15: Approaching Weight Management with Teens with Dr. Karla Lester

When it comes to weight management in the pediatric arena, we are faced with a lot of complexity. As a parent, it can be challenging to know where to start or how to approach the issue without causing harm to your child.

Unfortunately, where health and weight management is concerned, self-compassion is not the first thing that springs to mind. Instead, the toxic diet culture beliefs that we have been brought up with, often end up seeping into our teens’ way of thinking too. 

Board certified pediatrician and life coach Dr. Karla Lester is a passionate advocate for children’s health, and has worked tirelessly to teach kids, (and their parents!) to ditch self judgment, love themselves as they are, and feel empowered to take action on their health. I spoke with her to gain some insight into the role of weight stigma, toxic media messaging, and weight loss medications in tackling the childhood obesity epidemic.

Balancing body positivity and metabolic health

In a New York Times opinion article, author Aubrey Gordon claimed that since a visit to her pediatrician in fourth grade, she has felt like an “enemy combatant in the nation’s war on childhood obesity.” (“Leave Fat Kids Alone,” Nov. 13, 2020).

She recalls being told that “You’ll be thin and beautiful ... If you can just stay the same weight.” Looking back, she feels that the comment by her well-intended but misguided physician “planted the seeds of depression” that have plagued her ever since and put her on a path of restriction.

When the parents receive information like BMI figures, they can often feel a lot of guilt and shame. And so they go home and try to fix, solve, and control. They get rigid and are stuck in diet culture. And so we're not having helpful conversations to really support the parents to be able to make healthy habit changes.

But we can meet in the middle. You can be body positive and feel good about yourself. Self-love is a superpower, and in fact, that's what it takes. We think that we have to be negative, perfectionistic, grind out goals, and happiness is at the finish line. That's what diet culture teaches us and parents are really stuck in it. 

When we can start to meet in the middle, it enables us to really focus on reversing insulin resistance, taking positive action, and taking small steps toward health. Redefining health is the first step. 

Approaching weight loss with your child

Dr. Lester wrote a healthy conversation script that parents can use, called Cut the Cringe, and is available on her website. We have to be able to have these conversations because many kids are struggling with other issues such as mental health, or bullying, and parents really don’t know how to approach their concerns about their kid’s health.

But when it comes to addressing health concerns, it’s not about being told exactly what to do by a doctor or coach, because that just doesn’t work. The first place to start is with relational health, which is a part of health that will allow the parent to actually become the coach.

Instead of trying to immediately want to fix and solve it, as many parents want to do, take your foot off the gas when it comes to self-judgment, recognize when you're activated, and take responsibility for the comments you make about weight. 

Parents often say they can’t relate, especially if they don’t have weight issues themselves. But that’s simply not true. You're a human. You can relate to the perfectionism. You can relate to self-judgment. That's what this is. This is not about body or weight. And you never need to be in the exact position to be able to relate to an issue.

Fat Phobia, Weight Bias, and “Almond moms”

It was 10 years ago that a conversation between Yolanda Hadid and her daughter Gigi caught the public's attention .

"I'm feeling really weak. I had like, half an almond," Gigi Hadid told her mom Yolanda on an episode of the reality show The Real Housewives of Beverly Hills.

In response, Yolanda Hadid told her daughter, "Have a couple of almonds and chew them really well."

Today, the term "almond mom" is used to refer to a parent who imparts unhealthy food beliefs or restrictive and disordered eating on their child. The hashtag #almondmom brings up thousands of videos on TikTok alone of mostly young women impersonating their parents, usually moms, doing everything from restricting their own diet, to questioning their child's food choices and over-exercising.

Dr. Lester believes that what diet culture teaches us is that people say they’re pursuing health or wellness, but actually, they’re pursuing thin privilege. It’s all based on fatphobia and internalized bias. 

More parents are willing to deconstruct this and do the work but they have a really hard time giving it up because they want their child to have the social capital of thinness and they want their child to have that proximity to thin privilege. A lot of “almond moms” usually have untreated, unhealed, disordered eating. 

To begin overcoming weight bias, Dr. Lester recommends three places you can start:

• Self-awareness.

Forget about your child for a second. You need to do some work that's going to be needed on ground zero, which is you. Every single thing that happens to your child is not necessarily because you caused it. 

When you don't do the work to create powerful awareness around some of those toxic diet culture beliefs that you're staying attached to, the actions that follow include shaming your kid about food, which causes a lot of problems. 

• Understanding that body diversity is a fact. 

We're going to celebrate it. You don't cause and you don't control. Especially when they're an adolescent, their body is not something to fix or solve. They are not you, and they are unbroken.

• Notice when you're activated as a parent

For example, you might be triggered if you fixed a meal and they're going to the cabinet just after they ate. Maybe you shame them for that. Even with good intentions, we can cause harm, and so comments like these can have a lasting impact.

New guidelines around weight loss medications for adolescents

Watching the rates of severe obesity rise, especially during the pandemic, many pediatricians and childhood obesity experts are hopeful that medical treatment will finally have effective tools to help teen patients.

The results of the STEP TEENS phase 3 trial of once-weekly subcutaneous semaglutide 2.4mg (Wegovy) in adolescents aged 12 up to 18 years old with obesity look very promising.  

Published in November 2022 in the NEJM, the study showed that patients who received semaglutide vs. placebo had greater reductions in body weight, improvements in waist circumference, A1C, lipids (except HDL cholesterol) and alanine aminotransferase. 

The biggest benefit of GLP-1 agonists is the quietened “food chatter” that patients experience. For the first time, their mind is not constantly seeking and craving food. Patients also feel fuller faster as GLP-1 delays gastric emptying. 

It is encouraging to have weight loss medications that effectively treat the root cause: insulin resistance and sugar cravings from ultra-processed foods. 

However, there are important considerations that we must take into account. More screening for eating disorders is imperative, especially in the midst of social media pushing extreme thinness, and the celebrities on Ozempic.

We also need to address how the guidelines advocate for calorie restriction, which is always harmful. The cost, the health disparities, the fact that it's not covered for many, and the fact that those other supports are not in place also needs to be considered.

This is a new tool that society will need to grapple with. Alongside this, we need to ensure other supports are in place, and that parents are getting some of the help that they need. We need to realize that it's just not going to be solved with one prescription and a five minute visit.

The new GLP-1 agonists potentially reduce disease risk and chronic disease burden in teens with a once-weekly injection. It is important to focus on what the GLP-1 agonists are really treating and be excited about that instead of focusing on weight loss. We need to remain cautious around singular solution, quick fix thinking while treating a chronic complex disease in teens.

Finding a healthcare provider to support with this

You can go to abom.org (American Board of Obesity Medicine) to view a list of providers, and The American Academy of Pediatrics has the Institute for Healthy Weight may also offer support.

It is usually a children's hospital that will have a tertiary weight management program and sometimes they have wait lists.  

There are not loads of specialists in this area, and some are still stuck in the “calories in,  calories out” model. A pediatrician should be assessing for comorbidities like type two diabetes, pre-diabetes, and fatty liver disease. We want to target the comorbidities and those health issues because, especially with pediatric obesity, we have to treat the comorbidities first.

If you have a good relationship with your pediatrician or family doctor, you can probably do a lot within the primary care setting, but I am the only one I know who's doing metabolic telehealth for children and adolescents.

More about Dr. Karla Lester

Dr. Karla Lester is a pediatrician, Diplomate of the ABOM, Certified Life Coach and founder of IME Community for teens and drkarlamd Metabolic Telehealth. Dr. Lester has dedicated her pediatric career to creating community solutions for children’s health. She is the author of “the magical everywhere”, “12 months of self-love superpowers journal” and the “Health Yourself” eBook for teens. Follow Dr. Karla on TikTok where she is known for disrupting weight stigma and bias in medicine and calling out the harms of diet culture. Dr. Karla has been interviewed by NBC News, Today.com, Newsweek, Buzzfeed News, Fox News, and ABC News about the harmful “Almond Mom” trend. 

Website: www.imecommunity.com

Telehealth: www.drkarlamd.com

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YouTube: @imecommunity 

IME Community Podcast on Apple and Spotify

Doctors on Social Media: https://doctorsonsocialmedia.com/karla-lester-md/

KevinMD.com: https://www.kevinmd.com/post-author/karla-lester