0:12

Exploding to tell you things.

0:14

I Boyo Boyo Boyo Boyo

0:17

I'm gonna do it all at once. And it's just

0:19

gonna come out as like tower battle like

0:21

just everything. I am so grateful.

0:23

I have to say that you are looking into this one because

0:26

there's no question that we had to cover it.

0:28

Yeah. And I think I would

0:30

emotionally just like turn into

0:33

a fine

0:33

dust. Because

0:36

this makes me so

0:38

sad and angry.

0:39

That's what I'm gonna do to you over the course of next

0:41

three hours. Oh, okay. Doing this in

0:43

advance We're

0:44

gonna meet and see is the podcast that's just integrating

0:46

it to a find us.

0:47

Wait. This is this is the tagline that we're talking

0:49

with.

0:50

No. No. No. No. No. No. No. No. No. We're

0:52

not doing that.

0:53

Do do one.

0:54

Do one. Hi, everybody, and welcome to maintenance

0:56

phase. The

0:57

podcast that like you just the way

0:59

you are. Oh, you did like

1:01

a nice one. That's straight

1:03

from the mister Rogers playbook. And

1:05

I felt like we needed some niceness for

1:07

the extreme

1:09

grim goblin garbage

1:12

that we're about to sort through today.

1:14

We love you just as you are unless you work for the

1:17

American Academy of Pediatrics. Okay.

1:21

Then we have some questions. We

1:23

want you to be different. We don't

1:26

Like, what you're choosing to do

1:28

right now? Michael Hobbs.

1:30

I'm Aubrey Gordon. If you would like to

1:32

support the show, you can do that at patreon

1:34

dot com slash maintenance

1:36

phase. You can get merch at t

1:38

public. You can also subscribe through

1:40

Apple Podcasts, which is the same audio

1:42

content as the Patreon

1:44

-- Content audio. and Michael,

1:47

I feel like I am, like, getting

1:49

ready to be full of

1:51

rage. It's like a little propeller

1:53

on your head that, like, I get to spin around

1:55

when -- Yeah. -- when we do these episodes. And

1:58

III can just imagine and

2:01

you're just gonna lift off out of your seat.

2:04

Just getting ready for a lift off.

2:06

So, today, we are talking about the

2:08

American Academy of Pediatrics guidelines

2:11

on the treatment of childhood

2:13

obesity. They released the last

2:15

set of guidelines in two thousand seven.

2:18

The general approach for those

2:20

was watchful waiting if

2:23

your kid is fat they'll probably outgrow

2:25

it. We don't need to do anything aggressive. This

2:27

year, in January, they updated

2:30

the guidelines. And recommended a

2:32

much more aggressive approach.

2:35

Mhmm. The thing that got the most media coverage

2:37

was the fact that they are now recommending weight

2:40

loss drugs, and bariatric surgery for

2:42

kids as young as twelve. And

2:45

I went on to the AAP's website

2:48

I got the document. I pasted it into

2:50

word. It was a hundred and thirty six

2:52

pages. Mhmm. I went through it.

2:54

I checked the citations. I

2:56

talk to someone from the AAP, and

2:59

this episode is literally just

3:01

going to be us going through the document.

3:04

I'm going to do my best to try to make that interesting,

3:06

but I I might fail here.

3:09

You may be warned. So as

3:11

usual, we need to start episode with

3:13

a carnival of housekeeping. First

3:15

of all, this is gonna include a lot of like triggers

3:18

eating disorder, weight loss, calorie

3:20

stuff. It's also going

3:22

to include the word obesity a

3:24

lot, which is not a word that either

3:27

one of us like or

3:28

use.

3:28

But in the context of these studies because they

3:31

are exclusively based on

3:33

BMI categories, we kind of have

3:35

to talk about those categories when we're talking

3:37

about the studies. Yeah. And,

3:39

you know, we do episodes sometimes where it's like,

3:41

I look into an influencer and I tell you

3:43

about it and you've never heard of them. They're

3:46

always from Australia. And, you know,

3:48

that isn't fake. It's like the show isn't scripted. We're,

3:50

you know, we're coming in fresh to those episodes. This

3:52

is not one of those episodes. This is a topic.

3:54

That both of us have been thinking and

3:57

writing about for a very long

3:59

time and we're not

4:01

gonna pretend that we don't

4:03

already have issues. And of course, like

4:06

human biases that we are coming

4:08

in with. Yes. So The

4:10

purpose of these guidelines is

4:13

just to kind of get all of the evidence on

4:15

this issue in one place. So they've put together

4:17

a task force. There's like a committee. All these doctors

4:19

have spent years looking at every single thing that's

4:21

ever been published. And they wanna put it into

4:23

one place and on the basis of all

4:25

of the evidence. Make recommendations. That is

4:27

what they are setting out to do. Okay. Something

4:29

that I missed, but Reagan

4:32

Chastain, who wrote a bunch of really good subject posts

4:34

about this, she noticed is that if

4:36

you read the technical reports where they kind of go

4:38

through the evidence like paper by paper, they

4:41

explicitly say, that

4:43

they are excluding from the evidence

4:46

anything that doesn't deal with weight. Uh-huh.

4:48

This may seem like a small methodological

4:50

detail, but it's actually a huge deal. Because

4:53

there are numerous studies that

4:55

have showed pretty significant health benefits

4:58

for people who change their diet and

5:00

exercise habits even if their

5:02

weight does not change. Right? So according

5:05

to this document, right off the bat,

5:07

we're basically saying all of those

5:09

are considered ineffective

5:11

interventions. Because what we're looking at is

5:13

only weight status.

5:15

We're really concerned about the health of these

5:17

kids. Therefore, we're not looking at their

5:19

health. We're just looking at how fat they

5:21

are. It is actually fascinating to me that it like,

5:24

the the entire social

5:26

construction around this issue is

5:28

that, like, It's really only about the health. Right?

5:30

And, like, when I mean to a fat person on a plane, like,

5:32

I'm not doing it because I'm a dick. I'm doing it because I'm concerned

5:35

about their metabolic

5:35

risk. It's

5:36

good for them somehow. Then

5:38

you get into these documents and they're quite

5:40

just openly. Like, no, no, it's just about

5:42

the fatness. This kind of rhetoric of

5:45

sort of like, it's for your health is the thing

5:47

that you sort of shout out loud then quietly

5:49

into your research papers say, we didn't look

5:51

at anything about how Yeah. -- how

5:54

we get this, like, wild

5:57

difference in public opinion

6:00

between sort of like what people think

6:02

is the issue with fatness -- Mhmm. -- and

6:04

what researchers are even outlining

6:06

as issue with fat. That's right. Like, this is how

6:08

you get to the point where people really think

6:11

someone just gets so fat that they drop

6:13

dead, and that's like a way that people die. They

6:15

also mention at the very beginning that this

6:17

review will not be discussing obesity

6:20

interventions for children under the age of

6:22

two. Like, wow. Thank you.

6:24

I appreciate it. I appreciate it. How brave

6:26

to cut it

6:27

off? We're not gonna covering literal infants.

6:29

The opening salvo is we're

6:31

not gonna call your baby fat in

6:34

utero in your vouching. Exactly. Please

6:37

clap for our restraint. So I

6:39

don't know if we've talked about this on

6:41

the show show, but on

6:43

a number of bonus episodes now, we've talked

6:45

about the fact that, like, fat people

6:48

and fat stuff This issue

6:50

is in a weird transitional

6:52

period where there's growing societal

6:55

acceptance

6:56

but there's also these kind of remnants

6:59

of a huge amount of stigma.

7:01

Absolutely, there's like starting

7:03

to be a thing that happens when

7:05

I do research for this show and I'm sort

7:07

of knee deep in health and

7:09

wellness media about fitness and fat

7:11

people, usually, Those stories

7:14

are starting to change, and now they're

7:16

exactly the same stories as they were

7:18

before, but they include

7:21

maybe one personal story from a

7:23

fat person -- Mhmm. --

7:24

and maybe one paragraph on

7:26

weight stigma and why

7:27

it's important and then write back to but

7:29

also fat people are gonna die. Exactly. And

7:31

this is why I wanted to do an entire

7:33

episode on this document because

7:36

it's a portrait of, like,

7:38

the weird corner The

7:40

public health establishment has painted

7:42

itself into -- Uh-huh. -- where it now

7:45

rests onto completely contradictory

7:49

sets of beliefs. Yeah. It's basically

7:51

saying we agree with this copernicus guy,

7:53

but we're not ready to get rid of

7:56

Tolome and his little planetary loopy

7:58

loops.

7:58

We think Hobbs and Locke

8:01

have good points to make like bokeh.

8:03

Yeah. Bokeh. I always had with my dad on that one

8:05

You're dad. This is where we start getting

8:07

into this transitional period. Mhmm.

8:10

The first section is called HealthEquity

8:12

Considerations. Where we talk about

8:14

all of these social determinants of health

8:16

that affect obesity. So I'm gonna

8:19

send you a series of bricks

8:21

of text. There's like dot dot dots where, like,

8:23

I've cut a couple of paragraphs

8:25

in between and sort of condensed stuff. This fucking

8:27

document, Aubrey, the theth

8:29

out The amount of, like, editing

8:31

I had to do to make this readable -- Oh.

8:34

-- absurd. I had, like, a whole bunch of macros to

8:36

get rid of all the fucking acronyms. Whoa,

8:39

brick. Yeah. I know. I know. know. We can

8:41

we can take breaks. Long stigmatized as

8:43

a reversible consequence of personal

8:45

choices, Obesity has complex

8:48

genetic, physiologic, socioeconomic,

8:50

and environmental contributors. As

8:53

the environment has become increasingly obeseogenic,

8:56

access to evidence based treatment

8:58

has become even more crucial.

9:00

Mhmm. And then we've got a little ellipsis.

9:03

This

9:03

is the Michael Hobbs dot dot dot. Michael Hobbs These

9:05

are my choices. Children obesity results

9:08

from a multifactorial set of socio

9:10

ecological, environmental, and

9:12

genetic influence that act on children

9:15

and families. These influences

9:17

tend to be more prevalent among children

9:19

who have experienced negative environmental and

9:22

social determinants of health such as

9:24

racism. Overweight and

9:26

obesity are more common in children

9:28

who live in poverty. Children

9:30

who live in under resourced communities

9:33

in families that have emigrated or

9:35

in children who experience discrimination or

9:37

stigma. Michael Hobbs dot dot

9:39

dot

9:39

dot dot The American Academy of Pediatrics

9:42

is dedicated to reducing health disparities

9:44

and increasing health equity for all children

9:46

and adolescents. Attainment of these

9:49

goals requires addressing inequities in available

9:51

resources and systemic barriers to

9:53

quality healthcare services for children

9:55

with obesity. To that

9:57

end, practice standards must

9:59

evolve to support an equity based

10:01

practice paradigm. Well, so listen.

10:04

So far, I disagree with

10:06

the sort of framing around, like,

10:08

the problem here is fatness. Mhmm.

10:11

But in terms of the substance of what

10:13

they're saying, I don't disagree with

10:15

much of this. Right? Yes. This is an issue

10:17

that's much more complex than we give it credit

10:19

for. The interest thing that

10:22

they don't mention here is the role

10:24

of experiencing anti fat

10:25

stigma.

10:26

Would you like to hear our next two paragraphs?

10:29

Hello. Did I do a segue?

10:31

This is what is so interesting about this document

10:33

to me. It's like, much of it could have appeared

10:36

in your book. You are a much better fucking

10:38

writer than this obviously. But as

10:40

far as like acknowledging, everything

10:42

that we say on the show, this

10:44

document is pretty good like,

10:47

right after this little excerpt that we read,

10:49

there's a long section on racism.

10:51

There's a long section on toxic

10:53

stress and minority stress. And

10:56

then there's a section on weight stigma.

10:59

This part says individuals with overweight

11:01

and obesity experience weight stigma, victimization,

11:04

teasing and bullying, which contributes to binge

11:06

eating social isolation, avoidance of healthcare

11:08

services, and decreased physical activity. Importantly,

11:11

Internalized weight bias has been associated with

11:13

negative impact on mental health. Collectively,

11:15

these factors may adversely affect quality

11:17

of care, prevent patients with overweight and

11:19

obesity. From seeking medical care and

11:22

contribute to worsened morbidity and mortality

11:24

independent of excess adiposity. Pediatricians

11:27

and other primary care providers have been

11:29

and remain a source of weight bias.

11:31

They first need to uncover and address their

11:33

own attitudes regarding children with obesity.

11:36

Yeah. There's not a lot to actually like

11:38

quibble with here. Yeah. It's

11:40

like,

11:41

yeah, stigma matters. Doctors are source

11:43

of stigma and like stigma can have health

11:45

consequences on people. Right. And therefore,

11:47

what we need to do is we're gonna spend

11:49

the rest of this paper talking about how to

11:51

reduce stigma and end your own

11:53

highest. Right? This is what is so fucking incredible

11:56

to me about this transitional period. Right?

11:58

Mhmm. They will say all of these

11:59

things. But then do Nothing

12:02

with them.

12:03

Lip service. Lip service. Lip service. And

12:05

unfortunately, the lip service is pretty

12:07

fucking good. Yeah. Like lip

12:09

service is like, yeah, you're

12:11

you're saying all the stuff that we've been wanting

12:13

you to say. But we would also

12:16

like you to do something about

12:18

it. Right. This is the last time.

12:21

They're going to mention, like,

12:23

doctors are a source of medical

12:25

bias, but you know that

12:27

if you criticize the AAP

12:29

for any of this stuff like, this doesn't actually seem

12:31

like a very equitable

12:32

framework. They'll be like, uh-uh, The

12:34

very first section is called HealthEquity.

12:37

It's really astonishing that they're sort of

12:39

doing this, like, seem to be sallying

12:41

forth into a bigger, more complex conversation

12:44

and then do this weird hairpin turn and

12:46

be

12:46

like, yeah, the bullying of

12:48

fat kids is really a problem which is why we

12:50

need to eliminate fat kids and make them

12:52

all thin. We're like I don't think that's

12:54

the solution. So the next

12:57

section of the paper, after we've done all this

12:59

HealthEquity lip service stuff, We

13:01

then get to like the sort of

13:03

boilerplate section that me and you have read million

13:05

times where it's like the prevalence of childhood obesity

13:07

and I can't make cancer fat. Mhmm.

13:10

So they start up by noting that the

13:12

prevalence of childhood obesity has gone

13:14

from five percent in nineteen sixty

13:16

three. To nineteen percent in

13:18

twenty seventeen. This is something I've only

13:21

started noticing once I started doing

13:23

the show with you. They often note that the

13:25

The baseline is not zero percent. So

13:28

there's presumably always some

13:30

number of kids who are just

13:32

fat. I feel fascinated by

13:34

sort of the ways in which

13:36

our current biases

13:38

allow us to imagine that the

13:40

world is meant to be a particular

13:43

way -- Right.

13:43

-- and

13:43

that a particular kind of person

13:45

doesn't exist in the past or the future.

13:48

Remember when I went to that museum in Amsterdam and I

13:50

kept texting you with the paintings of fat people? Yeah.

13:53

It's like Aubrey look. Look at all these veggies.

13:55

It's like another painting of my fat birds eye. This

13:57

is great. Yeah. And

14:00

So another really weird thing about this document

14:02

is that there's almost nothing

14:04

about health risks. They

14:06

mostly cast this as a problem

14:09

in the sense that, like, fat kids will become fat

14:11

adults. So younger

14:13

kids like between seven and eleven, fifty

14:16

five percent of those kids become

14:18

fat adolescents. Yeah. And eighty

14:20

percent of fat adolescents become

14:23

fat adults. And so that's kind of like

14:25

the the trajectory that

14:27

they're warning us about. Is it like most

14:29

fat kids, become fat teenagers, become

14:32

fat adults? But then in the citation

14:35

that they use for this section, the paper

14:37

that they're citing also notes that

14:39

seventy percent of fat adults

14:41

weren't fat kits, which is

14:43

interesting to me. Oh. And then also

14:46

there's also some like

14:48

careful wording stuff. So

14:51

they say at one point The COVID-nineteen

14:53

pandemic has significantly affected

14:55

the lives and routines of children and adolescents.

14:58

In one analysis, The pandemic

15:00

period was associated with a doubling

15:03

in the rate of BMI increase

15:05

compared to the pre pandemic period.

15:07

And I was like a doubling in the rate of

15:09

BMI increase.

15:11

Oh, is it like three quarters of a pound

15:13

or some shit? No. It's basically during

15:16

the the first nine months of the pandemic,

15:18

you know, quote unquote normal weight kids

15:20

gained three pounds, and fat kids

15:22

gained six pounds. Okay. Okay. I

15:24

mean, is that noteworthy fine,

15:27

but also, like, do I really give

15:29

a shit about, like, three extra pounds? Also,

15:31

kids are supposed to be gaining weight because

15:33

they're growing. And we all fucking

15:36

gain weight in the pandemic surely. Like, if there's

15:38

one time, where everyone could just

15:40

gain some weight and everyone else could shut the fuck

15:42

up about

15:42

it. It's the pandemic. And also, like,

15:44

no one could shut up about it. Absolutely. Nobody

15:46

could shut up about it. But they weigh three more pounds.

15:48

I'm like, but they're alive. So then

15:51

we have a couple paragraphs

15:53

about health stuff. It's like type two diabetes,

15:55

blah blah, like, I'm not gonna read this stuff because we we've

15:57

all read these paragraphs a million times. And then

15:59

in the section about the health effects of

16:01

obesity, it says, in addition

16:03

to physical and metabolic consequences, obesity

16:06

in childhood and adolescence is associated with

16:08

poor psychological and emotional health,

16:10

increased stress, depressive symptoms,

16:12

and low self esteem. Yeah. It's like You

16:15

think? I can't imagine that any

16:17

of the rhetoric that we're advancing in this

16:19

document would contribute to that. Nothing

16:21

to see here. These are not health consequences

16:24

of fat ness. It drives me nuts

16:26

when public health agencies conflate the

16:28

health impact of obesity and the

16:30

health impact of people being shitty too

16:32

fat

16:33

people. Yeah. Historically, it does two

16:35

things. Right? One is that it continues

16:37

this sort of line of thinking that has been

16:39

very prevalent certainly in the US

16:41

for the last twenty years. Which is

16:44

everything that happens as a result

16:46

of someone being fat

16:48

is a direct result of the fat

16:50

cells in their body. Right? That there's like -- Right.

16:52

-- people get fat and then they get depressed. There's no

16:54

way to know why it just happens. And

16:56

the other thing that it does implicitly that

16:58

is absolutely fucking maddening

17:01

to me

17:02

is that it is implicitly blaming

17:05

fat people for the

17:07

behavior of garbage pieces.

17:09

Exactly. Yes. We then get

17:11

to the section that you've

17:13

been waiting for Aubrey, where they talk about the

17:15

use of the BMI as a screening

17:18

and diagnosis tool. I I first came

17:20

across this in a USA TODAY article about the

17:22

guidelines, not in the guidelines themselves, where

17:24

in back to back paragraphs.

17:27

It says young people who have a body mass

17:30

index that meets or exceeds the ninety

17:32

fifth percentile for kids of the same age

17:34

and gender are considered obese. Right?

17:36

So that's the definition of obesity

17:38

is kids that are fatter than ninety five

17:40

percent of kids. And then it

17:42

says obesity affects nearly

17:45

twenty percent of children and teens.

17:47

So twenty percent of children

17:50

and teens are fatter than ninety

17:52

five percent of children and

17:53

teens.

17:54

Oh my god. My colleagues In the guidelines,

17:57

it says the growth charts are based

17:59

on inhaines data from the nineteen sixties

18:01

through the early nineteen

18:02

nineties. Mhmm. So

18:04

basically, the definition of obesity is

18:06

not that you're fatter than ninety five

18:08

percent of kids. It's that you're fatter

18:11

than ninety five percent of kids in

18:13

the nineteen sixties. See

18:14

you. Totally. Twenty years ago.

18:17

And also, as you mentioned, you know, I understood.

18:19

Those percentile rankings I mean, they're they're just

18:21

descriptive. They're not based on like

18:23

health risks. Yeah, I mean, listen,

18:26

like every adult, I think that kids

18:28

today should be held to the exact

18:31

standard of my body and bodies like

18:33

mine when we were kids.

18:34

This is another sort of transition phase

18:37

thing in this document is that there are

18:39

so many studies now

18:41

documenting the limitations of

18:43

BMI. They have to acknowledge this

18:46

stuff. Yeah. Right? Like, the the whole point of this

18:48

doc is to bring together all of the evidence.

18:50

Right? So this is the

18:52

section where they essentially defend the

18:55

use of the BMI. There's

18:57

there's this weird circular logic

19:00

here where they say despite its

19:03

limitations, BMI is currently

19:05

the most appropriate clinical tool to

19:07

screen for excess adiposity and

19:09

make the clinical diagnosis of overweight

19:11

or obesity. Right? So it's like, say what

19:13

you want about the BMI, it's not perfect,

19:15

but it's the best tool we have

19:17

for diagnosing. Right. Fat and very

19:20

fat kids. But The definition

19:22

of overweight and obesity is

19:25

based on the BMI. The definition

19:27

of overweight his above the eighty

19:29

fifth percentile in the BMI. The definition

19:31

of obesity is above the ninety fifth

19:33

percentile on the BMI. Right. So

19:35

what they're saying here is the BMI. Is

19:38

very good at determining their

19:40

BMI. Yeah. Yeah.

19:42

Which, like, yeah, it sure is.

19:44

This year, I'm doing my own

19:46

employee evaluation. And

19:49

my evaluation of me as defined

19:51

by me is

19:52

I'm great, but also listen to this

19:54

Uh-oh. Okay. They conclude. The

19:56

BMI must be communicated to the

19:58

patient and family as it guides next

20:00

steps for comprehensive evaluation and

20:02

treatment of obesity and related comorbidities.

20:04

Yeah. As part of this, they have a flowchart

20:07

for doctors. You know, if if they

20:09

have these symptoms run this test, There's

20:11

literally no destination

20:14

at the end of the flowchart that is like don't bring

20:16

up their weight. Every single

20:18

person who is fat should get a lecture

20:20

about their weight. That is where it's leading

20:22

them. One of the most common stigmatizing experiences

20:25

that fat people report in the doctor's office

20:27

being lectured about weight loss before

20:29

or even in the absence of talking

20:32

about whatever symptoms or concerns

20:34

brought them in to begin with. And

20:36

that has been and continues to

20:39

be the prevailing

20:41

instruction given to medical

20:43

students and it's now

20:45

baked into our insurance system

20:47

Yes. -- such that if doctors

20:49

want to be paid for their work,

20:52

they are required to report

20:54

not only the patient's BMI,

20:57

but also that they were counseled on

21:00

weight Right. That is required in order

21:02

to get paid for your work as a health

21:04

care provider. That is bananas

21:08

to me that, like, medical institutions

21:10

right now today are deciding to

21:14

ignore or refusing to engage

21:16

with this thing that is like very

21:18

popularly discussed as being very

21:21

terrible and a reason to avoid

21:23

care. It all clicked into place for me

21:25

at the end of the section where they they give advice

21:27

to doctors on like how to bring this up

21:29

with patients. Right? Because there's all this research

21:32

now on weight stigma and all this research

21:34

about how doc doctors are one of the primary sources

21:36

of weight stigma. So how are they going to reconcile

21:38

this? Right? They have three rules

21:41

for doctors, for facilitating a

21:43

non stigmatizing conversation about

21:46

weight with kids. Right? So

21:48

the first tip is ask

21:50

permission to discuss the patient's BMI

21:53

and or weight. Number two,

21:55

use words that are perceived as new

21:57

by parents, adolescents, and children. Oh

21:59

god. Avoid labeling by using

22:01

person first language. No. I

22:04

know. Child with obesity, not

22:06

obese child, or my patient

22:08

is affected by obesity, not

22:10

my patient is obese. Preferred

22:13

words include unhealthy weight,

22:15

gaining too much weight for age,

22:17

and then there's a Spanish phrase which I'm not

22:19

going to try to pronounce. That means

22:22

too much weight for his or her health.

22:24

Jesus. Correct. Third rule before before

22:26

you go into liftoff. Third rule -- God,

22:28

Tim. -- recognize that discussing BMI

22:30

with children, adolescents, and families even

22:32

when using non stigmatizing language and

22:34

preferred terms can elicit strong

22:36

emotional responses, including sadness,

22:39

or anger, acknowledging and validating

22:41

those responses while keeping the focus on

22:43

the child's health can help to strengthen

22:45

the relationship between the pediatrician or

22:47

other primary healthcare provider

22:50

and patient and family to support

22:52

ongoing care. Oh my god. Can

22:54

you to listen. Listen. Listen. Thoughts.

22:57

Oh, Jesus. There's

22:59

a great stand up. Johann Miranda,

23:02

he's, like, unbelievably funny. Who

23:04

has a bit that's like, yeah, I don't feel

23:06

better if you call me a fucker of

23:08

mothers. Damn. It's

23:11

like brought to bear here, right, that this like

23:13

weird fancy footwork if we're just gonna

23:15

move around some words, feels

23:17

really strange to me. And as any fat

23:19

person who has tried to participate in

23:22

any kind of conversations about healthcare Twitter

23:24

knows, if you refer to yourself

23:26

as a fat person, there's a decent

23:28

chance that some thin

23:31

health care provider is gonna pop up out of trash

23:33

can and be

23:33

like,

23:34

actually, I think you mean person with overweight.

23:36

Yeah. And then we'll, like, talk over

23:39

fat people who are self

23:40

identifying, which

23:42

is healing, manning, and

23:44

documents like this sort put that

23:46

even further out into the world that's

23:48

like we've decided for you what language

23:51

affirms you. It reminds me a lot of

23:53

in the nineteen nineties when the term downsizing

23:55

know, people started to understand, like, what you actually

23:58

mean with that term. And so there was a move

24:00

to use the term rightsizing when you're

24:02

doing a bunch of layoffs. Right? Oh, we're rightsizing

24:04

the company. And it's this this idea

24:06

that, like, people will be less mad

24:08

about being fired --

24:11

Yeah. -- if you phrase it the right way. And, like,

24:13

No. Being fired sucks. You can

24:15

call it anything you want. At the

24:17

end of the day, that person is packing up

24:19

their desk and going home. And it it's the same

24:21

thing here. It's like there is no way

24:24

to bring this up with somebody that

24:26

is going to make them not understand what you're

24:28

actually telling them. Right. It's like hericature

24:31

of the arrogance of

24:34

doctors saying, oh, well, in

24:36

every interaction, I

24:38

have to bring up this patient's BMI even

24:41

if that person is a child, even if they're

24:43

not here for anything regarding

24:45

weight at all, but I'm bringing

24:47

it up in a way that's non stigmatizing.

24:50

Yeah. But

24:50

the stigmatizing part is that you're bringing it

24:52

up in every interaction. I'm trying to imagine

24:54

someone like punching me in the face than being

24:56

like, look, you must be feeling a lot of things

24:58

right now. It's gotta be really hard for you.

25:00

Right? Like, that's essentially sort of what we're

25:02

talking about here. It's like causing material

25:05

harm. Two fat

25:07

kids, and then being like, uh-oh,

25:09

but I used the right

25:10

language. So pat on my back, there's

25:13

nothing in this document other than those kind

25:15

of two perfunctory, bloodless

25:17

sentences of, like, doctors are a source for stigma.

25:20

There's nothing about, like, hey, really sit

25:22

down and think Does this patient

25:24

need a lecture for me about eating five

25:26

fruits and fucking vegetables right now if they

25:28

can bring to something completely else? Do

25:31

I maybe want to ask about like

25:33

other interactions this patient has had

25:35

with the healthcare system? Have they tried losing

25:37

weight before? What are their behaviors?

25:40

Maybe don't even bring up weight at

25:41

all. Just ask them, like, is there anything else you wanna

25:44

talk to me about today? Okay. Bye.

25:46

I was I think thirty

25:49

six years old the first time a doctor

25:51

asked me if I had an eating disorder. Mhmm.

25:54

Yeah. There is a place where there is

25:56

a known cluster of diagnoses

25:59

and bringing up this conversation will

26:01

make those actively worse.

26:03

Is around eating disorders in body dysmorpia?

26:07

Which are hyperactive particularly

26:10

in

26:10

adolescence. Right? Like -- Right. -- what happens

26:12

if that kid is already depressed? Well,

26:14

this brings us to the next section of the

26:16

document. Tell me, this is a huge

26:18

section. This is like probably a third of the

26:20

document. Is risk

26:23

factors for child and adolescent overweight

26:25

and obesity. And this walks through like

26:27

everything we know about the factors

26:30

that are associated with higher weight among

26:32

kids. Just like the HealthEquity section,

26:34

this is pretty good It's like

26:37

it goes over, so it, you know, it talks about socioeconomic

26:40

disparities. It talks about racial disparities. has

26:42

a whole thing about policy factors. There's

26:45

environmental smoke exposure, sleep

26:48

duration. There's a whole thing on adverse

26:50

childhood experiences like fat people

26:52

are more like to have been abused when they were

26:54

kids, which is a whole fucking can of worms that we talked

26:56

about.

26:56

Yeah. Yeah. Yeah. Yeah. There's genetic factors

26:59

-- Yeah. -- epigenetics. Autism

27:01

is associated with higher weights, ADHD

27:04

is associated with

27:05

that. They have a whole section on medications. It's

27:07

almost as if fat people

27:09

are not just fat

27:11

bodies walk

27:12

around, but people with lives

27:14

and health concerns and other things

27:16

going on. Within The way I

27:18

think that they are reconciling, all

27:21

of this information coming out about

27:23

social determinants of health, and all of the complex

27:26

cities about like why people are fat,

27:28

is this document explicitly says

27:31

that, like, you should incorporate all of

27:33

that context into your recommendations

27:36

to people for how to lose weight.

27:38

What? There is literally at

27:40

no point in this document. Does it

27:42

ever say tell people

27:45

that it's fine not to be trying to lose

27:47

weight. Right. Like, focus on housing

27:49

security. You don't need to worry about your weight right

27:51

now. Just get a place to live. So according to this

27:53

document, if a patient comes to you and says,

27:55

like, you know, I'm sixteen years old, I grew up in foster

27:57

care, I experienced horrific abuse,

28:00

I'm now on a medication for my

28:02

depression, and since I started taking it, I gained

28:04

twenty five pounds. There is nothing

28:06

in this document to just say,

28:08

that's

28:09

fine. Focus on being happy right now.

28:11

Yeah. No. According to this document,

28:14

if they are above the eighty fifth

28:16

percentile on the BMI, you

28:18

should tell them to lose weight. And it's all

28:21

punitive. Right? It's not goal oriented

28:23

behavior. It's not if we follow these steps,

28:25

then we know we produce these outcomes. It's

28:29

if we follow these steps, maybe something

28:31

happens, question mark, but we

28:33

don't really have evidence that anything does. And

28:35

the evidence we do is that people feel worse

28:37

than avoid healthcare. Right. The best

28:39

case scenario is that it's throwing stuff at

28:41

the wall and seeing what sticks. Right. And

28:43

the worst case scenario is that it's projecting

28:46

adult anxieties onto

28:48

children -- Right. -- and not only that,

28:50

but onto fat kids. Right. I

28:53

want everybody to think about every

28:56

media depiction you've ever seen about

28:58

a fat kid. Is it about how

29:00

well loved they are and how everyone's treating

29:03

them great? Right. want you to think about the fat

29:05

kids that you have known in your life. Were

29:07

they, like, living the life of Riley?

29:09

What's going on? Right. It's just astonishing

29:12

to me that the answer to all of this is

29:14

like, You see those kids over there?

29:16

They don't feel bad enough. Well, it's

29:18

also it doesn't give any specific advice

29:21

to doctors on, like, what they can

29:23

actually offer in, like, seven

29:25

minute appointment. So there's in the

29:27

one place that this document actually talks

29:29

about, like, a behavioral assessment, like

29:32

ask the kid What their diet

29:34

and exercise habits are, it says

29:37

dietary intake can be addressed by

29:39

assessing the following. Eating outside

29:41

the home consumption of sweet drinks,

29:43

portion size, meal habits, snack

29:45

habits, fruit and vegetable consumption.

29:48

What actual advice does this

29:50

lead you to give? Oh, try not to drink so much

29:52

soda. Like, you're gonna give them this like

29:54

101 Dr. Oz

29:56

level advice. Oh, turn to eat smaller

29:58

portions. Wow. Thanks.

30:00

Tell those fat toddlers to start taking the

30:03

stairs. And this is the part that I've been

30:05

saving Aubrey, because, like, you know, you're

30:07

almost exploded. So

30:10

it also says, that you

30:12

should try to assess whether the

30:14

kids are experiencing weight stigma.

30:16

What? So it says, A

30:19

common comorbidity of obesity in

30:21

children is weight based bullying and teasing.

30:23

If a patient responds affirmatively when asked

30:25

if they have ever been teased or bullied about their

30:28

weight, Pediatricians and other care providers

30:30

can consider provision of resources such

30:32

as those found at stopbullying dot gov

30:34

to the child as well as a local

30:36

counseling

30:37

referral. So then I go

30:39

to stop bullying dot gov.

30:41

Jesus god. And I typed in,

30:43

like, weight stigma, fatness, obesity, like,

30:45

all the various search terms. This quote

30:47

unquote resource has published three

30:49

articles about weight based bullying

30:52

in the last decade. What? The

30:54

first of them has like a list

30:56

of bullet points for adults

30:58

in case they like see weight based

31:00

bullying, whatever. The

31:03

list begins. How can I encourage

31:05

a healthy body image among adolescents?

31:08

One, promote healthy eating and

31:10

exercise how to shut the fuck

31:12

up my cough. So

31:15

the number one advice from this article

31:17

is, like, teach kids how to lose weight if they're being

31:19

bullied or being fat. Fuck you.

31:21

Are you being bullied? Step one. Have you

31:23

tried Weight Watchers? And then all of the

31:25

other articles on this quote

31:27

unquote resource are for adults.

31:30

It's like if you see kids bullying other kids, like

31:32

step in and try to stop it, which like

31:34

great, but that's not a resource for kids.

31:37

This is not a meaningful resource.

31:39

For most professional guidance, including

31:42

interventions around bullying -- Right. -- there are

31:44

more guidelines than just like, tell

31:46

them to knock it off. This is why I say that,

31:48

like, on I don't really, but, like, on

31:50

some level, I sympathize with the plight

31:53

that health care providers are in because

31:55

Much of the advice here is like

31:57

we'll link people up to resources. Right? Like,

32:00

not everything is within your jurisdiction. You

32:02

don't have the power to fix these much larger

32:04

problems like poverty, like bullying,

32:06

etcetera, so link people up to

32:08

resources. But there are no

32:10

resources. This isn't about setting up

32:12

a good patient experience for fat kids. It

32:14

isn't even about setting up a good professional experience

32:17

for pediatricians. Right? It

32:20

is about telling fat kids that they

32:22

are fat and doing everything we can to

32:24

make them thin. Right. The end. Right. Right.

32:26

Even if those things don't work, even

32:28

if they've been disproven.

32:30

Even if other people are still being jerks

32:32

to that kid doesn't matter. The thing

32:34

that

32:34

matters is making that fact it then. This

32:36

is what so frustrating is all of the recommendations

32:39

in this document pretend that we

32:41

exist in some kind of perfect world. There's

32:43

no meaningful engagement with the question of,

32:45

like, what can we do for fat kids

32:48

in the world that we have? Right? If

32:50

a kid is depressed, if they're being bullied,

32:52

I don't have the power to change the

32:54

way that they're being treated at school, What

32:57

I think every single doctor should actually

32:59

be doing is trying to

33:01

tell kids that they shouldn't go

33:03

on fucking diets. Yeah. Hey, don't

33:06

go on a diet. It's fine to look the

33:08

way that you look. If you go on a diet, you're

33:10

going to end up on some dumb fucking fat

33:12

diet, you're gonna gain all the weight back you're gonna

33:14

feel bad. Doctors don't

33:17

have the ability to like help

33:19

kids meaningfully lose weight, but they

33:21

do have the ability like, use their

33:23

credibility to be, like, whatever you find on

33:25

the internet is

33:25

bullshit, kiddo. The times that I have

33:27

most appreciated my health care providers

33:30

are when they invite me into nuance

33:32

and to understanding what's actually happening

33:34

here. Right? There are a lot people who

33:36

are gonna tell you they know how to manipulate

33:38

your body weight and they know how to make you smaller,

33:41

they don't. Yeah. The science tells us pretty consistently

33:44

that, like, an overwhelming majority

33:46

of efforts to lose weight, whatever you

33:48

call them, whether it's a diet or something

33:50

else. An overwhelming majority

33:52

of those lead you right back

33:54

to the size you were before or maybe little

33:56

bit bigger. Right. Nobody knows

33:58

how to do this. So your job

34:01

is to you know, eat foods

34:03

that are nourishing to you. Your job is

34:05

to find activity that you like. Your

34:07

job is to build strong relationships and

34:09

to you know, expect that

34:11

people treat you with respect and

34:14

that's where we leave it. Right. God.

34:15

Michael, I'm just realizing, we haven't even got

34:17

into the, like, drugs part of this.

34:20

We're not even in the bad shit. Okay.

34:22

Are you ready to hear about treatment options? Oh,

34:25

god. Am I? You are. You love

34:27

it. This is this is the good part. This is the

34:29

solutions. Okay. Let's do it. It's

34:31

actually less bad. Well,

34:33

it's gonna get bad, but it's not that bad at

34:35

first. Okay?

34:36

Alright. So the title for this is

34:39

intensive health behavior

34:41

and lifestyle treatment. IHBLT,

34:45

which I will not be calling at that

34:47

because that's ridiculous.

34:49

I do like that it has BLT in

34:51

it. Just

34:54

like as a I'm a pro BLT

34:56

person. That sounds tasty. It's an intensive

34:59

health BLT.

35:00

Oh, no. No. Wait. Now it's

35:02

all bad.

35:07

So every, like, municipal hospital has

35:09

a program like this. These are You

35:12

know, they're they're often run by dietitians

35:15

or obesity clinicians or something. And they're

35:17

basically like you know,

35:19

nutrition classes. And

35:22

for kids, they often include some sort of

35:24

sports or physical activity component

35:27

I looked up one of them. There's a program

35:29

in Durham, North Carolina called

35:32

Bull City Fit, where

35:34

they worked with the Park department to

35:36

get some sort of like community center and

35:39

dietitians and doctors would just kind of park

35:41

there one hour every

35:43

day, six days a week. And then families

35:46

could come in kind of whenever suited them. So they wanted

35:48

to create something that was like little bit flexible.

35:51

The goal was for everybody to attend one day a

35:53

week. And then you go there and it'd be like special programming

35:55

where like a nutritionist talks about how to

35:57

cook healthy meals or you practice

35:59

different sports to try to figure out one that you

36:01

like, etcetera. And so this is the first

36:04

stage of obesity. Treatment

36:06

is referring these kids to one of the

36:08

Bayalties.

36:09

And these are the Goddamn.

36:11

I'm gonna do it all episode now. I had

36:13

a delayed response to that.

36:16

Peter the interventions that start as young

36:18

as

36:18

two. Yes? Yes. But then there's kind

36:20

of like a weird lack of specificity in

36:23

these because what would one

36:25

of these programs even look like for a three year old?

36:27

Right? Then you're you're really talking about a parental

36:29

intervention. Well, and it doesn't seem to

36:32

like interrogate its own central

36:34

assumption, which is that individual behaviors

36:36

determine body size. Right. Right.

36:38

Right. The core assumption here is

36:40

just like we gotta make these fat kids

36:43

thin not. We've got to assess

36:45

the health of these fat kids and see if we can

36:47

support it more fully. And

36:50

on top of that, their strategy is to

36:52

make them thin are not exactly

36:54

shown to

36:55

have, like, a commanding majority decisive

36:59

impact on someone's individual weight

37:02

or their individual health. Right? Well, this

37:04

this is this is where we get to the

37:07

huge coffee cups

37:09

section of the treatments

37:11

that, quote, unquote, work. Mhmm. But they

37:13

only work under very specific

37:15

conditions. So it says there

37:18

there's all these like success factors

37:21

of these lifestyle treatment programs. The

37:23

first element is duration. Basically

37:25

any lifestyle intervention for

37:27

kids that's less than three months is

37:30

not gonna work. Mhmm. A million of these

37:32

have been tried and they essentially all

37:34

fail. And that's like most of these

37:36

programs. You know, they run for like six weeks

37:38

or they run for a month or whatever.

37:40

Less effective than fat. Camp. Exactly.

37:43

So the programs also have

37:45

to be super intensive. So kids

37:47

have to be in these things for at

37:49

least one hour week or they don't

37:51

really have an effect. They also they

37:53

have to be face to face. They also have to

37:55

be comprehensive, I. E.

37:57

The parents have to be involved. So it can't just be

37:59

like the kid trundles over after school

38:02

and like plays some basketball and then goes home,

38:04

no. The parents have to be there. And

38:06

oftentimes there's, like, participatory elements

38:09

where, you know, the parents have to be part of the cooking classes

38:11

or, like, play sports with the kids or whatever.

38:13

Can I ask you a clarifying question? Yes.

38:15

If all of those elements

38:18

are in place. If the stars are

38:20

aligned and these programs work

38:23

as well as they possibly can,

38:26

what are the weight loss rates

38:28

and what are the outcomes that they're

38:30

measured? I love this because this actually

38:32

isn't included in the guidelines. But

38:35

in technical report. If

38:37

you dive into the details, you

38:39

can find it and it says, as

38:41

described in the health, behavior, and lifestyle

38:43

treatment section, those who do experience

38:46

BMI improvement will likely note a

38:48

modest improvement of one percent to

38:50

three percent BMI percentile

38:52

decline. Great.

38:52

Good. Good. Good. Good.

38:53

We're back in fucking percentile declines and

38:55

all this nonsense. Basically, like, five

38:58

to ten pounds.

38:58

That is borderline normal

39:01

weight fluctuation territory. And

39:05

these these programs The biggest

39:07

problem with these programs is that, like, people

39:09

do not want to stick with them.

39:11

So the attrition rates in these

39:13

programs are For many of them, they're

39:15

they're over sixty five percent.

39:17

Yeah. In this Durham program, they

39:20

started with a hundred and seventy one kids

39:22

and they ended up with forty four. But

39:24

those are the only kids that this actually had

39:27

an effect on us twenty six percent

39:29

of the beginning kids. Some of the

39:31

other problems with these is their they're tiny.

39:34

Right? So this this is a program. It's a two year

39:36

program that reaches at

39:38

most. Right? If they had a one hundred percent

39:40

attendance rate the entire time, THEY WOULD

39:42

REACH one hundred and seventy one KIDS. Reporter:

39:45

RIGHT, THIS REPORT, THESE GUIDELINES

39:48

START OUT BY SAYING THAT fourteen point four

39:50

MILLION CHILDREN are too

39:52

fat. Alright. Well, listen, Mike, you gotta

39:54

think about this at scale. If we do

39:56

this with every fat kid in the country,

39:59

we'd have like three million

40:01

kids who all weighed three to

40:03

five pounds less than they do now. Come

40:06

on, ma'am. Think of the kids who lost

40:08

seven pounds. Think about the kids

40:10

who were temporarily

40:12

slightly thinner -- Yeah. -- and then kept

40:14

growing and their bodies changed anyway. Come

40:17

on, ma'am. Also, this I feel

40:19

like a really underrated element

40:22

of why these programs won't

40:24

work is in this survey where they surveyed

40:26

hospitals about their childhood obesity

40:28

interventions, eighty four percent

40:30

of them lost money.

40:31

The cost effectiveness here is beyond

40:34

reproach is what I'm hearing. And the thing is I don't

40:36

like, I don't care about these clinics losing

40:38

money or, like, donors or wasting their money. Like, I don't

40:41

give a shit. But the problem that

40:43

that creates is that these are not scalable.

40:46

Yeah. So it says, there are known

40:48

limitations for families to access and participate

40:50

in intensive health behavior and lifestyle treatment.

40:53

These limitations include the relative

40:55

scarcity of such treatment programs and

40:57

healthcare providers with experience in pediatric

40:59

obesity treatment. Family transportation challenges.

41:02

Loss of school or work time to attend multiple

41:05

recurring appointments during what are typically

41:07

working hours. Then it just says social determinants

41:09

of health, competing health issues for

41:11

children or family members, and mismatched

41:14

expectations between the family who may expect

41:16

significant weight loss and pediatricians or

41:18

other pediatric healthcare providers. So

41:20

it's like, oh, is that it? Oh, it's

41:22

not big enough and people can't

41:25

get there and it happens during

41:27

the work day and people

41:29

don't wanna go to them and they're poor

41:31

and like there's other things going on in their

41:33

lives.

41:34

I like that one of their bullet points is

41:36

social determinants of health, which is

41:38

like medical shorthand for

41:41

like all of society

41:42

and how the world works. It's just

41:44

like the entire social

41:47

and political and economic context

41:49

Anyway, look, these are perfect. Unfortunately,

41:52

minorities do exist. Doesn't

41:54

have to be a problem. But also, almost

41:57

all of the research into

42:00

fatness and fat people and particularly fat

42:02

kids, at least as much as I have seen,

42:05

proposes that there will be benefits to

42:08

these interventions and then measures

42:10

the benefits and comes up with a narrative

42:12

that reinforces the

42:13

benefits. They're not actually screening

42:16

for or looking for the harms

42:18

of

42:18

these interventions. Yeah.

42:19

So, like, I would also like to see

42:22

what's the difference crossed the board

42:24

in physical health outcomes and in mental

42:26

health outcomes between kids

42:28

who get few to know interventions about

42:30

their weight and kids who get lots and lots

42:33

and lots of interventions about their weight.

42:35

This actually leads to the next

42:37

section of the paper -- Mhmm. -- which is a

42:39

essentially the only place

42:42

in this entire one hundred and thirty six page

42:44

document that they mentioned eating disorders. Mhmm.

42:46

So when they're talking about these interventions

42:48

that, quote unquote, work, they sort of

42:51

have to acknowledge that there's been

42:53

years of criticism of this

42:55

approach from eating disorder practitioners and

42:57

like actual fat people. Yeah. So it says,

43:00

in the field of pediatric, actually, let me

43:02

send this to you. Mhmm. Send me a

43:03

quote. Yeah. Let me send you this little quote. In the field

43:05

of pediatric nutrition, in the treatment

43:08

of both obesity and eating disorders,

43:10

concerns have been raised as to whether diagnosis

43:13

and treatment of obesity may inadvertently

43:15

place excess attention on eating

43:18

habits, body shape, and body

43:20

size, and lead to disordered eating

43:22

patterns as children grow into adulthood.

43:25

The literature refutes this

43:27

relationship however. Dieting sixty

43:29

percent of the time, it works every time. Cardell,

43:31

at all, refer to multiple studies

43:34

that have demonstrated that although obesity

43:36

and self guided dieting consistently placed

43:39

children at high risk for weight fluctuation

43:42

and disordered eating patterns, Participation

43:44

in structured, supervised, weight

43:46

management programs decreases

43:49

current and future eating disorder symptoms.

43:52

Here's what I would like to say about this

43:54

quote, Mike. Oh. Give me

43:56

response. I myself was a product

43:58

of a struck shared supervised weight management

44:01

program, and I myself ended up

44:03

with an eating disorder. Oh, wait. So you were

44:05

on one of these,

44:06

like, intensive lifestyle BLT

44:08

thingies? I was on the, like,

44:11

early to mid nineties version

44:13

of them. So, like, things may have changed

44:16

or they may have not. But, like, my parents

44:18

were supposed to come with me. Okay. And they

44:20

had a parents class and I had a kids

44:22

class and and

44:24

it was one of the

44:26

earliest and strongest memories

44:29

that I have of Wade

44:30

Stigma. Absolutely.

44:31

Oh, really? Yes. You just go to this after school

44:33

program at somebody else's school,

44:36

you're there with a bunch of other fat kids

44:38

who know that they're there because they are viewed

44:40

as having sort of remedial

44:42

bodies. Right? You feel like

44:44

you're behind at school. You're having to

44:46

go to extra school because you're not good enough

44:48

the way you are. And the

44:51

lectures that we got were all

44:53

about behaviors that didn't

44:55

ring true to me that I didn't

44:57

recognize. Essentially what they

44:59

were describing was like the dangers of binge eating

45:01

or whatever.

45:02

And I was like, I don't do that.

45:04

Right. Is that how you see me? It

45:06

felt like a real crash course in like,

45:09

I have seen your body and therefore I

45:11

have determined your behaviors are this.

45:13

Right. And it just didn't mirror my

45:16

experience in any real way. And

45:18

I just remember feeling like that's

45:20

place where you go if

45:21

you mess up. Right. And they tried to make

45:23

it fun, and they tried to make it uplifting,

45:25

and they tried to talk about self esteem, and

45:28

that message came through loud and clear

45:30

regardless. Well, this is this is something forgot

45:32

to mention earlier. When it's talking about these lifestyle

45:35

programs, when it's saying, like, it has to be

45:37

comprehensive and the parents need to be involved, etcetera,

45:39

etcetera. It says children

45:41

learn goal setting, body acceptance,

45:43

and strategies to manage

45:45

bullying. And it's like, how would

45:47

you teach them body acceptance in a

45:49

class explicitly designed

45:51

to teach them how to change their bodies. Because

45:53

of our own conflictedness as adults

45:55

on this issue, we are sending profoundly

45:58

conflicted and conflicting sort

46:00

of direction to kids on this issue,

46:03

and we are training them

46:05

to have lifted relationships with

46:07

their own bodies, with the foods that they eat,

46:09

sometimes with their family members, sometimes with

46:11

their health care providers. Right? Like, This is

46:13

setting the tone on so many

46:15

fronts, and it's setting a bad

46:18

tone. Kids understand this. Like, kids

46:20

kids are kind of dumb and also very smart

46:23

in a lot of ways. Yeah. Like, kids get

46:25

this shit. They understand that it's completely

46:27

contradictory

46:27

and, like, they can't give you what you want. You're

46:30

telling them to stay in their seat and go to

46:32

the library at the same time. So to return

46:34

to this brick that you just read, I

46:36

I I've taken out some of the weird

46:39

medical language and and kind of boil it

46:41

down. It says, multiple studies

46:43

have demonstrated that although self

46:46

guided dieting consistently places children

46:48

at high risk for disordered eating patterns, participation

46:51

in structured weight management program decreases

46:54

eating disorder symptoms. So the basic

46:56

idea is that look, are there

46:58

diets that increase eating disorder behavior?

47:00

Of course, there are. But what we're talking

47:03

about is these intensive lifestyle

47:05

programs and they don't increase

47:07

the risk. But then they've just also

47:10

said that these structured programs

47:12

are not available. For

47:15

like ninety nine point seven percent

47:17

of children. What are we even doing

47:19

here? It's like, you're telling people not

47:21

to do? The thing that everyone

47:23

would do, go home and fucking Google. Right?

47:25

Look for a diet. You're like, oh, don't worry about

47:27

it. They're not gonna do that. They're gonna do

47:29

this thing that isn't available to them. Right.

47:32

It's just total the whole document is just

47:34

riddled with this weird head

47:36

in the sand

47:36

logic. There's a thing that's happened footing right

47:39

now where diets are calling themselves

47:41

not a diet. We're actually therapy.

47:43

We're actually a structured weight management

47:45

program. We're actually a blah blah blah. And

47:48

that means that there is now a

47:50

sort of sorting the wheat from the chaff

47:52

that people are trying to do, particularly people

47:54

from within the diet and weight loss industries. Of

47:56

being like, those are diets and diets

47:58

are crash diets and they're fat diets and they're

48:01

bad and you can't trust them. But you can trust

48:03

our weight management program or what

48:05

have you. Right? And it feels

48:07

like this is leaning into that

48:09

too. Yes. And to me, that is the

48:11

same kind of rhetoric that is being deployed

48:13

by, like, Nom. We have

48:16

two sections of this document left. We're we're

48:18

finally reaching the problematic parts.

48:20

Oh, we haven't gotten there yet. That's the

48:22

part this is the part that the Internet got

48:24

really mad about. And so as,

48:26

like, this is almost like the concept of this

48:28

show at this point. I'm like, I need to read this

48:30

document and make you get mad about something

48:32

else. Than nothing you were already mad

48:34

about. So

48:37

basically, the entire framework

48:40

scope of this document just

48:42

sucks. But now we get to

48:45

the other treatments that are available. So as well

48:47

as the intensive BLTs, which

48:50

are not actually available to most kids.

48:52

The next section is use

48:54

of pharmacotherapy. And

48:58

I am going to

49:00

send you a brick of text.

49:02

Love to brick. Mhmm. I'll

49:05

let you know when it comes through. Just no.

49:07

I haven't texted it yet because I need to I okay.

49:09

have to keep editing the fucking text of this to

49:11

make it readable because it's so It's

49:13

so like unreadably gibberish to

49:15

actually try to say it out

49:17

loud. It's so goofy and

49:18

then also footnotes in there and then also

49:20

it's just like, yeah. All over the place, man.

49:23

This is gibberish y, but we're gonna

49:25

we're gonna decipher it together. Quote,

49:27

although intensive, oh,

49:30

penalties just say BLTs. BLTs.

49:33

Although intensive health, behavior,

49:35

and lifestyle treatment has the largest

49:37

body of evidence meeting the evidence reviews

49:39

high quality evidence for effectiveness criteria.

49:43

It is important to consider the use of pharmacotherapy

49:45

for children and adolescents who require

49:48

an additional treatment option to manage

49:50

their obesity.

49:51

So for kids eight

49:53

through eleven, they can take weight loss drugs

49:55

if they're also doing some other

49:57

intervention. For kids older than

49:59

twelve, they can just like straight up take

50:01

weight loss drugs. Yeah. Boy oh

50:03

boy. Age eight, man. I don't

50:05

love it. If you know any kids that

50:07

are ages eight to

50:08

eleven, Like, I just want you

50:10

to think about that kid for a minute because

50:14

this sucks. It sucks.

50:16

I am a person who was put

50:18

on a weight loss drug when I was like

50:20

fourteen or fifteen. Yeah. And that drug was

50:23

Fen Fen. And I did it because

50:25

a doctor told me it was a safe thing to do.

50:27

And that drug was later pulled from the shelves

50:30

because it stopped people's heart

50:32

Right. The drugs that are emerging now

50:35

and this rapidly evolving field that

50:37

they're talking about so breathlessly here,

50:40

I'm assuming, you tell me if

50:42

I'm wrong, doesn't have a great body

50:44

of research into the effects on eight

50:46

year

50:46

olds. And certainly can't tell you

50:49

the long term effects on a year olds.

50:51

Right? I think you're being a little unfair. think

50:53

just because every previous weight loss

50:55

drug became a massive scandal. It

50:58

doesn't mean that these weight loss drugs will be. You're

51:00

actually revealing your own by

51:02

Yes. You're actually skinny

51:04

shaming? 0KKKKKKKKKK.

51:07

That's what you're gonna feel attacked. Listen, this

51:09

is definitely, like, cry punch

51:11

barf territory for me, where I'm just like,

51:14

it is so bleak

51:16

to say that the most important thing to

51:19

us about an a year old is that they become

51:21

thin? Well then, what what's so

51:23

weird about this section of

51:25

the document? Is is after they give this kind

51:27

of overall recommendation, they then run

51:30

through the weight loss drugs that

51:32

are available, and like the evidence on

51:34

what they do in adolescence. Mhmm. So

51:36

first one they recommend is metformin, which

51:39

is a diabetes drug. It basically says

51:41

like there's a couple of small studies

51:43

in teens but like they're

51:45

more or less inconclusive in

51:48

one study found that kids

51:50

lost one BMI point which

51:52

is like five pounds. And

51:55

the side effects on metformin are

51:57

profound

51:59

and weeks or months long,

52:01

sort of gastrointestinal effects. So,

52:03

like, some of that weight loss might just

52:05

be, you are so nauseous that you can't

52:07

eat. Yeah. It says twenty percent of kids

52:09

who took it had, like, gastrointestinal symptoms.

52:12

And it also said that, like, after you lose

52:14

this one point of BMI,

52:17

After six months, you keep taking it and don't

52:19

get any more weight loss. Great.

52:22

They also list fenturamine

52:25

which is half a Fenfen as we talked about in our

52:27

Fenfen

52:27

episode. Yeah. Fenner mean is still around.

52:30

It's still on the market. It's wild to see

52:32

that and pediatric recommendations just

52:34

existentially

52:35

wild. It says kind of casually that it's

52:37

approved for, like, three months at

52:39

a time for kids sixteen holder.

52:42

And then it also mentions this thing called

52:44

to pyramid. It says,

52:47

The major adverse effect is cognitive

52:50

slowing, which can interfere with

52:52

academic concentration or other

52:54

activities of daily living. Right.

52:56

It's gonna slow down your brain function

52:58

when you're in grade

53:00

school, but don't worry. These are

53:02

literally people in school. Like

53:05

by definition, these children

53:07

are in school. Why

53:09

would we be considering prescribing

53:12

a drug that hampers their academic

53:14

formats. I don't know why they're

53:16

even telling people that these are options like,

53:18

you know, a drug that's so addictive that you can

53:21

only take it for three months at a

53:22

time. And another drug that like

53:24

makes you incapable of doing school

53:26

work. Your kid might get a lot worse

53:29

at school, but they are

53:31

going to be working those shit

53:33

out of that Gap Kids ensemble.

53:36

They are going to be so thin.

53:38

So the only one that

53:40

on the surface seems like an

53:42

actual option and there's going to

53:44

be so much goddamn discourse about

53:46

in the next five years is

53:49

semi glutide, which is sold as

53:51

with govie -- Yeah. -- by Novo Nordisk. It

53:53

appears that it was, like, the same week that

53:55

these guidelines came out There was like

53:58

the one study on semaglutide in

54:00

adolescence. Yeah. This is a weekly injection.

54:03

It was study of, I think, a hundred

54:05

and thirty four kids. And

54:09

they lost sixteen percent

54:11

of their BMI on average. There

54:13

isn't a whole lot to debunk here simply because

54:15

like there's only this one study

54:18

that's been published. And it's a

54:20

pretty small number

54:22

of people. They also did this like pretty

54:24

intense screening they

54:26

screened out everybody that had, like,

54:28

you know, any disability, any mental health

54:30

stuff. Like, they wanted to get it down to, like, quote

54:33

unquote, normal kids. And then

54:35

they did a twelve week lifestyle

54:38

thing before they started on the drug.

54:40

Yeah. But then what's really where does this this

54:42

one study says that they followed

54:44

up with the kids for an additional seven

54:47

weeks after they finished the study

54:50

to see if like they had any other side effects but

54:52

then it didn't track whether they started regaining

54:54

the weight. It it it's very odd

54:56

to me. Like, the word regain

54:59

only appears once In the entire

55:02

AAP guidelines, hundred and thirty six

55:04

pages. Mhmm. I mean, there's also fad

55:06

diets that would also make you lose

55:08

fifteen percent of your body weight, every

55:10

diet works in the short term. The

55:12

question is, is this sustainable?

55:15

Right? The guidelines recommend that you shouldn't

55:17

be on it for more than two years. If

55:19

people are losing sixteen percent of their body

55:22

weight and then gaining back thirty percent of

55:24

it, then like, what are we doing here?

55:26

It's It's just really weird to me

55:28

that there seems to be no actual interest

55:30

in answering this question when people

55:32

losing weight in the short term is not hard.

55:35

Well, and if we return to

55:37

fan fan as my forever example

55:41

of like a weight loss drug, right, Fen

55:43

Fen got a bunch of breathless press

55:46

coverage based on not very much research.

55:48

Yeah. Similarly, Fen Fen

55:50

was rushed to market and We

55:53

didn't really learn about

55:55

the health effects of Fenfen until

55:57

people started dying. Right. I'm

55:59

not saying that these are drugs that are going

56:02

to kill people, but I am saying

56:04

one short term study

56:06

of a small group of adolescents

56:09

does not tell us that this is safe

56:12

or effective -- Yeah. -- for most

56:14

kids.

56:14

So can I read you something and you have to guess

56:16

who wrote it?

56:17

no. You're actually gonna like this part.

56:19

Okay. It says the use of

56:21

weight loss medications in obesity treatment has

56:23

complicated history. Many medications used

56:26

to treat obesity were eventually withdrawn from

56:28

the market or their use restricted after documentation

56:30

of dangerous side effects. Particular

56:32

care must be taken when the use of weight loss

56:35

medications is considered for children because

56:37

the long term effects of these substances on

56:39

growth and development have not been studied. Pharmacotherapy

56:42

alone has not proven to be an effective

56:44

obesity treatment. Medication used

56:47

as part of a structured lifestyle location

56:49

produces an average weight loss of five to

56:51

ten percent which typically plateaus at

56:53

four to six months of therapy after which

56:55

weight regain may

56:56

occur. Wait regain is common if

56:58

the drug is withdrawn. Do you know

57:00

who said that? I don't, but I'm guessing it's

57:02

dated like nineteen ninety

57:05

nine or

57:05

something. Like, it's gonna be, like,

57:07

old

57:07

as the hills. What? Who is it? That is the

57:09

American Academy of Pediatrics. In two thousand

57:11

seven. Great. That's their last set of guidelines.

57:14

And job. It's actually fascinating to

57:16

me that they were so kind

57:18

of sober and careful in

57:20

their last set of guidelines. And in this

57:23

one, nothing has really changed,

57:25

but they're much less conservative with

57:28

this stuff. Yeah. Fifteen years ago, they

57:30

were like, Every

57:32

previous attempt has gone pretty

57:34

badly and it seems like these

57:36

only really work if they're coupled with

57:39

like a much more comprehensive approach

57:41

that like is pretty rare in the US healthcare

57:44

system. So like let's all just like

57:46

be kinda suspicious of these

57:48

until we have really good data about

57:50

how they

57:50

work. And now, they're just like, mount

57:52

eight, eleven, twelve, Sure.

57:55

Yeah. I mean, this feels very much

57:57

like Sure, man. Let's go back to Lord of

57:59

the Rings. This feels very much like

58:02

I know everybody else who gets this ring.

58:04

How's things go? Any sideways?

58:08

This is the boramir. Strategy. I

58:11

feel like it's gonna work out for me. And

58:13

also this this document again in this,

58:15

like, head in the sandness that

58:18

runs throughout, it says

58:20

the current twenty twenty three guidelines

58:23

say no current evidence supports

58:25

weight loss medication use as monotherapy.

58:28

Pediatricians who prescribe weight loss medication

58:30

to children should provide or refer to

58:33

intensive behavioral interventions for

58:35

patients and families as an adjunct to

58:37

medication therapy. So like, okay, great.

58:39

Don't just do the weight loss pills.

58:41

Also do, like, these intensive BLTs,

58:44

whatever. But like, we know the

58:46

kids aren't going to get those because those aren't

58:48

really meaningfully available and nobody

58:50

sticks with those. Seventy five percent of the kids drop

58:52

out. So like you know that in the real

58:54

world, people are just going

58:56

to get the weight loss

58:57

drugs. Right? Yeah. We're all on the same page

59:00

about that right it's sort of

59:02

staggering to me that you could just

59:05

ignore the entire social context

59:07

and the entire context of your own

59:09

patients

59:10

lives. Yes.

59:11

But what if instead of saying a weight loss drug

59:13

child, we say a child with weight

59:15

loss drugs? No. Michael, that's

59:17

not helping.

59:23

God. It is so fucking

59:25

bleak. Okay. Speaking of bleak,

59:27

this is the part

59:28

this is the part that neither one of us have

59:30

wanted to get to. The final section

59:33

is about bariatric surgery. Are you sending

59:35

me a brick? No. This

59:38

this is too this is too

59:40

bleak. We've we've done two

59:43

entire bonus episodes on Patreon

59:45

about how neither one of us wanted to do an episode

59:47

about this. Because it's just,

59:50

like, really complicated and,

59:52

like, people have strong feelings and it's

59:54

just a whole fucking can of

59:55

worms. And it's, like, sad.

59:58

Yeah. It's really sad. The through line

1:00:00

for almost all the stories that I have

1:00:02

heard about weight loss surgery, is

1:00:05

like a deep and profound sadness.

1:00:07

Right? That, like, even people for whom

1:00:09

it is successful report,

1:00:11

like, this incredible sadness

1:00:14

at knowing now how differently people

1:00:16

treat them now that they're

1:00:17

thin. Right? Like, that's like the best case scenario.

1:00:19

So these guidelines recommend bariatric surgery

1:00:22

for kids whose BMI

1:00:25

is over thirty

1:00:26

five, which I looked this up for a five

1:00:28

foot eight kid, I don't know if that's like

1:00:30

size of a child.

1:00:31

That's not. Two hundred and thirty pounds

1:00:33

if you're five foot eight. Mhmm. I'm still not five

1:00:35

foot eight now and I'm forty. You're still

1:00:37

a child. Congratulations. I mean, in some

1:00:39

ways. So people

1:00:42

above BMI of thirty five with like,

1:00:44

a comorbidity. So, like, you have diabetes or

1:00:46

you have hypertension or sleep apnea or something

1:00:48

else. Those people are eligible for

1:00:50

referral to bariatric surgery. Anyone

1:00:54

with a BMI over forty, so

1:00:56

that would be two sixty five pounds,

1:00:58

if you're five at eight. Those people

1:01:00

don't have to have comorbid conditions. That's just

1:01:02

like every single one of them can

1:01:04

be referred to bariatric surgery.

1:01:07

The AAP kind of tries

1:01:10

to have it both ways here where they explicitly

1:01:13

say, like, we're not saying these people should

1:01:15

get bariatric surgery. We're just

1:01:17

saying it's okay to refer them to

1:01:19

a bariatric surgery provider. I

1:01:22

mean, you know, Yeah.

1:01:24

It's like, I'm not saying you should get glasses, but

1:01:26

here's the address of an optometrist. It's

1:01:29

like, well I'm not I'm not taking a half

1:01:31

too. I'm just saying it's an option that they should consider.

1:01:33

So this was recommended for kids twelve and up.

1:01:35

The evidence on this is

1:01:38

also kind of surprisingly thin honestly

1:01:41

for how long bariatric surgeries have been around.

1:01:43

And one thing that's interesting about this

1:01:45

is like bariatric surgeries have been prescribed

1:01:47

to children for like quite a

1:01:49

while. Yeah. I did a little research

1:01:51

on this for the book and

1:01:53

found a case study

1:01:56

of a bariatric surgery patient

1:01:58

who was three Great. Really? Yes.

1:02:01

Oh. The core issue here

1:02:04

isn't that For the first

1:02:06

time, kids are going to start

1:02:08

getting weight loss surgery. The core issue

1:02:10

here is the Professional Association

1:02:14

of pediatricians in the US

1:02:16

is providing guidance that

1:02:18

they can and sometimes should

1:02:21

refer thirteen year

1:02:22

olds. Yes. To get bariatric surgery.

1:02:24

So there's two long term studies of bariatric

1:02:27

surgery among adolescents. The first is in

1:02:29

Cincinnati, on fifty eight

1:02:31

kids who received the surgery, the

1:02:34

kids lost a huge percentage of their body weight

1:02:36

and they had pretty significant improvements.

1:02:38

In their diabetes, their

1:02:41

hypertension, like all of these kind of metabolic

1:02:43

health markers. One of the articles

1:02:46

about this cohort Also said

1:02:48

though, despite this impressive weight

1:02:50

reduction and the net improvement in cardiometabolic

1:02:52

variables, sixty three percent of

1:02:54

participants remain severely obese at

1:02:56

long term follow-up. Furthermore,

1:02:59

more than half of patients had iron deficiency

1:03:01

anemia at five years and seventy eight

1:03:03

percent showed vitamin D deficiency.

1:03:05

The other cohort is cohort in Sweden

1:03:08

of kids who got bariatric surgeries, again,

1:03:11

very significant weight loss. But then

1:03:13

that one also showed pretty significant

1:03:15

rates of vitamin deficiencies,

1:03:18

surgical complications, like various follow

1:03:21

ups they have to do. And it said,

1:03:23

adolescents who undergo bariatric surgery

1:03:26

must be followed up very carefully by

1:03:28

multidisciplinary teams. Including

1:03:30

psychologists who implement cognitive behavioral

1:03:32

therapy. Even after surgery such patients

1:03:35

can continue to maintain a BMI greater

1:03:37

than

1:03:37

thirty. In other words, they are still obese,

1:03:39

and often show symptoms of depression. So

1:03:41

they're still fat, but on the upside, now they're

1:03:43

also depressed. I really struggle

1:03:45

with this one, and this we've talked about on our Patreon

1:03:48

episode so many times is like the

1:03:50

kids who got these surgeries had

1:03:53

an average BMI of sixty And

1:03:55

I looked that up and for for a five foot

1:03:57

eight person that's four hundred pounds. If

1:04:00

you are a sixteen year old

1:04:02

girl, and you weigh four hundred

1:04:04

pounds, you are experiencing a

1:04:06

level of stigma from the world that

1:04:09

I think that I physically cannot fathom. And

1:04:12

If you look around the

1:04:14

world and you decide I

1:04:16

can't do this anymore and I

1:04:18

wanna get the surgery and it's worth the

1:04:20

risks, For me, I am not

1:04:22

gonna tell you that you made the wrong decision. This

1:04:25

is why it's so difficult for me to,

1:04:27

like, say anything definitive

1:04:29

about these things because I think

1:04:31

people who make the decision to do this,

1:04:34

I I don't wanna make them feel bad and, like,

1:04:36

if if a kid decides to do this, like, all

1:04:38

I want for that kid is to feel

1:04:40

like loved and happy for the rest of their

1:04:42

lives. Yeah. I am not ever here

1:04:44

to tell someone who is fatter than I have

1:04:46

ever been, how to live their life. And

1:04:49

it's like not how I wanna show up in the world,

1:04:51

so I'm like right there with you on that.

1:04:53

And also, I think

1:04:55

it's worth talking about the

1:04:57

really intense side effects of this. I think

1:05:00

we deserve research that tangles with

1:05:02

what are the negative outcomes of this, not

1:05:04

just in terms of your physical health, but

1:05:06

also in terms of your mental health. Right?

1:05:09

I think we deserve more and

1:05:11

better and deeper research if this

1:05:13

is the only path out that

1:05:16

fat people see and that very fat

1:05:18

people see, we have work

1:05:20

to do. And at the very least,

1:05:22

they deserve really solid reliable

1:05:26

information about a huge decision

1:05:28

to

1:05:28

make. The cohorts that we have now, the average

1:05:31

age was seventeen, These are kids

1:05:33

that are like pretty close to adulthood

1:05:36

and much more capable of

1:05:38

understanding the risks

1:05:40

of these surgeries, which you know, are are

1:05:42

considerable. Yep. So in the Swedish

1:05:45

cohort, twenty six percent

1:05:47

of the kids had moderate or severe

1:05:49

depression thirty two percent

1:05:52

had moderate or severe anxiety, sixteen

1:05:55

percent had suicidal ideation. Some

1:05:58

of that is because kids who get bariatric

1:06:00

surgery oftentimes have higher rates of

1:06:02

mental health issues to begin with,

1:06:05

but we've also had a number of other

1:06:07

studies that have showed higher rates

1:06:10

of depression, anxiety, suicidality,

1:06:13

after bariatric surgery. It's becoming

1:06:15

like one of the kind of known health risks

1:06:18

and, you know, roughly twenty percent of people gain

1:06:20

the weight back within seven

1:06:22

years. Bariatric surgery

1:06:24

appears to decrease the risk of some

1:06:26

cancers, but it increases the risks of

1:06:29

others. There's this weird

1:06:31

increase in the risk of holism

1:06:33

after bariatric surgery because your

1:06:35

stomach absorbs alcohol

1:06:38

more efficiently and so you just get like a bigger

1:06:40

spike. And then, you know,

1:06:43

the long term health effects of bariatric surgery

1:06:45

are like not very well studied.

1:06:48

There's very few studies that

1:06:50

look longer than ten years out.

1:06:52

Mhmm. And even the things like

1:06:54

nutritional deficiencies could

1:06:56

have health effects over

1:06:59

time. It's not a totally fair

1:07:01

comparison because most

1:07:03

of the risk factors of

1:07:05

obesity take decades. Right?

1:07:07

People are not generally dying

1:07:09

of heart attacks in their twenties and thirties.

1:07:12

But then the benefits of bariatric surgery

1:07:14

are being sold according

1:07:16

to, like, five and ten year data.

1:07:18

Yeah. And that Swedish study says quite

1:07:21

swedishly that adolescence

1:07:23

who get this procedure need to have a multidisciplinary

1:07:26

follow-up to make sure that these risks are

1:07:29

known and managed, but We

1:07:31

all know that that is not going to happen.

1:07:33

Right? It doesn't even happen in Sweden. It

1:07:35

notes in the study that only forty eight percent

1:07:38

of patients are actually getting the follow ups

1:07:40

that they need. Mhmm. Again, if people wanna

1:07:42

go forward with this, I'm really not here to

1:07:44

criticize anybody's decision, but it's like, at

1:07:46

a larger systems level.

1:07:49

It's worth considering whether people

1:07:51

are really going into this with like a

1:07:53

full understanding

1:07:55

of what it means to get these surgeries.

1:07:57

It makes me feel so

1:07:59

angry at

1:08:01

a level that

1:08:02

I, like, release struggle

1:08:04

to express. If I'm

1:08:06

honest, I don't usually struggle to express

1:08:08

myself. Mhmm. But this issue makes me

1:08:10

so angry because You're

1:08:12

taking kids sometimes have

1:08:14

other health problems and sometimes don't.

1:08:17

Yeah. You are making what are

1:08:19

often lifelong to say cisions --

1:08:21

Yeah. -- about how their body is going to function.

1:08:23

You're doing that with really thin

1:08:26

research. Right. You're doing this

1:08:29

in a setting where you know,

1:08:31

if a doctor and your parents

1:08:33

say you need to have a surgery, how

1:08:36

much agency do you really have

1:08:38

to say no to that?

1:08:39

Right?

1:08:40

Right. It is galling to me that this is wrapped

1:08:42

up in a document that pays lip service

1:08:44

to weight stigma and intends to do absolutely

1:08:47

nothing about it.

1:08:48

Nothing whatsoever. Yeah.

1:08:49

That doesn't really tangle

1:08:51

meaningfully with the incidents of eating disorders

1:08:54

for these kids. Yeah. There's no looking

1:08:56

at, like, suicidality and

1:08:59

-- Yeah. -- long term mental health,

1:09:02

there's just like so many angles

1:09:04

that we haven't looked at this

1:09:05

from. Because what we heard

1:09:07

was we've got a way to make fat

1:09:09

kids thin.

1:09:10

Mhmm. And we decided that was the most

1:09:13

important thing to do. Right. Like,

1:09:15

this is such a complete erasure of

1:09:17

the actual life experiences and

1:09:19

wants and needs of that

1:09:20

kids. It feels really telling. Well,

1:09:22

it's also it's telling that this comes

1:09:25

at the end of document that is, like, explicitly,

1:09:27

like, we don't care about health stuff.

1:09:30

Yes. Yes. By

1:09:33

the way, we're not looking at all that

1:09:35

stuff. We're we're only focused on

1:09:37

the size of the children. It it really

1:09:40

feels like it's like veering into double

1:09:42

speak territory -- Right. -- from

1:09:44

that perspective as someone who has lived

1:09:46

the life of a fat kid -- Mhmm. -- albeit

1:09:49

a while ago, it is like

1:09:51

deeply deeply painful

1:09:54

to think and talk about, you

1:09:56

know, like, I had a

1:09:58

really rough time as a fat kid.

1:10:01

Mhmm. And that was without the

1:10:03

American Academy of Pediatrics telling

1:10:05

my doctor to like triple

1:10:07

down. My understanding of like your childhood

1:10:09

experience is that basically every

1:10:12

single doctor who you saw should

1:10:14

have asked you about your history

1:10:17

and just concluded like, oh, this is like a little

1:10:19

fat kid. Yeah. Her body just wants to be fat.

1:10:21

We should just let her be like happy little fat kid.

1:10:24

And it's fucking wild to me

1:10:26

that, like, with all of the research we have

1:10:28

about,

1:10:28

like, different forms of obesity and things that

1:10:30

contribute in biological factors, whatever,

1:10:32

that there is nothing in this document

1:10:35

that is just like some kids are

1:10:38

fat. Right. This is, like, the weird

1:10:40

thing that would pop up in, like,

1:10:42

grade school. I will absolutely never forget.

1:10:44

I had two friends. Mhmm. And

1:10:46

they would just eat, like, whole

1:10:49

family size bags of chips

1:10:51

and be, like, I can just eat whatever and I never

1:10:53

gain weight. And there was this

1:10:56

weird celebration amongst

1:10:58

parents of, like, naturally thin

1:11:00

children. Yeah. But there was

1:11:03

absolutely never any acknowledgment

1:11:05

that some kids might also be naturally

1:11:08

fat. Right. That that same effect

1:11:11

might exist in kids with

1:11:13

higher body weights. No. That was always

1:11:15

about they don't have enough stick to

1:11:17

itiveness. We haven't found the right diet.

1:11:19

The parents aren't doing enough. That was always

1:11:22

a problem to solve. Right. That's

1:11:24

a bad way to grow up as a

1:11:26

kid. This whole thing is so

1:11:28

typical of this transition period where

1:11:30

it's like we're now acknowledging all

1:11:32

of The problems with the way

1:11:35

that this kind of care has been provided for

1:11:37

like four decades now, but

1:11:39

everything in this document. Is

1:11:41

defending, let's do the same

1:11:43

thing. Bring up weight at every fucking

1:11:46

visit. Give tedious advice

1:11:48

of, like, don't drink sodas. Invite

1:11:50

them to these intensive behavioral

1:11:52

programs that don't exist. Yeah.

1:11:55

And if those don't work because they never do,

1:11:57

then start them on weight loss drugs and surgery,

1:11:59

which we don't know what that does. And we don't

1:12:02

know what that does. Yeah. The actual paradigm

1:12:04

shift that they completely refuse to acknowledge

1:12:07

is just get rid of weight as

1:12:09

a variable completely. Yeah. Ask

1:12:12

kids about their behaviors. Right?

1:12:14

It doesn't even have to be fat kids. It's

1:12:16

like assess, okay, are the parents providing

1:12:19

decent meals however you want to define

1:12:21

that? Is the kid getting like thirty to

1:12:23

sixty minutes of exercise most days? And

1:12:26

if the kid is and they are fat

1:12:28

-- Yeah. -- maybe just have a fat kid

1:12:30

on your hands. Right? The most important

1:12:32

thing that doctors can be doing is shifting

1:12:35

away from a weight based paradigm and

1:12:37

toward a health based paradigm. I

1:12:40

think that there are probably

1:12:42

in existence somewhere parents

1:12:44

and kids who could actually use. Some

1:12:46

of these like nutrition classes, learning

1:12:48

to cook, I think that those people

1:12:50

probably exist. Yeah. But right

1:12:52

now, all we're doing is just assuming

1:12:55

that every single fat person has terrible behaviors

1:12:58

and that all of them need to change their

1:12:59

behaviors. And look, if you are prescribing

1:13:02

treatments that don't work

1:13:04

for the majority of people who undergo

1:13:07

those treatments or are inaccessible to

1:13:09

them or what have you. If

1:13:11

you are focusing a kid's

1:13:13

entire relationship with their healthcare

1:13:15

provider on manipulating their

1:13:18

weight, which likely won't be manipulated

1:13:20

in the long term. What

1:13:23

you are telling them is that

1:13:25

nothing matters as much

1:13:27

as how much they weigh. Right. You're

1:13:29

also conditioning those kids to

1:13:31

accept really subpar

1:13:34

behavior from people around them.

1:13:36

You're conditioning those kids to

1:13:38

expect to apologize for their

1:13:40

bodies before people even know

1:13:42

who they

1:13:42

are. I feel like the only thing on which

1:13:45

we agree with the AAP is that

1:13:47

we also think that children should be given

1:13:49

intensive BLTs but we

1:13:51

mean the actual sandwich. Yeah. I'm

1:13:53

a treat kids give them. It's crazy now.