No More Diets... and Other AAP Recommendations

Source: By Lars Aronsson [CC SA 1.0 (http://creativecommons.org/licenses/sa/1.0/)], via Wikimedia Commons

The American Academy of Pediatrics (AAP) has just released new guidelines for the prevention of obesity and eating disorders in adolescents. These guidelines are a departure from the previous 2007 weight-focused guidelines, which encouraged physicians to use the term “obese” (despite awareness of increased stigmatization) and suggested interventions including commercial weight loss programs, weight loss medications, very low calorie diets, and weight loss surgery for teens with BMIs in the severely obese category. The new guidelines were created with the recognition that obesity prevention must be considered in concert with eating disorder prevention.

The 2016 AAP guidelines outline the following 5 factors associated with both obesity and eating disorders:

Dieting—Dieting (defined as caloric restriction with the goal of weight loss) is a risk factor for both obesity and eating disorders. One study found that teens who diet are two to three times more likely to become overweight and one and a half times more likely to develop binge-eating disorder than teens who don’t diet. Dieting has emerged as the most important predictor to developing an eating disorder. One study showed that teens who severely restricted their caloric intake and skipped meals were 18 times more likely to develop an eating disorder than non-dieters; more moderate dieters were five times more likely to develop an eating disorder.

Family Meals—Regularly eating family meals together protects against both obesity and eating disorders. Some reasons for these benefits include parents choosing healthier foods than adolescents would choose on their own, parents modeling healthy food choices, more interaction between parents and teens, and parents being able to more closely monitor their child’s eating and intervene in eating related issues earlier if they do arise.

Weight Talk—Weight talk (defined as comments made by family members about their own weight or comments made to the child by parents to encourage weight loss) is associated with increased risk of both overweight and eating disorders. In contrast, families that focused the conversation on health instead of weight were less likely to diet and use unhealthy weight-control behaviors.

Weight Teasing—In overweight adolescents, weight-based teasing by family members and/or peers is common (one study reported 40% of early adolescent girls). Teasing by family members predicts development of overweight, binge eating, and extreme weight-control behaviors in both boys and girls. Research suggests that adolescent girls who were teased about their weight were twice as likely to be overweight five years later.

Healthy Body Image—Half of all teenage girls and a quarter of all teenage boys are dissatisfied with their body. The stats are even higher for "overweight" and "obese" teens. Body dissatisfaction is a well-known risk factor for eating disorders, unhealthy weight-control behaviors, and reduced physical activity. Families that focused on eating and exercising for health (instead of weight-loss) were more likely to raise adolescents who were more satisfied with their bodies.

The guidelines go on to recommend particular strategies for pediatricians to use in addressing weight-related issues. They focus on motivational interviewing (MI), which they define as a “collaborative, goal-oriented style of communication with particular attention paid to the language of change” and family based treatments. Pediatricians should assess for eating disorder behaviors using a list of high-risk eating and activity behaviors/clinical findings of concern. Included on the list is “rapid weight loss” which means that anyone quickly losing weight, even adolescents who meet BMI criteria for “obese” or “overweight,” should be assessed for disordered eating. This is an important step in diagnosing a population that is often neglected due to the misperception that eating disorders only occur in thin children. "Health not weight" is a theme running throughout the guidelines as physicians are encouraged to focus less on weight and more on healthy family-based lifestyle modifications.

These guidelines largely target parents as the agents of change. Parents should be healthy role models who provide easy accessibility to healthy foods and limit the availability of sweetened beverages (both sugar-sweetened and artificially sweetened). Parents should provide “home-prepared” family meals with little distractions and fewer discussions about weight and dieting. Parents should actively discourage dieting in their children. The article concludes with the following 6 guidelines for the prevention of obesity and eating disorders in adolescents:

1. Discourage dieting, skipping meals, and diet pills. Encourage healthy eating and physical activity that can be maintained in the long-run. Focus on healthy living and healthy habits rather than on weight.
2. Promote a positive body image. Do not focus on body dissatisfaction as a reason for dieting.
3. Encourage frequent family meals.
4. Encourage families not to talk about weight. Instead discuss healthy eating and being active to stay healthy. Facilitate healthy eating and physical activity at home.
5. Inquire about history of teasing and bullying in overweight and obese teenagers and address the issue with their parents.
6. Carefully monitor weight loss in an adolescent who needs to lose weight to ensure that the adolescent does not develop the medical complications of semi-starvation.

Eating Disorders Essential Reads

When the Shoe Fits, Wear It: Understanding Body Weight Set Point

Psychological Maintenance Processes of Binge-Eating Disorder

While these guidelines were developed for pediatricians, they are important for everyone to be aware of, especially parents and professionals working with parents and children.

Reference: Golden N, Schneider M, Wood C (2016). Preventing Obesity and Eating Disorders in Adolescents. Pediatrics: published online August 22, 2016.

Dr. Alexis Conason is a clinical psychologist in private practice in New York City specializing in body image and overeating disorders. To learn more about Dr. Conason's practice and mindful eating, please visit www.drconason.com, like her on Facebook, and follow her on Twitter.