fat bodies are less valuable, less lovable, and less attractive than thin bodies. Our whole world is built to celebrate and welcome thin bodies and push out larger ones. This is just another way we’re doing that.
Q: People may wonder why the AAP would put out guidelines that might be harmful for kids since this is an organization that clearly cares about children’s health.
A: It’s really tricky. Officially, in their paper, they say, “We have no financial disclosures to reveal, everything’s on the up and up.” But the AAP itself receives donations from pharmaceutical companies, including Novo Nordisk, which is the manufacturer of two of the biggest weight loss drugs. A lot of the authors on this paper have received research funds, speaking fees, consulting fees, etc., or they’re employed by centers that do bariatric surgery. That doesn’t need to get disclosed because it’s just their job. They’re considered an expert because of it, but they’re financially entangled with weight loss being a thing we push for. (Editor’s note: WebMD reached out to the AAP for comment. This is their reply: The AAP has a strict conflict-of-interest disclosure policy and process for all authors of policy statements, clinical reports and clinical practice guidelines. The authors include medical experts with a wide range of perspectives, medical specialties and professional experiences, including some who have conducted research on weight and obesity and others who have devoted their careers to this aspect of medicine. Their knowledge and expertise was important in the development of these evidence-based guidelines. The guidelines also underwent an extensive peer-review process among many other groups of pediatricians and pediatric specialists, and ultimately were approved by the AAP Board of Directors.)
Q: Is trying to lose weight always bad? The moms I interviewed for that article, both of whom use the new injectable weight loss drugs, said they found it reassuring to have a medical solution to their weight problems. It removed a lot of the shame to know it was a physiological thing. And doctors point out that if your child had diabetes you wouldn’t hesitate to give them drugs. So why is this different?
A: Why is because body size in and of itself isn’t a medical condition. Doctors have pathologized it and made obesity a diagnosis, but there’s a lot of evidence to suggest it shouldn’t be. So it’s not the same as giving your kid an inhaler for asthma or insulin for diabetes. That’s what I want -- I want doctors to medicate the actual medical conditions.
The moms you spoke to are being told over and over that their kid’s body is a problem, and they are to blame. Parents in general, but moms especially, get so much judgment if they have a fat kid. And if you’re a fat parent with a fat kid, doubly so. They’re being told if you don’t get this problem under control, your child will have lifelong health consequences. Your child will be bullied. Your child will be unpopular, unlovable, less employable, and so on. All of that is driven by bias. That’s not medical.
I empathize with parents -- they’re terrified for their kids so making kids smaller feels like the answer. But when we choose that, we reinforce anti-fat bias and we make it more powerful. And we say to these kids, yup, the bullies are right, your body is the problem, you are the problem. We need to change you. We don’t need to change this whole system.
Q: The AAP guidelines say that the treatments they’re recommending statistically don’t lead to eating disorders. You argue that in reality, they do.
A: Eating disorders are really underdiagnosed in fat people because we assume they only happen to thin white girls. But we know they happen to people of every age, every gender, every race. There’s a lot of evidence to show that fat folks, by the time they do get treated, are much sicker because doctors have been reinforcing that disordered behavior along the way. They’re so happy to see weight loss, they don’t question how the loss was achieved. But you absolutely can have an eating disorder, you can be experiencing the physical complications of eating disorders, the heart issues, the fainting, all of that, in a larger body. You don’t have to be emaciated to deserve treatment.
As for the AAP saying these programs don’t cause eating disorders, the research they used to determine that didn’t follow kids long enough. Often studies only follow people for 1 to 2 years. If you put a 10-year-old on a diet and follow them until they’re 11 or 12, that eating disorder may not onset until age 14 or 15.
And then when they did check for eating disorder symptoms, they looked for things like binge eating, overeating, purging. They looked for the symptoms they expect fat people to show, but they did not look for restriction, skipping meals, cutting out food groups, because No. 1, they don’t think fat people do that, and No. 2, that is exactly what they’re teaching the kids to do: to restrict.
Q: There are diseases with clear correlations to excess weight. I was just diagnosed with arthritis in my hip, and I suspect it has to do with the fact that I was 100 pounds overweight for years. How should we be talking about that?
A: We often rush to say weight is legitimately an issue without investigating. Might a thin person with the same habits have the same risk for the condition? Just focusing on making body size smaller won’t necessarily affect whatever lifestyle factors are at play.
There’s also the fact that people in larger bodies receive significantly worse medical care, so a thin person reporting symptoms might get treatment faster than a fat person. I remember interviewing a weight-inclusive doctor, and I asked about knee issues. I’m fat and I have knee problems. And she said, “I have knee problems, too. I get physical therapy, I’ve gotten surgery, I’ve been prescribed all these different treatments.” But fat people get told to lose weight to take pressure off your knees. They don’t get referrals to physical therapy and things that might help these issues. The bias becomes a self-fulfilling prophecy.
Of course, there are conditions where weight may play a causal role. I’m not disputing that. I don’t think anyone is disputing that. What we’re disputing is treating fat people like it’s their fault -- if only they’d had more willpower, they wouldn’t be in this situation. Denying them care in a punitive way. That’s the harder thing for the medical community to wrap their heads around. Even if you’re fat and unhealthy, your body is still worthy of dignity and respect and health care.
The last piece is that sustainable weight loss doesn’t work most of the time. Dieting has a huge failure rate. Medications and surgery may be starting to change that, but they come with significant side effects. The surgery is going to be lifelong, and the medication you have to stay on for life to sustain the weight loss. You’re looking at a lifetime of consequences.
Q: Let’s talk about the more positive side of things. In your book, you write about fat positivity and how to instill it, telling your child, “Your body is never the problem.” What does a kid get out of hearing that?
A: It’s not the doctor’s fault, but doctors always see bodies as problems to solve -- why is this symptom or behavior happening? For a kid sitting under the microscope, what a gross feeling that is, knowing someone has to invest time and money into fixing them. And with weight, it reinforces this whole larger bias.
But you can’t necessarily control what the doctor says in an appointment. You can ask not to discuss BMI or weight, you can try to set boundaries, but you can’t guarantee how the conversation will go. The only thing you can control is what your child hears you say. If you say to the doctor, “I don’t view their body as a problem,” at least your child comes away with the knowledge that my body is safe in my home, with my family. My parents don’t see me this way. It feels like an important foundation that so many fat kids don’t get.
Q: What about parents of thin kids? What should they be doing?
A: I really want parents of thin kids to be talking about this, for two reasons. One, thin kids aren’t immune to the harms of anti-fat bias. Not every thin kid will grow up to be a thin adult. I say this as a former thin kid who’s a fat adult. It’s really important that thinness not be so interwoven with their identity, that if they can’t maintain that thinness, they feel like they’re failing.
Thing two is, parents of thin kids need to talk about anti-fat bias the same way parents of white kids need to talk about racism. If we don’t have these hard conversations, if we don’t teach our kids to name and unlearn this bias, the rest of the culture is going to teach them instead.
It’s not that I want parents to try to keep their kids in a fat-positive bubble with no exposure to diet culture. I want parents to be naming these things, to be learning alongside their kids, to be having conversations so that we can help kids develop critical thinking skills. Then they can start to point out diet culture to us, they can say, “Hey, this is a really messed up way to talk about bodies in this TV show or this book I’m reading or this person I’m following on TikTok.” That is going to do more to buffer kids against these influences because we’re giving them the option to disagree with it. We’re giving them the option to think about going a different way.