I was overweight growing up, and I've just always had a natural attraction to all things sugary and sweet and junk food and delicious. So I was aware that I was overweight. I was so picked on over it.

'That's Tyler Bender. She's just 21-years-old, but she is a content creator who's already been thinking about food and weight and diet culture for quite some time.

So, like, my mom was pretty particular to not have juice, like juice, we don't drink our calories. So if I went to a friend's house and they had soda or full sugar juice and Capri Suns in the fridge, I would go ham.

'Now, Tyler no longer struggles with her weight, but the experience helped inspire some of her most popular videos on TikTok. They are basically skits of her poking fun at diet culture, especially so-called "Almond Moms." Now, if you're not familiar with this term, I wasn't, an almond mom is a parent who is obsessed with dieting and thinness, sometimes to an unhealthy extent. The term actually originated on reality television. This is when a mom on The Real Housewives of Beverly Hills encouraged her supermodel daughter to eat a few almonds and then, to quote, chew them really well.

How are you?

I'm feeling really weak.

Eat a couple of almonds. Chew them really well because your your stomach is nuts.

From there, the #almondmom hashtag really blew up online. In fact, millions have viewed posts from Tyler and others about the pressure to be thin, restrictive eating habits or how a parent's relationship with food and diet has impacted their children.

But we just ate six hours ago. Are you sure you're not thirsty?

Oof! Two pieces of bread?

All right, listen up. Here's what I want for Mother's Day. No candy. If you have to buy me something sweet. I love sugar free breath mints and fresh lemons.

And she sits me down with a cup of chocolate SlimFast. Do you think that's a great idea in sixth grade? No, but it's an almond mom.

Now, to be clear, Tyler says she's not making fun of anyone in particular. What she's trying to do is shine a light on the culture of this kind of restrictive eating through a character she calls the almond child.

Sorry I'm late. My mom wouldn't let me leave until I had a serving of kale soup. She says if I don't, I'll pig out. I'm not saying that we can't do the sleepover at my house. But I am saying that Kayley's mom buys Cheeto puffs.

'Tyler says the character is inspired by her own experiences growing up. Now, when she was a kid, Tyler says she did talk to her doctor about exercise, but not directly about diet or having excess weight. As a pre-teen, Tyler says she slimmed down by swimming and exercising and engaging in what she calls obsessive calorie counting and restrictive eating. And what it did was make her miserable. She tried discussing nutrition and weight with her parents, but says those talks were not always easy.

I think that conversation is so hard to navigate because it's like, okay, do we talk about like healthy habits to lose weight and get to a healthy BMI? Or do we talk about just loving yourself and owning the way you are? And it was so hard. I remember some days it would be like, you're perfect, you're beautiful. But then sometimes it was like, let's sign you up for swim lessons so that we can stay active.

'These are important issues that can be tough to navigate for kids - also their parents.

Parenting advice for overweight children, I think is so needed right now because we do have a childhood obesity epidemic. At the same time, we have so many teenage girls with eating disorders, so it's a very fine line.

Tyler spoke to us from her home in Colorado, and I think she touched on some really important things here. First of all, the number of children with obesity is on the rise. Just under 16% of children and adolescents between the ages of two and 19 are overweight. About 20% now have obesity. So the question I think for a lot of people, certainly a lot of parents, is how can they ensure their children get the food they need to grow and thrive? That's important, but also guiding them to avoid overeating or disordered eating. And when or how should a doctor step in to help if necessary? So in today's episode, I turn to a pediatric endocrinologist, Dr. Jack Yanovski, to try and get some answers.

Parents have to be alert and responsive to their children, and mostly not shaming them about their relationships with food to try to avoid these problems.

I'm Dr. Sanjay Gupta, CNN's Chief Medical Correspondent, and this is Chasing Life.

You know, I got to say, listening to Tyler talk about her experience managing her weight was really eye opening for me. I have three teenage daughters. I think about this topic all the time and I can tell you it's not easy. It's one thing to talk with pediatricians about my kids weight and eating habits. It's another thing to actually talk to my kids about it, even trying to figure out the right words to use and figuring out when someone might actually have a problem. The conversations about weight often mean talking about looks. It's very hard to disentangle those two things. But weight is more than that. It can be an indicator of health and how the body is functioning overall.

Most people who are heavy by the age of five or six will tend to continue to have problems with body weight throughout adolescence and into adulthood. So we know that those individuals will therefore accrue the greatest risks from their higher body adiposity, because they're going to continue to have high body weight throughout the years.

Dr. Yanovski is the head of the Growth in Obesity Section of the National Institute for Child Health and Human Development. In fact, he established that laboratory at the NIH in the 1990s. So he's been focused on the causes and consequences of high body weight in children for quite some time now.

I noticed that there was a growing problem with children having a high body weight. Essentially, from the 1970s to the '90s, there was a huge increase in the number of kids who are considered to have obesity, a high, too high a body weight for their own good.

There's no doubt tremendous implications of this. But over the time Dr. Yanovski has been at the NIH, we have learned a lot as well.

'Compared to 40 years ago. We know a quite a bit more. Not everything we need to know, but we first know that with younger children, given that their parents can control their environments to a larger degree, lifestyle or behavioral management can be successful. So there are studies that have extended for years after interventions that suggest that kids in the six, 7 to 12-year-old range can do pretty well with programs that are directed towards, what we call behavioral management. So that involves, of course, setting a satisfactory diet, giving exercise prescriptions and also doing behavioral modification. So teaching people about how to modify their homes, how to think about food, how to decide when they've had enough, training people to understand why they eat and when they eat. But certainly for younger kids it's 100% worth a try at a behavioral program, if you can find a high quality program that involves all of those components.

Now again, I'm a parent of three teenage daughters. So I could say firsthand that eating with my girls as young kids was very different than eating with them as teenagers. I still have influence, but they certainly have much more control over what and how much they eat.

The interesting thing about adolescent obesity is that adolescents are trying to do a lot in their lives. They're trying to do a lot of things all at once, and one of them is actually individuating from their parents. And so sometimes their best interests medically may not necessarily correspond to what they think is in their best interest to do at this moment. So it's very difficult, I think, for adolescents to follow behavioral management strategies. And that's why I think there's been an increasing interest in medicines, particularly for adolescents, when their body weights are high. We also know a lot more about how those medicines work and the advantages and limitations of them. We also have a lot of data now about adolescents who have undergone surgical procedures to try to help them lose weight, and that's a very extreme thing to do. But with extreme obesity, it may be necessary in order to get control of, of health.

Somebody comes to see you. You counsel children and their families at the NIH. How do you, how do you approach weight management? I mean, it's it's a sensitive topic. There's a lot of stigma around it. I'm sure you're dealing with children who've maybe some of them have dealt with that stigma. I'm just wondering, what's your approach?

Well, I mean, the first thing is you have to understand what's going on in the family. Who is upset about body weight? Often it's the parents are most concerned. And so that becomes a real issue. If a child isn't ready to buy into any kind of program. It can be difficult, but often it's really a matter of really taking your time, discussing slowly what's going on. In younger kids, as I said, we tend to offer relatively, less invasive approaches. And really, for everyone in the beginning, we think that everyone should try things that almost certainly do no harm in, in general, people have a lot of trouble sustaining motivation for doing those interventions over the very long term. And so. That's that's why people think about more intensive approaches to body weight. In part because they're not successful in everyone, but in part because it's hard to maintain weight loss even once it's been achieved. So, although there are better results for younger kids, not everyone is successful there. And certainly for adolescents, we see, not very good results for people who have extremely high body weight. And that's really where most of the medical risk is found. And so those are the people who therefore think about doing more. Then it has to be a family decision. Everyone has to agree that it's a good idea to try to do something more than the usual, which is diet and exercise and behavioral management. And it's a very difficult decision for many families to try, anything more because it is essentially medicalizing their child. Nobody wants to do that. But when there are real medical risks, when a child has, for instance, already developed sleep apnea, or crush fractures in their spine from their body weight, it's really necessary to act. And so that brings us to why we are now, seeing many more studies and even approvals by the Food and Drug Administration for medicines, for obesity and why some, adolescents are having bariatric surgery, a greater percentage every year.

Is there an ideal weight? I mean, I know that there are these ranges. But, like, here's what we want to shoot for. This is your ideal weight.

Well, I think we try to avoid that. You know, there's kind of perfectionistic words like ideal, in order to avoid stigmatization, and also prevent, you know, minimize the risk of people developing eating disorders where they decide that the ideal weight is considerably lower than wherever they are. You know, so that's why we only talk about averages. So the, the average weight changes every year. The mean weight for boys and girls goes up by a couple of pounds every single year. And then it accelerates during adolescence until it stabilizes in adulthood. What we use is the, those BMI charts, where there are lines drawn on the charts that indicate the 50th percentile, which means if you took 100 kids, 50 of them would be above that line and 50 below that would be the average weight. What I tend to think about more is that healthy weight range, which is usually somewhere between the 15th percentile and the 85th percentile, there'll be some kids who are slightly above it or slightly below it who will be absolutely fine. So use those charts as a guide, for what is likely to be helpful. But again, we don't we don't use them, to make a diagnosis of health or non health. We use it as a guide to who should be screened for whether they are healthy or not. So there's no real absolute, number that we should be using in children. We have to accept a range of healthy weights and, watch our children grow.

We're going to talk more about those growth charts a little later on, because that's really important. But I do want to emphasize something Dr. Yanovski just said. He uses the growth charts as a guide for who should be screened for underlying health conditions, not as a diagnosis. A lot of people get that wrong. It's more than just being above a certain percentile on the growth chart, that's cause for concern. You got to look at the trends as well, he says.

It's interesting because I think as we've talked about obesity, you know, the American Medical Association classified it as a, as a disease in and of itself about a decade ago. Is it thought of the same way among children? Is obesity, in and of itself, a disease in children?

More of the diseases that are caused by obesity show up in adults. But we still see the consequences of obesity in children. So for instance, we almost never saw what's called type 2 diabetes, the kind that adults get in kids until the recent increase in the rates of obesity. Now we see an ever growing number of adolescents who actually have high blood sugars to the point where they have real diabetes.

It's directly related to obesity?

'Well, in large part, it does seem to be in an otherwise, susceptible individual, having a higher body weight makes a lot of diseases show up in childhood. So high blood pressure is directly linked to high body weight. High blood sugar is found in kids with high body weight to a remarkable degree. And high cholesterol, high triglycerides, all the things that you see in adults. You also see in kids. Generally, they show up as medically distinguishable in adolescence, not so much in the younger kids, but we still see some children who have very significant problems related to their weight. One example is sleep apnea. When kids have an enormous amount of extra body adiposity, extra body fat, they can actually develop the same kind of sleep problems that adults do and even in childhood. So before the age of 12, we see this - children who need the same kind of treatments that adults get in order to be able to breathe normally.

And after the break, if you were overweight or obese as a child, what is the impact on your health as an adult, even if you lost the weight? We'll be right back.

'Do we worry about obesity in young people, especially pre-puberty young people? As much as we worry about it in adults.

Well there are several epidemiological studies, so observational studies that suggest that the risks for mortality and for certain cancers actually increases based on body weight in childhood. And even if people lose weight in adulthood, they still retain increased risk.

Really?

For early death from having high body weight in childhood. And that's why we say that it's not a benign condition, once it's present, in part because it usually does not remit. Most people who are heavy by the age of five or six will tend to continue to have problems with body weight throughout adolescence and into adulthood.

If we define obesity in and of itself as a disease, how how do you determine that a child is obese? And I and I'll preface by saying, as you know, and I've just learned this, but body mass index as a, as a measure is a pretty blunt tool. It was some 200 years old, and I think if I got the story correctly, it was mostly, based on men, specifically soldiers at the time, which has little relevance to today's world and even less relevance to children.

'Yeah. It's a it's a very important point that it was developed in the Cadillac Index, as it's called, where we take the weight in kilograms and divide it by the height in meters squared. Turned out to be a reasonable index in terms of a lot of disorders. So, for instance, if you were to plot body mass index against the probability of having type 2 diabetes, heart disease, high cholesterol, your, there is a, non-linear relationship. That is, it's not as severe at lower body weight, but actually quite, increased risks for all those disorders as the BMI gets to be over 30 in adults. Now in childhood, we similarly have been using the body mass index, again, using definitions that are determined based on the, weights and heights of children in the 1960s and 1970s and the reason why the standards at the centers for Disease Control uses and all the growth charts use, are based on that time is because it's subsequent to that, we saw this amazing increase in the number of individuals who have a body mass index over what was, the 95th percentile. So these percentiles are based on data from the past. And they basically mean that if you took 100 children, 95 of them would be below that number. Five would be above that number. Now, today, we don't just see people a smidge over that 95th percentile. So we've actually added an additional category, which is 120% of that 95th percentile.

Wow.

And we see an increasing number of children in that category alone. So in fact, that's the fastest rising group of people with obesity is the extreme obesity group.

'I do want to pause here for a moment and break that all down. To be clear, doctors do not use the same BMI cutoffs for children that they use for adults to define overweight and obesity. Instead, they use percentiles. And what a percentile is doing is basically comparing one particular child's measurements against the measurements of other children of the same age. Now, in this case, if a child is above the 95th percentile on the growth chart, that is, if a child is bigger than 95% of all other kids their age, then that child is considered to have obesity. And as Dr. Yanovski mentioned, in the late 1980s, he and other researchers noticed something more and more kids with high body weight. In fact, so much so that the chart has since been adjusted. Today, it includes a new curve for children who are at or above the 120th percentile. That category is called extreme or severe obesity. And as Dr. Yanovski says, it is the fastest growing group of children with obesity. But all of that still makes me wonder - just like with adults, is it possible to be healthy in a larger body?

If a child is above that, that percentile, that we're talking about classifying as obese having obesity. But their blood sugars are okay. They don't have hypertension. They don't have high triglycerides, things like that. Do they still have this disease? I again, I get that obesity is in and of itself a disease. But I've always struggled with this idea that if you have somebody who's carrying extra weight and classifying as as obese as a result, but they don't have any other physiologic, if you will, blood work abnormalities. How do you think about those patients?

We refer to them as the fit yet fat individual. And there is a small percentage of people who have obesity by these cut points, by BMI that do have, remarkably good physiology. What's been found in adults primarily it's adults have been followed long term, is that many of those people who present originally without any medical complications over time will often develop them. But a small percentage will continue to have good health. But extra weight actually also has other potential problems. For instance, on the joints. No matter what you do, carrying extra body weight is a risk for, greater joint disorders, so arthritis and and back pain. We did a study, actually, in kids that showed that people who carry extra body weight have many more complaints about their feet, their knees and their backs even before the age of 18. So, even if their overall, you know, physiology looks okay now, that doesn't mean that they're not accruing some risks for additional problems in the future.

If someone is is looked into this at all apparent, for example, thinking about this for their own child and saying, hey, look, I'm hearing a lot about these, these medications like Ozempic and Wegovy and Mounjaro, another one. But I don't know that it's right for my child. They might go online and they find that the American Academy of Pediatrics would actually say there can be a good use scenario for these medications, along with lifestyle changes. But the U.S. Preventive Task Force does not include these medications and their recommendations for addressing obesity. What do you think? How would you sort of work through the pros and cons of these?

Right. So I think the difference in the recommendations from the American Academy of Pediatrics and the Preventive Services Task Force are the process and timing that they, used to come up with their recommendations. The Preventive Services Task Force has a very long window when they propose a question to the point at which they prevent present their recommendations. And so they really didn't have the data from the last year or two to include in their recommendations. That's why they have virtually nothing about these very potent medicines that have now been approved by the Food and Drug Administration for use in adolescents.

They're that new?

They're that new exactly. And so that leads to, an important point that every parent has to consider, which is we only have a relatively few years experience with such medicines in adolescence. We have a lot more experience in adults to know what risks there might be. And we we try to use that information to inform what's likely to happen in adolescence. But we always keep in the back of our minds as pediatricians that something more could be around the corner that we just haven't been aware of. Because kids are not just small adults and even adolescents who are fairly sizable because they're typically these medicines, although they're approved for age 12 and above, they're often being prescribed for slightly older kids who are much closer to adult physiology. So we we have to be cautious when we approach parents, about presenting all the pros and cons of these medicines. And there are, you know, cons, no doubt. They said there's no free lunch. Well, there's no perfect medicine with absolutely no risks and only benefits.

'If a child has has not really reacted well to to lifestyle intervention programs and is having significant challenges with weight and all the the complications that come along with obesity. Would you would you recommend these medicate- medications to them?

Well, I only prescribe the medicines that are approved by the Food and Drug Administration. So right now there is nothing that is approved for body weight reduction, for body weight control for kids under the age of 12.

Should there be?

Well, I think we need the studies to assess safety and efficacy. And both of those things are very important.

What would the expectation be if a child, someone under the age of 18, started these types of medications, that they would stay on these medications for their whole life?

Well, nobody knows 100% whether if you took it for five or 10 years, you would recalibrate your systems in some way that you could then, slowly cut it back and maybe stop it. For those people who really have to ramp up to the absolute top dose, at least the studies in adults suggest that when you stop the medicine, there's weight regain. And even some of the early data in pediatric adolescent samples suggest that when you stop the medicine, there will be weight regain. You won't regain everything in three months, but you'll start to have that inexorable climb. And that's because when you stop a medicine, it no longer works or do what it did before. We never say to anybody, say with hypertension, with high blood pressure that, oh, your blood pressure is now normal. Let's stop your medicine because surely your blood pressure will stay normal. We know that's not going to happen. So our expectation is that many people, maybe not all, but many people will need to take them for the long term because otherwise the weight will come back; the complications of the weight will come back.

I know you said that, there have been times when you've recommended, Wegovy. How how young are we talking about here? Either in your practice or in any practice that you know of. What's the youngest sort of age range you've seen these medications used?

'Well, it's approved by the Food and Drug Administration from age 12 and up. So that's the age range where I have used it. And I think that's where most people are trying it. For certainly, insurance companies wouldn't reimburse you for the use under that age. It needs to be in the context of a research study until the medicines are approved. Now, there are other medicines that have sometimes been used off label, as it said. So they're not approved by the FDA for their use, but have been used for younger children. I generally don't use them myself, but there are many practitioners who do. So for instance, people use stimulants, the same kind of treatments that are used for, attention deficit disorder, A.D.D. The such people will, often lose a little bit of their appetite and may lose weight. And the same is true for, some people who have obesity. They may respond to those medicines and, they're approved for use, above the age of 16 years because of the way the Food and Drug Administration approved drugs before 16 and above. Now it's 18 and above, for newer medicines, when it's approved for adults. Something like phentermine is another similar agent to the stimulants that are used for A.D.D. and also suppresses appetite. And some people do very well with that medicine. It does cause some troubles with anxiety and can interrupt sleep. So it's not again for everyone. And then there are combination medicines that are also now been approved for children. A combination of that drug phentermine with an anti-seizure medicine or anti-migrant medicine called Topiramate or Topamax in combination is called Qsymia and together that is also approved for age 12 and above. And because it did induce weight loss, is on the order of closer to 8 to 10% compared to placebo treatment. So that's a decent amount of weight loss. It's not as good as the GLP one receptor agonist were of the semaglutide, the the Wegovy. That was more like 15% on average in kids. And so that's a you know, a more potent, medicine for weight loss. But these other approaches might be more available, little less expensive. Those are oral medicines, not medicines that you have to inject.

If a parent is listening right now and is is, worried that their child's weight is affecting their health. What should they do first and when should they potentially be calling someone like you?

Yeah. So generally, you should start with your health care provider. Remember, kids come in all different sizes and shapes, and their caloric demands will be very different based on where they are in their growth cycle. So have them measure and examine your child. See if they think it's a medically important condition. We're now recommending that everyone who has a BMI over the 95th percentile for age and sex need to have screening for those medical complications of weight. And in fact, the AAP, the American Academy Pediatrics recommends that above the 85th percentile. But start with your pediatrician. And then they can, if necessary, refer you to a high quality program. Unfortunately, there aren't enough high quality programs for everyone in the US, and many areas are woefully understaffed to do this kind of treatment. And a high quality program will have a behavioral therapist on the team, as well as a physician, and also perhaps a rehabilitation medicine or exercise person, all of whom can help develop a program that would be appropriate together with the dietitian who will develop a program of appropriate use of food, to do this kind of treatment. Usually they're found in children's hospitals, most pediatric endocrinologists. Again, a relatively small number of us in the country are very versed in the treatment of body weight, the evaluation of it and the consideration of these drugs. Sadly, your health insurance may have a lot to say about what kind of treatments you can get, both in terms of paying for the behavioral management strategies and certainly for the medicines or surgery. And so those all have to be taken into account. And so the health care providers really have to guide you into what's possible.

So look for high quality programs. Talk to your pediatrician or, if possible, a pediatric endocrinologist. Check to see what your insurance might cover. This is super helpful advice when it comes to addressing something that is challenging: overweight and obesity in children. And it is important to talk about the flip side of this as well. How kids might sometimes turn to disordered eating to manage their weight and even end up with serious conditions like anorexia or bulimia. So I asked Dr. Yanovski to share how he helps patients avoid or address that, and how parents can help as well.

I think one has to be careful about how one speaks about food and weight, so we have to be careful not to use language that is shaming; language that will lead people to try to hide what they do. And try to leave open lines of communication so that children can speak how they feel. And you can respond in a compassionate way. You know, as a parent, we often are disciplinarians, but we have to avoid going overboard in that direction so that we can remain available to our kids and help them, you know, work their way through a very difficult time in their lives, particularly as people pass through adolescence. They're at greater risk for eating disorders. And so we have to be, really watching to for any signs that might make us think they are doing that. So people who are sneaking food, people who are, you know, apparently vomiting after meals and people who are losing weight, who don't need to don't think of that as a good thing. Really try to bring that to medical attention early, because intervening early is actually very much more successful than people who have gone on for quite some time. Parents really aren't going to be in a position to ask their children, do you have X, Y, or Z? A lot of these disorders are, manifested in secret, and they'll continue to be manifested in secret with their parents. But unfortunately, I wish I had a magic way of speaking to a child to be sure to avoid it. I don't know of one.

'Look, I think it's fair to say there is no one-size-fits-all formula to avoid disordered eating or to avoid obesity. But despite that, Dr. Yanovski believes there is a lot of power here. There's a lot that parents and providers can do to help children manage their weight successfully. First and foremost, he says avoid practicing, quote, street corner medicine. Work with the physician to assess your child's health and their place on the growth chart. A pediatrician can primarily determine if your child's weight does put them at risk for health issues like sleep apnea or joint pain. If you or your child believes they have a problem related to weight. Dr. Yanovski says there are several things you can do to address it. It depends on their age and other factors, but they can include things like lifestyle changes, enrolling in a weight management program, and even using medical interventions like weight loss medications, or in rare cases, surgery. But no matter what, what you're going to hear from Dr. Yanovski is this emphasis that maintaining a consistent and healthy diet, consistent and healthy exercise routine, are key. No matter how old your child is or where they fall on the growth chart. And yes, you do need to talk to your kids about their weight and be careful when you do. Make it not about their looks, but more about the food they eat. Language that involves shaming or ridicule can contribute - there's plenty of evidence of this - it can contribute to unintended and unwanted consequences on their mental and physical health. I know that communicating with kids about their feelings, especially about things like weight, is not always easy. But we do know that there's a lot of stigma already associated with obesity and overweight. So when possible, keep the conversation as uplifting as possible. Next week on Chasing Life - menopause. We're going to talk to an expert about the role that weight and hormones play during that phase of life.

You know, people would say, I went to sleep and I woke up the next day and I promise you, I've gained 20 pounds.

That's next week. Thanks for listening.

Chasing life is a production of CNN Audio. Our podcast is produced by Eryn Mathewson, Jennifer Lai and Grace Walker. Our senior producer and showrunner is Felicia Patinkin. Andrea Kane is our medical writer and Tommy Bazarian is our engineer. Dan Dzula is our technical director. And the executive producer of CNN Audio is Steve Lichteig, with support from Jamus Andrest, John Dianora, Haley Thomas, Alex Manasseri, Robert Mathers, Leni Steinhardt, Nichole Pesaru and Lisa Namerow. Special thanks to Ben Tinker, Amanda Sealy, and Nadia Kounang of CNN Health and Katie Hinman.