The Utility of Terror for Decisions on Child Health

We count on newspapers for coming up with sensational headlines to inflame passions. Opinion pages seldom disappoint. But those flames of passion very often bring more heat than light. Such was the case yesterday when the New York Times published a sensational headline for an opinion article by a HAES activist, Virginia Sole-Smith. She wants us to know that an evidence-based clinical guideline for obesity care “terrifies” her. But terror is not a very helpful tool for improving the health of a child.

It gets in the way of objectively considering the facts – stubborn facts that don’t melt away because our feelings are strong.

Strong Feelings

If the release of these guidelines has done anything, it has certainly prompted some strong feelings. Sole-Smith does a fine job of expressing some of those feelings. She is terrified by “an epidemic of anti-fat bias, which results in the stigmatization of fat people in schools, workplaces, doctor’s offices and other public spaces.” With an impassioned straw-man argument she tells us:

“We cannot solve anti-fat bias by making fat kids thin.”

She is right on many counts. Right to stand resolutely against bullying and shaming people at any age because of their physical size. She is also right that a fixation on thinness and losing weight is not helpful for physical or mental health.

But she is wrong to dismiss the reality that too many kids are also suffering from the physical effects of the very real chronic disease of obesity. This, too can be terrifying, as a pediatrician from the medical school at the University of Minnesota explained when she saw Sole-Smith’s headline of terror:

“I’m sitting next to a colleague who says what terrifies her is her 15-year-old patient yesterday who has newly diagnosed portal hypertension. Now that’s scary!”

In liver disease, a problem kids with obesity are increasingly having, portal hypertension is a very serious complication.

Harsh Medical Problems

We have two very different medical problems before us – both very harsh.

On one hand, we have the very real harm stigma is causing to the physical and mental health of both kids and adults.

On the other, we have severe obesity harming the health of more and more kids. Obesity is not simply a problem of size. It is a problem of abnormal or excess adipose tissue that is harming the health of these kids. This is why we see, as Aaron Slusher and colleagues document in a new study, fatty liver disease has risen dramatically in recent years among children with obesity. Patients from the Yale pediatric obesity clinic have a 60 percent prevalence of this this condition – which can lead to liver cancer, cirrhosis, and death.

A False Choice

Sole-Smith and other HAES activists insist that we must choose between stopping weight stigma and offering medical care to kids with obesity. She supposes that medical care for obesity is exclusively about weight loss and “making fat kids thin.” But any obesity medicine physician will tell you that their aim is to improve the health of their patients. Not to make them thin.

The mistaken supposition about “making fat kids thin” reflects ignorance about obesity and its treatment. This is ignorance that some health professions also share. If we can can set aside that ignorance, then skilled health professionals can do much to improve the health of kids with obesity. And all of us can work to erase the stigma attached to weight by ignorance.

We can indeed do both. Terror is not very helpful for making decisions about the health of children.

Click here for the opinion piece by Sole-Smith and here for the new study on the rising prevalence of liver disease in children with obesity. For a thoughtful discussion about this subject, click here.

Vampire, painting by Edvard Munch / WikiArt

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January 27, 2023

2 Responses to “The Utility of Terror for Decisions on Child Health”

  1. January 27, 2023 at 9:06 am, Allen Browne said:


    Ms. Cole-Smith certainly lit a fire. Setting aside ignorance is best done with education. Education of the patients, the families, the providers, the payers, the policy makers and the public. Much work to do.


  2. January 27, 2023 at 4:15 pm, Mary-Jo said:

    I can’t imagine children with obesity, their parents, their families are feeling upset, ‘terrified’ even, that their pediatricians will now have good information and guidelines to help them feel better, get healthier, prevent further complications from and of their disease. If anything, the AAP Guidelines for the care of children with obesity will improve access to care, understanding of the disease, and finally, give both clinicians/HCPs and patients affirmation that healthcare for people with obesity matters. This is, actually, de-stigmatizing in that it signifies that children with obesity deserve to be taken seriously, be given options to improve their health, through their childhood, adolescence, and adulthood. I don’t think the fears of HAES activists are much on their minds.