On Monday, the American Academy of Pediatrics updated its guidelines on childhood obesity. The AAP is abandoning the “watchful waiting” approach that has long dictated how doctors treat children deemed obese because, as Dr. Ihuoma Eneli, who coauthored the guidelines, told the Associated Press, “Waiting doesn’t work.” According to the AAP, delaying intervening allows children to continue to gain weight throughout adolescence and adulthood, which eventually results in adult obesity. The new guidelines encourage doctors to prescribe drugs to adolescents under the age of 12 who are diagnosed with obesity and recommend weight-loss surgery to teens over the age of 13.
These guidelines are an essential part of a shift toward classifying obesity as a multilayered disease, which is helpful for those who want their health insurance to cover the costs of bariatric surgery. But they fail to challenge the warped idea of obesity to begin with. For as long as humans have existed, we have come in every shape and size, and yet, obesity is classified as having a Body Mass Index over 30. There aren’t any other measures taken to determine whether someone’s weight is unhealthy for their height or their body type. Instead, dividing weight by height, with no concern for differences in ethnicity or adiposity, is the sole determinant of obesity — and the BMI was never designed to be used that way. As the writer and fats rights activist Aubrey Gordon explains in a 2019 article for Medium, the BMI’s creator, Adolphe Quetelet, was neither a physician nor someone who had studied medicine. The fact that 200 years later, his invention is being used to invade children’s privacy and, sometimes, irreversibly alter the size of their stomachs shows how far we’ve gone off course. We’re still treating fatness as a moral failure that requires intense intervention, though scientists and physicians are promising they’re not.
Dr. Sandra Hassink, who coauthored the guidelines, told the Associated Press that these guidelines will divorce obesity from its association with a lack of personal responsibility and align it more with chronic disease. “This is not different than when you have asthma and now we have an inhaler for you,” Hassink said. Except treating the idea of obesity is quite different than treating childhood asthma given that performing weight-loss surgery, especially on children, is an extreme intervention that requires either stapling the stomach or literally removing pieces of the stomach to suppress appetites and increase metabolism. For at least the first week after weight-loss surgery, these children will be on liquid diets as their bodies recover. They’ll likely endure nausea and acid reflux. There’s also the possibility that their esophagus will dilate and they’ll be unable to ingest enough nutrients, leading to the development of anemia and gallstones.
We’re still treating fatness as a moral failure that requires intense intervention, though scientists and physicians are promising they’re not.
Those side effects appear to be a far cry from using an inhaler or undergoing professional-grade Albuterol treatments, but in the AAP’s view, these are necessary sacrifices. “What it offers patients is the possibility of even having an almost normal body mass index,” pediatrician Dr. Claudia Fox told the Associated Press. “It’s like a whole different level of improvement.” For children under the age of 13, pediatricians are prescribing Wegovy, a medication made by Novo Nordisk, that received authorization from the Food and Drug Administration on Dec. 23 to be prescribed as a weight-loss drug. (A different form of the medication is prescribed to treat diabetes.) Fox told the AP that she immediately prescribed Wegovy, which costs roughly $1,300 per month and isn’t often covered by insurance, to a 12-year-old female patient.
The AAP’s updated guidelines are part of a push among researchers, physicians, and scientists to complicate the ways in which we think about obesity. In a recent segment for 60 Minutes, correspondent Lesley Stahl waded into this conversation, one which has been plaguing the United States for more than two decades. Stahl calls upon experts and those afflicted with the so-called disease to offer context and perspective about how obesity has become, according to The Centers for Disease Control and Prevention, a “common, serious, and costly disease” that impacts 41.9% of Americans, leads to the development of several chronic illnesses such as Type 2 diabetes, hypertension, stroke, and multiple cancers, and costs the United States nearly $173 billion to treat.
Since the CDC declared obesity an epidemic in 1999, physicians, scientists, and researchers have been attempting to make sense of the reasons Americans are larger than we’ve ever been. Many reasons have been tossed around: In 1999, then–CDC director Jeffrey P. Koplan blamed a steady decline in physical activity, to which he offered a multitiered remedy: counseling obese patients in doctors’ offices, offering healthy food choices and opportunities to exercise in schools and workplaces, and building more sidewalks and bike paths in urban areas.
Since then, the United States has tried everything from implementing fresher, healthier menus in primary schools to shaming fat people to classifying obesity as a disease, but nothing has actually stopped Americans from gaining weight. During the 60 Minutes segment, Dr. Fatima Cody Stanford, an obesity doctor at Mass General Hospital and professor at Harvard Medical School, challenges the way we’ve been taught to think about obesity as a disease. As she notes, it’s not about “willpower” or simply “diet or exercise.” “My last patient that I saw today was a young woman who’s 39 who struggles with severe obesity,” Stanford said. “She’s been working out 5 to 6 times a week, consistently. She’s eating very little. Her brain is defending a certain set point.” In Stanford’s view, the brain controls how much food the body needs to eat and how much it stores within the body.
She also argues that obesity is genetic: In other words, if you were born to fat parents, then there’s a 50-85% likelihood of being fat even if you change your diet, exercise, sleep well, and manage your stress. Obesity, then, isn’t a moral failure; it’s more complex than that, and yet, Wegovy and its counterpoint, Ozempic, are being touted as possible solutions for this ever-growing epidemic. Rather than focusing simply on metabolism, these drugs are designed to connect the brain and the stomach while also suppressing the appetite. They are also touted as effective medications: Ozempic, Wegovy, and other medications prescribed for obesity are said to induce a weight loss of 15 to 22% of overall body weight. Most people begin at .25 milligrams a week and, depending on each patient’s side effects, they go up to .5 milligrams after a month. Eventually, over time, patients go up to 2.4 milligrams, which is the highest dose with the biggest payoff. The average weight loss at that level is 15 to 17% and one-third of those patients have 20% weight loss.
Of course, there’s a catch 22: Once you stop taking the medication, most people regain the weight they’ve lost. In that way, these medications are no different than any other diet — and they come with even more dire side effects. As Dr. Caroline Apovian, codirector of the Weight Management and Wellness Center at Brigham and Women’s Hospital in Boston, told 60 Minutes, side effects can range from nausea, vomiting, and diarrhea to pancreatitis. There are also other side effects that haven’t been studied: Mila Clarke, who began taking Ozempic for latent autoimmune diabetes in 2021, told the Cut that she began having cardiac symptoms within a week of taking Ozempic. “I could feel my heart beating out of my chest,” she said. “It was hard to breathe. I was woken up in the middle of the night from these heart palpitations. And I just could not take it anymore.”
This isn’t the first time physicians have peddled a miracle cure for obesity without considering the potential consequences. In the ’90s, as concerns about the size of Americans grew, doctors began describing the combination drug fenfluramine (an appetite suppressant) and phentermine (a type of amphetamine), better known as fen-phen, to patients with the express goal of helping them lose weight. The Food and Drug Administration approved the sale of fen-phen and doctors began prescribing it, but in 1997, amid a rise in fen-phen users developing cardiac issues, including pulmonary hypertension and leaky heart valves, manufacturers Wyeth-Ayerst Laboratories and Interneuron Pharmaceuticals were forced to remove their products from the shelves. Several people died from complications of their heart diseases. Eventually, 175,000 people filed claims against Wyeth-Ayerst, and the company settled the lawsuits for roughly $21 billion.
This isn’t the first time physicians have peddled a miracle cure for obesity without considering the potential consequences.
As Dr. Pieter Cohen, an associate professor of medicine at Harvard University, told MedPage Today in 2015, the deadly fen-phen fiasco revealed a lot about how the FDA thinks about obesity and the weight-loss medications prescribed to treat it. “It’s a cycle perpetuated by the FDA,” Cohen said. “It’s been going on since the amphetamines came out in the 1920s and ’30s.” In other words, if these newly approved weight-loss pills do have adverse side effects, the FDA may not revoke their authorizations until there are health disasters that are too large to avoid. Not to mention that the sudden craze, particularly around Ozempic, is leading to a shortage that could, ultimately, result in actual diabetics being unable to get their medication.
It is objectively a good move to unlink the idea of moral virtue from fatness. However, in these attempts to complicate our cultural understanding of fatness, the remedy remains the same: lose weight rather than changing the ways in which our society interacts with and treats fat people. Though Stanford, the obesity doctor, told 60 Minutes that “doctors do not understand obesity,” leading between 79 and 90% of physicians in the United States to have “significant bias towards individuals that are heavier,” there’s been no sustained push to retrain doctors to recognize and curb their unconscious fat bias. There isn’t a focus on food deserts that require impoverished people, many of whom are people from marginalized communities, to live without access to fresh fruits, vegetables, produce, and meat. Instead, the message remains that obesity is a complex disease that can be cured through diet, through exercise, and through continually escalating medical interventions ranging from dangerous drugs that have not been properly vetted to life-altering surgeries.
As much as some doctors may desire to stop treating fatness as an individual failing, their remedies and their approaches simply reinforce that status quo. If that belief isn’t interrogated and these medications aren’t properly studied, dying to be thin will become more than a rhetorical device. It will become a reality.●
Evette Dionne is a journalist, editor, and culture critic. She is the former editor in chief of Bitch Media and the current executive editor of YES! Media. Lifting as We Climb: Black Women’s Battle for the Ballot Box, Dionne’s middle-grade nonfiction book about Black women suffragists, was nominated for a National Book Award and won a Coretta Scott King author honor. She lives in Denver with her partner and her two pets and they are likely listening to Beyoncé right now.