November 11, 2022
You can’t turn on the radio or television, or even walk into most exam rooms these days without thinking about weight, and specifically the rising numbers of our patients who are designated as overweight or obese. But what does this mean for health? Conventional medical teaching is that being overweight is correlated with worse health outcomes. But….what if that’s wrong? What if there is a weight neutral approach to health that doesn’t focus exclusively on a patient’s BMI? Here to talk to us about weight-neutral health care is Ragen Chastain, speaker, writer, weight science expert and ACE certified health coach and functional fitness specialist.
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.
Welcome to Talking Pediatrics. I’m your host Dr. Angela Kade Goepferd. These days, you can’t turn on the radio or TV, or even walk into most of our exam rooms without thinking about weight, and specifically, the rising number of our patients who are designated as overweight or obese. But what does this mean for their health? Conventional medical teaching has us believe that weight and specifically having a higher weight is correlated with worse health outcomes across the board.
As a pediatrician, I’ve often felt the pressure to get ahead of a young patient’s trajectory with regard to their rising weight so that I can prevent a lifetime of health problems. But what if we’re wrong? What if there is a weight neutral approach to health that doesn’t focus exclusively on a patient’s BMI? Here to talk to us about this very idea is Ragen Chastain, speaker, writer, weight science expert, and ACE certified health coach and functional fitness specialist. Ragen, it is such a pleasure to have the chance to speak with you today.
Ragen Chastain: The pleasure is all mine. Thank you so much for having me.
Dr. Angela Kade Goepferd: Before we jump into talking about weight, I would love for folks to get to know you a little bit more and your work. Can you tell us a little bit about you, and the work that you do, and how you got invested and involved in doing weight-based or weight neutral work?
Ragen Chastain: So, my background is research methods and statistics. And I actually got into this for myself. I was trying to find the best diet. I had been yo-yo dieting for years and decided to do a literature review because that’s the kind of nerd I am, and discovered that there wasn’t a single study where more than a tiny fraction of people were succeeding at significant long-term weight loss. And that sent me down a rabbit hole of research that 20 years later has become my profession, understanding the research around weight science, its intersections with weight bias and health care and health care practice. And that’s how I got where I am.
Dr. Angela Kade Goepferd: So, let’s jump in with some language. In my introduction, I mentioned the words overweight and obese. One word I didn’t mention is the word fat. But can you teach us a little bit about the origin of some of those words and maybe how we might think about them differently or reframe our language a little bit?
Ragen Chastain: Overweight and obese as well as their person first counterparts, person with overweight and person with obesity, were literally terms that were made up to pathologize and medicalize all bodies of a certain size. They’re rooted in BMI and weight stigma, both of which are inextricably rooted in racism and anti-Blackness, and continue to disproportionally impact those communities. And I cannot recommend enough Sabrina Strings’s Fearing the Black Body and Da’Shaun Harrison’s Belly of the Beast to learn more about that. But those are terms that medicalize and pathologize bodies based on their size. And those are terms that are roundly rejected by weight neutral community, by fat activism community.
I prefer fat. It’s a reclaiming term for me, a way that I let my bullies know they can’t have my lunch money anymore, and they don’t medicalize and pathologize my body. Fat is a term that’s being reclaimed by a lot of fat people, but a lot of people who could be described that way don’t align with that term, which is totally valid. Other terms that are useful are higher weight, larger body, people of size, basically looking for terms that accurately describe bodies without medicalizing or pathologizing them and that weren’t used as a schoolyard taunt, essentially, are neutral terms that you can use.
Dr. Angela Kade Goepferd: I do think that language is really powerful. One of the things that I’ve heard you talk about specifically with regard to obesity is a little bit about the origin of that word. And I think it’s a word that we actually use a lot in healthcare. And once I heard you talk about it, I vowed to never use it again. Could you teach us a little bit about that word?
Ragen Chastain: It’s made its way into medical literature and it seems very scientific, but it’s literally rooted in a Latin term that just needs to eat until fat, so much more stereotype than science there.
Dr. Angela Kade Goepferd: I mean I always assume that there was some really scientific way that we came up with that term and I was actually being more sensitive by using that term versus other terms. But I’ve since decided that’s not a great term. And I think that your language is really helpful, particularly for those of us in pediatrics. I have three kids of my own. And when my children were young, they would often point to people and say, “That person’s fat.” They weren’t saying that as an insult to that person. They were saying that as a descriptor of size.
But I was very sensitive to that because some people do take that word as an insult or have been insulted or taunted by using that word. And so, I had to struggle a little bit with my kids around how we describe people without using words that might hurt their feelings, but also how there’s lots of other ways to describe people besides the size of their bodies. Would you have any other recommendations for us as we teach children about that type of language?
Ragen Chastain: I’ve been on the receiving end of a kid saying, “You’re so fat.” And I think just to say, yep, there’s fat people, there’s skinny people, there’s people all over the size range, all bodies are good bodies, at whatever level the kid is of understanding is a way to just accept it. Sometimes the kid says it and the parent looks like they’re going to die of shame and all their kid has accurately done is described my body.
So the idea that accurately describing my body is so shameful that you want to take your kid and run is a problem in and of itself. So just accepting like, yep, there’s bodies of all sizes and some people, as you go along, some people don’t like to be called fat because it’s been used as a bad thing, that kind of thing to educate your kid as you’re explaining that there’s nothing wrong with fat bodies.
Dr. Angela Kade Goepferd: Yeah, I love that all bodies are good bodies. I really love that. So, I also talked a little bit, speaking of language, about BMI in my introduction and the BMI is something in pediatrics that we pay a lot of attention to. We’re obviously doing checkups quite frequently with young kids and we’re always looking at their height relative to their weight and vice versa. And then, even at ill visits or visits where kids are not coming in for checkups, we’re often weighing them because we use weight to dose our medications and everything. So we look at weight and we look at BMI quite frequently. What can you share with us about the BMI and maybe what myths or misinformation might you want to bust for us relative to that?
Ragen Chastain: BMI as it’s used for adults was initially created by a statistician named Quetelet and he was trying to create an idea of the ideal man. And in his own words, everything differing from that proportion would constitute deformity, disease, or monstrosity. But he was pretty sure that the ideal man was a cisgender European dude because those are the only people he actually used in his sample. And so that body mass index was created based on this sample of cis-European white men and then made its way into science and medicine because it was a cheap alternative to actually looking at health for insurance companies. And this was pre-Obamacare when a high BMI was considered a preexisting condition and people could literally and were literally refused insurance because their entire body was considered a preexisting condition.
So, that worked its way, again, obese and overweight, as if it’s like a scientific idea that’s based on really excellent science. And then for kids, it was modified to be about percentiles originally using White kids from the ’50s. So there again, we see that racism and anti-Blackness. And so this idea has taken over that the job of medicine is to make every higher weight person fit into these percentiles or height and weight ratios, and that’s like the first and foremost job. And I think that’s where healthcare has gone off the rails. Because we know just like height, there’s going to be diversity of weights in simply bodies just like there’s diversity, like I said, heights, nose size, foot size, et cetera. And so when we try to wedge everyone into the same height weight percentile or proportion, we’re going to do a disservice to a lot of people.
Dr. Angela Kade Goepferd: And I think if we really think critically about BMI, not just as it relates to larger size bodies, but we often run into kids from different racial or ethnic backgrounds who have smaller size bodies and then they fall off of our BMI curves, and we get concerned, and sometimes they end up in nutritionist offices or even hospitalized sometimes. And really the curves just weren’t built for their bodies. And so I think knowing the roots of how we came up with that gold standard as we use it today measuring system, is really helpful.
In pediatrics, when we see kids that are by BMI measurement overweight or obese it almost always causes concern for us. I think we’ve traditionally associated higher weight with worse health outcomes. So, particularly in pediatrics, we try to correct that trajectory. So as you said, we can fit kids back onto the chart in what we think is interest of their health. We don’t tend to endorse dieting in kids, but we do tend to talk about different practices. Some of them that are quite popular include the 5210 plan for broadening your eating and reducing your screen time. And a lot of tenants that actually are very similar to dieting, even though we might not say the word dieting. And I’d love to learn from you a little bit about how having those conversations or encouraging that type of dieting behavior might help or might not help kids.
Ragen Chastain: And I want to start out by saying I think that the doctors who are doing this are really well meaning. I think they’re typically following their training. But if we take it back to the science which is what I always want to do, the research shows that trying to manipulate kids’ body size does not predict thinner kids, but it does predict eating disorders and disordered relationships with food movement and their bodies. And that’s quite a bit of research. And so even though it’s well-intentioned, I think we have to look at what is the actual impact of what we’re doing. And when you look at things that are typically recommended to higher weight kids, there’s mostly things that would be healthy for all kids.
Dr. Angela Kade Goepferd: Right.
Ragen Chastain: And so when we focus on size, we’re doing a double disservice, because we’re telling higher weight kids the only way for them to be healthy is to lose weight. We’re giving kids who fit into the percentiles of BMI that we consider “normal” or proper for their age that they must be fine because they’re fitting into this height weight ratio or percentile. And in both cases, that’s not actually looking at the health of the kid or the behaviors of the kid. And so, I think if we shift a focus to supporting the health of kids of all sizes rather than trying to manipulate kids into a certain size and hoping that health will occur from that, we would be in a better place, from a research basis, from a psychological impact basis, and just in general practice.
Dr. Angela Kade Goepferd: One thing that I heard you talk about before is weight cycling and the impact that that has on people’s health. And since I’ve heard you talk about that, I’ve been really aware of not wanting to induce that type of behavior in the patients that I’m caring for. Could you talk to us a little bit about that and why this weight cycling that’s typically associated with dieting is so harmful for our health?
Ragen Chastain: Weight cycling or yo-yo dieting occurs when people lose weight and gain it back. And it is the outcome of the vast majority of weight loss attempts. And weight cycling is independently associated with things like inflammation, a higher mortality risk overall. In fact, Bacon and Afamor found that weight cycling could actually account for all of the excess deaths that were attributed to obesity in both Framingham and the NHANES study.
It’s something that is also a cumulative effect. So the more you’re weight cycling, the more you’re exposing yourself to this risk. So if we start kids earlier in weight management attempts and we’re starting weight cycling earlier, then we’re exposing them to more of these risks. And weight cycling is correlated with almost all of the same negative health outcomes that are correlated with being higher weight. And so what may be happening is that in fact we’re blaming fat bodies for the impact of the weight cycling that they’ve experienced.
Dr. Angela Kade Goepferd: One of those interventions I’d like to talk with you a little bit more is bariatric surgery. I think it’s becoming more common for kids to get referred for bariatric surgery, but I’m not sure that many of us are really aware of what the data and outcomes are there or if that’s really in kids best interest. Could you talk to us about what you learned about bariatric surgery in kids?
Ragen Chastain: Sure. So the first thing I always want to point out about bariatric surgery is what it does is it takes a healthy, correctly functioning digestive system and it surgically puts it into a typically irreversible disease state. So we’re talking about a surgery that purposefully creates disease, and that’s the bottom line. The goal is to force behaviors that mimic eating disorders. So that’s what we’re talking about. There’s also very little long-term data on these surgeries even for adults. And so there’s that piece of it that the surgery is essentially experimental.
Beyond which with kids there are specific issues starting with informed consent. We’re talking about kids who don’t have a fully developed prefrontal cortex. We’re talking about even if they came to a tattoo artist with a parental consent, that person would likely refuse to give them a tattoo because they’re not able at their age to make that decision to have that permanent tattoo for example. But their parents are being able to consent to something that alters their digestive system permanently in ways that there’s physical issues like micronutrient deficiencies. Often with these surgeries they have to have access to expensive supplements, which there’s first the ability to afford them, second kids and taking supplements, all of that piece of it.
And then there’s also social interactions. Their eating is going to be different at every birthday party, every holiday, every interaction where food is part of that, they’re going to still be singled out forever. And we don’t have great data on what the impact of that is. And then these surgeries, they’re often recommended as a way to solve weight-based bullying, which is really telling kids like you should risk your life and quality of life to appease your bullies by looking like they think you should look. And that’s the solution to bullying. And I think that’s a dangerous message regardless.
Dr. Angela Kade Goepferd: Let’s talk a little bit more about weight-based bullying or the concept of weight stigma. When you spoke as a keynote speaker at our recent Twin Cities pediatric update conference, you shared an image of a girl who was larger size and the text that was underneath her said, “Being fat takes the fun out of being a kid,” which just broke my heart on so many levels. It was a heartbreaking image, one, of the girl. But I also have three kids of my own and they are all different sizes. And I have a child who is a larger size than my other kids and I would never want him to have that message. How does weight stigma impact kids?
Ragen Chastain: It impacts them across every aspect of their life. [inaudible 00:15:15] in 2021 found that there was a connection between stigma and both short and long-term psychological and emotional impacts, including psychosocial impairment, including a decreased executive functioning, reduced health related quality of life. And that’s something that we see over and over again is that when kids are experiencing weight stigma, then they are also seeing their bodies as not valid or worthy of care, which is not surprising. And so if you tell somebody over and over again, “Your body’s bad, it’s a sign that you’re weak willed, it’s a sign that you don’t eat right or exercise,” then they’re going to believe that. And when we tell them that eating an exercise or either punishment for being fat or to prevent being fat, then we develop disordered relationships, not just with bodies but also with food and movement.
Ruffle and Williams in 2021 did an incredible study that looked at weight neutral interventions for kids. And they found that among adolescents experiencing weight bias, increased harmful weight related behaviors and decreased engagement in health promoting behaviors, which led to worsened health outcomes. So again, when we go back to the research focusing on kids’ weight is not having good impacts on their health.
Dr. Angela Kade Goepferd: Just anecdotally from my own children being different sizes, it’s something that kids notice quite early. As young as four or five, I remember my youngest child saying to me, “Why does my body look different from my brothers?” And when I asked a little bit more about that, he said, “Well, their stomachs are flat and my stomach goes out.” And so kids are attuned to differences in size from a pretty young age. So I could imagine that some of this weight stigma and the disordered thinking that goes with it can start pretty young for kids. Is that what you found?
Ragen Chastain: Definitely. And the research is showing that kids are starting to diet younger and younger. I think the average we’ve got now is like eight years old. I believe that study is amongst cis girls, but we’re seeing younger and younger kids say that they would rather have horrible life consequences than be fat. And it permeates our whole society. Our society is rife with weight stigma so it’s not surprising that they get these ideas. And that’s why it’s really important that we are all working to counter those to let kids know, again, not my original line though, that all bodies are good bodies.
Dr. Angela Kade Goepferd: So bottom line, the assumption that we have had for forever in healthcare that having a higher weight leads to worse health outcomes. True or false?
Ragen Chastain: Really a good question. What happens is we’ve got these mitigating factors, what we would call in research, confounding variables, which include weight stigma, weight cycling, and healthcare inequalities, including everything from practitioner bias and not being included in research to structural bias where we don’t have the proper equipment for higher weight folks. So these three things are correlated with many of the same health issues to which being fat gets correlated, and they are not even mentioned, let alone controlled for in the research. So we actually don’t know for sure what higher weight people’s health outcomes would look like if they weren’t constantly subjected to weight stigma and weight cycling and healthcare inequalities. But the research we have shows that it would likely be quite a bit better.
Dr. Angela Kade Goepferd: One of the images again that you referenced in your keynote at the Twin Cities pediatric update was looking at fitness level relative to weight. And one thing that really stuck with me from that image, hopefully correctly, is that really your level of physical fitness and how active you are and how much you’re moving your body is a much better predictor of health than simply your size. And that even for people who are a smaller size, if they’re rather sedentary and not active, they have pretty bad health outcomes associated with that. Did I interpret that correctly or can you tell me a little bit more about that idea?
Ragen Chastain: Research finds again and again in looking at Mathison [inaudible 00:19:03], the Cooper Institute and longitudinal studies, Gazer and Angotti, et cetera, that health supporting behaviors are a much better predictor of current and future health than is body size or weight loss attempts. And Gazer and Angotti did an incredible job doing a pretty huge review of this. There’s also research for kids as well showing that in fact they were able to reduce their risk of low health related quality of life by 32.3% for each hour increase of exercise.
Dr. Angela Kade Goepferd: And I think that’s really highlighting the importance of us not associating exercise with some kind of a punishment for being of a higher weight or having a larger body. But that exercise is really something that we all hopefully can find ways to enjoy and that is really good for our health regardless of the size of our bodies.
So moving forward, I want people to leave with some really good ideas and tools. If we want to avoid weight stigma and avoid misusing a tool like the BMI that was probably not designed with most of our patients in mind, and promote health in our patients, what might be some weight neutral ways that we might talk about health, or particularly for patients who do have higher weights and we might be more worried about or families are more worried about them, how might we approach those conversations?
Ragen Chastain: First of all, focusing on behaviors and not body size and helping patients create a belief in their body that this is a good body, it’s valid, it’s worthy of care. And then helping to create healthy relationships with food and movement. In general, never ever talk negatively about kid’s body in front of them. So that’s maybe a conversation you have with the parent, but you can also say, “Look, we have these percentiles and they’re not anywhere close to the full story about your kid’s health. So while your kid is at this place in the percentile, I also just want to talk about their health in general, and that’s what I want to focus on.” So are they getting a lot of play? What is their food like? All of these things that we can talk about. Are they getting good sleep?
And I think it’s really important to understand health is far from being entirely within our control. And so much of health, including public health, has been about making fat people’s bodies the public business instead of creating access instead of decreasing barriers, instead of focusing on things like oppression. And so I always want to be clear about that when I talk about health. But making sure too that you’re providing evidence-based interventions, and this can take some digging. A lot of people really believe that weight controlled behaviors lead to thinner kids, but that’s simply not what the research tells us.
Dr. Angela Kade Goepferd: And what sorts of things have you found in the research that we might learn from or that would be more helpful for kids?
Ragen Chastain: Definitely recommend again that Ruffle and William study from 2021 that look at HAES intervention. So basically increasing access to a variety of foods, increasing access to movement that the kid enjoys. So much of our early childhood education around physical education is not created to develop a lifelong love of movement. Is the idea of movement is punishment is a fat body or it’s I talk to adults a lot who had really messy breakups with exercise because of the president’s physical fitness test, or the PACER test, or dodge ball or all of these early childhood experiences around movement.
Dr. Angela Kade Goepferd: All of the early gym trauma that we all experienced, yeah.
Ragen Chastain: Yeah, so much and so unnecessary. And so really helping kids to find ways to play and to move on their own terms. And again, this is kids of all sizes. You don’t have to play or move because you’re fat. You play and move because we find enjoyable ways to do it because it can make you feel better, all of those things.
Dr. Angela Kade Goepferd: And for those who aren’t familiar, you referenced HAES, that stands for health at every size. Can you tell people a little bit more about where they may find some resources related to health at every size?
Ragen Chastain: Sure. So health at every size is actually a trademarked term of the Association for Size, Diversity and Health. ASDAH.org is their website and they have a lot of resources. And so that is a good place to start around that. In general, HAES is like their brand of weight neutral health, and so they have a lot of resources including resources for working with kids.
Dr. Angela Kade Goepferd: Well, Ragen, thank you so much. This has been a really great conversation. I also did learn so much from you at the keynote presentation. One of the tips that I might share with our listeners is I’ve really stopped looking at the growth curve first before talking about healthy behaviors. So flip side of what we’ve been talking about is that I realized I wasn’t focusing enough on healthy foods and activity with kids who were not of larger size because I was looking at their BMI and thinking, oh, they look healthy. And so I’m doing a much better job I think at this point of talking about moving bodies, talking about foods that we’re eating, talking about getting good sleep with all kids and then looking at their growth curve rather than the other way around. So that’s just one small change that I’ve made. But I think that we have a long way to go. So I really appreciate you joining us and giving us some accurate information and helping us think a little bit differently about this topic.
Ragen Chastain: Thank you for what you do and thanks for including me a little bit in it. I am so grateful.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amy Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.