NATIONAL EATING DISORDERS ASSOCIATION STATEMENT OF CONCERN IN RESPONSE TO AMERICAN ACADEMY OF PEDIATRICS POLICY STATEMENT—PEDIATRIC METABOLIC AND BARIATRIC SURGERY: EVIDENCE, BARRIERS, AND BEST PRACTICES
November 4, 2019
The National Eating Disorder Association (NEDA) issues this position statement in response to the American Academy of Pediatrics (AAP) Policy Statement entitled “Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices” published online in October, and to be published in the upcoming December 2019 issue of Pediatrics (2019 Policy Statement).
In the United States, more than 30 million individuals suffer from eating disorders at some point in their lives. The majority of those with eating disorders live in “normal” weight or higher weight bodies. While eating disorders occur and persist through the lifespan, eating disorders in youth—when children are preparing to enter or going through puberty and are supposed to be growing and, specifically, gaining fat—are of particular importance in the eating disorders community. Indeed, eating disorders in youth and the early identification and intervention of same, across the weight spectrum, should be of paramount importance in all health and mental health-related fields. The lack of such prioritization can—and does—cause irreparable harm. For this and other reasons, NEDA is concerned about the position the AAP has taken regarding bariatric surgery in children with “severe obesity.”
This statement will delineate some of our specific concerns related to the 2019 Policy Statement. We look forward to initiating conversations with the AAP about this Policy Statement to ensure that children with a history of an eating disorder, a current eating disorder, or those at elevated risk for developing an eating disorder, are not harmed. We, of course, are equally concerned about the potential impacts of the Policy Statement on youth who have not and will not struggle with an eating disorder. NEDA’s statement, though, is issued on behalf of those in our community for whom we have significant concerns.
1. The issuance of the 2019 Policy Statement contradicts a 2016 AAP Clinical Report, entitled “Preventing Eating Disorders and Obesity in Adolescents,” published in the September 2016 issue of Pediatrics (2016 Clinical Report). In short, that report, made the following six recommendations:
a. Discourage dieting, skipping of meals, or the use of diet pills; instead, encourage and support the implementation of healthy eating and activity behaviors that can be maintained on an ongoing basis.
b. Promote a positive body image among adolescents. Do not encourage body dissatisfaction or focus on body dissatisfaction as a reason for dieting.
c. Encourage more frequent family meals.
d. Encourage families not to talk about weight but rather to talk about healthy eating and being active to stay healthy.
e. Inquire about a history of mistreatment or bullying.
f. Carefully monitor weight loss in an adolescent who needs to lose weight to ensure the adolescent does not develop the medical complications of semistarvation.
NEDA, while not in full agreement with the above recommendations, appreciates the AAP’s recognition of the importance of weight-neutral efforts in healthcare settings and the need to think critically about potential overlapping risk factors for eating disorders and obesity. We do not believe the 2019 Policy Statement is congruent with the 2016 Clinical Report and are significantly concerned that, in many instances, the position taken by the AAP in the 2019 Policy Statement at issue will serve to confuse pediatricians [and others relying on AAP publications] and cause harm to the very patients it is trying to help.
Minimally, NEDA feels strongly that the AAP should clarify the relationship it sees between the 2019 Policy Statement and the 2016 Clinical Report, including succinctly identifying when pediatricians should be acting contrary to the 2016 Clinical Report recommendation against dieting. If the AAP is working from the understanding that metabolic and bariatric surgery is a medical treatment that will not result in the same emotional and psychological stressors as dieting in youth, NEDA requests postoperative data indicating this concern has been assessed. We do not see such an analysis in the 2019 Policy Statement.
If the 2019 Policy Statement supersedes, in its entirety or in part, the 2016 Clinical Report, NEDA requests the AAP explains that decision. If it does not supersede the 2016 Clinical Report, and the AAP feels that “severely obese” youth should be treated by different standards than other youth, NEDA requests an explanation for that as well, including the AAP’s understanding of how weight stigma by health professionals impacts the mental and physical health of higher weight people.
2. The 2019 Policy Statement specifies that bariatric surgery is contraindicated for youth with a current eating disorder. NEDA notes that a history of an eating disorder and risk factors for the development of an eating disorder do not serve as a contraindication that surgery be performed. This is especially concerning to us. While 30 million people in the U.S. will experience an eating disorder at some point in their lives, at any given time, the number of those with a diagnosable eating disorder is much lower. Research indicates that among people who have bariatric surgery, the prevalence rate of postoperative eating disorders is significantly higher than in the general population. There is no indication in the 2019 Policy Statement that postoperative assessment for disordered eating or eating disorders was conducted. Issuing a position statement with organization- and profession-wide implications without knowing the risk related to postoperative eating disorders, when we know that eating disorders have the second highest mortality rate—second only to opioid use— of all mental health disorders, is deeply concerning.
Likewise, NEDA is concerned about the lack of reporting in the 2019 Policy Statement (and minimal reporting in the accompanying Technical Report) of other mental health markers, including substance use disorder. Data is repeatedly showing adverse mental health outcomes, including suicidality, for those who have bariatric surgery. In the eating disorders community, we are increasingly aware of the co-morbidity of eating disorders and substance use disorders following bariatric surgery. NEDA finds the 2019 Policy Statement’s lack of mention of postoperative mental health concerns especially problematic.
3. NEDA acknowledges the mean postoperative follow-up time for studies informing the 2019 Policy Statement (the longest of which had a mean follow-up of 8 years, consisting of 58 patients), and that the data collection indicates significant sustained improvements in certain health markers at the time of follow-up. However, NEDA also wishes to raise concern over the very small number of participants included in these studies. While the AAP acknowledges this limitation—because of the small percentage of youth who meet qualifying requirements (i.e., “severe obesity” and comorbid conditions)—NEDA opposes the results from approximately 240 youth being used as the basis for an organization- and profession- wide Policy Statement, especially when key provisions of that Policy Statement target oppressed and marginalized youth who—especially prior to 2014, when the 2019 Policy Statement notes adolescent bariatric surgery was given national accreditation—were not adequately represented in the studies on which the 2019 Policy Statement is based.
4. With a clear emphasis in the 2019 Policy Statement on ensuring access of bariatric surgery to marginalized youth, including Black and Latino youth, and low income youth, NEDA feels strongly that the AAP must be aware of, and that any position statement going forward must be informed by, emerging research that shows a strong correlation between food scarcity and binge eating disorder. Research indicates that 17% of the most food insecure children met clinical diagnostic criteria for binge eating disorder. This is approximately three times the rate of binge eating disorder in the general population. Notably, this study also found comparable trend for compensatory behaviors in the most food insecure youth, including vomiting, laxative and diuretic use, skipping meals, and exercise. This preliminary data is being replicated with comparable results.
5. In line with 4, above, NEDA urges the AAP to explain how the necessary postoperative supplemental and nutritional needs will be met by those of lower socioeconomic backgrounds. While we acknowledge that the 2019 Policy Statement recommends that both public and private insurance cover these items, without provisions in place to do so, NEDA is concerned insurance companies—at the recommendation of the 2019 Policy Statement—may be inclined to cover bariatric surgery in marginalized and low income youth without ensuring that the postoperative supplemental and nutritional needs of those receiving the surgery are met. This is especially concerning considering that nutrient deficiencies are the most common long-term complication of bariatric surgery and may lead to serious, permanent medical complications. NEDA is especially concerned about a lack of information about the long-term (into adulthood and advanced adulthood) consequences of nutritional deficiencies at such a young age. It is also notable that the success rate of the Roux-en-Y gastric bypass (RYGB)—referred to in the 2019 Policy Statement as the “gold standard for surgical management of severe obesity in adults and adolescents”—has a success rate directly proportionate to income level (i.e., lower socioeconomic status is associated with lower weight-loss outcomes).
6. NEDA appreciates the mention of weight stigma in the 2019 Policy Statement. However, the discussion of weight stigma as a barrier to doctors referring youth for surgery, citing the belief that weight is a personal responsibility rather than a medical problem, does a disservice to the vast amount of research implicating weight stigma and discrimination, especially among health care providers, in adverse physical and mental health outcomes for higher weight people. For those at risk of or living with an eating disorder, stigma—or the fear of being stigmatized if their weight fluctuates as a necessary result of improved health and recovery—can be a matter of life and death. Minimally, it is a matter of health and well-being. More importantly, it is a matter of social justice, as those experiencing discrimination based on body size are significantly more likely to simultaneously be the targets of discrimination based on intersectional issues (e.g., race, ability, socioeconomic status, etc.) and to be negatively impacted by multiple social determinants of health.
In response to this position statement, NEDA asks the AAP to provide timely, public feedback to information requested herein. Additionally, NEDA wishes for this position statement to serve as a point of entry for our organizations to discuss issues—clinical, research, and those related to public policy—related to disordered eating, eating disorders, and weight stigma and discrimination. To this end, we request a meeting among NEDA public policy staff and comparable AAP staff and will be in touch to arrange same.
This is by no means an exhaustive explanation of our concerns related to AAP’s 2019 Policy Statement, “Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices,” or a thorough review of data backing our position. Any questions or concerns about this position statement should be directed to Joslyn Smith, Director of Public Policy & Community Relations, at jsmith@nationaleatingdisorders.org.
The National Eating Disorders Association (NEDA) is the largest nonprofit organization dedicated to supporting individuals and families affected by eating disorders. NEDA supports individuals and families affected by eating disorders, and serves as a catalyst for prevention, cures and access to quality care. Through our programs and services, NEDA raises awareness, builds communities of support and recovery, funds research and puts life-saving resources into the hands of those in need. For more information, visit www.nationaleatingdisorders.org.