By Angela Fitch, MD, FACP, FOMA, Gene Beresin, Executive Director and Khadijah Booth Watkins, Associate Director

Posted in: Multimedia, Podcast

Topics: Bullying, Culture + Society, Healthy Living

We often hear about how stigma can prevent appropriate treatment for mental disorders and promote feelings of shame or low self-worth among those struggling with their mental health. Did you know the same is true for obesity? Obesity is a complex disease, and stigma prevents us from understanding what it actually is and how it can be effectively treated.

Today, Gene and Khadijah are joined by Dr. Angela Fitch, a leader in the field of obesity medicine, to learn more about what parents and clinicians can do to support kids affected by obesity, and help shift the culture around weight bias. They discuss personal biases, treatments for obesity, and the mental health toll obesity stigma can take on our children and teens who need us to step up on this issue.

Tune in and share with someone you know. Thanks for joining in this conversation.

Media List

Follow along with the conversation.

• Angela Fitch, MD, FACP, FOMA (Obesity Medicine Association)
• More About Knownwell (Knownwell.co)
• Consensus Statement on Obesity (The Obesity Society)
• What Is Body Composition? (WebMD)
• BMI ≠ Obesity = Excess Adiposity (ConscienHealth)
• Adipose Tissue (Body Fat) (Cleveland Clinic)
• Study: BMI Measurements Should Be Tailored to Race and Ethnicity (Verywell Health)
• Most Food in America is Hyper-Palatable and ‘Difficult to Stop Eating,’ Scientists Say (Newsweek)
• CBT Is Effective for Childhood Obesity (Beck Institute)
• Cognitive Behavioral Therapy, featuring Susan Sprich, PhD (MGH Clay Center)
• Is Your ADHD Brain Hard-Wired for Weight Gain? (ADDitude Magazine)
• Headless, Hungry, and Unhealthy: A Video Content Analysis of [Persons With Obesity] Portrayed in Online News (Journal of Health Communication)
• New guidelines for treating childhood obesity include medications and surgery for first time (NBC News)
• Weight Bias: People-First Language (Obesity Action Coalition)
• Digital Media and Body Image (MGH Clay Center)

 

Episode Transcript

SPEAKERS: Gene Beresin, MD, MA;  Khadijah Booth Watkins, MD, MPH; Angela Fitch, MD, FACP, FOMA

 

Angela Fitch, MD  00:00

And even that assumption, so to speak, that someone who lives in a larger body that you know has different behaviors than the rest of us that don’t have that struggle is wrong, right, that you know, to look at somebody and assume they don’t exercise or assume that they eat a certain way is is part of that biases. stickman. And makes matters worse, because there’s data to show when you unintentionally even, you know, say something to someone about that. And don’t provide them with evidence-based care that makes them worse, right? They may go home and have other eating disorder behaviors, like you talked about, you know, because of some of that bias and stigma towards them.

<MUSIC INTERLUDE>

Gene  00:41

Welcome back to shrinking it down mental health made simple. I’m Gene Beresin.

Khadijah  00:46

And I’m Khadijah Booth Watkins.

Gene  00:48

And we’re to child and adolescent psychiatrists at the Clay Center for Young Healthy Minds at the Massachusetts General Hospital. Today, we’re going to focus on a topic that we haven’t talked enough about, and that is obesity stigma, and how to and how it mentally impacts our kids and adolescents. nearly 70% of America is overweight are affected by obesity. And that includes as many as one in five children and teens. So it’s really not uncommon. And yet, even though it’s all around us, is so much weight bias. I will talk a lot more about about how it affects us personally, as well as our patients. But let me introduce our special guest today. Dr. Angela Fitch is a leader in the field of obesity medicine. She’s going to help us learn more about this issue and what we can do as caring adults to help support individual kids and hopefully help shift our culture. Welcome, Angela. It’s great to have you here.

Angela Fitch, MD  01:50

Thank you so much for having me. It’s a pleasure.

Khadijah  01:52

Just a little more background about Angela. She’s the current president of the obesity medicine Association and the 2017, winner of the clinician of the Year Award. She served as chair of the clinical management section of the Obesity Society in 2015 to 16, and she practiced primary care for 10 years before becoming a diplomat of the American Board of obesity medicine in 2012. She comes to knownwell by way of Boston, where she divides her time between academia, activism and medicine. She’s an assistant professor of medicine at Harvard University, the former co director of the Massachusetts General Hospital weight center, a board member of the Obesity Action Coalition, and the founding member of the Massachusetts Coalition for action on obesity. Dr. Fitch is board certified in obesity, medicine, internal medicine and pediatrics. So she is going to impart so much knowledge on us today.

Gene  02:44

Yeah, and well, I’m sure you will. I’m just sorry that we’ve kind of lost you from MGH, but we haven’t lost too, because you’ll probably have a bigger presence in your current role. So we know from the time you were here at the weight center. But she’s so passionate about reducing obesity, stigma and providing more compassionate care. For those who are overweight or affected by obesity that she really did. She left MGH to launch her own health care startup called known well. So as we begin this discussion, could you tell us a little about your new company, and what brought you to this juncture in your career?

Angela Fitch, MD  03:29

Yeah, we created knownwell out of a desire to provide non stigmatizing unbiased care for patients with obesity. And those who just weight concerns in general. My co founder is a person with obesity, she’s lived in a larger body than she was quite young, and experienced quite a bit of stigma throughout her lifetime, by just going to the doctor and having doctors say to her, you know, have you thought about losing weight? Have you tried to eat better? Have you tried to exercise more, and she was doing all those things. And it was not successful, because we know that we’ll talk about this a little bit further. But obesity is such a complex chronic disease that it’s not always fixable, so to speak, by lifestyle intervention, and she was trying to do this, and it was very challenging for her and she felt that stigma and bias, you know, throughout her lifetime, and she thought to herself, why don’t we have a clinic that’s more focused not just on on weight management, like we have that the major academic centers, you know, what referral place, but a place for a continued care, you know, chronological care throughout your entire lifetime, in a longitudinal fashion. So not an episodic session, but an ongoing fashion to really provide, you know, comprehensive metabolic health services in addition to a primary care needs. And so we’re going to combine the two together to form known well, it’s gonna start here at Boston and then it’ll have both virtual and in person, clinic appointments and support crew groups in a community and lots of other, hopefully good things to help people in this space to get the care that they, they so need.

Khadijah  05:09

Stigma is so tied to misinformation and misconceptions. Maybe we could start by sharing some of our own preconceived notions about obesity. I mean, we all have them. And it may make us a little bit vulnerable to do it on air. But hopefully, for those who are listening, they can think of one or two of their own biases. And by the end of the episode, we might be able to help them to make a shift. So Gene, why don’t you start? You’re in the hot seat.

Gene  05:34

Okay, I’ll start I’ll mention two areas of concern. First of all, I have to admit, I mean, I like almost everybody else I know, is concerned about appearance, and about how I look, it wasn’t a big deal. I mean, I was I was probably about, I would say 30 pounds overweight. And interestingly, when I developed an autoimmune illness, and I had to take massive amounts of steroids, you know, I and my doc said, Oh, watch out, you’re gonna, you’re gonna gain more, I actually lost 35 pounds, which is like, unbelievable. I didn’t do it on purpose, it just the weight just dropped off. So sometimes these things happen. But I do, but I but I have specialized in eating disorders and anorexia nervosa and bulimia nervosa and binge eating disorder. So I’m very, very, you know, ever since I started, you know, as a child, adolescent psychiatrist, I’ve been helping people concerned about their body image, that’s a big issue. The other thing I want to point out is that this stigma is not just in the general public, there is a considerable stigma among physicians, for example, I teach to medical students about all sorts of bias and stigma so that they can provide professional, compassionate, sensitive care. But it’s not unusual to hear folks in the emergency department get upset and biased against somebody who’s obese, because to put an IV line in is incredibly difficult. And I think what I hear a lot in between the lines is that it’s their fault. Kind of like the same kind of bias, we hear about addictions. And we hear about mostly addictions, I would say, but, but but it’s often not the patient’s fault. It’s, as we’ll hear from Angela, it’s a complex, it’s a complex sequence of biological psychological and socio environmental input. That was a perfect storm. It is. So you agree with that.

Angela Fitch, MD  07:49

Yeah. And that, but but the but that sort of feeling of that it should just be easy, you know, for me to, you know, do better in the world, right to, to simply, you know, control my eating and control. And I just by tivity, um, there’s been a lot of press recently in social media, and on the topic of, of obesity treatment, given the new treatments we have, and the new pediatric guidelines that we have, that have come out, which I’m sure will, we’ll talk about a little bit, but you know, with all those, that stigma, you see all those comments in the chat, and some of them are just really mean, you know, like, you know, people should just throw their mouth shut, or, you know, stop eating. And when we know, it’s not about that, you know, many of my patients I talk with have more higher quality diets than I do a lot of times and they have better physical activity patterns than I do. I have a patient who runs marathons, you know, and, and weighs greater than 200 pounds. So we can’t assume, you know, even that assumption, so to speak, that someone who lives in a larger body that you know, has different behaviors than then the rest of us that don’t have that struggle is wrong, right, that, you know, to look at somebody and assume they don’t exercise or assume that they eat a certain way is part of that bias and stigma and all that drives this sort of negativity out there in the world. And makes matters worse, because there’s data to show when you unintentionally even, you know, you know, say something to someone about that, and don’t provide them with evidence based care. That makes them worse, right? They may go home and have other eating disorder behaviors, like you talked about, you know, because of some of that bias and stigma towards them. So it’s a vicious cycle. That actually, you know, some of the data shows that by not treating obesity, we have a risk of making eating disorders worse versus many people think that by treating obesity, we’re going to make eating disorders worse. And actually, there’s some data to show it’s kind of the other way around.

Khadijah  09:50

That’s interesting. I guess I would say the bias that I would share is really I guess similar to what you said Jean and that I think many have us are often thinking about our weight or our body shape. And for me, I sometimes find myself getting caught in a negative loop around, you know, you should do better, you should work out more, you should eat more healthy, not really take into account, you know, the realistic barriers that that are in place and the physical barriers that are in place in terms of, you know, aging, and so on and so forth. There’s so many reasons, but I do get caught up in that loop. And when I recognize that I do, stop myself and try to reframe it and try to challenge those thoughts. But it’s really hard, because, you know, like, so many, we see what is supposed to be the image of beauty and the image of, you know, someone who looks good and healthy. And sometimes it doesn’t always, or often, it doesn’t always look like me. And so I find that it does become a challenge. But I think I am lucky, because I am able to recognize it and push back. Whereas you know, many people are not able to recognize it, and they kind of go down this rabbit hole, which can be very scared.

Gene  11:05

Right. Angela? Let’s, let’s start with a little bit about defining obesity. Just just to get to what you were saying Khadijah, if anyone has lost weight. The first thing somebody says that not universally, but the vast majority of the time is, you look great. You know, so you certainly have standards in our society. And I think we should talk more about that. But before we do, let’s define what at what actually is obesity, particularly in kids and teens? How would you? How would you describe it? How would you define it?

Angela Fitch, MD  11:44

Well, we as a society is actually you know, as the Obesity Medicine Association, ABC Action Coalition, the, the ADA, the dietician have come together actually to put a new definition on obesity in general to sort of take away that focus on just body size or BMI, right, or weight versus high, right, which traditionally has been our, our, our sort of metric of, of screening for obesity, right, but it’s never been, you know, no one has ever said, you know, as a physician or a clinician, you know, that someone has a BMI of this, oh, they have obesity, right, even, you know, we still look at people and we still assess, you know, their risk of that excess adiposity, right, because it’s really about excess fat, the excess adiposity is inflammatory, it creates inflammatory cytokines, it does not so great things, those cytokines, those inflammatory chemicals, affect your blood vessels affect your cardiovascular system affect your kidneys, you know, and then there’s insulin resistance, that also plays a role and affects blood sugar that also can affect, you know, all these organs. So it’s about how that excess adiposity, and genetic predisposition then plays a role in how it affects our health and well being. So it’s about you know, assessing that whole person all the time, not just looking at like, what number the BMI, but we do still use BMI as our sort of surrogate marker, because we have data at least, you know, again, one of the criticisms of BMI is it’s very rigid in terms of where it was studied was typically in Caucasian people. So we don’t have a lot of racial diversity across, you know, those BMI measurements. And we recognize that and we’re moving towards trying to find, you know, new measures for the body mass index, you know, instead of just looking at people’s height and weight, you know, potentially in the future. And we do this already at the weight center, or at our clinics that specialize in weight management, you know, we measure body composition, we measure adiposity directly, and we have some numbers around that to say, you know, this amount of adiposity is is likely to have an adverse effect on your health. And then of course, we assess, you know, are they going to do they have already other health conditions, many of our patients, even our kids that have, you know, traditionally a BMI greater than the 95th percentile, right? Is, is defined as obesity in children. And again, it’s, it’s a screening thing, you look at that, and then you look at the whole person, but that’s where you just kind of start from and saying, you know, that person is is at risk for obesity. Is this something that you as a clinician, you know, are diagnosing, you know, for that patient.

Gene  14:28

Just for the sake of the public, could you define BMI and adiposity? I think I know what they are. And I’m sure Khadijah does, but the audience might not.

Angela Fitch, MD  14:41

Well, so BMI is this body method x ray that the calculation done by our height and our weight. And in kids, we have a growth curve, just like we have growth curves for height and weight. You know, it’s not just one number because kids are growing constantly. But the idea that children will grow into their weights so to speak, meaning There’s always been a thought process and sort of, you know, older times, if you will, that that kids that were heavier, when they were younger, that they would just, you know, grow out of it. And that hasn’t been what we’ve seen clinically, right. So if a person is predisposed to excess storage of body fat, which is adiposity, right, so adiposity is a fancy word for adipose tissue, which literally just means body fat, or adipose tissue actually is our largest organ in the human body. So it’s fascinating that you know that we know very little about it, given that it’s our largest organ, and it’s actually an active Orient, it just doesn’t sit there, like it actually produces, unfortunately, some of these negative chemicals that cause inflammation and lead to inflammation and lead to insulin resistance. And so that’s a very vicious cycle. You know, having some body fat is normal, right. So as you mentioned, with some of our patients that are too small, that’s also not good for them, you know, if you have too little body fat, that’s also can be a problem for your health, and have health effects. We see that in elite athletes a lot too, and their bone density, right. But if you have too much that also has leads to these adverse effects on health, and that’s what we want to focus on is the health of it, right? Not so much just the number and trying to get to a certain number that was never the intention of these, these, these, these graphs and these BMI eyes.

Khadijah  16:30

And so we touched on a little bit about the different things that contribute to obesity, and how why people might struggle with their weight. And so many people, I’m sure assume that it is due to poor food choices, or maybe overeating. And who would we be if we didn’t blame parents and I say that with all sarcasm. But of course, people have blamed parents for for the obesity, or kids who struggle with their weight. But these these thoughts, these assumptions all drive the biases that we that we see. And we hear that we’re fighting so hard again. And so like most of the things in medicine, it’s not that straightforward. You know, obesity is also like an onion, there’s so many layers. So can you speak to some of the contributing factors to to obesity for children and adolescents?

Angela Fitch, MD  17:14

Well, you hit on them, they’re a little bit, you know, meaning that there’s so many contributors today in our environment. And it really is this mismatch between our genetic predisposition towards energy storage, because we were, you know, created as humans to our default engineering, so to speak, is to gain weight, you know, to store energy, right, that’s our default, like, otherwise, we would have, you know, died in the wilderness during times of famine in our history, right. So we’re engineered to gain weight. So actually trying to make the human body lose weight is very challenging, because you’re going against Mother Nature and Mother Nature’s a formidable foe, I must say, and all these factors in the environment such as, you know, like you said, it’s many times pet, we take a lot of things on his parents, I know me as a parent, right? I mean, you feel like, you know, oh, I should have done that, or I should have done that, or I could have done that better, and this wouldn’t have happened. And we take a lot of that on and, and we take that sort of blame and stigma with us too. And, and that’s what we have to try to, you know, get around and try to create positive change and the environments we live in, because the environment itself is counterproductive, to health and well being. So things like stress around bullying, you know, at at school, for whatever reason. Things like a social media, like we talked about earlier, I mentioned earlier, exposure to screens, which then creates sleep cycle disruptions. So the more we’re exposed to screens, the more sleep cycle disruption we have. And when we have sleep cycle disruption, that leads to energy storage, independent, sort of, of what you’re eating, you know, it adds to that desire of the body to store energy when you don’t sleep well. And then also, you know, our processed food environment. So the biggest thing that we’ve found in research lately, is not so much about just, you know, sort of like calorie is a calorie of the calorie, but that the calories that come from processed food or ultra processed food is the new terminology, meaning, you know, things that are coming out of boxes instead of coming from the ground or coming from the earth, right? So we focus on really, you know, saying to people refocus on eating more whole foods, right, so not things that come out of boxes, but things that that that come you know, from the grocery store, blueberries, strawberries, broccoli, cauliflower, I mean, even if you’re putting some cheese on it or something to make it flavorful, right? It’s it’s about having that unprocessed food that we tend to do better as a human being, you know, when it relates to our energy storage, then when we eat some of this processed foods, such as, say Pop Tarts or crackers or other types of foods that are very much around us all the time. And that’s what makes it so hard because it’s part of our daily living. We’re asking people to live have completely opposite of the society they’re popped in, which is very challenging to do.

Gene  20:06

And I might add to that, you know, just the Super Bowl was just on. And there was so many ads for this delicious, delicious looking fast foods and people like enjoying themselves and eating things that were totally price as huge in calories and not one add on exactly what you said, on how can we learn to eat in a healthy way. Because it’s good for you. Actually, it tastes good.

Angela Fitch, MD  20:41

Yeah, and it’s also a you know, it’s also a learned behavior, right? When you’re around all this food that’s very hyper palatable, we call it that’s a fancy word for tastes like really, really good meaning people engineered that way. I mean, it’s made that way on purpose to have people eat more of it, so they sell more of it, because we’re in a capitalist society, that that’s how those companies continue to operate. And so you know, when you have these foods that are extremely tasty, they’re very hard not to eat. So it’s very challenging. And we, you know, we try to also make it known that, you know, just because you have some of those foods, doesn’t mean that you have to have more of them, right, trying to not have them on a regular basis, right. And so, we talk a lot about in a healthy lifestyle, you know, not dieting, we don’t want to be on a diet, we want to live a healthier lifestyle that can hopefully produce, you know, greater health benefits by infusing more whole foods into that diet, and crowding out the processed food, right. So instead of cutting it out, because the minute you say to yourself, I can’t have those Cheez Its, or whatever the, you know, the cracker of the day, maybe, instead of having saying I can’t have that, you try to have something else in addition, right, so add a plant or add a protein to that, so that you’re gonna feel fuller, you know, versus eating that, that processed food that doesn’t make you feel very full.

Khadijah  22:07

So our kids are feeling stigmatized, not only by their peers. And you talk a little bit about bullying, but it also happens as Jane mentioned, but their caregiver, they’re their primary caregivers, or their physicians and and their families. And I know that it’s often that they don’t understand the complexities of the problem and all of the layers that we’ve just talked about, um, but it’s often that our kids feel blamed and singled out and devalued. So how can we talk to our kids about weight in a way that is supportive and unhealthy? That doesn’t induce kind of shame and blame?

Angela Fitch, MD  22:37

Yeah, it is very hard, right? I mean, for anybody to talk about, it’s a, you know, it’s a, it is a condition that we wear on the outsides of our body. Right. So, Gene, you mentioned having an autoimmune disease, you, we might not know you have that right? If you don’t tell us, whereas, you know, when we struggle with our weight, or struggle with obesity, you know, that’s outwardly visible to everybody. And so that also creates sort of a, you know, a confidence issue, you know, with that, you know, that people can see that I’m that I’m, you know, not trying hard enough, right. And so, you know, people internalize that. So I think really, even if they don’t outwardly say it, you know, the kids and teens take it in, right, and they internalize it. And so really, you know, we encourage providers to talk openly about the fact that, again, it’s not your fault, right? This is about in what I the little tagline I like to use is, you know, this is about your chemistry, not your character, right, these are complex systems that are going on in your body complex interactions that involve, you know, brain hormones, and gut hormones and, and all sorts of other, you know, complex pathways and metabolism. And this is not your fault. Now, if you want to change it, we have to work on it, right? It’s not going to change by itself. So if you if you want it to change, and you’re, you’re motivated to make it change, there’s where we have, you know, there’s where we can work together, really saying, hey, we want this to be a team, not a like, a me versus you or parents versus kids, right? Because sometimes it gets into that, you know, how come dad can eat the cheese? It’s an I can’t, right? So that’s really not, you know, we have to make it a whole family affair, really, you know, so that everybody is trying to make behaviors based on health. Again, if we can sort of, you know, talk more about the health effects of these things, because even people who are leaner, that have a ultra processed food diet are not as healthy. That’s where, you know, focusing on the health of these behaviors, moving our bodies more huge benefits to our mental health, to our physical health to our cardiovascular health to our sleep, right. So it’s just good for us to move not because we want to lose weight, but because it’s really good for our health. So refocusing, as you mentioned earlier, you know, refocusing our thought patterns around that and and over and over, you know, which is part of cognitive behavioral therapy, you know, that part of it is really what’s necessary to sort of reframe the situation on an ongoing basis.

Gene  25:10

I love what you said, this is not about chemistry, but about character.

Angela Fitch, MD  25:15

No, not about character, not about character, but about chemistry.

Khadijah  25:20

Word order matters here.

Angela Fitch, MD  25:22

Yeah, word order matters it dramatically. Right? Right. It’s it, or people will say, you know, it’s, it’s about biology, not just behavior, right? That’s another way to say it.

Gene  25:34

That’s a really good one, to be one instead of a C one. And speak of biology, you know, I just want to mention that, you know, there are mental health issues, and social challenges that cause changes in mental health, that do affect our, our appetite are the kinds of foods we reach for, especially teenagers. So we know with depression, for example, that adults will not be able to sleep and will lose their appetite, whereas teenagers will actually want to sleep more and well, their appetite will increasingly go for the carbs. But what can you talk a little bit about what some of the mental health and social challenges there are, that speak directly to the chemistry and other things we have to be on the lookout for?

Angela Fitch, MD  26:27

Yeah, so you know, there is a big overlap, right? For multitude of reasons, again, because a lot of this, you know, lives in this combination space were like, you know, behaviors such as moving more and performing physical activity, especially at a higher intensity even, you know, where you might be playing a basketball game, or, or swimming, you know, even competitively, those types of behaviors, actually, you know, have been shown to alter our brain chemicals in a positive way, right, increase serotonin increase dopamine, and make us feel better, whereas the opposite makes us you know, in a more downward spiral, so, it is important to treat the whole person, right, so to recognize those mental health challenges and get treatment, you know, via, as you mentioned, you know, cognitive behavioral therapy is sort of the root of, of some of this treatment, and some other types of therapy, that, that you guys are much more well versed at that I have even but the idea of, you know, working with people on these issues, and then of course, medication to if medication is is necessary can also be helpful, just to treat the underlying the underlying psychiatric issue or mental health issue, that may be playing a role, right with the eating behavior. So it’s not always just treating the eating behavior, it also can be treating, you know, the underlying depression, anxiety, or, in particular, we see a lot of, of overlap with ADHD as well. And that sort of brain chemical pattern that people have, where, for example, you know, when kids might be younger, they tend to be more, if they’re more hyperactive, they tend to move around more and eat a little bit less, because they’re not as focused on eating. But as they get older, they sometimes tend to be more sedentary and, and instead of like being hyperactive with movement around the house, you know, they’re hyperactive with, you know, putting food in their mouth, right in order to sort of get that stimulus because the ADHD brain wants extra stimulus, right. And so again, when we treat that overlapping ADHD and allow people to focus on some of these healthier behaviors, it allows them to be able to get out of that cycle. So it’s about recognizing these cycles and breaking the cycles wherever we can, whether their mental health cycles or physical chemistry cycles, right, or insulin resistance cycles, which are more metabolic cycles, that also, you know, play a role.

Khadijah  28:50

And so I want to talk a little bit about what some of the treatments are, that exists for obesity, we also know that everybody’s different, and everybody’s body is different. And so I would imagine, we have to think about treatment, and how we tailor it to match and meet the young person’s needs. I mean, is it realistic to think that we can treat this without changing food preferences or without, you know, inserting exercise or without the whole family having to make the lifestyle change?

Angela Fitch, MD  29:16

Well, I think, you know, we should always try that regardless. I mean, we should always strive for that as our goal is to cause meaning. You know, even myself, I’m constantly trying to make better health choices in the world around me, right? No one is expected to be perfect. And we talked about that a lot, right? Because there is this sort of like guilt and shame that that’s it and people are like, Oh, I ate that. And then you know, I’m a bad person. So now I’m gonna eat more of that. And so again, we have to break some of those cycles with recognizing that, that we do live in this environment, and we can change it as much as we can. But it’s, it’s a very challenging thing to do. We also have to recognize that we have data I mean, the scientific data shows that with a lifestyle intervention and intensive behavioral intervention where people are meeting with a dietitian meeting with a psychologist, you know, coming in once a week, and really working on this behavior change, right stress management, sleep, physical activity, all the factors that are involved in our lifestyle that make it a healthier one, or promote health and well being. When people are working on that the the amount of weight loss that people can get, or obesity treatment that people can get is very low. So on average, people will lose around two to 3% of their body weight in terms of, of making lifestyle changes. So the the response to that treatment, so that intervention, that response, that intervention is not super good, right? I mean, meaning, you know, unfortunately, this is just in people, but people think it’s their fault. Like, oh, the Johnny, it was good for him, right? Why is it not, you know, good for me, there’s something wrong with me, I’m not trying hard enough. But actually, it’s just a treatment response, just like we’d have any other treatment that we give somebody, and maybe it doesn’t work, you know, for them because of these other like that, like you said, can you show that heterogeneity of the disease, it’s so hetero heterogeneous, it’d be like if we gave the same cancer drug to all cancers, right, we don’t do that now. Because we know specifically, certain ones respond to certain treatments. And we know for a fact that while lifestyle is great for prevention of obesity, it’s not once people have the disease state, it’s very hard to treat it with lifestyle intervention alone, we don’t get as good a response as we get with medication and surgery.

Khadijah  31:32

That is so important, I think, to know and to hear, because I can imagine how demoralizing and defeating it is to constantly be on these various plans, and not really be getting anywhere and giving it 120% each time. So I think that’s so important for people to hear. Can you talk a little bit about the medication that does exist for obesity? Or in other treatments? Yeah, like, what does it do? How does it work?

Angela Fitch, MD  32:00

Yeah, and, you know, um, you know, with the, with the guidelines that came out recently, by the American Academy of Pediatrics, they sparked a lot of controversy, even again, in the mental health space and the eating disorder space. But from what we know, of those of us that treat the disease, right, we see the opposite happened, we see when we treat the disease, where we give people a tool to break these cycles of chemistry, right? When we interact at that chemistry level. With interventions, we actually allow the person to be more successful with some of those things, right. So when you give people this tool, and you give people this ability to, for example, with some of our medications, which activate a receptor in the brain called GLP. One, when you activate that receptor, you actually don’t want as many of these foods like that literally is a chemical reaction that says, you know, this doesn’t look very good. Or you take a few bites of it, you’re like, Oh, that was enough, I’m done. You know, and this is like, really a complicated thing that thankfully, we have these medicines to help, right? In the past, we didn’t. And now we get, you know, for example, with weight management, like I said, with lifestyle intervention, only about 5% of people are able to produce a 20% reduction in their BMI or 20%, weight loss. But when we have medication combined with lifestyle, now 40% of people are able to achieve that same goal. So now we took 5% of people, and we increase that to a 40% response rate. I mean, that’s, that’s, that’s why there’s so much discussion about it, and why it’s so revolutionary, because it actually is giving us magnitudes better treatment response than without it. And that’s where, you know, we recognize it’s hard for kids to be on medication and hard to think about putting our kids on medication or having that as a tool. But we do it because, you know, if we don’t do it there, there’s data to show that kids live 10 year shorter life expectancy than they would have if they didn’t get treatment, there’s data to show that they get diabetes that they get, you know, kidney disease, fatty liver disease, you know, end up with a liver transplant. So these are real problems, you know, as we get later in life if we don’t do something earlier,

Khadijah  34:16

Those are incredible numbers. Wow.

Gene  34:18

So let’s shift gears a little bit to to the if the impact of the media. Digital media can have a negative impact on young people, and we hear about concerns related to body image, and an unrealistic depictions of thinness. Exactly. So there was a study in 2013 that found the majority of one line news coverage of people who were you know, with obesity in a stigmatizing way their heads rough and cropped out of videos, they were more likely to be shown eating unhealthy foods, more likely to be dressed sloppily with no fitting clothing is applied to is applied to children, not just adults. So That’s news coverage. And then of course, there was the Instagram scandal, which, in which, in which photos were actually doctored to make the bodies look thinner. And that would be stigmatizing for those who didn’t have those kinds of bodies. So I wonder if you could comment on, on the impact of news media coverage, and when social media and how that affects our teams.

Angela Fitch, MD  35:32

Yeah, it adds to all that, that we’ve been talking about, right, it adds to more of that shame, bias and stigma, you know, internalized as well. And it happens for all, you know, different types of people, as you mentioned earlier, right. And we have to just keep reframing that and keep having that discussion, that open discussion that, you know, everybody’s body is different. And living in a larger body isn’t necessarily wrong. And that’s okay to be, you know, to have that body size, and your body is different. And there’s different cultures, right, that have different body shapes and sizes that aren’t as affected on their health. And then there’s other cultures, such as people of Asian descent, where if they have more of a, they tend to gain more visceral adiposity, or gain more fat in their midsection. And even at a lower absolute weight, they have more metabolic disease, they have more diabetes, they have more prediabetes. So we have to get away from I know, it’s easier said than done, because it’s been centuries, but I mean, we have to get away from worshipping of thinness, right and, and really focus on health and, and well being and, and not putting so much of our happiness, I have many patients come in, and they’re like, I would be happy if I just lost 20 pounds. And I’m like, Well, you should be happy now. Like, your happiness shouldn’t be a factor of how much you know, of what your body looks like, or how much you weigh. And so we hope to help fight how people find that happiness, no matter what their body shape or size is, because it’s not something that we should, you know, that we should attach our happiness to, although, again, recognize, easier said than done and takes a lot of work, you know, to try to, to work around that.

Khadijah  37:13

We want our kids to be healthy. And that I think drives a lot of the the concern and the high kind of express or intense emotion around talking about some of this with with with our kids. And at the same time, we don’t want them to feel bad about themselves, we want them to have, you know, high self-esteem and confidence. So let’s talk a little bit about language, because we talked about earlier about the order words matter, but words themselves matter and what we, how we use them and talking to people and describing people when they’re present or not present is really important as well. So what type of language should we use intentionally when we’re talking about as a, as a, as a physician, or patients or as a parent, our kids?

Angela Fitch, MD  37:56

Yeah, so again, we, this is a, it’s a, it’s challenging, and it’s evolving with time, right. And again, this focus on, you know, having healthful patterns of living for the health of it not for the weight of it, is key. And, you know, and not talking about restricting or being on a diet, or you can’t have that or that’s not, you know, good for us, but we you know, we try to infuse our day with more of these, you know, helpful things, you know, sleep, focus on sleep, and focus on some of these other you know, factors, you know, for the other reasons than directly related to weight. So, we talk about that a lot. We also talk, you know, in what we call people first language, which is not to say, this is a, you know, 12 year old, obese female, because that really is stigmatizing in and of itself, like if you mentioned, you know, like as talking clinicians to each other, because it really sort of says that this female this 12 year old is defined by their disease, right? We don’t say this is a 12 year old, cancerous female. You know, we say this is a 12 year old with cancer, because she has a disease that’s unfortunately affecting her life. And that’s the same way with obesity. If someone has obesity, you know, we like to use the word obesity, you know, having obesity noticed earlier, we said affected by obesity or having obesity instead of obese, you know, people who are obese. And so we really want to focus on that patient first language we call it, which is to sort of rid the world of the word obese. And, and, you know, talk more about the disease process that ensues when we have that tendency towards excess body fat storage and how we’re trying to work on you know, getting rid of that fat instead of just, you know, changing our weight, right. So you can do that by not losing any weight. If you gain you know, five pounds of muscle and you lose five pounds of fat. Your weight doesn’t change at all, but you’re much better off from a standpoint of your body composition. And, and of how your body is going to see that, you know that that weight, right. So it’s really more of that focus on on, you know, towards our the health benefits of everything that we’re doing, versus the focus on just a number on the scale.

Khadijah  40:16

So this people first or patient first way of kind of reframing or talking about what the what is the problem, that’s the way to really help patients and our kids know that we kind of understand and we empathize with them, and that we’re not blaming them.

Angela Fitch, MD  40:32

Yes. And I think outwardly saying that to write that, again, this is a process that’s occurring in your body that that could lead to, you know, unwanted health effects, right? Or maybe there’s already unwanted health effects that are occurring. And, and so let’s focus on how we can you know, how we can make that better together as a team. Right. And I think that, that team approaches is where, you know, it’s parent team, or caregiver team or teacher team or, you know, whole school team, right? I mean, there’s a lot of teams at school. So trying to, you know, say, Hey, I have these people to support me, I think is critical.

Khadijah  41:09

We talk about bystander training for many different things. But when we hear people talking about weight in negative ways, or ways that are that that kind of fuel the stigma, do you have any suggestions? Because it can be hard sometimes to step up and stand out and speak up? Up? Do you have any suggestions of ways that we can intervene and help other people recognize that what they’re saying is hurtful and not helpful?

Angela Fitch, MD  41:33

Yeah, I guess just just saying that, you know, something that, you know, those types of words can be hurtful. So, you know, consider thinking about that a little bit further, right. And especially, we know, you know, from, as you are probably aware, you know, from like eating disorder, research that a lot of that also comes from people, you know, hearing people make those comments about people, right, so, having a family member, for example, that tends to make a lot of comments about people’s bodies, can also, you know, lead towards people, children, you know, developing disordered eating patterns from hearing that all the time. So again, it’s just something to say, hey, you know, maybe that’s not something we should be talking about, you know, that’s, you know, something individual to that person. And, and that’s that person’s own prerogative, and you don’t know, you don’t know what’s going on, you know, in that person’s life just by can’t judge a book by its cover, so to speak, right? And we really shouldn’t be judging anybody based on any kind of stigma, whether it’s racial, ethnic, gender, right, it should all be hopefully, based on what we talked about earlier. Right, which is, you know, getting to know people for who they are and their personality.

Gene  42:40

Well, I hope that many of the families that are listening, and in general will have conversations, I mean, it. It’s one of those things that so shameful for the teenager, for example, who is obese. But, but if we move in that direction, if we tend to have —

Khadijah  43:00

— struggling with obesity.

Angela Fitch, MD  43:02

They have obesity, yes.

Gene  43:05

Yes. Thank you.

Angela Fitch, MD  43:08

We all — I mean, we all do it. That’s the thing. It’s so like, ingrained in our culture and society, right. That’s where we have to really I mean, and again, we have to really kind of, you know, that correct ourselves, right?

Gene  43:20

Yes, I thank you for that correction, because it’s so easy to slip into it. And, and, frankly, conversations with corrections like that are super important, because it’s just the way we’ve been used to talking for so for so long. Now, is there anything that we haven’t discussed, that’s important, free for you to touch on?

Angela Fitch, MD  43:46

No, we covered a lot I feel like. But I just would, you know, again, touch on the, you reiterate the concept that that? That it is sometimes okay, right for people to to live in larger bodies, and that’s okay. Right. Having that outward discussion about that, though, is what’s critical, and understanding how that’s affecting the person. And really getting to the bottom of that, recognizing that in a, in a no shame, no blame sort of environment, that hey, you know, there is treatment for this. And we have treatment, as we mentioned, that produces, you know, eight times the outcome. That’s what we want to really strive to reinforce, is this is treatable, and we have people who can help you.

Gene  44:33

Thanks so much for tuning in everybody. And thank you, Angela. This was really great. Remember that for those who listening, we’ll see you back here on the third Thursday of next month. And if you’ve liked what you’ve heard, leave us a review. We hope that our conversation will help you to have yours. I’m Gene Beresin.

Khadijah  44:57

I’m Khadijah Booth Watkins.

Angela Fitch, MD  44:59

Thank you so much for having me.

<MUSIC INTERLUDE>

Angela Fitch, MD  45:06

I have seasonal affective disorder because I hate it when it’s not sunny. Well, I follow this. This guy named Dr. Haberman. He’s a neuro. He’s a neuroscientist. I can’t remember what his he’s out in California, I think Stanford or one of those places and he has a really interesting podcast. So he was covering like, you should go outside and look like face the sun. Like you have to look at the sun. For like, 20 minutes. <laughing> I’m like, How do you do that?

Khadijah  45:36

<laughing> That sounds dangerous.

 

Episode produced by Sara Rattigan

Music by Gene Beresin