Doctors Have a New Plan for Fat Kids

Last month the American Academy of Pediatrics released a new set of guidelines for "childhood obesity." We have some comments.

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Links!

• The 2023 American Academy of Pediatrics Guidelines 
• The 2007 guidelines 
• Pros and cons of bariatric surgery in adolescents 
• Serious Issues With the American Academy of Pediatrics Guidelines For Higher-Weight Children and Adolescents 
• Semaglutide treatment for obesity in teenagers: a plain language summary of the STEP TEENS research study 
• Patients’ views of long-term results of bariatric surgery for super-obesity: sustained effects, but continuing struggles 
• Long-Term Outcomes After Bariatric Surgery 
• Suicidal thoughts and behaviors in adolescents who underwent bariatric surgery 

Transcript

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[Maintenance Phase theme] 

Michael: I am exploding to tell you things.

Aubrey: Boy, oh boy, oh boy, oh boy.

[laughs]

Michael: I'm going to do it all at once, and it's just going to come out as like Tower of Babel, [makes bursting noises] just everything.

Aubrey: I am so grateful, I have to say, that you are looking into this one, because there's no question that we had to cover it.

Michael: Yeah.

Aubrey: I think I would emotionally just like turn into fine dust, [Michael laughs] because this makes me so sad and angry.

Michael: That's what I'm going to do to you over the course of the next 3 hours.

Aubrey: Oh, hurray.

Michael: You are knowing this in advance.

Aubrey: Welcome to Maintenance Phase, the podcast that's disintegrating into a fine dust.

Michael: Wait, is this the tagline? --Is this what we're going with?

Aubrey: No, no, no, no, no, no. We're not doing that.

Michael: Do one.

Aubrey: Do one.

Aubrey: Hi everybody, and welcome to Maintenance Phase, the podcast that likes you just the way you are.

Michael: Oh, you did like a nice one.

Aubrey: That's straight from Mister Rogers' playbook. I felt like we needed some niceness for the extreme, grim, goblin garbage that we're about to sort through today.

Michael: We love you just as you are unless you work for the American Academy of Pediatrics, in which case--

[laughter]

Aubrey: Then, we have some questions.

Michael: We want you to be different.

Aubrey: We don't like what you're choosing to do right now.

Michael: I'm Michael Hobbes.

Aubrey: I'm Aubrey Gordon. If you'd like to support the show, you can do that at patreon.com/maintenancephase. You can get merch at TeePublic. You can also subscribe through Apple Podcasts, which is the same audio content as Patreon.

Michael: Same content audio.

Aubrey: Michael, I feel like I am getting ready to be full of rage.

Michael: There's like a little propeller on your head that I get to spin around when we do these episodes. I can just imagine [makes whizzing sounds] and you're just going to lift off out of your seat. [laughs]

Aubrey: Just getting ready for lift-off.

Michael: Today, we are talking about the American Academy of Pediatrics guidelines on the treatment of childhood obesity. They released the last set of guidelines in 2007. The general approach for those was watchful waiting. If your kid is fat, they'll probably outgrow it. We don't need to do anything aggressive. This year in January, they updated the guidelines and recommended a much more aggressive approach. The thing that got the most media coverage was the fact that they are now recommending weight loss drugs and bariatric surgery for kids as young as 12. I went onto the AAP's website, I got the document, I pasted it into Word. It was 136 pages. I went through it, I checked the citations, I talked to someone from the AAP. This episode is literally just going to be us, going through the document. I'm going to do my best to try to make that interesting, but I might fail. [Aubrey laughs] There, you've been warned.

So, as usual, we need to start this episode with a carnival of housekeeping. First of all, this is going to include a lot of triggery eating disorder, weight loss, calorie stuff. It's also going to include the word "obesity" lot, which is not a word that either one of us like or use. But in the context of these studies, because they are exclusively based on BMI categories, we kind of have to talk about those categories when we're talking about the studies.

We do episodes sometimes where it's like I look into an influencer and I tell you about it, and you've never heard of them. They're always from Australia, [Aubrey laughs] and that isn't fake. The show isn't scripted. We're coming in fresh to those episodes. This is not one of those episodes. This is a topic that both of us have been thinking and writing about for a very long time, and we're not going to pretend that we don't already have issues and of course, like human biases that we are coming in with.

Aubrey: Yes.

Michael: The purpose of these guidelines is just to kind of get all of the evidence on this issue in one place. So, they've put together a task force. There's like a committee. All these doctors have spent years looking at every single thing that's ever been published, and they want to put it into one place and on the basis of all of the evidence, make recommendations. That is what they are setting out to do.

Aubrey: Okay.

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

Aubrey: "We're really concerned about the health of these kids. Therefore, we're not looking at their health. We're just looking at how fat they are."

Michael: It is actually fascinating to me that the entire social construction around this issue is that it's really only about health. "When I mean to a fat person on a plane, I'm not doing it because I'm a dick, I'm doing it because I'm concerned about their metabolic risk." [crosstalk]

Aubrey: It's good for them somehow. Yeah.

Michael: But then, you get into these documents and they're quite just openly, "No, no, it's just about the fatness."

Aubrey: This kind of rhetoric of, "It's for your health," is the thing that you shout out loud and then quietly into your research paper say, "We didn't look at anything about health." It's how we get this wild difference in public opinion between what people think is the issue with fatness and what researchers are even outlining as the issue with fatness. This is how you get to the point where people really think someone just gets so fat that they drop dead, and that's like a way that people die.

Michael: They also mentioned at the very beginning that this review will not be discussing obesity interventions for children under the age of two. [Aubrey chuckles] I just like, "Wow, thank you. I appreciate it."

Aubrey: How brave to cut it off.

Michael: [laughs] We're not going to be covering literal infants.

Aubrey: The opening salvo is, "We're not going to call your baby fat in utero. You're welcome."

Michael: [laughs] Exactly.

Aubrey: "Please clap for our restraint."

Michael: I don't know if we've talked about this on the show-show. But on a number of bonus episodes now, we've talked about the fact that fat people and fat stuff, this issue is in a weird transitional period where there's growing societal acceptance, but there's also this kind of remnants of a huge amount of stigma.

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

Michael: Exactly. This is why I wanted to do an entire episode on this document, because it's a portrait of the weird corner the public health establishment has painted itself into, where it now rests on two completely contradictory sets of beliefs.

Aubrey: Yeah.

Michael: It's basically saying, "We agree with this Copernicus guy, but we're not ready to get rid of Ptolemy and his little planetary loop-de-loops."

Aubrey: We think Hobbes and Locke have good points to make, like, "Okay, okay."

Michael: Yeah, but I always side with my dad on that one though.

Aubrey: Oh, your dad? [laughs]

Michael: This is where we start getting into this transitional period. The first section is called Health Equity Considerations, where we talk about all of these social determinants of health that affect obesity. I'm going to send you a series of bricks of text, there's like dot, dot, dots where I've cut a couple of paragraphs in between and condensed stuff. This fucking document, Aubrey, the amount of editing I had to do to make this readable. Absurd. I had a whole bunch of macros to get rid of all the fucking acronyms.

Aubrey: Whoa. Brick.

Michael: Yeah, I know, I know, I know. We can take breaks.

Aubrey: "Long stigmatized as a reversible consequence of personal choices, obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. As the environment has become increasingly obesogenic, access to evidence-based treatment has become even more crucial…"

Michael: This is the Michael Hobbes, dot, dot, dot.

Aubrey: Michael Hobbes, dot, dot, dot.

Michael: These are my choices.

Aubrey: "Childhood obesity results from a multifactorial set of socioecological, environmental, and genetic influences that act on children and families. These influences tend to be more prevalent among children who have experienced negative environmental and social determinants of health, such as racism. Overweight and obesity are more common in children who live in poverty, children who live in underresourced communities, in families that have emigrated, or in children who experience discrimination or stigma." Michael Hobbes, dot, dot, dot.

Michael: Dot, dot, dot.

Aubrey: "The American Academy of Pediatrics is dedicated to reducing health disparities and increasing health equity for all children and adolescents. Attainment of these goals requires addressing inequities in available resources, and systemic barriers to quality healthcare services for children with obesity. To that end, practice standards must evolve to support an equity-based practice paradigm."

Well, so listen, so far I disagree with the framing around the problem here is fatness. But in terms of the substance of what they're saying, I don't actually disagree with much of this.

Michael: Yes.

Aubrey: This is an issue that's much more complex than we give it credit for. The interesting thing they don't mention here is the role of experiencing antifat stigma.

Michael: Would you like to hear our next two paragraphs?

Aubrey: Oh, did I do a segue?

Michael: This is what is so interesting about this document to me, is much of it could have appeared in your book. You are a much better fucking writer than this, obviously. But as far as acknowledging, everything that we say on this show, this document is pretty good. Right after this little excerpt that we read, there's a long section on racism. There's a long section on toxic stress and minority stress, and then there's a section on weight stigma. This part says, "Individuals with overweight and obesity experience weight stigma, victimization, teasing, and bullying, which contributes to binge eating, social isolation, avoidance of healthcare services, and decreased physical activity. Importantly, internalized weight bias has been associated with a negative impact on mental health. Collectively, these factors may adversely affect the quality of care, prevent patients with overweight and obesity from seeking medical care, and contribute to worsened morbidity and mortality independent of excess adiposity. Pediatricians and other primary care providers have been and remain a source of weight bias. They first need to uncover and address their own attitudes regarding children with obesity."

Aubrey: Yeah.

Michael: There's not a lot to actually quibble with here.

Aubrey: Yeah.

Michael: It's like, "Yeah, stigma matters. Doctors are a source of stigma. Stigma can have health consequences on people."

Aubrey: "Therefore, what we need to do is we're going to spend the rest of this paper talking about how to reduce stigma and end your own bias," right?

Michael: This is what is so fucking incredible to me about this transitional period. They will say all of these things but then do nothing with them.

Aubrey: Lip service, lip service, lip service.

Michael: Unfortunately, the lip service is pretty fucking good. The lip service is like, yeah, you're saying all the stuff that we've been wanting you to say, but we would also like you to do something about it. This is the last time they're going to mention, "Doctors are a source of medical bias." But you know that if you criticize the AAP for any of this stuff, "This doesn't actually seem like a very equitable framework," they'll be like, "Ah, ah, ah, the very first section is called Health Equity."

Aubrey: It's really astonishing that they're sort of doing this like seem to be sallying forth into a bigger, more complex conversation and then do this weird hairpin turn and be like, "Yeah, the bullying of fat kids is really a problem, which is why we need to eliminate fat kids and make them all thin." We're like, "I don't think that's the solution."

Michael: The next section of the paper, after we've done all this health equity lip service stuff, we then get to the boilerplate section that me and you have read a million times where it's the prevalence of childhood obesity and like, "How many kids are fat?" They start out by noting that the prevalence of childhood obesity has gone from 5% in 1963 to 19% in 2017. This is something I've only started noticing once I started doing the show with you. They often note that the baseline is not 0%. There's presumably always some number of kids who are just fat.

Aubrey: I feel fascinated by the ways in which our current biases allow us to imagine that the world is meant to be a particular way and that a particular kind of person doesn't exist in the past or the future.

Michael: Remember when I went to that museum in Amsterdam, and I kept texting you with the paintings of fat people?

Aubrey: Yes [laughs].

Michael: It's like, "Aubrey, look."

Aubrey: Look at all these fatties.

Michael: [laughs] It's like another painting of a fat person.

Aubrey: This is great. Yeah.

[laughter]

Michael: Another really weird thing about this document is that there's almost nothing about health risks. They mostly cast this as a problem in the sense that fat kids will become fat adults. So, younger kids, like between 7 and 11, 55% of those kids become fat adolescents and 80% of fat adolescents become fat adults. That's kind of the trajectory that they're warning us about, is that most fat kids become fat teenagers become fat adults.

But in the citation that they use for this section, the paper that they're citing also notes that 70% of fat adults weren't fat kids, which is interesting to me.

Aubrey: Oh.

Michael: There's also some careful wording stuff. They say at one point, "The COVID-19 pandemic has significantly affected the lives and routines of children and adolescents. In one analysis, the pandemic period was associated with a doubling in the rate of BMI increase compared to the pre-pandemic period." I was like, "A doubling in the rate of BMI increase?"

Aubrey: Oh, is it like three-quarters of a pound or some shit?

Michael: No, it's basically during the first nine months of the pandemic-

Aubrey: Yeah.

Michael: -Normal weight kids gained 3 pounds and fat kids gained 6 pounds.

Aubrey: Okay.

Michael: Okay. I mean, is that noteworthy? Fine. But also, do I really give a shit about three extra pounds? Also, kids are supposed to be gaining weight because they're growing, and we all fucking gained weight in the pandemic. Surely if there's one time where everyone could just gain some weight and everyone else could shut the fuck up about it, it's the pandemic.

Aubrey: Also, no one could shut up about it.

Michael: Absolutely. Nobody could shut up about it.

Aubrey: But they weigh three more pounds. I'm like, "But they're alive."

Michael: So, then we have a couple of paragraphs about health stuff. It's like type two diabetes, blah, blah. I'm not going to read this stuff because we've all read these paragraphs a million times. In the section about the health effects of obesity, it says, "In addition to physical and metabolic consequences, obesity in childhood and adolescence is associated with poor psychological and emotional health, increased stress, depressive symptoms, and low self-esteem."

Aubrey: Yeah.

Michael: It's like, "You think?" [laughs]

Aubrey: "I can't imagine that any of the rhetoric that we're advancing in this document would contribute to that. Nothing to see here."

Michael: These are not health consequences of fatness. It drives me nuts when public health agencies conflate the health impacts of obesity and the health impact of people being shitty to fat people.

Aubrey: Yeah. Rhetorically, it does two things, right? One is that it continues this line of thinking that has been very prevalent, certainly in the US for the last 20 years, which is, "Everything that happens as a result of someone being fat is a direct result of the fat cells in their body." "People get fat and then they get depressed. There's no way to know why. It just happens." The other thing that it does implicitly that is absolutely fucking maddening to me, is that it is implicitly blaming fat people for the behavior of garbage people.

Michael: Exactly, yes. We then get to the section that you've been waiting for, Aubrey, where they talk about the use of BMI as a screening and diagnosis tool.

Aubrey: No.

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

Aubrey: Oh, my God, Michael.

Michael: in the guidelines. It says, "The growth charts are based on enhanced data from the 1960s through the early 1990s." So, basically, the definition of obesity is not that you're fatter than 95% of kids. It's that you're fatter than 95% of kids in the 1960s.

Aubrey: Yeah, totally, totally, totally. [laughs].

Michael: 40 years ago. Also, as you mentioned-- [crosstalk] those percentile rankings, they're just descriptive. They're not based on health risks.

Aubrey: Yeah. Listen, like every adult, I think that kids today should be held to the exact standard of my body and bodies like mine when were kids.

Michael: This is another transition phase thing in this document is that there are so many studies now documenting the limitations of BMI. They have to acknowledge this stuff. The whole point of this document is to bring together all of the evidence. This is the section where they essentially defend the use of the BMI. [Aubrey laughs] There's this weird circular logic here where they say, "Despite its limitations, BMI is currently the most appropriate clinical tool to screen for excess adiposity and make the clinical diagnosis of overweight or obesity."

Right. It's like, "Say what you want about the BMI. It's not perfect, but it's the best tool we have for diagnosing fat and very fat kids." But the definition of overweight and obesity is based on BMI. The definition of overweight is above the 85th percentile in the BMI. The definition of obesity is above the 95th percentile on the BMI. So, what they're saying here is the BMI is very good at determining their BMI. [laughs]

Aubrey: Yeah, yeah.

Michael: Which, yeah, it sure is.

Aubrey: "This year, I'm doing my own employee evaluation, and my evaluation of me, as defined by me is, I'm great."

Michael: But also, listen to this show.

Aubrey: Uh-oh, okay.

Michael: They conclude, "The BMI must be communicated to the patient and family as it guides the next steps for comprehensive evaluation and treatment of obesity and related comorbidities." As part of this, they have a flowchart for doctors. If they have these symptoms, run this test. There's literally no destination at the end of the flowchart that is, "Don't bring up their weight." [Aubrey laughs] Every single person who is fat should get a lecture about their weight. That is where it's leading them.

Aubrey: One of the most common stigmatizing experiences that fat people report in the doctor's office is being lectured about weight loss before, or even in the absence of talking about whatever symptoms or concerns brought them in to begin with. And that has been and continues to be the prevailing instruction given to medical students. And it's now baked into our insurance system such that if doctors want to be paid for their work, they are required to report not only the patient's BMI, but also that they were counseled on weight loss. That is required in order to get paid for your work as a healthcare provider. That is bananas to me. That medical institutions right now today are deciding to ignore or refusing to engage with this thing that is very popularly discussed as being very terrible and a reason to avoid care.

Michael: It all clicked into place for me at the end of this section where they give advice to doctors on how to bring this up with patients. Because there's all this research now on weight stigma and all this research about how doctors are one of the primary sources of weight stigma. How are they going to reconcile this? They have three rules for doctors for facilitating a non-stigmatizing conversation about weight with kids. The first tip is, ask permission to discuss the patient's BMI and/or weight. Number two, use words that are perceived as neutral by parents, adolescents, and children.

Aubrey: Oh, God.

Michael: Avoid labeling by using person first language.

Aubrey: No.

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

Aubrey: Jesus Christ.

Michael: Third rule before you go into liftoff. Third rule--

Aubrey: Goddammit.

Michael: Recognize that discussing BMI with children, adolescents, and families, even when using non-stigmatizing language and preferred terms, can elicit strong emotional responses, including sadness or anger. Acknowledging and validating those responses while keeping the focus on the child's health can help to strengthen the relationship between the pediatrician or other primary healthcare provider and patient and family to support ongoing care.

Aubrey: Oh, my God. So, listen, listen, listen.

Michael: Thoughts?

Aubrey: Oh, Jesus. [Michael laughs] There's a great stand-up, Johan Miranda. He's unbelievably funny, who has a bit that's like, "Yeah, I don't feel better if you call me a fucker of mothers."

[laughter]

Aubrey: It's brought to bear here. This weird fancy footwork of, "We're just going to move around some words," feels really strange to me. As any fat person who has tried to participate in any kind of conversations about healthcare on Twitter knows, if you refer to yourself as a fat person, there's a decent chance that some thin healthcare provider is going to pop up out of a trashcan and be like, "Actually, I think you mean a person with overweight."

Michael: Yeah, God.

Aubrey: And then, we talk over fat people who are self-identifying, which is killing maddening. Documents like this put that even further out into the world that's like, "We've decided for you what language affirms you."

Michael: It reminds me a lot of in the 1990s when the term "downsizing," people started to understand what you actually mean with that term. So, there was a move to use the term "right sizing" when you're doing a bunch of layoffs. "Oh, we're right sizing the company." It's this idea that people will be less mad about being fired if you phrase it the right way. And like, no, being fired sucks. You can call it anything you want. At the end of the day, that person is packing up their desk and going home. And it's the same thing here. It's like there is no way to bring this up with somebody that is going to make them not understand what you're actually telling them.

It's like a caricature of the arrogance of doctors saying, "Oh, well, in every interaction, I have to bring up this patient's BMI even if that person is a child, even if they're not here for anything regarding weight at all. But I'm bringing it up in a way that's non-stigmatizing." But the stigmatizing part is that you're bringing it up in every interaction.

Aubrey: I'm trying to imagine someone punching me in the face and then being like, "Look, you must be feeling a lot of things right now. It's got to be really hard for you." That's essentially what we're talking about here, is causing material harm to fat kids and then being like, "Ah, ha. But I used the right language," so pat on the back.

Michael: There's nothing in this document other than those kinds of two perfunctory bloodless sentences of, "Doctors or a source for stigma." There's nothing about hey, really sit down and think, does this patient need a lecture from me about eating five fruits and fucking vegetables right now if they came in with something completely else? Do I maybe want to ask about other interactions this patient has had with the healthcare system? Have they tried losing weight before? What are their behaviors? Maybe don't even bring up weight at all. Just ask them, "Is there anything else you want to talk to me about today? Okay, bye."

Aubrey: I was, I think, 36 years old the first time a doctor asked me if I had an eating disorder. There's a place where there is a known cluster of diagnoses, and bringing up this conversation will make those actively worse, is around eating disorders and body dysmorphia, which are hyperactive, particularly in adolescence. Like, what happens if that kid is already depressed?

Michael: Well, this brings us to the next section of the document.

Aubrey: Tell me.

Michael: This is a huge section. This is probably a third of the document, is Risk Factors for Child and Adolescent Overweight and Obesity. This walks through everything we know about the factors that are associated with higher weight among kids. Just like the Health Equity section. This is pretty good. It goes over-- it talks about socioeconomic disparities. It talks about racial disparities. It has a whole thing about policy factors. There's environmental smoke exposure, sleep duration. There's a whole thing on adverse childhood experiences, like fat people are more likely to have been abused when they were kids, which is a whole fucking can of worms that we talked about.

Aubrey: Yeah, yeah, yeah, yeah.

Michael: There's genetic factors. Epigenetics. Autism is associated with higher weights. ADHD is associated with that. They have a whole section on medications.

Aubrey: It's almost as if fat people are not just fat bodies walking around, but people with lives and health concerns and other things going on.

Michael: But then, the way I think that they are reconciling all of this information coming out about social determinants of health and all of the complexities about why people are fat is this document explicitly says that you should incorporate all of that context into your recommendations to people for how to lose weight.

Aubrey: What?

Michael: There is literally, at no point in this document does it ever say, "Tell people that it's fine not to be trying to lose weight."

Aubrey: Like, "Focus on housing security. You don't need to worry about your weight right now. Get a place to live."

Michael: According to this document, if a patient comes to you and says, "I'm 16 years old. I grew up in foster care. I experienced horrific abuse. I'm now on medication for my depression and since I started taking it, I gained 25 pounds." There is nothing in this document to just say, "That's fine. Focus on being happy right now."

Aubrey: Yeah.

Michael: No. According to this document, if they are above the 85th percentile on the BMI, you should tell them to lose weight.

Aubrey: And it's all punitive. It's not goal-oriented behavior. It's not, "If we follow these steps, then we know we produce these outcomes." It's, "If we follow these steps, maybe something happens? But we don't really have evidence that anything does. The evidence we do have is that people feel worse and avoid healthcare." The best-case scenario is that it's throwing stuff at the wall and seeing what sticks. The worst-case scenario is that it's projecting adult anxieties onto children. And not only that but onto fat kids.

I want everybody to think about every media depiction you've ever seen about a fat kid. Is it about how well loved they are and how everyone's treating them great? I want you to think about the fat kids that you have known in your life. Were they living the life of Riley? What's going on? It's just astonishing to me that the answer to all of this is, like, "You see those kids over there? They don't feel bad enough."

Michael: Also, it doesn't give any specific advice to doctors on what they can actually offer in like a seven-minute appointment. In the one place that this document actually talks about a behavioral assessment, like ask the kid what their diet and exercise habits are, it says "Dietary intake can be addressed by assessing the following: Eating outside the home, consumption of sweet drinks, portion size, meal habits, snack habits, fruit, and vegetable consumption." What actual advice does this lead you to give? "Oh, try not to drink so much soda." But you're going to give them this, like, 101 Dr. Oz-level advice? "Oh, try to eat smaller portions." Wow, thanks.

Aubrey: "Tell those fat toddlers to start taking the stairs."

Michael: This is the part that I've been saving, Aubrey, because you're going to explode.

Aubrey: Oh, no, Michael.

Michael: It also says that you should try to assess whether the kids are experiencing weight stigma.

Aubrey: What?

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

Aubrey: Jesus, God.

Michael: And I typed in, "weight stigma, fatness, obesity," all the various search terms. This "resource" has published three articles about weight-based bullying in the last decade.

Aubrey: What?

Michael: The first of them has a list of bullet points for adults in case they see weight-based bullying, whatever. The list begins, how can I encourage a healthy body image among adolescents? One, promote healthy eating and exercise habits.

Aubrey: Shut the fuck up, Michael.

Michael: [laughs] Fuck off. The number one advice from this article is teach kids how to lose weight if they're being bullied for being fat? Fuck you.

Aubrey: Are you being bullied? Step one, have you tried WeightWatchers?

Michael: All of the other articles on this resource are for adults. It's like, "If you see kids bullying other kids, step in and try to stop it." Which, great, but that's not a resource for kids. This is not a meaningful resource.

Aubrey: For most professional guidance, including interventions around bullying, there are more guidelines than just, "Tell them to knock it off."

Michael: This is why I say that like on-- I don’t really but on some level, I sympathize with the plight that healthcare providers are in, because much of the advice here is, "We'll link people up to resources. Not everything is within your jurisdiction. You don't have the power to fix these much larger problems like poverty, like bullying, etc. Link people up to resources." But there are no resources.

Aubrey: This isn't about setting up a good patient experience for fat kids. It isn't even about setting up a good professional experience for pediatricians. It is about telling fat kids that they are fat and doing everything we can to make them thin. The end. Even if those things don't work, even if they've been disproven, even if other people are still being jerks to that kid, doesn't matter. The thing that matters is making that fat kid thin.

Michael: This is what's so frustrating, is all of the recommendations in this document pretend that we exist in some kind of perfect world. There's no meaningful engagement with the question of, "What can we do for fat kids in the world that we have?" If a kid is depressed, if they're being bullied, I don't have the power to change the way that they're being treated at school. What I think every single doctor should actually be doing is trying to tell kids that they shouldn't go on fucking diets. "Hey, don't go on a diet. It's fine to look the way that you look. If you go on a diet, you're going to end up on some dumb fucking fat diet. You're going to gain all the weight back. You're going to feel bad." Doctors don't have the ability to help kids meaningfully lose weight, but they do have the ability to use their credibility to be like, "Whatever you find on the internet is bullshit, kiddo."

Aubrey: The times that I have most appreciated my healthcare providers are when they invite me into nuance and to understanding what's actually happening here. There are a lot of people who are going to tell you that they know how to manipulate your body weight, and they know how to make you smaller. They don't. The science tells us pretty consistently that an overwhelming majority of efforts to lose weight-- whatever you call them, whether it's a diet or something else, an overwhelming majority of those lead you right back to the size you were before or maybe a little bit bigger. Nobody knows how to do this. So, your job is to eat foods that are nourishing to you. Your job is to find activity that you like. Your job is to build strong relationships and to expect people treat you with respect. And that's where we leave it.

God, Michael, I'm just realizing we haven't even got into the drugs part of this.

Michael: [laughs] We're not even into the bad shit.

Aubrey: Okay. Are you ready to hear about treatment options?

Aubrey: Oh, God. Am I?

Michael: You are. You love it. This is the good part. This is the solutions.

Aubrey: Okay, let's do it.

Michael: It's actually less bad. Well-- I'm just going to get bad but it's not that bad at first.

Aubrey: Okay. All right.

Michael: So, the title for this is Intensive Health Behavior and Lifestyle Treatment. I-H-B-L-T, which I will not be calling it that because that's ridiculous.

Aubrey: I do like that it has B-L-T in it.

[laughter]

Aubrey: I'm a pro-B-L-T person. That sounds tasty.

Michael: It's an intensive health B-L-T.

Aubrey: Oh, no, wait, no. Now, it's all bad.

[laughter]

Michael: Every municipal hospital has a program like this. They're often run by dietitians or obesity clinicians or something, and they're basically like nutrition classes. For kids, they often include some sports or physical activity component. I looked up one of them. There's a program in Durham, North Carolina, called Bull City Fit, where they worked with the Parks Department to get some like, community center and dietitians and doctors would just kind of park there one hour every day, six days a week. Then, families could come in kind of whenever suited them. They wanted to create something that was a little bit flexible. The goal was for everybody to attend one day a week. And then, you'd go there and there'd be special programming where a nutritionist talks about how to cook healthy meals or you practice different sports to try to figure out one that you like, etc. This is the first stage of obesity. Treatment is referring these kids to one of the BLTs.

Aubrey: And these are the-- [laughs] Goddammit.

Michael: I'm going to do it all episode, now.

Aubrey: I had a delayed response to that. [laughs]

Michael: I'm keeping it.

Aubrey: These are the interventions that start as young as two. Yes?

Michael: Yes. But there's kind of a weird lack of specificity in these because what would one of these programs even look like for a three-year-old? Then, you're really talking about parental intervention.

Aubrey: Well, it doesn't seem to interrogate its own central assumption, which is that individual behaviors determine body size. The core assumption here is just like, "We got to make these fat kids thin." Not, "We've got to assess the health of these fat kids and see if we can support it more fully." On top of that, their strategies to make them thin are not exactly shown to have a commanding, majority, decisive impact on someone's individual weight or their individual health.

Michael: Well, this is where we get to the huge caveats section of the treatments that "work," but they only work under very specific conditions. It says there's all these success factors of these lifestyle treatment programs. The first element is duration. Basically, any lifestyle intervention for kids that's less than three months is not going to work. A million of these have been tried and they essentially all fail. That's most of these programs. They run for like six weeks or they run for a month or whatever.

Aubrey: Less effective than fat camp.

Michael: Exactly. The programs also have to be super intensive. Kids have to be in these things for at least 1 hour a week or they don't really have an effect. Also, they have to be face-to-face. They also have to be comprehensive, i.e., the parents have to be involved. So, it can't just be like the kid trundles over after school and plays some basketball and then goes home. No. The parents have to be there. Oftentimes, there's participatory elements where the parents have to be part of the cooking classes or play sports with the kids or whatever.

Aubrey: Can I ask you a clarifying question?

Michael: Yes.

Aubrey: If all of those elements are in place, if the stars are aligned and these programs work as well as they possibly can, what are the weight loss rates and what are the outcomes that they're measuring?

Michael: I love this because this actually isn't included in the guidelines, but in the technical reports, if you dive into the details, you can find it. It says, "As described in the Health, Behavior, and Lifestyle Treatment section, those who do experience BMI improvement will likely note a modest improvement of 1% to 3% BMI percentile decline."

Aubrey: Great, good, good, good, good, good.

Michael: We're back in fucking percentile declines and all this nonsense, basically like 5 to 10 pounds.

Aubrey: That is borderline normal weight fluctuation territory.

Michael: These programs, the biggest problem with these programs is that people do not want to stick with them. The attrition rates in these programs are-- for many of them, they're over 65%. In this Durham program, they started with 171 kids and ended up with 44. Those are the only kids that this actually had an effect on. That's 26% of the beginning kids. Some of the other problem with these is they're tiny. This is a program, it's a two-year program that reaches at most, if they had a 100% attendance rate the entire time, they would reach 171 kids.

Aubrey: Good Lord.

Michael: This report, these guidelines start out by saying that 14.4 million children are too fat.

Aubrey: All right, well, listen, Mike. You got to think about this at scale. If we do this with every fat kid in the country, we'd have like 3 million kids who all weighed 3 to 5 pounds less than they do now. [Michael laughs] Come on, man.

Michael: Think of the kids who lost 7 pounds.

Aubrey: [laughs] Think about the kids who were temporarily slightly thinner and then kept growing and their bodies changed anyway. Come on, man.

Michael: Also, I feel like a really underrated element of why these programs won't work is in this survey where they surveyed hospitals about their childhood obesity interventions, 84% of them lost money.

Aubrey: The cost effectiveness here is beyond reproach is what I'm hearing.

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

Then, it just says, "Social determinants of health, competing health issues for children or family members, and mismatched expectations between the family who may expect significant weight loss, and pediatricians or other pediatric healthcare providers." So, it's like, "Oh, is that it? Oh, it's not big enough, and people can't get there. It happens during the workday, and people don't want to go to them and they're poor, and there's other things going on in their lives." [laughs]

Aubrey: I like that one of their bullet points is social determinants of health, which is medical shorthand for, "All of society and how the world works." It's just like, "The entire social and political and economic context." Anyway.

Michael: Yeah, look, these are perfect. Unfortunately, minorities do exist. Doesn't have to be a problem.

Aubrey: But also, almost all of the research into fatness and fat people, and particularly fat kids, at least as much as I have seen, proposes that there will be benefits to these interventions and then measures the benefits and comes up with a narrative that reinforces the benefits. They're not actually screening for or looking for the harms of these interventions.

Michael: Yeah, yeah, yeah, yeah.

Aubrey: So, I would also like to see what's the difference across the board in physical health outcomes and in mental health outcomes between kids who get few to no interventions about their weight and kids who get lots and lots, and lots of interventions about their weight.

Michael: This actually leads to the next section of the paper, which is essentially the only place in this entire 136-page document that they mention eating disorders. So, when they're talking about these interventions that "work," they sort of have to acknowledge that there's been years of criticism of this approach from eating disorder practitioners and actual fat people.

Aubrey: Yeah.

Michael: So, it says "In the field of pediatrics--" actually, let me send this to you.

Aubrey: Mm. Send me a quote.

Michael: Yeah, let me send you this little quote.

Aubrey: "In the field of pediatric nutrition in the treatment of both obesity and eating disorders, concerns have been raised as to whether diagnosis and treatment of obesity may inadvertently place excess attention on eating habits, body shape, and body size, and lead to disordered eating patterns as children grow into adulthood. The literature refutes this relationship, however."

Michael: Dieting, 60% of the time, it works every time.

Aubrey: "Cardell et al., referred to multiple studies that have demonstrated that although obesity and self-guided dieting consistently place children at high risk for weight fluctuation and disordered eating patterns, participation in structured, supervised weight management programs decreases current and future eating disorder symptoms." Here's what I would like to say about this quote, Mike.

Michael: Ooh, give me your thoughts.

Aubrey: I myself was a product of a structured, supervised weight management program, and I myself ended up with an eating disorder. [laughs]

Michael: Oh, wait, so you were one of these intensive lifestyle BLT thingies?

Aubrey: I was on like early to mid-90s version of them. So, things may have changed or they may have not, but my parents were supposed to come with me and they had a parent's class and I had a kid's class, and da, da, da. It was one of the earliest and strongest memories that I have of weight stigma. Absolutely.

Michael: Oh, really?

Aubrey: Yes. You just go to this after-school program at somebody else's school. You're there with a bunch of other fat kids who know that they're there because they are viewed as having remedial bodies. You feel like you're behind at school. You're having to go to extra school because you're not good enough the way you are. The lectures that we got were all about behaviors that didn't ring true to me, that I didn't recognize. Essentially, what they were describing was the dangers of binge eating or whatever. I was like, "I don't do that. Is that how you see me?"

It felt like a real crash course in, "I have seen your body and therefore, I have determined your behaviors are this." And it just didn't mirror my experience in any real way. I just remember feeling that's a place where you go if you mess up. They tried to make it fun and they tried to make it uplifting, and they tried to talk about self-esteem, and that message came through loud and clear regardless.

Michael: Well, this is something I forgot to mention earlier. When it's talking about these lifestyle programs where it's saying, "It has to be comprehensive and the parents need to be involved, etc., etc.", it says, "Children learn goal setting, body acceptance, and strategies to manage bullying." How would you teach them body acceptance in a class explicitly designed to teach them how to change their bodies?

Aubrey: Because of our own conflictedness as adults on this issue, we are sending profoundly conflicted and conflicting direction to kids on this issue. We are training them to have conflicted relationships with their own bodies, with the foods that they eat, sometimes with their family members, sometimes with their healthcare providers. This is setting the tone on so many fronts, and it's setting a bad tone.

Michael: Kids understand this. Kids are kind of dumb and also very smart in a lot of ways. Kids get this shit. They understand that it's completely contradictory and they can't give you what you want.

Aubrey: You're telling them to stay in their seat and go to the library at the same time.

Michael: To return to this brick that you just read, I've taken out some of the weird medical language and kind of boiled it down. It says, "Multiple studies have demonstrated that although self-guided dieting consistently places children at high risk for disordered eating patterns, participation in structured weight management program decreases eating disorder symptoms." The basic idea is that, "Look, are there diets that increase eating disorder behavior? Of course, there are. But what we're talking about is these intensive lifestyle programs and they don't increase the risk."

But then, they've just also said that these structured programs are not available for like 99.7% of children. What are we even doing here? It's like you're telling people not to do the thing that everyone would do. Go home and fucking google, right? Look for a diet. You're like, "Oh, don't worry about it. They're not going to do that." They're going to do this thing that isn't available to them. The whole document is just riddled with this weird head-in-the-sand logic.

Aubrey: There is a thing that's happening right now where diets are calling themselves not a diet. "We're actually therapy. We're actually a structured weight management program. We're actually a blah blah, blah." That means that there is now a sorting the wheat from the chaff that people are trying to do. Particularly, people from within the diet and weight loss industries are being like, "Those are diets and diets are crash diets, and they're fad diets, and they're bad, and you can't trust them. But you can trust our weight management program," or what have you. It feels like this is leaning into that too. To me, that is the same kind of rhetoric that is being deployed by like Noom.

Michael: We have two sections of this document left. We're finally reaching the problematic parts.

Aubrey: Oh, we haven't gotten there yet, huh? Good.

Michael: This is the part that the internet got really mad about. This is almost like the concept of this show at this point. I'm like, "I need to read this document and make you get mad about something else than that thing you were already mad about."

[laughter]

Michael: Basically, the entire framework scope of this document just sucks. But now, we get to the other treatments that are available. As well as the intensive BLTs, which are not actually available to most kids, the next section is Use of Pharmacotherapy. And I am going to send you a brick of text.

Aubrey: Love to brick. I'll let you know when it comes through.

Michael: No, I haven't texted it yet because I need to-- I have to keep editing the fucking text of this to make it readable because it's so unreadably gibberish to actually try to say it out loud.

Aubrey: It's so goofy. And then also, footnotes in there. And then also, it's just like-- yeah, all over the place, man.

Michael: This is gibberishy, but we're going to decipher it together.

Aubrey: "Although intensive--" Ooh.

Michael: BLTs. Just say BLTs.

Aubrey: BLTs. "Although intensive health behavior and lifestyle treatment has the largest body of evidence meeting the evidence reviews high-quality evidence for effectiveness criteria, it is important to consider the use of pharmacotherapy for children and adolescents who require an additional treatment option to manage their obesity."

Michael: For kids, 8 through 11, they can take weight loss drugs if they're also doing some other intervention. For kids older than 12, they can just like straight up take weight loss drugs.

Aubrey: Yeah. Boy, oh, boy. Age eight, man.

Michael: I don't love it.

Aubrey: If you know any kids that are ages 8 to 11, I just want you to think about that kid for a minute, because this sucks.

Michael: It sucks.

Aubrey: I am a person who was put on a weight loss drug when I was like 14 or 15 and that drug was fen-phen. I did it because a doctor told me it was a safe thing to do. That drug was later pulled from the shelves because it stopped people's hearts. The drugs that are emerging now and this rapidly evolving field that they're talking about so breathlessly here, I'm assuming, you tell me if I'm wrong, doesn't have a great body of research into the effects on eight-year-olds, and certainly can't tell you the long-term effects on eight-year-olds.

Michael: I think you're being a little unfair. I think just because every previous weight loss drug became a massive scandal, [Aubrey laughs] doesn't mean that these weight loss drugs will be.

Aubrey: You're actually revealing your own bias. [laughs]

Michael: You're actually skinny shaming right now?

Aubrey: Okay. Good.

Michael: This is what you're doing? I feel attacked.

Aubrey: Listen, this is definitely like cry-punch-barf territory for me, where it is so bleak to say that the most important thing to us about an eight-year-old is that they become thin--

Michael: Well, then what's so weird about this section of the document is after they give this kind of overall recommendation, they then run through the weight loss drugs that are available and the evidence on what they do in adolescence. The first one they recommend is metformin, which is a diabetes drug. It basically says there's a couple of small studies in teens, but they're more or less inconclusive. One study found that kids lost 1 BMI point, which is like 5 pounds.

Aubrey: And the side effects on metformin are profound and weeks or months-long, sort of gastrointestinal effects. So, some of that weight loss might just be you are so nauseous that you can't eat.

Michael: Yeah, it says 20% of kids who took it had gastrointestinal symptoms. It also said that after you lose this one point of BMI, after six months, you keep taking it and don't get any more weight loss.

Aubrey: Great.

Michael: They also list phentermine, which is half off fen-phen, as we talked about in our Fen–Phen episode. 

Aubrey: Yeah, phentermine is still around. It's still on the market. It's wild to see that in pediatric recommendations. Just existentially wild.

Michael: It says kind of casually that it's approved for like three months at a time for kids 16 and older. It also mentions this thing called topiramate. It says, "The major adverse effect is cognitive slowing, which can interfere with academic concentration or other activities of daily living."

Aubrey: It's going to slow down your brain function when you're in grade school. But don't worry.

Michael: These are literally people in school. Like, by definition, these children are in school. Why would we be considering prescribing a drug that hampers their academic performance? I don't know why they're even telling people that these are options. A drug that's so addictive that you can only take it for three months at a time? And another drug that makes you incapable of doing school work?

Aubrey: "Your kid might get a lot worse at school, but they are going to be working the shit out of that Gap Kids ensemble. They are going to be so thin."

Michael: The only one that on the surface seems like an actual option and there's going to be so much goddamn discourse about in the next five years is semaglutide, which is sold as Wegovy by Novo Nordisk. It appears that it was the same week that these guidelines came out, there was like the one study on semaglutide in adolescence. This is a weekly injection. It was a study of, I think, 134 kids and they lost 16% of their BMI on average. There isn't a whole lot to debunk here simply because there's only this one study that's been published and it's a pretty small number of people. They also did this pretty intense screening. They screened out everybody that had any disability, any mental health stuff. They wanted to get it down to " normal kids." And then, they did a 12-week lifestyle thing before they started on the drug.

What's really weird is this one study says that they followed up with the kids for an additional seven weeks after they finished the study to see if they had any other side effects. But then, it didn't track whether they started regaining the weight. It's very odd to me. The word "regain" only appears once in the entire AAP guidelines, 136 pages. I mean, there's also fad diets that would also make you lose 15% of your body weight. Every diet works in the short term. The question is, is this sustainable? The guidelines recommend that you shouldn't be on it for more than two years. If people are losing 16% of their body weight and then gaining back 30% of it, then what are we doing here? It's just really weird to me that there seems to be no actual interest in answering this question when people losing weight in the short term is not hard.

Aubrey: And if we return to fen-phen as my forever example of a weight loss drug, fen-phen got a bunch of breathless press coverage based on not very much research. Similarly, fen-phen was rushed to market and we didn't really learn about the health effects of fen-phen until people started dying. I'm not saying that these are drugs that are going to kill people, but I am saying one short-term study of a small group of adolescents does not tell us that this is safe or effective for most kids.

Michael: So, can I read you something? You have to guess who wrote it?

Aubrey: Oh, no.

Michael: You're actually going to like this part.

Aubrey: Okay. [laughs]

Michael: It says, "The use of weight loss medications in obesity treatment has a complicated history. Many medications used to treat obesity were eventually withdrawn from the market or their use restricted after documentation of dangerous side effects. Particular care must be taken when the use of weight loss medications is considered for children because the long-term effects of these substances on growth and development have not been studied.

Pharmacotherapy alone has not proven to be an effective obesity treatment. Medication used as part of a structured lifestyle modification produces an average weight loss of 5% to 10%, which typically plateaus at four to six months of therapy, after which weight regain may occur. Weight regain is common if the drug is withdrawn." Do you know who said that?

Aubrey: I don't, but I'm guessing it's dated like 1999 or something. Like, it's going to be old as the hills. What? Who is it?

Michael: That is the American Academy of Pediatrics in 2007.

Aubrey: Great. Good, good.

Michael: That's their last set of guidelines.

Aubrey: Good job.

Michael: It's actually fascinating to me that they were so kind of sober and careful in their last set of guidelines and in this one, nothing has really changed. But they're much less conservative with this stuff. 15 years ago, they were like, "Uh, every previous attempt has gone pretty badly. It seems like these only really work if they're coupled with a much more comprehensive approach that is pretty rare in the US healthcare system. So, let's all just be kind of suspicious of these until we have really good data about how they work." And now they're just, "8, 11, 12, sure."

Aubrey: Yeah. I mean, this feels very much like-- Sure, man. Let's go back to Lord of the Rings. This feels very much like, "I know everybody else who gets this ring has things go pretty sideways."

[laughter]

Michael: This is the Boromir strategy?

[laughter]

Aubrey: "But I feel like it's going to work out for me."

Michael: Also, this document, again, in this head-in-the-sandness that runs throughout it, it says, "The current 2023 guidelines say no current evidence supports weight loss medication use as monotherapy. Pediatricians who prescribe weight loss medication to children should provide or refer to intensive behavioral interventions for patients and families as an adjunct to medication therapy. So, okay, great. Don't just do the weight loss pills. Also, do these intensive BLTs, whatever. But we know the kids aren't going to get those because those aren't really meaningfully available, and nobody sticks with those. 75% of the kids drop out. So, you know that in the real world, people are just going to get the weight loss drugs. We're all on the same page about that, right? [laughs]

Aubrey: It's sort of staggering to me that you could just ignore the entire social context and the entire context of your own patients' lives.

Michael: Yes, but what if instead of saying a weight loss drug child, we say a child with weight loss drugs?

Aubrey: No, Michael, that's not helping. [Michael laughs] Oh, God, it is so fucking bleak.

Michael: Okay, speaking of bleak, this is the part--

Aubrey: This is the part.

Michael: --That neither one of us have wanted to get to. The final section is about bariatric surgery.

Aubrey: Are you sending me a brick?

Michael: No, uh, this is too bleak. We've done two entire bonus episodes on Patreon about how neither one of us wants to do an episode about this, because it's just really complicated and people have strong feelings and it's just a whole fucking can of worms.

Aubrey: And it's sad.

Michael: Yeah, it's really sad.

Aubrey: The throughline for almost all the stories that I have heard about weight loss surgery is like a deep and profound sadness. That even people for whom it is a successful, report this incredible sadness at knowing now how differently people treat them now that they're thin. That's like the best-case scenario.

Michael: These guidelines recommend bariatric surgery for kids whose BMI is over 35, which I looked up for a 5'8" kid. I don't know if that's the size of a child.

Aubrey: That's not.

Michael: 230 pounds, if you're 5'8". I'm still not 5'8" now and I'm 40.

Aubrey: You're still a child. Congratulations.

Michael: In some ways. People above a BMI of 35 with comorbidity, so you have diabetes or you have hypertension or sleep apnea or something else, those people are eligible for referral to bariatric surgery. Anyone with a BMI over 40, that would be 265 pounds, if you're 5'8", those people don't have to have comorbid conditions. Just every single one of them can be referred to bariatric surgery. The AAP kind of tries to have it both ways here where they explicitly say like, "We're not saying these people should get bariatric surgery, we're just saying it's okay to refer them to a bariatric surgery provider." I mean, you know. It's like, "I'm not saying you should get glasses, but here's the address of an optometrist." That's like, "Well--"

Aubrey: "I'm not saying they have to. I'm just saying it's an option that they should consider."

Michael: This was recommended for kids 12 and up. The evidence on this is also kind of surprisingly thin, honestly, for how long bariatric surgeries have been around. One thing that's interesting about this is bariatric surgeries have been prescribed to children for quite a while.

Aubrey: Yeah. I did a little research on this for the book and found a case study of a bariatric surgery patient who was three.

Michael: Wait, really?

Aubrey: Yes.

Michael: Ohhh.

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

Michael: There's two long-term studies of bariatric surgery among adolescents. The first is in Cincinnati on 58 kids who received the surgery. The kids lost a huge percentage of their body weight and they had pretty significant improvements in their diabetes, their hypertension, like all of these kinds of metabolic health markers. One of the articles about this cohort also said though, "Despite this impressive weight reduction and the net improvement in cardiometabolic variables, 63% of participants remained severely obese at long-term follow-up. Furthermore, more than half of patients had iron deficiency anemia at five years, and 78% showed vitamin D deficiency." 

The other cohort is a cohort in Sweden of kids who got bariatric surgeries. Again, very significant weight loss. But then, that one also showed pretty significant rates of vitamin deficiencies, surgical complications, like various follow-ups they have to do. It said, "Adolescents who undergo bariatric surgery must be followed up very carefully by multidisciplinary teams, including psychologists who implement cognitive behavioral therapy. Even after surgery, such patients can continue to maintain a BMI greater than 30." In other words, they are still obese and often show symptoms of depression.

Aubrey: So, they're still fat, but on the upside, now they're also depressed.

Michael: I really struggle with this one and this is what we've talked about on our Patreon episode so many times is the kids who got these surgeries had an average BMI of 60. I looked that up and for a 5'8" person, that's 400 pounds. If you are a 16-year-old girl and you weigh 400 pounds, you are experiencing a level of stigma from the world that I think that I physically cannot fathom. If you look around the world and you decide, "I can't do this anymore and I want to get the surgery and it's worth the risks for me," I am not going to tell you that you made the wrong decision. This is why it's so difficult for me to say anything definitive about these things because I think people who make the decision to do this, I don't want to make them feel bad. If a kid decides to do this, all I want for that kid is to feel loved and happy for the rest of their lives.

Aubrey: Yeah. I am not ever here to tell someone who is fatter than I have ever been how to live their life and it's not how I want to show up in the world. So, I'm like right there with you on that. Also, I think it's worth talking about the really intense side effects of this. I think we deserve research that tangles with what are the negative outcomes of this, not just in terms of your physical health, but also in terms of your mental health. I think we deserve more and better and deeper research. If this is the only path out that fat people see and that very fat people see, we have work to do. And at the very least, they deserve really solid, reliable information about a huge decision to make.

Michael: The cohorts that we have now, the average age was 17. These are kids that are pretty close to adulthood and much more capable of understanding the risks of these surgeries, which are considerable. In the Swedish cohort, 26% of the kids had moderate or severe depression, 32% had moderate or severe anxiety, 16% had suicidal ideation. Some of that is because kids who get bariatric surgery oftentimes have higher rates of mental health issues to begin with. But we've also had a number of other studies that have showed higher rates of depression, anxiety, suicidality after bariatric surgery. It's becoming one of the kind of known health risks, and roughly 20% of people gain the weight back within seven years. Bariatric surgery appears to decrease the risk of some cancers, but it increases the risks of others. There's this weird increase in the risk of alcoholism after bariatric surgery because your stomach absorbs alcohol more efficiently and so you just get a bigger spike.

The long-term health effects of bariatric surgery are not very well studied. There's very few studies that look longer than 10 years out, and things like nutritional deficiencies could have health effects over time. It's not a totally fair comparison because most of the risk factors of obesity take decades. People are not generally dying of heart attacks in their 20s and 30s. But then, the benefits of bariatric surgery are being sold according to 5 and 10-year data.

That Swedish study says, quite Swedishly, that adolescents who get this procedure need to have a multidisciplinary follow-up to make sure that these risks are known and managed. But we all know that is not going to happen. It doesn't even happen in Sweden. It notes in the study that only 48% of patients are actually getting the follow-ups that they need. Again, if people want to go forward with this, I'm really not here to criticize anybody's decision, but at a larger systems level, it's worth considering whether people are really going into this with a full understanding of what it means to get these surgeries.

Aubrey: It makes me feel so angry at a level that I really struggle to express. If I'm honest, I don't usually struggle to express myself. This issue makes me so angry because you're taking kids who sometimes have other health problems and sometimes don't. You are making what are often lifelong decisions about how their body is going to function. You're doing that with really thin research. You're doing this in a setting where if a doctor and your parents say, "You need to have surgery," how much agency do you really have to say no to that? It is galling to me that this is wrapped up in a document that pays lip service to weight stigma and intends to do absolutely nothing about it.

Michael: Nothing whatsoever. Yeah.

Aubrey: That doesn't really tangle meaningfully with the incidence of eating disorders for these kids. There's no looking at suicidality and long-term mental health. There's just so many angles that we haven't looked at this from because what we heard was, "We've got a way to make fat kids thin and we decided that was the most important thing to do." This is such a complete erasure of the actual life experiences and wants and needs of fat kids. It feels really telling.

Michael: Well, also, it's telling that this comes at the end of a document that is explicitly like, "We don't care about health stuff." [laughs]

Aubrey: Yes. Jesus.

Michael: [laughs] "By the way, we're not looking at all that stuff. We're only focused on the size of the children."

Aubrey: It really feels like it's veering into double-speak territory. From that perspective, as someone who has lived the life of a fat kid, albeit a while ago, it is deeply, deeply painful to think and talk about. I had a really rough time as a fat kid, and that was without the American Academy of Pediatrics telling my doctor to triple down.

Michael: My understanding of your childhood experience is that basically every single doctor who you saw should have asked you about your history and just concluded, like, "Oh, this is a little fat kid. Her body just wants to be fat. We should just let her be a happy little fat kid." It's fucking wild to me, that with all of the research we have about different forms of obesity and things that contribute and biological factors, whatever, that there is nothing in this document that is just like, "Some kids are fat."

Aubrey: This is the weird thing that would pop up in grade school. I will absolutely never forget. I had two friends, and they would just eat whole family-sized bags of chips and be like, "I can just eat whatever, and I never gain weight." There was this weird celebration amongst parents of naturally thin children, but there was absolutely never any acknowledgment that some kids might also be naturally fat.

That same effect might exist in kids with higher body weights. No, that was always about, "They don't have enough stick-to-itiveness. We haven't found the right diet. The parents aren't doing enough." That was always a problem to solve. That's a bad way to grow up as a kid.

Michael: This whole thing is so typical of this transition period where it's like, "We're now acknowledging all of the problems with the way that this kind of care has been provided for four decades now." But everything in this document is defending, "Let's do the same thing. Bring up weight at every fucking visit. Give tedious advice of don't drink sodas. Invite them to these intensive behavioral programs that don't exist. And if those don't work," because they never do, "then start them on weight loss drugs and surgery."

Aubrey: Which we don't know what that does.

Michael: And we don't know what that does. The actual paradigm shift that they completely refuse to acknowledge is just "Get rid of weight as a variable completely. Ask kids about their behaviors." It doesn't even have to be fat kids. It's like, assess, "Okay, are the parents providing decent meals?, " however, you want to define that. "Is the kid getting 30 to 60 minutes of exercise most days? If the kid is and they are fat, maybe you just have a fat kid on your hands."

The most important thing that doctors can be doing is shifting away from a weight-based paradigm and toward a health-based paradigm. I think that there are probably in existence somewhere parents and kids who could actually use some of these nutrition classes, learning to cook. I think that those people probably exist. But right now, all we're doing is just assuming that every single fat person has terrible behaviors and that all of them need to change their behaviors.

Aubrey: Look, if you are prescribing treatments that don't work for the majority of people who undergo those treatments or are inaccessible to them or what have you, if you are focusing a kid's entire relationship with their healthcare, provider on manipulating their weight, which likely won't be manipulated in the long term, what you are telling them is that nothing matters as much as how much they weigh. You're also conditioning those kids to accept really subpar behavior from people around them. You're conditioning those kids to expect to apologize for their bodies before people even know who they are.

Michael: I feel like the only thing on which we agree with the AAP is that we also think that children should be given intensive BLTs, but we mean the actual sandwich.

Aubrey: Yeah. [laughs]

Michael: Feed the kids. Give them spicy now.

[Transcript provided by SpeechDocs Podcast Transcription]