Today I’m wading through the Fast Trackers’ JAMA publication, Symptoms of Depression, Eating Disorders and Binge Eating in Adolescents With Obesity. There’s so much going on here that it’s going to be a two-parter. This will make more sense if you’ve already read Part 1, where I discussed the weight cycling and health outcomes for the trial.
This was a tough read, because of the overarching lens of pathology through which this team view larger bodied people. Please know that my dissection of the paper includes multiple references to fat phobic language and explicit discussion of eating disorder symptoms, so please take care & perhaps skip this post if that’s not safe for you right now.
The paper has an overload of 19 authors, including the Fast Track team’s MVP Hiba Jebeile, a research dietitian recently back from a jaunt to Venice, Italy, where she presented data from 4 weeks of the experiment to claim that it’s totally safe to inflict extreme diets on teenagers.
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Citing Jebeile herself, the article leads by claiming that ‘adolescents with obesity’ are ‘vulnerable to impaired psychosocial health’. Whilst acknowledging that larger bodied teens have higher rates of eating disorders and depression than thinner ones, there’s no curiosity regarding why this is so. The authors appear to believe that it’s mysteriously ‘caused’ by simply existing in a larger body, without interrogating the cultural pressures which kids in marginalised bodies face – often from health professionals running weight loss trials.
Once again referencing their own publication (a staggering 12 of 25 references in the introduction cite their own work), they recount a meta-analysis which claimed that teens enduring ‘professionally supervised’ weight loss programs show:
‘A reduction in symptoms of depression, binge eating, and shape and weight concerns, with no change in eating concerns or global risk. All outcomes were reduced at a follow up of 14 weeks to 6 years from baseline.’
This delusional meta-analysis has been heavily cited by weight loss researchers desperate to continue to believe that behavioural weight loss programs a) work, b) are harmless, and c) worth the risk. It’s even been used to justify an ‘aggressive’ approach to child and adolescent weight loss in the recently updated American Academy of Pediatrics Guidelines. But it’s based almost entirely on short-term data and ignored massive drop out rates. An honest review should have concluded that the entire field of child and adolescent weight loss research needs to sit in a corner and take a good long hard look at itself.
Hidden within wildly optimistic conclusions are statistics demonstrating a substantial proportion of teens – between 5-9% – developed disordered eating and eating disorders after participating in ‘professionally supervised’ weight loss programs. I wrote about this meta analysis, and had my concerns published in the same journal.
After assuring the reader of the safety of teen weight loss, they claim that there’s now a need to establish the safety of more extreme diet regimes, which are apparently necessary for teens with ‘severe obesity’ or ‘complications’ (they cite themselves again here).‘Very low calorie diets’ and ‘intermittent fasting’ – which happen to be particular favourites for this team – are given as examples.
The aim of this paper was to ‘understand the effect of obesity treatment on symptoms of depression and disordered eating and how these change over time.’ But this is a sanitised version of the history of the Fast Track trial. An accurate justification would acknowledge widespread concern from the global eating disorder community, the established literature demonstrating a strong connection between extreme dieting and the development of eating disorders, and the highly controversial nature of the Fast Track team’s stance.
But the Fast Track team are the climate change deniers of the eating disorder community. Reading their work is akin to reading a paper written by a coal mining company who insist that climate change isn’t as bad as everyone thinks. And claiming that stripping the earth of natural resources is just fine – as long as they’re in charge!
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Did Screening & Monitoring Protect the Fast Track Kids From Eating Disorders?
In the ‘Outcome of Screening and Monitoring’ section, we’re presented with a dismembered array of statistics designed to portray positivity, but there’s a suspicious lack of detail. A scientific study on the impact of screening & monitoring should provide a comprehensive flowchart so readers can easily trace the results of screening and how this impacted risk as time went on.
The Fast Trackers didn’t do this, and I suspected that the data presented didn’t include all the details. So I constructed my own flowchart, and my hunch was confirmed:
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I’ve added symbols to help us talk through multiple oversights and data gaps. The red flags at the top alert us to the most glaring issue: a huge number – 110 kids (78%) – met criteria for disordered eating before the trial even started. 53 (38%) had Eating Disorder Examination Questionnaire (EDE-Q) scores above 2.7, which is highly suggestive of an eating disorder. Half reported binge eating, 8 (6%) were purging, and 3 (2%) were using laxatives – these are very worrying signs in such a young and vulnerable population.
In spite of staggering numbers of disordered eating, no-one was excluded, and only 7 kids (6%) were identified as ‘requiring support’. We’re not told why these kids were chosen or how they were different to the other 103 reporting clinically disturbed eating, who were left to fend for themselves.
‘Support’ involved additional visits with the Fast Track dietitian, psychologist* or paediatrician ‘as needed’ and was provided if ‘they were not already engaged in support’. We’re not informed how many teens were already accessing ‘support’, or what kind. Given that ‘currently undergoing treatment for an eating disorder’ was meant to be an exclusion criteria, this is confusing.
The fact that teens received ‘support’ for worsening disordered eating caused by extreme dieting from the very same team inflicting the diet is troubling. Recovery from disordered eating requires trust and safety, and in this very high risk age group, health professionals should have significant experience in eating disorder treatment.
The clinical psychologist hired by the Fast Track team had no background in eating disorders, and her career trajectory is firmly pro-weight loss. During the trial Novo Nordisk even paid for her to attend an obesity conference and present Novo Nordisk funded research on ‘barriers’ for adolescents discussing weight loss with health professionals (hint: it’s the parents fault). This clinical psychologist is now ensconced at Sydney University, undertaking a PhD on ‘psychosocial outcomes’ of larger bodied teenagers under the supervision of Professor Louise Baur, ex-president of the Novo Nordisk funded World Obesity Federation and part of their paid ‘speakers’ bureau’. Professor Baur also has no background in eating disorder treatment, but has publicly recommended that larger bodied children be reported to child protective services as cases of ‘child neglect’.
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The question marks in our flowchart depict critical information which is absent. Teens dropped out at every phase – 31% were gone by the end of the year. The paper only reports the total number of drop outs at each time point. It should report how many kids from the disordered eating group dropped out compared to the numbers dropping out of the normal eating group. Clearly, if disordered kids dropped out at a higher rate than the normal eaters, then what looked like a reduction in disordered eating is just a mirage.
The paper should also report the number of teens changing category (ie, from normal eaters to disordered eating, or vice versa), vs. the number of teens staying the same. Oddly, The Fast Trackers did report this data for the Eating Disorder Questionnaire and the Binge Eating Scale (but not the depression scale). Scientific papers should be consistent, not selective, when reporting psychometric information. Such inconsistency is peak Fast Track.
At the end of the year, eating disorder screening data is missing for 5 teenagers, without explanation. There’s also question marks for the 103 teens identified as disordered at baseline who weren’t offered support – we don’t know what happened to them. How many of this group dropped out? Critically, how many progressed to being ‘identified’ as needing help as the trial continued?
The bandaid icon brings us to the fate of the 7 offered ‘support’ at baseline. 2 were referred for specialist psychological help for disordered eating when the trial finished. There’s no information on the fate of the other 5. Did they drop out? Get better? Stay disordered but not referred on? Or did they get worse? It’s a mystery.
The cartoon health professional brings us to 7 additional teens (7%) – all girls, 5 from the Fasting group and 2 in the Continuous Dieters group – who were identified by the Fast Track dietitian as needing help.
We’re not told how the dietitian was able to differentiate kids who were in trouble from those who were simply doing what they were told. I have been an eating disorders therapist for many years and would struggle to do this: strict prolonged dieting is essentially identical to restrictive eating disorder behaviour. The problems flagged by the dietitian included:
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The paper doesn’t disclose if these girls were flagged as disordered at baseline but not given support, or if they were ‘normal eaters’ to begin with and then developed problems. This is important information. Given the huge numbers of disordered kids, it’s likely they were flagged at baseline but not offered support – a clear screening failure.
The ambulance icon brings us to the casualties of the Fast Track: 2 teens removed by investigators due to Severe Adverse Events. There’s no data provided about which group these kids were in at baseline (disordered or normal eater).
One child from the Fasting group was removed in week 22 after developing Atypical Anorexia Nervosa (AAN). This was after the dietitian transitioned her to a maintenance diet after reaching ‘goal weight’, but she was also flagged as a teen needing ‘support’, highlighting the impossibility of safely monitoring extreme weight loss.
The other teen, from the Continuous Dieting group was removed at week 14 after ‘re-emergence of prior body image concerns and related poor self-esteem’. No further details are given, but because they didn’t state that this person had been flagged during their careful monitoring, it’s likely that this casualty came as a surprise to the Fast Trackers.
Although the researchers are quick to attribute any improvements to the experiment, they’re totally unwilling to accept responsibility when it comes to harm. They framed body image and self esteem problems serious enough to warrant removal from the trial as a ‘re-emergence’ of prior issues but don’t acknowledge the catalyst was their year-long diet.
Although it’s clear that the extreme fasting diet directly resulted in a child developing AAN – a consequence which they were warned about by the entire eating disorder community – they blame the COVID pandemic and ‘virtual appointments’, which is just diabolical.
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My WTF icons take us to the end of the Fast Track Trial, where 61% of kids still met the ‘red flag’ category of disordered eating, from 78% at the start. There’s no way to know if this small difference was simply because the disordered teens dropped out early.
As an eating disorder therapist, seeing such high numbers of disordered eating remaining at the 12 month mark is confronting. Eating disorder treatment isn’t perfect, but there are highly effective interventions out there. It’s awful to think that these teens are still suffering after being prescribed a year of lacklustre dieting, when they could be receiving the help they need to improve their relationship with eating, weight and body issues.
The little ghost represents a teen who was apparently referred for specialist help at the end of the trial, but we’re not given any information about how they got there, which group they belonged to – nothing.
The remaining WTF in our flowchart is that the Fast Trackers only referred 3 teens for psychological treatment of disordered eatingat the end of the year, leaving the remaining 53 disordered eaters without specialist help. This level of ‘’support’ is woefully inadequate.
Screening and monitoring did not meaningfully protect the Fast Track teens, even when problems were right under their nose. Rapid weight loss experienced by a child later diagnosed with AAN was misinterpreted as hitting ‘goal weight’. Most kids met criteria for clinically disordered eating at baseline, yet none were excluded, and just a fraction were offered ‘support’. It’s likely that those identified in later stages were flagged initially but not offered support, and the team have left this screening failure entirely out of the discussion.
These are clear failures on the Fast Track team’s part to act to protect the children, and we should have an honest explanation of why this happened.
Even in the event that all of the adolescents identified as needing ‘support’ during the trial started out as ‘normal’ eaters at baseline, and thendeveloped disordered eating patterns, this also represents a screening failure – demonstrating that there’s no way to protect teens from the dangers of extreme dieting – there can be absolutely no ‘pre-warning’ signs. Because the diet itself is the cause.
1 of the 2 – 50% – of severe adverse events resulting in the teens being removed from the experiment was not identified via screening. As the eating disorder community has been saying for many years, strict dieting, even in the absence of any pre-existing risk factors, can cause disordered eating.
The Fast Track team repeatedly congratulate themselves for their screening processes, claiming that this ‘enabled adolescents requiring support to receive this early,’ with no mention of the multiple problems we’ve uncovered here. This team simply love a broad conclusion, avoiding the pesky details (like the truth) at all costs.
I personally LOVE a pesky detail, so I’ve sent off a list of questions to the Fast Track team, hoping to be able to fill in my flowchart. If reading this has you filled with curiosity, you can contact the study author via email at hiba.jebeile@sydney.edu.au, to ask your own questions.
I’ll be back with Part 2, where we’ll dive into the results of the psychometric testing for eating disorders, binge eating and depression. Brace yourselves for more climate change denial!
Thanks for sticking with me through this epic post, and stay strong my diet culture dropouts,
Louise x
*The psychologist only joined the trial after the first 51 kids were recruited, a move which happened after the global pushback and subsequent trial changes.
If you are struggling with issues relating to food, your body, exercise, or with an eating disorder, I can help (and I’m not sponsored by Novo!). I have offices at Flourish Kirribilli, in Sydney, and am also available for online appointments. If you’re a health professional I also provide clinical supervision, and my books are currently open.
