January 12, 2024 • 51 mins
According to the 1964 Mary Poppins children's film, "just a spoonful of sugar" is said to make the medicine go down. But what if we say that those daily spoons of sweetness may actually result in the need for kids to take medication? According to the American Diabetes Association, approximately 30 million people in the United States alone in 2021 were diagnosed with diabetes mellitus, Types I and II combined, with 352,000 of these being under the age of 20. Diabetes is a chronic condition influenced by the body's inability to either produce the insulin hormone or effectively utilize it. Truly, hormones and their balance influence the optimal functioning of the human body, especially in the youth. According to the American Board of Pediatrics, if left untreated, diabetes and other leading chronic diseases influenced by hormones, such as obesity, can lead to detrimental health concerns, such as cardiovascular disease and mortality. Endocrinology is the complex field of hormones and their equilibrium, and there is no space for sugarcoating in this domain.
We are joined in this episode by Dr. Sheila Pérez-Colón, a board-certified pediatric endocrinologist based in Puerto Rico. She received her BS in Biology from the University of Puerto Rico, MD from the Universidad Autonoma de Guadalajara with its pathway completion at New York Medical College (where she attained a #1 class rank), Pediatrics Residency at Maimonides Medical Center/Infants and Children's Hospital of Brooklyn, and Pediatric Endocrinology fellowship at SUNY Downstate Health Sciences University where she later served as an Assistant Professor of Medicine. Dr. Sheila became an attending physician in offices across the United States, having been the Diabetes Clinic Director at Kings County Hospital in New York City, Baptist Health South Florida, and Kaiser Permanente in Los Angeles. Having moved back to Puerto Rico in 2020 to serve her homeland, she currently stands as the Owner of Elite Endocrine MD, a direct specialty care practice that focuses on pediatric diabetes, obesity management, thyroid disorders, and pubertal disorders. Dr. Sheila has over 15 publications on prediabetes, autoimmune thyroiditis, and adolescent obesity and has been featured on Yahoo! News and Everyday Health.
Livestream Air Date: March 28, 2023
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Hi everyone, happy Friday! How has your week been? Well regardless of how it has been,
(00:10):
I hope you all have a sweet day ahead whenever you may be listening to this episode. And
I am placing emphasis on the word sweet because as you can tell from our episode title, we
will be tackling some sugary conversations in today's episode. Speaking of sugary and
sweet, who here has a sweet tooth? I am raising my hand right now, both hands, and I hope
(00:31):
you are too. Honestly, I don't trust anybody who does not have a sweet tooth. I am joking,
but honestly though, I live for sweets and desserts and pastries. Cakes? Yes. Juices?
Yes. Ice cream? Yes. Boba? Hell yes. Mustn't eat dessert after every meal? That's me. In
(00:52):
fact, I don't know if you know, but if I am planning to go out for dinner with friends
and I am 100% sure that there would be no plants for dessert or no dessert places nearby
the restaurant at all, I would decide to just not go out. Is it an addiction? Probably,
but I am owning up to it. Kidding aside, I agree. I need to wash my sugar and general
(01:14):
carb intake, given my family history of diabetes on both sides. I mean, has anybody here watched
the movie Mary Poppins? Do you remember the song, Just a Spoonful of Sugar? This is a
spoon full of sugar makes the medicine go down. The medicine. Truly though, a spoonful
or more of sugar every day will probably require us to take more medication. The unwanted D
(01:38):
word, diabetes, a chronic disease that's always paired with the word sugar and sweet.
According to the American Diabetes Association, approximately 30 million people in the United
States alone in 2021 were diagnosed with diabetes, both types 1 and type 2 combined, with 352,000
of these being under the age of 20. It truly is a rampant epidemic, or even a pandemic.
(02:04):
Diabetes is a byproduct of the body's erroneous handling of the insulin hormone. Hormones
are signaling molecules and chemicals released by different parts and organs of our body
to regulate our physiology and behaviour. Our body strives for balance and harmony of
these hormones, the crux of the field of endocrinology, because the excess or deficiency of any of
these can lead to diseases and conditions, one being obesity, a topic we touch upon greatly
(02:29):
in this episode. During the last season of the podcast, we sat down with board certified
endocrinologist Dr. Rocio Salas-Whalen to talk about all things obesity medicine in adults.
In this episode, I wanted to take it a step further, or should I say, a step back in time
when it comes to children. There is a common misconception that children are just small
(02:51):
adults, but this is farther from the truth. The approach to children's bodies and health
is so complex and different from adults, and we need a rightful expert to guide us through
it. This why I am so honored to have our expert guest for today, Dr. Sheila Perez-Colon, a
New York-trained and Puerto Rico based board-certified pediatric endocrinologist, assistant
(03:11):
professor of medicine and diabetes clinic director. Having moved back to Puerto Rico
to serve her homeland, she currently stands as the owner of Elite Endocrine MD, a direct
specialty care practice, the first one in Puerto Rico at that, that focuses on pediatric
diabetes, obesity management, thyroid disorders and pre-bordered disorders. Endocrinology
(03:31):
is such a complex topic, and Dr. Sheila is here to break it down for us with no spoonful
sugar coating. I hope you enjoyed today's episode. Have a great day.
Hello. How are you? I'm good. Thank you so much for joining me tonight. We're miles
(03:53):
apart. We're miles apart. We're miles apart, but we're in the one space today. We have
so much to talk about, and I was so excited to receive your message. Time's just flying
by. How is the weather? It's like so warm. Have you been here before? Never been. You
should just come and visit. It's very warm and sunny, beautiful beaches. So yes. Yes.
(04:16):
I mean, you were here in New York before too. So I guess you know the expectation of how
the weather is cold and then it's hot and then it's raining all the time. Dr. Sheila,
if you could first please introduce yourself to everybody. Thank you so much. Hi everyone.
My name is Dr. Sheila Perez-Colon. I am a board-certified pediatric endocrinologist.
(04:37):
I did my residency and my fellowship in New York City. I stayed there working for a few
years. Yes. We missed so much. I missed it. It was such a wonderful experience. Then I
went to LA for a year. I did work there as an endocrinologist as well. And because I'm
originally from Puerto Rico, I want to really be close to the island and to the family.
(04:59):
So I moved to Miami in 2019 and I worked there until 2022. So for three years I did work
there. And maybe seven months ago I arrived here in Puerto Rico. I brought a new model
here for medical care, which is specialty care. And I opened my private practice here
and I am so happy to be here. Yeah, that's amazing. I mean, I can't imagine the amount
(05:23):
of wonder and change of the care that you bring to Puerto Rico and Nara, which you will
talk about. Well, I wanted to dive first into the journey that it took to get to where you
are now, which you all know is a very long journey, right? Usually it's four years of
college and then four years of medical school and then however amount years of residency
(05:44):
and fellowship if one chooses to do so, right? So can you take us through that journey from
college to all the way through fellowship? So let's see. I did my high school here in
Puerto Rico. I did my biology degree in Puerto Rico as well in the University of Puerto Rico,
which is an excellent university here in the island. After that I went to medical school.
(06:04):
I went to the Universidad Autónoma de Guadalajara and there it's a five years actually medical
school. It's not four. So for the three years I stayed there in Guadalajara, which was an
excellent experience and I learned so much. But for the last two years you have the opportunity
to go to New York and do the rotations, clinical rotation and be there for two years. So I
(06:25):
did that. I actually went to Maimonides Medical Center for my fourth year of medical school
and for the fifth one, which is called the fifth pathway, I did it in New York Medical
College. That's in Valhalla, New York. After that then I stayed for residency in Maimonides
Medical Center for those three years, as you mentioned, and then I stayed for a specialty
(06:46):
for pediatric endocrinologist. At that time, which was, oh my God, I graduated in 2013
from Philadelphia. So at that time, Chris, it was a combined program. It was between
like SUNY Downstate Medical Center and Maimonides. So I remember going around between hospital,
being on call. We actually go to other hospitals as well, like Lutheran. I was driving with
(07:08):
so many consults, but it was so great and I learned so much. So I'm very grateful for
that.
I mean, honestly, Maimonides is such a good pediatric hospital. I think I did my rotations
in the PICU and NICU at Maimonides. So you can tell that the team really, really loves
their patients and send the kids. But you know, like you said, it's such a long time,
(07:32):
right? I mean, where did this inspiration come from to become a physician? Is it family,
friends or personal experience?
I think, well, I don't have anyone in my family being a doctor, but I'm the first doctor in
the family. In terms of experience, I need to definitely give it to my pediatrician.
My pediatrician many years ago here in Puerto Rico, I do recall as a child going with my
(07:52):
mom to the office and how he was talking to my mom, how he was examining me. So I did
love how he interacted with the family and with the child itself. At that time, Chris,
I remember it was like paper-sharp. We didn't have like electronic medical records. I remember
the doctor going back and forth and looking through the lab. I don't know, that really,
really, I was so happy, you know, what he was doing. So I wanted to do that. Moreover,
(08:16):
I do this kind of person that I want everyone to be kind of happy, like when persons are
in disagreement and I'm always trying to comfort everyone. So I think maybe those two things
really is what inspires me to go to medical school.
What is it about the pediatricians that they're always so nice and so lively? You know, everyone
(08:37):
that I talk to, I think one of the key people in their childhood memories are their pediatricians.
I mean, I wanted the pediatrician a lot as a kid because I had childhood asthma. And
I just remember how kind and just so loving pediatricians are. It's beautiful. But, you
know, amidst all of that, dog, like you said, it's a long road, but that long road is not
(09:00):
just like an easy road, right? There's a lot of sacrifices. I mean, I can't imagine being
a medical student before, right? Like you have to say no to a lot of parties or gatherings
because you have to study a lot of the time involved, the stress and all of that. Given
the length and the stress of the road, now that you are a fully practicing physician,
(09:23):
is there any regrets in the road that you take?
Honestly, I don't have any regrets. And I'm very honest. I went to medical school because
I was really passionate about it. I was determined and this decision was even from high school.
I knew I was going to medical school, so I planned everything. So I have no regrets at
all. However, dog, yes, it was, right? Did I miss a lot of important moments in life?
(09:50):
Yes, I did. Like family birthday, you know, like friend's wedding, like even our kid milestone.
We were all starting. So it's a tough road. But for me, I always knew I wanted to be a
pediatric, actually, and even a pediatric endocrinologist. I went because I already
knew I wanted to do endocrinologist. So it's something that I do love. It's something that
every morning I wake up so happy to go and see my patient. So I guess if you have the
(10:14):
passion, even that tough road, and it is, you can make it and you will be happy.
That's beautiful. And that's so encouraging. And it's so interesting for you to say that
you knew that you wanted to be a pediatrician and a pediatric endocrinologist. I wanted
to ask, how do you know that? Is it from your pediatrician as a child or was it the rotation
(10:35):
in medical school?
Even from high school, right? We go into this and you start to hear about hormones and biology.
So that already intrigued me. Like, I want to know more about that. And in medical school,
I fell in love with that complex endocrinism, as you know. So I fell in love with that.
You know, like we could be on a stable state. So any increase in the hormones or any deficiency
(10:58):
of the hormone could lead to so many conditions or diseases that for me was like, I needed
to. And it's like a puzzle, right? A puzzle is like, if something is done, what should
I do to bring it up and to make the kid and the family, you know, wealth overall. So yeah,
I always knew it. It's so fun, the endocrine system. I love it.
(11:18):
A few months ago for our second season, we had Dr. Rocio Salasuelan-An, who is an obesity
expert, right? Which is obviously an endocrinologist, but we didn't really touch upon endocrinology.
And you know, it's always so hard to find a guest on the podcast to do endocrinology
because I feel like it's such a hidden secret garden in medicine, right? For those who are
(11:42):
listening now, who may not know what endocrinology is, and I know you already give a hint of
it. What is the field of endocrinology? What do you deal with? And what do you think pediatrics
and the chronology make? How is it different from...
So endocrinology is right. As a pediatric endocrinologist, I do treat several, most
of the hormonal condition, actually all of them. So I treat conditions such as like pre-diabetes,
(12:07):
diabetes, type one or type two, thyroid disease, either hypothyroidism or hyperthyroidism,
to irritable condition. Nowadays we see like girls and actually boys are getting into
puberty early. So I do manage that diagnosis and manage that. I do treat patients with
growth concern, for example, those patients who are too short, they may have growth hormone
(12:30):
deficiency. They may not. We do the work and then we'll see if we need to treat or even
too tall. So like I mentioned before, our system is kind of in a balance. Any excess
or deficiency of a hormone could lead to conditions and definitely decrease obesity. This is something
that I love to talk about because most of the time we think like obesity is just like
(12:51):
maybe a physical characteristic, but it's not that. It's so much more. Obesity is a
disease and it's a chronic disease and we need to recognize and acknowledge it. So we're
able to prevent the complications. And for your other question, like what was the different
right between like treating maybe adult patients? So pediatric patients are definitely different
(13:12):
starting from basics. An adult can say what's wrong, how do they feel, pediatric patients
they don't. Maybe they're adolescent or young adult, they do, but in small kids they can't.
So it's like trying to figure out what is going on with them, going by what the family
member is saying, because now it's not the patient, it's the mother, the guardian, the
father, whoever is taking care of the family. I do love pediatric endocrinologists because
(13:36):
children have social imagination and they see everything is like possible, right? There's
nothing impossible for a child, but at the same time when they are sick, they're so vulnerable
like I wanted to be there to help on those moments. So there's a big difference between
adult endocrine and pediatric endocrine. Although many of the conditions by definitions are
(13:57):
the same, for example, that is step one, there's insulin deficiency is the same for pediatrics
or adult. Hypothyroidism, there's deficiency of the title hormone is the same, but the
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I think especially here in America, I think one of the biggest misconceptions by the general
public is that children are just small adults, right? Which is completely wrong because I
feel like though anatomically it might be the same, it's like the size is different,
the physiology changes as someone grows up, even especially pre-peabody and then post-peabody.
(17:47):
And I must admit that the endocrine system is always the one system during exams and
studying that my brain is always like, there's so much to know. Let's say like the heart,
right? All you have to know is literally how the heart works and how it may, I don't know,
affect other body systems. But when it comes to the endocrine, just like how many different
(18:09):
organs interplay, right? Like you have the hypothalamus, you have the thyroid, parathyroid,
the testes, the ovaries, the adrenals. It's like information overload all the time.
The endocrine system controls the function of the whole body. The pancreas, like the
pituitary, the pituitary actually, and this is how I explain to patients and to family.
It's like the one that is driving, right? Because it sends signals for your development,
(18:33):
as you mentioned. For example, cortisol, make sure your blood pressure is okay, your blood
pressure is okay. So it's such important. And yes, endocrine has a lot to do with your
overall, all the functions of your body. But I do love your field. Cardio is so exciting.
I remember the rotation and I did learn a lot. So I do what you do.
(18:54):
Yeah, it is fun. But I must say the endocrine is on another level, I must say, because I
think besides the physical, right? And the physiological, the endocrine actually taps
in because it is hormonal, like into like the psychosocial, so the emotions, right?
Like if something wrong is with the lungs, it's like, I think the manifestation is when
someone breathes and potentially blood gases. But when there's something wrong with any
(19:19):
of the endocrine organs, right? It's not just something wrong with the body, but people's
emotions get involved, right? And because hormones can influence how someone feels,
especially when it comes to the sexual reproductive organs, right? And I wanted to know, like,
if you walked into your clinic today, what would you think would be the top three reasons
(19:39):
why someone would see a pediatric endocrinologist or specifically in your practice?
Three of them. Number one will be type 1 diabetes, the increase of the increase in type 1 diabetes.
And actually here in Puerto Rico, you know, a lot of diabetes type 1, new onset. So that
is number one. Number two, I will say thyroid hypotension. It's very common in clinic. We
(20:02):
see it almost every day. I see it every day. And then the other one will be, can I say
two on the last one? Because they are like, I will say, we break rules here. Evaluation
for, right? But I can't leave alone like puberty, puberty, precocious puberty. Like I mentioned
before, it's a topic and it's a diagnosis that is now maybe more recognized and more
(20:23):
diagnosed. We saw increase in the diagnosis of precocious puberty during the pandemic.
And there are studies even done to see, is this just the sedentaryism that happened?
That the weight and the increasing weight increased the hormones for us to go into early
puberty or was it something else? So I will say that those diagnoses are the most common,
(20:44):
but now and then you will see a genetic syndrome, like a Turner syndrome, you name it, adrenal
insufficiency. It's so bad. Our clinic has, every patient is different. It's amazing.
I'm in love with it.
I'm actually very curious, given that you studied here in New York and did your rotations
here and work in New York and LA and Florida. What do you think is the difference when it
(21:06):
comes to health and I guess the giving that help to Puerto Rico? How are the patients
different? How is the care different? Because I know there's also like cultural and social
aspects that come into that.
I think every place that I have been is completely different and in a good way has made me experience,
(21:26):
right? Because I have different diagnoses that I may just have seen maybe in New York
or in Miami, but Puerto Rico is where I was born, right? This is like my home. So I just
have dreamed to come back to Puerto Rico because here there's a huge need of doctors. The medical
system is suffering now and has been for so many years. So for me, returning to the island
(21:49):
was I see it as like I'm contributing to the change. So I'm happy. And when I am in clinic
with patients that speak my language from my heart, I feel such a joy and it's the place
that I should be. Even though you give your care and I love all my patients from everywhere
because I do keep in contact with many of them. There's nothing like helping your place, your
(22:12):
home place, the training. I got all the experience. I'm ready. Why not to bring it back to your
island that is meeting and is suffering? So I'm here.
That's beautiful. I love that doc. You know, we were talking about a big problem, which
is obesity, right? I feel like if you look into like news in the United Kingdom or some
(22:34):
news in Asia, there's always a running joke that the United States is the nation of obesity,
right? And I mean, it's not just a stereotype. It actually is true. I mean, the rates of
obesity in the United States is high, maybe relative to other countries in the world,
right? And then we think of the United States, most of the time people think of what extra
(22:55):
large sodas and burgers and fries. I want to know, is that issue of obesity also a prevalent
problem in Puerto Rico? Yes, it is. It's almost the same in the United
States. Like the diet, right? I don't like to say diet. I usually say like the meals
or the food. Yes, those processed food, like high sugary drinks, right? Like we're exposed
(23:21):
to those. Definitely the sedentaryism, like kids are not going out to play anymore. I
remember when I was growing here, like I was out and maybe playing outside with the ball
or riding a bike. You don't see that. I actually moved here a few months ago. I live in a neighborhood
that there's some kids and I don't see them outside playing anymore, right? So it's on
(23:41):
their iPad, on their screen. So there's so many factors that influence on that. However,
a lot of genetic factors. Obesity is a multifactorial condition, right? So there's the environmental
factor, genetic factors, but also, you know, like how our lifestyle, it's very important.
But I do see increasing obesity here in Puerto Rico, in the pediatric population, as well
(24:05):
as in the adult population in the US. I see. Yeah. And so when it comes to obesity,
I think the big question when it comes to obesity is what is obesity? And I think the
general public, the first thought when it comes to obesity is when it comes to someone's
size, right? How the waist measurement is, or what is the number on the scale, or what
(24:27):
someone eats. I think those are the general public definitions of what obesity is. But
I feel like there's a rise, especially with things to physicians like you and endocrinologists
who are trying to break this stigma and this misconstrued perception of the public that
obesity is a fault of the patient or a fault of the person who is obese. I want to know,
(24:52):
as a physician, as an expert in this field, what is your definition of obesity? And for
all of your patients who come to you with a problem of obesity, how do you diagnose
that? Is it based on the number of the scale? Is it based on what they eat? Is it based
on the measurement? For me, the definition of obesity is a chronic disease that can lead
(25:13):
to other comorbidities or other diseases, right? So, it predisposes you to prediabetes,
to diabetes type 2, to inflammation of the liver or fatty liver, could affect your bones,
so it affects everything and could lead to other diseases. How do we diagnose obesity
in pediatric? In pediatric, we go by what we use is the body mass index or the BMI.
(25:37):
What is this? This is just the ratio, right, between the weight of the patient and the
height of the patient. That gives me a number, which is the BMI. And when the patient comes
to the clinic, traditionally, right, we do the vital signs, we do the weight and height,
and we plot them on the growth chart. Depending on the percentile with that BMI stand, then
we will say this patient is overweight, is on a healthy weight, or has obesity. We should
(26:01):
say anymore like patient is obese, we should say patient has obesity. So, in terms of percentile,
any percentiles like is from 85 percentile to 94, this is considered overweight, the
pediatric patient is overweight. And from 95 percentile and above, we consider this
patient has obesity or has overweight if it is from 85 to 94 percentile. And Chris, recently,
(26:27):
the CDC, and I put this on my social media, in Instagram, is like the CDC even makes some
extension to the growth chart, to the BMI growth chart recently, as recent as 2023,
to increase those percentile, to include the 99 percentile. Because nowadays, there's an
epidemic of obesity in children that we couldn't track how this patient were progressing. So,
(26:51):
we need to understand that to that degree, it does affect. So, that's the definition
of obesity. We do it by that number, the BMI. But again, in my education, every day I speak
with my patients and with the family, it's not just a number. And there's a, right, that
we can measure obesity and the waste, all that. But that's the definition that we use
(27:13):
globally in pediatric. I love the point that you make that we change the terms from the
person is obese to the person has obesity, right? And I love that it kind of like takes
away the fault and the blame from the person who has it or is experiencing it, right? And
I want to know, as we know, the obesity has a lot of comorbidities. And we have seen data
(27:36):
on the effects it may have on cardiovascular systems or pulmonary, right? And other parts
of the body and other systems of the body. How much more dangerous is it for a child
to have obesity as opposed to an adult? And I'm not trying to make a competition between
adults and children who has obesity, but is it more alarming if a child has obesity?
(28:01):
Yes. My answer will be yes. And I'll tell you why. Because if a child has obesity and
they start having this chronic condition early, we may tend to see or they have increased
risk of the complications to be seen early. For example, and Chris, I do see it in clinic
very often. I do diagnose patients who are 11, 12, 10 years old with type 2 diabetes,
(28:22):
which this is a condition that usually we use to remember that was only for adults.
And when it's a condition for adults, I do see it mentioned early on. I do see like sleep
apnea secondary to the obesity. So yes, it will make damage. And as you mentioned in
terms of basculature, yes, there's a lot of endothelial changes that happen from early
(28:43):
on. So I will say it's more severe and it's very alarming. I'm really into like educating
the population, the community as much as I can to recognize it as a condition because
chronic condition it is that way. You know, in the society, maybe we will get some help
for education, actually for treatment if we need it. Otherwise, if we don't get like that,
(29:05):
then it will stay like that. And then our kids may not reach, you know, maybe an adult
age.
Yeah, definitely. When it comes to that, and we'll talk about increments a little bit more
in a bit, but for this children who do have obesity and are already, you know, feeling
the effects, the comorbidities of it and we see more elevated blood pressures or it's
(29:28):
not unheard of that kids already have hypertension, right? Or earlier incidences of even heart
attacks and strokes and teens and adolescents, right? Or young adults. What is the key to
solving this problem of obesity as a first line? Even before medications, what would
be your recommendation for someone comes into your clinic and like, doc, my son or my daughter
(29:52):
or my child is having a problem with this. What would be your first recommendation? Is
it already medications? Is it weight loss by, I don't know, by eating?
I love that you asked that because number one is to recognize, right? That the patient
is suffering from this condition. We need to recognize it. Not only the physician who
is seeing the patient, right? In the patient, but also the family members, because like
(30:17):
going back to pediatric, most of the patients in pediatric depends on their family members.
They are their model, right? So I usually start with, you know, like we're going to
work this together. Let's try to figure it out. We need to do like what is called a motivational
history taking for us to pick some board and then we will go forward. The main recommendations
(30:37):
for the treatment of obesity are not medications or surgery. We basic, which is seeing what
we can change in these patients environment. Number one, always decrease like sugary drink,
juices decrease like sodas, for example, in the past. And it happened to me here in Puerto
Rico. I remember my lovely grandmother always telling me like as a child, like drink juice,
(31:00):
drink juice because juice has vitamin C and that may be, but now we're learning. So he's
trying to change those beliefs we have in the past to say, we need to do it in moderation.
So decrease sugary drink, encourage water, right? Encourage the intake of vegetables
and fruits. Most adolescents and more kids, and I have one beautiful daughter and she
(31:22):
don't like vegetables. So I tried to make it interesting, for example, and fun. So I
go to the grocery store with her and I actually did it this way. I'm like, okay, let's go
to the aisle of the vegetable and you choose, choose three of them, whichever you like.
I'm not going to tell you. So they feel like they have some autonomy and yeah, when they
go home, they actually want to try it. So make it fun. Increase physical activity. The
(31:45):
recommendations are to do 16 minutes per day of physical activity during childhood and
adult and make it fun again. Don't make it boring. And they don't need to pay a gym actually
to be doing. Many patients say, you know, for several reasons, I want to go to the gym
or I can't afford it, whichever is the situation across, you know, even in us. And I'm like,
you don't need to go. You can go up and down the stairs in your building. You can go outside.
(32:09):
You can go to the park. Do you like to dance? Put your pots and start dancing and just take
it. But we need to move. We need to make it fun. And number three is sleep pattern. And
this is the one we forget about. It's so important to kind of actually prevent even obesity.
We know that patient who has some compromise in their sleep, they sleep a few hours or
(32:31):
they don't sleep well. There's some changes in hormone, leptin and ghrelin. I'm not going
to go into all the details. But there's that happened. The study has shown the next day
or for the next few days, you will be taking some more calories and more carbohydrates
in your choice, even without you realizing. So he's doing the basic changes first.
I think as a society too, we tend to forget the basics, right? And I think this is why
(32:57):
incretins is such a very interesting topic. And I think it has to do with social media
too that I know incretins have been here for a while, right? It's probably more two decades
where we have data and it's been out and about. But it's just recently that it's so hot on
fire news. And I think social media has a way to play in that. I got all the viral things
(33:20):
going on. I actually took the subway the other day and there are posters of free weight loss
injections all across Times Square. And I'm like, hmm, there is a revolution going on
in our society in the height of social media and ideals and physical ideals online, right?
(33:40):
I think the words have been buzzing all around the news, right? Things like Ozempic and Rigovi
and Manjaro and Zosenda. Doc, what are incretins? And first of all, why do you think it's so
controversial? Like how do they work? What are the intentions for them? What are not
the intentions for these medications?
So, as you mentioned, incretins has been out for a while. Maybe around like 2000, it was
(34:06):
already out. So they are not new. However, their effect is very positive. It has a good
effect. So how do they work? So they suppress your appetite, right? So it increases your
society. It also like decrease the gastric empty. So when you eat, it takes longer for
your digestion. So then you get full faster. And it has many other benefits to the heart
(34:31):
and even to the brain. So those are good medicines and we see very good results. However, for
the last around two years or so, right, it has been on the media. Like you mentioned,
everything that is on the media, everyone wants to try it. When we are exposed to the
same and we listen to it every day, you want to know what is it and you want to try it.
And because they are so good on the effect, because they do help in weight loss. So everyone's
(34:56):
one set. But I do think at first there was a questionable shortage, right, of the patient
everyone was using. But as of now, we do have enough supply, but we need to use it carefully
a pediatric endocrinologist, which I see patients from birth up to 21 years of age.
Do I prescribe it? Yes, I do. Do I have patients on those medications? Yes. But I go by certain
(35:20):
criteria. I don't give it to anyone. You know, they may come to my clinic because they want
to have some weight loss or they don't like how they look. I don't prescribe it like that.
I start with basic. We're going to send you to a registered dietitian. We're going to
do it for a month. We're going to come here to my clinic every month because I'm going
to be monitoring. And at that time you get the history, what they have done. So there's
(35:42):
some step. I don't jump into the medication. For example, Olsenpik and Wegobi, those are
the maglutide, which is DLP1 receptor analog, which is an infratin, right? And Olsenpik
is the one that is injected once a week versus Wegobi, which also is injected once a week,
but it was approved by the FDA, Wegobi for obesity. And Olsenpik was kind of for diabetes
(36:06):
type two. The spenda or liraglutide is the one that was given or is given daily injection.
But yeah, they are very successful. They do have side effects. I usually, when I started,
I go over the side effect, the possibilities. I'm like, listen, you can see some weight
loss and what we aim for is approximately like to lose two pounds per week. We will
(36:28):
do it slowly. We don't want to do it too fast because that's when you can see maybe
gallbladder disease, the pancreatitis, dehydration. So we want to prevent that. But yes, that's
my thinking. They are there. I do use it, but I use it with caution. I encourage patients
not to get it from anywhere because as you mentioned, you have seen it there in the train
(36:49):
station. I have seen it here everywhere. And I know this is globally. So we need to be
careful. We need to be tight with the medical provider for this medication to be started.
Yeah. I was going to say that it's very interesting how endocrinologists are so careful with these
medications, but it seems like other practitioners or other providers of these medications, they
(37:14):
have no expert training in these medications, don't have the sense of carefulness to prescribe
these. Right? I mean, it's very, very interesting for me to talk with endocrinologists. They're
like, yeah, we're very careful when it goes to these medications. And then outside, when
you walk in the streets and just see it in any billboard.
Maybe because they may or may not, but I think they may not have seen those side effects.
(37:38):
Maybe they go to any kind of clinic, you name it. I don't know. That is by a physician who
is treating it. They just go home, come back in, I don't know when. And all these side
effects, the patient end up in the ER, the patient go to another doctor, and maybe they
don't see the side effects, but we do see it. And that's why, you know, with the experience,
(37:58):
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(42:03):
My alarm is just like, what is going on here?
And I think this leads to the things that we see on media,
like rapid weight loss,
because the providers don't know how to touch
in the medications or things that now they're calling
the ozempic phase, right?
Now we see this mostly in adults,
but I guess especially with you,
(42:23):
the more careful monitoring situation with children,
how are the parents' reception of these medications?
Excellent question. First, I want to bring to the table
that the American Academy of Pediatrics
actually recently published some guidelines saying,
it's okay for pediatric patients, for example,
from 12 years and above who has obesity
(42:47):
to be treated with this medication.
And even they suggested that we could consider
bariatric surgery from patients age of 13 and above
who has severe obesity.
So it's there.
It's not that we're doing it without any advice
or any recommendation.
We are doing it correctly.
However, I would say both, Chris, I have both spectrum.
(43:10):
I may have some parents that are really into it.
They already have it.
Some of them are already on the medication
and they're in the benefit
and they would like the child to try it.
And others are like, okay, we try, for example,
for a long time, the intervention and we offer,
and they're like, no, I'm afraid.
I'd rather stay doing the physical activity
(43:31):
or the changes in lifestyle, which is okay too.
I never push for a medication at all.
And again, I'm so cautious
well to whom I prescribe those medications,
but I do prescribe because I want to prevent
on my patient who has severe obesity
that to develop type two diabetes, hypertension,
liver problem, we know it will lead to that.
(43:53):
And I want to prevent that.
And I know I have the,
I could contribute to for healthy.
But again, it's a process.
A four month before you go there.
That's such a very important point to make is
I love reading comments on Instagram.
And there was a post, I think a month or so ago
by the New York Times where it was talking about Ozempic
(44:16):
and a lot of the comments,
I don't know if you've seen them, they're like,
oh, these doctors love to prescribe these medications
because they can get money from it.
And I think they don't see the side of the story.
Like you're just saying where
that is not our first line of defense.
We care for these patients.
We want to avoid all the comorbidities related to it.
(44:39):
And there's a whole guideline.
I talk to myself, I don't get any money at all.
For this patient is not in my interest at all.
I do it because I'm a medical professional.
So I do it when it's indicated.
But yeah, there is a lot of mis-education.
We need to actually educate the population, the community.
(44:59):
And that's why I talk for myself.
I started to go now on social media
because I want to give proper education to the community.
Otherwise, everyone will go and get the Ozempic
on a spa or things like that.
Yeah, and it's a safety risk, right?
Lives are involved and stuff like that.
Well, I wanted to ask, we talked a lot about how
beyond the children, the parents are also part of the care,
(45:22):
well, a big part of the care when it comes to pediatrics.
I think the main reason why I couldn't go into pediatrics
is I was so scared of the parents.
It's like most of the time, the patients are the parents.
They come in with their preconceived notions,
whether of how they were raised or cultural aspects,
(45:43):
potentially religious aspects, social aspects,
and the expectations they have for their child.
And just the concept, I mean, you're a parent,
so I know you can relate to this.
The concept of what is right and best for my child, right?
But here comes along another person in the story,
which is you, the physician as well,
who based on the guidelines and the recommendations
(46:06):
are giving expert medical advice that may sometimes
be kind of not in the way of how a parent may see
is right or best for their kid.
As the physician, how do you reconcile
that idea of parents are part of the care and have like,
this is what's best for my child versus your expert
(46:28):
recommendations?
I would say, of course, we all do
have both type of situations, right?
Those patterns that will go straight forward.
This is what the doctor is saying.
And even because of cultural belief, right?
This is how it is.
Don't even ask questions.
And I do have other parents who really want to know why
or they have their belief.
I usually start this thing with everyone,
with my patient, their family.
(46:50):
It's like try to listen to their concern,
why they are saying that, why they are doubting
on the management, why they have so many questions about it.
To kind of create some rapport between us
so we can have an open conversation, right?
Chris, in this new model actually
that I brought to the IHC, the direct specialty
care in pediatric immunology, I actually
(47:10):
give patients more time to stay with me.
Instead of the traditional medical system
of seeing patients very quick, I can stay
with my patient for an hour.
So I'm like, listen to them.
They see there's no rush.
Again, no judgment, right?
So I don't judge the family or the patient, right?
Because we have different beliefs.
It means that I'm right and they're wrong.
(47:30):
Not at all.
Sometimes it may be more education.
I may provide them with even evidence-based island
or information.
This is written more, come back to me.
Let's talk about it.
So I try to create that relationship.
But number one is I always respect them, right?
I always love them.
And then I try to answer their questions.
Yeah, both of you are amazing.
(47:53):
And I can't imagine also the stress that comes with,
I mean, people's lives in your hands as a physician
and especially with children, right?
The next generation of people in this world.
How do you decompress out of work and out of, I guess,
the rage in social media as well, especially in your field?
How do you decompress out of work after all of this?
(48:14):
We need to decompress, right, Chris?
You know, because we're so busy, so stressful.
We take care of so many patients' lives, right?
And we do so many decisions.
I do decompress by doing exercise.
I do love to do exercise.
That's something that we should, and I always recommend it,
do it.
For any stress situation, go and run if you like
or do exercise.
I do like to meditate.
(48:35):
I love it.
I feel like it really relaxes me.
And then I spend time with my family.
I do enjoy being with my husband and with my daughter,
going out, laugh, dance, go eat like a very Puerto Rican meal.
So yes, those are the ways that I decompress
and I take care of myself.
Yeah, that's beautiful.
(48:55):
And, Doc, let's say a parent or a guardian
is watching to our video or along the lines,
listening to our podcast episode.
And they're just so nervous and so heartbroken
because their child has obesity.
And they don't know what to do.
And obviously, they're scared for the health of their child.
(49:18):
As a pediatric endocrinologist, what
would be your message for that parent who
is struggling about the struggle?
That you're not alone.
Definitely, you're alone.
And it's not your fault. Like in the video before,
there's different factors that could be causing your child
having obesity.
The first step is to recognize it.
So by that pattern, recognizing that a patient has obesity
(49:41):
is a good step to start.
And then again, be a role model, please, for your child.
This is so important.
They look up to us.
We cannot tell them, don't drink that juice.
That juice is for the brother.
It's for me.
Or you don't do that.
We can't judge the child.
We need to lead by example and get help.
Make sure you go and get and see your pediatrician regularly,
(50:03):
number one, because even if you go for regular checkup,
we can identify the trend of that BMI or percentile
that I spoke.
And we can take some action earlier.
And by some action, again, doesn't
mean that it's medication.
Maybe just seeing you every month instead of every year,
when it may have been too late.
Yeah, and seek support.
Look for support.
(50:23):
You're not alone.
We are here for you.
And we can make it.
But don't let your child have obesity.
We need to stop child obesity.
Doc, that is so beautiful.
I am so grateful for the time and the expertise
that you have shared with me today.
Thank you so, so much.
And it would be such a big honor to hear from you again.
Thank you so much for having me.
It's a pleasure.
I did have so much fun.
(50:45):
I'm going to plan to go to New York soon.
I really want to go.
So I will contact you to see which family.
If you come to Puerto Rico, please let me know.
Because I would like to take you around and give you
some food and music.
Yeah, I would love that.
Dr. Perez-Fuentes, thank you so much.
I hope you have a great rest of the night.
And to you and to everyone who's watching.
(51:05):
Yeah, thank you, Doc.
Bye.
Hi everyone, happy Friday! How has your week been? Well regardless of how it has been,
(00:10):
I hope you all have a sweet day ahead whenever you may be listening to this episode. And
I am placing emphasis on the word sweet because as you can tell from our episode title, we
will be tackling some sugary conversations in today's episode. Speaking of sugary and
sweet, who here has a sweet tooth? I am raising my hand right now, both hands, and I hope
(00:31):
you are too. Honestly, I don't trust anybody who does not have a sweet tooth. I am joking,
but honestly though, I live for sweets and desserts and pastries. Cakes? Yes. Juices?
Yes. Ice cream? Yes. Boba? Hell yes. Mustn't eat dessert after every meal? That's me. In
(00:52):
fact, I don't know if you know, but if I am planning to go out for dinner with friends
and I am 100% sure that there would be no plants for dessert or no dessert places nearby
the restaurant at all, I would decide to just not go out. Is it an addiction? Probably,
but I am owning up to it. Kidding aside, I agree. I need to wash my sugar and general
(01:14):
carb intake, given my family history of diabetes on both sides. I mean, has anybody here watched
the movie Mary Poppins? Do you remember the song, Just a Spoonful of Sugar? This is a
spoon full of sugar makes the medicine go down. The medicine. Truly though, a spoonful
or more of sugar every day will probably require us to take more medication. The unwanted D
(01:38):
word, diabetes, a chronic disease that's always paired with the word sugar and sweet.
According to the American Diabetes Association, approximately 30 million people in the United
States alone in 2021 were diagnosed with diabetes, both types 1 and type 2 combined, with 352,000
of these being under the age of 20. It truly is a rampant epidemic, or even a pandemic.
(02:04):
Diabetes is a byproduct of the body's erroneous handling of the insulin hormone. Hormones
are signaling molecules and chemicals released by different parts and organs of our body
to regulate our physiology and behaviour. Our body strives for balance and harmony of
these hormones, the crux of the field of endocrinology, because the excess or deficiency of any of
these can lead to diseases and conditions, one being obesity, a topic we touch upon greatly
(02:29):
in this episode. During the last season of the podcast, we sat down with board certified
endocrinologist Dr. Rocio Salas-Whalen to talk about all things obesity medicine in adults.
In this episode, I wanted to take it a step further, or should I say, a step back in time
when it comes to children. There is a common misconception that children are just small
(02:51):
adults, but this is farther from the truth. The approach to children's bodies and health
is so complex and different from adults, and we need a rightful expert to guide us through
it. This why I am so honored to have our expert guest for today, Dr. Sheila Perez-Colon, a
New York-trained and Puerto Rico based board-certified pediatric endocrinologist, assistant
(03:11):
professor of medicine and diabetes clinic director. Having moved back to Puerto Rico
to serve her homeland, she currently stands as the owner of Elite Endocrine MD, a direct
specialty care practice, the first one in Puerto Rico at that, that focuses on pediatric
diabetes, obesity management, thyroid disorders and pre-bordered disorders. Endocrinology
(03:31):
is such a complex topic, and Dr. Sheila is here to break it down for us with no spoonful
sugar coating. I hope you enjoyed today's episode. Have a great day.
Hello. How are you? I'm good. Thank you so much for joining me tonight. We're miles
(03:53):
apart. We're miles apart. We're miles apart, but we're in the one space today. We have
so much to talk about, and I was so excited to receive your message. Time's just flying
by. How is the weather? It's like so warm. Have you been here before? Never been. You
should just come and visit. It's very warm and sunny, beautiful beaches. So yes. Yes.
(04:16):
I mean, you were here in New York before too. So I guess you know the expectation of how
the weather is cold and then it's hot and then it's raining all the time. Dr. Sheila,
if you could first please introduce yourself to everybody. Thank you so much. Hi everyone.
My name is Dr. Sheila Perez-Colon. I am a board-certified pediatric endocrinologist.
(04:37):
I did my residency and my fellowship in New York City. I stayed there working for a few
years. Yes. We missed so much. I missed it. It was such a wonderful experience. Then I
went to LA for a year. I did work there as an endocrinologist as well. And because I'm
originally from Puerto Rico, I want to really be close to the island and to the family.
(04:59):
So I moved to Miami in 2019 and I worked there until 2022. So for three years I did work
there. And maybe seven months ago I arrived here in Puerto Rico. I brought a new model
here for medical care, which is specialty care. And I opened my private practice here
and I am so happy to be here. Yeah, that's amazing. I mean, I can't imagine the amount
(05:23):
of wonder and change of the care that you bring to Puerto Rico and Nara, which you will
talk about. Well, I wanted to dive first into the journey that it took to get to where you
are now, which you all know is a very long journey, right? Usually it's four years of
college and then four years of medical school and then however amount years of residency
(05:44):
and fellowship if one chooses to do so, right? So can you take us through that journey from
college to all the way through fellowship? So let's see. I did my high school here in
Puerto Rico. I did my biology degree in Puerto Rico as well in the University of Puerto Rico,
which is an excellent university here in the island. After that I went to medical school.
(06:04):
I went to the Universidad Autónoma de Guadalajara and there it's a five years actually medical
school. It's not four. So for the three years I stayed there in Guadalajara, which was an
excellent experience and I learned so much. But for the last two years you have the opportunity
to go to New York and do the rotations, clinical rotation and be there for two years. So I
(06:25):
did that. I actually went to Maimonides Medical Center for my fourth year of medical school
and for the fifth one, which is called the fifth pathway, I did it in New York Medical
College. That's in Valhalla, New York. After that then I stayed for residency in Maimonides
Medical Center for those three years, as you mentioned, and then I stayed for a specialty
(06:46):
for pediatric endocrinologist. At that time, which was, oh my God, I graduated in 2013
from Philadelphia. So at that time, Chris, it was a combined program. It was between
like SUNY Downstate Medical Center and Maimonides. So I remember going around between hospital,
being on call. We actually go to other hospitals as well, like Lutheran. I was driving with
(07:08):
so many consults, but it was so great and I learned so much. So I'm very grateful for
that.
I mean, honestly, Maimonides is such a good pediatric hospital. I think I did my rotations
in the PICU and NICU at Maimonides. So you can tell that the team really, really loves
their patients and send the kids. But you know, like you said, it's such a long time,
(07:32):
right? I mean, where did this inspiration come from to become a physician? Is it family,
friends or personal experience?
I think, well, I don't have anyone in my family being a doctor, but I'm the first doctor in
the family. In terms of experience, I need to definitely give it to my pediatrician.
My pediatrician many years ago here in Puerto Rico, I do recall as a child going with my
(07:52):
mom to the office and how he was talking to my mom, how he was examining me. So I did
love how he interacted with the family and with the child itself. At that time, Chris,
I remember it was like paper-sharp. We didn't have like electronic medical records. I remember
the doctor going back and forth and looking through the lab. I don't know, that really,
really, I was so happy, you know, what he was doing. So I wanted to do that. Moreover,
(08:16):
I do this kind of person that I want everyone to be kind of happy, like when persons are
in disagreement and I'm always trying to comfort everyone. So I think maybe those two things
really is what inspires me to go to medical school.
What is it about the pediatricians that they're always so nice and so lively? You know, everyone
(08:37):
that I talk to, I think one of the key people in their childhood memories are their pediatricians.
I mean, I wanted the pediatrician a lot as a kid because I had childhood asthma. And
I just remember how kind and just so loving pediatricians are. It's beautiful. But, you
know, amidst all of that, dog, like you said, it's a long road, but that long road is not
(09:00):
just like an easy road, right? There's a lot of sacrifices. I mean, I can't imagine being
a medical student before, right? Like you have to say no to a lot of parties or gatherings
because you have to study a lot of the time involved, the stress and all of that. Given
the length and the stress of the road, now that you are a fully practicing physician,
(09:23):
is there any regrets in the road that you take?
Honestly, I don't have any regrets. And I'm very honest. I went to medical school because
I was really passionate about it. I was determined and this decision was even from high school.
I knew I was going to medical school, so I planned everything. So I have no regrets at
all. However, dog, yes, it was, right? Did I miss a lot of important moments in life?
(09:50):
Yes, I did. Like family birthday, you know, like friend's wedding, like even our kid milestone.
We were all starting. So it's a tough road. But for me, I always knew I wanted to be a
pediatric, actually, and even a pediatric endocrinologist. I went because I already
knew I wanted to do endocrinologist. So it's something that I do love. It's something that
every morning I wake up so happy to go and see my patient. So I guess if you have the
(10:14):
passion, even that tough road, and it is, you can make it and you will be happy.
That's beautiful. And that's so encouraging. And it's so interesting for you to say that
you knew that you wanted to be a pediatrician and a pediatric endocrinologist. I wanted
to ask, how do you know that? Is it from your pediatrician as a child or was it the rotation
(10:35):
in medical school?
Even from high school, right? We go into this and you start to hear about hormones and biology.
So that already intrigued me. Like, I want to know more about that. And in medical school,
I fell in love with that complex endocrinism, as you know. So I fell in love with that.
You know, like we could be on a stable state. So any increase in the hormones or any deficiency
(10:58):
of the hormone could lead to so many conditions or diseases that for me was like, I needed
to. And it's like a puzzle, right? A puzzle is like, if something is done, what should
I do to bring it up and to make the kid and the family, you know, wealth overall. So yeah,
I always knew it. It's so fun, the endocrine system. I love it.
(11:18):
A few months ago for our second season, we had Dr. Rocio Salasuelan-An, who is an obesity
expert, right? Which is obviously an endocrinologist, but we didn't really touch upon endocrinology.
And you know, it's always so hard to find a guest on the podcast to do endocrinology
because I feel like it's such a hidden secret garden in medicine, right? For those who are
(11:42):
listening now, who may not know what endocrinology is, and I know you already give a hint of
it. What is the field of endocrinology? What do you deal with? And what do you think pediatrics
and the chronology make? How is it different from...
So endocrinology is right. As a pediatric endocrinologist, I do treat several, most
of the hormonal condition, actually all of them. So I treat conditions such as like pre-diabetes,
(12:07):
diabetes, type one or type two, thyroid disease, either hypothyroidism or hyperthyroidism,
to irritable condition. Nowadays we see like girls and actually boys are getting into
puberty early. So I do manage that diagnosis and manage that. I do treat patients with
growth concern, for example, those patients who are too short, they may have growth hormone
(12:30):
deficiency. They may not. We do the work and then we'll see if we need to treat or even
too tall. So like I mentioned before, our system is kind of in a balance. Any excess
or deficiency of a hormone could lead to conditions and definitely decrease obesity. This is something
that I love to talk about because most of the time we think like obesity is just like
(12:51):
maybe a physical characteristic, but it's not that. It's so much more. Obesity is a
disease and it's a chronic disease and we need to recognize and acknowledge it. So we're
able to prevent the complications. And for your other question, like what was the different
right between like treating maybe adult patients? So pediatric patients are definitely different
(13:12):
starting from basics. An adult can say what's wrong, how do they feel, pediatric patients
they don't. Maybe they're adolescent or young adult, they do, but in small kids they can't.
So it's like trying to figure out what is going on with them, going by what the family
member is saying, because now it's not the patient, it's the mother, the guardian, the
father, whoever is taking care of the family. I do love pediatric endocrinologists because
(13:36):
children have social imagination and they see everything is like possible, right? There's
nothing impossible for a child, but at the same time when they are sick, they're so vulnerable
like I wanted to be there to help on those moments. So there's a big difference between
adult endocrine and pediatric endocrine. Although many of the conditions by definitions are
(13:57):
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or adult. Hypothyroidism, there's deficiency of the title hormone is the same, but the
management is completely different, the follow-up is more close, so it's different.
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I think especially here in America, I think one of the biggest misconceptions by the general
public is that children are just small adults, right? Which is completely wrong because I
feel like though anatomically it might be the same, it's like the size is different,
the physiology changes as someone grows up, even especially pre-peabody and then post-peabody.
(17:47):
And I must admit that the endocrine system is always the one system during exams and
studying that my brain is always like, there's so much to know. Let's say like the heart,
right? All you have to know is literally how the heart works and how it may, I don't know,
affect other body systems. But when it comes to the endocrine, just like how many different
(18:09):
organs interplay, right? Like you have the hypothalamus, you have the thyroid, parathyroid,
the testes, the ovaries, the adrenals. It's like information overload all the time.
The endocrine system controls the function of the whole body. The pancreas, like the
pituitary, the pituitary actually, and this is how I explain to patients and to family.
It's like the one that is driving, right? Because it sends signals for your development,
(18:33):
as you mentioned. For example, cortisol, make sure your blood pressure is okay, your blood
pressure is okay. So it's such important. And yes, endocrine has a lot to do with your
overall, all the functions of your body. But I do love your field. Cardio is so exciting.
I remember the rotation and I did learn a lot. So I do what you do.
(18:54):
Yeah, it is fun. But I must say the endocrine is on another level, I must say, because I
think besides the physical, right? And the physiological, the endocrine actually taps
in because it is hormonal, like into like the psychosocial, so the emotions, right?
Like if something wrong is with the lungs, it's like, I think the manifestation is when
someone breathes and potentially blood gases. But when there's something wrong with any
(19:19):
of the endocrine organs, right? It's not just something wrong with the body, but people's
emotions get involved, right? And because hormones can influence how someone feels,
especially when it comes to the sexual reproductive organs, right? And I wanted to know, like,
if you walked into your clinic today, what would you think would be the top three reasons
(19:39):
why someone would see a pediatric endocrinologist or specifically in your practice?
Three of them. Number one will be type 1 diabetes, the increase of the increase in type 1 diabetes.
And actually here in Puerto Rico, you know, a lot of diabetes type 1, new onset. So that
is number one. Number two, I will say thyroid hypotension. It's very common in clinic. We
(20:02):
see it almost every day. I see it every day. And then the other one will be, can I say
two on the last one? Because they are like, I will say, we break rules here. Evaluation
for, right? But I can't leave alone like puberty, puberty, precocious puberty. Like I mentioned
before, it's a topic and it's a diagnosis that is now maybe more recognized and more
(20:23):
diagnosed. We saw increase in the diagnosis of precocious puberty during the pandemic.
And there are studies even done to see, is this just the sedentaryism that happened?
That the weight and the increasing weight increased the hormones for us to go into early
puberty or was it something else? So I will say that those diagnoses are the most common,
(20:44):
but now and then you will see a genetic syndrome, like a Turner syndrome, you name it, adrenal
insufficiency. It's so bad. Our clinic has, every patient is different. It's amazing.
I'm in love with it.
I'm actually very curious, given that you studied here in New York and did your rotations
here and work in New York and LA and Florida. What do you think is the difference when it
(21:06):
comes to health and I guess the giving that help to Puerto Rico? How are the patients
different? How is the care different? Because I know there's also like cultural and social
aspects that come into that.
I think every place that I have been is completely different and in a good way has made me experience,
(21:26):
right? Because I have different diagnoses that I may just have seen maybe in New York
or in Miami, but Puerto Rico is where I was born, right? This is like my home. So I just
have dreamed to come back to Puerto Rico because here there's a huge need of doctors. The medical
system is suffering now and has been for so many years. So for me, returning to the island
(21:49):
was I see it as like I'm contributing to the change. So I'm happy. And when I am in clinic
with patients that speak my language from my heart, I feel such a joy and it's the place
that I should be. Even though you give your care and I love all my patients from everywhere
because I do keep in contact with many of them. There's nothing like helping your place, your
(22:12):
home place, the training. I got all the experience. I'm ready. Why not to bring it back to your
island that is meeting and is suffering? So I'm here.
That's beautiful. I love that doc. You know, we were talking about a big problem, which
is obesity, right? I feel like if you look into like news in the United Kingdom or some
(22:34):
news in Asia, there's always a running joke that the United States is the nation of obesity,
right? And I mean, it's not just a stereotype. It actually is true. I mean, the rates of
obesity in the United States is high, maybe relative to other countries in the world,
right? And then we think of the United States, most of the time people think of what extra
(22:55):
large sodas and burgers and fries. I want to know, is that issue of obesity also a prevalent
problem in Puerto Rico? Yes, it is. It's almost the same in the United
States. Like the diet, right? I don't like to say diet. I usually say like the meals
or the food. Yes, those processed food, like high sugary drinks, right? Like we're exposed
(23:21):
to those. Definitely the sedentaryism, like kids are not going out to play anymore. I
remember when I was growing here, like I was out and maybe playing outside with the ball
or riding a bike. You don't see that. I actually moved here a few months ago. I live in a neighborhood
that there's some kids and I don't see them outside playing anymore, right? So it's on
(23:41):
their iPad, on their screen. So there's so many factors that influence on that. However,
a lot of genetic factors. Obesity is a multifactorial condition, right? So there's the environmental
factor, genetic factors, but also, you know, like how our lifestyle, it's very important.
But I do see increasing obesity here in Puerto Rico, in the pediatric population, as well
(24:05):
as in the adult population in the US. I see. Yeah. And so when it comes to obesity,
I think the big question when it comes to obesity is what is obesity? And I think the
general public, the first thought when it comes to obesity is when it comes to someone's
size, right? How the waist measurement is, or what is the number on the scale, or what
(24:27):
someone eats. I think those are the general public definitions of what obesity is. But
I feel like there's a rise, especially with things to physicians like you and endocrinologists
who are trying to break this stigma and this misconstrued perception of the public that
obesity is a fault of the patient or a fault of the person who is obese. I want to know,
(24:52):
as a physician, as an expert in this field, what is your definition of obesity? And for
all of your patients who come to you with a problem of obesity, how do you diagnose
that? Is it based on the number of the scale? Is it based on what they eat? Is it based
on the measurement? For me, the definition of obesity is a chronic disease that can lead
(25:13):
to other comorbidities or other diseases, right? So, it predisposes you to prediabetes,
to diabetes type 2, to inflammation of the liver or fatty liver, could affect your bones,
so it affects everything and could lead to other diseases. How do we diagnose obesity
in pediatric? In pediatric, we go by what we use is the body mass index or the BMI.
(25:37):
What is this? This is just the ratio, right, between the weight of the patient and the
height of the patient. That gives me a number, which is the BMI. And when the patient comes
to the clinic, traditionally, right, we do the vital signs, we do the weight and height,
and we plot them on the growth chart. Depending on the percentile with that BMI stand, then
we will say this patient is overweight, is on a healthy weight, or has obesity. We should
(26:01):
say anymore like patient is obese, we should say patient has obesity. So, in terms of percentile,
any percentiles like is from 85 percentile to 94, this is considered overweight, the
pediatric patient is overweight. And from 95 percentile and above, we consider this
patient has obesity or has overweight if it is from 85 to 94 percentile. And Chris, recently,
(26:27):
the CDC, and I put this on my social media, in Instagram, is like the CDC even makes some
extension to the growth chart, to the BMI growth chart recently, as recent as 2023,
to increase those percentile, to include the 99 percentile. Because nowadays, there's an
epidemic of obesity in children that we couldn't track how this patient were progressing. So,
(26:51):
we need to understand that to that degree, it does affect. So, that's the definition
of obesity. We do it by that number, the BMI. But again, in my education, every day I speak
with my patients and with the family, it's not just a number. And there's a, right, that
we can measure obesity and the waste, all that. But that's the definition that we use
(27:13):
globally in pediatric. I love the point that you make that we change the terms from the
person is obese to the person has obesity, right? And I love that it kind of like takes
away the fault and the blame from the person who has it or is experiencing it, right? And
I want to know, as we know, the obesity has a lot of comorbidities. And we have seen data
(27:36):
on the effects it may have on cardiovascular systems or pulmonary, right? And other parts
of the body and other systems of the body. How much more dangerous is it for a child
to have obesity as opposed to an adult? And I'm not trying to make a competition between
adults and children who has obesity, but is it more alarming if a child has obesity?
(28:01):
Yes. My answer will be yes. And I'll tell you why. Because if a child has obesity and
they start having this chronic condition early, we may tend to see or they have increased
risk of the complications to be seen early. For example, and Chris, I do see it in clinic
very often. I do diagnose patients who are 11, 12, 10 years old with type 2 diabetes,
(28:22):
which this is a condition that usually we use to remember that was only for adults.
And when it's a condition for adults, I do see it mentioned early on. I do see like sleep
apnea secondary to the obesity. So yes, it will make damage. And as you mentioned in
terms of basculature, yes, there's a lot of endothelial changes that happen from early
(28:43):
on. So I will say it's more severe and it's very alarming. I'm really into like educating
the population, the community as much as I can to recognize it as a condition because
chronic condition it is that way. You know, in the society, maybe we will get some help
for education, actually for treatment if we need it. Otherwise, if we don't get like that,
(29:05):
then it will stay like that. And then our kids may not reach, you know, maybe an adult
age.
Yeah, definitely. When it comes to that, and we'll talk about increments a little bit more
in a bit, but for this children who do have obesity and are already, you know, feeling
the effects, the comorbidities of it and we see more elevated blood pressures or it's
(29:28):
not unheard of that kids already have hypertension, right? Or earlier incidences of even heart
attacks and strokes and teens and adolescents, right? Or young adults. What is the key to
solving this problem of obesity as a first line? Even before medications, what would
be your recommendation for someone comes into your clinic and like, doc, my son or my daughter
(29:52):
or my child is having a problem with this. What would be your first recommendation? Is
it already medications? Is it weight loss by, I don't know, by eating?
I love that you asked that because number one is to recognize, right? That the patient
is suffering from this condition. We need to recognize it. Not only the physician who
is seeing the patient, right? In the patient, but also the family members, because like
(30:17):
going back to pediatric, most of the patients in pediatric depends on their family members.
They are their model, right? So I usually start with, you know, like we're going to
work this together. Let's try to figure it out. We need to do like what is called a motivational
history taking for us to pick some board and then we will go forward. The main recommendations
(30:37):
for the treatment of obesity are not medications or surgery. We basic, which is seeing what
we can change in these patients environment. Number one, always decrease like sugary drink,
juices decrease like sodas, for example, in the past. And it happened to me here in Puerto
Rico. I remember my lovely grandmother always telling me like as a child, like drink juice,
(31:00):
drink juice because juice has vitamin C and that may be, but now we're learning. So he's
trying to change those beliefs we have in the past to say, we need to do it in moderation.
So decrease sugary drink, encourage water, right? Encourage the intake of vegetables
and fruits. Most adolescents and more kids, and I have one beautiful daughter and she
(31:22):
don't like vegetables. So I tried to make it interesting, for example, and fun. So I
go to the grocery store with her and I actually did it this way. I'm like, okay, let's go
to the aisle of the vegetable and you choose, choose three of them, whichever you like.
I'm not going to tell you. So they feel like they have some autonomy and yeah, when they
go home, they actually want to try it. So make it fun. Increase physical activity. The
(31:45):
recommendations are to do 16 minutes per day of physical activity during childhood and
adult and make it fun again. Don't make it boring. And they don't need to pay a gym actually
to be doing. Many patients say, you know, for several reasons, I want to go to the gym
or I can't afford it, whichever is the situation across, you know, even in us. And I'm like,
you don't need to go. You can go up and down the stairs in your building. You can go outside.
(32:09):
You can go to the park. Do you like to dance? Put your pots and start dancing and just take
it. But we need to move. We need to make it fun. And number three is sleep pattern. And
this is the one we forget about. It's so important to kind of actually prevent even obesity.
We know that patient who has some compromise in their sleep, they sleep a few hours or
(32:31):
they don't sleep well. There's some changes in hormone, leptin and ghrelin. I'm not going
to go into all the details. But there's that happened. The study has shown the next day
or for the next few days, you will be taking some more calories and more carbohydrates
in your choice, even without you realizing. So he's doing the basic changes first.
I think as a society too, we tend to forget the basics, right? And I think this is why
(32:57):
incretins is such a very interesting topic. And I think it has to do with social media
too that I know incretins have been here for a while, right? It's probably more two decades
where we have data and it's been out and about. But it's just recently that it's so hot on
fire news. And I think social media has a way to play in that. I got all the viral things
(33:20):
going on. I actually took the subway the other day and there are posters of free weight loss
injections all across Times Square. And I'm like, hmm, there is a revolution going on
in our society in the height of social media and ideals and physical ideals online, right?
(33:40):
I think the words have been buzzing all around the news, right? Things like Ozempic and Rigovi
and Manjaro and Zosenda. Doc, what are incretins? And first of all, why do you think it's so
controversial? Like how do they work? What are the intentions for them? What are not
the intentions for these medications?
So, as you mentioned, incretins has been out for a while. Maybe around like 2000, it was
(34:06):
already out. So they are not new. However, their effect is very positive. It has a good
effect. So how do they work? So they suppress your appetite, right? So it increases your
society. It also like decrease the gastric empty. So when you eat, it takes longer for
your digestion. So then you get full faster. And it has many other benefits to the heart
(34:31):
and even to the brain. So those are good medicines and we see very good results. However, for
the last around two years or so, right, it has been on the media. Like you mentioned,
everything that is on the media, everyone wants to try it. When we are exposed to the
same and we listen to it every day, you want to know what is it and you want to try it.
And because they are so good on the effect, because they do help in weight loss. So everyone's
(34:56):
one set. But I do think at first there was a questionable shortage, right, of the patient
everyone was using. But as of now, we do have enough supply, but we need to use it carefully
a pediatric endocrinologist, which I see patients from birth up to 21 years of age.
Do I prescribe it? Yes, I do. Do I have patients on those medications? Yes. But I go by certain
(35:20):
criteria. I don't give it to anyone. You know, they may come to my clinic because they want
to have some weight loss or they don't like how they look. I don't prescribe it like that.
I start with basic. We're going to send you to a registered dietitian. We're going to
do it for a month. We're going to come here to my clinic every month because I'm going
to be monitoring. And at that time you get the history, what they have done. So there's
(35:42):
some step. I don't jump into the medication. For example, Olsenpik and Wegobi, those are
the maglutide, which is DLP1 receptor analog, which is an infratin, right? And Olsenpik
is the one that is injected once a week versus Wegobi, which also is injected once a week,
but it was approved by the FDA, Wegobi for obesity. And Olsenpik was kind of for diabetes
(36:06):
type two. The spenda or liraglutide is the one that was given or is given daily injection.
But yeah, they are very successful. They do have side effects. I usually, when I started,
I go over the side effect, the possibilities. I'm like, listen, you can see some weight
loss and what we aim for is approximately like to lose two pounds per week. We will
(36:28):
do it slowly. We don't want to do it too fast because that's when you can see maybe
gallbladder disease, the pancreatitis, dehydration. So we want to prevent that. But yes, that's
my thinking. They are there. I do use it, but I use it with caution. I encourage patients
not to get it from anywhere because as you mentioned, you have seen it there in the train
(36:49):
station. I have seen it here everywhere. And I know this is globally. So we need to be
careful. We need to be tight with the medical provider for this medication to be started.
Yeah. I was going to say that it's very interesting how endocrinologists are so careful with these
medications, but it seems like other practitioners or other providers of these medications, they
(37:14):
have no expert training in these medications, don't have the sense of carefulness to prescribe
these. Right? I mean, it's very, very interesting for me to talk with endocrinologists. They're
like, yeah, we're very careful when it goes to these medications. And then outside, when
you walk in the streets and just see it in any billboard.
Maybe because they may or may not, but I think they may not have seen those side effects.
(37:38):
Maybe they go to any kind of clinic, you name it. I don't know. That is by a physician who
is treating it. They just go home, come back in, I don't know when. And all these side
effects, the patient end up in the ER, the patient go to another doctor, and maybe they
don't see the side effects, but we do see it. And that's why, you know, with the experience,
(37:58):
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(42:03):
My alarm is just like, what is going on here?
And I think this leads to the things that we see on media,
like rapid weight loss,
because the providers don't know how to touch
in the medications or things that now they're calling
the ozempic phase, right?
Now we see this mostly in adults,
but I guess especially with you,
(42:23):
the more careful monitoring situation with children,
how are the parents' reception of these medications?
Excellent question. First, I want to bring to the table
that the American Academy of Pediatrics
actually recently published some guidelines saying,
it's okay for pediatric patients, for example,
from 12 years and above who has obesity
(42:47):
to be treated with this medication.
And even they suggested that we could consider
bariatric surgery from patients age of 13 and above
who has severe obesity.
So it's there.
It's not that we're doing it without any advice
or any recommendation.
We are doing it correctly.
However, I would say both, Chris, I have both spectrum.
(43:10):
I may have some parents that are really into it.
They already have it.
Some of them are already on the medication
and they're in the benefit
and they would like the child to try it.
And others are like, okay, we try, for example,
for a long time, the intervention and we offer,
and they're like, no, I'm afraid.
I'd rather stay doing the physical activity
(43:31):
or the changes in lifestyle, which is okay too.
I never push for a medication at all.
And again, I'm so cautious
well to whom I prescribe those medications,
but I do prescribe because I want to prevent
on my patient who has severe obesity
that to develop type two diabetes, hypertension,
liver problem, we know it will lead to that.
(43:53):
And I want to prevent that.
And I know I have the,
I could contribute to for healthy.
But again, it's a process.
A four month before you go there.
That's such a very important point to make is
I love reading comments on Instagram.
And there was a post, I think a month or so ago
by the New York Times where it was talking about Ozempic
(44:16):
and a lot of the comments,
I don't know if you've seen them, they're like,
oh, these doctors love to prescribe these medications
because they can get money from it.
And I think they don't see the side of the story.
Like you're just saying where
that is not our first line of defense.
We care for these patients.
We want to avoid all the comorbidities related to it.
(44:39):
And there's a whole guideline.
I talk to myself, I don't get any money at all.
For this patient is not in my interest at all.
I do it because I'm a medical professional.
So I do it when it's indicated.
But yeah, there is a lot of mis-education.
We need to actually educate the population, the community.
(44:59):
And that's why I talk for myself.
I started to go now on social media
because I want to give proper education to the community.
Otherwise, everyone will go and get the Ozempic
on a spa or things like that.
Yeah, and it's a safety risk, right?
Lives are involved and stuff like that.
Well, I wanted to ask, we talked a lot about how
beyond the children, the parents are also part of the care,
(45:22):
well, a big part of the care when it comes to pediatrics.
I think the main reason why I couldn't go into pediatrics
is I was so scared of the parents.
It's like most of the time, the patients are the parents.
They come in with their preconceived notions,
whether of how they were raised or cultural aspects,
(45:43):
potentially religious aspects, social aspects,
and the expectations they have for their child.
And just the concept, I mean, you're a parent,
so I know you can relate to this.
The concept of what is right and best for my child, right?
But here comes along another person in the story,
which is you, the physician as well,
who based on the guidelines and the recommendations
(46:06):
are giving expert medical advice that may sometimes
be kind of not in the way of how a parent may see
is right or best for their kid.
As the physician, how do you reconcile
that idea of parents are part of the care and have like,
this is what's best for my child versus your expert
(46:28):
recommendations?
I would say, of course, we all do
have both type of situations, right?
Those patterns that will go straight forward.
This is what the doctor is saying.
And even because of cultural belief, right?
This is how it is.
Don't even ask questions.
And I do have other parents who really want to know why
or they have their belief.
I usually start this thing with everyone,
with my patient, their family.
(46:50):
It's like try to listen to their concern,
why they are saying that, why they are doubting
on the management, why they have so many questions about it.
To kind of create some rapport between us
so we can have an open conversation, right?
Chris, in this new model actually
that I brought to the IHC, the direct specialty
care in pediatric immunology, I actually
(47:10):
give patients more time to stay with me.
Instead of the traditional medical system
of seeing patients very quick, I can stay
with my patient for an hour.
So I'm like, listen to them.
They see there's no rush.
Again, no judgment, right?
So I don't judge the family or the patient, right?
Because we have different beliefs.
It means that I'm right and they're wrong.
(47:30):
Not at all.
Sometimes it may be more education.
I may provide them with even evidence-based island
or information.
This is written more, come back to me.
Let's talk about it.
So I try to create that relationship.
But number one is I always respect them, right?
I always love them.
And then I try to answer their questions.
Yeah, both of you are amazing.
(47:53):
And I can't imagine also the stress that comes with,
I mean, people's lives in your hands as a physician
and especially with children, right?
The next generation of people in this world.
How do you decompress out of work and out of, I guess,
the rage in social media as well, especially in your field?
How do you decompress out of work after all of this?
(48:14):
We need to decompress, right, Chris?
You know, because we're so busy, so stressful.
We take care of so many patients' lives, right?
And we do so many decisions.
I do decompress by doing exercise.
I do love to do exercise.
That's something that we should, and I always recommend it,
do it.
For any stress situation, go and run if you like
or do exercise.
I do like to meditate.
(48:35):
I love it.
I feel like it really relaxes me.
And then I spend time with my family.
I do enjoy being with my husband and with my daughter,
going out, laugh, dance, go eat like a very Puerto Rican meal.
So yes, those are the ways that I decompress
and I take care of myself.
Yeah, that's beautiful.
(48:55):
And, Doc, let's say a parent or a guardian
is watching to our video or along the lines,
listening to our podcast episode.
And they're just so nervous and so heartbroken
because their child has obesity.
And they don't know what to do.
And obviously, they're scared for the health of their child.
(49:18):
As a pediatric endocrinologist, what
would be your message for that parent who
is struggling about the struggle?
That you're not alone.
Definitely, you're alone.
And it's not your fault. Like in the video before,
there's different factors that could be causing your child
having obesity.
The first step is to recognize it.
So by that pattern, recognizing that a patient has obesity
(49:41):
is a good step to start.
And then again, be a role model, please, for your child.
This is so important.
They look up to us.
We cannot tell them, don't drink that juice.
That juice is for the brother.
It's for me.
Or you don't do that.
We can't judge the child.
We need to lead by example and get help.
Make sure you go and get and see your pediatrician regularly,
(50:03):
number one, because even if you go for regular checkup,
we can identify the trend of that BMI or percentile
that I spoke.
And we can take some action earlier.
And by some action, again, doesn't
mean that it's medication.
Maybe just seeing you every month instead of every year,
when it may have been too late.
Yeah, and seek support.
Look for support.
(50:23):
You're not alone.
We are here for you.
And we can make it.
But don't let your child have obesity.
We need to stop child obesity.
Doc, that is so beautiful.
I am so grateful for the time and the expertise
that you have shared with me today.
Thank you so, so much.
And it would be such a big honor to hear from you again.
Thank you so much for having me.
It's a pleasure.
I did have so much fun.
(50:45):
I'm going to plan to go to New York soon.
I really want to go.
So I will contact you to see which family.
If you come to Puerto Rico, please let me know.
Because I would like to take you around and give you
some food and music.
Yeah, I would love that.
Dr. Perez-Fuentes, thank you so much.
I hope you have a great rest of the night.
And to you and to everyone who's watching.
(51:05):
Yeah, thank you, Doc.
Bye.
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