Shireen Tune in to hear Dr. Sutaria discuss the mental health impacts for children experiencing obesity and how social identities further affect that relationship. He outlines what is being done to help end the childhood obesity epidemic and what else can be done in this fight. Keep listening to learn how you can better support the mental health of children experiencing obesity.

Podcasting from Dallas, Texas. I am Shireen and this is the Yumlish podcast. Yumlish is working to empower you, to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week. 

Dr. Sharlin Sutaria is a clinical doctor specializing in public health medicine with an interest in preventing ill health through lifestyle modification. Welcome, Dr. Sutaria.

Dr.Sutaria: Thanks for having me.

Shireen:  Absolutely. To dive right in, what drew you to medicine and how did you become interested in childhood obesity specifically?

Dr.Sutaria: Sure. So, my journey to medicine was fairly traditional. My understanding of medicine at the time of entering medicine was quite limited with very much a focus on diseases and identifying diseases, treating diseases. But then, well, I started practicing medicine. I started becoming interested in preventing disease. and then I started recognizing and seeing more and more – perhaps false is a strong word – but I started seeing more and more disadvantages of modern medicine, how it disempowers the patient, how it's a very imbalanced relationship between the doctor and the patient. The doctor holds all the knowledge and the patient is the recipient of that knowledge and does what the doctor tells them to do.

And I became more and more aware that all my training was very much governed towards a pharmacological sense of medicine that you tell me, your signs and symptoms, and I give you a pill or a surgical intervention to treat it. Then when I started looking at the evidence-based for some of those medical interventions, for some of these pills, you realize it's, it's actually quite poor, quite limited.

And you never give patients the opportunity to think of other options, to think of other ways they might help themselves or other things they can do, which is a non-pharmacological approach. That's obviously changed since I started practicing. And now there is more and more of a focus on preventative health care and lifestyle modification, but still the training is very much steeped in this sort of pharmacologically driven, diagnosis-based medicine, which I think is useful, but, you know, we need more than that now, especially with this plague of non-communicable chronic diseases. Most of the illnesses which I see nowadays are because of lifestyle factors. It's not because of acute infections. It's lifestyle factors are what people have been doing to themselves for many, many years.

Ultimately, I started moving away from clinical medicine and I started drifting into public health and preventative medicine. And then I started drifting into pediatrics and childhood health care problems and that led me to childhood obesity, but with a slightly different view of it. My interest in childhood obesity was the association with mental wellbeing. So a lot's been written about obesity and the physical health care problems of physical health problems. And I think if you ask any person on the street, they'll know, yes, if you're obese, you're more at risk of type two diabetes, which is a risk factor for heart disease strikes, but I don't think many people know there's an association between obesity and mental wellbeing.

And that's not to say even medically, we fully understand the relationship. But I think sometimes that acknowledging that there is a connection is quite useful for individuals, partly because we know that telling people who are overweight or obese that this has a future risk to your physical health or physical harm doesn't seem to motivate people sufficiently to change their behavior whereas acknowledging that there might be a link between their weight and the mental wellbeing and how they're feeling now might be a stronger motivator for you to change to change your behavior or to try and encourage a healthier lifestyle when you can see actually that might benefit me immediately, not this far off future risk of a heart attack I may or may not have, but actually this could improve my wellbeing today, tomorrow this week. So then I became very interested in childhood obesity and the association with mental wellbeing. Subsequently, I've done a  few research areas around that topic in general. 

Shireen: Perfect. And so why is it important to prevent and decrease the rates of childhood obesity? You talked about mental health, but just specifically within this age group, why is that important? 

Dr.Sutaria: Well, yes, it's a really good question. What we're basically asking is it really a problem is being overweight or obese as a child, particularly problematic. And the answer is a bit complex. It's sort of a yes and no. The yes answer is well, childhood obesity seems to lead to adult obesity and we know adults who are obese or overweight have a much higher risk of, you know, all these physical and cardiometabolic health problems we discussed.

But then if that obese child doesn't become an obese adult. It's not quite clear then if those risk factors. You know, the risk of developing hypertension or diabetes is still strong. So whether obese childhood then becomes a non-obese adult, whether that's actually no longer going to increase your risk of cardiometabolic disorders.

But what we generally know is most children who are obese, overweight are likely to become overweight adults and obese adults. So from that alone, there's a good reason to intervene. Ignoring the benefit to you as an individual, there's certainly a population benefit, an economic benefit in tackling weight problems earlier in life before they manifest into disease, it's costly to treat. So there's certainly an economic benefit. That's certainly a benefit to the individual themselves. And then, acknowledging the link between obesity and mental wellbeing: an unhappy child is going to be an unhappy adult and the unhappy adult has its own sort of problems.

Shireen: And so let's, let's dig into the mental health component for a second. Can you help us understand what are the mental health impacts for children experiencing obesity?

Dr.Sutaria: That broadly links to the study, which we did, where it was a meta analysis, a type of study, basically where we looked at around 140,000 children across different countries aging anywhere between 5 and 18 years of age. And the marker of  mental wellness or the lack of mental wellness we used was depression or depressive symptoms. And we wanted to answer the question well, is it associated with depression? And what we found quite conclusively was yes, it is that obese children have a 30% increased risk of depression compared to non-obese children. 

But then when we looked into more detail within the data we found, actually the relationships were much more complicated and that risk translates to almost a zero risk among boys, We didn't really find an increased risk of being an obese child or an obese boy, and then developing symptoms of depression. Whereas in females, the risk was even higher. It's around 40, 50%. And that was what was interesting about that is that it wasn't just a risk of you having depressive symptoms now. It was also a similar magnitude risk of developing depressive symptoms anywhere between 2 to 10 years. So it seemed to be an independent risk factor for developing depression as well. 

And then we try to look into more details in terms of different ethnicities and different countries.

And again, the relationships get more and more complicated and more and more unclear. But broadly it comes right down to how we think they're related, how childhood obesity and mental illnesses are related, what the etiology is, what the pathology is and there's different theories that carry different weights.

One is a biological theory. So we know that being overweight or obese is a sort of inflammatory state, which can affect your neuro endocrine system, which can affect your hormones, wishing affects your mood. So there may be good biological reasons why being overweight could lead to a depressive state of mind.

And, and that probably accounts for some of it, but the larger factor is probably psychosocial factors. Say for example, if you're an overweight child in a society that stigmatizes obesity or being overweight, then you can internalize that and develop abnormal or negative thoughts about your own body image, which then manifest as symptoms of depression or unhappiness.

And similarly, you know, if you live in a society where depression is or obesity is stigmatized, You may, as a child, sort of face weight-based teasing, which again, you internalize and can manifest as being very unhappy, even depressed. Why the relationship isn't so clear and boys, or seems to be lacking in boys, may be because being an overweight boy or being an obese boy doesn't carry the same risk of weight-based teasing. So, it may be in a social structure. A larger boy may be a more dominant boy and may be seen as stronger or more athletic in some ways. And it may be so they're less likely to be victimized or teased for their weight. And it could be that boys aren't subject to the same level of negative stereotypes or negative imaging about their weight whereas females, probably are, you know, in most Western societies now the ideal female form is very much based upon a thin, a thin weight or low body weight. Whereas with men it's probably not so strong. 

Shireen: You talked about the impact by gender. What does it look like for race or ethnicity or even other social identity?

Dr.Sutaria: So this is really difficult and it's really nuanced as well. I think, broadly speaking, when we looked at different countries, the lower the countries, in low income countries, there was a weaker relationship between obesity and depression among children. And it could be that in lower income countries weight is seen differently. So being a larger, higher weight is seen positively associated with affluence and success. And being very thin is associated with a lack of money, lack of resources for food whereas in the higher income countries, that relationship is very different. And that perhaps explains some of the differences which we saw between countries and certainly some of the countries which we looked at. I think Iran comes to mind. Again, there was no real relationship between weight and depression.

Within ethnicity, again, it's a bit, it's a bit complicated and I think we can tease this out of any of the data which we've looked at, but we did other studies where we've looked at ethnicity in it in different way, because I think it depends partly on whether you're first or second generation immigrant. So I can speak about London, you know, where I'm based, where I live and I'm in the base, a place called Tower Hamlet. So, that's where we carried out the research and in tower hamlets, there's a large Bangladeshi population. And within that population, you've got the first generation who came over in the seventies and eighties. And then obviously they've had children and have subsequent children, some of them.

And clearly there's a disconnect between the way the different generations view weight. So the first generation seem to view weight and weight much more similarly to the low-income countries where they originated from. So they see having a higher weight or being overweight, they see it as a, certainly as a, as a positive attribute.

And perhaps it is in those low-income countries where it's likely that if you have a bigger child, they're probably protected in some ways against the diarrheal type diseases or wasting diseases that they're subject to in other countries. 

Shireen: So considered a stronger, healthier baby.

Dr.Sutaria: Exactly. Yeah. And there's logic in that thought process. It is probably – having a bigger baby in, in a resource poor country like Bangladesh –  probably prognostically more advantageous. Your child's probably more likely to not succeed, but to live compared to a lower, smaller baby.

Shireen: How has COVID-19 impacted childhood obesity and mental health?

Dr.Sutaria: Yeah. So it's quite hard to say at this stage. I've seen a little bit about TV watching going up considerably among school-aged children during the COVID pandemic. It's going to be hard to know the prolonged effects, irrespective of what the changes have been over the past year or 18 months now, it's whether any of those changes will lead to sustained changes in children's, you know, eating or behaviors over many, many years. 

So for example,  one of the advantages of COVID I know we didn't talk much about their bunches of COVID, but one of them shift was a shift to home working and freeing people up from commuting, which meant they could make more meals at home, which they meant they could eat healthier diets, spend more time with their children, play outside with the children. And if those habits are maintained, that's likely to have a long-term prognostic benefit in children. However, there's certainty a discrepancy in who can benefit from or who benefited from COVID-19. And it certainly in the UK, it is clear that the most affluent people benefited in some way, you know, middle-class white collar type jobs, office based jobs, where you could sit at home work. You've saved money from your commute. You can spend more time with children. 

The people at the low end of that spectrum, who in the UK tend to run our public services. They're the ones who clean our hospitals who drive our buses, their type of work doesn't lend itself to working from home.

They would still need to commute to work. Lots of people in the UK are on zero hour contracts. So if they're not working, they're not earning. So they're incentivized and almost pressured to go to work, And so it's likely that, in that group, we're not really gonna see a big difference in those behaviors, if anything, it's potential that they've developed some poor behaviors or poor eating habits.

Shireen: In addition to the financial impact as well, right? There, with the zero hours, you mentioned there's a financial impact and then a health impact as well. 

Dr.Sutaria: Yes, that's on. So, obviously having less economic resources is going to influence what you can do and what you can buy. 

Shireen: How can children experiencing obesity be better supported in preventing and managing these mental health issues?

Dr.Sutaria: Again, it’s a good question and there's probably no one individualized approach that's right for one child or one family, I think partly it's firstly, recognizing that your child is overweight or obese. And we know from studies, my colleagues, colleagues have done that parents are very bad at recognizing that their child is overweight or obese. And in fact, doctors find it very difficult to recognize it. And only that doctors also find it very hard to bring it up and talk about it. So I guess, firstly, it's, it's being able to recognize that your child might be overweight and obese and then understanding the risk that that carries in terms of not just your physical health, but so your, your mental wellbeing.

And then trying to understand the factors that led to your child becoming overweight or obese. And I think that's where the more individual approach is needed. You know, like I was saying before, it may be that your child's symptoms of depression and they've waited because of weight based teasing. It wouldn't be useful to further stigmatize or victimize a child and say, look, you're overweight. It may not help their case at all. So, so we're very individualized approach is needed trying to understand the factors or risk factors that led them to becoming overweight or obese. Once you've understood those factors, which led to the symptoms of depression or depressive illness, but also recognizing that the inverse is true as well. You know, it's not a unit directional relationship. It could be that the depressive symptoms or being happy led to weight changes. And we know that certainly among adults, that when your mood is poor, when you're suffering from poor mental health, it's likely to impact how you eat and what you eat. 

So I guess understanding which direction you think that that relation is happening, but also recognizing that it could also be a bit of both as well. So there's another school of thought, which is sort of more of a, actually this is a manifestation of a common etiology.

So, for example, you know, if you're, if you're born in a certain place and have limited resources, limited access to healthy food and limited access to open spaces and places. Then the chances are, you're probably going to manifest symptoms of both. You're probably going to develop depressive type disorders and have an unhealthy eating pattern, which will lead to overweight and obesity.

So it may be that both are happening independently of one another. And it's just a manifestation of a particular set of circumstances. To undo those circumstances is very difficult and that's where one has to recognize. It may be beyond the power of any individual,  to change your circumstances, to make such radical changes.

And this is where, you know, we, broadly speaking, the society to step in government, to step in, doctors in a way to step in as well. And I guess part of it is how you want to frame this. Whether you want to go to one extreme and say, well, actually this, all the individual's responsibility, family responsibility or whether you acknowledge that actually society plays a role in this government plays a role in this and the solution doesn't lie within the individual. It lies more broadly speaking, with society and with the government, recognizing that Interventions tailored, purely at the individual, are often less effective than broader interventions at the national level or policy type levels, regulation type interventions. That's probably going to have a bigger impact and help more people simultaneously.

Shireen: You know, and over here, the term, the buzzword is social determinants of health, right? Really, it's your product of your environment. So outside of things that you can control, there are other things in the works as well as potentially working against your health. What are governments, healthcare providers, families doing to help end the childhood obesity epidemic and what else do you think they should be doing? And I recognize that governments in the UK look very, very different than here in the United States. But what are you generally seeing? 

Dr.Sutaria: So here. I think we have it just a bit easier. Because we have a smaller population. We have the, uh, nationalized healthcare service. So we have things like the national weight measurement program, which measures children's height and weight at the age of five. And then again at 10 – key points in their life. And then we feed back the information to parents. And, you know, we'll say this is your child's weight and based on their weight, you know, this, the category they're in and signpost them to, you know, sort of advice they can be given or where they can get further information.

I think that's really a good starting point to start measuring basically and start to understand on a population basis. Now what's the weight of your population? What's the, what's the trend in the changes in the weight of your population? From the point of childhood, capturing it early, if you wait too long, it's probably going to be harder to at least individual changes that can counteract or that can undo some of those things that you've learned over many, many years. So that's probably very important. I don't know if you have anything similar in the U S any national weight measuring program for children. 

Shireen: Not that I'm aware of. I mean, there are points where it is calculated but that is mostly during infancy as far as I’m aware. When you go for it, when you, I mean, also when you go for a pediatric checkup, they do the height and weight, but I don't, I'm not sure how many conversations are coming out of those, around that. 

Dr.Sutaria: Yeah. That's another issue actually. We seem to even, even when doctors recognize that a child might be overweight or obese, they seem reluctant to talk about it. And that could be because, you know, medically speaking, we don't have very good interventions for childhood obesity. You know, that there's been many randomized controlled trials over the years and you know, lots of weight based programs, but it seems really difficult to develop a program which can effectively reduce weight over a long period of time. So often these patients will show improvements in weight over a six week period or six month period. But then when you follow up the children over one or two years, it seems like that the weight tracks back to how it, you know, the trajectory I was on originally. 

And, we certainly know what components of weight-based programs work better. Any program which involves family and, you know, involving others and broader society. And there've been some, some examples of, and I think it's that it's Amsterdam, where they've got like a healthy cities program where they've done multiple interventions on lots of those social determinants. And they’re seeing good results in the weight of children.

They seem to be bucking the trend and seeing weight go down. But they've had a very joined up approach, targeting many different aspects, you know?  I think that's probably the main thing I would actually do about what governments and societies can do. We shouldn't focus too much on individual interventions or their, what we call magic bullets, a single solution to tackle childhood obesity or a single pill in particular. And you know, certainly bariatric surgery is not going to be the solution. 

So we need to think more broadly about interventions, which help not just childhood obesity, but mental wellbeing. In the ideal scenario, which I've created in my mind, what I'd like to see is a society where the default way of being leaves you eating healthily, being happy, and, you know, being able to actively exercise and things like that, it shouldn't be. You shouldn't need to make any effort to achieve these core things. And if we can structure society to change so that by default, even if you don't do very much, you can at least achieve these few things in it. You can lead a meaningful life.

The default is for you to walk rather than going to the car. The default is for you, you know, where it's easier for you to grab an apple than to grab a packet of crisps. If that was a default then, then I think that would certainly achieve improvements in outcome, not just in weight, but in mental wellbeing and you know, a broader impact.

There was a discussion about climate change in the UN reports just yesterday or the day before. 

But I love how these things tie into environmental benefits. You know, say if people are walking around and taking a car, that's not just good for the exercise levels. It's good for pollution levels.

It's good for ensuring a healthy weight avoiding weight gain. So, I think we shouldn't worry too much about what we can achieve. You know, we shouldn't focus too much on obesity, but look at more structural problems we have in society that are leading to these common problems that we're seeing, not just in, uh, here in London, but within the US because it seems to be the same common factors involved. And if we can address those factors and yes, you know, one of the benefits of that would be children are less likely to be obese. We'll see you in prison and mental wellbeing. We'll see reductions in environmental pollution. So there's, there's profound benefits to be had, but we try and we need to try and structure society so those benefits can be seen for the default behaviors and not just the benefit of a few people who can change their behavior because they've got the economic or affluence or some advantage in life so they can actively make positive decisions. But one wants to be able to, to allow people to make positive decisions without actively even knowing that they're making positive decisions. If that, if that makes sense. 

Shireen: It does. And so what you're saying is make it incredibly easy for them to eat healthy, live a healthy lifestyle just generally. And if he can do that and more structurally the problem solves itself. 

Dr.Sutaria: Exactly. Yep. Rather than focusing so much on obesity that you feed the stigmatized obese individuals, making them feel more like a victim, making them hate themselves and internalize that hate and manifest in all signs of depression and anxiety. So in some ways it's almost forgetting about obesity and it almost becomes secondary because you're, you're solving more of the structural. 

Shireen: Yeah. I see what you're saying. There’s a lot of work ahead. Dr.Sutaria, we're toward the end of the episode. At this point, what would you like for our listeners to know about how they can connect with you or learn more about you? 

Dr.Sutaria: Sure. I'm more than happy to  be connected on LinkedIn and I'm happy to share my email if anyone wants further information. And then you can see more of the work I'm doing currently. So I currently spend part of my time working for an additional healthcare company where we're trying to do some of the things I was talking about. Bringing information back into the hands of users. So, you know, you don't have to go down a very pharmacological based approach to medicine and that you can start to understand your illness and what you can do to improve your health by bypassing sort of formalized pharmacological healthcare, if that makes sense.

Shireen: Is there any specific website? 

Dr.Sutaria: Yeah, so if you just Google healthily, um, you should fall upon it and it's, uh, it's a useful resource for any, most of the chronic conditions I think we covered. In particular, what an individual can do to help alleviate some of the symptoms and signs. Also, you know, the importance of recognizing when you've got signs of symptoms, being able to recognize whether it's that they're being caused by something, which you need to actually see a doctor for where that she's a something you can self-manage and you know, by, in a supportive manner, say I think one of the problems right now, which we see is people like confidence in, in acknowledging their own illness and managing their own illness. And they have to by default use a very formalized medical service. So Healthily tries to sort of hold your hand. Yeah. And allow you to track how you're doing and, you know, to see if there's any improvement while still being safe and acknowledging, there still is a role for that traditional form of medicine, but often it's much later in the pathway then you often think it is certainly.

Shireen: Perfect. Awesome. Well, thank you so much Dr.Sutaria for your time, Truly appreciate it. It's been a pleasure having you on. 

Shireen: Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn. For tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspectives. You can also visit our website Yumlish.com for more recipes advice and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first. Stay well.

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