[DR. CRISTINA CASTAGNINI] Behind The Bite podcast is part of a network of podcasts that are good for the world. Check out podcasts like the Full of Shift podcast, After the First Marriage podcast and Eating Recovery Academy over at practiceofthepractice.com/network. Welcome to Behind The Bite podcast. This podcast is about the real-life struggles women face with food, body image and weight. We're here to help you inspire and create better healthier lives. Welcome. Well, hello everyone. Today, I honestly find myself sitting here just I'm unable to identify exactly what it is that I'm thinking and feeling, because I guess I'm feeling a strong mix of shock, sadness, disbelief, disappointment, and anger. I have a lot of thoughts, and it's almost to the point where I'm at a loss for words in case you can't tell. It's been for a few days now, and you may be wondering why on earth I am in this state right now, and I'm going to tell you it. A few short days ago, January 9th, to be exact I received an alert on my phone about a news article that just came out about the American Academy of Pediatrics. They came out with new guidelines for treating childhood obesity and that immediately caught my attention for several reasons. The main reason was the word obesity. To my knowledge that word obesity, it's not an illness, and it's certainly not something that needs to be treated. So I sat there wondering, why on earth are their guidelines created to treat something that I don't know to be an illness. I have to tell you, when I first started reading them, I thought they were a joke, or at least I was hoping they were, I guess, because I simply could not believe that anyone who's actually caring for and treating children and adolescents in this day and age would write this. It's long and with each and every page I read, I grew more, more angry. I seriously, I was reading this with absolute horror that these guidelines were now actually in existence. There is no way I can go into all that, these guidelines go into. I'm going to put a link in the show notes so that you guys can access it yourself. Like I said, it's very long, it's very detailed, but I'm going to give you a very brief overview of what's in there and then we're going to get into this today for our podcast. They state the BMI is the gold standard measurement of body composition, and it's to be used as a screening and diagnostic tool. Now, if any of you've ever listened to any of my podcasts where I've discussed my views on the BMI, then you know that it is not a valid measurement tool by any stretch of the imagination and not even sure why it's still even in existence. But the most shocking thing of all is that these guidelines are for children starting at the age of two and they include recommendations for medications and bariatric surgery for the first time. Yes, bariatric surgery. So, as I said, my head right now is spinning. What I really want to do is help all of you gain more of an understanding about these guidelines and have a discussion about what the potential and negative dangers are for what these guidelines really mean. There are so many scary implications about what can happen once they're implemented. As you can tell, I'm really at a loss of words. I'm struggling to get my words out. So I cannot think of a better guest to have with me here today to do just that. We have an amazing guest, Chevese Turner. For any of you who do not know who she is, she really is amazing. As CEO of the Body Equity Alliance, she leads their efforts to engage with corporate partners in advocacy and serve as advisors on public policy, education, marketing and communications related to eating disorders, weight stigma and weight discrimination and health equity. Their mission is to address this injustice in all aspects of society so individuals of all sizes can enjoy the attention, care, dignity, respect, and rights they deserve as human beings. Chevese's dedication to public health began when she ran part of a team working to ensure cancer patients had ongoing access to critical treatments. She was driven by her own struggles in recovery and founded the Binge Eating Disorder Association, BETA to address the unmet needs of people with the most prevalent eating disorder. After 10 years of pioneering work, BETA merged with the National Eating Disorders Association, NETA, in 2018 after noteworthy milestones that included working to add binge eating disorder to the Diagnostic and Statistical Manual fifth Edition, Developing National Awareness Week, addressing weight stigma and intersecting oppressions, creating industry leading educational programming and public policy work at the state and national levels. Chevese has a dedication to healthcare as a human right. This has all prepared her to help clients make important shifts in their own work. All right, Chevese, thank you so much for being here. Wow, we are going to get into this, so these new guidelines. I know we've been chatting a little before we hit record, and I think both our heads are spinning a bit but where are you at with all this? [CHEVESE TURNER] Well, first thanks for having me. Oh boy, as a person who has really undergone some medical trauma as a child, when I was dieted and put on weight loss drugs by pediatricians this has me really, I really am, I'm concerned about the children who are in a place where they are going to be offered weight lost drugs that are drugs that were developed for diabetes and bariatric surgeries, and ugh, who knows what else. Weight management is not without its risks and these products and these surgeries are not without their risks. I'm not sure that consent is actually going to be realistic in these situations. What I mean by that is that parents are going to receive certain statements that say, this does not guarantee long-term weight loss. It does not guarantee no risk of serious adverse events or even death. I think those are things that we really need to think about and parents need to think about, what are the risks, and do you really want your child be put on a medication that is going to affect hormones and brain health before they even reach 13 age years, not to mention what bariatric surgery does. I call it stomach amputation, but that's not the medical term. So yeah, I'm very concerned. [DR. CRISTINA] Just as you were talking, I'm thinking, I wonder what the message parents are going to actually get, because I was reading the guidelines and it seems like the parents are going to be getting this message almost like, if you don't do something about this, you're a bad parent. Like, I would feel that way as a parent if I got this message. I think based on what the guidelines are saying, it's like your kids can be at risk for bullying and having chronic illnesses that are going to really affect their lives in a negative way. Like they plan out all these horrendous things, which I'm thinking any person on this planet is subjected to these things. Why are they saying it's because of weight? It's really horrible that they're just pinpointing it to this one thing and then they're going to go to parents who of course love their children and go, oh my God, I would do anything to make sure they're healthy and happy. If I can prevent any negative effects in their life, of course I'm going to do this. The doctor's saying it. So yeah, what if I say no to drugs? What if I say no to bariatric surgery? Would I blame myself as a parent because I didn't follow these protocols? Like, that's horrible. [CHEVESE] I agree. I absolutely incur that parents are going to feel guilty. Just thinking about, my parents used to say to me, we just, we love you so much and we don't want you to be bullied and harassed and made fun of. My mother experienced that when she was a child and so I knew it came from a place of love, actually but really what it is, is weight bias and weight stigma. Those guidelines are actually right that fat kids experience those things. As a former fat kid, I can tell you that is very real. We don't, I mean, would we, what would we do to kids who experience other oppressions? We can't change body color. We can't change if someone expresses their gender in a certain way, that is the gender they are, we can't just change that. There was diversion therapy that was done at the time to try to change people who thought or identified as LGBTQ. That's not possible. We can change weight, but only with really terrible, difficult behaviors and drugs and surgeries that are really, really harmful. And usually the outcome is something very negative, including the risk of eating disorders, which have the highest mortality rate, second only to opioids within the mental health area. So yeah, this is really dangerous. We need to work simultaneously on helping kids who are fat live lives free from bullying. That comes down to us. We have to change the way that our culture sees sadness and approaches it, and we have to provide them a way to live free from oppression. This is, and when you think about the kids who are black and sad or have even more oppressions, they're targeted even more. Even though these guidelines talk about racism and homophobia and other oppressions, they're not considering that at the foundation of weight stigma is actually racism. Weight biases are built on racism. We could go on for hours just about that but there's some really good books out there that address this and research and so forth so I'm not just pulling something out of thin air. But yeah, this is terrible for things and for parents. [DR. CRISTINA] Yeah, that's a big topic. We could go off on like a whole tangent on that. But if anyone listening's going, like, what, is there a book I can read to understand that more, do you have one I could put in the show notes? [CHEVESE] Yes, definitely. Dr. Sabrina String has written a fabulous book and I'll give you the title and information to put in the show. [DR. CRISTINA] Great, thank you. But I agree with you. I was reading the guidelines and thinking about all of this, and to your point too, it's like this is a cultural, like, societal issue too. It's like we're, diet culture, and we stigmatize and demonize people who don't conform to this ideal. We're saying, well, because you don't something is wrong with you. Now. They've created this chronic illness that I don't know, should be spot. I've been doing this like 25 years. I have never in my life ever put a diagnostic, like I've never put as a diagnosis obesity ever. Now in the guidelines are saying psychologists need to be treating this as well along as part of the treatment team. I'm going, what am I treating? First of all, I don't know, this is an illness and I've never seen a treatment protocol for this. I'm sorry, I'm thinking it's a made up illness, but like, what am I treating and how am I going to treat this? Somebody becomes and says, I was referred by my MD, my pediatrician, you need to help me and you need to treat this. I'd be like, deer in headlight. What would you do? [CHEVESE] Well, I think what psychologists and any therapist trained to help people, whether it's a mental health illness or just navigating daily life, the treatment here is the chronic trauma of weight bias in our culture. That's what we need to be treating. I'm not one to say that there aren't things that go on in the human body that could be related to fat cells. I have some of those disease states that are related to fat cells. Whether they actually are or not, I have no idea. There's a lot of correlation but don't actually see causation. But there are treatments for those things and it's quite different to put a 40-year-old person on some blood pressure medication or even a diabetic drug than putting a young person, a child or an adolescent on a drug that is going to affect hormones and metabolism long before anything shows up. So I know that the thoughts are we want prevent any of these states. I think prevention is always a good thing, but we, not everyone who is fat has these cause or I guess correlated disorders and diseases. So how do we know which person will or won't and how do we know that it is definitely related to fat cells? The AMA, their own committee did not want obesity to be labeled as a chronic disease. But the role of medications and treatments was therefore medical society and it's how they're funded. It's very difficult to fund nonprofits and medical societies and so they really depend on pharma and other medical-related companies. [DR. CRISTINA] Let's get into that for a second, because another big topic. I'm just reading that too and it's like saying this chronic illness is going to potentially cause other chronic illnesses and I'm going, wait a minute, hold on. Because when I think about, say, let's take diabetes for instance, because you were saying if you don't lose weight, of you don't go into lower BMI category, which I want to get into later you might have diabetes, you might get diabetes later. When someone says to me, I have diabetes, I think, all right, if you don't manage this and get this under control, I know what might happen. You might have neuropathy, you might go blind, all these things, same with other illnesses. If you have hypertension, you might be prone to stroke, heart attacks. There might be some things. So it's like, what do you do to prevent those outcomes? Obesity, I'm going, what is going on? What are we treating? What are we trying to prevent? They're saying all these chronic illnesses may happen, but I've never seen weight loss as part of any treatment plan. I've never seen weight loss cure or prevents anything. Like, I don't see anything. To your point, I've had plenty of patients in all sizes of bodies in all BMI categories who've had diabetes, who've had hypertension, who've had all chronic illnesses and weight loss or weight gain did not affect the outcome of whatever happened. So that's what kills me is like, what is, why is weight a criteria? Why are they saying if you lose weight that's going to make this illness happen or not or the outcome better or worse? I'm just shaking my head [CHEVESE] Yeah, not to mention the risk that does come with weight loss. There are many risks and I think that it's not common that someone would think that weight loss comes with risks, but it does because it's the method of how we approach weight loss and the fact that we know that a very high percentage of people regain their weight after, or within five years and the people that don't, there are things going on there and there is a suggestion that perhaps even eating disorder behaviors are at play in some people who are able to keep weight loss after they keep weight off after they have lost weight. So weight science is very, very young and there's a lot that we don't understand. I just keep going back to the outcomes of this pursuit of weight and what it means not only to the body when you are cycling up and down, up and down. We know from anorexia that there's a lot of strain put on the heart when there are behaviors and amounts of weight loss. It doesn't appear that there's been any sort of consideration for that. Why is it that the heart responds to weight loss in one way anorexia but we don't think that happens when we started a higher weight? So these are all theories, but we never look at the things that are going to actually tell us more about what we're recommending. We don't look at the harms of weight loss and the long-term effects of that, even though it's scaring us straight in the eye. I mean, so many of us have these experiences and how does that contribute to this later in life? So there's just so many questions and so many problems. [DR. CRISTINA] Well, to your point too, right, these experiences, and the guidelines are talking about adverse childhood experiences and how those can contribute to all sorts of problems. I'm thinking how over the years how many patients, even myself included, have heard very traumatic messages from going to the doctor and how that affected self-esteem, body image, wanting to change your body led to like, contributed to factors of like later having eating disorders and things. I don't know. Okay, let me just read this because this actually, like, I don't think this wording is any better. They say children with obesity or adolescents with overweight, instead of saying obese children or overweight adolescents, I'm sorry, what? Like they're saying that's a better way to communicate and that's less stigmatizing and less harmful. What do you think? [CHEVESE] Yeah, so it's person first language. I think that they are, I think that the oppressors are asking the oppressed to get on board with their language. They've tried to solve things because essentially, in my opinion, I think they knew they had a PR problem and so it was important to come up with language that was softer and more palatable to people and it fits into their chronic disease point of view around this. But it's not helpful. It doesn't change anything. It doesn't change when a child sitting in front of a doctor and they say, oh, you're a child with obesity. The word obesity is so stigmatizing and I can only imagine how that feels to a child now and mom and dad, your child has obesity and with that comes the blame that we hear so much about. Basically, we're giving you tools now to further suppress your child and to run around after them and say, you have this disease. I don't want you to die. It just, it takes the anxiety of so many levels. And I'm aware that some people listening to this are going to say, what in the world is she talking about? Okay, this is way too much. I know from lived experience and the language of oppression is it comes from the fact that people are biased and that weight is something that is, back to what we were talking about, bullying, harassment and so forth. People are really harmed and language does harm and people, while it may be a little bit softer it's still the same thing. It's still naming with something that most people are just horrified by. [DR. CRISTINA] Yeah, I can't see this going well and a child coming out unscathed emotionally from an appointment like that or constantly going and knowing like, okay, from this point forward, I have to eat differently. I have to live a life differently because something is wrong with me. [CHEVESE] Right, exactly. How does that feel next to their thin friends whom they may have had just such a great time playing with and engaging in activities and now they're thinking, oh, I have a disease and I'm different from them. You can see it on the outside that I'm different, instead of my body is just as good as your body. It's not good. There, I don't want to take away from the fact that there is an intersection of disabilities and higher weight for children, adolescents than adults and that there are plenty of people who are dealing with actual diseases in their lives. I don't want to take away from that and make it sound like the disease is a horrible thing. I have a hidden disease system. I don't think of myself as a horrible person. But we know the connotation of obesity in the culture and what it means and to make it disease is when there aren't disease processes in your child the same as an adult most often, I just really think that we're setting kids up for a lot of psychological issues. [DR. CRISTINA] To your point, if that child say that you're talking about this fictional child this very young, they're starting at age two and above, right? [CHEVESE] Oh, yeah. [DR. CRISTINA] Anyway, I mean if they're thinking this about themselves, and so they're going about life and they have no actual like, chronic illness at that point, they're just told, okay, your body is in this BMI category, we've deemed as diseased. You're different in their mind and they're, let's say all their labs, everything's normal, everything's fine, which most likely will be but they're going about like, oh, something is actually wrong with my body. Now to your point, you're going to get potentially pumped with a drug that, the guidelines don't say what's drugs, but I mean, we can go a little bit and think about what they might be. Or to the other extreme bariatric surgery, let's say they actually go forth. Let's say this person's body is just genetically to be the way it is and it's just not societally acceptable and the doctors are still like, sorry, it's, you're still in this category. Nothing "is working." This is what we need to do next. I mean, you mentioned this before, how's this going to affect brain development, puberty, hormones, nutrition? I mean, what's going to happen? [CHEVESE] So many things. And humans prefrontal cortex is not, are not developed until they're in their mid-20s. They can't make decisions about these things for themselves in a way that is, or that could be expected. Their parents, as we were talking about before, are going to be making the decisions for them being pressured. I mean, I'm on lots of chat boards and various groups and social media groups where people are telling their story from childhood and adolescent and adulthood as well and they're being shamed. They're going to the doctor and being told at every appointment that they should have bariatric surgery or that they should go on one. It's not being presented in balanced way, being presented as you are going to die. That's not fair. There is another way. I mean, I do not diet. I will never diet again. I have a doctor who is a weight inclusive doctor who never weigh, never pressures me to lose weight. And my endocrinologist as well. I do have some disease processes going on in life by, and I'm doing great. I'm a 54-year-old woman who's living life and I know that everyone is different and there are different considerations for different people. But to put these types of drugs and very invasive surgeries into the childhood realm is just really what are we thinking and very hard there, I think in my own mind. [DR. CRISTINA] Well, I mean going down the potential drugs we think might be prescribed here. I mean, one that's newly added to the eating disorder world here. The diabetes drug, Ozempic, I mean, what happened there? [CHEVESE] I'll say, full disclosure the drug category are one agonist and I am on one of those products for diabetes. It has been a really, both really great and very difficult. Because the side effects, the adverse events are not minimal. The way that these drugs act cause a lot of gastric distress, upset stomach, nausea, vomiting. I mean, it's a lot to pay for treatment in terms of the side effects. Putting the child on that type of a product, do we even know that the dosages are safe in children? Now I expect that the FDA would have looked at that. I hope so. I haven't seen anything that indicates the children would get a lower dose. I'm on a very, very low dose and significant side effects so I can only imagine how child is and what is that concentration in school? So just being preoccupied with your body, we know this for mainly eating disorders, being preoccupied with your body, its size and how it looks makes your brain focus on your body. It's the same with food. If you're restricting, if you're always hungry, then your brain compensates by over-concentration on food. Anybody who's ever been on a diet knows that to be true. So with these drugs comes appetite suppression. But so you, so there's that part, but you still have the concern around body and so forth and the same thing happening. I remember sitting in class thinking about what my classmates thought about my body and being so preoccupied with that or the fear of the upcoming gym class and what that meant for my body that I couldn't focus on my studies or what was happening in the classroom. And there is research supporting that. There is research showing that when children are restricted and they're in the process of eating disorders and they have body dissatisfaction that their ability to concentrate on their studies is very, very low. So this is something that parents have to consider. Again, back to that consent, are the consent being given making parents aware of that because that will affect their whole lives. We know the focus on grades and the anxiety around grades for parents and children. This is a whole other level of anxiety that we're now having. [DR. CRISTINA] Oh yeah, nobody's even brought up like how it's going to affect like all what you just said. Like how are they focusing? How are they functioning in their day-to-day? How are they doing academically? Oh my, it's a lot. It's like I said, my head spins. You go down the different rabbit hole of every different aspect and it's like, there's so much to this. Like I don't even know how, it scares me to think of all the negative implications and where this is going to end up. [CHEVESE] Yeah, and I think it's also important and I think that mostly from the eating disorders community, because I don't see other communities, other fields being very concerned. So I think most of the concern is coming from us because we are the front lines of what happens when this type of thing is going on in children. I think it's up to us to also educate parents and let them know that you are not a bad parent if you don't follow your doctor, your pediatrician's orders and have your child get surgery or go on one of these drugs. There are other ways and there are clinicians out there who are experienced in helping. So if you're concerned about your child's weight, if you're concerned about their eating problems, if they're concerned about their mental health in any way I'm sure you can provide some resources to people in the show notes and I'm happy to help with that. There are people out there that can help and there are other ways, and I know that that treatment is not available to everybody. It does cost us to go to therapy, to seek a nutritionist, and these things are not well covered by insurance. Then there is the fact that the more oppressions you experience if you're a black child who identify as gay, you are much less likely to either have insurance. So these things are, they're real-life consequences and there are other ways and I hope that people will look for them and explore or at least get educated to extend that they can before they agree to allow their child to put through these things and to ask the difficult questions to ask before you give consent, what is the likelihood that my child will regain the weight? What is the likelihood the struggle will cause further problems down the road? Insulin resistance, we don't, if you're giving a drug that is meant for diabetes I don't know, I haven't seen any studies, but is there a chance that this to further that sort of makes sense? So yeah, ask the hard questions. [DR. CRISTINA] I think that's going down that line. Let's say somebody does go on one of these medications meant for diabetes when the child doesn't have diabetes like Ozempic because it is being used for weight loss. Then okay, they've lost the weight, let's say that even happens and then they go off of the medication now because they don't have diabetes. They've reached their "goal." I mean, you and I both know there's articles out there, people who've gone off of it and the weight is coming back. So what then? [CHEVESE] The companies have said, these are drugs for a lifetime, so can you imagine starting an injectable drug at age five? I realized there are diabetic things type one out there and possibly some type twos who are having to do so for kids who know disease processing, processes having to give themselves or their parents give them shots for the rest of their lives. We don't know what the long-term, these donors have been out for a minute. And the phase three studies, phase three is not that long when you're looking for long-term side effects and adverse event. So it's only in phase four, which is the marketing phase where people and physicians and like people start reporting their adverse event. So drugs that are on the market really, we don't know. It's the long-term that tells us. For children this is probably the start of another weight or a weight cycle for them, which we know most people when they lose cycle will lose weight, gain it back, and research shows that oftentimes they gain 20% more than what they lost. So we actually get that or the time as we diet. [DR. CRISTINA] It's setting them up for a lifelong of who knows what. I mean, again, to the point we have no idea what implications this is all have, but it's not, doesn't not sound good, any of it. And again, like, it's so long. But I think every page made my head spin. Even like there's something about, part of it is having to eat healthy foods and I'm, I mean there's a whole thing on that and as an eating disorder person, ah, like I'm trying to help people get rid of like labeling food as healthy, unhealthy, and here they are promoting like categorizing foods and I'm going, oh, that alone is like, what is happening? What? [CHEVESE] We don't even what healthy food is. I mean really we don't. There are government guidelines that change, there's a lot of concern about process and auto-process but in reality nobody can tell us what is healthy. I think there's some research to support vegetables and fruit and so forth, but it does vary also depending on the person and there is no guideline that tells us definitively these are the healthy foods. If you tell me, well, eating clean, what is eating clean? And people tell, people say clean, then my thought about that, people during that time, I can't think of the word but that time in history lived to be --- they had appendix. Their appendix were there because they ate food that had rocks and sticks and all kinds of things in them. The appendix had, I mean, I understand, I'm trying to bit silly, but we just don't know the bottom line. [DR. CRISTINA] No. I don't know, my take on it is anybody who tries to really be so "good" and like follow a meal plan, like that's not eating disorder treatment, but like really just be strict with their foods and say, I can't have these and I can only have this, that's setting somebody up too for having disordered eating or an eating disorder later on and not having a relationship with food where they can just, it's healthy, I mean, emotionally healthy because then it's like whatever you tell yourself you can't have, that's what happens. Then you want it more and then you have a very, then you come see somebody like me or you and work on how to have a relationship where food is not emotionally tied and that's a whole nother problem. [CHEVESE] Yes. I think that is, it's so important and yet it gets by the, they probably don't understand it. For those who do they say, yeah, but eat healthy, blah, blah. But it's really true, because our brains, as a child I limited and restricted all the time. The candy was bad, jam was bad, anything with sugar was bad and that only whole grains were good and that sort of thing. So I was always thinking, and I started binging when I was five, I would sneak food wherever I went at my grandparents' house and we would visit somebody's house and I would sneak food, take it home with me. When I got older, I would go to the grocery store with my mom and have my own money and buy food and sneak it out to the car while she wasn't, I would go off on my own. My brother and I did that and everyone would say, oh, she loves candy, she loves candy, she's sneaking food. I was hungry. I was hungry and the things that I was being denied are things that everybody does, most everybody. If you're not allowed to have them, our brains go, oh man, I really want that and then you try to get as much as you can when you have access to it. So it really is important putting good and bad really does, accept how people have a relationship with food. [DR. CRISTINA] I mean really we could probably talk all day on that. [CHEVESE] We could [DR. CRISTINA] And I appreciate that you're going to help with the show that's adding some useful and helpful links for people because I agree with you. I think people aren't being vocal enough. I know these guidelines just came out like recently, so maybe it's not out enough to the public and I think the more people are vocal and getting the word out and did really discussing like what, like the underbelly of all this could be and what people might be hearing as parents in the pediatrician's office and really informing them of like you said, their choices or there's alternatives to this. I think that's great. I think people need to be informed and aware. So I really appreciate you being on here and talking more about this. I know you're out there like writing away and discussing this out in the world so thank you for doing that as well. We need more of you. [CHEVESE] I hope that many more will do so and one day at a time. [DR. CRISTINA] Any last final words before we end? [CHEVESE] No, I think we covered a lot and I just hope that everyone will take the opportunity to really think about it and do what's right for children, including professionals. [DR. CRISTINA] Thank you so much. [CHEVESE] Thank you. [DR. CRISTINA] This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, accounting, clinical, or any other professional information. If you want a professional, you should find one.