John Donvan

This is Open to Debate. I’m John Donvan. Hi, everybody. Around this time last year, the American Academy of Pediatrics put out a press release where the first sentence sounded an urgent and concerning kind of note, it began by saying, “More than 14.4 million US children and teens live with a common chronic disease. That disease is obesity.” The Academy had just published a new set of guidelines for treating kids who are overweight or obese, as defined by a measurement called the BMI, the Body Mass Index.

While acknowledging that there’s an interaction of all kinds of factors involved in kids putting on weight, the guidelines also called for early intervention, including trying to change what and how kids eat early, including the use of drugs. Think Wegovy and Ozempic for kids who have reached the age of 12, and bariatric surgery for kids who have reached the age of 13, if their weight is at the higher end of the BMI range. Right out of the gate, these new guidelines proved controversial and in the months since, the arguing has not abated one bit with disagreements that are as much philosophical as they are medical. Given that the health of millions of US children is at stake, physical health as well as mental health, this was an argument that we’ve been wanting to visit in the way that we do at Open to Debate.

So here we are in time for National Nutrition Month, ready to ask this question, are the AAP’s child obesity guidelines good medicine, or are they too extreme? So let’s meet our debaters arguing that the AAP’s childhood obesity guidelines are good medicine. We have Dr. Julia Nordgren. Julia is a pediatrician who specializes in childhood obesity, cholesterol issues, and nutrition. She’s an attending physician at the Stanford Weight Clinic, as well as the lipid and weight management specialist at the Palo Alto Medical Foundation. She’s also a trained chef and has a cookbook called The New Family Table. Welcome, Julia, to Open to Debate.

Julia Nordgren

(laughs). Thank you so much. It’s wonderful to be here.

John Donvan

And arguing that the answer to that question is that these guidelines are too extreme, we also have another pediatrician, Dr. Janna Gewirtz O’Brien. Janna provides care to adolescents and young adults at the Hennepin Healthcare Clinic in Minneapolis, and she teaches at the University of Minnesota Medical School. She also serves on the executive board of the Minnesota Chapter of the American Academy of Pediatrics. So she is not opposed to the AAP in general. Welcome, Janna, to Open to Debate. And you have a little bit of a disclaimer you wanna make on that last point I think.

Janna Gewirtz O’Brien

Yes. The d- views I discuss today do not represent the University of Minnesota or the Minnesota Chapter of the American Academy of Pediatrics. These views are my own.

John Donvan

Okay, thank you for that clarification. And I, I want to ask you something else, a question I actually wanna put to both of you. I’m just cu- curious, what motivates you when you got into this field to wanna work with kids? And wa- since you were the last to speak, Janna, why don’t you go with that question?

Janna Gewirtz O’Brien

Sure. So specifically I’m a specialist in adolescent medicine, meaning I’m an expert in adolescent and young adult health ages 11 to 24. And I came into this field because I love walking alongside young people and their families and supporting them as they grow and seeing them develop into humans that love themselves and actualize their identities and goals.

John Donvan

You care. It’s c- very, very clear. And Julia, we know you care as well, but I’d just like to know again, the, the origins of your interest in working with kids.

Julia Nordgren

Yeah. I am very similarly minded. I think so many of us go into pediatrics because we have the opportunity to be with children and walk them through the most critical parts of their lives. And I think another wonderful thing about pediatrics is that we can all always be on the same page. We want these kids to grow up to be healthy and strong.

John Donvan

I am hearing some common values, but we are here to debate. So we’re gonna-

Julia Nordgren

We are.

John Donvan

… we’re gonna be listening to you disagree on a couple of things, and we want to hear what those things are right now by moving into our opening statements. Julia, you’re up first. And again, the question is, are child obesity guidelines good medicine or too extreme? You’re saying good medicine. Tell us why.

Julia Nordgren

Yes. Well, these are great medicine. So I have been taking care of kids with obesity for two decades. And finally, dawn is breaking on a new era of obesity management for children and adolescents. This new beginning was really ushered in by the AAP with these practice guidelines. And they are so well-researched, they are so well-intentioned. These are long overdue guidelines. They understand the science behind obesity, the complications, and the complexities of caring for these patients, and what treatments might actually help these kids get better. For so many years, we’ve all struggled with caring for children with obesity. It’s hard to talk about. No one wants to have a conversation that makes parents feel blamed or makes kids feel embarrassed or ashamed of themselves. No, it might be more comfortable just to be hopeful and optimistic that no, they’ll just grow out of it.

Julia Nordgren

But the problem is that just doesn’t work. There is no evidence that supports watchful waiting as an effective treatment for obesity. This is a disease that most kids will not outgrow, and the longer we wait, the worse it will get. I hear the facts. A child who has obesity by age three has a 90% chance of being an obese adolescent and adult. A 12-year-old with severe obesity is virtually guaranteed to become a severely obese adult. And a severely obese adult we know they have a shorter lifespan, they have a lower quality of life, and they’re riddled with health issues, diabetes, early heart disease, infertility, obesity related cancers. I mean, the list goes on and on. And these are real problems. We just can’t pretend that these kids with obesity are just happy and healthy kids. With a high measure of weight for height, many of them are really suffering.

Julia Nordgren

They’re tired, they don’t feel well. These are kids more at risk for depression, anxiety, high blood pressure, sleep apnea, back pain, leg pain. And these kids are teased. I mean, they’re teased not only on the, on the field, or, uh, in school and PE class, they’re teased by their siblings and they’re teased by their parents. It’s such a hard problem. And the stigma about obesity, it’s so real and we really need to address that. But in the meantime, we need to understand something important. Obesity is not a matter of willpower. This is not a moral failing on the part of children. This is a disease and this is not a disease only for parents who don’t care about their kids. Really, the opposite is true. Obesity is a multifactorial, chronic relapsing disease. It has genetic underpinnings, it has environmental societal inputs, and it’s a disease state that lies in the hormonal and neurologic pathways that control appetite and energy regulation.

Julia Nordgren

And as the body develops excess adiposity or fatty tissue, these pathways reset to maintain and preserve the new body mass. So this altered energy regulation system is the physiologic root to this disease. And of course it can be stabilized somewhat with diet and exercise changes, but these hormonal and neurologic systems are altered. And this has lifelong effects for children. But thankfully, we have some new effective tools. We have medicines that are so promising, they are so effective. We have surgical treatments that lead to durable weight loss and a true reduction of disease burden for these kids. And the AAP guidelines are a roadmap for us, and they help us as caring, compassionate pediatricians do what we do best. We can treat kids expertly with empathy so that they have the tools and the treatment that they need to have a long, healthy, and amazing life.

John Donvan

Thank you very much, Julia. And Janna, it’s your turn now. You are arguing that the child obesity guidelines are too extreme. This is your turn to tell us why.

Janna Gewirtz O’Brien

Yes, thank you. So as a board certified pediatrician and an adolescent medicine physician with expertise in eating disorders, these guidelines are too aggressive, recommending intensive and potentially harmful interventions for up to one in five children and adolescents is dangerous. And if implemented, they can cause serious harm to children and adolescents in the short and the long term. Think about the kids and teenagers you know in your lives. Their bodies are changing, they’re figuring out who they are. They’re navigating a complex world that’s full of messages telling them what they should and shouldn’t look like.

Janna Gewirtz O’Brien

They’re hearing online and offline that their bodies are a problem. And that thin bodies are an ideal, an ideal that emerged three to four decades ago and has been internalized in the form of diet culture and a massive, highly profitable diet industry and pharmaceutical industry. These guidelines again suggest that one in five of these children and adolescents and their families should hear the message that their bodies are not okay at every single healthcare visit with their doctors, and that they should receive aggressive medications and/or weight loss surgery.

Janna Gewirtz O’Brien

Again, that’s one in five kids that we’re telling that message to. I take issue with three major points in the AAP guidelines. First of all, the guidelines suggest that medical decisions hinge on the basis of body mass index or BMI, which is an inherently flawed measure that is not a reliable surrogate for health. It was developed as a population health measure, interestingly, by a statistician and astronomer. It was primarily developed among white men in the 19th century in Belgium.

Janna Gewirtz O’Brien

Even the American Medical Association made a statement in June 2023, recognizing issues with us- using BMI as a measurement due to its historical harm and its use for racist exclusion in the years that followed its development, and because BMI is primarily based on data collected from previous generations of non-Hispanic white populations. It also doesn’t account for muscularity, which is why many muscular people are told that they’re “severely obese” and it doesn’t account for puberty and variation in normal body size, which are both really important during the adolescent years.

Janna Gewirtz O’Brien

Second, even if we were to assume that everyone living in a larger body were a problem and that larger bodies are a problem and are all sick, these aggressive interventions, including weight loss pills in children as young as 12 and surgery for kids as young as 13, are potentially dangerous, are just not that effective in the short or the long term, have major risks. And we have very little information about how they affect growth and development among children and adolescents. They’re expensive, they’re also difficult to sustain even if they are funded and stopping them leads to rapid ups and downs in weights called weight cycling, which we know are actually dangerous for health.

Janna Gewirtz O’Brien

Finally, there is evidence that eating disorders can and do emerge as a result of weight loss interventions. And I see young people in my practice all the time who develop disordered eating after hearing from their doctors that their weight is too high. This is such a concern that the Academy of Eating Disord- for Eating Disorders and several other large eating disorder organizations immediately put out statement opposing these guidelines. With 50% of female adolescents having engaged in some form of disordered eating, we need to take this seriously. And yet the guidelines fail to mention eating disorders beyond a single statement and did not include any people with eating disorder expertise or for that matter, anyone with lived experiences of eating disorders or any fat people in the development of these guidelines.

Janna Gewirtz O’Brien

And finally, I’ll close with this. These guidelines reinforce weight stigma and the thin ideal, which is rooted in racism, classism, and sexism, weight stigma and anti-fat bias and discrimination are a threat to health. In fact, in 2017, the AAP put out a strong policy statement titled Stigma Experienced by Children Adolescents with Obesity, as we heard from my colleague, and outline the physical and mental health effects of experiencing stigma. “It’s associated with social isolation, avoidance of healthcare, decreased physical activity, poor mental health, increased morbidity and mortality independent of a person’s excess weight.” And I’m gonna put that in quotes. These guidelines acknowledge that, and yet they do almost nothing about it beyond saying, “Ah, this is a problem. We need to address it.”

John Donvan

Thank you very much Janna and Julia. Now we know where each of you stand and why on the question that we’re asking. We’re gonna take a quick break and when we come back we’ll get deeper into the conversation. The question we’re taking on the childhood obesity guidelines, are they good medicine or too extreme? I’m John Donvan. This is Open to Debate, and we’ll be right back.

John Donvan

Welcome back to Open to Debate. I’m your moderator, John Donvan. And we’re taking on this question, the child obesity guidelines, are they good medicine or too extreme? We’ve heard opening statements from our two debaters, Julia Nordgren and Janna Gewirtz O’Brien, both pediatricians. Julia, whose work with kids focuses on issues related to obesity and Janna who works with adolescents. What I heard you saying in your opening arguments, again, I, I, I think it’s clear that you both have the, uh, the best outcomes for kids in mind, that you both like working with kids and you’re very committed to it, but you have a fundamental disagreement about certain aspects of these guidelines.

John Donvan

Julia, I hear you saying that you think they’re good medicine because they’re well researched, they address the science. What’s new tools recently, especially in the hands of doctors, to actually have an effective and durable impact on, uh, kids who are seen as putting on too much weight? You make the point, it’s not about willpower, it’s about biology and that the biology needs help and that the help is there now and you’re in favor of putting that in place. And if that’s not happening, you are concerned about the 90% of kids who are obese, uh, remaining obese through the rest of their lives and bringing in a, a rash of, uh, health problems that we’re all familiar with, including diabetes, heart disease, shorter lifespan, and certain kinds of cancers.

John Donvan

Janna, I’m hearing you saying that having a larger body does not mean that you are sick. You find these measures to be too aggressive, especially as they would apply to one in five children. You’re saying that their impact could be dangerous, that they’re built around the notion that a thin body isn’t ideal and you’re arguing that it’s not. You point out that the BMI is flawed, it doesn’t account, for example, for muscularity and the therapies themselves, you’re saying, and the science is not really that clear that they are effective in the long term.

John Donvan

And there’s a certain also, uh, an impact on mental health and physical health with the possibility that when kids feel stigmatized by being told that they need to lose weight, that can result in eating disorders. So there’s a lot to dig into there. And I wanna go back to you, Julia, and ask you very fundamentally, what do you think would be the outcome of a world in which these guidelines had not been issued? Or if they’re so criticized that at some point the AAP would rescind them. In other words, you’re talking about the good of having these things there. What’s the bad of having them not there?

Julia Nordgren

Well, the bad of having them not there is we’re just rudderless as physicians that we just don’t have any science or effective treatment or parameters for having clear discussions about what might really be going on with these kids. The argument that we’re telling kids that they’re sick, that’s just untrue. If kids come into us with a high BMI or an abnormal pattern of weight gain, kids who have gained weight throughout the pandemic, these kids are coming to us with concerns with abnormal growth patterns. That’s our job. Our job is to do pattern recognition.

Julia Nordgren

As pediatricians, you don’t ever look at one moment on the BMI and say, “Well, you’re severely obese.” I mean, that’s just, that’s just absurd for… to, to think that, uh, that caring pediatricians are using this as the only measure of counseling parents or patients on, on whether or not they have something that needs to be fixed. If we don’t have clear evidence-based scientific guidelines that help us have conversations about treatments, we’re just sitting watching these kids develop early diabetes, early heart disease. I mean, your kids in clinic, you’re seeing kids with PCOS, and, um, trouble, you know, menstrual irregularities. I mean, these are problems that are rooted in obesity.

John Donvan

What I think I hear you saying is that the status quo is unacceptable because the status quo-

Julia Nordgren

Totally.

John Donvan

… is resulting in more kids having these issues and having them into adulthood. And I want to take that to you, Janna, that something needed to be done, something dramatic needed to be done. Do you agree that something needed to be done at around or before the time these guidelines came out?

Janna Gewirtz O’Brien

Um, well, yes. I think something dramatic does need to be done. I think doctors including us, need to look inward at our own bias. There is immense stigma in healthcare. It’s documented that one in four nurses with which a person interacts thinks that a person living in a larger body is disgusting. It’s documented that medical professionals starting in medical school think that people living in larger bodies are lazy and will make poor decisions about their health. And this has been documented over and over again in the literature. So yes, I do think something dramatic needs to be done and needs to be us looking inward. I also just wanna tackle for a second something that was said. It was said that our do- our job as doctors is to help do pattern recognition. And to watch… our job is to doctors is to help young people grow and thrive.

Janna Gewirtz O’Brien

And right now what I’ve heard loud and clear is that helping young people growing and thriving means telling them on the basis of BMI and BMI alone. And let’s just be clear, I wanna point that out. These guidelines are saying if somebody is overweight or obese, and even if they do not have any of the diseases that Julia mentioned, that they should still be recommended medications as young as 12 and referred for bariatric surgery as young as 13 on the basis of a number alone, which is BMI, which is flawed racist classes and sexist.

John Donvan

Janna, I’m, I’m, I’m jumping in just because you’ve said so much, I wanna let, uh, Julia respond to the, the whatever part of that you would like to first, Julia.

Julia Nordgren

Yeah. The assumption that a pediatrician that recognizes a high BMI that isn’t using their clinical judgment to say, actually you’re extremely muscular. Nobody’s gonna take that extremely muscular football player that doesn’t have abdominal adiposity or true adiposity.

John Donvan

Can you use the… explain the term adiposity for folks who don’t know?

Julia Nordgren

Sure. Adiposity just means fatty tissue. So that the argument here is hinging on having a larger body is wrong. Well, that’s just untrue. Bodies come in all shapes and sizes. We are pediatricians, we understand that and we celebrate that. The key thing here is what is causing disease in the short term and the long term. It’s abnormal development of excess adiposity. Is BMI a perfect marker of excess adiposity? No. BMI does weight for… it’s a measure of height for weight. So it does not take into account muscularity, it doesn’t take into account breast tissue, glandular tissue, uh, density of bones. There’s so much that’s unaccounted for, but it actually is the best, cheapest, most effective marker or measurement that approximates excess adiposity that is harmful fatty tissue that causes disease.

Janna Gewirtz O’Brien

Yes. So BMI I’ve already shared, developed and has been primarily validated in white non-Hispanic populations. It cannot be broadly applied. It also doesn’t account like we were talking about for puberty. The other piece is this guideline specifically doesn’t actually include any studies that look at anything else aside from BMI. They excluded specifically any studies that focused on lifestyle changes alone, even though the American Heart Association themselves has documented that specifically physical activity and cardio respiratory fitness are actually great predictors of health over time.

John Donvan

I d- But are, are you suggesting that, that Julia’s position is that the BMI is the be all and end all? Because I don’t think that’s what I hear her saying. I think she’s arguing that it’s a starting point.

Janna Gewirtz O’Brien

Julia’s position is stating that BMI should be taken in context. These guidelines, however, specifically state one of their key action statement is that on the basis of BMI alone, someone should intervene. So I think Julia’s statement is absolutely what pediatrician should do. Take it as a small, small, small point in time. And I think many pediatricians in this course of a 20 or 15-minute long well visit are saying, “Sorry, your BMI is too high. It’s a problem.” And then they’re intervening with potentially problematic statements that in- that include weight stigma.

John Donvan

Julia, do you have, do you wanna say anything else about the BMI in response to what’s just been said?

Julia Nordgren

I think BMI is, it’s a really an excellent marker. I mean, I… regardless of its historical beginnings, I mean that’s a whole other conversation

laughs) about everything in medicine, we have normative values, we understand normal patterns of growth, and we can see this, you’re doing a physical exam, I think you’re missing the point. BMI is a very, very good surrogate marker of excess adiposity that causes problems. It should be taken with all these other things. So I-

Janna Gewirtz O’Brien

I think-

Julia Nordgren

I, I, I don’t think-

Janna Gewirtz O’Brien

I, I think-

Julia Nordgren

… the beginnings of the… how-

Janna Gewirtz O’Brien

The normal… It’s not about the origin though. It’s also about that it’s primarily been valid- validated in predominantly white non-Hispanic populations in the last 20 years. And that is, and the norm that we’re applying is a one size fits all approach that doesn’t recognize the wide diversity of bodies that exist among adolescents and deviations in when puberty begins in both across different populations. And it leads to people being mislabeled and labeled as diseased, as having a chronic illness even when they followed along the same curve for BMI, even by our normative values for their whole lives.

John Donvan

All right. Jan- Janna-

Julia Nordgren

But that’s just not correct. That’s just not correct.

Janna Gewirtz O’Brien

That is, that is correct.

Julia Nordgren

It is not.

Janna Gewirtz O’Brien

I see it in my practice all the time.

Janna Gewirtz O’Brien

Tell that to the young person I saw earlier today who was told that her body was a problem, even though she’s trended at the 95th percentile for her whole life and then rapidly lost 20 pounds after starting a weight loss medicine and is profoundly undernourished.

Julia Nordgren

Well-

Janna Gewirtz O’Brien

And their family.

Julia Nordgren

I’m assuming they’re seeing a girl with an, an eating disorder. So this girl has a different disease, so she’s talking-

Janna Gewirtz O’Brien

It is not a different disease.

Julia Nordgren

… about a girl with a different disease.

Janna Gewirtz O’Brien

It is not a different disease.

Julia Nordgren

A 20-pound weight loss is anorexia. That’s a different disease than obesity.

Janna Gewirtz O’Brien

I wanna be clear this-

Julia Nordgren

They sometimes go together. These diseases go together. We are not comparing the, when we’re looking at a BMI chart for someone who is black or Hispanic or Asian or white, we are not comparing their BMI in that moment to a white child’s BMI at a different moment, we are comparing their BMI to their prior BMI to their prior BMI. We are looking at trends for them and them alone. We are not pitting one racial group against another racial group. We are not discriminating against a child because they are white or because they are black or because they are Hispanic. We are looking at their body mass index. We are assessing their excess adiposity and their personal risk of disease in the present and in the future. We are not in those clinics exhibiting racist behaviors when we’re assessing a child and their health and wellbeing in the moment and making risk assessments for the future. And it’s just not true.

John Donvan

Let’s move on. Let’s move on to pa- pa- uh, beyond the BMI question to the res- type of response questions. So the, the guidelines also call for the use of pharmaceuticals for, for, for 12 year olds and bariatric surgery for 13 year olds if they’re at the higher end of the, of the weight range. You made the argument, Janna, that the science really is not in on the impact of the pharmaceuticals. Can you take a minute more to explain your position on that?

Janna Gewirtz O’Brien

Oh, absolutely. The ones I’m very concerned about, I’ll start with, are the ones that have more recently come out onto the market, market. Wegovy, which you mentioned being recommended for children. This has certainly not been evaluated over a long period of time. The studies on it originally in adolescents actually screened out anybody with any mental health concerns. There’s high rates of GI upset with it. There’s some speculation about poor mental health outcomes with it. But I think the most important thing with it, aside from being extremely expensive and most of these studies being highly profit-driven, is that after more than two years, most of these adolescents, as soon as they discontinued it, gained the weight right back.

Janna Gewirtz O’Brien

And weight cycling itself is not actually something to be taken lightly. It is potentially dangerous. It is associated with the higher risk of all cause mort- all cause mortality, meaning these rapid ups and downs in weight. And actually it’s thought that a lot of the correlation that Julia was talking about between weight and physical disease is at least to some extent, attributable to this idea of weight cycling. Things like Wegovy and other medicines like phentermine, topiramate lead to distorted patterns of behavior and they don’t do what actually what Julia advocates for in her blog, which are like developing a healthy relationship with food over time.

Julia Nordgren

Well, I’d like to point out that these things can and absolutely should be done at the same time. And any pediatrician or any physician who’s prescribing weight loss medications without advocating and working and talking constantly about developing a healthy relationship with food, first of all, there’s… if you’re not taking time to talk about that, you’re not worth yourself as a pediatrician. That is our job. We need to be helping kids love their bodies, accept their bodies, care for their bodies, developing a healthy relationship with delicious, nutritious food. And that is the foundation of health. So anybody who is getting a prescription for weight loss medications, if they have a good pediatrician and educated pediatrician, they have done their work of lots of counseling about what is a healthy relationship with food like, how can I improve that? What do you feel? Like, what, what, what are your flavors that you love? How can I help you with habits?

John Donvan

But, but Julia, whe- whe- but where are you on the challenge to the, to the impact of the medication that Janna brought to you?

Julia Nordgren

Okay. So first of all, a healthy relationship with food goes hand in hand with weight loss medications. These are not diametrically opposed. They should be done together at the same time repeatedly. One interesting point that Janna makes is that this weight cycling going up, going down is harmful. So let’s be clear, chronic obesity is a harmful disease. Left untreated, it causes medical problems. Kids who are obese have concurrent problems. They have joint pain, they have back pain, they have sleep apnea. If we treat this disease for two years, so like any chronic disease treatment, when you treat it and then you stop treating, yes, that disease comes back because it’s a chronic disease. So I hear you arguing, which seems implausible, that, oh, you should just stay obese because if we treat your obesity and then it comes back after two years, well, that could be bad for you. Well-

John Donvan

All right. Time out. I, I, I wanna ask Janna if that is in fact what you’re saying. That’s an interesting crystallization of your argument.

Janna Gewirtz O’Brien

That’s actually not what I’m saying. What you are proposing is that they go on a medication that is potentially harmful and dangerous with a large side effect profile that also pathologizes their body. And then as soon as they go off the medication, they go back to the prior, almost always, go back to the prior curve that they were on or back to the prior growth trajectory they were on. That’s not a return of the disease, that’s a return to the body that was a healthy weight for them potentially.

Julia Nordgren

But it wasn’t.

Janna Gewirtz O’Brien

And they’re recommending-

Julia Nordgren

(laughs).

Janna Gewirtz O’Brien

But they’re… you haven’t actually, you haven’t actually said that though, because these guidelines are only making this point on the basis of BMI alone, even in kids without diabetes, without PCOS, without, uh, obstructive sleep apnea. And-

Julia Nordgren

So you wanna wait? You wanna wait for them to get PCOS?

Janna Gewirtz O’Brien

The-

Julia Nordgren

Do you wanna wait until they’re infertile and having babies that are large for gestational age or small for gest- I mean, you wanna wait for them to develop obesity related cancers? I mean, that’s one way to look at it.

laughs).

Janna Gewirtz O’Brien

Okay. First of all, I think the notion that all obese people are sick just needs to be called out right now. Not all obese people go on to develop illness. If we look at these, at the numbers here, first of all, 30% of adolescents who are obese are not obese at 30 years of age. Second of all, there is a phenomenon, and I wanted to say 40% of adults who meet criteria for obesity are actually have no cardiometabolic disturbance whatsoever. So we’re providing an aggressive medication early on for diseases that primarily do not actually cause harm until at least later into adulthood to prevent diseases that they may or may not develop and potentially promoting eating disorders.

Janna Gewirtz O’Brien

And let me just tell you, eating disorders are among the most fatal psychiatric illnesses and cost millions of dollars to our society. And no, they do not. You said, made this point that eating disorders are separate than obesity. 50% of young people with anorexia have a history of obesity in the past. 50% of people in bariatric surgery clinics have a history of binge-eating disorder.

Julia Nordgren

Janna? Janna?

John Donvan

Janna, in fair, Janna, Janna-

Janna Gewirtz O’Brien

Yeah.

John Donvan

… in fairness to Julia, I’ve got a, I’ve got a let break in and then I have a question for you, Janna, that I think is sort of fundamental to your point or to our understanding your point.

Janna Gewirtz O’Brien

Okay.

John Donvan

But, uh, Julia, take a moment. Go.

Julia Nordgren

So I have, um, I have a kid who has severe obesity. And his se- obesity is so bad that he will need a hip replacement. And his teasing at school is so relentless. These bullies at school, you know what they do? They kick him in the hip. He has erosive hip disease from his obesity. I… it… I would be so irresponsible to try to teach this boy to love his illness. That’s just love your back pain, love your diabetes, love your stretch marks, love how it feels to be totally winded when you’re running in PE and you can’t keep up with your peers. These are real physical problems. This is not that the child is bad or the child needs to be solved. You are the one that’s saying a thin body is an ideal body.

Julia Nordgren

I have never said that. No pediatrician that practices compassionate expert care will tell the child their body is a problem and it needs to be fixed. Obesity is a metabolic and neuroendocrine disease that can go along with many other diseases. That is the root cause of a lot of these other problems. It is the root cause for diabetes. Heart disease, a heart attack doesn’t happen in one day.

John Donvan

We’re coming up to a break. So I, I wanna put this question to you before we do, Janna, essentially to, to quote what Julia just said, that obesity is a disease. The AAP statement says a- obesity is a disease. Do you believe that obesity is a disease? When you say that a large body does not mean you’re sick, does it ever mean you’re sick?

Janna Gewirtz O’Brien

I think there are certain people who have a higher BMI that also have illnesses, and that those illnesses, including the hip pain that the kid you’re talking about experienced are… should be treated as they absolutely should. These guidelines hinge and they label as somebody with an elevated BMI alone or carrying excess weight alone as having a disease. And that is just not true to the nuance of the reality. I wanna also just touch on one other thing, which is I think really important here, which is this bullying piece.

Janna Gewirtz O’Brien

Bullying and experiencing weight stigma, which is a form of discrimination based on size, our response to that should not be, let’s make you thinner. I’m borrowing this, I’m taking out the point about the hip pain here. Absolutely. Kids with hip pain should be treated for their hip pain. But bullying is not a reason to aggressively treat somebody for medications. The answer to racism isn’t bleach your, uh, isn’t straighten your hair and assimilate. The answer to transphobia isn’t conversion. The answer to size, diversity, and size discrimination is not be thinner and change yourselves.

John Donvan

We’re gonna take a break right now, and when we come back, we’re gonna have some other voices come into the, uh, program to also join in with some questions. We’re taking on this issue. Childhood obesity guidelines, are they good medicine or too extreme? We’ll be right back after the break. I’m John Donvan. This is Open to Debate. Welcome back to Open to Debate, where we’re taking on the question, childhood obesity guidelines, good medicine, or too extreme? I’m John Donvan, your moderator, and I’m joined by our debaters, pediatricians, Janna Gewirtz O’Brien and Julia Nordgren. We’re gonna bring in some other voices now, uh, to ask some questions. First up, we have the journalist Elaine Chen. Elaine is a cardiovascular disease reporter at STAT. Elaine, welcome. Uh, thanks for joining us on Open to Debate and come on in with your question, please.

Elaine Chen

Thank you so much for inviting me on. Is there a way to provide and treat, um, children and adolescents with medications, particularly some of the new ones like Wegovy without pausing harm to their mental health and body image issues and raise the risk of eating disorders? Is it possible to have both at the same time? And if so, what does that look like?

Julia Nordgren

Oh, yes, it can absolutely be done. Kids with obesity, because they have a physiologic alteration in their energy balance, so their energy system gets set to protect their altered fat mass, they often come with, um, lack… a sense of frustration, a sense of hopelessness, a sense of why being not good enough. Why is this not getting better? I’ve been trying so hard to eat better and to exercise more, and I’m just not seeing the results. That’s so depressing. And, and frankly, some kids are s- have such high obesity that they’re really physically unable to exercise effectively.

Julia Nordgren

And so in an ideal world where you want all these things to be in place, a medication can be an extremely effective adjunct to their care plan. And these kids see, wow, I actually, I can lose weight. I am eating better. I am feeling more hopeful. And so the kids that I’ve treated in clinic have across the board in my practice, this does not apply to everyone, experienced improved mental health, more hopefulness, more determination and feel, not that they’ve fixed a problem, but these children have said to me in different ways, “I feel more like myself. This is the person I wanna be. I’m… I feel great. I feel energized. I’m going to my formal. I’m going for a lead designer of yearbook. I feel better, more hopeful, more determined, and my mental health is better.”

John Donvan

Yeah. Janna, if you could take that question on, uh, and again, I’m hearing Elaine asking, not so much now about the effectiveness or long-term consequences on the body, but on the mental health impact of being encouraged or ins- or guided to using medications to lose weight. And Julia’s saying she thinks the mental health impact is actually quite positive. Uh, I, I know that you’ve already alluded to you thinking the opposite, but can you take it in more detail?

Janna Gewirtz O’Brien

So I think you asked if it’s possible to give medications and not promote disordered eating with medications, which is a different story. Absolutely. In an ideal world, we have pediatricians that have worked to dismantle their own internalized weight bias. We have long-ter- kind… term conversations with families promoting a balanced approach to movement, to developing a healthy relationship with food. And we’re supporting young people’s mental and offic- and physical health during the process. That is in an ideal world, that is not what most people who are living in larger bodies experience when they’re getting these medications. And then I wanna make one more point on this, which is that the rebound weight gain is high. And with many young people who stop the medicines when they’re required to. For instance, phentermine needs to be stopped after three months, they gain the way back and then they’re like, well, now I’m a failure.

Janna Gewirtz O’Brien

This medicine didn’t even work for me. And that is the majority of people that get these medicines. I do wanna just acknowledge here that we have no one living in a larger body in this room or in this space talking about this right now. If we did, they would say that they were told over and over and over again that their bodies needed to change. Listen to the Maintenance Phase Podcast. Listen to those podcasts and hear them talk from their own voices rather than listening to us talk about this. These medications are potentially harmful, dangerous, and they do promote disordered eating and there is evidence that they do.

Julia Nordgren

Well, that’s a very interesting assumption you just made. How do you know the body that I’m living in? How do you know the body that I have lived in? You are making assumptions. You are judging me based on what you see on my picture.

Janna Gewirtz O’Brien

Yes, I am.

Julia Nordgren

So I think if you’re talking about weight bias, then where is your weight bias?

Janna Gewirtz O’Brien

I’m making an assumption because you haven’t disclosed anything about your identity and we haven’t started from a place of relative positionality here.

Julia Nordgren

Well, would I? I… my body is not relevant in this conversation. We’re talking about children with obesity. We are talking about children with a, an endocrine disease, a neurologic disease. That is the re- that is the reality. The, the ideal world that you described. That’s my real world. The world where kids are treated horribly by doctors or experiencing weight bias, certainly that needs to be worked on at the same time. We can’t, but we can’t wait for the world to be perfect in order to treat children with a disease that overlaps with perceptions that aren’t true for them. It is not true that kids who are, have obesity are lazy, are bad people who don’t care about themselves. And I go to bat for these kids. You wouldn’t believe what I do to try to make these kids lives more comfortable. I write letters to PE teachers to say, “Hey, don’t force this kid into an embarrassing situation.”

Janna Gewirtz O’Brien

So first of all, I am making assumptions based on appearance because we didn’t say that identit- that identity piece. I just wanna name that, yes, your world sounds great and I think you are… seem like a great person.

Julia Nordgren

(laughs).

Janna Gewirtz O’Brien

It’s not an… front to you.

John Donvan

I also wanna explain to people who are only hearing us and not seeing us, that we are able to see ourselves on, um, on a o- online connection platform. We are not in the same room and we can see each other head and shoulders. Elaine, thanks for your question. I want to bring in, uh, McKenzie Prillaman. McKenzie is a, a freelance science journalist whose work has appeared in nature and science news among other places. McKenzie, thanks for joining us at Open to Debate. And come on in, please, with your question.

McKenzie Prillaman

Let’s say that there are some very thorough doctors who have checked their internal biases and have determined that their adolescent patients’ health might very much benefit from these more intensive treatments, anti-obesity medications, bariatric surgery, even mental health counseling. These are expensive and time-consuming treatments. How do we ensure that kids and teens in lower socioeconomic households even have the opportunity to participate in these kinds of weight interventions?

John Donvan

Julia, do you wanna take that first?

Julia Nordgren

Sure. I mean, this is an… this is like a crazy evolving landscape. Yes, these medications are very expensive. And I practice in California and in this kind of beautiful twist of irony, I have fewer insurance barriers on kids who have poverty and who qualify for, uh, health plans. And it’s interesting that the harder times I have when I want to advocate for a child to receive treatment because they have severe disease, they have complications. When my clinical judgment and w- working with the family, I will say this is always shared decision making that the benefits of treatment along with the risks of treatment outweigh the risks of not treating and the benefits of not treating. So we’re always doing this very, very careful weighing. The money is a really, really big issue. It will change when some of these medications come off patent, when they’re more available. We could talk a lot about the pharmaceutical companies and the price gouging, and, um, it’s a really huge problem.

John Donvan

Let’s, let’s use that point to let Janna jump in if you’d like to on the same question, Janna?

Janna Gewirtz O’Brien

Yeah. I’m brought… I’m glad you brought this up as an equity issue because I think it is an equity issue across the board.

Julia Nordgren

Yeah.

Janna Gewirtz O’Brien

The drivers of obesity as a number and also of the correlating diabetes and heart disease are in fact structural inequities in our society. A lack of access to nutritious foods, structural oppression, trauma. In fact, we know that discrimination, racism, all of those increase the stress response, which as we’ve talked about is a physiologic part of all of this, right? Now onto your really good question, which is even in a society where every single doctor has grappled with their own weight stigma, which I wish would, would happen.

Julia Nordgren

(laughs).

Janna Gewirtz O’Brien

I think we both actually wish that would happen.

Julia Nordgren

(laughs). Me too.

Janna Gewirtz O’Brien

Because we’ve all, we’re both there. Like I think we agree on that. We’re talking about the three interventions that we’re talking about are intensive behavior and lifestyle treatment. That was one that was recommended by the AAP, which requires of note, 26 plus hours of face-to-face time over the course of three to 12 months, which as somebody who works primarily in, um-

Julia Nordgren

(laughs).

Janna Gewirtz O’Brien

… a predominantly almost all public insurance or uninsured practice and also works with youth experiencing homelessness, nearly impossible for almost all of my patients to physically implement. And then there’s these very expensive medications and also bariatric surgery, which again, this is driven. I just wanna name by a large capitalist enterprise that has convinced us that we need to be aggressive here. That’s part of this. And also has a lot of profit to gain from this. Um, so yes, we have the equity issue is the driver of obesity in the first place, but there is also an equity issue in who can actually access these and who can access the foods that we’re talking about and who has access to green space and who has safe communities and who’s experience, experiencing a tremendous amount of toxic stress related to various intersecting identities of oppression, like being black, being gay, being queer, and being fat.

John Donvan

I wanna thank you for that, McKenzie. Uh, now let’s bring in Tristan Justice. And Tristan is the western correspondent for The Federalist. He’s actually working on a book about the o- obesity epidemic in the US. Tristan, thank you for your patience in waiting and come on in with your question, please.

Tristan Justice

Research suggests that half the nation will be obese by the end of the decade with severe implications for the future of chronic disease. Are you at all, and I know there’s been a lot of talk during this conversation about weight stigmatization, but are either of you concerned at all about the complete dis- uh, destigmatization surrounding excess weight that it might normalize acute addiction to the point where even more aggressive innovations will be needed in the medical industry to combat, uh, weight gain or deeply that we should maintain some level of stigmatiz- stigmatization on the same level as we stigmatize something like smoking?

Janna Gewirtz O’Brien

I disagree that we should further stigmatize people because stigmatization is associated with poorer physical health outcomes, poorer mental health outcomes, avoidance of going to the doctor in the first place. I’m just gonna quote Taylor Swift. She said, “Shame never made anybody less gay.”

Julia Nordgren

(laughs).

Janna Gewirtz O’Brien

Shame also never made anybody less fat. I do wanna make one more thing here that I need to call out one more point he said that I think is important here. He made the assumption that all people living in larger bodies are addicted to food, which I think both of us can plainly say that food addiction is actually not a driving cause of obesity. The driving cause of people living in larger bodies, and that number going up are the structural factors and the multifactorial factors we were causing… talking about earlier. And that the AAP actually really does a good job of about outlining in this guidance.

John Donvan

Julia, you’re up on this one.

Julia Nordgren

I think that’s a really, really tricky question because I think that we’re somehow equating stigma and shame with avoidance of behaviors like eating and health, which I just don’t think is a logical or scientifically sound assumption to make. I do think that we have normalized a lot of behaviors, not necessarily related to body size, but related to the habits that can create a larger body size. As an example, we’ve normalized being too busy to cook for our families. We’ve normalized eating on the run, all of this advertising of fast food. I mean, my kids are exposed all day to negative food environments, unhealthy food environments. It is so hard to do what Janna and I both want kids to do, which is develop a healthy relationship with food.

John Donvan

Tristan, thank you for your question. And that is a wrap on this portion of the program. And now we go to the home stretch. Uh, the home stretch is a closing statements from each of you making up our third round. In that section, you each get up to two minutes to make one more time, the argument that you’re making that these guidelines are good medicine or too extreme. And Julia, you’re up first. Again, you’re arguing that they’re good medicine. Please tell us one more time why you’re taking that position.

Julia Nordgren

Well, thank you so much for this amazing conversation on the great medicine presented by the AAP guidelines. And just to be clear, these guidelines aren’t saying that anybody at this particular size should be prescribed a medication. They should be offered a conversation about treatment options, which may include medication and surgery. So we are pediatricians, we are the adults that care about these kids and are more invested in their health and wellbeing than anyone outside of their families. Our offices should be safe places and we need to treat our patients openly, honestly, and respectfully. Whether they have obesity, asthma, or diabetes, we have effective treatments.

Julia Nordgren

And no treatment is ever perfect or without risk, but not offering conversations and education about these treatments at the root cause of their disease, the neuroendocrine, hormonal disruption of altered fat mass, avoiding that doesn’t serve our children and that is not good medicine. And I’d like to leave you with the words of a parent of a 16-year-old who is currently getting medical treatment for her obesity. And she wrote me a beautiful letter and in that letter she wrote, “I can’t express to you how much this treatment has helped our daughter and our family. Our relationships have improved, our stress levels are reduced, and dinner time is no longer a time of anguish. She still has a long way to go. But treatment has transformed my daughter at a time where high school social challenges and general teenage life demand so much. This has been an ideal time to break negative habits that we’re setting in on the mental and physical front. I know my daughter will continue her journey with the hope and determination that she was lacking before. For that, we are so very grateful.”

John Donvan

Thank you very much, Julia. And Janna, you get the last word here, your closing statement to tell us why you think these guidelines are too extreme.

Janna Gewirtz O’Brien

The time is now for those of us in healthcare to actually take a good look inward, to be skeptical about what we’ve been taught, about flawed racist measures that don’t reliably predict health. To recognize the harm that we’ve caused with this very weight focused and obsessed paradigm. We did actually, I know that Dr. Julia made the argument that BMI, that no one would ever make a decision about surgery or medications without the full context. But that is actually not true. The key action statement in this guideline says, “On the basis of weight, of, of BMI specifically alone, that we should intervene with potentially very dangerous, aggressive, and expensive interventions with a high profit margins for one in five children.” We’re talking about medications and we didn’t even get to the point about bariatric surgery that we’re recommending during a critical window of development when we actually know very little about the lo- short and long-term impact on their health.

Janna Gewirtz O’Brien

I also would like to close with the story of a young person I work with, and it’s an all too common story in my practice. It’s a story of a sweet 15-year-old Latina girl who played soccer and volleyball, who had been told her whole life by doctors and by almost everyone around her that her body was too big. She received multiple trials of medications that worked momentarily and then “failed,” leading to her to feel defeated and like she had “failed.” By the time I saw her, she was struggling with an eating disorder and was starving and malnourished. We needed to do so much work to get back to a place where she actually could have a healthy relationship with food and movement and her body again. What patients need to hear from their pediatricians, they need to hear from us, that we affirm them, that we support them, that we care deeply about their health.

Janna Gewirtz O’Brien

We should not be creating spaces where they’re afraid to come in to see us because we’re going to talk about weight no matter what, even when they come in for appendicitis. So where do we go from here? We need to urgently work, work to create a world where doctor’s offices are affirming, safe, and supportive. In pediatrics, we need approaches that de-emphasize BMI and refocus on health and health behaviors. We need to encourage youth to nourish their bodies, have a healthy relationship with food, engage in movement that they enjoy, and love their bodies and who they are. What I’m describing are the tenets of a weight neutral health and every size approach, which has actively been studied over the last three decades. This is where we need to go in the future. I’m gonna close with a quote from Sonya Renee Taylor’s book, The Body Is Not an Apology. “What if we all became committed to the idea that no one should have to apologize for being a human in a body?”

John Donvan

Thank you, Janna. And that is a wrap on our debate and I want to thank everyone who participated, starting with my fellow journalists, Elaine, McKenzie, and Tristan, for bringing in your interesting questions, getting us to an interesting place. But especially, I want to thank our two debaters, Julia Nordgren and Janna Gewirtz O’Brien. It was so clear throughout this debate and people who couldn’t see didn’t… were, were not able to see how often you were actually smiling at one another.

laughs).

Julia Nordgren

(laughs).

John Donvan

As fierce as the conversation got, it’s so clear you have shared values, but that in the areas where you disagreed, you disagreed with one another with such deep respect, which is the thing that we aim to, to prove here at Open to Debate is possible in the, in the way that we talk with each other. So you were such fantastic examples. And also shed light on understanding the issues before us. So I wanna thank both of you so much for joining us on Open To Debate.

Julia Nordgren

Thank you for having me.

Janna Gewirtz O’Brien

Thank you for having us. And yes, it wouldn’t be uncommon for us to now go to coffee and just learn from each other and enjoy each other’s company.

Julia Nordgren

Yeah, we probably will in fact

laughs).

Janna Gewirtz O’Brien

We would. We would.

(laughs). Yeah.

Julia Nordgren

Yes.

John Donvan

And finally, a big thank you to you, our audience for tuning into this episode of Open To Debate. You know, as a nonprofit, we are working to combat extreme polarization through proving there is such a thing as good argument and civil debate. And that work is made possible by listeners like you and by the Rrosenkranz Foundation and by supporters of Open to Debate. Our chairman is Robert Rosenkranz. Our CEO is Clay O’Connor. Lia Matthow is our Chief Content Officer. This episode was produced by Alexis Pancrazi and Marlette Sandoval. Editorial and research by Gabriella Mayor and Andrew Foote. Andrew Lipson and Max Fulton provided production support. Millie Shaw is Director of Audience Development. The Open to Debate team also includes Gabrielle Iannucelli, Rachel Kemp, Linda Lee, and Devon Shermer. Damon Whitmore mixed this episode. Our theme music is by Alex Clement. And I’m John Donvan. We’ll see you next time on Open To Debate.