For a 9-year-old patient at a Los Angeles obesity clinic, barriers to health are everywhere

This is part of a series about new obesity drugs that are transforming patients’ lives, dividing medical experts, and spurring one of the biggest business battles in years. Read more about The Obesity Revolution.

LOS ANGELES — On this pleasant spring day, patients and uniformed health care workers crisscross the UCLA medical campus like ants on a picnic table. In a small medical office a few floors above the sun-drenched buzz, kids and parents trickle into the waiting room, masked and a little sleepy after lunch. This is the Fit For Healthy Weight Clinic, for children and teens with weight-related health issues.

By the time 9-year-old LR arrives — a tad late, because her school had forbidden any more early dismissals — the Fit Clinic providers are well into their weekly relay race. The front desk calls for her, and she is ushered into a room with her mom.

LR is here because this clinic offers the kind of intensive health behavior and lifestyle treatment the American Academy of Pediatrics recommended earlier this year for basically all children on the threshold of obesity. In a few years, she’ll be at an age where the academy said children with obesity should be considered for even more aggressive options, including a new generation of weight loss drugs or bariatric surgery.

Behavioral therapy isn’t seen as a cure-all, but it’s an effort to avoid or delay the more drastic measures. It’s medicine driven by motivational interviewing, unearthing and addressing each family’s unique challenges. It focuses more on overall well-being than on weight loss.

Some eating disorder experts say it’s impossible to enroll children in such programs without stigmatizing them for their weight, or even putting kids at risk for hard-to-treat eating disorders. And the evidence is mixed on how well such clinics actually work in reducing obesity. But others see this kind of treatment as a potent tool to curb an ever-growing wave of chronic conditions, many of them associated with higher weight.

UCLA’s program, started by pediatrician Wendy Slusser, has been open for 15 years — a rarity. Many of the AAP-approved intensive behavioral programs are still in or near academic medical centers. And while some are run through schools, local governments, or YMCAs, they are still few and far between. The closest Y health program to LR is over five hours away, in Silicon Valley.

While many clinics like the Fit Clinic closed once they ran out of grant funding, UCLA’s Department of Pediatrics has kept the Fit Clinic going. But even this clinic is limited.

It only runs one half-day per week. Still, patients flock to it from as far away as Fresno, a valley city nearly four hours from L.A. by car. One family took three buses — a two-hour commute each way — to get to appointments.

The clinic’s makeshift headquarters is a room with little more than four desktop computers, a whiteboard, and informational pamphlets. This is where the baton gets passed.

Pediatrician Cambria Garell, eager and poised, usually takes the lead. When she returns from seeing a patient, she shares notes with her teammates: psychologist Natacha Emerson, licensed clinical social worker Bobby Verdugo, and registered dietitian Yoko Takashina, along with a couple of interns and fellows. They put their heads together and quickly discuss each case, tapping into their respective expertise to fill in corners of the big picture. Then the next provider goes in, and so on.

Patients, including LR, are referred by their primary care providers because of weight concerns. In general, kids at the Fit Clinic have a BMI above the 95th percentile — higher than 95% of kids their same age and sex, the usual threshold for obesity. But the clinic also takes kids with a BMI above the 85th percentile, if they have comorbidities. Many do, and many had those other health issues uncovered at the Fit Clinic.

Patients have PTSD, anxiety, depression, high blood pressure, elevated A1C, developmental disorders, pain, obstructive sleep apnea, and fatty liver disease, among other conditions. Many of the children come from low-income or low-education families, or have a neglected disability, such as ADHD or autism spectrum disorder. They live in under-resourced areas. About half are Hispanic or Latino. Another universal trauma that comes up a lot? The pandemic. The clinic is “so much about all these other things,” Verdugo said.

As far as the providers are concerned, obesity is frequently a symptom of deeper issues that haven’t been dealt with. When Garell looks in a patient’s chart at their body mass index and sees a line shaped like a hockey stick — consistent for years and then a sudden upward spike — “That tells me that something happened. There’s a trauma.”

A patient’s first visit to the clinic is often two or three hours long. After that, providers often spend 30 minutes each with families, rummaging for insights and going deeper than what routine pediatrics visits allow: What do you have for breakfast? How’s your sleep? What do you do for fun? Are you dating? “We’re more interested in, ‘Let’s look at the larger dynamic,’” Verdugo said. “Being well is not just running in the park.”

And still, none of that holistic care equals 26 face-to-face hours per year — what the AAP guidelines recommend per patient for behavioral therapy. This clinic is just 5% of Garell’s clinical hours. She’s also seeing patients at a high-need family clinic, and is a primary care doctor.

Fit Clinic is reaching about 15 hours with each patient by the three-month mark, Garell estimates. Few make it to the full 26. But they need to get new families off the waitlist and in the door.

Before her first Fit Clinic appointment in 2021, LR (STAT is not using her full name to protect her privacy) was on the waitlist for a year. Covid and life interrupted subsequent appointments, so it’s only recently that she’s been seeing the doctors consistently. She’s still getting used to them, and how many there are.

In the appointment room, she’s quiet and shy, nervously peering out from under a surgical mask and hoodie. When she finally slides her hood back, her hair is up in pigtail twists, some of them snaked with egg-yolk-colored streaks from when she asked her mom to give her blond highlights.

“Her school is giving me such a hard time,” her mom, Jessica Gonzalez, tells Garell. Even though she explained LR’s health issues, school officials made Gonzalez sign a paper saying LR won’t have any more absences, tardies, or early dismissals. That’s why they were late to this appointment.

They run through updates: LR has an albuterol inhaler she uses before P.E. to help her breathe, and is starting a steroid nasal spray for her congested nose, but she also struggles to breathe through her mouth. It’s evident when she speaks — her words dense with stuffiness, sentences nipped at the end to make room for labored, shallow breaths. LR will see an ear, nose, and throat doctor soon, to see if removing her tonsils might help. But all of these issues make it hard for LR to sleep. For months, Gonzalez has been trying to arrange a sleep study, but all her calls go to voicemail.

When LR does find rest, it’s often plagued by nightmares. She dreams of her two younger brothers, ages 3 and 4, being harmed. A creepy lady picks the meat off of children’s bones. Her family members turn into ogres and attack her. LR is often awake into the wee hours, playing video games (sometimes with her dad). By morning, it’s so hard to wake up that her mother often has to yell her name, or shake her, or sprinkle water on her face. “It sounds like we still need some help,” Garell says to them.

LR’s been trying to create healthy habits with tips from the Fit Clinic grown-ups. It’s here that she’s learned how inadequate rest makes it harder to have a good day — to eat healthfully, or have the necessary fuel to learn and be physically active. At the clinic, they talk about all kinds of things.

Garell asks about the family’s nighttime routines, and suggests stopping the use of devices a few hours before bedtime. “Do you know why I ask about screens and sleep?” Garell asks LR, between typing out notes and listening to the girl’s heartbeat. The blue light from devices reduces her body’s production of sleepiness hormones, she explains to LR. Gonzalez nods along. Garell also wants mom to have more alone time in the evenings, and more time to sleep. By the time the kids are finally dozing off, it’s close to midnight.

LR’s weight and body mass are tracked in her electronic health record, but the numbers never come up in conversation. There are other things to talk about.

Not long ago, tests showed LR had abnormal liver function, a marker of potential nonalcoholic fatty liver disease, which is on the rise in young people and especially in Latino kids. Her triglycerides, blood pressure, and blood sugar were high.

From a health standpoint, this is a pivotal point in LR’s life. She’s approaching puberty, when kids naturally gain weight and undergo body changes, so controlling issues before then is important. Actually doing so is more complicated.

LR is more preoccupied with being the last one standing on a round of Fortnite and mastering her multiplication tables than getting a workout in or eating enough protein. She’s interested in the mysteries of outer space and the collection of tiny, food-shaped erasers on her night stand. She likes “ABC” by the Jackson 5 and her dog, Lucky, and her grandma’s sweet tamales. She’s not ruminating on how small choices now could have a domino effect. She’s a child.

It’s some of the adults in her life who see her larger body size and blood tests as problematic, and feel a sense of urgency to change the way she lives. They can see the future that might await LR if she doesn’t get healthier.

Like many of the children at the Fit Clinic, LR has already experienced disruptions to her life. Last summer, her Santa Monica elementary school was shut down after contractors found extensive water damage and some mold in the building. It was a Title I school, educating mostly low-income kids of color who live in and around the expensive Westside of already-expensive Los Angeles. When school district officials announced families would need to find another place to enroll their kids come fall, parents were angry. Allegations of neglect flew. Gonzalez wondered if the school worsened LR’s breathing.

She transferred to a school about 10 minutes from where she lives. At the new school, kids play on broad lawns and multicolored playgrounds surrounded by bougainvillea-covered fences. The teachers are strict and the families are fancier. LR qualifies for free school lunch, and can take home a bag of meals for the weekend, but it’s mostly canned foods, unappetizing and heavy to carry. Instead, her mom uses food stamps and a couple dozen dollars left over from government help to feed her three picky eaters.

Food, because of the Fit Clinic, is a big topic of conversation lately in LR’s house. Or, houses. Her parents split in the fall, and dad moved into a two-bedroom apartment down the block. LR spends time at her dad’s on weekends, but usually lives at her grandparents’ house, where she concocts “scientific experiments” — potions, Gonzalez clarifies — and tucks them in the shelf behind the bathroom mirror. (Other “experiments” included shaving her knee to “know what happened,” and chopping off pieces of her hair.)

Gonzalez, LR, and the boys live with the grandparents and two other family members. It’s a lot of people in one unit, a second-floor spot that’s still too far off the ground for Gonzalez’s taste. She’s afraid to get too close to the staircase railing. LR, though, is a daredevil who wants to ride the tallest and fastest roller coasters at Disneyland. She’s a lot like her dad, an Alabama-born teacher who met Gonzalez through a mutual friend on Myspace, and moved out West to be with her. “We think alike, we look alike, and we act alike,” LR says of her dad.

The lessons from the Fit Clinic seem to be helping LR already. Her liver function tests have normalized. Garell says diet adjustments, like cutting down on juice and soda, likely helped (research suggests sugary drinks can wreak havoc on the liver). Her cholesterol normalized, and her weight was stable from December to March.

In the spring, LR also completed a four-week virtual course Verdugo created, called “Fit Mind.” A grant-funded pilot to teach children about mindfulness, the Fit Clinic patients are beta testers. Through that course, she learned some ways to fall asleep faster: listening to white noise of a babbling brook, elevating her head for easier breathing, using a sleep mask, and turning down the thermostat.

But she also learned about mindful eating, which Verdugo said is the kids’ favorite part of the curriculum. “If Cookie Monster was sitting at the table and not eating fast,” LR starts. “Oh, mindful eating,” she says, remembering the term. When Cookie Monster ate, if he just focused on eating — not watching TV, or scrolling TikTok, or doing something else while chowing down — it increased his attention to the food, and kept him from overeating. The participants learned games they could play with family at the dinner table to be more mindful, to slow down. LR was taught about body cues, and how it can take 20 minutes for her brain to receive the signal that she’s full. She learned about “fun foods,” like cake and candy and soda, and how they’re great to be enjoyed sometimes, but not all the time.

Mindfulness is the ability to notice things without judging them or trying to fix them — so, the opposite of obesity medicine. Integrating such an approach into the Fit Clinic’s programming is bold. But it’s in line with the times. Similar teachings, like the popular “intuitive eating” concept, tell people to let go of restrictive mindsets that label certain foods as good or bad, and instead focus on how they feel and what they crave. Research suggests intuitive eating can have positive effects on adults’ self-image and well-being.

A growing number of studies suggest a person’s weight isn’t just a matter of willpower, that it’s influenced by numerous environmental and genetic factors. Some kids can’t feel full, or train themselves to crave fruits and veggies. Because of that, mindfulness won’t be helpful for everyone when it comes to food. But what if children could regard their bodies with that mindfulness?

Could they become more focused on sensation than on appearance, more aware of how their choices make them feel, whether it has to do with food or anything else? Verdugo teaches stress management and emotional awareness, too. Could those skills help kids already at a disadvantage move through difficult moments more deftly?

Gonzalez loved the program. Like many parents at the clinic, she has her own complex history with food. She grew up in a home with countless rules, both spoken and unspoken — one of which was that they ate the same traditional Mexican dishes all the time. Her mother, an immigrant from Ciudad de México, still keeps 10 pounds of white rice and beans in her pantry at all times, and is reluctant to change her menu at all. Until recently, Gonzalez had never tried an Indian cuisine. The Fit Clinic has opened her mind.

“How do I teach her if I don’t know myself?” she said. Taking the lessons from Verdugo’s classes, Gonzalez reminds LR to slow down while eating, and says she doesn’t need to finish everything on her plate if she’s full. But then Gonzalez feels bad for wasting food. They’re operating on a shoestring budget as is. One time, at the Burger King drive-thru, LR saw a man who looked unhoused and asked Gonzalez to give him some money. They gave the man $3, but then they were short 75 cents when it came time to pay for their food.

Still, she encourages LR to follow her curious palette and try new foods, including tropical fruit. But if she doesn’t like it, “I really don’t want to throw a $7 fruit away,” Gonzalez said.

A couple of years ago, Gonzalez’s father became ill and she quit her longtime job as a children’s center assistant to take care of him and her three young children. She enrolled in classes at a local college in hopes of getting a degree in early childhood education, but with a newly diagnosed learning disability and all of her caretaking duties, her grades plummeted. “By the time I have time by myself to do homework, it’s 11 o’clock,” she said.

Gonzalez moved in with her parents, helping out with errands, caregiving, cooking, and cleaning in exchange for the low rent. She also sought out government assistance, but each month that still only leaves her with $27 in her wallet and SNAP benefits to stock their fridge and pantry — not enough. She recalls a week in early April when two containers of strawberries were $8.99. “Do I buy strawberries or do I buy meat?” she said.

Grocery trips are carefully mapped — the list made up of affordable, easy-to-prepare foods the kids will eat. Still, Gonzalez often winds up making two or more meals. LR doesn’t like mac and cheese or spaghetti, but the youngest son almost exclusively eats pasta. Her other son only wants chicken nuggets and french fries from McDonald’s, so she buys frozen nuggets and fries and tells him they’re from the drive-thru. “It says it’s all-natural. I don’t know if it’s really true,” she said, glancing at a label on the bag in her hand. She often calls a brother in Texas to decipher what’s healthy and what’s not.

Going to the Fit Clinic has helped with that, too. When Takashina, the dietitian, enters the room, Gonzalez and LR are immediately engaged. At their first appointment, Gonzalez told Takashina that LR only liked to eat pizza, and that she didn’t know what to do. Takashina said that’s fine, she can eat pizza, but two slices maximum, plus a salad, a piece of fruit, and some water, Gonzalez remembered. “We were like, ‘Oh.’” It was a valuable reframe.

LR last saw Takashina in January, and they made a game plan. “Do you remember our goals?” she asks. LR says yes: eat fresh fruit and salad at school every other day. One last goal, which LR forgot, was trying to drink flavored water instead of soda or juice on the weekends.

“Out of 10, how many times were you able to make it?” Takashina asks. Eight times, LR responds.

“Wow! Good job! I’m proud of you.”

She asks LR how many glasses of water she drinks per day, miming cups with her hands. And then, just as they’re about to reinstate the salad and fruit goal, LR chimes in, asking if she can keep just the fruit goal. She doesn’t like the purple cabbage in the school salads.

Takashina latches on, asking what’s in the school salad, and how big the portions are, and whether LR feels full after. It’s a small cup, and students are limited to one serving, LR says. Plus, it doesn’t include her favorite green: spinach. But Gonzalez makes a spinach salad that LR likes. “Maybe you can make it,” she tells her mom, and it can be a larger portion, Takashina adds. Together, they decide on a plan. Spinach salad, fruit, and water.

This is the point of all the talking.

Health, as an ideal, can be hard to define. What does health mean for a single parent trying to get by with little money? What does it look like for kids whose safety nets are full of holes? At the Fit Clinic, success is a flexible thing.

One patient, a teen wracked with social anxiety and pain at the first appointment, started seeing a mental health therapist, opening up emotionally and getting some pain relief. “Now we have a child that’s theoretically on a different trajectory,” Verdugo said.

Another patient finally agreed to do the virtual Fit Mind program instead of making the long commute to the clinic (a feat that involved Garell downloading the Zoom app onto the patient’s phone during their last appointment). This way they can meet more often.

The clinicians say the Fit Clinic’s goal for many patients is to “slow down the weight gain trajectory” if it’s abnormal, or maintain the same weight while improving behaviors and treating those underlying conditions, Garell said. “Many comorbidities will improve with very little change in weight or BMI.”

For LR, the team wants to see improvements in her blood pressure, blood sugar, and sleeping issues. Success would mean LR is getting enough sleep, moving her body in a way that feels good almost every day, eating a nutritious diet with regular snacks and water intake, developing positive self-esteem and stress management skills, and doing well in school both socially and academically, Garell told STAT.

For patients like her, who meet the criteria for “severe obesity” — 20% higher than the 95th percentile for BMI — lifestyle changes alone probably won’t result in significant weight loss. If LR stays on her current BMI trajectory, she is likely to qualify in a few years for more intense interventions. If LR had “a goal to lose weight specifically or if there was a weight-related comorbidity that necessitated weight loss, we could consider starting medications and/or discuss surgery,” Garell said in an email. But drugs and surgery don’t fix the systemic issues that make children unwell in the first place.

The clinic’s ethos can rub people the wrong way. Some parents balk at the idea that their children should stay the same weight, or that measures other than weight loss are good enough, providers told STAT. Others insult or shame their children, triggered by their own poor body image or eating issues. Mending those toxic family dynamics is also part of the tough work Fit Clinic providers undertake.

Caregivers need help, and Verdugo knows that. By the time families start connecting the dots in the Fit Mind program, it’s coming to an end. He’s hoping to add more resources for parents and guardians. He is also developing a scale to measure patients’ food trauma and body image.

The need is there. The ideas are there. It’s the money and staffing that isn’t, he said. Clinics like these aren’t cash cows for health systems. The only reason Verdugo could do the Fit Mind program was because a grant funded it for a year. That money ran out in June.

“I think these programs are seen as these goodwill projects that don’t make any money, but from a public health standpoint, this, in 10 years? Let’s deal with it now,” he said.

Gonzalez grapples with the path that led LR here. She knows genetics play a role. She has three hernias, and thyroid problems that have caused continuous weight gain. She was prescribed Wegovy in February but stopped it because of her increased risk of thyroid cancer. She also had gestational diabetes during her third pregnancy. LR’s dad has high blood sugar, and LR’s glucose was high in her latest lab results.

Gonzalez’s mother, LR’s abuela, is on metformin to control her blood sugar, and has struggled with her weight, too. Gonzalez thinks her parents “enabled” LR by feeding their granddaughter copious treats and saying she’d grow out of it. Now, they fault Gonzalez for her kids’ health issues.

And even though some of her metrics — like cholesterol — improved with better habits, LR still gained weight between her last Fit Clinic appointment in March and a routine check-up in June. Recently, LR has started worrying about her weight gain. Her self-esteem dips when she can’t run as fast as she wants. Gonzalez tries to stay positive, even if she doesn’t understand how LR could’ve gained weight while living more healthfully.

“I was just trying to encourage her like, ‘Let’s not worry about the numbers. Let’s just try to eat better,’” Gonzalez said. “Because I know what it’s like to have somebody tell you, ‘You’re so fat. Stop eating.’ I don’t want her to have an eating disorder.”

Gonzalez is tender toward her daughter, even in the face of so many life pressures. When LR makes jokes at her expense, like telling a reporter that her mom will “roundhouse kick” her if she acts up at the doctor’s office (complete with a visual demonstration), Gonzalez laughs along or shakes her head in bemusement. She tries her best to field her daughter’s everlasting parade of questions and comments — Know how long a pregnancy would last on the moon? Why are you so bad at gaming? And so forth. Gonzalez makes an effort to spend one-on-one time together, even if it just means running errands. It feels like they’re in this together.

“I’m not looking for her numbers to drop or anything like that,” Gonzalez says while sitting at the kitchen table in a royal blue dress. “I think success would be: her being mindful — that’s the word — about her body.” If LR can make peace with her body, she can weather a lot of things, her mom reasons.

Gonzalez also apologizes to LR a lot for mistakes she’s made as a parent. Some are clear mess-ups, the short-fuse snaps or hurtful comments that even well-meaning parents make. But so many of the apologies are for other, more amorphous things. A vapor cloud of regret in the distance, a broad marine layer of maternal guilt drifting inland from the Pacific and bathing the whole neighborhood in gray. Sorry I couldn’t protect you. Sorry I didn’t know better.

Her son’s blood pressure is climbing. Gonzalez already got him referred to the Fit Clinic, to intervene earlier and avoid some of her daughter’s struggles.

Eventually, once she knows her kids are OK, she might be able to address her own health issues, to rest easy. She won’t have to hide in the bathroom to get a moment to herself.

With the kids, “I feel like I’m losing little bits here and there,” Gonzalez said. “But I feel like I’m already lost. Like I’m drowned.”

At the end of May, the Fit Clinic got some good news. UCLA Pediatrics will increase funding so Garell and her team can serve more patients. She expects the money will cover the team’s time at the clinic, and let them add a couple of extra half-days.

Verdugo can continue the virtual Fit Mind program, where LR learned about Cookie Monster’s unmindful eating. They’re also hoping to do group visits, which would allow for more face time at a cost-efficient rate.

LR, meanwhile, will make the nerve-wracking transition into fourth grade and double digits.

She really wanted to spend her summer at a swimming camp at the public pool nearby. But like many things in a populous city, getting into camp requires something beyond competitiveness. It requires strategy.

For the past four years, Gonzalez has tried to enroll LR in the program to no avail. The only way a neighbor was able to get her child in was by waking up at 5:50 a.m. and following a tactical protocol — log on early, put the camp in your shopping cart, pre-load your credit card information — on par with what’s required to get tickets for Coachella music festival.

Gonzalez tried again this year, waking up at 5 a.m. No luck. “It is impossible,” she wrote in a text. LR is also No. 7 on the waitlist for another city-run summer camp. But it’s OK. She’ll still take LR to the pool so she doesn’t feel like she’s missing out. And in mid-July, LR will take her first airplane ride to visit her uncle near Austin, Texas.

They will make do.

STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.