Intro: Welcome to Pediatric Voices, Duke Children's podcast about kids healthcare. Now, here's our host, Dr. Richard Chung.

Dr Richard Chung (Host): Hello and welcome to Pediatric Voices, expert Insights about timely topics in children's health, brought to you by Duke Children's Hospital and the Department of Pediatrics at the Duke University Medical Center. My name is Dr. Richard Chung, a physician at Duke Children's and a co-host of this show.

Host: Today, we'll explore the topic of childhood obesity. Physical growth and development are central aspects of childhood and adolescence. Supporting all children and youth to view themselves positively and giving them what they need to be healthy is relevant to all of us.

To help us understand childhood obesity better, I'll be speaking with Dr. Sarah Armstrong. She is Chair of the Section on Obesity of the American Academy of Pediatrics, and a co-author on the new 2023 AAP Clinical Practice Guideline for the evaluation and treatment of children and adolescents with obesity. Here at Duke, she directs Duke's Healthy Lifestyles Program and is Division Chief for general pediatrics and adolescent health. Welcome, Sarah.

Dr Sarah Armstrong: Thank you so much for having me.

Host: So, this is going to be a great conversation. This is such a critical topic. And we have, in my view, one of the world's experts on this important subject. And before we get to that topic though, Sarah, I'd love to give the listeners a little bit of insight about you. I shared a little bit about your titles and roles, but can you tell us in more concrete terms, what do you do every day? What is your current work?

Dr Sarah Armstrong: Well, thanks for asking. I feel like I have one of the best jobs. I get to work every day alongside an amazing team of clinicians. And really, this is team-based care, so I'm working alongside other physicians, advanced practice providers, but also nutritionists, physical therapists, mental health professionals, community health workers, community members like leaders in the parks and recreation and YMCA community, and we really all bring such a different view to this challenge of childhood obesity. And being able to partner with children and adolescents and their families and understand their perspective, and what they need to be successful and be healthy to meet their own goals according to their values, is really just a real gift. So, that's been a real fun life journey for almost 20 years now. So, thanks for asking.

Host: That's really great. So, it sounds like a very team-based approach and it really is coming at these clinical or health issues from multiple different angles, which will be evident, I think, in our conversation. I know the other role that you play is in research and actually discovering new things so that we can do even better tomorrow and, in the future, for kids and families. Is that correct?

Dr Sarah Armstrong: Yeah, that's absolutely true. You know, I've long been interested in childhood obesity, not necessarily as just a function of behavior, but as a function in context of the environments in which children and families live. And so, it's been a real learning journey for me to partner with communities to do community-engaged research, so we can understand more about those contexts and those communities that influence child health at such a very basic level.

Host: Can you share with the listeners a little bit about maybe your personal and family background or how you kind of came into this field of children's health in the first place?

Dr Sarah Armstrong: Well, interestingly, I grew up with a brother who has developmental disabilities. And initially, I wanted to focus my work in pediatrics with children who have intellectual, developmental, physical disabilities. And when I got my first job out of training, what I realized is I had been very well trained to treat ear infections and other kind of illnesses of children. But really, what I was seeing, and this was in the early 2000s as the child obesity epidemic was really just ramping up, is that children that were affected by obesity were not able to live their daily lives similar to some of the limitations that I had seen in children who had other types of disabilities. And so, I became very interested in helping these children be able to meet their own goals for health, but also just for daily life and be able to do the things that they love to do, participate in those activities in the way that all children really should be able to. So, I came at it interestingly from sort of a disabilities angle, but then really got interested in the nutrition, physical activity, and community-based aspects of care.

Host: So, it sounds like really setting every child and young person up to succeed, to live a full life, regardless of what other health or developmental challenges they might encounter along way.

Dr Sarah Armstrong: Exactly. And whatever that means for them, right? Because it might mean something different for every child and every family.

Host: That's great. And we'll talk about that, sort of how do we get from a high level subject like childhood obesity and actually understand the individual in front of you, so that we can care for them well. Let's talk about that topic of childhood obesity. You know, whenever we're trying to share new information with different audiences, we like to start just with the top line headlines. You know, what are the two or three things you feel like all families should know about this topic?

Dr Sarah Armstrong: Well, I think first and foremost, Richard, families should understand that this is not their fault. And that goes against the grain of our culture. Everywhere you look, I think people really have been incorrectly made to feel like a person in a bigger body is just a person in a thin body who either ate the wrong foods or too much of them, or wasn't active enough, and that if only they would do X, Y, or Z, they could have this healthy, thin body. And that is just not true. And so, I hope that families listening really understand that here at Duke Children's, we take that approach, that this is a medical condition just like any other, and that it's not their fault and they will never experience blame or shame for seeking help, any more so than they would for seeking help for any other condition we hear from our providers.

Host: That's a critical point, and I think it gets at some themes related to stigma and the barriers to care that many young people and their families experience, which we'll get to in a bit. And so, it seems pretty analogous to, as you said, other medical conditions that, you know, we wouldn't blame somebody for seeking treatment for their asthma or for their other health conditions. Is that right?

Dr Sarah Armstrong: Absolutely. And the other thing that I really want families to hear and know is that effective treatment exists. Even just over the past five years, we've seen major breaking advances in treatment and how effective it can be. So, I think that's really important for people to know that there is hope for their children to be able to seek treatment, select the ones that are right for their family. Not everybody's going to pick the same thing, but there are choices and options that work. And so, I hope that message of hopefulness families could hear as well.

Host: That's great to hear, and we will get into some of those nuances in just a bit. I wanted to ask a little bit about body mass index or BMI. This is certainly a clinical term or detail that is sometimes used. It's also something that's commonly talked about and discussed. And I think probably with insufficient understanding and context. And so, can you tell families or other listeners what is body mass index? Is it helpful and to what extent is it?

Dr Sarah Armstrong: Yeah. Richard, thank you so much for asking, because I think there is a lot of confusion about body mass Index. So, you know, prior to 2000, we didn't even have body mass index on the growth curve. So, this was just added as of 2000. And there's a lot of concern about where does it come from. Who are the children that were measured that show us this body mass index? And for folks listening who haven't heard of body mass index or BMI as it's called, it's just a ratio of weight to height. And pediatricians and other healthcare providers plot that ratio on a growth curve and can tell parents what percent their child is related to other children of the same age and sex at birth that their child is.

So, for example, if your doctor says your child is at the 75th percentile for BMI, that means if there were a hundred children, you know, that were the same, that were boys like your child, and the same age, say 10 years old as your child, your child would have a higher body mass index than 75 of those hundreds. So, it's a little bit confusing and there's some math involved there, which is never easy. But I think in terms of the question where did that come from? Like, where do those numbers come from? They are now, they didn't used to be, but they are now as of 2000, representative of the whole United States. And their representative in the amounts that existed during the times those surveys were done, which were between the 1960s and 1990s. So in that time period, about 75% of the children were white, about 15% were black, maybe 8-10% were Hispanic, smaller numbers of Asian American Pacific Islander children and other. So if you are applying that number to one of those lower represented groups, it may not be exactly the right implication for that group because it's nationally representative data. So, that's kind of the challenge of taking a number that's based on a sample across the country and applying it to one individual child. It doesn't take into account their environment, their family history, all of those personal factors. But it is still a useful number.

And we've looked at so many other things. Waist circumference and hip to waist ratio and skin fold thickness. Nothing comes close to predicting a child's health as well as BMI. So while it has its flaws and I think we have to interpret it with caution and make it unique for every child, it still is a valuable tool for clinicians to use and knowing when do I check for diabetes? Should I be monitoring their blood pressure? Are they at risk for heart disease? It helps us as clinicians guide what tests we do. But I don't think families should feel like it's a judgment or a diagnosis or a decision that's being made about the child. It really just does help us help keep your child safe by doing the right screening tests.

Host: Sure. So, it seems like it is a potentially useful detail, a clue, to how we might best care for a particular kid, but it has to be interpreted within context and it has to be discussed with some nuance. I think the challenge of numbers, of course, you know, as somebody who works with teens primarily and families as well, is that numbers seem so pristine. They seem like they are very definitive and black and white and oftentimes families want those things, right? But it can also have this really double-edged effect, where a high number might feel like that judgment, even if it isn't necessarily expressed as such.

Dr Sarah Armstrong: I agree. And, Richard, that's on us as clinicians to make sure families understand that we're not making some sort of a judgment for a child who has a high BMI, that we are using it as a tool to know how best to care for that child. So, I think we can always improve and do better on how we communicate that with families and help them understand that as well.

Host: Now, this topic of BMI, is this related to the other term I often hear, which is a weight set point or some other kind of weight that a child is "supposed to be"? What does that exactly mean? How should families think about that?

Dr Sarah Armstrong: Yeah, that feels kind of frustrating too sometimes, right? If you're working really hard to change your body mass index to hear a term like weight set point, it feels like, "Well, wait, what? I can't change it?" Well, the truth is that there's many, many systems in the body that regulate our body weight. And those systems are very powerful. The way I talk to kids about it sometimes is imagine, for example, you tried to decide, "I'm not going to sleep anymore. I'm just going to stay awake all the time, because I could get so much more done." Eventually, your systems would take over and get you back to a point where you were sleeping because that's how our bodies work and those systems are super powerful.

Similarly, with a weight set point, our bodies resist starvation. I mean, we have had millennia of evolution to try to avoid starving. And so, those systems are really strong. And if we make ourselves hungry and we try to change our weight set point too quickly, those systems are going to kick in and just like it'll force us to sleep, it's going to force us to find ways to get back to that set point. So, it's not that it's not changeable, it's just that we have to be slow and patient about how we change that weight set point through positive changes in lifestyles that don't involve quick fix dieting or other things that sort of might feel like fad approaches to this. I often tell children, you got to slide beneath the radar of your body's set point. So, slow and steady wins the race with this one.

Host: Got it. Let's shift a little bit to some of the health impacts of increased weight and the reason why treatment is even discussed in the first place. And so, what are the medical or mental health or other health concerns that arise because of this?

Dr Sarah Armstrong: You know, Richard, when we were talking before about BMI and whether that's sort of the end-all be-all diagnosis. I think this gets to why we measure it in the first place and why we talk about this in the first place, and I think we can think about it in two categories. One is health risks that come with elevated BMI now and future risks that might come from elevated BMI. So, the things that could happen now for children whose BMI is in a high zone include early phases of chronic diseases like diabetes, high blood pressure, high cholesterol; a condition called fatty liver disease, which is just inflammation in the liver when it's trying to process too many extra calories. Families might notice in this pre-diabetes state a darkening rash around the back of the neck that might extend to the front, that's just the body kind of saying, "I'm having a little bit of a hard time processing the extra sugar in my body and I need a little bit of a break." Other conditions though that may be less well known to people are orthopedic things that might happen. So, sometimes knee pain, ankle pain, flat feet, other things can develop at this age, at early life that might lead to disability later. And we don't want to end up with young adults who have trouble getting around and moving because we didn't pay attention to these things when they were young.

And then of course, the emotional and mental health consequences. We know that depression is more common in children with obesity than it is in children without obesity. And some of that may be related to the obesity itself. Some of it may be related to the way the world treats kids, frankly, with obesity and how hard that can be for them to navigate the world, facing a lot of stigma and bias. So, those things definitely impact their overall emotional health and development.

Host: Thank you for mentioning that. Let's loop back to that topic of stigma and the mental health distress that that might create for a young person going through this experience. And so, what is weight stigma, if we could kind of put a finer point on it, how does that affect not only the care that they receive, but as you mentioned, the day-to-day experiences of a young person?

Dr Sarah Armstrong: Well, we know from lots of literature now that children with obesity, children living in bigger bodies, experience stigma from nearly everywhere. There is almost no aspect of their life where we haven't been able to document stigma. So, at school, both unfortunately from teachers and peers, they experience assumptions about their academic potential or about their lifestyle habits that may or may not be true. In their own homes, from well-meaning parents trying to help them make behavior changes, may feel more like reinforcing, bullying or teasing messages they heard at school; siblings can often be a source of stigma. In society and in the community, we see so many messages, particularly in children's media. Unfortunately, weight-stigmatizing messages are actually more prevalent in children's media than in adult media. And if you're not sure about that, think to any sort of animated film you can think of and maybe the character in a bigger body and you'll think, "Oh, I see. They are making assumptions about personality that may not be necessarily positive."

And then, last, but I think really important to acknowledge as a healthcare provider myself is the health system is a really important source of stigma for children. I think well-meaning healthcare providers and nurses, physicians, all the way up and down the healthcare system try to reinforce that healthy body weight's important, but may ultimately make assumptions about what people are or aren't doing. And that leads parents and children and teenagers to avoid care because they don't want to hear those stigmatizing messages. And it can also lead to missed diagnoses if, for example, knee pain is attributed to excess weight without an x-ray to document that there's not something else going on. So, there are harms for children that are emotional but also physical that are associated with weight stigma.

Host: So, it sounds like due to the broader societal context, this is a really kind of fraught area of conversation, particularly for a young person who's going through development and trying to figure out who they are and trying to develop a sense of self-esteem and worth and value in this world. And a question that's coming to mind is just how do we then talk about this. If the baseline is this kind of stigmatized and pretty hostile environment, how does, let's say, a parent at home engage their young person in this kind of conversation? Or how does the doctor raise the conversation without also doing harm along the way?

Dr Sarah Armstrong: It is a really tricky thing to do and this is a question that comes up all the time. I think we have two things going on. One is that there's a loud growing voice out there saying we should leave people with obesity alone, not talk about it in healthcare systems at all for fear of doing harm. Well, I don't necessarily agree with that because, as I've mentioned, there are real health risks associated with obesity, and there are successful treatments, both for the obesity itself and for the comorbidities that can be life-extending, life-saving, life-enhancing that we wouldn't want children not to have access to. So, I think we are in a position where we have to address this. And at the same time, we know that if we address it in a way that makes assumptions about people and their lifestyle habits and behaviors, then we can also do harm to families by being one of those sources of stigma. So, it does feel like, as a parent or as a healthcare provider, sometimes very much caught in the middle of these things.

I think as with any other health condition, emotional or physical health condition, if we can come at it from the place of what are your values and goals, how can we better understand your health, what you would like to achieve, and how can we work together to support that, I think that we can both help children improve their health and reassure them that we are not blaming them for their own health condition or shaming them or stigmatizing them for that. So, I think starting with the patient and family, if you're a parent talking with your child about it, just asking really open-ended questions. You know, what are your concerns about this? What are your goals? What are your values? How can I help you meet those? And is it okay for me to discuss some potential treatments that you might be interested in? And it's okay for you to say, "No, that I'm not interested in that right now," and that's okay too. So, really open-ended questions, asking and really careful listening, I think is how we're going to navigate this tricky thing together.

Host: That's very helpful. So, it sounds like starting really with a focus on the individual, right? And their experience affirming their value and worth and all of the wonderful things that they bring to each day. But also, then informing them of all the options available. And working with them through your expertise as well as the families their own expertise, right, on who they are and what they value and what they care about and trying to navigate that together without any pre-judgment about one thing or the other. That sounds like a really helpful approach. Let's get into the treatment.

So, I mentioned at the top that you were one of the key authors of this clinical practice guideline. And for the audience who isn't in medicine, these are kind of landmark documents that are meant to really guide practice broadly across a variety of settings. And so, what are the treatments available and what changes might be worth mentioning over the past several years?

Dr Sarah Armstrong: There are a lot of changes over the past several years. And I think some people feel like maybe the changes are moving too fast. Some people feel like it's not moving fast enough, but we're fortunate to be in this place. So, the treatments that we have now fall generally into three buckets: behavioral changes, medications and surgery. And so, this is a very wide range.

So in the lifestyle change bucket, what we are not talking about is we're not talking about putting children on diets. I have to be really clear about this, because I think that has been a lot of the concern that when healthcare providers start to help children with obesity, that we're going to do harm by putting them on diets. Children really shouldn't be on any kind of restrictive eating patterns or programs early in life. We know that children who do diet or have restrictive eating patterns are both more likely to develop obesity later in life because these things are generally short-lived and don't work very well, and they're more likely to develop disordered eating patterns and really ruin that important relationship with food. So, just to be really clear when we're talking about lifestyle changes, what we're talking about is helping develop patterns of eating where we recognize our internal cues for hunger and fullness. We're really mindful about enjoying the foods. We're encouraging family eating together at home to foster the relationship that builds around family meals, encouraging more healthy food consumption and activity movement that's joyful. This should not be a no pain, no gain of the 1980s. It's really, you know, activities that make you happy, make you feel proud of your body and make you feel good. So, that's the lifestyle bucket that really I think has been misunderstood, but really is intended to be a partnered activity with families.

Host: Now, the question of medication and surgical options in this space may be unfamiliar to families. So, how do you talk to families about the role of those specific options in the current landscape?

Dr Sarah Armstrong: Yeah, of course. Now, this may change as early as two weeks from now, because this is all changing very rapidly, but there are new classes of medications that have really just been discovered that have led to the development of these new, what we call GLP-1 agonists that you may have heard of in the news, that go by the names of things like Wegovy and Ozempic, Victoza, Saxenda, some of these fancy-sounding names. These medications are injectables. And so, that's one thing parents should really know about. Some are daily, some are weekly. And there is another medication too that's taken by mouth, but has some other limitations as well. But these medications generally for ages 12 and older, although there are some studies in younger ages that are coming up, really are quite effective in helping to turn down the food-seeking, craving behavior that is really hard to overcome when you're trying to implement a healthy lifestyle. So, they're not weight loss medicines per se. They really help people who have trouble with hunger and appetite and waking up in the middle of the night seeking food or between meals always seeking food. Parents, who can't keep their kids away from the kitchen because it's really a very strong drive, can really help turn down the dial on that, so that they can make those healthy changes. And these medications have been shown to be very effective in combination with lifestyle treatment.

Host: So Sarah, we've talked about behavioral approaches as well as medications. You mentioned surgical options as well. So, how do you talk to families about that?

Dr Sarah Armstrong: Yeah. Now, this is a situation that not all families obviously would opt for, but there are some children who develop such severe degrees of obesity that becomes really limiting for them or maybe they have a health problem that's very significant and threatening to their health. Surgery really is a definitive way to help treat the obesity and those comorbidities at the same time, and we know that it is safe and effective.

So here at Duke, we have the only adolescent-certified program, where we are credentialed to do bariatric surgery in teens age 14 and older in the state of North Carolina. So, we do see folks from all over who really have those very specific needs and more severe situations. We work with the Duke Metabolic and Bariatric Surgery Program. They're excellent and they're wonderful with teens, you'd be happy to know. And so, we're able to really partner with them to make sure children are evaluated and informed and educated with their families before the procedure, select the right procedure that's right for them, and then have long-term followup between the two programs. So in this circumstance, it really is safe, effective and life-saving for the children who need that.

Host: I wanted to sort of shift gear to the world outside the clinic. So, there's a lot of evidence to show that there are societal factors, structural issues, that make it more or less likely that an individual child, depending on their circumstance, might run into challenges in this way. And so, how do you think about that as an obesity specialist and how do you work on that yourself?

Dr Sarah Armstrong: Well, it's an ever-changing topic. But right now, what we do know is that there are significant and concerning disparities among children of different races and ethnicities and socioeconomic backgrounds in terms of both how common obesity is, how severe obesity is and how often children develop the health problems related to obesity.

Richard, I'm going to be honest, we don't fully understand all these things yet. But I think what we do understand is that when we assess a child who has a high BMI, we absolutely have to take all of that environmental context into consideration. We have to understand where their families come from, what barriers they've experienced, and things like food insecurity plays a huge role in just access to healthy food, and also safe neighborhoods, places to play. So, the new clinical practice guidelines are very clear about assessing the whole child, not using just that number, but really thinking about all those things when we develop a care plan to make sure that there are solutions in place for families for some of those barriers they may be experiencing.

Host: Related to that, as a thought experiment, this might be a little bit of a stretch, but knowing you, Sarah, it's not an entire stretch of the imagination. Let's say in several years you are President Sarah Armstrong of these United States, what is the first policy change you would advocate and even implement to improve the health of children in our community?

Dr Sarah Armstrong: It's a hard situation to imagine. Not sure I even want to imagine that. But I think really the area that from a policy perspective that we could most influence the health of children would be in the ways that we feed them using all of the public benefit programs that we have. So, this includes the foods that are on the Women Infant Children Program, how we feed pregnant moms and then provide food for children whose parents can't afford the food early in life; the SNAP program, which picks up on that and continues to provide access to resources; and the school lunch program, which then picks up children in the public school system. Those programs have shown to influence health and improve health. But I think there's a long list of ways that we could improve those programs. Ensuring that the foods that we provide children are healthy, and that all children have access to those foods on a regular basis. So, I think really focusing on that early life feeding structure could be really beneficial.

Host: Wonderful. Well, I'm voting for you, Sarah. So, just let me know when that campaign begins. We'll kind of round things out here. Thank you, Sarah Armstrong, for coming and sharing your expertise on this really critical topic. I think we started with a quick view into your sort of upbringing and how you came into children's health. And you mentioned just your focus on helping all children and youth really live full, healthy and thriving lives regardless of what health circumstances or otherwise they might encounter. And we talked a bit about the evolution of understanding around increased weight and obesity in children and youth and evolutions in how we discuss and support and also treat in specific circumstances. You emphasized the importance of really looking at the individual child and the individual family to understand who they are specifically, not just as a data point on a growth curve, but really as a whole human being. Affirming who they are, what's going well for them, and really supporting them to thrive in the ways they want. And then, really informing them about what options are available, so that they can make informed decisions that are right for them and their family. We also pointed out that it's a complex environment with all the stigma and other negative dynamics that are swirling around us. And so, we have to be quite sensitive and thoughtful as caring professionals, because we first want to do no harm certainly while we help children over time. So, thank you, Sarah, for sharing your expertise.

Just to kind of round things out, separate from this topic, what inspires you most day to day? You know, healthcare professionals are under a lot of pressure and are tired. But what inspires you? What keeps you going?

Dr Sarah Armstrong: I think the thing that inspires me most, Richard, and this is probably true for you too, are the patients that show up every day to do this hard work. This is my job. I mean, I come to work to do this. But they're choosing to come and share these hard journeys, make themselves vulnerable. As I mentioned before, like healthcare experiences have not always been positive for these families. But to be able to show up, these children and parents have such bravery in doing it, that every time I meet a new family or get to journey with the family through this, it's so inspiring. And I have so much humility for the hard work that these families are able to do to overcome big barriers. So, it's really just such an honor to get to work with the families.

Host: It really truly is for sure. And I definitely resonate with that. It's incredible to enter into the lives of different young people and their families and just see that they're just trying to do their best and coming alongside them and just making it at least a little bit easier for them to thrive and to live full lives. I think it's just such a privilege. So, thank you again, Sarah Armstrong.

This is Pediatric Voices, produced by the team at DoctorPodcasting. Thanks to Dr. Ann Reed and the administrative team at Duke Children's for their support. Find our show and hit the subscribe button wherever you find your favorite podcasts. Also, we would love to hear from you. You can connect with us at dukechildrens.org or on Facebook, Twitter and Instagram. Please send us your feedback about the show, including suggestions for future topics. Thanks for being a part of the show. I look forward to talking with you again.