So going back more than 30 years, I was involved in work on childhood obesity. It was a prevalent problem at the time, but little attention was being devoted to children and weight issues. And it was fair to say that the field, as it were, was an academic backwater. Little was known about short and long-term effects of childhood obesity. The social and emotional lives experienced by the children hadn't really been documented or studied much. There was very little known about treatment or strategies for parents, but thankfully, things are different now. Thanks in part to the work of a number of really innovative people in the field, and one of the most innovative is our guest today, Dr. Joseph Skelton. He's a professor of pediatrics and founder and director of Brenner Fit. FIT stands for Families in Training, which is the family-based pediatric obesity program at Wake Forest University School of Medicine. He's also editor of the Journal of Childhood Obesity is involved in clinical care, research, education, and community outreach. Dr. Skelton has just published what I think is a really important book through the American Academy of Pediatrics, entitled Your Child Is Not Their Weight: Parenting in a Size Obsessed World. I was asked to review the book and was delighted to see it before it was published and just was so happy to see that such a book existed at all, but such a good quality book at entering the picture. Really a very important advance in our field.

Interview Transcript

There have been some books about pediatric weight issues in the past. Who is this book for and how is it different than what's been out there?

I feel overall the big audience for this book is any parent, especially of my generation, that were raised during some really toxic diet culture in the '70s, '80s, and '90s. And so, I think the main folks that that's for is that parent: I want my kids to eat healthy, to be active, to lead healthy lives. But I don't want them to become concerned about their weight to feed into our culture's focus on the ideal body image. I don't want to feed into that. But you know I do want to pay attention to the health habits. How can I do this in a healthy way? How can I focus on health habits with my kid that's not a focus on weight and do it in a way that's backed up by science. You know, that's what parents always want to know. Am I doing this right? Am I causing harm? And it is actually who the book is dedicated to, you know, all those parents that were raised in a toxic diet culture and want to do things differently with their children.

So, in modern day America, what is life like for a child whose weight exceeds the standards that we know might be healthy, and for the parents who are raising those children?

From personal experience and 20 years of running a program, as well as what the research shows, it can be kind of rough. Despite a lot of the advances that we've made around weight bias we're still in a place that kids are trying to live up to this idealized body image. And then they have all these toxic messages when it comes to nutrition and body image. I think it's rough. We know that kids in bigger bodies tend to have a lower quality life. They tend to have more symptoms of depression, anxiety; and it's because of this world that we live in.

You mentioned messages that they might be getting from places like the media, but what are interactions like with peers and teachers and doctors and others in their lives that are affecting how they feel?

Yes. So, the adults in their life were raised in that toxic culture. They're my generation and the generation behind me that was raised in that. You know, there's the myth that a smaller body is healthier than a bigger body. And I think we can't break away from that. And I think that still sort of comes through. We still see this as a lifestyle issue, and everyone has an opinion. Everyone has a thought of, you know, well, I did this... and I lowered my cholesterol... I did this and I lost weight, you need to do it too. And I think in the medical profession, because of a lack of understanding, a lack of training - I think that still occurs. I don't do a ton of medical education. I'm getting more and more into it, especially when it comes to areas around nutrition. But that's what I'm trying to avoid in the next generation of healthcare providers and even actually a lot of our community collaborators, teachers, and stuff like that. To get away from that. This is not a simple issue, so don't share advice because sometimes that advice can be damaging or could be wrong. You know, good lord how much I hear about carbs on a weekly basis. And not the carbs I like to talk about, which is around dessert and Carolina Gold rice and all these other food stuff. But it tends to be around sort of demonizing certain foods and just really bad messages that still are floating around out there.

Let's dive in a little deeper about what you refer to as toxic diet culture that was especially pronounced in previous generations. What does that mean? Does it affect standards for what the ideal body looks like? What about messages about how much control you have over that yourself, and how responsible you are for your weight? How your self-image should be influenced by how you look? But tell us more about what you mean by that.

We wanted this to be a book that didn't necessarily dwell on weight so much, but actually one of the first chapters is to say let's cover how complex weight really is. We know that 50% or more of someone's weight is heavily, heavily influenced by their genetics. Where they live, you know. The amount that our lifestyle affects that is much, much smaller. It's the minority of what goes into our body size. And even that, our habits are so influenced by the world around us. But it's, you know, trying to get people to understand that, hey, body sizes are just different. I love this picture from the Olympics and it was a medalist in gymnastics- it was Simone Biles; you know, the huge media personality of Ilona Maher who is a bronze medalist in rugby; and then one of the women's basketball players. You're talking 4'9", 5'10" and pure muscle and six foot seven, all people at the top of their game. And not only different heights, different body types. And, you know, body type is a hard thing to talk about because there's not standard body types. We're all just built differently. And starting that message at a young age that people are just oftentimes built differently. There's very little control that we have over our weight. And even though there are things that we can do about weight, what you can do is you can focus on your habits for health. And that has just gotten lost. We talk about in the book the, we call it veiled weight talk, and it's basically where you're just substituting the word health for the word weight. And kids pick up on that. They know when their parents and others are talking about weight. And so, a really big thing we want to accomplish is like, Hey, you know, eating for health is important. Being active for health is important. In my world, and I did one part of my early research in this, and we always try to have that message as there's so much more to health than weight. In our medical world right now, our primary outcome on these lifestyle changes that people are making is weight.

You mentioned genetics as a contributing factor to who is affected by the problem. Tell me how you look at the food environment out there that people are exposed to now, and things like food marketing and the processing of foods. The availability of all these foods that are contributing to obesity and things. And the reason I ask is, you know, there was a time in our country when the prevalence of childhood obesity was probably close to zero. And there are plenty of countries around the world where that's still the case. But now in many countries there's large amounts of childhood obesity. And it's not as if the genetics have changed. When people move from other countries to the United States, their weight tends to go up. Their genes obviously don't change. There's something pretty toxic about the food environment that's driving this. So, thinking about things that way, does that help parents by shifting some of the blame from them and their children to an environment that they might be able to manage in some way?

Absolutely. Because parents…they blame themselves oftentimes. You know, how did I let this happen? What did I do to sort of cause it happen and it's not. So, we do try to shift that of looking at ourselves as the reason blame. But you can kind of look at the - and I'm just going to focus on nutrition as the focus - the broader food environment and how that impacts. We tend to get a lot of buy-in or understanding when you talk about how they are trying to market to kids. And so, for any parent, all you have to do is bring up the checkout line at a grocery store, you know? And all the things that are at the kids' level that is just made to make your life as a parent hard when you're trying to feed your kids well-balanced regular meals but you're just kind of constantly walking through this landmine. It's the same thing with electronics and social media. There are so many things that they have a lot more money than you do to market to you than you do to protect yourself against it. And it absolutely influences it. And the way I talk about this is really when it comes down to snack foods, and using the parenting language that snacks get you between long periods of time between meals, but that got co-opted by companies marketing snack foods. And when you see food, smell food or hear about food, you kind of want that food. And that's what parents have every day to now the point is. Snacks always have to be crunchy, salty, and sweet, and we're supposed to give kids snacks when they ask for it, because that's what these companies tell us about hunger. You know, hunger hits us every time and you have got to have this bar to sort of get through that. Parenting is hard enough and then trying to parent through this when they're directly marketing kids... you know, in most European countries, they're not allowed to market to kids. In some countries it's age eight. Some countries it's age 12 because they don't quite recognize this is marketing, they're want you to buy this. It makes it a lot harder for parents.

You know, when I was on the faculty at Yale, I got to know a political scientist. A very impressive person named Jacob Hacker. And he'd written a book called The Great Risk Shift. What he talked about was how government and American businesses have systematically shifted the responsibility for overcoming harm from products from themselves onto the consumer. And that's really true in a way here, isn't it? Because the problem is created by corporations who are marketing unhealthy foods in such high levels. It's not the only cause, but it's certainly an important one. But the responsibility for solving the problem then falls to the parents and the children who have it. And one party has way more resources than the other. As you said, it's really not a fair fight and parents have a very tough battle dealing with these things.

Yes. There was a marketing study called The Nag Factor, and I'm an old Simpsons fan, you know. You imagine the people behind the one-way mirror watching things and trying to manipulate. And that's what the nag factor was. How can we get kids to nag their parents more effectively? And what they found is parents that were immune to nagging tended to be the more educated, higher-income parents. And so, they literally had this plan of we need to change how we're getting these kids to nag. We need to give them reasons to nag. And that's when you started seeing vitamin C, high in protein. So, you think the checkout at the grocery store is bad, but then the signage in the commercials each and every day are giving kids reasons they can go to their parents to tell them get me this. Because nagging is not going to be enough for the high-income parents. They have to have some purpose behind it.

You know, when I was growing up, the only way I saw advertisements for food was on Saturday morning cartoon television. And there were three channels showing it. Well, it shows how old I am, but now it's just an avalanche of messages on social media, built into gaming, and it's just everywhere. And it's probably pretty hard for parents to control that. Wouldn't you say?

Well, now that you've said that, that's what my phone's going to start doing. The next time I open up my Facebook, there's going to be an ad for some sort of food camp because it's listening to us. Absolutely. Oh yeah. There's just no comparison. And I think that's also something very hard for parents, regardless of the topic, is what worked for me that my parents used is different than for my kids. And even between your kids. You know, my 24-year-old and my 20-year-old are completely different kids. You wouldn't even know they're related and different personalities. And so, what worked for one, you can't necessarily apply to the other. And whereas we love the idea of multi-generation households and, you know, being involved and being there to give advice. And you should take the advice of your parents, but it doesn't always apply. It's just a different world. I feel like I need to give credit to my East Tennessee farming roots. There are two stories I always remember my dad talking about when they would go to a car hop. Maybe some of your listeners know what a car hop is maybe they don't. It's like a Sonic, you know, it's the old school drive up. Or for you Atlanta folks, like the varsity drive up. My grandparents would make my dad put on his Sunday clothes. You know, that was how rare they went out is they would actually get dressed up driving into town to go try these hamburgers and these French fries. Versus now you can you DoorDash that 24/7. I mean just what a different world and concept. And I still have to share this other story for my grandfather, who my oldest son is named after, he was a tobacco and sustenance his farmer in East Tennessee. And every time I have a med student that's a vegetarian in my cooking class, I always tell the story of he came home one day, and he was talking to my aunt. He says, you know what? The county agent said one day people are going to be eating soybeans. That's so funny. Soybeans were fed to cattle back then. It's really just how drastically we change and now it's changing even faster. I mean, my grandchildren will be light years different than what my children are.

Let's dive back into your book. Tell me about the collaboration with the American Academy of Pediatrics and how did the book come about?

They have had two books in the past that were sort of geared towards parents, you know, how to address weight in your kids if your child has a problem with their weight, what can you do about it? Well-written books. They had done well. But they were looking to try to do something different. It was kind of time to sort of update that. And the last book was great by Natalie Muth. It was a fantastic book. So, a lot of my friends were on the 2023 clinical practice guidelines. And when that came out, there was a huge blowback from the eating disorder community. And, again, it's sort of the polarization of our country right now. And, they had asked me to speak at a conference saying, hey, can you try to do something in the middle? They knew that we included elements of the body positivity movement in what we do. We're big adherents and teachers of authoritative parenting. And they said could you try to give a talk that kind of goes in between what we're trying to do with the treatment of obesity that's affecting children's health as well as the body positivity movement. It's kind of, again, speaking of the Saturday morning cartoons, it was kind of those things that everyone stepped back, and Bugs Bunny was still in the front and got volunteered. It was sort of one of those situations. And so, I gave this presentation and they said, hey, well, what do you think about turning this into a book? Would you be interested in writing a book? And I said, absolutely not. I don't have time. And never in a million years would I do it. But this needed to be out there. So, first of all, the AAP asks, as a pediatrician, you do it. And second of all, I feel like this book needs to be out there. Both for who I talked about earlier, those parents that don't want to hurt the kids' feelings, make them hate their bodies, feel like something's wrong with them, which is what a lot of kids say. But it's also for those parents that are wanting to do something. These are the parents that, you know, they want to put their kid on a diet or make a comment to them of you sure you need to have seconds on that? You know, which we know can do damage. And of course, parents, you know, they don't want to hurt their kids and get in the way. And so, it was kind of geared toward those parents that were starting down an avenue that may not have been safe. You know, they don't have access to a good evidence-based program. And so, it's also for those parents that says, hey, your kids aren't little adults. Don't take these weight loss approaches to kids. It's just a different beast.

We'll come back in a minute and talk about specific parenting strategy, but you alluded to this blowback from the eating disorders fields and the clinical guidelines. Tell us a little bit more about that, because it's one of the key features that would drive the need for a book like yours.

I'm not an eating disorder specialist, but there was a big concern that one of the big recommendations that was new was that you can't have watchful waiting anymore. It used to be, you know, if younger children were starting to gain weight, before you intervene or start into treatment or start to change a lot that maybe just wait to see if, you know kind of the old-fashioned thing, are they going to outgrow it? Are they going to go through a growth spurt? So that was a part of the recommendations. The evidence says that watchful waiting in today's world, you're unlikely to see a kid outgrow it anymore, including bariatric surgery, use of medications and things like that. And so, they felt like this increased focus that this was going to cause pediatricians and parents to focus even more on weight and therefore lead to eating disorders. And then that was coinciding over the previous five years, a lot of studies were coming out and then it got put into a couple of systematic reviews of meta-analyses that showed that kids in bigger bodies, kids with overweight and obesity, had a two to three times higher prevalence of eating disorders. Because typically eating disorders are always thought to occur in underweight or thinner children. But it actually is much higher risk of these in children in bigger bodies. And so, we use that term threading the needle, how do you help families who want to do something about their child's weight for health reasons but not worsening disorders. And so that blowback was really saying, hey, by increasing focus on this, you're going to make things worse with that. And it was kind of surprising. A lot of my good friends were on that practice guidelines and they're kind of taken aback because these are experts in the field. Well-meaning people that for 10, 15, 20 years had dedicated their careers to helping these kids looking for help. And I think any care provider to be accused of causing harm is always, always jarring.

Tell us how you navigate that and what sort of advice do you give parents in this book?

Yeah, so one is that I call weight literacy. It's sort of understanding this is a complex issue. It's not something you did. This is something that happens. We can't always explain it. There are still things, this is where you read too much of this science, it gets you really paranoid about microplastics and things like that. There are some legitimate arguments to me be made there in endocrine disrupting chemicals and stuff like that. We can't always explain why kids are growing bigger than other kids or at a heavier weight. So, the weight literacy, sort of, understanding this is a complex issue, this is not a lifestyle issue. And the second thing is it's worthwhile to focus on healthy eating and physical activity for health. Sometimes that will see improvements in weight, sometimes it won't. But it's still important to do. That's the idea of getting away from that weight being the primary outcome. We feel like this is a great adjunct for someone who might be pursuing bariatric surgery or medications, because it does give us the opportunity to not keep pushing kids harder on nutrition and physical activity, which could lead to that disorder eating. And I think the final thing is sometimes parents and kids are aligned. You know, give me a 15-year-old girl that wants to lose weight. A 15-year-old girl that wants to lose weight, that is unfortunately a child that's very high risk of developing disordered eating. And maybe the parents really wanted to help. But what oftentimes we see a lot is tension brewing between the parent and child. The parent making efforts to help the child with their health and their weight, and the child interpreting those efforts as you think I'm fat, you think I'm ugly, you think something's wrong with me. And it's causing that tension: you know, you can't eat too much of that. Taking Food away. That movie Spanglish with Adam Sandler, several scenes in that sort of reflect that of just small comments that parents can make. You know, actually wanting to help and how that can hurt children. And what we would hope for a lot of parents is to say how can you do this in a way that can be helpful. And one of our chapters is called how to not talk to your children about their weight. You know, the idea that parents don't need to feel that pressure to bring that up. Now, if their child wants to talk about it, absolutely they need to be there, and we give a lot of tips for that. But, you know, your job as the parent, you don't really have control of your child's weight, but there's lots that you can control and lots that you can do to promote the healthy development of your child.

You know there's a heavy dose of compassion in your book. That was one thing that appealed to me about it and impressed me. Because if one thinks about a book for parents on dealing with their overweight children, you sort of default to, oh, this book is probably a diet or an exercise program, or things like that about how the child can change their weight. And you're talking much more here about understanding the psychological world of the child. Being sensitive to possible risks of talking to them in ways that are unhelpful or lead to eating disorders and things like that. It's wonderful that you pay so much attention to those issues. And it's very affirming because you're saying that there are some things parents can do about this in ways that affirm their children, accept them as individuals. It's built into the title of your book that your child is not their weight. And that just means so much, I think.

Oh, thank you. That is what we had hoped. I mean, you know, parents love their children and in endless, endless ways. And the parents are the key to their children and their children's health. And I feel like sometimes we push too hard. Now we're doing it for good reasons. We want this child to be healthy. We want to help make some improvements. And we put a lot on the parents' back. And I think sometimes then that pressure then is extended to the children. And a lot of this is trying to get parents some insights of, we know you love your children. Here's how to make sure that your child is being loved. You know, the old parenting typology, and I kind of go through some of that history in there, really kind of gets at that. But sometimes we do or say things that doesn't make their children feel loved by accident of course. And it sort of highlights that, not to make parents feel bad, just so they're aware. I've been guilty of it. None of us are perfect parents. And you know, making sure that our kids are feeling, loved by us. Family-based treatment is obviously the key. And I always think of one of your, one of your hypertension studies, I think from 1983. I still quote it to this day. You know, the idea that even though we talk about family-based treatment, we're usually dealing with a parent and a child. The dyad. Now they're representative of the family and I've always felt like something was, sort of, missing there. And two things really influenced me. One of that is one of my co-authors, Dara Gardner-Edwards, who is a licensed clinical social worker. And they are all about the family. They know how to do family assessments. And so, recognizing there's more than just those parents and the child in the clinic with you. In addition to that, working the whole field, I didn't know about human development and family studies. Didn't know that was a field and actually came from the University of Minnesota. I was one of the early. Strong program. So, UNC-Greensboro, our neighbor over there. I started working with a professor over there, Cheryl Buehler, and we would go meet over sushi and she essentially taught me a four-hour freshman-focused family studies course. And just this whole other world, social science world of family dynamics and recognizing when you're working with that child and parent. You may or may not be affecting the family dynamics in the household, of that family system. And so being able to extend differently and having some more appreciation of the complexity of families and the relationships with families. Hopefully we're helping people understand making changes in health habits, relationships matter. We have a project going right now, led by one of my medical students. She was always impressed, in shadowing with us, of how many siblings were picky eaters. And I brought this up to my team, like, oh yeah, this is a huge stress. You know, this parent is obviously wants to change the habits of the entire family but is obviously focused on this child we have in clinic. But the struggle of having this other kid that's a picky eater really throws off those dynamics. And being able to account for that and that stress that that puts on families, and what can we do around that?

Oh, that's so interesting. You know, the more aggressive, dramatic treatments that are being used for adults like bariatric surgery and the GLP one drugs, how do they fit into this picture?

Yeah, so we feel like it's a perfect adjunct if someone is pursuing with this with their child, because it still is talking about that parenting approach. And it's not really going to change anything with how you're parenting around these things. You know, bariatric surgery for many years has been done safely and effectively in children. Not that it's always perfect, but again, because of the cost, the idea that it's not reversible and typically you want that done in a center that's very experienced with working with kids. So, access issues tend to be really big with that. It can be very effective for some kids but is not available to everyone. We're in the same situation with the medicines with GLP1s. There's one that has been approved for use down to age 12, and overall, they tend to work very well with kids. But we're in the real world now. We're learning a lot about that. It can be miraculous for some children because it gives them success with their weight. It takes pressure off themselves. We're always trying to prevent that restriction, both in hearing that from another adult or the child doing it themselves, trying to tell themselves to eat less. It's always going to backfire. It's going to increase your hunger and things like that. And having that GLP1 is going to help with that. It's actually going to lower that pressure. And oftentimes they can get in that healthy routine much quicker. In others, it's causing some problems. We are seeing some kids that it is absolutely wiping out their appetite. And we're figuring out now the kids are sort of at risk for that. And you can't do that. The kids gotta eat. But for some kids, they just lose all appetite whatsoever. And they can't not eat. And so, we're still figuring out through the real world. But I think, what we're also finding is the job that we do in these multidisciplinary teams, it's just as important if not more important when you're using medications than when you're not.

Let me ask you a big picture question and let me see how optimistic you might feel about how, where things are going. So, think of a physician who is treating people with lung cancer. So, the lung cancer is caused by this terrible environmental influence: cigarettes. And the physician then is in the position of having to treat the people who have that really unfortunate problem. And thank God there are physicians who do that, and there's research showing how to treat it effectively. But of course, it would be better if the environmental insult that's causing the problem in the first place didn't exist. That would make everybody happier, except for the companies that sell the product. So, do you think you and colleagues who are doing similar work are faced with a similar kind of a problem? There are all these environmental things that are helping push this problem in the first place. Thankfully, there's kindness, compassion and effective care available and your book helps push that forward even further. But are you hopeful at all that the environmental situation, you know, all the bad foods and stuff out there is changing in a positive way so that there might be less of the problem, or it might be easier on the children now who deal with the problem? Some people think it's getting worse. Others think we might see some progress. But what do you think about that?

My brother is an HR guy and he kind of talks about these different typologies with that. And, I forget, I'm called something like the mad scientist, which is you're very pessimistic in complaining, but you have enthusiasm. I don't really know how to take that. But I think, you know, I'm enthusiastic obviously about this topic and what we can do to help parents. But I'm a little pessimistic when it comes to the broader world. I think there's enough, and not saying that every for-profit company's bad, but I think a lot of history is on my side with that. I don't get paid more the more kids I see and the better success I have. I don't get paid more. My job is to be here to help. But, you know, companies, every time I see a for-profit company that comes out and says safety is our number one priority. Or, you know, your satisfaction is number priority, I'm like, no, it's not. Your number priority are your shareholders. And I think that's a very, you know, jaded way to say, I don't quite trust companies right now because of that. Are there some positives that you see, and do you see some changes being made in some menus? Do you see some different products out there that are really trying to get it healthy? But it's hard. I think I have some trust issues and I think that's well founded. Maybe that's my Appalachian background. I tend to be very distrustful of the large mining companies coming in. That, speaking of your lung analogy, that I think I have some healthy distrust that is well founded. So, I think trying to help, and that's obviously a big movement that we have, of trying to help people be more discerning parents, more discerning consumers. But it's hard because they, like you said earlier, they have a whole lot more marketing dollars to convince you to buy their product than we have trying to convince them to make smarter choices about it.

BIO

Joseph A. "Joey" Skelton, MD, MS, FAAP, FTOS, DABOM is a Professor of Pediatrics, and of Epidemiology and Prevention, at Wake Forest University School of Medicine. He is the Founder and Director of Brenner FIT® (Families In Training), an interdisciplinary pediatric obesity treatment, prevention, research, and educational program. He serves as the Director of the Center for Prevention Science in Child and Family Health, Vice Chair of Research for the Department of Pediatrics, Associate Leader of Community and Stakeholder Engagement at Wake Forest University School of Medicine. He is the Editor-in-Chief of the journal Childhood Obesity. He is board certified in Pediatrics and Obesity Medicine. His research and clinical work has focused on the treatment of children with obesity. He has secured nearly $10 million in funding over the past 15 years, has given over 50 national and international presentations, and has over 130 peer-reviewed publications. He enjoys teaching cooking classes that are both fun and informative to anyone who will listen.