Maintenance Phase - Doctors Have a New Plan for Fat Kids

Episode Date: February 28, 2023

Last month the American Academy of Pediatrics released a new set of guidelines for "childhood obesity." We have some comments. Support us:Hear bonus episodes on PatreonDonate on PayPalGet Maintenance Phase T-shirts, stickers and moreBuy Aubrey's new bookListen to Mike's new podcastLinks!The 2023 American Academy of Pediatrics Guidelines The 2007 guidelines Pros and cons of bariatric surgery in adolescents Serious Issues With the American Academy of Pediatrics Guidelines For Higher-Weight Children and Adolescents Semaglutide treatment for obesity in teenagers: a plain language summary of the STEP TEENS research study Patients’ views of long-term results of bariatric surgery for super-obesity: sustained effects, but continuing struggles Long-Term Outcomes After Bariatric Surgery Suicidal thoughts and behaviors in adolescents who underwent bariatric surgery Support the show

I'm gonna do it all at once and it's just gonna come out. It's like tower of battle. Like just everything. I am so grateful. I have to say that you are looking into this one because there's no question that we had to cover it. Yeah. And I think I would emotionally just like turn into a fine dust because this makes me so sad and angry. Uh, that's what I'm gonna do to you over the course of the next three hours. Oh, great.

You're knowing this in advance. Welcome to maintenance phase. The podcast that! You're knowing this in advance. Welcome to Maintenance Phase! The podcast that's just integrating into a find-us! Wait, is this the tagline you just were going with? No, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no Oh, you did like a nice one. That's straight from the Mr. Rogers playbook. And I felt like we needed some niceness for the extreme grim goblin garbage that we're about to sort through today. We love you just as you are

unless you work for the American Academy of Pediatrics in the case. Then we have some questions. We want you to be different. We don't like what you're choosing to do right now. I'm Michael Hobbs. I'm Aubrey Gordon. If you would like to support the show, you can do that at patreon.com slash maintenance

phase. You can get merch at T public. You can also subscribe through Apple Podcast, which is the same audio content as the Patreon content audio. And Michael, I feel like I am like getting ready to be full of rage. It's like a little propeller on your head that like I get to spin around when we do these episodes. And I get just to imagine that you're just gonna lift off out of your seat. Just getting ready gonna lift off out of your seat. Just getting ready for a lift off.

So today we are talking about the American Academy of Pediatrics guidelines on the treatment of childhood obesity. They released the last set of guidelines in 2007. The general approach for those was watchful waiting. If your kid is fat, they'll probably outgrow it. We don't need to do anything aggressive. This year in January, they updated the guidelines and recommended a much more aggressive approach. The thing that got the most media coverage was the fact that they are now recommending weight loss drugs and

bariatric surgery for kids as young as 12. And I went on to the AAP's website, I got the document, I pasted it into word, it was 136 pages. I went through it, I checked the citations, I talked to someone from the AAP, and this episode is literally just going to be us going through the document. I'm going to do my best to try to make that interesting,

but I might fail. There you've been warned. So as usual, we need to start this episode with a carnival of housekeeping. First of all, this is going to include a lot of like sugary eating disorder, weight loss, calorie stuff. It's also going to include the word obesity a lot, which is not a word that either one of us like or use, but in the context of these studies, because they are exclusively based on BMI

categories. We kind of have to talk about those categories when we're talking about the studies. And, you know, we do episodes sometimes where it's like, I look into an influencer and I tell you about it and you've never heard of them. They're always from Australia. And that isn't fake, like the show isn't scripted. We're coming in fresh to those episodes. This is not one of those episodes. This is a topic that both of us have been thinking

and writing about for a very long time. And we're not gonna pretend that we don't already have issues. And of course, like human biases that we are coming in with. Yes. So the purpose of these guidelines is just to kind of get all of the evidence on this issue in one place. So they've put together a task force,

there's like a committee, all these doctors have spent years looking every single thing that's ever been published, and they wanna put it into one place and on the basis of all of the evidence make recommendations. That is what they are setting out to do. Okay. Something that I missed, but Reagan Chastain, who wrote a bunch of really good sub-stack

posts about this, she noticed, is that if you read the technical reports where they kind of go through the evidence like paper by paper, they explicitly say that they are excluding from the evidence anything that doesn't deal with weight. This may seem like a small methodological detail, but it's actually a huge deal because there are numerous studies that have showed pretty significant health benefits for people who change their diet and exercise habits, even if their weight does not change. So according to this document, right off the bat, we're basically saying all of those are considered ineffective interventions because what we're looking at is only weight status.

We're really concerned about the health of these kids, therefore we're not looking at their health, we're just looking at how fat they are. It is actually fascinating to me that the entire social construction around this issue is that it's really only about the health, right? And when I'm mean to a fat person on a plane, 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.

No, no, it's just about the fatness. This 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 papers, say, we didn't look at anything about how. Yeah, we're, 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 is the issue with fatness. This is how you get to the point where people really think someone just gets so fat that they drop dead and that's like a way that people die. They also mention at the very beginning that this review will not be discussing obesity interventions for children under the age of two.

Just like, wow, thank you. I appreciate it. I appreciate it. I appreciate it. I'm so brave to cut it off. We're not going to be covering literal infants. The opening salvo is we're not going to call your baby fat in utero. Yeah, exactly. Please clap for our restraint.

So I don't know if we've talked about this on the show show, but on a number of bonus episodes now, we've talked about the fact that like fat people and fat stuff, this issue is in a weird transitional period where there's growing societal acceptance, but there's also these kind of remnants of a huge amount of stigma. Absolutely, there's like starting to be a thing

that happens when I do research for the show and I'm sort of knee deep in health and wellness media about fatness and fat people, usually. Those stories are starting to change and now they're exactly the same stories as they were before, but they include maybe one personal story from a fat person and maybe one paragraph on weight stigma and why it's important and then right back to but also fat people are gonna die.

Exactly. 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 to completely contradictory sets of beliefs. Yeah, it's basically saying we agree with this Copernicus guy but we're not ready to get rid of Tolemie and his little planetary loop de loops. We think Hobbes and Locke have good points to make like book a Yeah, but okay, I always say it was my dad on that one though. Oh, your dad. This is where we start getting into this transitional period. The first section is called health equity considerations,

where we talk about all of the social determinants of health that affect obesity. So I'm gonna send you a series of bricks of text. There's like dot, dot, dots where like I've cut a couple of paragraphs in between and sort of condensed stuff. This fucking document, Aubrey, the about the amount of like editing I had to do to make this readable absurd. I had like a whole bunch of macros to get rid of all the fucking acronyms. Whoa, brick.

Yeah, I know, I know, I know, I know. We can take breaks. Long stigmatized as a reversible consequence of personal choices, obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. As the environment has become increasingly obesity genic, access to evidence-based treatment has become even more crucial. And then we've got a little ellipsis.

This is the Michael Hobbs, dot, dot, dot. Michael Hobbs, dot, dot, dot. Michael Hobbs, dot, dot, dot. These are my choices. Child and obesity results from a multifactorial set of socio-ecological, environmental, and genetic influences that act on children and families. These influences tend to be more prevalent among children who have experienced negative environmental and social

determinants of health, such as racism. Overweight and obesity are more common in children who live in poverty, children who live in under-resourced communities, in families that have immigrated, or in children who experience discrimination or stigma. Michael Hobbs, dot, dot, dot. The American Academy of Pediatrics

is dedicated to reducing health disparities and increasing health equity for all children and adolescents. Ataimin of these goals requires addressing inequities in available resources and systemic barriers to quality health care services for children with obesity. To that end, practice standards must evolve to support an equity-based practice paradigm. Well, so listen, so far, I disagree with the sort of framing around like the problem here is fatness, but in terms of the substance of what they're saying, I don't actually disagree with much of this, right? Yes. This is an issue that's much more complex than we give it credit for.

The interesting thing that they don't mention here is the role of experiencing anti-fat stigma. Would you like to hear our next two paragraphs? Oh, did I do a segue? This is what is so interesting about this document to me, is like, much of it could have appeared in your book. You are a much better fucking writer than this, obviously. But as far as like, acknowledging everything that we say on this show, this document is pretty good. Like right after this little excerpt that we read, there's a long section on racism, there's a long section on toxic stress and minority stress, and then there's a section

on weight stigma. Huh! This part says, individuals with overweight and obesity experience weight stigma, victimization, teasing, and bullying, which contributes to binge eating, social isolation, avoidance of healthcare services, and decreased physical activity. Importantly, internalized weight bias has been associated with negative impact on mental health. Collectively, these factors may adversely affect quality of care, prevent patients with overweight and obesity from seeking medical care, and contribute to worsened morbidity and mortality, independent of excess adiposity. Pediatricians and other primary care providers have been and remain a source of weight bias. They first need to uncover and address their own attitudes regarding children with obesity.

Yeah, there's not a lot to actually like, quibble with here. Yeah. It's like, yes, stigma matters, doctors are a source source of stigma and like stigma can have health consequences on people Right and therefore what we need to do is we're gonna spend the rest of this paper talking about how to reduce stigma and end your own bias, right? This is what is so fucking incredible to me about this transitional period, right? They will say all of these things, but then do nothing with them. Lip service, lip service, lip service. And unfortunately, the lip service is pretty fucking good. But the lip service is like, yeah, you're saying all the stuff that we've been wanting you to say.

But we would also like you to do something about it. This is the last time they're going to mention like doctors are a source of medical bias. But you know that if you criticize the AAP for any of this stuff like, uh, this doesn't actually seem like a very equitable framework, they'll be like, uh, uh, the very first section is called health equity. It's really astonishing that they're sort of doing this like seem to be salient forth into a bigger, more complex conversation and then do this weird hairpin turn and be like, yeah, the bullying of fat kids is really a problem, which is why we need to eliminate fat kids and make them all thin.

We're like, I don't think that's the solution. So, the next section of the paper, after we've done all this health equity lip service stuff, we 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 cancer fat. So they start up by noting that the prevalence of childhood obesity has gone from 5% in 1963 to 19% in 2017. This is something I've only started noticing once I started doing the show with you. They often note that the baseline is not zero percent. So there's presumably always some number of kids who are just fat.

I 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. Remember when I went to that museum in Amsterdam and I kept texting you with the paintings of fat people? Yes!

It's like Aubrey looked at all these fangs! It's like another painting of a fat person! This is great! Yeah! So another really weird thing about this document is that there's almost nothing about health risks. They mostly cast this as a problem in the sense that like fat kids will become fat adults. So younger kids like between 7 and 11, 55% of those kids become fat adolescents,

and 80% of fat adolescents become fat adults. And so that's kind of like the trajectory that they're warning us about, is it like most fat kids become fat teenagers, become fat adults. But 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.

Oh! And then also, there's also some like careful wording stuff. So they say at one point, the COVID-19 pandemic has significantly affected the lives and routines of children and adolescents. Oh. In one analysis, the pandemic period was associated with a doubling in the rate of BMI increase compared to the pre-pandemic period. And I was like, a doubling in the rate of BMI increase. Oh, is it like three quarters of a pound or some shit?

No, it's basically during the first nine months of the pandemic. Yeah. Quoticoot normal weight kids gained three pounds and fat kids gained six pounds. Okay. Okay, I mean, is that noteworthy fine, but also like, do I really give a shit about like three extra pounds? Also, kids are supposed to be gaining weight because they're growing and we all fucking gained weight

in the pandemic, surely, like if there's one time where everyone could just gain some weight and everyone else could shut the fuck up about it, it's the pandemic. And also like, no one could shut up about it. Absolutely nobody could shut up about it. It's the pandemic. And also like no one could shut up about it. Absolutely. Nobody could shut up about it. But they weigh three more pounds.

I'm like, but they're alive. So then we have a couple paragraphs about health stuff. It's like, time to diabetes. Well, like, I'm not going to read this stuff because we've all read these paragraphs a million times. And then in the section about the health effects of obesity, it says, in addition to physical and metabolic consequences, obesity in childhood and adolescence is associated

with poor psychological and emotional health, increased stress, depressive symptoms, and low self-esteem. Yeah, it's like, you think? I can't imagine that any of the rhetoric that we're advancing in this document would contribute to that, nothing to see here. These are not health consequences of vatness. It drives me nuts when public health agencies conflate the health impacts of obesity

and the health impacts of people being shitty to fat people. Yeah, rhetorically it does two things, right? One is that it continues this sort of line of thinking that has been very prevalent certainly in the US for the last 20 years, which is everything that happens as a result of someone being fat is a direct result of the fat cells in their body, right? That there's like, people get fat and then they get depressed. There's no way to know why it just happens.

And the other thing that it does implicitly that is absolutely fucking maddening to me is that it is implicitly blaming fat people for the behavior of garbage people. Exactly. Yes. We then get to the section that you've been waiting for, Aubrey, where they talk about the use of the BMI as a screening and diagnosis. No.

I first came across this in a USA Today article about the guidelines, not in the guidelines themselves, where in back-to-back paragraphs, it says, young people who have a body mass index that meets or exceeds the 95th percentile for kids of the same age and gender are considered obese. So that's the definition of obesity is kids that are fatter than 95% of kids. And then it says, obesity affects nearly 20% of children and teens. So 20% of children and teens are fatter than 95%

of children and teens. Oh my God, Michael. In the guidelines, it says, the group charts are based on inhance data from the 1960s through the early 1990s. So basically the definition of obesity is not that you're fatter than 95% of kids. It's that you're fatter than 95% of kids in the 1960s.

Yeah, totally 40 years ago. And also as you mentioned, those percentile rankings, I mean they're just descriptive. They're not based on like health risks. Yeah, 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.

This 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. The whole point of this document is to bring together all of the evidence, right? So this is the section where they essentially defend

the use of the BMI. Ha! There's this weird circular logic here, where they say, despite its limitations, BMI is currently the most appropriate clinical tool to screen for excess adiposity and make the clinical diagnosis of overweight or obesity. So it's like, say what you want about the BMI, it's not perfect, but it's the best tool we have for diagnosing fat and very fat

kids. But the definition of overweight and obesity is based on the BMI. The definition of overweight is above the 85th percentile in the BMI. The definition of obesity is above the 95th percentile on the BMI. Right. So what they're saying here is the BMI is very good at determining their BMI. Yeah. Yeah. Which like, yeah, it sure is. This year, I'm doing my own employee evaluation,

and my evaluation of me, as defined by me, is I'm great. But also listen to this shit. Uh-oh. Okay. They 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. As part of this, they have a flow chart for doctors. 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 them. One 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. And 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. That is required in order to get paid for your work as a healthcare provider. That is required in order to get paid for your work as a health care provider. That is, but nanas 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. It all clicked into place for me at the end of the section where they give advice to doctors on how to bring this up with patients, right? Because 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. So how are they going to reconcile this, right? They have three rules for doctors, for facilitating a non-stigmatizing conversation

about weight with kids, right? So the first tip is ask permission to discuss the patient's BMI and or weight. Number two, use words that are perceived as neutral by parents, adolescents, and children. Oh, God. Avoid labeling by using person first language. No!

I know, child with obesity, not obese child, or my patient is affected by obesity, not my patient is obese. Preferred words include unhealthy weight, gaining too much weight for age, and then there's a Spanish phrase which I'm not going to try to pronounce, that means too much weight for his or her health.

Jesus, great. Third rule, before you go into lift-off, third rule. God damn it. Recognize that discussing BMI with children, adolescents, and families, even when using non-stigmatizing language and preferred terms, can elicit strong emotional responses, including sadness or anger. Acknowledging and validating those responses while keeping the focus on the child's health can help to strengthen the relationship between the pediatrician or other primary health care provider

and patient and family to support ongoing care. Oh my god. Can you so listen, listen, listen. Thoughts? Oh Jesus. There's a great stand up. Yohan Miranda. He's like unbelievably funny, who has a bit that's like, yeah, I don't feel better if you call me a fucker of mothers. Yeah, it's like brought to bear here, right? That this like weird, fancy footwork of we're just going to move around some words. Feels really strange to me. And as any fat person who has tried to participate in any kind of conversations about health care on Twitter knows, if you refer to yourself as a fat person, there's a decent chance that some thin healthcare provider is going to pop up out of a trash can and be like, actually, I think

you mean person with overweight. And then we'll like talk over fat people who are self identifying, which is maddening and documents like this. Talk to a woman. And put that even further out into the world that's like, we've decided for you what language affirms you. It reminds me a lot of, in the 1990s, when the term downsizing, people started to understand

what you actually mean with that term. And so there was a move to use the term right sizing when you're doing a bunch of layoffs. Oh, we're right sizing the company. And it's this idea that like people will be less mad about being fired. If you phrase it the right way. And like, no, being fired sucks, you can call it anything you want. At the end of the day, that person is packing up their desk and going home. And it's the same thing here. It's like there is no way to bring this up with somebody that is going to make them not understand what you're actually telling them. It'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, but I'm bringing it up in a way that's non-stigmatizing. But the stigmatizing part is that you're bringing it up in every interaction. I'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. It's got to be really hard for you. Right? That's essentially sort of what we're talking about here is like causing material harm to fat kids and then being like, uh, but I used the right language.

So pat him back. There's nothing in this document other than those kind of two perfunctory bloodless sentences of like doctors or a source for stigma. There's nothing about like, hey, really sit down and think, does this patient need a lecture from me about eating five fruits and fucking vegetables right now if they came into something completely else? Do I maybe want to ask about other interactions as patient has had with the healthcare system?

Have they tried losing weight before? What are their behaviors? Maybe don't even bring up weight at all? Just ask them, is there anything else you want to talk to me about today? Okay, bye. I was, I think, 36 years old. The first time a doctor asked me if I had an eating disorder. Mm.

There's a place where there is a known cluster of diagnoses and bringing up this conversation will make those actively worse is around eating disorders in body dysmorphia, which are hyperactive, particularly in adolescents, right? Like, what happens if that kid is already depressed? Well, this brings us to the next section of the document. Tell me. This is a huge section.

This is like probably a third of the document is risk factors for child and adolescent overweight and obesity. And this walks through like everything we know about the factors that are associated with higher weight among kids. Just like the health equity section, this is pretty good. It's like it goes over. So it, you know, it talks about socioeconomic disparities. It talks about racial disparities. It has a whole thing about policy factors. There's environmental smoke exposure, sleep duration. There's a whole thing on adverse childhood experiences

that like fat people are more likely to have been abused when they were kids, which is a whole fucking can of worms that we talked about. Yeah, yeah, yeah, yeah. There's genetic factors. Epigenetics. Autism is associated with higher weights. ADHD is associated with that.

They have a whole section on medications. It's almost as if fat people are not just fat bodies walking around, but people with lives and health concerns and other things going on. But then the way I think that they are reconciling all of this information coming out about social determinants of health and all of the complexities about like why people are fat is this document explicitly says that like you should incorporate all of that context into your recommendations to people for how to lose weight. What? There is literally at no point in this document, does it ever say tell people that it's fine

not to be trying to lose weight. Right. Like, focus on housing security. You don't need to worry about your weight right now. The jacket is a place to live. So according to this document, if a patient comes to you and says, like, you know, I'm 16 years old, I grew up in foster care, I experienced horrific abuse, I'm now on a medication for my depression and since I started taking it I gained 25 pounds.

There is nothing in this document to just say, that's fine. Focus on being happy right now. Yeah. No. According to this document, if they are above the 85th percentile on the BMI, you should tell them to lose weight. And it's all punitive. Right.

It's not goal-oriented behavior. It's not if we follow these steps then we know we produce these outcomes. It's if we follow these steps, maybe something happens question mark, but we don't really have evidence that anything does. And the evidence we do have is that people feel worse than avoid healthcare.

Right. The best case scenario is that it's throwing stuff at the wall and seeing what sticks. Right. And the worst case scenario is that it's projecting adult anxieties on to children, and not only that, but on to fat kids. I want everybody to think about every media depiction you've ever seen about a fat kid.

Is it about how well loved they are and how everyone's treating them great? I want you to think about the fat kids that you have known in your life, were they like, live in the life or highly? What's going on? Right. It's just astonishing to me that the answer to all of this

is like, you see those kids over there? They don't feel bad enough. Well, it's also, it doesn't give any specific advice to doctors on like what they can actually offer in like a seven minute appointment. So there's in the one place that this document actually talks about like a behavior assessment, like ask the kid what their diet and exercise habits are. It says, dietary intake can be addressed by assessing the following. Eating outside the home, consumption of sweet drinks,

portion size, meal habits, snack habits, fruit and vegetable consumption. What actual advice does this lead you to give? Oh, try not to drink so much soda. Like you're gonna give them this like 101 Dr. Oz level advice? Oh, try to eat smaller portions. Wow, thanks. Tell those fat toddlers to start taking the stairs. And then this is the part that I've been saving, Aubrey, because like, you're gonna explode it. So it also says that you should try to assess whether the kids are experiencing weight stigma.

What? So it says, a common comorbidity of obesity and children is weight-based bullying and teasing. If a patient responds affirmatively when asked if they have ever been teased or bullied about their weight, pediatricians and other care providers can consider provision of resources, such as those found at stopbullying.gov, to the child, as well as a local counseling referral. So then I go to stopbullying.gov. Jesus God.

And I typed in like weight stigma, fatness, obesity, like all the various search terms. This quote unquote resource has published three articles about weight-based bullying in the last decade. What? The first of them has like a list of bullet points for adults in case they like see weight-based bullying, whatever. The list begins, how can I encourage

a healthy body image among adolescents? One, promote healthy eating and exercise had a- Shut the fuck up, fuck my cough! So the number one advice from this article is like teach kids how to lose weight if they're being bullied, for being fat. Fuck you! Are you being bullied?

Step one, have you tried weight watchers? And then all of the other articles on this quote unquote resource are for adults. It's like if you see kids bullying other kids, like step in and try to stop it, which is like great, but that's not a resource for kids. This is not a meaningful resource. For most professional guidance,

including interventions around bullying, there are more guidelines than just like, tell them to knock it off. This is why I say that like, I don't really, but like on some level, I sympathize with the plight that healthcare providers are in, because much of the advice here is like, we'll link people up to resources, right? Like, not everything is within your jurisdiction.

You don't have the power to fix these much larger problems, like poverty, like bullying, et cetera. So link people up to resources. But there are no resources. This 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. Right. The end. Right. 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.

This is what so frustrating is, 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.

Yeah. 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 going to end up on some dumb fucking fat diet, you're gonna gain all the weight back, you're gonna feel bad. Doctors don't have the ability to help kids meaningfully lose weight, but they do have the ability to use their credibility to be whatever you find find on the internet is bullshit kiddo.

The times that I have most appreciated my healthcare providers are when they invite me into nuance and to understanding what's actually happening here, right? There are a lot of people who are going to tell you that they know how to manipulate your body weight and they know how to make you smaller. They don't. The science tells us pretty consistently that like an overwhelming majority of efforts to lose weight, whatever you call them, whether it's a diet or something else,

an overwhelming majority of those lead you right back to the size you were before, or maybe a little bit bigger. Nobody knows how to do this. So your job is to eat foods that are nourishing to you. Your job is to find activity that you like. Your job is to, you know, eat foods that are nourishing to you. Your job is to find activity that you like. Your job is to build strong relationships and to, you know, expect that people treat you with respect. And that's where we leave it.

Right. God, Michael, I'm just realizing we haven't even got into the, like, drugs part of this. We're not even in the bad shit. Ugh. Okay, are you ready to hear about treatment options? Oh, God, am I? You are, you love it. This is the good part, this is the solutions.

Okay, let's do it. It's actually less bad, well, I'm just gonna get bad, but it's not that bad at first. Okay, all right. So the title for this is Intensive Health Behavior and Lifestyle Treatment, IHBLT, which I will not be calling it that because that's ridiculous.

I do like that it has BLT in it. Just like, as I'm a pro BLT person, that's on Stasty. It's an intensive health BLT. No, no, wait, no, no, it's not bad. So every municipal hospital has a program like this. These are, you know, they're often run by dieticians or obesity clinicians or something. And they're basically like nutrition classes. And for kids, they often include some sort of sports

or physical activity component. I looked up one of them, there's a program in Durham, North Carolina called Bull City Fit, where they worked with the Parks Department to get some sort of like community center and dietitians and doctors would just kind of park there one hour every day, six days a week, and then families could come in kind of whenever suited them. So they wanted to create something that was like a little bit flexible. The goal was for everybody to attend one day a week, and then you'd go there and it'd be like special programming or like a nutritionist talks about

how to cook healthy meals or you practice different sports to try to figure out one that you like, etc. And so this is the first stage of obesity treatment is referring these kids to one of the bale teas. And these are the goddamn it. I'm gonna do it all at the same time. I had a delayed response to that. And keeping it.

These are the interventions that start as young as two, yes? Yes, but then there's kind of like a weird lack of specificity in these because what would one of these programs even look like for a three year old, right? Then you're you're really talking about a parental intervention. Well, and it doesn't seem to like interrogate its own central assumption, which is that individual behavior is determined body size, right? Right.

The core assumption here is just like we got to make these fat kids thin. Not, we've got to assess the health of these fat kids and see if we can support it more fully. And on top of that, their strategy is to make them thin are not exactly shown to have like a commanding majority decisive impact on someone's individual weight or their individual health, right? Well, this is where we get to the huge coffeeots section of the treatments that quote unquote work, but they only work under very specific conditions. So it says there's all these like success factors

of these lifestyle treatment programs. The first element is duration. Basically any lifestyle intervention for kids that's less than three months is not going to work. A million of these have been tried and they essentially all fail. And that's like most of these programs. You know, they run for like six weeks or they run for a month or whatever. Less effective than fat camp. Exactly. So the programs also have to be super intensive. So kids have to be in these things for at least one hour a week

or they don't really have an effect. They also, they have to be face to face. They also have to be comprehensive. I.E. the parents have to be involved. So it can't just be like the kid trundles over after school and like plays some basketball and then goes home, no. The parents have to be there. And oftentimes there's participatory elements

where the parents have to be part of the cooking classes or play sports with the kids or whatever. Can I ask you a clarifying question? Yes. If all of those elements are in place, if the stars are aligned and these programs work as well as they possibly can. What are the weight loss rates and what are the outcomes that they're measuring?

I love this because this actually isn't included in the guidelines, but in the technical report, if you dive into the details, you can find it and it says, as described in the health, behavior, and lifestyle treatment section, those who do experience BMI improvement will likely note a modest improvement of 1% to 3% BMI percentile decline. Great, good, good, good, good, good, good, good, good. We're back in fucking percentile declines in all this nonsense, basically like five to 10 pounds.

That is borderline normal weight fluctuation territory. And these programs, the biggest problem with these programs is that like, people do not want to stick with them. So the attrition rates in these programs are, for many of them, they're over 65%. In this Durham program, they started with 171 kids, and they ended up with 44.

Like those are the only kids that this actually had, an effect on that's 26% of the beginning kids. Some of the other problems with these is they're tiny, right? So this is a program, it's a two year program that reaches at most, right? If they had a 100% attendance right the entire time, they would reach 171 kids.

Good Lord. This report, these guidelines, start out by saying that 14.4 million children are too fat. All right, well listen Mike, you gotta think about this at scale. If we do this with every fat kid in the country, we'd have like three million kids who all weighed three to five pounds less than they do now.

Come on, man. Think of the kids who lost 7 pounds. Think about the kids who were temporarily slightly thinner and then kept growing in their bodies changed anyway. Come on, man. Also, I feel like a really underrated element of why these programs won't work is in this survey where they surveyed hospitals about their childhood obesity interventions, 84% of them lost money. The cost effectiveness here is beyond reproaches what I'm hearing.

And the thing is, I don't care about these clinics losing money or donors are wasting their money. I don't give a shit. But the problem that that creates is that these are not scalable. So it says there are known limitations for families to access and participate in intensive health behavior and lifestyle treatment. These limitations include the relative scarcity of such treatment programs and health care providers with experience in pediatric obesity treatment, family transportation challenges, loss of school or work time to attend multiple recurring appointments during what are typically working hours.

Then it just says social determinants of health, competing health issues for children or family members, and mismatched expectations between the family who may expect significant weight loss, and pediatricians or other pediatric health care providers. So it's like, oh, is that it? Oh, it's not big enough. And people can't get there. And it happens during the work day. And people don't want to go to them and they're poor. And like, there's other things going on in their lives. I like one of their bullet points is social

determinants of health, which is like medical shorthand for like all of society and how the world works. It's just like the entire social and political and economic context. Anyway, look, these are perfect. Unfortunately, minorities do exist. Doesn't have to be a problem. But also, almost all of the research into fatness and fat people and particularly fat kids, at least as much as I have seen, 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. They're not actually screening for or looking for the harms of these interventions. Yeah.

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. This 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. So 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. Yeah. So it says, in the field of pediatric, actually, let me send this to you. Mm, send me a quote. Yeah, let me send you this little quote. In the field of pediatric, actually, let me send this to you. Hmm, send me a quote. Yeah, let me send you this little quote. In the field of pediatric nutrition, in the treatment of both obesity and eating disorders,

concerns have been raised as to whether diagnosis and treatment of obesity may inadvertently place excess attention on eating habits, body shape, and body size, and lead to disordered eating patterns as children grow into adulthood. The literature refutes this relationship, however. Dieting, 60% of the time, it works every time. Cardell, at all, refer to multiple studies that have demonstrated that, although obesity

and self-guided dieting consistently place children at high risk for weight fluctuation and disordered eating patterns, participation in structured, supervised weight management programs decreases current and future eating disorder symptoms. Here's what I would like to say about this quote, Mike. Oh, giving your thoughts. I myself was a product of a structured, supervised weight management program, and I myself ended up with an eating disorder. Oh wait, so you were on one of these like intensive lifestyle BLT thingies? supervised weight management program, and I myself ended up with an eating disorder.

Oh wait, so you were on one of these like intensive lifestyle BLT thingies? I was on the like early to mid 90s version of them. So like things may have changed or they may have not, but like my parents were supposed to come with me and they had a parents class and I had a kids class and da da da da, And it was one of the earliest and strongest memories that I have of weight stigma.

Absolutely. Oh really? Yes, you just go to this after school program at somebody else's school. You're there with a bunch of other fat kids who know that they're there because they are viewed as having sort of remedial bodies, right? You feel like you're behind at school,

you're having to go to extra school because you're not good enough the way you are. And the lectures that we got were all about behaviors that didn't ring true to me, that I didn't recognize. Essentially what they were describing was like the dangers of binge eating or whatever. And I was like, I don't do that. Is that a UC me?

It felt like a real crash course in like, I have seen your body and therefore, I have determined your behaviors are this. And it just didn't mirror my experience in any real way. And I just remember feeling like, that's a place where you go if you mess up. And they tried to make it fun. And they tried to make it uplifting. And they tried to make it fun, and they tried to make it uplifting,

and they tried to talk about self-esteem, and that message came through loud and clear regardless. Well, this isn't the effort I got to mention earlier. When it's talking about these lifestyle programs, and we're saying it has to be comprehensive and the parents need to be involved, et cetera, et cetera. It says, children learn goal-setting, body acceptance, and strategies to manage bleeding.

And it's like, how would you teach them body acceptance in a class explicitly designed to teach them how to change their bodies? Because of our own conflictedness as adults on this issue, we are sending profoundly conflicted and conflicting sort of direction to kids on this issue. And we are training them to have conflicted relationships with their own bodies, with the foods that they eat, sometimes with their family members, sometimes with their healthcare providers, right?

Like, this is setting the tone on so many fronts and it's setting a bad tone. Kids understand this. Like kids are kind of dumb and also very smart in a lot of ways. Yeah, like kids get this shit. They understand that it's completely contradictory and like they can't give you what you want.

You're telling them to stay in their seat and go to the library at the same time. So to return to this brick that you just read, I've taken out some of the weird medical language and kind of boiled it down. It says, multiple studies have demonstrated that although self-guided dieting consistently plays and kind of boiled it down. It says, multiple studies have demonstrated that although self-guided dieting consistently places children

at high risk for disorder eating patterns, participation in structured weight management program decreases eating disorder symptoms. So the basic idea is that, look, are there diets that increase eating disorder behavior? Of course there are. But what we're talking about is these like intensive lifestyle

programs, and they don't increase the risk. But then they've just also said that these structure programs are not available for like 99.7% of children. What are we even doing here? It's like you're telling people not to do the thing that everyone would do. Go home and fucking Google, right? Look for a diet. You're like, oh, don't worry about it. They're not going to do that. They're going to do this thing that isn't available to them.

Right. It's just total, the whole document is just riddled with this weird head in the sand logic. There's a thing that's happening right now where diets are calling themselves not a diet. We're actually therapy. We're actually a structured weight management program. We're actually a blah, blah, blah. And that means that there is now a sort of sorting the wheat from the chaff that people are trying to do, particularly people from within

the diet and weight loss industries of being like, those are diets and diets are crash diets and they're fat diets and they're bad and you can't trust them. But you can trust our weight management program or what have you, right? And it feels like this is leaning into that too. And to me, that is the same kind of rhetoric that is being deployed by like, noom. So we have two sections of this document left. We're finally reaching the problematic parts. Oh, we haven't gotten there yet.

It's the part. This is the part that the internet got really mad about. And so as, like, this is almost like the concept of this show, at this point, I'm like, I need to read this document and make you get mad about something else than the thing you were already mad about. So basically, the entire framework scope of this document just sucks.

But now we get to the other treatments that are available. So as well as the intensive BLTs, which are not actually available to most kids, the next section is use of pharmacotherapy. And I am going to send you a brick of text. Love to brick. Mm-hmm. I'll let you know when it comes to ranges. No, t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t-t in there and then also, it's just like, yeah, all over the place, man. This is gibberishy, but we're gonna, we're gonna decipher it together.

Quote, although intensive, oh, Bilties, just say BLTs. BLTs. Although intensive health, behavior, and lifestyle treatment has the largest body of evidence meeting the evidence reviews high quality evidence for effectiveness criteria, it is important to consider the use of pharmacotherapy for children in adolescence who require an additional treatment option to manage their

obesity. So for kids 8-11, they can take weight loss drugs if they're also doing some other intervention. For kids older than 12, they can just like straight up take weight loss drugs. Yeah, boy oh boy, age eight, man. I don't love it. If you know any kids that are ages eight to 11, like I just want you to think about that kid for a minute, because this sucks.

It sucks. I am a person who was put on a weight loss drug when I was like 14 or 15, and that drug was fenn-fen. And I did it because a doctor told me it was a safe thing to do. And that drug was later pulled from the shelves because it stopped people's hearts. The drugs that are emerging now and this rapidly evolving field

that they're talking about so breathlessly here, I'm assuming you tell me if I'm wrong, doesn't have a great body of research into the effects on eight-year-olds. And certainly can't tell you the long-term effects on eight-year-olds, right? I think you're being a little unfair. I think just because every previous weight loss drug became a massive scandal, doesn't mean that these weight loss drugs will be. You're actually revealing your own bias.

You're actually skinny-shaming? Oh, kink, kink, kink, kink, kink, kink, kinkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo ginkgo gink old is that they become thin? Well, then what's so weird about this section of the document is after they give this kind of overall recommendation, they then run through the weight loss drugs that are available and the evidence on what they do in adolescents. So, the first one they recommend is Metformin, which is a diabetes drug. It basically says there's a couple of small studies in teens, but they're more or less inconclusive. One study found that kids lost one BMI point, which is like five pounds.

And the side effects on metformin are profound and weeks or months long, sort of gastrointestinal effects. So some of that weight loss might just be you are so nauseous that you can't eat. Yeah, it says 20% of kids who took it had like gastrointestinal symptoms. And then it also said that like, after you lose this one point of BMI, after six months, you keep taking it

and don't get any more weight loss. Great. They also list a fentermine, which is half of fentphen, as we talked about in our fentphen episode. Yeah, fentermine is still around. It's still on the market. It's wild to see that in pediatric recommendations, just existentially wild.

It says kind of casually that it's approved for like three months at a time for kids 16 and older. And then it also mentions this thing called tapiramate. It says the major adverse effect is cognitive slowing, which can interfere with academic concentration or other activities of daily living. Right. It's going to slow down your brain function when you're in grade school, but don't worry. These are literally people in school. Like by definition, these children are in school.

Why would we be considering prescribing a drug that hamper their academic performance? I don't know why they're even telling people that these are options like, you know, a drug that's so addictive that you can only take it for three months at a time. And another drug that like makes you incapable of doing school work? Your kid might get a lot worse at school, but they are going to be working the shit out of that gap kids ensemble.

They are going to be so thin. So the only one that on the surface seems like an actual option, and there's going to be so much goddamn discourse about in the next five years, is semaglutide, which is sold as wugovii by Novo Nordisk. It appears that it was like the same week that these guidelines came out. There was like the one study on semaglutide

in adolescence. This is a weekly injection. It was a study of I think 134 kids, and they lost 16% of their BMI on average. There isn't a whole lot to debunk here simply because, like, there's only this one study that's been published, and it's a pretty small number of people. They also did this, this like pretty intense screening.

They screened out everybody that had like, you know, any disability, any mental health stuff. Like, they wanted to get it down to like quote unquote normal kids. And then they did a 12 week lifestyle thing before they started on the drug. But then what's really weird is this one study says that they followed up with the kids for an additional seven weeks after they finished the study to see if they had any other side effects. But then it didn't track whether they started regaining the weight. It's very odd to me.

The word regain only appears once in the entire AAP guidelines, 136 pages. I mean, there's also fad diets that would also make you lose 15% appears once in the entire AAP guidelines, 136 pages? I mean, there's also FAD diets that would also make you lose 15% of your body weight. Every diet works in the short term. The question is, is this sustainable, right? The guidelines recommend that you shouldn't be on it

for more than two years. If people are losing 16% of their body weight and then gaining back 30% of it, then like, what are we doing here? It's just really weird to me If people are losing 16% of their body weight and then gaining back 30% of it, then what are we doing here? It's just really weird to me that there seems to be no actual interest in answering this question when people losing weight in the short term is not hard. Well, and if we return to FENFEN as my forever or example of like a weight loss drug, right?

FENFEN got a bunch of breathless press coverage based on not very much research. Similarly, Fenfen was rushed to market and we didn't really learn about the health effects of Fenfen until people started dying. Right. I'm not saying that these are drugs that are going to kill people, but I am saying one short term study of a small group of adolescents does not tell us that this is safe or effective for most kids. So can I read you something and you have to guess who wrote it? Oh no. You're actually going to like this part.

Okay. It says, the use of weight loss medications in obesity treatment has a complicated history. Many medications used to treat obesity were eventually withdrawn from the market or their use restricted after documentation of dangerous side effects. Particular care must be taken when the use of weight loss medications is considered for children because the long-term effects of these substances on growth and development have not been studied. Pharmacotherapy alone has not proven to be an effective obesity treatment. Medication used as part of a structured lifestyle modification produces an average weight

loss of 5-10%, which typically plateaus at 4-6 months of therapy after which weight regain may occur. Weight regain is common if the drug is withdrawn. Do you know who said that? I don't, but I'm guessing it's dated like 1999. Oh, it's gonna be like old as the hills. What, who is it? That is the American Academy of Pediatrics in 2007.

Great. That's their last set of guidelines. And it's actually fascinating to me that they were so kind of sober and careful in their last set of guidelines. And in this one, nothing has really changed, but they're much less conservative with this stuff. 15 years ago, they were like,

eh, every previous attempt has gone pretty badly. And it seems like these only really work if they're coupled with a much more comprehensive approach that is pretty rare in the US healthcare system. So let's all just be kind of suspicious of these until we have really good data about how they work. And now they're just like, Mt. 8, 11, 12, sure.

Yeah, I mean, this feels very much like, sure man, let's go back to Lord of the Rings. This feels very much like, I know everybody else who gets this ring has things go sideways This is the Boramir strategy I feel like it's gonna work out for me. And also this this document again in this like head in the sandness That runs throughout it says the current

2023 guidelines say no current evidence supports weight loss medication use as monotherapy. Pediatricians who prescribe weight loss medication to children should provide or refer to intensive behavioral interventions for patients and families as an adjunct to medication therapy. So like, okay, great, don't just do the weight loss pills, also do like these intensive BLTs, whatever. But like, we know the kids aren't going to get those, because those aren't really meaningfully available, and nobody sticks with those.

75% of the kids drop out. So like, you know that in the real world, people are just going to get the weight loss drugs, right? We're all on the same page about that, right? It's sort of staggering to me that you could just ignore the entire social context and the entire context of your own patient's lives. Yes, but what if instead of saying a weight lost drug child, we say a child with weight lost drugs? No, Michael, that's not helping. God, it is so fucking bleak.

Okay, speaking of bleak, this is the part that neither one of us have wanted to get to. The final section is about barriad or surgery. Are you sending me a brick? No, this is too bleak. We've done two entire bonus episodes on Patreon about how neither one of us wanted to do an episode about this because it's just like really complicated and like people have strong feelings

and it's just a whole fucking can of worms. And it's like sad. Yeah, it's really sad. The through line for almost all the stories that I have heard about weight loss surgery is like a deep and profound sadness, right? That like even people for whom it is successful report like this incredible sadness at knowing now

how differently people treat them now that they're thin, right? That's like the best case scenario. So these guidelines recommend bariatric surgery for kids whose BMI is over 35, which I looked this up for a five foot eight kid. I don't know if that's like the size of a child. That's not.

230 pounds if you're five foot eight. I'm still not five foot eight now and I'm 40. You're still a child, congratulations. I mean, in some ways. So people above BMI of 35 with a comorbidity, so you have diabetes or you have hypertension or sleep apnea or something else. Those people are eligible for referral

to bariatric surgery. Anyone with a BMI over 40, so that would be 265 pounds if you're five at eight. Those people don't have to have comorbid conditions. That just like every single one of them can be referred to bariatric surgery. The AAP kind of tries to have it both ways here where they explicitly say like,

we're not saying these people should get bariatric surgery. We're just saying it's okay to refer them to a bariatric surgery provider. I mean, you know, yeah. It's like, I'm not saying you should get glasses, but here's the address of an optometrist. It's like, well, I'm not saying they have to. I'm just saying it's an option that they should consider.

So this is recommended for kids 12 and up. The evidence on this is also kind of surprisingly thin, honestly, for how long bariatric surgeries have been around. And one thing that's interesting about this is like, bariatric surgeries have been around. And one thing that's interesting about this is, like, bariatric surgeries have been prescribed to children for, like, quite a while. Yeah. I did a little research on this for the book and found a case study of a bariatric surgery patient who was three.

Great. Really? Yes. The core issue here isn't that for the first time, kids are going to start getting weight loss surgery. The core issue here is the professional association of pediatricians in the US is providing guidance that they can and sometimes should refer 13-year-olds

to get bariatric surgery. So there's two long-olds to get bariatric surgery. So there's two long-term studies of bariatric surgery among adolescents. The first is in Cincinnati, on 58 kids who received the surgery. The kids lost a huge percentage of their body weight and they had pretty significant improvements in their diabetes, their hypertension, like all of these kind of metabolic health markers. One of the articles about this cohort also said, though, despite this impressive weight reduction and the net improvement in cardiometabolic variables, 63% of participants remained severely

obese at long-term follow-up. Furthermore, more than half of patients had iron deficiency anemia at five years, and 78% showed vitamin D deficiency. The other cohort is a cohort in Sweden of kids who got bariatric surgeries, again, very significant weight loss. But then that one also showed pretty significant rates of vitamin deficiencies, surgical complications,

like various follow-ups they have to do. And it said adolescents who undergo bariatric surgery must be followed up very carefully by multidisciplinary teams, including psychologists who implement cognitive behavioral therapy. Even after surgery, such patients can continue to maintain a BMI greater than 30. In other words, they are still obese and often show symptoms of depression. So they're still fat, but on the upside, now they're also depressed. I really struggle with this one, and this is what we've talked about on our Patreon episode so many times, is like the kids who got these surgeries had an average BMI of 60, and I looked

that up and for a five foot eight person, that's 400 pounds. If you are a 16 year old girl, and you weigh 400 pounds, you are experiencing a level of stigma from the world that I think that I physically cannot fathom. And if you look around the world and you decide, I can't do this anymore, and I want to get the surgery and it's worth the risks for me, I am not going to tell you that you made the wrong decision. This is why it's so difficult for me to say anything definitive about these things, because I think people who make the decision to do this,

I don't wanna make them feel bad, and if a kid decides to do this, all I want for that kid is to feel loved and happy for the rest of their lives. Yeah, I am not ever here to tell someone who is fatter than I have ever been, how to live their life. And it's like not how I want to show up in the world. So I'm like right there with you on that.

And also, I think it's worth talking about the really intense side effects of this. I think we deserve research that tangles with, what are the negative outcomes of this, not just in terms of your physical health, not just in terms of your physical health, but also in terms of your mental health, right? I think we deserve more and better and deeper research. If this is the only path out that fat people see

and that very fat people see, we have work to do. And at the very least, they deserve really solid, reliable information about a huge decision to make. The cohorts that we have now, the average age was 17. These 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. Yep. So in the Swedish cohort, 26% of the kids had moderate or severe depression, 32% had moderate or severe anxiety, 16% had suicidal ideation. Some of that is because kids who get bariatric surgery oftentimes have higher rates of mental

health issues to begin with, but we've also had a number of other studies that have showed higher rates of depression, anxiety, suicidality, after bariatric surgery. It's like, it's becoming like one of the kind of known health risks. And you know, roughly 20% of people gain the weight back within seven years. Bariatric surgery appears to decrease the risk of some cancers, but it increases the risks of others. There's this weird increase in the risk of alcoholism after bariatric surgery because your stomach absorbs

alcohol more efficiently, and so you just get like a bigger spike. And then, you know, the long-term health effects of bariatric surgery are like not very well-study. There's very few studies that look longer than 10 years out. And, you know, things like nutritional deficiencies could have health effects over time. It's not a totally fair comparison because most of the risk factors of obesity take decades, right? People are not generally dying of heart attacks in their 20s and 30s.

But then the benefits of bariatric surgery are being sold according to like five and ten-year data. And that Swedish study says quite sweetishly that adolescents who get this procedure need to have a multidisciplinary follow-up to make sure that these risks are known and managed, but we all know that that is not going to happen. It doesn't even happen in Sweden. It notes in the study that only 48% of patients are actually getting the follow-ups that they need.

Again, if people want to go forward with this, I'm really not here to criticize anybody's decision, but it's like at a larger systems level, it's worth considering whether people are really going into this with like a full understanding of what it means to get these surgeries. It makes me feel so angry at a level that I like really struggle to express. If I'm honest, I don't usually struggle to express myself, but this issue makes me so angry because you're taking kids who sometimes have other health problems and sometimes don't.

You are making what are often lifelong decisions about how their body is going to function. You're doing that with really thin research. You're doing this in a setting where, you know, if a doctor and your parents say you need to have a surgery, how much agency do you really have to say no to that, right? It 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. Nothing whatsoever, yeah. That doesn't really tangle meaningfully with the incidence of eating disorders for these

kids. There's no looking at like suicidality and long-term mental health. There's just like so many angles that we haven't looked at this from. Because what we heard was we've got a way to make fat kids thin. And we decided that was the most important thing to do. Like this is such a complete erasure of the actual life experiences and wants and needs of fat kids. It feels really telling. Well, it's also, it's telling that this comes at the end of a document that is like explicitly like we don't care about health stuff. Yes.

Jesus. By the way, we're not looking at all that stuff. We're only focused on the size of the children. It really feels like it's like veering into double speak territory. Right. From that perspective, as someone who has lived the life of a fat kid, albeit a while ago, it is like deeply, deeply painful to think and talk about, you know, like I had a really rough time as a fat kid, and that was without the American Academy of Pediatrics telling my doctor to like, triple down. My understanding of like, your childhood experience is that basically every single doctor who

you saw should have asked you about your history and just concluded like, oh, this is like a little fat kid. Yeah. Her body just wants to be fat. We 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. Right, 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. And there was this weird celebration amongst parents of like naturally thin children. But there was absolutely never any acknowledgement that some kids might also be naturally fat. Right. That same effect might exist in kids with higher body weights. No, that was always about, they don't have enough stick to it if this, we haven't found the right diet,

the parents aren't doing enough. That was always a problem to solve. Right. That's a bad way to grow up as a kid. This whole thing is so typical of this transition period where it's like, we're now acknowledging all of the problems with the way that this kind of care has been provided for like four decades now.

But everything in this document is defending. Let's do the same thing. Bring up weight at every fucking visit, give tedious advice of like, don't drink sodas, invite them to these intensive behavioral programs that don't exist. And if those don't work because they never do, then start them on weight loss drugs and surgery.

Which we don't know what that does. And we don't know what that does. The actual paradigm shift that they completely refuse to acknowledge is just get rid of weight as a variable completely. Ask kids about their behaviors. Right, it doesn't even have to be fat kids. It's like assess, okay, are the parents providing

decent meals, however you want to define that, is the kid getting like 30 to 60 minutes of exercise most days. And if the kid is and they are fat, maybe you just have a fat kid on your hands, right? The most important thing that doctors can be doing is shifting away from a weight-based paradigm and toward a health-based paradigm. I think that there are probably in existence somewhere, parents and kids who could actually use some of these nutrition classes, learning to cook.

I think that those people probably exist. But right now, all we're doing is just assuming that every single fact person has terrible behaviors and that all of them need to change their behaviors. And 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 healthcare 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. You're also conditioning those kids to accept really subpar behavior from people around them.

You're conditioning those kids to expect to apologize for their bodies before people even know who they are. I feel like the only thing on which we agree with the AAP is that we also think that children should be given intensive bilties, but we mean the actual sandwich. I love kids. Kids give them a spicy day out. Thank you. you