Testing The Claim That Pediatric Weight Management Interventions Decrease Eating Disorders

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I think that one of the more dangerous and disingenuous parts of the new American Academy of Pediatrics guidelines is their claims about eating disorders. These are claims that I am hearing echoed in other spaces as well, so I wanted to write about them in depth. In terms of the guidelines themselves, I wrote a deep dive about their three main recommendations around “Intensive Health Behavior and Lifestyle Treatment (IHBLT), weight loss drugs, and weight loss surgeries here. I also looked into undisclosed conflicts of interest here.

When it comes to eating disorders they claim (in bold, title case) that “Evidence-based Pediatric Ob*sity* Treatment Reduces Risks for Disordered Eating.” Is this remotely true? Let’s get into it.

They begin by saying “concerns have been raised as to whether diagnosis and treatment of ob*sity [in the case of these guidelines starting at the age of two] may inadvertently place excess attention on eating habits, body shape, and body size and lead to disordered eating patterns as children grow into adulthood.”

Well, let’s examine the situation. They are “diagnosing” kids as having a “disease” based solely on their body size and shape, and then recommending “Intensive” interventions and dangerous drugs and surgeries that put significant focus on food and food restriction with the goal of changing the child’s body size and shape. There is nothing inadvertent about this, it’s about as advertent as it can get.

They go on to claim “Cardel et al refer to multiple studies that have demonstrated that, although ob*sity and self-guided dieting consistently place children at high risk for weight fluctuation and disordered eating patterns, participation in structured, supervised weight management programs decreases current and future eating disorder symptoms (including bulimic symptoms, emotional eating, binge eating, and drive for thinness) up to 6 years after treatment. “

I’ll get to the research they cite in a minute, but I want to point out that in their list of current and future eating disorder symptoms, they left a few out including (from the AAP’s OWN 2016 paper on eating disorders prevention in adolescents):

“Severe dietary restriction, skipping of meals, prolonged periods of starvation, or the use of self-induced vomiting, diet pills, or laxatives”

Let’s remember that even if their “intensive” behavioral therapy recommendations don’t devolve into disordered eating and eating disorders (and they certainly could,) their recommendations around pharmacotherapy and weight loss surgery literally induce all of these symptoms, sometimes for the rest of the child’s life.

It’s pretty difficult to reduce eating disorders symptoms when you’ve created 100 pages of guidelines to literally recommend them. This reminds me of something the brilliant Deb Burgard says, which is that we prescribe to fat people what we diagnose and treat in thin people, and in this case the people are children.

Now, I don’t know if those symptoms are left out accidentally because the authors are so ignorant about eating disorders and higher-weight kids that they assume higher-weight kids aren’t susceptible to these (potentially fatal) symptoms, or if they left them out on purpose because they know that being honest about this renders their claims of their “treatments” decreasing eating disorder symptoms not just false, but patently ridiculous. Either way, the fact that they don’t even mention these symptoms means that, at best, they don’t have the expertise necessary to even talk about this, let alone create guidelines.

Ok, so let’s look at the research they cite to back up their claims that ob*sity “treatment” reduces risks for disordered eating.

Forkey H, Szilagyi M, Kelly ET, Duffee J; Council on Foster Care, Adoption, and Kinship Care; Council on Community Pediatrics; Council on Child Abuse and Neglect; Committee on Psychosocial Aspects of Child and Family Health. Trauma-informed care. Pediatrics. 2021;148(2):e2021052580

Given that this clinical report doesn’t mention supervised weight management programs, eating disorders, or eating disorder symptoms, I would suggest that it does not support their claims.

Something interesting that it does talk about is that higher-weight children are “more likely to experience discrimination, both overt and as a series of microaggressions (small slights, insults, or indignities either intentional or unintentional) that accumulate over time” and that “the lifelong effects of toxic stress are statistically related to many adult illnesses, particularly those related to chronic inflammation, and causes for early mortality.”

This is important because the authors of the AAP guidelines are ignoring it in order to uncritically assume that if higher-weight kids have these health issues then it is because of their weight without mentioning that (as explained in a study they, themselves, cited) it might not be their weight but, in fact, the weight stigma they experience that is the root.

The next study is Jebeile et al., (2019) Association of pediatric ob*sity treatment, including a dietary component, with change in depression and anxiety: a systematic review and meta-analysis.

We’re getting warmer here, at least this study actually talks about “ob*sity” treatment. However, they do not examine eating disorder symptoms, they look at changes in depression and anxiety. They find that “structured, professionally run pediatric ob*sity treatment is not associated with an increased risk of depression or anxiety and may result in a mild reduction in symptoms.” First, note the use of “may result,” not exactly a clear conclusion. Beyond this, the studies offer follow-up between 2 weeks to 15 months. We know that weight regain typically starts around the 12 month mark, but this study fails to address (or even consider) what will happen to depression and anxiety symptoms during/after weight regain.

I wonder if the study authors actually meant to cite this study, by the same authors:

Jebeile et al.. (2019). Treatment of ob*sity, with a dietary component, and eating disorder risk in children and adolescents: A systematic review with meta-analysis.

I noticed right away that there was a letter written about this study by Louise Adams. I know Louise, I have been a guest on her podcast All Fired Up (including recently with Fiona Willer to talk about the dangers of Wegovy and Saxenda). Her letter to the editor was behind a paywall, and while I could access it, I knew that if I wrote about it nobody else who wanted to read it could. So I reached out to her and I got something even better. I received the full text of the letter she wrote (not the shorter version that they published.) Here is the summary, the letter is re-printed in its entirety at the end of the piece. Her work is always spot on, you can check out her work and sign up for her newsletter here.

Here is Louise Adams’ summary of the issues with this study:

Given the errors and serious omissions in Jebeile et al’s article, the findings and conclusions of this review are unreliable. I am concerned that the overarching message of this paper projects an air of certainty regarding the long-term safety and efficacy of adolescent weight loss interventions on ED risk that does not reflect adequate data and places children and adolescents at risk of harm. I am concerned that this paper will be used as evidence to justify ever more invasive weight loss trials and products in vulnerable adolescent populations. The authors’ conclusion that ‘structured and professionally run ob*sity treatment leads to a reduction in the prevalence of ED, ED risk, and ED-related symptoms for most participants’ is extraordinarily misguided, given that (a) quality long-term data were available for only 7.5% of the sample, and (b) clear evidence of a subset of adolescents who developed ED symptoms was present in the longer term studies. Moreover, the high numbers of missing data due to adolescents lost to follow up is important to note and cannot be overlooked as a potential indicator of even higher risk.

In our conversation, Louise pointed out that her concern that this study would be used to justify additional weight loss trials is exactly what happened here. She also mentioned that in the “conflicts of interest” section of her letter to the editor, the original study authors pushed for her to include “The author discloses that in addition to practicing as a consultant clinical psychologist in private practice, she derives income from an online anti‐diet program for adult chronic dieters.” She points out that their zeal for conflict of interest disclosures did not extend to their own study. In fact they claimed “no conflicts of interest”  despite the fact that they worked at the adolescent ob*sity clinic and that Baur didn't disclose her role as president of the weight loss industry-funded  World Ob*sity Federation. I discussed the issues with the false equivalence between anti-diet work and diet industry work here.

The last study they cite is Cardel MI, Newsome FA, Pearl RL, et al. Patient-centered care for ob*sity: how health care providers can treat ob*sity while actively addressing weight stigma and eating disorder risk. J Acad Nutr Diet. 2022;122(6): 1089–1098

The short story about this study is that it reads like a bunch of diet industry shills trying to co-opt the language of weight-neutral health in order to obfuscate the plain fact that intentional weight loss is incompatible with eating disorders prevention and treatment, so they can continue to market the same old failed “interventions” for “ob*sity”* and dodge responsibility for all the harm they create. I did a deep dive into this paper here.

The challenges in diagnosing EDs in the context of the treatments recommended in these guidelines are due to the fact that the behaviors recommended by these guidelines (and created by the drugs and surgeries recommended) are consistent with eating disorders symptoms. Another way to say this is that the same behaviors that are considered red flags for an eating disorder in thinner children are being recommended as “healthcare” for higher-weight children bolstered by the dubious claim that they will reduce eating disorder symptoms.

I do not think any of the research they cite comes close to supporting their claim that “evidence-based pediatric ob*sity treatment reduces risks for disordered eating.” In fact, I think significant research (which I wrote about here) shows that if the American Academy of Pediatrics guidelines are followed, they will create a generation of kids struggling with disordered eating and eating disorders , starting as early as two years old.

Compounding the issue, since (by their own admission,) the “treatments” recommended by their guidelines almost never result in significant, long-term weight loss, these kids will still be higher-weight and, thus, have a more difficult time getting properly diagnosed with these life-threatening conditions (especially if their doctors read claims that the weight loss “treatments” the kids have survived supposedly prevent eating disorders.) This will do the most harm to higher-weight kids who are multiply-marginalized and/or under-resourced who, even if they can get a correct diagnosis, will have a very difficult time getting treatment.

The top eating disorders organizations have come out unequivocally against these guidelines:

International Federation of Eating Disorders Dietitians

National Alliance for Eating Disorders

Shame on the AAP for bending themselves (and the data) into pretzels to defend and recommend a dangerous and failed weight loss paradigm to children as young as two years old.

Here is Louise’s full letter

Professor David York
Editor-in-Chief
Ob*sity Reviews
444 W Willis #307
Detroit
MI 48201

Dear Professor York,

I am writing to bring to your attention my significant concerns about an article recently published in Ob*sity Reviews:

Jebeile, H, Gow, ML, Baur, LA, Garnett, SP, Paxton, SJ, Lister, NB. Treatment of
ob*sity, with a dietary component, and eating disorder risk in children and adolescents: A systematic review with meta-analysis. Ob*sity Reviews. 2019; 20: 1287– 1298. https://doi.org/10.1111/obr.12866

Please note that I send you this communication not with a view to being published in your journal (unless you believe this to be appropriate - I leave this decision to your discretion), but to ask that you consider the points I make below and consider retracting the article.

This review sought to investigate the impact of ob*sity treatment, with a dietary component, on eating disorder (ED) prevalence, ED risk, and related symptoms in higher weight children and adolescents. The review analysed 29 studies, claiming data for 2589 adolescents. The authors concluded that ‘structured and professionally run ob*sity treatment was associated with reduced ED prevalence, ED risk, and symptoms’. I have three main concerns about the quality of this paper: (1) review methods, (2) follow up period definitions and (3) omission of dietary restraint analysis. These concerns are detailed below:

1. Review Methods: Decision to Run a Meta-Analysis

The fact that a meta-analysis was conducted rather than a narrative summary is troubling considering the heterogeneity of the studies included. The 29 studies involved interventions ranging from 1 week to 13 months. 11 of the studies had no follow up period. Those with follow ups varied considerably, ranging from 12 weeks to more than 5 years post intervention. The intervention types and locations were vastly different: including inpatient and outpatient hospital programs, school-based health clinics, and even an intervention in which adolescents attended a Jenny Craig program.

A systematic review of 9 adolescent weight management interventions exploring the same subject - ED risk factors - by De Giuseppe and colleagues (2019) shared five papers in common with Jebeile et al (2019). However, De Giuseppe et al concluded that a meta analysis was not possible due to heterogeneity of the papers, and instead conducted a narrative summary of the findings. I believe that Jebeile et al should also have conducted a narrative review due to the heterogenity of the studies. Both Jebeile et al and De Giuseppe et al conducted a quality assessment, albeit using different assessment tools. Jebeile et al used the US Academy of Nutrition and Dietetics Quality Criteria Checklist (Handu et al 2016) and rated 11 of their included papers as ‘positive’ and 25 as ‘neutral’. The De Giuseppe et al (2019) study utilised the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies (Thomas et al, 2004). For 4 of the 5 studies in common, Jebeile et al ’s quality ratings were higher than those assessed by De Giuseppe et al :

Study Cited                                         Jebeile et al (2019)          De Giuseppe et al (2019)

Cohen et al (2018)                           Positive                                                Moderate

DeNiet et al (2012)                          Positive                                                Moderate

Halberstadt et al (2016)                 Neutral                                                 Weak

Goossens et al (2011)                     Neutral                                                 Weak

Saverstani et al (2009)                    Neutral                                                 Moderate

There is clear disagreement between these authors as to the quality of the same studies, with Jebeile et al consistently producing more positive assessments.

2. Follow Up Period Definitions

18 studies cited by Jebeile et al included follow up periods. In their Eligibility Criteria they stated that data at last follow up was ‘defined as a period in which there was no contact with study personnel and no intervention delivery’ (pg 1288). Given this definition, the paper should have consistently referred to follow up periods from the end of intervention rather than baseline.

However, throughout the paper and supplementary document, Jebeile et al (2019) repeatedly provide data reflecting time periods from baseline, often without explicitly stating that the period cited was taken from baseline and did not reflect their given definition.

An example of this is on page 4 under “Prevalence of diagnosed eating disorders”, where Jebeile et al stated that “from 110 participants who completed the 24 month follow-up measures in the study by Braet et al…”. This should have been reported as a 14 month follow up.

A further correction is needed in that the Braet et al (2004) study only had data on ED measures for 89 participants, not 110. Another example of this type of error in the reported number of participants occurred in the reporting of the De Bar et al (2012) study, where they stated that the intervention had n=100 in usual care and n=100 in the usual care control group, when in fact there were n=90 in the intervention group and n=83 in the control group. It is of concern that both of these errors overstated the number of participants in their dataset.

Defining the follow up period in one way in the Eligibility Criteria and reporting it another way throughout the paper had the impact of making the included studies’ follow up periods appear longer than they actually were. It is critical that the correct follow up period definition is adhered to, as Jebeile et al have used these to claim that a ‘strength’ of their meta-analysis was that it ‘addresses concerns over longer term ED risk….with follow-up timepoints of up to 6 years from baseline, including seven studies with a follow up of >2 years” (p. 1295). If we use the correct definition for follow up periods as beginning from the end of an intervention period, only 3, not 7, of the studies in their meta analysis have a follow up period of 2 years or longer, representing just 7.5% of the total sample. This low number certainly does not adequately address concerns over longer term ED risk in adolescents, and represents a weakness, not a strength, of the meta analysis.

3. Quality of the Analysis of Risk Posed by Adolescent Weight Loss Interventions

Jebeile et al’s claims regarding the safety of adolescent weight loss interventions is at odds with the widely held view, supported by theories of the etiology of ED development (Ahern, Bennett, Hetherington, 2008; Berge et al, 2018, Fairburn, Cooper, Doll, Welch,1999, Golden et al, 2016, Ouwens et al, 2009, Polivy & Herman, 1985, Stice & Presnell, 2007) and a substantial body of longitudinal research (Field et al, 2003,Neumark-Sztainer et al, 2007, Patton et al, 1999, Stice 2001, Stice et al, 2000, Stice et al, 2005, Urvelyte & Perminas, 2015) which demonstrate that over time, dieting is a major risk factor for both increased weight and increased risk of development of disordered eating and ED. In order to accurately assess the impact and potential harms of adolescent weight loss interventions, three conditions must be met:

1) Quality data that captures disordered eating/eating disorder symptomatology for a period of at least 2 years, if not longer, after the diet intervention ends. This is because in childhood and adolescence eating disorders can take considerable time to appear; Stice and Van Ryzin (2019) have identified a 4-step pathway of eating disorder development which demonstrated that eating disorder symptoms did not appear until, on average, 26.8 months after youths began dieting.

The need for longer follow up data has been apparent for a considerable time: over 20 years ago, Casper (1996) discussed this need to improve research standards and recommended even longer minimum follow-up durations of 4 years.

2) ED instruments that have been developed and normed for higher weight adolescents. These measures should include an exploration of internalised weight stigma, so that researchers can untangle the apparent positive impact of weight loss from the experience of a reduction in internalised and external weight bias. Unfortunately such ED instruments do not yet exist. In the absence of such sensitive measures, quality studies must include follow up data for ED measurements of some kind.

3) In order to determine the efficacy of weight loss interventions, best practice is to include a control group from the same population (Brown et al, 2019). It is even more important in youth, since BMI algorithms include the speed of growth, not just height and weight, and weight loss and gain are being assessed in relation to other youth. To answer the question of the impact of dieting, it is important to track the weight trajectories of larger bodied adolescents who do not diet. Phenomena such as regression to the mean (RTM) in higher weight adolescents and normal variations in growth spurts can impact significantly, and without control groups the true impact of weight loss interventions on larger youths will remain unknown. Brown et al (2019) have called for researchers to “clearly, and without reservation, acknowledge the distinct possibility that RTM could explain the improvements after intervention (p.4)”.

None of the studies included in Jebeile et al’s meta-analysis met all 3 of these requirements. None of the studies included a randomised control group with 2 year post intervention data. Only 3 studies - Braet et al (2000, 2006), and Goossens et al (2011) meet criteria for providing ED measures with a follow up period after the intervention of 2 years or longer. Once drop out rates and the number of adolescents with complete ED data at follow up are factored in, Jebeile et al’s paper included quality data on 195 adolescents; just 7.5% of the sample.

It is accurate to state that the meta-analysis revealed more about how much we do not know about the link between adolescent weight loss interventions and ED development, rather than claiming evidence of safety. I am concerned that the way this paper is written obscures the true message of the data. The authors’ conclusions do not mention the dearth of meaningful long-term data, instead the opposite message - one that suggested a degree of certainty - was conveyed.

A closer examination of the 3 studies with longer term data on ED is warranted. Braet et al (2000) conducted a three-armed intervention on 136 adolescents aged between 7 and 17 years. There was no control group. The intervention compared 3 conditions of a CBT based ‘healthy eating’ program. A follow up was conducted 4.6 years after the intervention ended.

ED data were available for only 53 of the original 136 participants (39% of the sample). A large number of adolescents did not return for follow up, and it is plausible that these youths may be experiencing negative impacts from the intervention. The authors called for “caution in interpreting these data” given the large amount of missing data.

Participant data for the Dutch Eating Behaviour Questionnaire (DEBQ) was gathered at baseline and at follow up. The results of the DEBQ showed a significant reduction in external eating, a significant increase in restrained eating, and no change in emotional eating.

Braet et al also administered the Eating Disorder Inventory (EDI) at the 4.6 year follow up. These results revealed that girls scored higher than average on the Drive for Thinness subscale, and boys scored significantly higher than average on the Body Dissatisfaction subscale. 9% of the sample had a score of five or more on the Bulimia EDI-subscale. Analysing a subsample of 76 of the youths, one had been hospitalised in an eating disorder unit.

In terms of weight reduction, the Braet et al study showed that mean % overweight was 55% at the outset and 42% at follow up. Without a control group it is not possible to interpret these results. Further, almost half of the subsample reported that they had continued to seek weight loss after the intervention ended. This would impact on ED measurements: if adolescents are still dieting, some ED symptoms (eg binge eating) may not be apparent. This does not mean however that they have not been harmed, or that an ED will not develop in the future.

It is important to note that other authors in the field have cited the Braet et al (2000) study as evidence for the emergence of ED symptoms after weight loss interventions.

For instance, Goossens et al (2011) make the following statement: “results from a recent study...demonstrate that despite initial improvements (post-treatment and 2-year followup), eating pathology stagnated and even tended to increase in a subsample of youngsters at 3-year follow-up.”

It should further be noted that the description of Braet et al’s (2000) study presented in Table S2 in Jebeile et al’s paper lists only the DEBQ and omits the EDI . Furthermore, the elevated Bulimia subscale scores in Braet et al’s study were omitted in section 3.6.1. Bulimic Symptoms, despite the obvious relevance. In fact the Braet et al (2000) study is completely absent from this section, which is of concern. Jebeile et al state that “Two studies reported on participants with scores above a clinical cut-point for bulimic symptoms”. This should be corrected to say 3 studies, and include an overview of the Braet et al (2000) EDI data including that girls scored higher than average on the Drive for Thinness subscale, boys scored significantly higher than average on the Body Dissatisfaction subscale, 9% of the sample had scores above a clinical cut-off point for Bulimia, and one participant had been hospitalised for an eating disorder.

The study by Braet et al (2006) followed 150 adolescents through a ten-month inpatient weight loss program. 2 years later, 110 youths provided weight data and Eating Disorder Examination (EDE) data was collected for 86 participants at baseline and follow up. This represents an absence of data for 43% of the sample.

In terms of weight, the authors reported a 10% reduction in adjusted BMI, but without a control group it is not possible to ascertain the actual impact of the weight loss intervention. Of note, 75% of the sample were reported to be regaining weight after the intervention, even though 78% reported that they were engaging in further weight loss attempts after the study period ended.

The overall EDE scores were reported as reduced at the 2 year follow up mark, but detailed subscale data was not reported. The same sample was discussed in a 2009 study by Goossens et al, where they reported increases in dietary restraint scores, and further warned that “in younger age groups, as was the case in this study, restraint attitudes have probably not yet reached their peak, and, as a consequence, full-blown eating disorders are still hard to detect.” The authors themselves are acknowledging that even a two year follow up is not enough time for ED symptoms to start showing in this population.

The third study by Goossens et al (2011) was conducted on a sample of 108 adolescents aged between 10 and 17. There was no control group. The intervention was a 10 month inpatient program (the same program reported in Braet et al 2006). The follow up period was five years and two months after the intervention ended. Overall, 48% of the sample were lost to follow up, and the authors obtained complete ED measures (Child Eating Disorder Examination [chEDE] and the EDI) for 56 adolescents.

No participants met criteria for binge-eating disorder (BED) at baseline. However, at follow-up, 5.4% met BED criteria. 8.3% of youths who did not report Objective Binge Eating (OBE) at baseline reported OBE at follow up. 8.5% of youths who did not report Subjective Binge Eating (SBE) at baseline reported SBE at follow up. Half of the adolescents who reported OBE at baseline still reported OBE at follow up.

In summary, the data for studies with follow up periods of 2 years or longer show that from an initial pool of 394 youths, data on 195 were available, representing just 49.5% of the starting sample. Within this group, roughly 5-9% are showing signs of disordered eating and increased risk of ED following weight loss interventions. Disordered eating symptoms arise over time, and are easily erased when meta analyses include no or short term follow up periods. It is imperative that any research in this area focuses on long term outcomes, not allowing the shorter term data to obscure the big picture. We must also keep in mind the fate of the large group of adolescents (in this case, roughly half) who are lost to follow up. The fate of these youths is too often overlooked, and it is plausible that many of these people end up with disordered eating and ED.

3. Omission of Dietary Restraint Analysis

Jebeile et al’s paper does not include a section reporting the impact of adolescent weight loss interventions on dietary restraint (DR) , a glaring omission given this is a central precursor to and symptom of eating disorders. In the studies included in the review, ample data was collected for DR and warrants further analysis.

The differing frames between the eating disorder literature, in which DR clearly features as a central symptom of EDs, and the ob*sity research literature, in which DR is viewed as desirable for larger bodied people, is critically important to highlight. The treatment of ob*sity requires a practice that has been found to be a gateway to the development of eating disorders for people with eating disorders. For ob*sity researchers to omit any analysis of the impact of adolescent weight loss interventions on DR is a tacit admission that higher weight people should be prescribed what is diagnosed as disordered eating in thinner people.

Many of the papers in the meta analysis demonstrated increases in DR soon after the intervention (eg, Braet et al 2000, Braet et al 2006, Brennan et al 2012, Goossens et al 2011, Halberstadt et al 2016, Saverstani et al, 2009). Several of the authors involved in these studies themselves raised the issue of dietary restraint as an important issue to study in adolescents, noting that it is important that interventions do not make DR worse. For example, Braet et al (2000) note that “ we wanted to avoid the type of dietary restraint that has been linked to the development of eating disorders” .

In comparison, the De Giuseppe et al (2019) analysis discussed DR at length, noting conflicting results. Some studies found the interventions reduced DR, whilst others found they increased it. Regardless of whether DR is viewed as a precursor to both weight regain and the development of ED (Jansen et al, 2009, Stice et al, 2005), or viewed as a necessary and potentially useful method of weight control for larger sized adolescents (Smith et al 2018), this topic needs to be analysed, discussed and argued, not ignored.

Given the errors and serious omissions in Jebeile et al’s article, the findings and conclusions of this review are unreliable. I am concerned that the overarching message of this paper projects an air of certainty regarding the long-term safety and efficacy of adolescent weight loss interventions on ED risk that does not reflect adequate data and places children and adolescents at risk of harm. I am concerned that this paper will be used as evidence to justify ever more invasive weight loss trials and products in vulnerable adolescent populations. The authors’ conclusion that ‘structured and professionally run ob*sity treatment leads to a reduction in the prevalence of ED, ED risk, and ED-related symptoms for most participants’ is extraordinarily misguided, given that (a) quality long-term data were available for only 7.5% of the sample, and (b) clear evidence of a subset of adolescents who developed ED symptoms was present in the longer term studies. Moreover, the high numbers of missing data due to adolescents lost to follow up is important to note and cannot be overlooked as a potential indicator of even higher risk.

I respectfully request that this paper be considered for retraction. Thank you for considering my submission, I await your response.

Yours sincerely,
Louise Adams
Clinical Psychologist
Untrapped
Sydney, Australia

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*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.