Weight Inclusive - not Weight Centric - Approaches Help Prevent and Treat Eating Disorders in Children & Adolescents
written by Patrilie Hernandez, MS Founder & CEO, Embody Lib
If you have worked in the Public Health Nutrition field in any sort of capacity over the past few decades, you might have sat in on at least one meeting where someone brought up the rising rates of Type 2 Diabetes in children and teens, flagging it as the emerging area of interest. This isn't meant to overshadow the 'obesity' epidemic, of course, which is often attributed as the direct cause of this 'next childhood epidemic,' in addition to other chronic diseases.
Although data does support statistically significant increases in diabetes among children and adolescents over the past 20 years, Type 2 Diabetes affects about 1.3% of youth under 19. According to cited data from a 2023 review, Type 2 Diabetes prevalence is 67 per 100,000 youth aged 10-19, with onset being disproportionately higher among Black, Native American, and Latine/Hispanic youth. While estimates show that these numbers will double by 2050, the narrative fails to include that this includes both Type 1 and Type 2 diabetes mellitus, with rates increasing proportionally for both.
Why do I bring this up, and what does this have to do with weight-inclusive nutrition and eating disorders in children and teens? A fair amount, actually.
Widely accepted "evidence-based" interventions for Type 2 Diabetes and 'obesity' tout intentional weight loss, primarily through lifestyle changes that modify diet and exercise behaviors. However, weight-inclusive health and eating disorder prevention/treatment providers suspect these interventions fuel disordered eating and exercise behaviors that can lead to eating disorders.
Their concern is well supported; based on the DSM-5, the prevalence of eating disorders in children and adolescents (aged 11 to 19 years) is estimated to be between 1.2% (for boys) and 5.7% (for girls), significantly increasing over the past decade and doubling since the COVID-19 Pandemic began in 2020.
Furthermore, a 2023 study concluded that 22% of the over 63,000 people between the ages of 6 and 18 they sampled exhibited signs of disordered eating.
That's roughly 1 in 5 children and teens.
And disordered eating behaviors seem to be more common in those diagnosed as 'overweight' or 'obese.' According to a 2016 Clinical Report published by the American Academy of Pediatrics, adolescents categorized as 'overweight' have been shown to engage in self-induced vomiting or laxative use more frequently than their 'normal-weight' peers.
But even if disordered eating behaviors alone may not qualify as an eating disorder, they are a good predictor of developing an eating disorder later on, especially in young people.
This same 2016 report also stated that most adolescents who develop an ED were not previously overweight, but we know not to be the case any longer. Mounting evidence shows a positive relationship between BMI and the probability of developing disordered eating among children and adolescents, despite those invested in 'anti-obesity' initiatives claiming otherwise.
A 2022 paper by Cardel et al. concluded that evidence-based obesity treatment rarely "leads to, or exacerbates, pre-existing distorted or obsessive thoughts and behaviors around weight and food, which potentially increase risk of Eds." But if we look closely at the 2019 Jebeile et al. study cited to support this statement, we can easily refute its credibility. Weight-inclusive health educator Ragen Chastain does a great job critiquing this study, citing researcher Louise Adams, who submitted a letter calling for the paper to be retracted. You can learn more about this by listening to this post on Ragen's Substack.
Despite the research, data, and lived experience demonstrating the heightened risk for disordered eating and development of an ED in those with a childhood history of having:
'overweight' or 'obesity'
substantial weight gain during adolescence
experienced weight stigma
This same subset of children and teens is most likely to be targeted in 'anti-obesity' interventions. How do interventions where success is primarily measured by reductions in weight and body size help mitigate disordered eating and ED risk? In short, they don't.
Even if the nutrition counseling provided doesn't explicitly promote skipping meals, taking diet pills, or compensatory behaviors, what do you think will happen when a child/adolescent eats the way their dietitian/nutritionist tells them to and doesn't lose weight? Or if they end up gaining weight?
More likely than not, the child/teen will feel shame or a sense of failure for not doing the program "right." Unfortunately, instead of embracing their body size as is (because that goes against the very goal of the 'anti-obesity' intervention), there is a high chance they will resort to more extreme behaviors to get the desirable results (thinness), laying the groundwork for a possible Eating Disorder.
Taking weight as a marker of success off the table and applying a weight-inclusive approach to nutrition and health aligns with - and doesn't negate - what we are learning (and already know) about the complexity of body size/weight and what determines health outcomes.
Anyone who works in Public Health nutrition and claims their practice is informed by evidence-based information, cutting-edge research, and lived experience should be initiating THIS conversation at their next meeting.