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It's Hard to Be a Teen: Eating Disorders, GLP-1s, and How to Help · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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So one of the reasons why I went into this is because I feel like as a teenager,
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I also struggled a lot. And so I want to be there to help teenagers now.
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But they're dealing with so much more than, you know, I think I ever even dealt with.
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I'm Holly Wehment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit, depending on our topic or podcast.
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I'm so excited because today here in the podcast studio is Dr. Jelena Castillo.
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Jelena, thank you so much for being here in the podcast studio.
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Of course, happy to be here.
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You just finished your training at Baylor College of Medicine?
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Yes, that's where I finished my fellowship. And then before that,
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I did my general pediatrics training at Hopkins. I did med school here at UT
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San Antonio, so it is partially home for me.
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And your husband is a sleep medicine doctor and you met in medical school? Yes, we did.
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You're really passionate about helping teenagers.
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Yes, I have had this passion since medical school, actually,
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once I discovered that this was a field. I was very excited to see that there
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was something that is devoted to teenagers. And I think it's such a unique time of life.
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I always cared about like preventative medicine. And I think that's in general pediatrics.
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We care about, you know, future outcomes and what that means when you grow up and become an adult.
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But adolescence is like the time where they're getting their behavior routines
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and kind of getting those messages. And I think that's a key time to really
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affect them for the rest of their life as they kind of learn how to navigate
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things without their parents.
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This is a very important time. Eating disorders.
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How do you diagnose that? It can be hard because eating disorders broadly,
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you know, kind of talk about.
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You know, someone's relationship with food and relationship with their body
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in a way that really impairs their life.
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And there really can be a spectrum. There's kind of this more disordered eating
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where, you know, they have a poor relationship with body and food,
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but it's not really affecting their life yet.
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And then, you know, the spectrum where it becomes very obvious,
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you see like physical changes.
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And so it's kind of hard to to see what's in between of that spectrum.
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And so it can be really hard. It takes a lot of like conversations with parents,
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seeing what they notice, as well as like really having that good rapport with
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a teenager to really understand what they're thinking and what their mindset is.
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When is an eating disorder an emergency? Eating disorders, I say,
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have two parts to it. And so it's what happens to the body and then what happens to the mind.
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And so when the kind of effect to someone's body where we have such extreme
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malnutrition, where it kind of affects your vital signs and you really notice
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a very big change in weight, that's where it becomes an emergency.
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And you really need to kind of seek care immediately or go to the hospital because
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there can be a lot of changes to kind of your heart, your liver,
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your brain that we really need to monitor closely.
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But until then, you know, there can be a spectrum. And really that mindset is
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what kind of leads to those changes to the body.
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And those kind of have a spectrum and might not always be an emergency.
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You're able to see patients stat when it comes to an eating disorder.
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Yeah, I'll be able to kind of triage and see, like, depending on the availability
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of my clinic and kind of how urgent the need is.
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Are eating disorders becoming more common? Yeah, that is a concern.
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And so I will say it's a very unique cultural moment for kind of people's relationship
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or society's relationship with food and society's relationship with their bodies.
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So first of all, with food, there's not a day goes by that's,
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you know, we kind of notice these like food recall, FDA kind of food safety concerns.
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And that's kind of a conversation about, in general in society,
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about the safety of our food, where food's coming from, the concern of processed
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food, if that has any effect on our bodies, that we're still kind of trying to unravel and study.
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And so that kind of can cause a lot of concern in teenagers when they hear that
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and affect their relationship with food, but also kind of an interesting cultural
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moment of how society views bodies.
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And I do want to point out that there is a concern for weight bias.
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So weight bias, kind of the judgment that by how someone looks or,
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you know, how big or small their body is, what their BMI or weight is,
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can automatically determine if your health status is.
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And I have to point that out because it's not only present in society,
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but in medicine, we know that there's still somewhat of a weight bias that's
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present that, you know, automatically because you have a higher BMI,
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then you are unhealthy without, you know, doing any labs.
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And so I think that is a kind of big moment in society where we're focused on
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health and it's like, OK, you must be thin to be healthy.
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And then we're also some concerns about the popularity of GLP-1 medications
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and kind of what we're seeing more in commercials and media.
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And so, you know, GLP-1 agonist medications are great medications.
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They're definitely revolutionary.
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But I think what we are seeing in commercials is really not so much focusing
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on the health benefits of it, but focusing on the thinness.
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If you want to be thin, then, you know, this is a medication for you.
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And I don't know if that's always the best message for teenagers,
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especially teenagers who are very exposed to social media and have unrealistic
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body expectations from social media already.
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They follow a lot of influencers that manipulate their bodies in a certain way.
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And I can't even imagine with AI-generated bodies, how teenagers can view bodies.
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And so that kind of all goes together with GLP-1, that just this culture that
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is now promoting thinness.
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And GLP-1s to just lose weight, not because someone is obese.
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Yes. So anecdotally, I think other adolescent medicine specialists who work
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with other patients with eating disorders, we've had like a conversation among
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our field of this emergence of cases where people are misusing or abusing GLP-1s.
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I've had patients that report that teenagers who are not prescribed the medication
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use their parents or, you know, usually have easier access when you're 18.
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And so 18-year-olds who are able to get it easily accessible online and online
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providers don't necessarily know that they had an eating disorder or were being
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treated for an eating disorder.
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And so kind of that misuse and abuse is also very concerning.
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We always, like in pediatrics, talk about the importance of parents locking
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up their medications and just making sure it's the same with like poison safety.
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But also kind of parents should have like an honest conversation if they themselves
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are using GLP-1s about what that means for their health and have an honest conversation
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with their children about kind of bodies and how they view their bodies.
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I think that's something, again, teenagers are very hardwired to listen to other
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people and kind of they care about what other people think very much so.
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And so I think just having that conversation is important, as well as making
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sure the medication is safely put away.
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Pediatricians have told me they get asked a lot by families about their teenagers
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wanting these medications.
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So, really, you need to have those teenagers screened by a provider and just
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make sure that these medications are used if they have a risk for diabetes,
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if they have a risk for dyslipidemia or liver disease.
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We need to get those labs first as well as kind of notice their growth trend
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and see, like, what severity of obesity if they have it.
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And so, really, right now is only FDA approved for those who are 12 and over, first of all.
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But then once they hit that age, then just have a conversation about what they're
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trying to achieve with GLP-1s. Again, not always thinness, but just making sure
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that you have their health in mind.
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To quiet the food noise, there's other solutions. Yeah.
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So especially like if you're an adolescent and still kind of developing that
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relationship with food, I really think there's great like therapy and kind of
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before you even reach for medications that can help you early on to have that
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better relationship with food as you are a teenager.
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But there's also other medications that are safer that are available for those
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who kind of struggle with that food noise or more kind of binge eating disorder type thoughts.
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And so I think GLP-1s are just like what are being marketed now is very popular.
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But there's a lot of medications that have been around for a long time that
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I think are safer if that's like your specific goal is addressing the food noise.
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Such as ADHD medications? Yeah, that's a common reason why some younger people
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have a lot of like maybe thoughts around food is because actually they have
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maybe more of an untreated ADHD and that's a safer medication that a lot of children are on.
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So I would say sometimes not always jumping to a GLP-1, but there's medications like that.
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Other medications that can really help along with think therapy is a big,
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big part and a big role when you're young. Mm-hmm.
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And it doesn't seem like there's a lot of talk about the potential.
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Side effects or complications down the road. That's why it's so,
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we have to be very mindful of us prescribing these medications,
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especially in young people, because we don't know the long-term side effects.
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We also know that, especially adolescents, that it's a key time of growth,
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not just like weight gain, but also like height.
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And so we don't know if becoming kind of, we're essentially making them malnourished
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to some degree with these medications, if that'll affect them for their growth
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potential or long-term kind of concerns.
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But yeah, there's just like so many unknowns, especially if you start a medication
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like this in young children, we also don't have great information of when you stop.
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And so it's also the concern of like, how long are they meant to be on this
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medication? We don't know.
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A friend of mine, her daughter is taking this and then she had to have urgent gallbladder surgery.
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Those are all side effects of malnutrition in general. And so especially,
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and it increases your risk, especially if you are losing weight very fast,
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which is what a lot of these GLP ones do.
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A typical rate for if you're aiming to lose weight is really should be about one to two pounds a week.
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And so if that is generally a more healthy way and will have less complications
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to your pancreas, less complications to your gallbladder.
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But again, these GLP ones kind
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of sometimes do that faster, and that's why it can increase that risk.
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So what advice do you have for pediatric practitioner listeners?
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What do you say? Just being honest that we still have a lot of information on these medications.
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And that's, I think, if it is definitely indicated for your child,
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a specialist could kind of help you determine that.
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But just, I think I've had these conversations with parents where it seems like
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this is their, all their hope is in a GLP one because like they think this will
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help their child, you know, be happier, will help them, you know, socialize more.
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They're just so self-conscious, all these things. And having them understand
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that this medication helps a lot of things, but might not, you know,
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be the cure-all or fix-all for your child that you're hoping for,
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especially with all the unknowns.
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And so trying to balance that, you know, the risks in the future that we still don't know.
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You know, we just don't have the studies for long-term use. Exactly.
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What can the pediatric practitioner-listener treat in clinic?
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First, kind of understanding what kind of eating disorder you think the patient might have.
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First thing people typically notice, or pediatricians would typically notice,
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is in the growth chart. That's, you know, we love our growth chart,
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so we notice that there's some weight loss.
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And so that kind of usually triggers, like, let me see if there's anything else going on.
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I think it is important to really be honest with the teenager and ask them.
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It helps to ask them alone, because sometimes they, if you have a good rapport
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with them, They may say things that they don't want to say in front of their parents.
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And ask them kind of bluntly and honestly.
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I have some pediatricians that they say like, well, I am afraid it's going to
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trigger something if I ask them.
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I, you know, are they afraid that, oh, they're just going to lie to me or not be forthcoming.
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But I think it's still, you should still try to ask.
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And so kind of the questions I ask kind of depend on what kind of eating disorder it could be.
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And so I'll kind of just go through like the main eating disorders we kind of
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see and maybe kind of help you figure out what kind of questions to ask.
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And so the main eating disorder is really binge eating disorder.
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It's actually the most common eating disorder. And that one doesn't always cause weight loss.
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But it really is kind of like when you're eating more than normal in a short
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time and you feel like you're out of control with your eating.
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And there's a lot of shame or regrets about eating after that.
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And so it's just good to kind of ask those questions. Like, do you feel like
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you have to eat alone? Do you feel like you feel out of control with your eating?
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And getting like a dietary recall of their day can be helpful to kind of really
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determine is like, is that a larger amount than an adult would eat in one sitting?
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Then there's also anorexia nervosa. So that's what I think culturally people
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kind of know. It's not as common as binge eating disorder, but I think it's
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always in the media, so people know about it.
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And so that one is, that's what triggers the weight loss. And then they also
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have a fear of weight gain. So kind of one thing I asked is,
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if you were to gain five pounds tomorrow, how would you feel?
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And there's also kind of body dysmorphia as well. And so I do ask them,
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like, how do you feel about your body? Is there anything you would change about it?
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And kind of think that's very telling of their mindset about how they feel they are like.
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What are some example answers?
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Teenagers say like, oh, that'd be absolutely awful. I had one teenager kind
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of tear up and they're like, would you really make me do that?
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And so I think that's very telling that that's that's there.
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They're so fearful of it that just the thought of gaining five pounds is so scary to them.
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If a teenager says something like that, what do you say?
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Kind of explain that it is what people in society don't tell you and social
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media does not tell you, is that, yes, teenagers are supposed to be growing.
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It is normal for them to be growing as you go through puberty.
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And actually, you grow until your 20s.
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I remember when I went to college and I got my freshman 15 and everyone kind
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of shamed me for it. They're like, oh, you gained so much weight in college.
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And then I found out that's normal. Everyone has a freshman 15 because your
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body, I was just growing into an adult body.
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And so I can think normalizing that because I was like, you might not,
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you, maybe the images you see are adult bodies that are done growing,
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but that is not you. Your body is full of hormones and it's supposed to grow.
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That is part of being a teenager and getting an adult body.
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So trying to normalize that, like, that is part of the process and that's just
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kind of what your body needs to do to be healthy.
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Yes. And I remember at UT Austin, freshman year in the dorm,
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there was so much talk about this freshman 15 and how horrible it would be.
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And so then I feel ridiculous saying this now, but I decided like,
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I'm just not going to eat for a while, for a couple of days.
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I was walking on campus and I fainted and chipped a tooth and I had to go to the nurse.
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Even throughout someone's lifespan you are like depending if you're male or
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female have like different changes to body composition have like different kind
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of muscle mass versus fat mass that's always constantly changing it's just very
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rapidly in adolescence so you notice it more
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and so i think a general acceptance that like your body as
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as it goes to different life stages is going to change and so
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you know trying to very hard to be like let me change my diet or exercise So I prevent that.
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A lot of these are just kind of natural changes that everyone goes through,
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but we don't talk about it. Right.
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Is there anything that's important to say if that adolescent sounds very concerned
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about gaining five pounds?
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It should trigger that, you know, they might be having like an eating disorder,
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specifically anorexia or nervosa, and seeing if, you know, if it's starting
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to affect them medically,
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seeing if they need to kind of escalate to more treatment and kind of like speak
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with a mental health provider to kind of talk about their ideas of body and weight and food.
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But yeah, I think just kind of, again, reassuring that this is gaining weight
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as a normal process and kind of gauging like how fearful are you.
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And if they're truly that afraid, then I think it does point that they might need more treatment.
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And I remember friends when I was a teenager in high school,
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I remember them talking about purging like it was no big deal,
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you know. And of course, it is a big deal, but how common is that?
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Yeah. And so the anorexia nervosa is, you know, one eating disorder.
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And then another common one people think of is bulimia nervosa.
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And that's where it has more of the binge and then the purging episodes.
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And I think people always think about purging as like the vomiting.
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That can be common. There's also purging like taking laxatives.
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I see on Instagram like diet teas that people try to say, which are essentially
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diuretics. Overexercise can also be a way people purge.
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And so that's a little bit more bulimia nervosa.
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And what's hard is I do get more nervous about patients who say they purge because
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it can affect your health more rapidly, especially those who are taking laxatives
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or vomiting a lot. It can really affect your electrolytes.
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That can affect your heart and in some cases cause arrhythmias.
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And so I've had patients that have had such significant vomiting or laxative
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use that their potassium was low and has to be hospitalized.
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And I have to tell them, like, it was so bad that, you know,
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your heart could have just stopped and they don't believe me.
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They say, like, I feel fine. And I was like, well, I had one patient,
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actually, who he came to the emergency room because they felt like their hands weren't working right.
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We found out it's because they were purging and had a really low potassium.
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And I tried to explain. I was like, you know, your hands are a muscle and they
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weren't working right. Your heart's a muscle. It almost didn't work right because
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of what you were doing. And so I think those those patients make me nervous
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and have more risk of medical compromise. Yes.
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Oh, that's terrible. But it's such a great example, though, of the dangers in it.
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I remember a friend in grad school at Northwestern, she would take laxatives,
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and it just sounded so terrible.
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It can be very dangerous. I think what's hard when I think of like bulimia versus anorexia.
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So with bulimia, not just the purging, but commonly think of it as like more,
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there's a term in psychiatry, ego dystonic versus ego syntonic.
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So ego dystonic is the idea that like you don't like what you're doing.
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And then ego syntonic is like you think that you're doing the right thing,
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that you're trying to fit what you're doing into your world of view.
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And so bulimia, I do find that patients who are doing the purging,
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they know it's wrong. They're very distressed. They're like,
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they don't want to do this. They know this is gross and, you know,
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they want to stop, but they can't stop.
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And that's where they, you know, kind of seek more help.
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Versus heart of the anorexia nervosa, there's not purging and there's more restriction,
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but they think that this is fine. Like this is what everyone's doing.
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Everyone's restricting to be skinny, and they think it is normal.
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And sometimes it can be harder to treat those patients because they might not
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even think that it's wrong.
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And that was my next question about anorexia. I remember seeing along the river
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in New Braunfels, people walking with their inner tubes and.
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They looked like college-aged kids, and one of the girls looked so thin,
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like it was alarmingly so. It just looked extremely dangerous.
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How dangerous is it, and why is it so hard to treat anorexia?
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Yeah, so it can be very dangerous because those with anorexia are more likely
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to have that extreme kind of weight loss than bulimia, which we kind of see
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more like waxing and waning weights.
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And it can be hard because some people think it was like, if I just tell them
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to look in front of the mirror and that you look fine or like you need to stop,
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there's no convincing them. Again, it's egosyntonic. So they don't.
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And that's part of the body dysmorphia. They don't see what you see in the mirror.
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What's also hard is that even though it's very obvious to other people and you
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get their weights and it's concerning, a lot of people with anorexia actually
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tell me that they don't feel sick, that they felt fine.
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Yeah, maybe they felt a little dizzy and maybe they didn't like feel the greatest,
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but they didn't feel like absolutely sick. And so when they end up in the hospital,
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they kind of report to me like, oh, I don't know why I have to be here. I'm fine.
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And it's not until I, you know, nourish them again that they reflect back and
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they're like, I think I normalized a lot of the things I was feeling.
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Like, yeah, I don't think it was normal that I was always falling asleep in
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class and feeling so sluggish and, you know, maybe feeling a little faint.
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They kind of just like normalize and think that that's just like everyone feels like that.
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So I think that's what's really hard, too, is that, again, that egocentronic
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kind of, it turns into very hard as a provider to, you know.
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You can show them the growth charts, you can show them their weight,
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you can show them all these things, and it's still, there's no convincing someone
20:29
out of a eating disorder.
20:30
I have an attending that calls it like a kind of mind-control alien.
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When your brain is in a starvation mode, we know that it doesn't have all the
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kind of serotonin and all the neurotransmitters to really think straight.
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But especially like if you're that malnourished, it doesn't think straight even more.
20:49
So when is it time to refer out?
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It can be hard to like diagnose in the first place. And so if you have a suspicion,
20:58
you know, adolescent providers can be really good about asking the right questions
21:01
and getting the right rapport to even make the diagnosis. So that's one thing.
21:05
But definitely, again, if the main thing we look at is vital signs and then
21:09
the degree of malnutrition.
21:11
There's a lot of ways to kind of measure malnutrition in a growing person.
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We pay attention if they have like weight loss greater than 10% of total body weight in a year.
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And then also we kind of notice as well, like their growth charts percentile for BMI.
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So for example, I had one patient that they always grew actually in the 90th
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percentile for their BMI.
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And then suddenly lost a lot of weight and they were in the 50th percentile.
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And they had just moved. And so they saw a new pediatrician and they just saw,
21:42
oh, 50th percentile, you're in a healthy body weight.
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That's fine. But didn't notice that like in six months ago, they were 90th percentile
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and they had lost all that weight very quickly, half their body in,
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you know, that short of a time.
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And so that is an eating disorder as well. So I think paying attention to the
21:56
trend of weight and not just like the total like BMI is very helpful.
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And then also looking at vital signs. So if the heart rate is less than 50,
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if the blood pressure is less than 90 over 50, then those are reasons that they
22:10
need to be referred sooner.
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The vital signs look more normal, still refer, but it doesn't have to be like.
22:18
That soon? Yeah, it doesn't have to be as urgent. I think it's still,
22:21
you know, always good to refer and kind of help with that education of nutrition.
22:26
Again, I think even if you're in the spectrum of more disordered eating and
22:29
not really an eating disorder, full-blown eating disorder, there's a lot of
22:32
like nutrition education that can happen before it turns into a full-blown eating disorder.
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And so I still think I'm happy to kind of help with that education for teenagers.
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My friendly psychiatrists are also very helpful. I think a lot of eating disorders,
22:47
they are comorbid with things like depression, anxiety, other mood disorders.
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And so they can kind of help tease that out as well.
22:55
And so, yeah, eating disorder specialists, like adolescent medicine providers,
22:58
we help with that a little bit. But if it turns out to be a lot more mood related
23:03
or a lot more kind of depression is the main driver of the eating disorder,
23:07
the psychiatrist is very helpful.
23:09
In San Antonio, there's a gap where we don't have a teenage gynecologist specialist,
23:14
but you will see some teenage gynecology patients like up to age 26?
23:19
Yes, I will also be seeing that.
23:21
And actually, common thing that even before, like for eating disorders,
23:25
back to eating disorders...
23:26
Sometimes if you don't even notice like their weight loss or vital signs,
23:30
but as people are, young girls are losing weight, they lose their periods.
23:34
And that's often a first sign of malnutrition. And so I've had patients that
23:37
come to me like, oh, yeah, I don't have my period. I haven't had my period in a while.
23:40
And then I diagnosed them with eating disorder. So I think it does come together.
23:44
We know in adolescence, your kind of cycle of hormones is still trying to figure itself out.
23:50
And so it is normal to kind of have like some skip periods or,
23:53
you know, not have periods for a while.
23:55
But then we get concerned if you really haven't had a period for like three
23:58
months or more, and especially six months or more.
24:01
That's where we kind of have to investigate it or something else going on.
24:03
And especially paired with the weight loss or, you know, we get a dietary history
24:07
and there is some kind of malnutrition or disordered eating there.
24:11
And then that's where we kind of pay attention.
24:13
When someone loses weight quickly, can it cause GI upset for a while after that
24:19
or anything you want to say there?
24:20
Yeah. So what I tell teenagers is when you enter malnutrition and lose weight
24:25
really quickly is that it affects all parts of your body.
24:28
And we can't always measure everything about it. But again, we say head to toe.
24:33
Actually, a common thing is hair. A lot of young girls are like,
24:36
I've been noticing I've been losing hair.
24:37
That's a symptom malnutrition, cognitive fog. It can actually affect your heart.
24:42
You lose some muscle mass in your heart. And for your lungs,
24:46
it can going to cause some fluid in your lungs if you're really malnourished.
24:49
And then to your gut, yes, it can affect how your gut is able to kind of.
24:55
Processed food. And so it can cause like some gut slowing. So we say it affects
25:00
all your muscles. If you lose a little muscle in your heart,
25:03
then you also lose a muscle in your guts. And it kind of the muscle tone of
25:06
your gut is not always like where it was before.
25:08
And so that's actually a common thing that people with eating disorders notice
25:12
that they are really constipated.
25:13
Part of it is because they're probably really dehydrated. But part of it too
25:16
is that they just have some slower guts emptying than compared to others.
25:20
And that gets better with time. And so as we kind of enter the the feeding stage
25:24
and kind of like have them eat their nutrition i kind of say like you will have
25:28
some stomach discomfort,
25:30
as it slows down and you actually have to eat despite that because it's you
25:34
may not think it but like you need the nutrition to eventually build up the
25:37
muscle in your gut and it will feel better even though it feels like i don't
25:40
want to eat because my stomach hurts
25:42
so kind of just like trying to shift that that like you still have to have the
25:45
nutrition even if it's uncomfortable,
25:47
and then we said the effect of the.
25:49
The menstrual cycle as well The reason we pay attention to that a lot in adolescence
25:54
is because estrogen is a very important cofactor in building bone density.
26:00
And you get most of your bone density when in adolescence and you actually stop
26:04
getting bone density when you're in your 20s.
26:06
And so if you don't have your period, that kind of shows that you have low estrogen
26:10
because of your malnutrition and can affect you and increase your risk for osteoporosis in the future.
26:17
And so people who had suffered from eating disorders when they were younger,
26:20
in their like maybe 40s, may be having like fractures and osteoporosis.
26:25
Then, you know, it's typically in your 50s or 60s that you start paying attention to that.
26:28
So that's why we really focus on that, especially in adolescence.
26:32
A lot of teenagers, like a lot of us gained weight during the pandemic and then
26:38
they lost it rapidly. Yeah.
26:41
When I give nutrition advice, I always kind of talk about it's important to
26:46
achieve balance. So I always try to like not have a idea of restriction,
26:50
like take away like sodas, take away.
26:53
You probably have less sodas, but I try to frame it more like you just want
26:56
more balanced nutrition.
26:57
And so I kind of say like you can't always have, you know, one type of food
27:01
group. You can't always just have carbohydrates on your plate.
27:04
You need to balance it with some protein and some vegetable.
27:07
And so the MyPlate actually is a perfect visualization of kind of like a balanced plate.
27:11
I think promoting balance over restricting, like don't have that,
27:15
don't have that, I think is a better message for teenagers.
27:19
Demonizing desserts can also be concerning because, yes, I understand like sweets
27:22
and like carbohydrates and things like that.
27:25
If you're eating too much of it, it has a lot of concerns. But I think then
27:28
some people end up feeling guilty for any time they have a treat.
27:30
And I was like, it's okay. Everyone has a treat sometimes. Again,
27:34
you just want to have, that shouldn't be all day, every day you're having a treat.
27:38
You have to have other food groups too with that. And so, again,
27:41
really having that balance instead of being like, don't have this, don't have that.
27:45
A lot of it too, I do have had teenagers that like kind of fill up on like sodas
27:50
and juices and then don't have anything else. And so, again,
27:54
it's really part of that balance. I was like, you should have other things besides
27:56
just soda because, yes, it can fill you up.
27:59
And then you also have, you need to have water too. I've had some teenagers
28:03
that just didn't like the taste of water and just always, you know,
28:07
very picky people. And so they always just drank juice and always just drank
28:10
soda. And it did affect their kidneys.
28:13
I noticed some dehydration from their kidneys when I had some urine tests.
28:16
And so I said, you need to also have just straight water as well to really hydrate. That's great advice.
28:23
What do you say when it comes to water? It's hard because we live in a sunny
28:27
area, so probably more than other people.
28:30
But I think, I do think teenagers generally under water. Yes, why is that?
28:35
I think it's just a lot of teenagers are busy and they forget.
28:38
And I think their cues, maybe, my opinion, I think they just say cues for thirst
28:43
is downplayed compared to like all the other things they want to achieve in
28:47
their life. And so it's just an often forgotten thing.
28:50
And I have a lot of teenagers say like, oh, I have a lot of headaches.
28:52
I wonder why. And I was like, do you not drink water? It's usually the common
28:55
reason why a lot of adolescents, you know, don't or have headaches because they're so dehydrated.
29:01
And my daughter, my youngest daughter said, she's 15, she was saying that most
29:05
of her friends do not eat breakfast because she was starting to skip breakfast
29:09
and she's not doing that as much anymore.
29:11
But it was stressful. She was saying, like, I'm like the only one who eats breakfast.
29:16
Yeah. So it can be hard because in adolescence, we also know,
29:19
like, sleep is different in teenagers.
29:22
Teenagers naturally are more night owls and are more likely to have like naturally
29:26
feel sleepy later and then wake up later and so that doesn't really
29:30
go well with the school schedule and stuff and so i understand a lot of teenagers
29:34
honestly just like sleep through breakfast and that's why like that's why they
29:37
can't eat breakfast and i still say it's very important so you still need to
29:39
have breakfast and three meals a day even if like on the way to class or on
29:43
as we're driving somewhere have a bar
29:45
you still need to have breakfast but i just know it's it's hard with their sleep
29:49
schedule and then just like what society puts on them as a schedule. Yes.
29:54
Anything else you want to say about social media?
29:57
Social media has been a very big topic in adolescent health,
30:02
and especially with the rise of it.
30:04
And so that's a common question we have from parents.
30:06
I think I've had a lot of both spectrum of parents. They're like,
30:10
I do not want any social media. I take away their phones, none of that.
30:13
Versus parents who use a lot of social media themselves, who are like,
30:16
I think it's fine, right? It's not that bad whether a kid during the visit is
30:19
on social media and seems to have like an obsession with it.
30:22
But I think the AAP, we used to have kind of screen time limits that we tried
30:27
to promote. And we're trying to kind of get away from that because it can be
30:30
hard. A lot of screens are integrated in kids' lives now.
30:33
Schoolwork is on screens. And so you can't put a hard limit on computers when that's a needed tool.
30:40
And so I like thinking of like social media as that it is a tool and that it's like driving a car.
30:47
You can have a teenager kind of do that alone safely once you kind of give them guardrails first.
30:53
So it can be, I think it's important early on for parents to kind of set the
30:56
rules and guardrails early on so they can be safe. And so we kind of talk about
31:01
the five C's of media use, and that's how we kind of like screen if there's
31:06
any concerning media use.
31:08
And so we kind of think about the child, you know, how much they are using social
31:13
media, if they have any like underlying mental health concerns.
31:16
We think about the content, just making sure it's safe content. We think about calm.
31:21
So making sure that they're not using this as their only tool for emotional
31:26
regulation, that they have other ways to kind of cope with negative emotions.
31:29
Crowding out. So if it's just taking up their whole day, that's concerning.
31:33
But then the last thing is communication. So, again, I always tell parents,
31:36
I think it's important early before you kind of give them the iPad or give them,
31:41
you know, the device to set expectations of like what media use should be.
31:47
And so I actually had a co-fellow in fellowship that this was her main project
31:52
is that she was very interested in social media and how it affects teenagers and families.
31:56
And one of the findings she found actually was that parents had a lot more social
32:01
media use than their children. And the children were actually like,
32:04
I'm worried about my mom. They are using, they're the ones that I think have
32:07
a problem with social media.
32:08
And so I think starting with parents and having them understand that,
32:11
you know, social media, maybe they have to think about their own social media
32:14
use before they can have that conversation with their teenagers about what is
32:18
appropriate use. That's a really good point.
32:21
And with the way we eat as well, right? They're watching us or they're watching,
32:25
our behaviors, right? Yeah, yeah.
32:28
One of the things we talk about when we do nutrition education is kind of mindful eating.
32:32
And so one of the first things is eat without your phones, eat without the TVs.
32:36
And it can be hard if that's a family culture. Is it like, oh,
32:39
we're all just watching TV while we eat or we're all on our phones while we eat.
32:43
And I think that can affect your relationship with food if you're not noticing
32:46
what you're eating. So I think that's the first step. And mindful eating can
32:49
be helpful to have that better relationship with food. It's just really tasting
32:52
the food and not being distracted. Yes.
32:55
And then we eat less of it, probably. Yeah. And you really it's really listening
32:59
to your body about because your body knows what it needs. And so I think relearning
33:02
those cues about like when you're not distracted, your brain will know like
33:05
when it's full and when it's not. But you have to pay attention to it.
33:10
This is also interesting, Jelena. Thank you so much. I know there's so much
33:14
that we could cover here.
33:17
Is there an age that you recommend it's okay for a teenager to get a cell phone?
33:23
Yeah, it can be really hard. I think it depends on the kid, depends on kind
33:27
of like your relationship and like your trust with them.
33:31
Again, it's kind of putting those guardrails about like, do I trust that you
33:34
can, you know, use this responsibly and kind of like building their autonomy
33:39
with the phone or device and that just depends on every kid whenever they you
33:42
know you feel that they can handle it or mature enough
33:45
but they do have quote-unquote dumb phones now because i know that it's always like,
33:49
a concern about like well how i contact my kid and so they do have phones that
33:53
allow you to text and call but without all the other social media internet things
33:57
and so that's why i tell parents like if you don't feel like you can trust your
33:59
kid yet with with that you know internet uh use by it by themselves
34:03
uh but you still want to keep in contact with them, then maybe that's a device
34:06
you can consider before you upgrade to like the smartphone.
34:09
The AP actually has like a way to like create like a media plan.
34:13
So it's like a media contract even.
34:15
And so it walks you through how to talk to your teenager and before you give
34:18
them the phone about like, OK, how about we only do use the phone like five hours a day?
34:22
And then, you know, after five hours, we'll have to tell you to do something
34:25
else. And so, again, having those limits before they have the device,
34:28
because I think it's harder when you give them unrestricted access and then
34:31
take it away. Then it feels like a punishment that they didn't, you know, deserve.
34:35
Right. And five hours sounds like a lot, but I guess that's being more realistic.
34:40
Yeah. Whatever you think is, you know, appropriate with their schedules and stuff. Yeah.
34:43
Is there anything else, Jelena, high level for pediatricians when it comes to
34:47
teenagers and social media, eating disorders, anything else you want to mention that.
34:52
You know, being a pediatrician myself, I think a lot of pediatricians get really
34:58
concerned when their patient enters puberty.
35:00
And I think it's also part of
35:02
kind of a cultural idea that adolescence and puberty is so scary and bad.
35:06
Or, you know, you're not going to be a child anymore and that's going to be very different.
35:10
And so I think, I hope that we can try to become, be part of a culture where,
35:16
we normalize and even maybe celebrate puberty.
35:18
That's what I always try to say. Like, it's actually an exciting time.
35:21
You finally get to be more of an adult and it's, you know, you get to be more
35:26
independent. And really, that's the time where you get to choose who you want to be.
35:30
If you're into video games, I kind of say, you know, you're a level zero adult
35:34
and you can level up many different ways.
35:36
You can choose whatever you want to do. And that's it's an exciting time.
35:38
You have so much opportunity.
35:39
And so I think there's a way for pediatricians to also kind of embody that positivity
35:44
and kind of that time of opportunity. And not it's all not all just doom and
35:48
gloom. You're going to be emotional all the time. you're losing your childhood.
35:52
It's actually a great time. It's very exciting.
35:54
It is. I love that. It is such an exciting time.
35:57
Do you have any advice for parents who are the parents of teenagers?
36:02
And when you're wondering, like, did you just say that to me?
36:06
Like, I can't believe that you just said that to me.
36:10
Don't say that. Or what are you supposed to say?
36:14
Yeah, I think, yes, adolescents, again, one of the things that they are navigating is their emotions.
36:20
And it is natural as well, like with kind of the hormonal changes in puberty,
36:23
that they process emotions differently than an adult.
36:27
And it's their first time really feeling those big emotions that,
36:30
you know, by an adult, it's like, oh, yeah, I felt disappointed before.
36:32
But if it's your first time, you think back to the first time you ever felt
36:35
disappointed, then you would understand like why your teenager,
36:39
you know, felt that intensely and why they maybe said those things.
36:42
And so kind of some grace that it is normal for them to kind of learn that those
36:47
how to handle those negative emotions.
36:49
Of course, putting boundaries if it's very, very rude and very,
36:52
you know, uncalled for. Say you don't say that again, but I understand you had
36:55
a bad day. So let's try again.
36:57
Yeah. Do over. Yeah. And kind of give them a space to be like,
37:00
you can have these, you know, intense emotions, but we need to be able to handle
37:03
it in a better way than, you know, than you did today.
37:07
And the magic of saying sorry. You don't lose anything by saying sorry.
37:11
Right. Exactly. That's an important lesson.
37:15
Is there one thing that you think is plaguing, maybe that's too strong of a
37:19
word, but the biggest challenge for teenagers right now?
37:24
So that's hard. I guess the most timely one is really AI.
37:30
I think that's still going to be an emerging kind of how that plays into society
37:34
in general, but especially with adolescents who grew up with unrestricted access
37:39
to Internet and social media, how AI will kind of play into that.
37:43
So I do think that's like an emerging kind of possible threat,
37:47
depending on how it shapes out that I want everyone to kind of be mindful of. And I'm surprised with,
37:54
My kids and their friends, like they try to be very careful about using it.
37:59
And there's times when I think like, well, you could really,
38:02
that would be helpful for this.
38:04
And then they're worried about using it. And my daughter who's in college talks,
38:09
about like the water use and all of that.
38:12
And then I'm surprised that these younger kids, they tend to almost be anti-AI in a way.
38:20
Yeah, I think that's why I can kind of go both ways. I've had some teenagers
38:23
that use it a lot and some that are more like conscious of its effects in society
38:27
and so are more hesitant.
38:29
And again, it's hard to say because it's so new and emerging that we don't know
38:34
what effects it will have in society.
38:36
But I'm glad that, you know, more and more teenagers who are socially conscious
38:40
understand that they need to be mindful of it instead of.
38:43
But I do worry about like maybe younger teenagers who if that becomes part of
38:46
their daily life and don't question it and grow up in that, what will that,
38:50
how will that affect their development?
38:53
And, I mean, it is really like anyone, an AI bot talking to your teenager,
38:58
it's kind of a scary thought, but it could seem like it's a friend.
39:02
Yeah. I've had teenagers who have used AI to kind of feed into their eating
39:07
disorders, you know, kind of, you know, they would ask AI, oh,
39:10
how many calories is this?
39:11
And then, oh, is this a program amount of calories? And the AI bot will spit
39:15
out what a normal amount of calories for an adult, but not, you know,
39:18
say, you know, you're still a growing teenager.
39:20
It's very different needs for you. And then it kind of, they would use AI to
39:23
kind of really promote that, that the AI would support their eating disorder
39:27
and think that, okay, well, it seems like it's okay. And so it can be a problem.
39:33
What about the advice or pressure from coaches?
39:38
My son's basketball coaches wanted him to gain lots of weight and drink these
39:42
drinks to make him suddenly gain weight. What about that pressure?
39:46
Is that important to mention here in this conversation?
39:48
Yeah, definitely kind of pressure from sports. I've seen that a lot.
39:54
There is something called relative energy deficiency in sports, RED-S.
39:58
It was formerly called the female athlete triad, but we know that it can happen
40:02
to male athletes as well.
40:03
And it causes malnutrition, but there's not so much body dysmorphia.
40:08
It's a little more like there's just a mismatch of kind of like the energy you
40:12
output in your sport. And then you're just not taking enough nutrition for that.
40:17
And so I think it's hard, especially like high school coaches,
40:21
because they're really thinking about like, oh, for college,
40:23
there can be a lot of pressure.
40:26
I think kind of understanding like what the child's goals are and what's realistic,
40:30
because, you know, not every child who does, who exceeds in high school sports
40:35
may not reach the collegiate level. And so kind of is it all the pressure that the coach is putting?
40:40
Is it just kind of causing more dysmorphia if it's not going to have a goal?
40:44
If you're, you know, not really, you know, a lot of sometimes children early
40:48
on, they say, I really want to do this sport and then they don't like it in the future.
40:52
And either parents or the coach will want to accept that. And they're like,
40:55
but you could be so good and there's more pressure. And so really making sure
40:58
that that is what the child wants, that they really are dedicated to the sport.
41:03
And understanding that, you know, nutrition is very important,
41:07
especially when you're an athlete. We have, you know, Olympic athletes,
41:10
high-level athletes, and they are very mindful of nutrition,
41:13
eat a lot differently and more than the regular population.
41:18
And that, you know, achieving a certain body type for a sport,
41:21
it maybe just shows that you should not be in that sport.
41:24
If you didn't have that kind of genetic body for that, you know,
41:27
there shouldn't be a push and kind of, again, causes this body dysmorphia if
41:30
you don't fit the phenotype for that sport. Mm-hmm.
41:34
And my son, one of his best friends, on the advice of the coaches,
41:37
he gained a lot of weight and he played baseball for a local high school.
41:42
And now he has two terrible injuries, had two different surgeries,
41:46
and so probably is not getting the scholarship or going to play in college,
41:52
and there's just so much pressure. Yeah, and I think.
41:57
Again, I think just making sure that you, sports is, A, meant to be fun.
42:02
So making sure that you're still having fun while you're doing it.
42:04
That's really supposed to be the point of it. Not a pathway,
42:07
this is what's getting me to college, or I'm going to be the Reebok spokesperson
42:12
or whatever. You know, that kind of thing, that pressure.
42:14
Yeah. If you're not having fun, you're not supposed to be doing it.
42:17
You shouldn't be doing it.
42:18
And then we also try to tell, like, young athletes, it's also just not a good
42:21
idea to, like, stay with one sport forever.
42:24
All good athletes kind of like, you know, if you're athletic and you like your
42:28
sport, try other sports too.
42:29
It also helps prevent injuries because you're using different muscles for different sports.
42:33
And so you, you know, are less likely to have overuse injuries.
42:37
And so I think I also worry when someone like decides on the sport and this
42:40
is going to be my sport forever and don't explore other things.
42:43
And that, you know, that does kind of like lead to injury and kind of just like
42:46
this unneeded pressure for this one sport. When, again, it's supposed to be
42:49
fun and it's supposed to kind of like help you kind of like learn more about
42:53
yourself and more and more about how to work with a team.
42:56
And so doing a lot of different sports kind of helps you with that social development. That's great.
43:01
Well, Julina, this is so fascinating. Here on Pediatrics Now,
43:05
I like to promote having a life outside of medicine.
43:08
I know you recently got back from Japan. Yes. With your parents.
43:13
Yes. And you climbed a very tall mountain.
43:18
Yes. So first time in Japan, I was there for two weeks and with my parents and
43:22
my husband and a group of my parents' friends, we climb out Fuji and it was a two-day hike.
43:28
So one day to go up, we stayed like in a cabin at the top.
43:32
Then we summited and it was a beautiful sunrise that we saw and then came all
43:35
the way back and it was the hardest hike I've ever done.
43:39
Maybe I'm not the fittest because I've been so busy. I don't have a lot of time
43:42
to exercise, but my parents are very fit and they run marathons and,
43:46
you know, have a lot of time to exercise. And even they struggled with the hike.
43:50
So I was like, okay, it's not just me.
43:52
Even though I did try to train for it, I tried to do a lot of hikes and stuff
43:55
because people warned me about it could be very difficult, but it was very difficult,
43:59
but it was definitely worth it. It was beautiful when we got to the top.
44:03
Did you start very early? We probably started midday, like I think 11.
44:08
Because then when the cabin we stayed at wasn't completely at the peak.
44:11
And so we got to the cabin around 8 p.m. and then we slept until really 1 a.m.
44:16
And then we hiked the rest of the three hours to the peak for the 4 a.m. sunrise.
44:22
And then we just hiked all the way down And we got back down by like 5 p.m.
44:26
Wow. And so what got you through when it was so hard?
44:31
I think just a lot of encouragement from family and friends and just kind of,
44:37
you know, understanding that like I can do this. Yeah.
44:42
Are you reading anything, watching anything that you want to recommend that
44:46
helps you unplug? I don't say balance.
44:50
Yeah, I actually love to read. And so one of the recent books I read was Kin by Tayari Jones.
44:56
It was a beautifully written book. It's about two African-American girls who
45:01
grew up in the South in, I think, the 1950s.
45:03
And they grew up without mothers. And so they kind of formed a sisterhood with each other.
45:08
And it kind of goes through their lives and really explores what it's like,
45:12
like what family really means. That even if you're not, you know,
45:15
kin by blood, that you can be kin in a lot of other ways. Oh, that sounds beautiful.
45:35
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