Pediatric Obesity Care with Dr. Stasia Hadjiyannakis

– Welcome back to “Scale Up Your Practice,” the podcast from Obesity Canada. I’m Dr. Roshan Abraham, a family physician and associate professor at the University of Alberta.

– And I’m Michelle McMillan, a lived experience advocate with Obesity Canada. This podcast brings together lived experiences, research and clinical expertise to explore what it really means to offer obesity care that is grounded in evidence and empathy.

– Today’s episode is supported by an unrestricted educational grant from Eli Lilly Canada, where we’re continuing our Celebrating Canadian Excellence series, spotlighting leaders shaping the future of obesity care.

– And today, we’re thrilled to welcome someone who’s made a lasting impact in the pediatric obesity space. Dr. Stasia Hadjiyannakis, is a endocrinologist, a researcher, a clinician, and an advocate for young people living with obesity. Welcome.

– Thank you both. So grateful for the time with the two of you today.

– Dr. Hadjiyannakis, welcome to the show. Let’s start from the beginning. What drew you into pediatric endocrinology and specifically into the world of pediatric obesity?

– I’ve always loved the systems of endocrinology and it felt like a very logical field. I also loved the opportunity to work with children living with chronic conditions and also feeling like there was some intervention that we could offer. When I went on to fellowship, I started to see patients living with obesity, young people living with obesity, and started to learn more about insulin resistance and the role insulin resistance played. And in particular, young teenage girls with PCOS or kids living with lipid conditions. And I was disheartened. I understood the complexity of the physiology, but was disheartened by the lack of really acceptance into the endocrine clinic, really acceptance to actually even follow these young people, even to accept referrals. I was always sort of told that, we don’t manage obesity and endocrinology. We just rule out traditional endocrine causes of obesity and then we send back to their primary care physician or send them back really on their own–

– On their own.

– Without any support. And that felt, it just felt wrong to me. And I had, at the same time I had a real curiosity about what was happening for them physiologically and in their bodies. Because clearly there was something different in the way their bodies were expending energy, the way their bodies were responding to insulin, the impact that that could have on them. I was lucky enough then to, once I finished fellowship, to work as just a visiting professor in San Francisco with Dr. Robert Lustig, who is a neuroendocrinologist. And then I just dove into like the neuroendocrinology of body weight regulation and it blew my mind open. And also just to really understand that disconnect was, once I’d learned about leptin and ghrelin and just the way our neuroendocrine system defends against weight loss, I was so, it felt so wrong in terms of the advice that we were providing to patients, the way patients felt when they were coming to see us with obesity and the lack of care or follow up or even a discussion of how complex the condition was. And it was really, that was back in 2003. And it’s taken, I feel still we have a long way to go, even though we’ve understood the neuroendocrine system for decades now, there’s still this disconnect around the individual control over body weight regulation.

– Yeah, that’s so interesting because we’ve talked about previously on the podcast about obesity really being a brain disorder. It’s a chronic, but it’s not based in your stomach, it’s based in your brain. And so, yeah, I love the fact that you’re studying both aspects of that and in particularly youth, because there’s so many challenges of dealing with youth who are living with obesity. I’m curious why your focus on youth? Is there something that attracted you to it?

– As a medical student, I thought I was going to do pediatrics. I just love the patient population. I love teenagers in general just because they’re world, they’re just discovering the world and themselves, and physiologically their bodies are changing so much. So when it comes to body, because the endocrine is really also a study of growth and body size regulation and what happens at that time of puberty where our body naturally wants to grow and gain weight more rapidly, and what happens around that time from a weight management perspective, but that’s the physiology of it. But just the joyfulness of young people, their openness, their lack of filter, and they’ll just tell you how they feel. Their curiosity. And just that they come in and sometimes you have to work at that. I know that’s true in adults, but that connection and connecting at a level that speaks to them every day is different, so I love it

– You are making a strong case for pediatric endocrinology. The fervor and the passion you have for the work that you do Stasia, is just immensely, it’s awe inspiring, honestly the way that you talk about it. It’s incredible. I’m so glad that we have you here. You’ve been involved in so many facets of this field, from clinical practice to research, to advocacy, looking back, what’s something you’re especially proud of?

– Well, I most enjoy my clinical work. I most enjoy listening to my patients experience. I most enjoy hearing from patients after they come back in their early twenties to tell me what they’re up to. I love graduation photos in this time of year because many of them are moving on or graduating from high school, which is lovely. I think at the same time, if I think about combining my practice and the joy in meeting these young people, I think some of the tools I’m most proud of are tools that were inspired by Dr. Aria Sharma and his group in terms of the Edmonton Obesity Staging System. And really trying to get our healthcare colleagues to really think about the complexity of obesity and understanding health risk beyond anthropometric measures. And if I’ve made a little change in that area in the way healthcare providers assess obesity, the way they look at anthropometry and recognize the limitations of it in terms of what it means and health risk, and in terms of expanding the way someone completes an assessment for someone living with obesity, that would probably be the thing I’m most proud of. And just grateful that Dr. Sharma sort of gave us this framework that we could then adapt to pediatrics. I still remember when those articles came out in CMHA and reading them, and I’m like, we need this for peds, we need something like this for peds to just organize the way we think about pediatrics and obesity and understanding, truly understanding health risk in a better way.

– That’s a good thing to be proud of. It really is. Yeah, yeah. Just that shift and how we think about things. And so now I’m going to pick your brain a little bit about the shift because you know, pediatrics usually you’re not in the room just with the child or the adolescent, sometimes yes, maybe. But I’m curious, when you talk to the families or colleagues, you know, who may have some antiquated views that obesity is just about behavior or willpower or bad parenting maybe, I’d be curious with all your knowledge, how do you help reframe it to explain the science of obesity to people?

– Yeah, I would share, I like to share my knowledge and I like to share information based on science. I like to stay curious about where their ideas might be coming from and just sort of say, you know, would you be surprised to know that body weight regulation is far more complex than we’ve been led to believe? I understand where this thinking may be coming from, but we’ve learned so much over the last two decades that have really refuted those ideas fully and completely. It’s simply not true. It’s categorically false that body weight regulation is simply energy in and energy out, or how you just, the eat less move more has been debunked over and over and over again. I share with my colleagues who say, well… It’s very difficult to hear when colleagues say, “Well, look at their parents.” And I say, “Yeah, obesity or our body shape “and size is highly genetically determined. “It’s polygenic, some of us inherit genes “that will predispose our body “to a certain body shape and size, “in the same way that tall parents will have tall children, “people who have a higher body weight “are more likely to have children “who also have a higher body weight, “so that’s why you’re seeing that, “it’s not an indicator of parenting style “or opportunities for physical activity “or home food environments. “Like you really need to park your assumptions “and explore first before you make “any of those assumptions.”

– Beautifully said. I know we’ve talked a lot in past episodes right now a little bit about clinical assessment, as a primary care provider I’m especially curious about how in the last few years what the literature is telling us in regards to obesity care and specific pediatric obesity care, and specifically around family support or even mental health. Any new revelations, anything that can help support colleagues in this? Because I do find that that’s always a challenge even if you get past sort of those initial assumptions in sort of the clinical world, family support and mental health, and how we can actually do better in those areas.

– Oh, absolutely, yes. I think I’ll start with mental and neurodevelopmental health first. I think that I was surprised by some things that we were seeing in our practice, but the one thing that maybe wasn’t surprising to me was how common social anxiety was. And that’s the most common thing we see, of course, in pediatric obesity. And for me, I struggle with this because I think that depending on a young person’s temperament, they may be more vulnerable to develop social anxiety. But certainly what’s happening is this reaction to the experiences of bias and discrimination. So this weight bias and discrimination actually contributes significantly to the prevalence of social anxiety that we see in pediatric obesity. And that’s the number one issue. And in my mind, I’m like, is it really pathology in the young person or are they responding appropriately to a harsh environment or an environment that is excluding them because of their body shape or size? And we’re labeling the young person as socially anxious when it’s really, we really need to do better about having zero tolerance for weight bias and discrimination. And then of course when you experience social anxiety, you can imagine that engaging in activities that may help you with your physical, mental, social health becomes harder. And then certain activities will be more comfortable, like screen-based activities or socializing online, maybe a more comfortable thing. And then everybody’s telling you, “Oh, your screen time is too high.” But if you’re just, if you’re not paying attention to the fact that I’m actually socially anxious and I need some help with that and to build my comfort and confidence, my self-esteem, my body image, and then yeah, maybe I will start to be able to explore things that feel more safe and then increase my social connections. So social anxiety is both a response, I think, to the way the world treats young people who are living with obesity and then becomes a barrier to weight management and can contribute to poor health outcomes. So that’s a big one. The one that I was surprised by, and maybe I shouldn’t have been, but our neurodevelopmental differences. So when I think about pediatric weight management, there’s an over representation in weight management clinics of kids living with neurodiversity. So whether that’s ADHD, which is the second most common thing we see, or ASD, or some kind of developmental coordination difficulty, which now makes more sense to me, but I wasn’t expecting it. And certainly when we’re seeing kids living with ADHD, appropriate treatment and support for ADHD will be important in terms of responsiveness to weight management intervention. And same for ASD and other neurodevelopmental differences. And that group, I feel like we have a ways to go in terms of really tailoring our interventions, even just assessing for those if they coexist and helping to find supports for those. And then family supports. I think in my experience, I think that when you’re looking at pediatric obesity, of course it also disproportionately impacts children, and populations, and parents who are already exposed to higher rate often or higher rates of social stressors, including poverty, racism, discrimination, and other forms of past trauma, historical trauma. And sort of consideration for those things is important as we assess children living with obesity too, and get those supports in place and understand that framework. Though sometimes you have families who are dealing with discrimination from a body weight perspective, but other forms of discrimination in terms of social status or race or ethnicity as well.

– Yeah, what I hear you saying is something that we often talk about on the podcast here about treating the whole patient and in this case, treating the whole family unit because there are so many complex things that could be going on in addition to living with obesity, which is a chronic disease. So yeah, that’s very complex as if I didn’t think endocrinology wasn’t already complex enough.

– But you’re right, like those family systems, if one person is struggling, the care of the young person is dependent on the health, mental health, physical health, social health, financial health of that parent or caregiver as well, or other members of the family and what else is going on, what’s on their plate to deal with.

– True, true. Now that you’ve kind of highlighted a few areas, I’m going to ask you, what do you still see even with the knowledge that you have about the biggest gaps that we need to research and address within the care system for pediatrics living with obesity.

– Well, when I think about, so if I put on my endocrinology hat, when I think about the way we approach other chronic conditions I see a great disparity in the way that we approach pediatric obesity management. We’ve just talked a lot about how complex the condition is. I follow kids living with diabetes, which is also a complex condition. There is no, you know, every young person with diabetes, for the most part in my, at least in my city of Ottawa, has access to a diabetes clinic where they have access to allied health professionals, including diabetes nurse educators, dieticians, social workers, yet children living with severe complex obesity have to wait one to two years for an assessment, to our clinic are only followed for two years, and then we discharge back to primary care. And that just seems such a disconnect, even though we recognize it as a chronic condition, we’re saying, oh, you only need two years of intensive care and then we’ll send you back to your primary care physician, which may be okay for some kids, but there isn’t that option of ongoing chronic care. I don’t think we’ve matched the care that we provide with the complexity of the condition. So there’s certainly gaps in that. I still think there’s great gaps. We may be doing better, but in a medical education and making sure that obesity has its proper place in our medical schools, in our residency programs, in our fellowship programs, and the influence of more senior physicians who may not have had that education on young trainees in terms of their interpretation of obesity and how it should be treated. So I feel like there’s still a gap in knowledge and appreciation of the complexity of the condition, and you can see it right on the clinical ground level and still in our training programs.

– And that’s such a powerful statement to reiterate. I’m glad you brought up medical education. I know that’s something that I obviously love to talk about whenever we have the opportunity, and it really ties into bias. I mean the complexity of these, of pediatric obesity, adult obesity is something that should be taught in great detail in medical school, medical training. It covers so many of our CanMEDS roles more so than other conditions, and in fact, it’s probably the only condition that really hits off on all CanMEDS roles so effortlessly, partially because of the sheer amount of bias that has prevented us as a society really of treating this like another chronic disease. So I think it’s always important for us to recognize that there is still work that’s to be done. And we always appreciate the amazing work that you and others are doing in this field. But you do still see bias on a regular basis. And so this is an opportunity for us to reflect on that and perhaps hear from you about a time when you’ve witnessed weight bias and how it can actually impact patient care.

– Yes, there’s unfortunately many examples, but the one young man I was thinking about more recently is a young man I’ve been following since he was maybe nine or 10 years old, he is almost 18 now. He’s super bright, interested in lots of different things and shared that he might be interested in becoming a surgeon one day. Oh, I’m going to get a bit teary. And I think he shared his desire to go into medical school and potentially become a surgeon with a friend of his whose father was a surgeon. And the feedback he got was that he may need to consider, you know, working on his health a little bit more if he wants to do that type of grueling job, which under, you know, is very sort of veiled attempt to sort of point out that maybe his body weight may be a barrier to his career goals. And he came back to me after that and we talked to, and you know, just trying to undo some of that messaging and say, “You’ll be a marvelous surgeon “if that’s what you want to do. “There is absolutely no reason for you “not to pursue medicine “or to feel like you need to somehow change your body “in a dramatic way in order for you “to pursue your career aspirations or goals, “and we’d be so lucky to have you in the profession.” But that was just a bit heartbreaking. Well, it was heartbreaking to hear him come back and feel like his body weight would be a barrier or his body size or shape would be a barrier to something that he wants to pursue.

– Yeah, that’s so challenging from so many angles. I’m going to use the word kind, but that’s not quite the right word, for you to take the time with the patient because it might have just been an offhand remark, right? Something that the person who said it didn’t give five seconds thought to it after it was said, maybe the person even thought it was helpful. Maybe you should consider some other type of medicine. I don’t know how that would be relevant, but yeah, and just, yeah, the little things that can make big impressions on people who are living with obesity.

– Yeah, I think that’s so crucial for listeners to hear is that these small little moments, these pockets of time that we have with patients can actually have lasting impacts. On that note, what practical steps can primary care providers, like pediatricians, family, doctors, or other frontline clinicians take to start building that more supportive evidence-based and bias-free care environment for children living with obesity and their families?

– I think really starting with parking our assumptions, staying curious. I think in my experience, young people living with obesity want an opportunity to talk about their experience of living with obesity with someone that they trust and feel comfortable with. I don’t buy this that they’re not aware. In my experience, they’re aware. They just might not be comfortable talking about it with you, but they’re aware, they need to feel comfortable and safe. I think to stay curious about what their experience is in terms of physically, how are they physically moving through the world? Are there any physical difficulties that they’re coming across related to their body size? Is it holding them back from doing things that they want to do in a physical way? So that could be things like a particular sport that they want to play, or stairs or furniture or desks at school, or finding clothing that they feel comfortable in. And then the second thing is, how are they feeling socially? Do their feelings about their body ever impact their social comfort or confidence? Does it hold them back from trying things that they might be interested in? And what are those things that you’re interested in, and how can we get you to a place where you’re able to do those things and feel good about it? So yeah, what is your worry and your experience, if worry if it’s there or what’s your experience of living in this world in the body that you have and is it causing difficulty for you? And if it’s not, that’s great

– Exactly. Exactly.

– Like, that’s okay, we don’t have to change. We want to be there. I want to be there in case that changes for you. I’m not going to discharge you. I’m going to see you again. We’re going to continue to screen for, you know, once a year we’re going to screen for your metabolic health issues. I’m going to do a screen for your mechanical health issues when you come. I’m going to do a mental health and social screen when you come. And if things are good, great. Yeah, we’re going to keep doing that, but I want you to know I’m here if you are starting to run into any difficulties. Now, if I have a young person who’s like, yes, Stasia I’m having musculoskeletal, I’m having some muscle and joint pain. I’m really struggling with sleep apnea, and I’m having trouble wearing pap therapy and you know my blood work looks a little, I’m starting to have some, maybe some dyslipidemia, that’s our ESP right there, you know? Then we start to go, okay, well maybe your body is causing you some, you know, is struggling a little bit. Let’s think about how we could address that. But for a primary care physician, I think the first thing is what’s that young person’s experience so far? Complete your metabolic, biomechanical mental health, social health assessment. Identify if there are any what EOSP stage are they at, if they’re stage zero, fantastic. And then if they’re struggling, if they’re stage two biomechanically, you know, work on some things around there, we have interventions now that may be able to help our young people achieve improved biomechanical health through support with weight loss or improved metabolic health as well. So we have tools now, but complete that assessment before you give any advice. I think an incomplete assessment or advice before you’ve completed an assessment is not helpful and could potentially be harmful. So finish that assessment. Take your time. We’ve got time, it’s not an acute issue. Take your time with it and then come up with a shared plan that includes the patient’s concerns, their values, their preferences, takes into account the context in which they live and what’s within reach for them right now. And come up with a plan and see them again and follow up.

– I love that how you say it. It’s not an acute. And I think when you say that, that’s so important because so many people living with obesity, they’ve had a lot of negative experiences, unfortunately in the healthcare system. So it may take them some time to realize what a fantastic physician Stasia is. But the first time they might be like, yeah, no, everything’s fine. I don’t need to see… I can imagine my teenagers being like, yep, nope, it’s all good. It’s good how soon can I get out of this office?

– Totally, totally.

– Oh, gosh.

– This happened, this totally happened.

– Oh my gosh. Seems all the time.

– But yes, yes. By kind of like, I’m like, okay, that’s great. And then as we get to know… You’re so right. But as we get to know each other, especially if I show an interest in who they are, like what are they up to? What are they interested in? How do they spend their time? You know, get to know them as a human being, then they will start to open up and tell you a little. You have to earn their trust and they have to know that it’s a safe place to talk. And it’s okay if they don’t want to share the first time, the sixth time, the seventh time they meet me, we have time and we’ll get to hopefully a place where they feel comfortable talking about things, but I don’t think we should force it, and I think they won’t come back.

– So given that, you know, and we’ve talked a little bit about some challenges within the healthcare system and how obesity is not always treated equally as other chronic diseases. In a perfect world where you have a magic wand and you know, time and money and all those things didn’t matter, what would be the one thing that you would wave that magic wand and change within our healthcare system?

– Oh, do you know what? I honestly think one of the biggest barriers for me is if I could eliminate weight bias and discrimination, if I could do that and separate this idea that you have some knowledge of how healthy someone is based on their body size or how they’re living their life based on their body size. When a person walks in that there’s assumptions being made, or all this advice being given to young people who are being told there’s something wrong with their body. I think the harm in terms of health and mental health and social health that is experienced by the presence of the ongoing pervasive nature of weight bias and discrimination makes weight management and achievement of health goals so much harder. It holds people back from coming to see physicians. It holds people back socially. It forces them into unhealthy, restrictive dieting practices that just lead to potentially more harm. It holds sometimes teens back from living their lives fully and just being accepted for who they are and not being judged. When I talk about kids, kids and parents talking about what is their biggest worry, like what is their worry for their young… Why are you worried about weight? Why is that something you’re worried about? That is the number one thing from both parents and kids, is that I’m worried about being judged. I’m worried about being, I don’t feel comfortable going out because I worry about how people will perceive me when I’m out. I’m not comfortable eating at school because I’m worried what people will think. And then of course, parents, the thing that’s heartbreaking is parents, because it’s such a hereditary condition, it runs so strongly in families, parents have had those experiences as kids and they want to protect their kids from those experiences. I was naive when I started in this work. I think I thought, oh yeah, I’m sure mom and dad are going to be worried about risk for type two. You know, I’m sure they want to see the blood work, and they want to see changes in improvements in blood work. And every time parents and kids, of course they care about metabolic health but it’s really the social impact of living with obesity, which then of course negatively impacts health. So if we could eliminate that experience, that negative experience, those wrong assumptions, I think that our kids would do, our kids and adults would do better. Yeah, that’s the one thing, if I could wish that away, that weight, that preoccupation with body weight. I remember a young person coming back. She had type two diabetes and she had, you know, markedly elevated blood sugars. We treated the diabetes with insulin because she needed it, her body weight increased, but she was better, she was healthier when she came back to see me, but her mom was so upset that the body weight increased. And I was like, oh, no, no, no. You know, she’s a metabolic, she’s so much healthier right now than she was four months ago. Like, her body’s feeling so much better. And yet there’s this feeling that somehow, there’s this misunderstanding that because the weight increased a bit that she’s somehow not healthy, and it causes just so much harm.

– I mean, I think that’s where we have to try, right? I mean, organizations like Obesity Canada are institutions, especially as institutions. I think we need to be held accountable as educational institutions that are providing degrees to healthcare professionals, that we have a duty to instruct about all types of bias. But I think definitely weight bias and stigma is an area that we just don’t talk about nearly enough. So I’m hopeful that we can at least move forward in that direction. I don’t know if we’ve got a magic wand. What gives you hope about the future of pediatric obesity care?

– This I think, honestly, Obesity Canada has given me so much hope over the years. From 2004 when I finished that extra training in San Francisco, and found this place of like-minded, curious people who sort of understood obesity as a complex condition, the fact that it’s been recognized as a chronic condition, the fact that it’s hopefully found a home in medicine rather than like in the past, it was like, oh, no, no, I’m not going to see my doctor about weight. That’s something I should just do on my own. I should be able to control this by myself. I remember so many young teens who were like, “No, no, I don’t need any help with this. “I can do this, I can do this.” And sort of trying to kind of teach like this is not something that you’re not doing… This is not because you’re not doing something right or that you’re doing something wrong or that you cause this for your body, this is what I went to school… Like we have trained professionals who can support you with this. You do not have to do this alone. And I hope the message of, you do not have to do this alone, and that this is not something you need to fix, and that we have a better understanding of this condition than we have. I just want that to percolate so that it’s not just people living with obesity who are hearing that. I’m grateful that people living with obesity are hearing that. I want the world to hear that. Like, I want my patients not to be told that there’s something wrong with their body and not to be, to be treated as respectfully and kindly as my kids with type one diabetes might be treated when they get a new diagnosis of type one diabetes and the understanding that they may get from their healthcare providers and their friends and their families. We don’t have that in obesity management, I don’t think. Sorry. I was supposed to be hopeful, but I think it’s coming. I think it’s definitely coming. I am also very grateful that we have some tools now that it is being taken seriously., that we have some medication that can be helpful, that we have surgical options that can be helpful for kids as well. I’m grateful that the toolbox has expanded.

– I mean, all of that is wonderful and you’ve added so many little nuggets that I’m squirreling away in my brain, right? But one of the things that we like to do during the podcast is to ask our guests if there’s one just kind of small nugget of information that our listeners who are primarily healthcare providers could take with them to tomorrow at the office, tomorrow when they meet a patient. Just a little thing that they could do that would improve the lives of their patients living with obesity.

– Yeah, I think the one thing when you walk into a room to meet a new patient, the most important thing you can be is curious and no judgment and no immediate sort of decisions about what that person is there to see you about. I like to start every visit to just learn who that patient is first before you, and what’s important to them, before you jump into trying to fix. I think doctors always kind of try to fix, I think we have that tendency of wanting to fix things. And I think if you can listen more and be more curious before you jump in to try and fix something that may not actually be in need of fixing, I think that would be one thing.

– You’re channeling some Ted Lasso from Walt Whitman there, curious, not judgmental, loving it.

– I love Ted.

– Yeah, I can see why But thank you again for being here and for your ongoing work to support kids and families across Canada.

– Oh, thank you so much for the opportunity. I loved chatting with you

– If our listeners would like to learn more about pediatric obesity, be sure to visit Obesity Canada’s education resources where you can take many free online courses, including two on pediatric obesity. Head to education.obesitycanada.ca. E-D-U-C-A-T-I-O-N.oobesitycanada, all together, .ca to start learning today for free.

– And if today’s conversation sparked new ideas, I know it did for me, or helped you see things a little differently, share this episode with a colleague or leave us a review to help more people discover the podcast.

– And don’t forget to subscribe on your favorite podcast platform so you never miss an episode. Until next time, stay curious, stay kind, and keep scaling up your practice. This podcast is intended for informational and educational purposes only, and does not constitute medical advice. The content shared in this podcast should never be used as a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare professional with any questions you may have regarding your health or a medical condition. The information and treatments discussed in this podcast are based on Canadian guidelines and approved practices as of the time of recording. If you’re listening from outside of Canada, please consult your local healthcare professional to ensure compliance with your region’s medical standards, guidelines, and recommendations. The creators of this podcast disclaim all liability for any decisions or actions taken based on the content discussed. Listening to this podcast does not establish a professional or patient/client relationship.