Weight stigma in children and teens [PODCAST]

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“Let’s meet in the middle and listen to what’s happening in communities. All across U.S. communities, there are pockets of promise and programs focused on family interventions, behavior change, and health disparities, but there are many obstacles to true change. Currently, the work relies on visionary champions within a community, but when the champion leaves the work, the work often goes away.

There is a lack of resources on every level, from public health, research, primary care, specialty care, and advocacy, especially to sustain and scale effective efforts. The burden of sustainability must not be placed on one champion’s shoulders, but rather viewed as an opportunity for sustainability and must be a shared effort among multiple partners representing multiple sectors.”

Karla Lester is a pediatrician.

She shares her story and discusses the KevinMD article, “When it comes to weight stigma in children and teens, let’s meet in the middle.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Karla Lester. She is a pediatrician and life coach, and she co-wrote the KevinMD article “When it comes to weight stigma in children and teens, let’s meet in the middle.” Karla, welcome to the show.

Karla Lester: Thank you, Kevin. Happy to be here.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Karla Lester: Thanks again for having me. I’m a general pediatrician. I’ve been a community pediatrician for a long time, and I’ve been addressing the childhood obesity epidemic on every level, local, state, national level, for the last 17 years. I started with developing a clinic in my practice, and then I started my own nonprofit organization called Teach a Kid to Fish, and our vision was creating community solutions for children’s health. I started that in 2008. I left my practice to do that and built a beautiful community collaborative that was so amazing.

And then I saw the need to create a clinic, so I also founded, helped to fund, and pulled together all the community programming, and was a pediatrician for a pediatric weight management program. And then I saw the need to create a population health center, so I moved my nonprofit to that. So I followed the expert committee recommendations that came out in 2007 basically to a T, and took those and operationalized those and created whole organizations around that.

And then I ended up having my own weight issue and discovered the transformative power of life coaching in 2017, and joined Weight Loss for Doctors Only, and started reading The Obesity Code by Dr. Jason Fung, and thought, “Wow, we’ve gotten this wrong,” especially for teens, when we look at what’s available and what’s helpful for teens. And what I started out to do when I started, especially, my nonprofit, which was to get something helpful and impactful, I just thought, “We’re really not doing it.”

Kevin Pho: So I’m certainly interested in hearing more about the misconceptions that we have in obesity and teens, and that’s going to transition, certainly, into your KevinMD article that you co-wrote, and it’s titled “When it comes to weight stigma in children and teens, let’s meet in the middle.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to co-write it?

Karla Lester: I was excited to co-write it with my daughter, Katherine, who’s a college student. She’s a pre-med and journalism major, and she’s been working with me as I launch my new web-based life and weight coaching platform for teens called IME Community. So check it out, imecommunity.com. And we have been doing literature searches and looking at what’s out there and what’s effective for teens, and there’s not much. And also, the prevalence of severe obesity in teens is 9 percent. When I started my nonprofit, it was 4 percent. When I started the clinic, it was 6 percent. Now, as I start IME Community, it’s 9 percent.

And so we had all these articles, and what happened, and the reason why we wrote the article, was the New York Times opinion piece by Aubrey Gordon, who’s a Health at Every Size advocate, which is amazing. She wrote a very powerful opinion piece, and it drove a lot of controversy in the physician world. So pediatricians like me, who are doing good work, who’ve been really committed to addressing the childhood obesity epidemic for a lot of years, really thought that they should write a rebuttal to her opinion piece. But I actually read her piece, and I agreed with it. Her piece was about how all of the efforts to address childhood obesity in the United States have caused more stigma and shame and haven’t been helpful. And she had a really profound, powerful personal story of how her pediatrician had called her out as a fairly young child for being overweight and actually sent her on a path of harm.

And so I thought, “Wow, we have all these amazing doctors who are saying we need to refute her article,” on this listserv that I’m on, and they’re wanting to talk about how important it is as a health issue, and that we shouldn’t just accept our weight, because it is a health issue. And we all know that as physicians, that it is, and it’s the number one chronic disease, especially in children, and all the comorbidities and shortened life, and we know all the data.

And so my theory is, I’ve been working on this forever and had my own personal weight loss journey, and with the launch of IME Community, I think we should meet in the middle. And so we can value and validate and listen to the stories of our patients who’ve undergone weight-based victimization, which the article highlighted: a weight-based victimization study that showed that it’s a stigma obstacle course in our country. And we can relate to that and validate those stories and listen, and we can do better.

And then in health systems, teens right now in America either swing to one extreme of the pendulum or the other, and it’s really not helpful either way. So either it’s self-acceptance and Health at Every Size, and be happy that this is going to be your future, and maybe you feel stuck in the shame and stigma for wanting to lose weight and not being happy, and that doesn’t resonate with everybody. Or they swing over here to where health systems are, and we all know that when they’re focused on their profit margins, the teens are funneled to the bariatric pathway. And a lot of health systems are still focusing on low-calorie, very restriction, and their profits, and so that’s not helpful either. And so they’re kind of stuck, and there’s really nothing there, so we need to start meeting in the middle.

Kevin Pho: So can you share an example of the stigma of obesity in teens, either a story or an anecdote, where that stigma really harmed them in terms of their weight loss goals?

Karla Lester: Yes. I mean, I’ve taken care of a lot of teens with severe comorbidities. One patient I can think of, who weighed over 400 pounds, was coming in from outstate Nebraska to see me. And when you look at what the evidence base shows in best practice, you need at least 26, at a very minimum, contact hours of comprehensive behavioral intervention within two to 12 months. And so somebody who’s coming from hours away to a clinic that is focused on maybe the bariatric funnel, linking into the bariatric pathway, is not going to get even the evidence base. And so we have comorbidity clinics, which are fine. I mean, we need those, but it’s just that that’s not going to be a helpful intervention.

And so one of the stories he would talk about a lot was his weight-based victimization in PE class. His PE teacher just thought he was lazy, and he would almost push him harder and kind of call him out during PE class. He was a high school student, and he would talk a lot about how he hated that PE teacher, and it was just causing so much harm. I mean, this school should be a safe place for him. And then he comes to clinic, and sure, we’re nice people, but it’s just, we’re not even providing what the evidence base shows he needs.

Kevin Pho: So for patients in similar situations who have been shamed, perhaps in PE class, what kind of approach, what kind of advice do you share with them?

Karla Lester: Well, first of all, I mean, listening is the most important thing we can do as physicians, and being a compassionate listener, and that’s relationship building and building up trust over time. And the thing that I said, and I said this in the article, is let’s start asking permission. I mean, that’s in motivational interviewing and the five A’s of obesity management: First, just ask permission and say, “Is it OK if we talk about your weight and your growth chart?” And you should ask the parent and the child or teen permission. And if they say no, then you can say, “I get it, and I understand, and thank you for your response.” And then you pivot, because your next step is assessment. So just because they don’t want to talk about their weight doesn’t mean that you can’t address what are significant health issues.

So doctors really need to learn just the simple acts of listening, being compassionate, connecting, building trust, and talking about it as a, neutralizing it as a health issue. And I say really focus in on what comorbidities you’re wanting to target and what their risks are, and try not to draw a lot of alarm, because what happens is alarm can cause short-lived panic.

And what I’m finding, as I’m coaching some parents too, of preteens and teens who are struggling with their weight or body image, is that when the doctor says, “Oh, look at this growth chart,” and maybe drives more shame, the parents have a lot of shame about it. Maybe they’re overweight as well, and they feel like they may have caused it, so they want a quick fix. So what do we do? We judge when we feel that shame and guilt. So then they may go home, and weight-based victimization studies show that parents bully their kids too. And so we don’t want, as physicians, to be a part of perpetuating that or making that worse.

We want to have neutral conversations about, “These are the specific things. I’m glad you shared that you don’t want to talk about your weight. I get it. And I also want to recommend that we do these lab studies to check for prediabetes and some of these things, and we’ll draw that today, and I’ll let you know what the results are.” And we don’t need to be alarmist, because it only draws short-lived panic. It doesn’t necessarily drive action.

Kevin Pho: Now, you mentioned that the childhood obesity rate currently is 9 percent, and that’s steadily gone up. Now, in your view, what are some of the underlying reasons driving that increase?

Karla Lester: Well, it’s 9 percent of severe obesity in teens, so in adolescents. So that means it’s like 120th percentile, the 95th percentile cutoff for obesity, and that’s the class 3 obesity that’s growing, increasing most, in 12- to 19-year-olds.

So the problem with our expert committee recommendations is that those were developed in 2007, and have we revisited those? I mean, why? We haven’t really, necessarily. And also, for teens, there’s four stages of treatment that are recommended. So when we have so many who are severely obese, it’s really “do not pass go” on the first three stages, and you head right toward the tertiary care centers, where they look at very low-calorie diets, which we know don’t work and can backfire and make things worse. You’re looking at pharmacologic management, you’re looking at meal replacements, you’re looking at bariatric surgery. So we’re saying all medical management has failed and they need bariatric surgery, without having effective medical management.

Kevin Pho: We’re talking to Karla Lester. She is a pediatrician and a life coach, and she co-wrote the KevinMD article “When it comes to weight stigma in children and teens, let’s meet in the middle.” Karla, for those general pediatricians and family physicians who may be listening to this podcast, what are some of the misconceptions they have about teenage obesity, and what is some of the advice that you can give them?

Karla Lester: Well, I’ve been the visionary champion in my community on this issue, and I mean, I have such amazing relationships and connections with all of the pediatricians and family docs in my community. I mean, it’s the number one chronic disease that children are facing. We all need to be the visionary champion on this issue. We all need to be the community champion, the go-to on this issue. And there’s still stigma, there’s still bias, and we still blame the victim. When I’ve done surveys and looked at what physicians think the number one barrier is to addressing childhood obesity within their primary care practices, it’s parental apathy.

So I mean, I really want to encourage all of us to start being more innovative and flexible and agile and curious, and just start by asking, and start reaching out and figuring out how you’re going to address it, and almost look at it as a continuous quality improvement project that you have on your own. And also, I think, the coaching. I’m going to be offering the ActivistMD network that I’m creating, because I’ve had outreach from amazing doctors who think about this like me, and we want a new way forward. We want something better for our patients and our families and our communities and ourselves. We don’t want to spend our entire careers addressing the number one, or not addressing the number one, chronic disease that our patients are facing. It’s not why any of us went into pediatrics. It’s a helpless, hopeless feeling.

And so I think the thing is, if you think it’s parental apathy, I would suggest kind of looking at some of those beliefs that aren’t really helping you in your practice, and I would challenge that belief, because I find that it’s the opposite. I think parents are very motivated to address this. I think they’re highly concerned, and they’re worried that they’re going to cause harm if they address it, and they look to us as physicians for the answers, and physicians and health systems haven’t been giving it to them.

Kevin Pho: What are some things, a piece of advice you give to parents, so they don’t perpetuate the weight stigma?

Karla Lester: The most important thing parents can do, and my daughter and I put this link in your KevinMD article, which was showing that the protective factors and risk factors are the same for the development of eating disorders as for the development of weight gain or becoming overweight. And the things that parents can focus on are promoting a positive body image and family mealtimes, and that’s really it. And so no diet, no restriction, no quick fixing, no blaming.

And when I’m coaching parents, what I’m finding is they have these beliefs about their kids, and these are preteens, where the parents are already saying, “Oh, she’s unmotivated,” or, “I really want her to sign up for IME Community, but I know she won’t do it because she doesn’t care,” or, “She still hides food.” But she’s learning, and she’s like 11, and I’m like, “She needs to eat.” And they are driving shame. And so just promoting a positive body image and self-acceptance, being compassionate parents, and of course role modeling that compassion and healthy body image themselves, is going to be super helpful.

Kevin Pho: And we’re speaking in the middle of February, and we’re one year into the pandemic, and I know the pandemic has had a pretty big effect on childhood obesity. What are some things that we can do to help mitigate that going forward?

Karla Lester: Well, what the COVID pandemic has highlighted is what we’ve known all along, is that we have disparities and that those are worsening. And same thing with, I mean, there’s disparities, and then there’s worsening obesity. And again, I would say really to have a compassionate approach, and to ask permission to talk about it, but not to have any quick fixes, not to get alarmed, to take small steps, and to still focus on the positive body image and the family mealtimes.

And one thing I’ve noticed too, and obviously all of us experience this, is that we haven’t had as many opportunities for fun. We have to create those. And so some of the coaching that I do, and some of the podcasts that I do, are like, make it fun to get it done. I mean, you can have fun and be healthy too. So I think that we have to be really intentional about our health.

And one of the things I also talk about in the article is one of the problems we’ve had is we just offer bullet-point recommendations. Well, that’s not really helpful. Because you asked me about this earlier, what are the causes. We know that there are so many causes of the childhood obesity epidemic, but if we really look at our food system, I think you could hone in there and see that the refined carbs and the processed, ultra-processed foods, and especially all the marketing of those foods to kids, has made it really hard to raise healthy children. And so if we can really encourage families to focus on the family mealtime and having quality food, and transition off of some of the refined carbs and sugary foods, especially starting with sugary drinks, and drinking more water, and making those simple changes to focus on just health and not focus on the weight at all.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Karla Lester: I want to leave the message, because I know mostly we’re physicians who are watching, that this is everyone’s issue. This is the number one disease that our patients are facing, and the parents need help, and they’re going to look to us. So let’s really step it up. Let’s all be that visionary champion within our community. Let’s listen and validate the stories of our patients, where we listen and learn. We’ve gone wrong in some ways, and let’s throw that out, and then let’s start looking at what’s worked and move forward with that. And then let’s just be really creative and compassionate and really help our patients and their families moving forward.

Kevin Pho: And how can people reach you?

Karla Lester: They can reach me either by checking out my website, imecommunity.com, where self-love is your superpower to achieve your weight and life goals and make your mark in the world, which I’m excited about, or DrKarlaActivistMD, imecommunity.com.

Kevin Pho: Karla, thank you so much for sharing your time and insight, and thanks again for being on the show.

Karla Lester: Thank you, Kevin. I appreciate it.

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