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Weighing the Options

Original illustration by Emmie Wu '24, an Illustration and Jewelry + Metalsmithing major at RISD

Last winter, two men awaiting sentencing at Rikers Island—a jail complex infamous for neglecting to provide critical medical care to its inmates—underwent elective weight-loss surgeries. Luis Perez and David Mustiga had both been recruited by Bellevue, a New York public hospital, a few months prior. Perez, who received the surgery first, told Mustiga that it was more excruciating than being hit by a car, but Mustiga’s surgeon cautioned him that this would be his last chance to get the procedure.

Both men’s health deteriorated over the next year. Mustiga, having lost more than 100 pounds, developed anemia and experienced rapid hair loss. Perez couldn’t eat without vomiting and was left with a yellow complexion. Neither was able to keep up with the surgery’s intensive recovery guidelines, which recommended attending Zumba classes and drinking mass quantities of Crystal Light—lifestyle changes difficult to accommodate even outside of a prison cell.

In the same month Mustiga and Perez underwent their procedures, the American Academy of Pediatrics (AAP) changed its childhood obesity treatment guidelines for the first time in 15 years. In addition to recommending weight-loss drugs for 12-year-olds, the AAP endorsed the use of weight-loss operations, or bariatric surgeries, to treat children as young as 13. Alarmingly, only thin evidence addresses the long-term safety of adolescent bariatric surgery, and health professionals have pointed to the procedure’s risks for any patient. The AAP’s new guidelines are just one example of the medical establishment’s excessive emphasis on weight loss as the nucleus of well-being—often at the grave expense of other health outcomes.

To be sure, higher weights are associated with several comorbidities, including type 2 diabetes, hypertension, and heart disease. Prevention of these conditions is allegedly the driving force of the campaign against obesity. Counterintuitively, then, the AAP excluded studies specifically targeting comorbidities from its literature review—the basis of its treatment guidelines—explaining that it “did not attempt to address treatment strategies for comorbidities… The primary intended outcome [of the studies] had to be obesity, broadly defined, and not an obesity comorbidity.” Rather than confronting obesity’s actual health risks, weight loss is the AAP’s one-size-fits-all solution.

The AAP’s solitary focus on weight is made more problematic by its use of the body mass index (BMI) as the primary determinant of which children need treatment. The history of the metric is laden with racism, fatphobia, sexism, and conflicts of interest, not to mention minimal scientific rigor. Ancel Keys, the physiologist who developed BMI in the 1970s, called obesity “ethically repugnant” and “disgusting.” It was born from a study of men exclusively from European countries and the United States. Now, we know that people of Asian descent tend to be at a higher risk for comorbidities at relatively low BMIs, and people of Polynesian descent generally have more lean mass than others, even when classified as obese. BMI is influenced by myriad factors, including genetics, unique to each individual. The AAP recognizes these complex factors, yet puzzlingly treats BMI as an across-the-board measure of both size and health.

BMI cutoffs, which form the foundation of our understanding of obesity, are backed by tenuous evidence at best. Katherine Flegal, an epidemiologist who researches weight and mortality, explained, “These are arbitrary numbers” likely selected because of “digit preference” for multiples of five. As recently as 1995, the World Health Organization (WHO) refrained from using BMI to classify obesity, stating, “There is no agreement about cut-off points for the percentage of body fat that constitutes obesity.” Just two years later, the International Obesity Task Force—later revealed to be funded by weight-loss drug companies—offered the WHO a hefty grant in exchange for the opportunity to consult on the now-widespread cutoffs: A BMI of 25 to 29.9 designates an individual as overweight, and a BMI of 30-plus classifies them as obese. When the pharmaceutical-bankrolled WHO guidelines went public in 1998, 29 million Americans became “overweight” overnight, and weight-loss drugs like Redux and Xenical (Ozempic’s predecessors) were born with silver spoons in their mouths.

The fragile credibility of BMI makes the AAP’s excessive recommendations all the more troubling. Bariatric surgery is the most controversial of the crop. Although performing weight-loss operations on adolescents is not new, endorsement of the practice by the leading authority on pediatric healthcare will no doubt increase the procedure’s prevalence.

In some ways, the AAP’s recommendation makes sense: Bariatric surgery enables weight loss and reduces comorbidity prevalence. The same body of literature that promotes the procedure, however, either glosses over its long-term impacts or fails to properly study them—especially in adolescents. By recommending bariatric surgery to children with scant evidence of its long-term safety, the AAP risks displaying the same negligence as the surgeons who operated on Perez and Mustiga. 

People who undergo bariatric surgeries face a host of mental and physical side effects. We know the operation makes adults more likely to die by suicide and develop alcohol-use disorder. Up to 21 percent of patients become unable to properly absorb protein, producing symptoms like Perez’s non-stop vomiting. Patients also lose between 8 and 13 percent of their bone mass, making them 2.4 times more likely to endure a fracture in the 15 years post-surgery. 

Less information is available on bariatric surgery’s health implications for adolescents, but the data we do have are distressing. Though reoperation rates are low for adults, one study found that almost 10 percent of teen patients who receive gastric bypasses—which the AAP recommends for 13-year-olds—require reoperations or develop life-threatening conditions. And that’s for a cohort with a mean age of 17. Adolescents are also more likely than adults to become nutrient-deficient post-surgery.

The AAP’s literature review—reputedly made up of “large” studies showing that adolescent bariatric surgery is “safe and effective”—does not exclude these troubling results. One repeatedly cited study had a sample size of 81 teenagers, a quarter of whom underwent additional abdominal surgeries for dangerously rapid weight loss or other complications. A whopping 72 percent became deficient in nutrients. Other AAP-backed studies had short durations, shrouding their participants’ long-term health outcomes.

The AAP, and the medical establishment as a whole, should shape their recommendations with positive health outcomes, not weight loss, as the primary goal. The Health at Every Size approach proposes that physicians exhibit weight neutrality and emphasize improving health markers. A recent meta-analysis found that, as compared to traditional weight-loss interventions, weight-neutral approaches improved eating disorder symptoms while evincing identical impacts on blood pressure, lipid and glucose levels, and even weight. The AAP’s new guidelines ignore the very real possibility of improving people’s health without relying on scientifically thorny measures like BMI.

A weight-neutral approach would help doctors disentangle medical advice from their unconscious weight-related biases. Medical settings are onerous for larger-bodied people, over half of whom report hearing inappropriate comments from physicians. These experiences are not just uncomfortable: Weight stigma is linked with diabetes risk and obesity itself. The AAP gives only piecemeal nods to this discrimination, like recommending that physicians say “child with obesity” rather than “obese child”—a practice called “person-first language,” which many larger-bodied people argue makes fatness seem taboo. Rather than making pacifying appeals to semantics, the AAP should genuinely change the way it thinks about weight. For the sake of the 13-year-olds in its guidelines, this work must start now.