WW are back with another dastardly attempt to snag a customer base of lifelong weight cyclers. The launch of their Kurbo app, targeted at kids aged 8-17, really takes the biscuit. WW are repeat offenders: just last year I ranted with anti-diet dietitian Rebecca Scritchfield about the plan to sink their hangry claws into American teenagers by offering them ‘free’ memberships. This caused such a furore that they actually gave up, which was an awesome win for worldwide sanity.
But like an endless game of diet culture whack-a-mole, WW are back, and I’m afraid it’s worse than ever.
For those who haven’t heard, the Kurbo app looks like a game, except it uses a traffic light system to police kids’ food choices, and restrict their calorie intake. The app is ‘free’, but there are ‘health coaches’ (not qualified health professionals) which costs $70 US per month. It’s downright scary to see some of these ‘coaches’ advice to young kids:
Needless to say, eating disorder professionals and people with lived experience of eating disorders are LIVID. The push back has been impressive, with heaps of articles and opinion pieces, including this incredible smackdown coordinated by Ragen Chastain & featuring countless experts in the field of eating disorders. Christy Harrison, The Food Psych herself, wrote a blistering article for The New York Times. And the always fired up Rebecca Scritchfield released a really great podcast episode about the WW Kurbo App.
The enormous SCREW YOU is heartening, but WW are not backing down. In their usual gaslighting way, they’re actively denying reality:
“This isn’t a weight loss app,” Gary Foster, chief scientific officer at WW, told HuffPost. “This is an app that teaches in a game-ified, fun, engaging way what are the basics of a healthy eating pattern.”
How on earth Gary Foster can say this, whilst the Kurbo site is full of ‘before and after’ weight loss pictures (results not typical of course), is beyond me.
But this is what got me LITERALLY frothing at the mouth: WW are using a research paper which was published by our old pals, the Fast Track team, to justify their enormously irresponsible app.
I shit you not.
Whenever the critics raise the issue of risk, WW are firing back with sparkly ‘evidence’ that weight loss diets for kids are definitely 100% safe and don’t cause eating disorders. In one news article it was reported that:
“In a recent review of literature aimed to investigate the impact of obesity treatment, with a dietary component, on eating disorder prevalence, eating disorder risk and related symptoms in children and adolescents with overweight or obesity, it was found that structured and professionally run obesity treatment leads to a reduction in the prevalence of eating disorder, eating disorder risk and eating disorder‐related symptoms for most participants,” Gary Foster, chief scientific officer at WW, told MobiHealthNews in an email Q&A. “
The Fast Track team released their review in May this year. When I found out it was published I realised that it would be used to push their agenda of putting ever more kids on diets. I knew this would suck, but had no idea that the WW shitshow would jump on the bandwagon so very quickly. What an unholy alliance!?
The Lead Author of the Fast Track Review on Twitter #dietsaregreat
The Fast Track team have airily decided that their paper is ‘proof’ that there’s no harm in forcing kids to diet. They have already used it to defend their ongoing research, including the dreaded semi-starvation Fast Track Trial itself. To see their paper being used to promote the spread of childhood dieting globally just makes me sick to my stomach.
Although the dangers of childhood and adolescent dieting are well established in eating disorder research, in obesity research there is a push to establish the completely opposite idea: that it’s perfectly safe. Especially if it’s done by ‘experts’.
And now we’re seeing just how awful the consequences can be. The message that childhood weight loss programs do no harm, and even REDUCE the risk of eating disorders, has already made it into the New York Times, The Atlantic, and The Conversation. It’s also impacting academic conversation, with an opinion piece in Childhood Obesity, stating that childhood weight loss programs “actually decreased eating disorder prevalence and risk”.
And all of this is thanks to the Fast Trackers’ paper. So let’s take out our fine tooth comb and see just how trustworthy these claims are. The review analysed 30 studies, claiming data on 2589 adolescents.The authors concluded that:
‘structured and professionally run obesity treatment was associated with reduced ED prevalence, ED risk, and symptoms’.
The 30 studies included weight loss trials on kids aged 7-16. The length of the diets varied A LOT – from 1 week to 13 months. 11 studies had no follow up period, they just stopped collecting data when the diet ended. 18 studies that did bother to follow up also had huge variation, following the teens post-diet for periods ranging from 12 weeks to more than 5 years (although most of them were the shorter time frames – only 2 studies followed up for longer than 4 years). The types of diets the kids undertook, and the places they did them in were vastly different. Some took place at inpatient or outpatient hospital programs, some at school-based health clinics, and one was a Jenny Craig program! (So now apparently Jenny Craig are classified as ‘professionally run obesity treatments?!?! Lawd, give me strength!)
Looking for the harmful impact of dieting is tricky- we need to make sure we’re keeping an eye on people long enough for the harmful effects to show up. It’s like smoking – if researchers only followed people up for a year or 2 after they started smoking, there’d be no symptoms, and it would be easy to conclude (falsely) that smoking wasn’t harmful! Of course, that’s not the case – but this is the problem we’re seeing in diet impact research. We’re just not looking for long enough.
For years, researchers and clinicians have been pleading for higher quality weight loss diet research with much longer follow up periods. In order to accurately assess the potential harms of adolescent weight loss interventions, we need to rely on good quality data that captures the emergence of eating disorder symptoms for a period of at least 2 years, if not longer, after the diet ends. This is because in childhood and adolescence, eating disorders take a long time to rear their ugly head. One study found that it took more than 2 years after teens started dieting for eating disorder symptoms to arise.
Only 3 papers included in the Fast Tracker’s review – Braet and colleagues (2000, 2006), and Goossens et al (2011) followed up kids for 2 years or longer after the diets finished. That’s a measly 394 kids. And once we factor in the number of kids who dropped out, and incomplete data (about half), there is actual eating disorder data on 195 adolescents; just 7.5% of the sample.
Fun Fact: It took me weeks of trawling back through the original papers to get these statistics because the Fast Tracker’s paper didn’t provide them. This is not ok: basic information like this should be clearly spelled out. I am VERY OVER the smoke and mirrors this team use!
Obviously, 195 kids is WAY less than the 2589 number being bragged about all over Twitter. The Fast Tracker’s analysis revealed more about how much we do not know about the link between teenage weight loss interventions and eating disorder development, rather than providing any evidence of safety. But the Fast Trackers have smoothed over these cracks, and actually had the audacity 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).
More smoke and mirrors here: by reporting follow up times from baseline (when the experiments began) rather than from the end of the diet, it makes it look like they followed the kids for longer than they actually did. And this is downright naughty, because their own criteria defined follow ups as starting from the end of an intervention, not baseline.
So to be super clear, there were only 3 (not 7) studies with a follow up period of 2 years from the end of the diets (not baseline). So let’s see what happened to those kids:
The Braet and colleagues (2000) study compared 3 different conditions of a ‘healthy eating’ program (aka a diet). There were 136 teens aged 7-17. 4.6 years later, they collected eating disorder measures for 53 kids (39% of the sample). 61% of the original kids didn’t come back. Dutch Eating Behavior Questionnaire (DEBQ) data for the remaining kids showed a reduction in external eating, a significant increase in restrained eating, and no change in emotional eating. The remaining kids also completed the Eating Disorder Inventory (EDI). These results showed that girls scored higher than average on Drive for Thinness, and boys scored significantly higher than average on Body Dissatisfaction. 9% of the sample had a score of five or more on the Bulimia EDI-subscale. One kid had been hospitalised in an eating disorder unit.
Other researchers have used the Braet et al (2000) study as evidence for the emergence of ED symptoms after teen weight loss interventions:
“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.” (Goossens et al 2011)
This is very troubling information, and to make it worse, it has been left out of the Fast Trackers’ paper. I am not joking: The EDI results have been totally omitted. It’s not listed in the study’s Supplementary Table, and the entire paper is not mentioned in section 3.6.1. Bulimic Symptoms, despite the obvious relevance.
The second study with longish term follow up involved 150 adolescents (aged 7-17) in a 10-month inpatient weight loss program. 2 years later, complete Eating Disorder Examination (EDE) data was available for 86 participants. We don’t know what happened to 43% of the kids.
Overall EDE scores were reported as ‘reduced’ at the 2 year follow up mark, but detailed subscale data was not reported. Sleuthily, I managed to track down this group of kids in a 2009 study, where they reported increases in dietary restraint scores. The authors also 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 emphasising that even 2 years follow up is not long enough for ED symptoms to start showing in kids and teens.
Dietary restraint (DR) is an important eating disorder symptom, but the Fast Track review did not bother to examine it. Which is weird, given that another recently released review paper on exactly the same topic found that almost half of the studies resulted in increased DR. These authors thought this was important enough to discuss at length. But apparently our Fast Track researchers don’t?
Many studies included the Fast Tracker’s analysis showed that the diets caused increases in DR (eg, Braet et al 2000, Braet 2006, Brennan et al 2012, Goossens et al 2011, Halberstadt et al 2016, Saverstani et al, 2009). Could this be why the Fast Trackers did not want to talk about it? Many of the authors involved in the original studies themselves raised the issue of DR as an important issue to study in adolescents, noting that it is important that interventions do not make DR worse. Braet et al (2000) said that
“we wanted to avoid the type of dietary restraint that has been linked to the development of eating disorders”.
Eating disorder professionals view DR as a precursor to the development of eating disorders, while obesity researchers see it as a great way to teach larger kids to diet. Regardless of where you sit ethically, this topic deserves to be analysed, discussed and argued. For the Fast Trackers to simply ignore 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. This is not ok.
The third long term study was conducted on 108 adolescents aged 10-17. The diet was a 10 month inpatient program (the same one reported in the second long term study). The follow up period was 5 years and 2 months after the diet ended. 48% of the sample were lost to follow up, and complete ED measures were taken for 56 kids.
At the beginning of the diet, no kids met criteria for binge-eating disorder (BED). But by follow-up, 5.4% met BED criteria. 8.3% of kids who did not report Objective Binge Eating (OBE) at baseline reported OBE at follow up. 8.5% of teens 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.
So here’s what we know from taking a deep dive into the actual data on the longer-term outcomes for kids who go through weight loss programs. From an initial pool of 394 kids, we lost roughly half. Within this smaller pool of 195 kids, dietary restraint is increased, and somewhere between 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 scientific papers do not clearly report or analyse long term impacts. We must also keep in mind the large group of adolescents (in this case, roughly half) who were lost to follow up. The fate of these youths is too often overlooked, and it is very plausible that many end up the offices of eating disorder professionals like me.
So there you have it everyone – apologies for the epic post, but this is really important stuff! The Fast Tracker’s review is riddled with flaws, errors, and omissions, and their conclusions simply do not match the data. I’m so concerned about the review and the potential impact it might have that I have written to the editor of Obesity Reviews, where it was published. I’ve stated the points raised above, as well as numerous other nerdy issues. Questions about the rigor of childhood obesity research are a hot topic lately: A just-released review article in Obesity Reviews featured a group of 18 obesity researchers expressing concern about the current trend of overly enthusiastic conclusions being made by childhood obesity researchers. This group were calling for improved practices across the field. Given this climate, I am hopeful that the Fast Trackers’ paper will be retracted, or at least heavily corrected.
The WW debacle is just a taste of what will come unless we stand up and fight against the weight-centric power houses that currently dominate our culture. Please, continue to fight hard, to push back. To ask questions, make complaints, and raise hell! Our children’s futures depend on it. An incredible 110000 people around the world have signed a petition demanding that the WW app be taken down – please sign it here (if you haven’t already!.
If you are struggling with issues relating to food, your body, exercise, or with an eating disorder, I can help! I’m available for online appointments – just a click away! If you’re a health professional I also love to do online supervision, and the books are currently open, so send me an email at louise@untrapped.com.au and let’s get started!
