Special Edition: Dangerous New American Academy of Pediatrics Guidelines for Higher-Weight Children

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At their base, the guidelines recommend intentional weight loss for higher-weight children via “Intensive Health Behavior and Lifestyle Training” starting as early as age two (2) with drugs as young as twelve (12) and surgeries starting as early as age thirteen (13).

There is a lot to unpack here, and this will be a multi-part series but I have had a flood of requests to write about them since they came out, and I had to get very familiar with them because I presented Grand Rounds at Children’s Minnesota this morning, so I thought I would get started with this first ever special edition of the newsletter so that I could get this info to you sooner and keep Saturday’s newsletter from becoming a novel!

I’m going to start with conflicts of interest because I believe these form the rickety scaffolding upon which the rest of these recommendations rest.

When I think about conflicts of interest, I generally feel that having a conflict of interest is not proof of bias, but is certainly a red flag indicating the need for taking a deeper look. Failing to freely and openly disclose a conflict of interest, on the other hand, seems more to me like a red flag doused in gasoline and set on fire. There’s a lot of the latter type of red flags in these guidelines.

To address conflicts of interest, the guidelines themselves state:

FINANCIAL/CONFLICT OF INTEREST DISCLOSURES: An Independent review for bias was completed by the American Academy of Pediatrics. Dr Barlow has disclosed a financial relationship with the Eunice Kennedy Shriver National Institute of Child Health and Human Development as a co-investigator.

That’s it. That is the only conflict of interest information provided. The same language is provided at the top of the guidelines and under the section “competing interests.” I cannot find any link to the actual review that they performed (if I missed it/you have it, please feel free to leave it in the comments!) I have to tell you that Dr. Barlow’s disclosed relationship is pretty much the least of my concerns here.

For example, based on their disclosure language you might not guess that, of the 14 authors who are medical doctors, at least 7 have taken money from companies that are developing or sell weight loss products that either directly benefit, or may benefit from these recommendations either through the development of a new drug, or approval of an existing drug for adolescents. The amount ranged from less than $20 for food and beverage (amounts like this typically indicate that the doctor had attended one or more “educational” seminars by these companies and have been found to influence behavior,) to one author who took more than $50,000 primarily for consulting and speaking engagements on behalf of these companies.

One of the companies that many took money from was Novo Nordisk, the pharmaceutical company that is aggressively marketing the drugs that are discussed in the guidelines (with an acknowledgment that they were included in the guidelines even though the research for them was published after the evidence review had already been completed.) Also, these numbers are only for 2015-2021 and where data is available. We know that Novo Nordisk has been pouring money into their effort to promote Wegovy and make good on their promise to shareholders that they would use the drug to double their “ob*sity* sales” by 2025, so it’s possible that quite a bit more money has changed hands than is represented here.

Regardless, as you can see, none of these payments are mentioned in the conflict of interest statement.

Based on the American Academy of Pediatrics’ conflict of interest statement, you also might not guess that, in fact, Novo Nordisk is a “Patron” of the American Academy of Pediatrics itself- donating somewhere between $25,000 and $49,999 to the organization.

Other “patrons” of the AAP include:

GlaxoSmithKline, maker of the weight loss drug alli

Genentech, which sells the weight loss drug Xenical

Prolacta, which manufactures human milk-based nutritional products that they claim lowers the risk of ob*sity

Of course, none of this is proof that they manipulated the guidelines to benefit these companies, but absolutely none of this is disclosed in the conflict of interest statement which, again…big red flag for me.

Considering all of this, I am unconvinced that the American Academy of Pediatrics was in a position to conduct an “Independent review for bias” of guidelines that are incredibly favorable for their “patrons” and the companies from which the authors received money, and the authors themselves.

You may also be surprised to learn that disclosure rules don’t even require that they acknowledge that almost every author has a career that is based in the “higher-weight as lifelong chronic illness” model that these guidelines embrace and perpetuate. There are authors who run pediatric weight loss clinics, authors who run pediatric weight loss surgery programs, authors who are employed as pediatric weight management specialists. Below you’ll find a list of the authors with information that I pulled from their various online bios about their past and current work in pediatric “ob*sity” as well as the payments I found to them on openpayments.cms.gov

For almost all of the authors, these recommendations will increase the market for their services. That doesn’t necessarily mean that’s why they are making the recommendations, but it’s still the literal definition of a conflict of interest. And yet, no disclosure of this is even required and, as you might imagine, none is made.

There is also one oddity that I want to point out. Sarah C. Armstrong (who, of the authors who are MDs, took the most money from pharmaceutical companies that do or may benefit from these guidelines at $51,050.45) claims “I subscribe to a "health at every size" approach to supporting children, teens, and young adults living with ob*sity” on the same webpage on which her title is “Medical Weight Management Specialist.” That is, quite literally, impossible as those two things are mutually exclusive.

Health at Every Size™ stands completely opposed to the concept of weight management and the pathologizing of body size, including the use of the term “ob*sity.” There is no ambiguity or grey area here, Health at Every Size™ is the trademarked brand of the Association for Size Diversity and Health, there are literally rules for this. So, from my perspective either Dr. Armstrong (a medical doctor who is co-authoring guidelines for other doctors) doesn’t understand the basic principles upon which she claims her practice is built, or she is co-opting the language of weight-neutral health in order to promote weight loss. Either way, to me this is concerning enough to point out.

I want to be clear, I don’t think that these authors are necessarily trying to create profit for themselves, or to harm children. There are a LOT of degrees and certifications held by these authors, and many hold positions at prestigious universities and healthcare facilities. I think they are probably well-intentioned and truly believe that they are doing what’s best for children. (As someone who is both queer and fat, I can imagine that if, a few decades ago, you had gotten together a group of doctors who had centered their careers on treating “homosexuality,” you would have gotten guidelines very much like this.)

I also think that they are deeply misguided (and experiencing paradigm entrenchment,) and that’s not surprising given the billions that the weight loss industry has poured into conflating health with weight and weight loss, including in the research, and the (mis) education of healthcare practitioners. Still, I believe that, if adopted, these guidelines will do massive harm. In Saturday’s regular edition of Weight and Healthcare there is a deeper dive into the guidelines themselves. And a piece specifically about their eating disorders claims is here.

Here is the author list with payments and info I found about their work within the body size as pathology paradigm (note that this is not an exhaustive list and includes past and present work)

Sarah E Hampl

• Novo Nordisk, $15.15

• Pediatrics, Weight Management

Sandra G Hassink

• Director of the AAP Institute for Healthy Childhood Weight

• Began the weight management clinic at Nemours/AI DuPont Children’s Hospital in 1988

• Has collaborated in basic research efforts to identify pathophysiologic mechanisms of ob*sity

• Has lectured widely in the field of pediatric ob*sity

• Authored A Parent’s Guide to Childhood Ob*sity, Pediatric Ob*sity: Prevention, Intervention, and Treatment Strategies for Primary Care, and Clinical Guide to Pediatric Weight Management

• Dedicates a significant portion of her time to advocacy and policy development on ob*sity prevention and treatment.

• Served on the IOM committee on Accelerating Progress on Ob*sity Prevention and was an author on the Expert Recommendations for Ob*sity

Asheley  C Skinner

• Areas of expertise: Implementation Science, Health Services Research, Child Ob*sity

Sarah C. Armstrong

• Genetech $41,250.45, Pfizer $5,000, Novo Nordisk $4,800

• Medical Weight Management Specialist

Sarah E. Barlow

• Echosens $94.89, Alexion 84.31, Abbvie $52.83, Ethicon 51.10, Novo Nordisk 32.27, Avanos $14.13

• Oversees an integrated program in ob*sity care that spans community programs, primary healthcare and tertiary care

Christopher F. Bolling

• Allergan 145.29, Tris Pharma $50.82, GlaxoSmithKline $45.82, Sanofi $44.71, Takeda $30.39, Astra Zeneca 23.87

• Ob*sity Task Force Chair, KY Chapter, American Academy of Pediatrics

Kimberly C. Avila Edwards

• Co-founded the Texas Center for the Prevention and Treatment of Childhood Ob*sity at Dell Children's Medical Center in 2010

• On the steering committee for the Institute for a Healthy Childhood Weight from 2012-2016

• Chaired the Ob*sity Committee of TPS (Texas Pediatric Society) from 2007 to 2011

Ihuoma Eneli

• Director of the Center for Healthy Weight and Nutrition at Nationwide Children's Hospital

• Oversees a comprehensive pediatric ob*sity center with activities that include advocacy, prevention, medical weight management and adolescent bariatric surgery

• Directs the Primary Care Ob*sity Network (PCON) which provides ob*sity-related training, resources and community integration for 21 primary care practices in Central Ohio

• Has particular interest in intervention research for pediatric ob*sity

• Member of the National Academy of Sciences Roundtable on Ob*sity Solutions

Robin Hamre

• Ob*sity prevention program team leader for the Centers for Disease Control and Prevention

Madeline M. Joseph

• Chief, Division of Pediatric Bariatrics University of Florida Health

Doug Lunsford

• Lead Patient Principal Investigator, PCORnet Ob*sity Study
  member of the Parent and Patient Leadership Team for the Healthy Weight Network

• Co-founder of the Healthy Weight Community

• Twitter Bio: Working to end childhood ob*sity

Eneida Mendonca

• Biomedical Informatics expert, no link to ob*sity medicine

Marc P. Michalsky

• Novo Nordisk $13,576.47

• Surgical Director for the Center for Healthy Weight and Nutrition at Nationwide Children's Hospital

• Serves as a clinical investigator on several National Institutes of Health (NIH)-sponsored research initiatives examining outcomes following surgical weight reduction in the severely ob*se adolescent population.

• Dr. Michalsky's team currently performs gastric sleeve surgery, gastric bypass surgery, and adjustable gastric banding on severely ob*se adolescents

Nazrat Mirza (Rhythm Pharmaceuticals $526.50, Novo Nordisk $64.54)

• Medical Director, IDEAL Pediatric Weight Management Clinic

Eduardo R. Ochoa

• Merck $3,868.16

• Principle investigator for the Children's Health Watch Little Rock site at Arkansas Children's Hospital

Mona Sharifi

• Studies the effectiveness, cost-effectiveness, and implementation of novel primary care-based interventions for childhood ob*sity

• Yale School of Medicine Ob*sity Research Working Group

Amanda E. Staiano

• Pennington Biomedical Research Center. Assistant Professor, Pediatric Ob*sity and Health Behavior Lab

• Studies the best ways to target children and adolescents who are most at-risk for ob*sity and chronic disease, tailoring physical activity interventions to help these children and adolescents achieve a healthy weight

Ashley E. Weedn

• Novo Nordisk $64.52

• During residency, she trained at the University of California at San Francisco in pediatric weight management

• Her clinical and research interests are in childhood ob*sity.

• She leads several pediatric ob*sity projects

• Serves as the Medical Director of the OU pediatric multidisciplinary weight management clinic

• Co-chairs the Ob*sity Special Interest Group of the Academic Pediatric Association

• Serves as a Childhood Ob*sity Advisor for the American Academy of Pediatrics

• Founded and co-chairs the Ob*sity Committee through the Oklahoma Chapter of the American Academy of Pediatrics

• Works with pediatricians across the state to address childhood ob*sity, including development of toolkits and webinars for primary care providers on childhood ob*sity assessment and management.     

Susan K. Flinn

• Writer/editor for hire

Jeanne Lindros

• Manager, Ob*sity Initiatives, American Academy of Pediatrics

• Co-presenter: Virtual reality-based training for motivational interviewing around childhood ob*sity – are pediatricians “game”?

Kymika Okechukwu

• Senior Manager, Evidence-Based Medicine Initiatives  - American Academy of Pediatrics

Stay tuned for Saturday’s deep dive into the guidelines!

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.