00:01:22.940we want you to be different we don't like what you're choosing to do right now i'm michael
00:01:30.020hobbs i'm aubrey gordon if you would like to support the show you can do that at patreon.com
00:01:35.020slash maintenance phase you can get merch at t public you can also subscribe through apple
00:01:40.840podcasts which is the same audio content as the patreon content audio and michael i feel like i
00:01:48.000am like getting ready to be full of rage it's like a little propeller on your head that like
00:01:54.880i get to spin around when yeah when we do these episodes and i i i can just imagine
00:01:59.520and you're just gonna lift off out of your seat just getting ready for a lift off so today we
00:02:07.280are talking about the american academy of pediatrics guidelines on the treatment of
00:02:12.820Childhood Obesity. They released the last set of guidelines in 2007. The general approach for those
00:02:20.260was watchful waiting. If your kid is fat, they'll probably outgrow it. We don't need to do anything
00:02:26.240aggressive. This year in January, they updated the guidelines and recommended a much more
00:02:33.620aggressive approach. The thing that got the most media coverage was the fact that they are now
00:02:39.120recommending weight loss drugs and bariatric surgery for kids as young as 12. And I went
00:02:46.360on to the AAP's website. I got the document. I pasted it into Word. It was 136 pages. I went
00:02:54.120through it. I checked the citations. I talked to someone from the AAP. And this episode is
00:03:00.600literally just going to be us going through the document. I'm going to do my best to try to make
00:03:06.040that interesting, but I might fail. Sarah, you've been warned. So as usual, we need to start this
00:03:12.560episode with a carnival of housekeeping. First of all, this is going to include a lot of like
00:03:17.460triggery eating disorder, weight loss, calorie stuff. It's also going to include the word
00:03:23.940obesity a lot, which is not a word that either one of us like or use. But in the context of
00:03:30.000these studies, because they are exclusively based on BMI categories, we kind of have to
00:03:35.360talk about those categories when we're talking about the studies. And, you know, we do episodes
00:03:40.680sometimes where it's like, I look into an influencer and I tell you about it and you've
00:03:44.640never heard of them. They're always from Australia. And, you know, that isn't fake. Like the show
00:03:49.360isn't scripted. We're, you know, we're coming in fresh to those episodes. This is not one of those
00:03:52.920episodes. This is a topic that both of us have been thinking and writing about for a very long
00:03:59.560time. And we're not going to pretend that we don't already have issues. And of course, like
00:04:05.940human biases that we are coming in with. Yes. So the purpose of these guidelines is just to kind
00:04:13.580of get all of the evidence on this issue in one place. So they've put together a task force.
00:04:17.880There's like a committee. All these doctors have spent years looking at every single thing that's
00:04:21.580ever been published. And they want to put it into one place and on the basis of all of the evidence,
00:04:26.280make recommendations. That is what they are setting out to do. Something that I missed,
00:04:31.300but Reagan Chastain, who wrote a bunch of really good Substack posts about this, she noticed
00:04:35.560is that if you read the technical reports where they kind of go through the evidence like paper
00:04:39.740by paper, they explicitly say that they are excluding from the evidence anything that doesn't
00:04:47.220deal with weight. This may seem like a small methodological detail, but it's actually a huge
00:04:52.200deal because there are numerous studies that have showed pretty significant health benefits
00:04:58.160for people who change their diet and exercise habits, even if their weight does not change.
00:05:04.280Right. So according to this document, right off the bat, we're basically saying all of those
00:05:09.520are considered ineffective interventions because what we're looking at is only weight status.
00:05:15.700We're really concerned about the health of these kids. Therefore,
00:05:18.460we're not looking at their health. We're just looking at how fat they are.
00:05:22.000It is actually fascinating to me that it's like the entire social construction around this issue is that like it's really only about the health. Right. And like when I mean to a fat person on a plane, like I'm not doing it because I'm a dick. I'm doing it because I'm concerned about their metabolic risk. It's good for them somehow. But then you get into these documents and they're quite just openly like, no, no, it's just about the fatness.
00:05:43.220This kind of rhetoric of sort of like it's for your health is the thing that you sort of shout out loud and then quietly into your research paper say we didn't look at anything about how is how we get this like wild difference in public opinion between sort of like what people think is the issue with fatness and what researchers are even outlining as the issue with fatness.
00:06:07.780Right. Like this is how you get to the point where people really think someone just gets so fat that they drop dead.
00:06:13.560And that's like a way that people die.
00:06:15.220They also mention at the very beginning that this review will not be discussing obesity interventions for children under the age of two.
00:06:22.780Just like, wow, thank you. I appreciate it.
00:06:35.500exactly please clap for our restraint so i don't know if we've talked about this on the show show
00:06:42.620but on a number of bonus episodes now we've talked about the fact that like fat people and fat stuff
00:06:49.100this issue is in a weird transitional period where there's growing societal acceptance but there's
00:06:56.800also these kind of remnants of a huge amount of stigma absolutely there's like starting to be a
00:07:04.100thing that happens when I do research for this show and I'm sort of knee deep in health and
00:07:09.860wellness media about fatness and fat people, usually those stories are starting to change.
00:07:15.560And now they're exactly the same stories as they were before, but they include maybe one
00:07:22.000personal story from a fat person and maybe one paragraph on weight stigma and why it's important.0.95
00:07:28.120And then right back to, but also fat people are going to die.0.98
00:07:31.000Exactly. And this is why I wanted to do an entire episode on this document, because it's a portrait of like the weird corner the public health establishment has painted itself into, where it now rests on two completely contradictory sets of beliefs.
00:08:39.640Yeah, I know. I know. I know. I know. We can we can take breaks.
00:08:42.360Long stigmatized as a reversible consequence of personal choices, obesity has complex genetic, physiologic, socioeconomic and environmental contributors.
00:08:51.980As the environment has become increasingly obesogenic, access to evidence-based treatment has become even more crucial.
00:09:06.780Childhood obesity results from a multifactorial set of socio-ecological, environmental, and genetic influences that act on children and families.
00:09:16.320These influences tend to be more prevalent among children who have experienced negative
00:09:21.120environmental and social determinants of health, such as racism. Overweight and obesity are more
00:09:27.340common in children who live in poverty, children who live in under-resourced communities,
00:09:32.980in families that have immigrated, or in children who experience discrimination or stigma.
00:09:38.760Michael Hobbs dot dot dot. The American Academy of Pediatrics is dedicated to reducing health
00:09:44.160disparities and increasing health equity for all children and adolescents. Attainment of these
00:09:49.120goals requires addressing inequities in available resources and systemic barriers to quality health
00:09:54.280care services for children with obesity. To that end, practice standards must evolve to support an
00:10:00.800equity-based practice paradigm. Well, so listen, so far, I disagree with the sort of framing around
00:10:08.380like the problem here is fatness. But in terms of the substance of what they're saying, I don't
00:10:14.000actually disagree with much of this right yes this is an issue that's much more complex than
00:10:18.740we give it credit for the interesting thing they don't mention here is the role of experiencing
00:10:25.180anti-fat stigma would you like to hear our next two paragraphs oh did i do a segue this is what
00:10:32.460is so interesting about this document to me is like much of it could have appeared in your book0.93
00:10:36.640you are a much better fucking writer than this obviously but as far as like acknowledging
00:10:41.860everything that we say on this show, this document is pretty good. Like right after this little0.99
00:10:48.100excerpt that we read, there's a long section on racism. There's a long section on toxic stress
00:10:54.200and minority stress. And then there's a section on weight stigma. This part says individuals with
00:11:00.880overweight and obesity experience weight stigma, victimization, teasing, and bullying, which
00:11:05.260contributes to binge eating, social isolation, avoidance of healthcare services, and decreased
00:11:09.300physical activity. Importantly, internalized weight bias has been associated with negative
00:11:13.680impact on mental health. Collectively, these factors may adversely affect quality of care,
00:11:18.500prevent patients with overweight and obesity from seeking medical care,
00:11:21.920and contribute to worsened morbidity and mortality independent of excess adiposity.
00:11:26.960Pediatricians and other primary care providers have been and remain a source of weight bias.
00:11:31.640They first need to uncover and address their own attitudes regarding children with obesity.
00:11:36.060yeah there's not a lot to actually like quibble with here yeah it's like yeah stigma matters
00:11:42.440doctors are a source of stigma and like stigma can have health consequences on people right and
00:11:47.180therefore what we need to do is we're going to spend the rest of this paper talking about how
00:11:51.780to reduce stigma and end your own bias right this is what is so fucking incredible to me about this
00:11:56.980transitional period right they will say all of these things but then do nothing with them lip
00:12:03.300lip service lip service lip service and unfortunately the lip service is pretty
00:12:07.440fucking good right the lip service is like yeah you're you're saying all the stuff that we've0.89
00:12:13.200been wanting you to say but we would also like you to do something about it right this is the0.96
00:12:19.660last time they're going to mention like doctors are a source of medical bias but you know that
00:12:27.560if you criticize the aap for any of this stuff like oh this doesn't actually seem like a very
00:12:32.320equitable framework, they'll be like, ah, ah, ah, the very first section is called health equity.
00:12:37.380It's really astonishing that they're sort of doing this, like, seem to be sallying forth
00:12:42.180into a bigger, more complex conversation and then do this weird hairpin turn and be like,
00:12:47.360yeah, the bullying of fat kids is really a problem, which is why we need to eliminate0.99
00:12:51.560fat kids and make them all thin. We're like, I don't think that's the solution.0.98
00:12:55.880So the next section of the paper, after we've done all this health equity lip service stuff,
00:13:00.860We then get to like the sort of boilerplate section that me and you have read a million times where it's like the prevalence of childhood obesity and like how many kids are fat.
00:13:10.060So they start out by noting that the prevalence of childhood obesity has gone from 5% in 1963 to 19% in 2017.
00:13:20.200This is something I've only started noticing once I started doing the show with you.
00:13:23.680They often note that the baseline is not 0%.
00:13:27.120So there's presumably always some number of kids who are just fat.
00:13:32.560I feel fascinated by sort of the ways in which our current biases allow us to imagine that the world is meant to be a particular way and that a particular kind of person doesn't exist in the past or the future.
00:13:48.280Remember when I went to that museum in Amsterdam and I kept texting you with the paintings of fat people?
00:14:20.200And 80% of fat adolescents become fat adults.
00:14:23.900And so that's kind of like the trajectory that they're warning us about is that like most fat kids become fat teenagers, become fat adults.
00:14:32.980But then in the citation that they use for this section, the paper that they're citing also notes that 70% of fat adults weren't fat kids, which is interesting to me.
00:14:45.500And then also there's also some like careful wording stuff.
00:14:50.100So they say at one point, the COVID-19 pandemic has significantly affected the lives and routines
00:14:56.980of children and adolescents. In one analysis, the pandemic period was associated with a doubling
00:15:02.800in the rate of BMI increase compared to the pre-pandemic period. And I was like,
00:15:08.660a doubling in the rate of BMI increase? Oh, is it like three quarters of a pound or some shit?0.99
00:15:14.240No, it's basically during the first nine months of the pandemic,0.98
00:15:18.500quote unquote normal weight kids gained three pounds and fat kids gained six pounds okay okay0.92
00:15:24.740i mean uh is that noteworthy fine but also like do i really give a shit about like three extra0.95
00:15:31.000pounds also kids are supposed to be gaining weight because they're growing and we all0.95
00:15:35.700fucking gained weight in the pandemic surely like if there's one time where everyone could just gain0.95
00:15:40.380some weight and everyone else could shut the fuck up about it it's the pandemic and also like no one1.00
00:15:44.840could shut up about it absolutely nobody could shut up about it but they weigh three more pounds
00:15:48.520i'm like but they're alive so then we have a couple paragraphs about health stuff it's like
00:15:54.600type 2 diabetes blah blah like i'm not going to read this stuff because we we've all read these
00:15:57.720paragraphs a million times and then in the section about the health effects of obesity it says in
00:16:03.360addition to physical and metabolic consequences obesity in childhood and adolescence is associated
00:16:08.200with poor psychological and emotional health increased stress depressive symptoms and low
00:16:13.220self-esteem yeah it's like you think i can't imagine that any of the rhetoric that we're
00:16:18.500advancing in this document would contribute to that nothing to see here these are not health
00:16:23.280consequences of fatness it drives me nuts when public health agencies conflate the health0.84
00:16:29.000impacts of obesity and the health impacts of people being shitty to fat people yeah rhetorically0.59
00:16:34.360it does two things right one is that it continues this sort of line of thinking that has been0.74
00:16:39.640very prevalent certainly in the u.s for the last 20 years which is everything that happens as a
00:16:46.000result of someone being fat is a direct result of the fat cells in their body right that there's
00:16:52.500like right people get fat and then they get depressed there's no way to know why it just0.72
00:16:55.960happens and the other thing that it does implicitly that is absolutely fucking maddening to me is that0.98
00:17:03.300it is implicitly blaming fat people for the behavior of garbage people exactly yes we then0.98
00:17:11.000get to the section that you've been waiting for aubrey where they talk about the use of the bmi0.94
00:17:17.040as a screening and diagnosis tool i i first came across this in a usa today article about the
00:17:22.200guidelines not in the guidelines themselves where in back-to-back paragraphs it says young people
00:17:29.060who have a body mass index that meets or exceeds the 95th percentile for kids of the same age and
00:17:34.260gender are considered obese, right? So that's the definition of obesity is kids that are fatter
00:17:39.600than 95% of kids. And then it says, obesity affects nearly 20% of children and teens.
00:17:47.700So 20% of children and teens are fatter than 95% of children and teens.
00:18:17.220And also, as you mentioned in my episode, those percentile rankings, I mean, they're just descriptive.
00:18:22.660They're not based on like health risks.
00:18:24.680Yeah. I mean, listen, like every adult, I think that kids today should be held to the exact standard of my body and bodies like mine when we were kids.
00:18:34.740This is another sort of transition phase thing in this document is that there are so many studies now documenting the limitations of BMI. They have to acknowledge this stuff. Yeah. Right. Like the whole point of this document is to bring together all of the evidence. Right.
00:18:50.460So this is the section where they essentially defend the use of the BMI.
00:18:57.540There's this weird circular logic here where they say, despite its limitations, BMI is
00:19:04.680currently the most appropriate clinical tool to screen for excess adiposity and make the
00:19:09.640clinical diagnosis of overweight or obesity, right?
00:19:12.700So it's like, say what you want about the BMI, it's not perfect, but it's the best
00:19:17.140tool we have for diagnosing right fat and very fat kids but the definition of overweight and
00:19:24.020obesity is based on the bmi yeah the definition of overweight is above the 85th percentile in the
00:19:30.560bmi the definition of obesity is above the 95th percentile on the bmi right so what they're saying
00:19:36.460here is the bmi is very good at determining their bmi yeah yeah which like yeah it sure is
00:19:44.460This year, I'm doing my own employee evaluation, and my evaluation of me, as defined by me, is I'm great.0.99
00:19:55.500They conclude, the BMI must be communicated to the patient and family as it guides next steps for comprehensive evaluation and treatment of obesity and related comorbidities.
00:20:05.240As part of this, they have a flow chart for doctors.
00:20:07.800You know, if if they have these symptoms, run this test. There's literally no destination at the end of the flow chart that is like, don't bring up their weight. Every single person who is fat should get a lecture about their weight. That is where it's leading.
00:20:22.520One of the most common stigmatizing experiences that fat people report in the doctor's office is being lectured about weight loss before or even in the absence of talking about whatever symptoms or concerns brought them in to begin with.
00:20:35.560And that has been and continues to be the prevailing instruction given to medical students. And it's now baked into our insurance system such that if doctors want to be paid for their work, they are required to report not only the patient's BMI, but also that they were counseled on weight loss.
00:21:00.540That is required in order to get paid for your work as a health care provider.
00:21:05.280That is bananas to me that like medical institutions right now today are deciding to ignore or refusing to engage with this thing that is like very popularly discussed as being very terrible and a reason to avoid care.
00:21:23.520It all clicked into place for me at the end of the section where they give advice to doctors on like how to bring this up with patients, right?
00:21:30.760Because there's all this research now on weight stigma and all this research about how doctors are one of the primary sources of weight stigma.
00:21:37.300So how are they going to reconcile this, right?
00:21:39.880They have three rules for doctors for facilitating a non-stigmatizing conversation about weight with kids, right?
00:21:47.620So the first tip is ask permission to discuss the patient's BMI and or weight.
00:21:54.520Number two, use words that are perceived as neutral by parents, adolescents, and children.
00:24:29.860It's like a caricature of the arrogance of doctors saying, oh, well, in every interaction, I have to bring up this patient's BMI, even if that person is a child, even if they're not here for anything regarding weight at all.
00:24:45.920But I'm bringing it up in a way that's non-stigmatizing.
00:24:50.340But the stigmatizing part is that you're bringing it up in every interaction.
00:24:53.480I'm trying to imagine someone like punching me in the face and then being like, look, you must be feeling a lot of things right now.
00:24:59.340it's got to be really hard for you right like that's essentially sort of what we're talking0.56
00:25:03.200about here is like causing material harm to fat kids and then being like uh but i used the right
00:25:11.000language so pat on the back there's nothing in this document other than those kind of two
00:25:15.960perfunctory bloodless sentences of like doctors are a source for stigma there's nothing about
00:25:21.000like hey really sit down and think does this patient need a lecture from me about eating0.94
00:25:26.560five fruits and fucking vegetables right now if they came into something completely else do i0.97
00:25:31.320maybe want to ask about like other interactions this patient has had with the health care system0.98
00:25:36.740have they tried losing weight before what are their behaviors maybe don't even bring up weight
00:25:41.620at all just ask them like is there anything else you want to talk to me about today okay bye i was
00:25:47.320i think 36 years old the first time a doctor asked me if i had an eating disorder
00:25:53.080there's a place where there is a known cluster of diagnoses and bringing up this conversation
00:26:00.740will make those actively worse is around eating disorders and body dysmorphia
00:26:06.120which are hyperactive particularly in adolescence right like what happens if that kid is already
00:26:13.820depressed well this brings us to the next section of the document tell me this is a huge section
00:26:19.320this is like probably a third of the document, is risk factors for child and adolescent overweight
00:26:25.380and obesity. And this walks through like everything we know about the factors that
00:26:30.240are associated with higher weight among kids. Just like the health equity section, this is pretty
00:26:35.580good. It's like it goes over. So, you know, it talks about socioeconomic disparities. It talks
00:26:41.600about racial disparities. It has a whole thing about policy factors. There's environmental smoke
00:26:46.680exposure sleep duration there's a whole thing on adverse childhood experiences like fat people are0.99
00:26:52.900more likely to have been abused when they were kids which is a whole fucking can of worms that0.94
00:26:56.040we talked about yeah there's genetic factors yeah epigenetics autism is associated with higher0.98
00:27:02.800weights adhd is associated with that they have a whole section on medications it's almost as if
00:27:08.300fat people are not just fat bodies walking around but people with lives and health concerns and
00:27:15.980other things going on. But then the way I think that they are reconciling all of this information
00:27:22.980coming out about social determinants of health and all of the complexities about like why people
00:27:27.500are fat is this document explicitly says that like you should incorporate all of that context
00:27:34.460into your recommendations to people for how to lose weight. What? There is literally at no point
00:27:41.560in this document does it ever say, tell people that it's fine not to be trying to lose weight?
00:27:47.640Right. Like focus on housing security. You don't need to worry about your weight right now. Get a
00:27:51.820place to live. So according to this document, if a patient comes to you and says like, you know,
00:27:56.120I'm 16 years old. I grew up in foster care. I experienced horrific abuse. I'm now on a medication
00:28:01.980for my depression. And since I started taking it, I gained 25 pounds. There is nothing in this
00:28:07.300document to just say, that's fine. Focus on being happy right now. Yeah. No. According to this
00:28:13.260document, if they are above the 85th percentile on the BMI, you should tell them to lose weight.
00:28:19.900And it's all punitive. Right. It's not goal oriented behavior. It's not if we follow these
00:28:25.520steps, then we know we produce these outcomes. It's if we follow these steps, maybe something
00:28:31.040happens, question mark. But we don't really have evidence that anything does. And the evidence we
00:28:35.840do have is that people feel worse and avoid health care. Right. The best case scenario is
00:28:40.460that it's throwing stuff at the wall and seeing what sticks. Right. And the worst case scenario
00:28:44.620is that it's projecting adult anxieties onto children. Right. And not only that, but onto
00:28:51.200fat kids. Right. I want everybody to think about every media depiction you've ever seen about a0.98
00:28:58.880fat kid. Is it about how well loved they are and how everyone's treating them great? Right. I want
00:29:04.560you to think about the fat kids that you have known in your life. Were they like living the
00:29:08.920life of Riley? What's going on? Right. It's just astonishing to me that the answer to all of this
00:29:14.260is like, you see those kids over there? They don't feel bad enough. Well, it's also it doesn't give
00:29:19.900any specific advice to doctors on like what they can actually offer in like a seven minute
00:29:25.780appointment. So there's in the one place that this document actually talks about like a behavioral
00:29:31.120assessment, like ask the kid what their diet and exercise habits are, it says dietary intake can
00:29:38.300be addressed by assessing the following. Eating outside the home, consumption of sweet drinks,
00:29:43.500portion size, meal habits, snack habits, fruit and vegetable consumption. What actual advice
00:29:49.480does this lead you to give? Oh, try not to drink so much soda. Like you're going to give them this
00:29:53.960like 101 dr oz level advice i'm gonna try to eat smaller portions wow thanks tell those fat
00:30:01.660toddlers to start taking the stairs and then this is the part that i've been saving aubrey because
00:30:06.040like oh no you're gonna explode so it also says that you should try to assess whether the kids
00:30:14.380are experiencing weight stigma what so it says a common comorbidity of obesity in children is
00:30:21.840weight-based bullying and teasing. If a patient responds affirmatively when asked if they have
00:30:26.300ever been teased or bullied about their weight, pediatricians and other care providers can
00:30:30.500consider provision of resources, such as those found at stopbullying.gov, to the child, as well
00:30:36.100as a local counseling referral. So then I go to stopbullying.gov, and I typed in like weight
00:30:44.040stigma, fatness, obesity, like all the various search terms. This quote-unquote resource has
00:30:48.780published three articles about weight-based bullying in the last decade what the first
00:30:54.820of them has like a list of bullet points for adults in case they like see weight-based bullying
00:31:01.220whatever the list begins how can i encourage a healthy body image among adolescents one promote0.98
00:31:09.100healthy eating and exercise head up shut the fuck up michael off so the number one advice from this1.00
00:31:17.300article is like teach kids how to lose weight if they're being bullied for being fat fuck you are1.00
00:31:21.920you being bullied step one have you tried weight watchers and then all of the other articles on0.97
00:31:27.560this quote-unquote resource are for adults it's like if you see kids bullying other kids like
00:31:32.660step in and try to stop it which like great but that's not a resource for kids this is not a
00:31:37.760meaningful resource for most professional guidance including interventions around bullying right
00:31:44.240There are more guidelines than just, like, tell them to knock it off.
00:31:47.900This is why I say that, like, I don't really, but, like, on some level, I sympathize with the plight that health care providers are in because much of the advice here is, like, we'll link people up to resources, right?
00:31:59.840Like, not everything is within your jurisdiction.
00:32:02.060You don't have the power to fix these much larger problems like poverty, like bullying, etc.
00:32:10.960This isn't about setting up a good patient experience for fat kids. It isn't even about setting up a good professional experience for pediatricians, right? It is about telling fat kids that they are fat and doing everything we can to make them thin. The end, right? Even if those things don't work, even if they've been disproven, even if other people are still being jerks to that kid, doesn't matter. The thing that matters is making that fat kid thin.
00:32:36.380This is what's so frustrating. It's like all of the recommendations in this document pretend that we exist in some kind of perfect world. There's no meaningful engagement with the question of like, what can we do for fat kids in the world that we have? Right? If a kid is depressed, if they're being bullied, I don't have the power to change the way that they're being treated at school. What I think every single doctor should actually be doing is trying to tell kids that they shouldn't go on fucking diets.
00:33:04.620yeah hey don't go on a diet it's fine to look the way that you look if you go on a diet you're going0.99
00:33:10.840to end up on some dumb fucking fad diet you're going to gain all the weight back you're going0.93
00:33:14.580to feel bad doctors don't have the ability to like help kids meaningfully lose weight but they do have1.00
00:33:21.460the ability to like use their credibility to be like whatever you find on the internet is bullshit0.79
00:33:26.140kiddo the times that i have most appreciated my health care providers are when they invite me into0.62
00:33:31.960nuance and to understanding what's actually happening here, right? There are a lot of people
00:33:36.600who are going to tell you that they know how to manipulate your body weight and they know how to
00:33:40.180make you smaller. They don't. The science tells us pretty consistently that like an overwhelming
00:33:45.500majority of efforts to lose weight, whatever you call them, whether it's a diet or something else,
00:33:51.080an overwhelming majority of those, um, lead you right back to the size you were before,
00:33:55.920or maybe a little bit bigger right nobody knows how to do this so your job is to you know eat
00:34:03.020foods that are nourishing to you your job is to find activity that you like your job is to build
00:34:08.200strong relationships and to you know expect that people treat you with respect and that's where we
00:34:14.740leave it right god michael i'm just realizing we haven't even got into the like drugs part of this
00:34:19.800we're not even in the bad shit okay are you ready to hear about treatment options0.88
00:34:24.200oh god am i you are you love it this is this is the good part this is the solutions okay let's do0.89
00:34:31.100it it's actually less bad well it's gonna get bad but it's not that bad at first okay all right so
00:34:37.120the title for this is intensive health behavior and lifestyle treatment i h b l t which i will
00:34:46.480not be calling it that because that's ridiculous i do like that it has blt in it
00:34:51.860just like as i'm a pro blt person that sounds tasty it's an intensive health blt
00:40:32.060The cost effectiveness here is beyond reproach is what I'm hearing.
00:40:35.600And the thing is, I don't like, I don't care about these clinics losing money or like donors
00:40:39.580are wasting their money. Like I don't give a shit. But the problem that that creates is that0.99
00:40:44.500these are not scalable. So it says there are known limitations for families to access and
00:40:50.220participate in intensive health behavior and lifestyle treatment. These limitations include
00:40:54.480the relative scarcity of such treatment programs and healthcare providers with experience in
00:40:59.380pediatric obesity treatment, family transportation challenges, loss of school or work time to attend
00:41:04.460multiple recurring appointments during what are typically working hours. Then it just says social
00:41:09.000determinants of health, competing health issues for children or family members, and mismatched
00:41:14.080expectations between the family who may expect significant weight loss and pediatricians or
00:41:18.700other pediatric healthcare providers. So it's like, oh, is that it? Oh, it's not big enough
00:41:23.800and people can't get there and it happens during the workday and people don't want to go to them
00:41:30.660and they're poor and like there's other things going on in their lives i like that one of their
00:41:35.440bullet points is social determinants of health which is like medical shorthand for like all of
00:41:42.140society and how the world works just like the entire social and political and economic context0.92
00:41:49.420anyway look these are perfect unfortunately minorities do exist doesn't have to be a problem0.77
00:41:55.540But also almost all of the research into fatness and fat people and particularly fat kids, at least as much as I have seen, proposes that there will be benefits to these interventions and then measures the benefits and comes up with a narrative that reinforces the benefits.
00:42:14.100They're not actually screening for or looking for the harms of these interventions.
00:42:19.040Yeah. So like I would also like to see what's the difference across the board in physical health outcomes and in mental health outcomes between kids who get few to no interventions about their weight and kids who get lots and lots and lots of interventions about their weight.
00:42:35.180This actually leads to the next section of the paper, which is essentially the only place in this entire 136-page document that they mention eating disorders.
00:42:46.140So when they're talking about these interventions that, quote-unquote, work, they sort of have to acknowledge that there's been years of criticism of this approach from eating disorder practitioners and, like, actual fat people.
01:02:01.000The core issue here isn't that for the first time, kids are going to start getting weight loss surgery.
01:02:09.800The core issue here is the Professional Association of Pediatricians in the U.S. is providing guidance that they can and sometimes should refer 13-year-olds to get bariatric surgery.
01:02:24.940So there's two long-term studies of bariatric surgery among adolescents.
01:02:28.380The first is in Cincinnati on 58 kids who received the surgery.
01:02:33.880The kids lost a huge percentage of their body weight, and they had pretty significant improvements
01:02:38.660in their diabetes, their hypertension, like all of these kind of metabolic health markers.
01:02:44.800One of the articles about this cohort also said, though, despite this impressive weight
01:02:50.140reduction and the net improvement in cardiometabolic variables, 63% of participants remained severely
01:03:46.220And this is what we've talked about on our Patreon episode so many times is like the
01:03:50.240the kids who got these surgeries had an average BMI of 60. And I looked that up and for a five
01:03:57.560foot eight person, that's 400 pounds. If you are a 16 year old girl and you weigh 400 pounds,
01:04:05.440you are experiencing a level of stigma from the world that I think that I physically cannot
01:04:10.840fathom. And if you look around the world and you decide I can't do this anymore and I want to get
01:04:19.100the surgery and it's worth the risks for me I am not going to tell you that you made the wrong
01:04:23.960decision this is why it's so difficult for me to like say anything definitive about these things
01:04:30.260because I think people who make the decision to do this I don't want to make them feel bad and
01:04:35.940like if if a kid decides to do this like all I want for that kid is to feel like loved and happy
01:04:41.540for the rest of their lives yeah I am not ever here to tell someone who is fatter than I have
01:04:46.360ever been how to live their life. And it's like not how I want to show up in the world. So I'm
01:04:51.400right there with you on that. And also, I think it's worth talking about the really intense side
01:04:59.080effects of this. I think we deserve research that tangles with what are the negative outcomes of
01:05:04.160this, not just in terms of your physical health, but also in terms of your mental health, right?
01:05:08.700I think we deserve more and better and deeper research.
01:05:13.080If this is the only path out that fat people see and that very fat people see, we have work to do.
01:05:21.400And at the very least, they deserve really solid, reliable information about a huge decision to make.
01:05:29.220The cohorts that we have now, the average age was 17.
01:05:32.080These are kids that are like pretty close to adulthood and much more capable of understanding the risks of these surgeries, which, you know, are considerable.
01:05:43.940So in the Swedish cohort, 26% of the kids had moderate or severe depression.
01:07:40.860Again, if people want to go forward with this, I'm really not here to criticize anybody's
01:07:44.960decision, but it's like at a larger systems level, it's worth considering whether people
01:07:51.220are really going into this with like a full understanding of what it means to get these
01:07:56.880surgeries. It makes me feel so angry at a level that I like really struggle to express. If I'm
01:08:06.080honest, I don't usually struggle to express myself, but this issue makes me so angry because
01:08:11.560you're taking kids who sometimes have other health problems and sometimes don't yeah you are making
01:08:18.400what are often lifelong decisions about how their body is going to function you're doing that with
01:08:24.860really thin research right you're doing this in a setting where you know if a doctor and your
01:08:32.920parents say you need to have a surgery how much agency do you really have to say no to that right
01:08:40.060It is galling to me that this is wrapped up in a document that pays lip service to weight stigma and intends to do absolutely nothing about it.
01:08:55.320There's no looking at like suicidality and long term mental health.
01:09:01.640there's just like so many angles that we haven't looked at this from because what we heard was
01:09:07.920we've got a way to make fat kids thin and we decided that was the most important thing to do
01:09:14.480like this is such a complete erasure of the actual life experiences and wants and needs of fat kids
01:09:21.280it feels really telling well it's also it's telling that this comes at the end of a document
01:09:26.300that is like explicitly like we don't care about health stuff yes jesus uh by the way we're not
01:09:34.520looking at all that stuff we're we're only focused on the size of the children it it really feels
01:09:40.380like it's like veering into double speak territory right from that perspective as someone who has
01:09:46.160lived the life of a fat kid albeit a while ago it is like deeply deeply painful to think and talk
01:09:55.180about you know like i had a really rough time as a fat kid and that was without the american academy
01:10:04.020of pediatrics telling my doctor to like triple down my understanding of like your childhood
01:10:09.880experience is that basically every single doctor who you saw should have asked you about your
01:10:16.440history and just concluded like oh this is like a little fat kid yeah her body just wants to be fat0.98
01:10:21.540We should just let her be like a happy little fat kid. And it's fucking wild to me that like with all of the research we have about like different forms of obesity and things that contribute and biological factors, whatever, that there is nothing in this document that is just like some kids are fat.0.94
01:10:38.280Right. This is like the weird thing that would pop up in like grade school. I will absolutely never forget. I had two friends and they would just eat like whole family size bags of chips and be like, I can just eat whatever and I never gain weight.0.94
01:10:54.360and there was this weird celebration amongst parents of like naturally thin children yeah
01:11:01.720but there was absolutely never any acknowledgement that some kids might also be naturally fat right
01:11:09.140that that same effect might exist in kids with higher body weights no that was always about
01:11:15.780they don't have enough stick-to-itiveness we haven't found the right diet the parents aren't
01:11:20.740doing enough that was always a problem to solve right that's a bad way to grow up as a kid this
01:11:26.840whole thing is so typical of this transition period where it's like we're now acknowledging
01:11:31.980all of the problems with the way that this kind of care has been provided for like four decades now
01:11:38.520but everything in this document is defending let's do the same thing bring up weight at every0.76
01:11:45.640fucking visit give tedious advice of like don't drink sodas invite them to these intensive0.85
01:11:52.220behavioral programs that don't exist yeah and if those don't work because they never do0.99
01:11:57.000then start them on weight loss drugs and surgery which we don't know what that does and we don't
01:12:02.040know what that does yeah the actual paradigm shift that they completely refuse to acknowledge
01:12:06.820is just get rid of weight as a variable completely yeah ask kids about their behaviors
01:12:39.560I think that there are probably in existence somewhere parents and kids who could actually use some of these like nutrition classes, learning to cook.
01:12:49.600I think that those people probably exist.
01:12:52.240But right now, all we're doing is just assuming that every single fat person has terrible behaviors and that all of them need to change their behaviors.
01:12:59.960And look, if you are prescribing treatments that don't work for the majority of people who undergo those treatments or are inaccessible to them or what have you, if you are focusing a kid's entire relationship with their health care provider on manipulating their weight, which likely won't be manipulated in the long term, what you are telling them is that nothing matters as much as how much they weigh.
01:13:28.940You're also conditioning those kids to accept really subpar behavior from people around them.
01:13:36.120You're conditioning those kids to expect to apologize for their bodies before people even know who they are.
01:13:43.320I feel like the only thing on which we agree with the AAP is that we also think that children should be given intensive BLTs, but we mean the actual sandwich.