In this conversation, Dr. Alaina Vidmar and Dr. Kamran Samakar discuss the complexities of pediatric obesity, emphasizing that it is a chronic disease influenced by genetics, biology, and environment. They highlight the importance of understanding the stigma surrounding obesity and the need for comprehensive treatment approaches that include medication, surgery, and lifestyle changes. The conversation also addresses the rising rates of childhood obesity, the challenges of weight loss, and the criteria for seeking help. They advocate for a patient-centered approach that meets families where they are and provides education on nutrition and health. This conversation explores the complexities of pediatric obesity treatment, highlighting the efficacy of GLP-1 medications, and the role of bariatric surgery. Transformative stories from patients illustrate the profound impact of these interventions on children's lives.
For more information please refer to.
https://www.chla.org/blog/experts/care-innovation/qa-when-bariatric-surgery-right-youth-obesity
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Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.
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Episode Transcript
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Unknown (00:00):
Welcome back to your child is normal, the podcast
where we have honestconversations about kids' health
and their well being. Now ifyou're a parent struggling to
help your child with severeobesity, you are not alone.
Millions of children in the USface the same challenge. Now the
truth is, traditional advicelike just eat less and move more
often isn't enough. So what arethe other options? Well, today,
we're joined by Dr Elena Vidmar,a pediatric endocrinologist
(00:23):
specializing in childhoodobesity, and Dr Cameron samakar,
a bariatric surgeon, andtogether, they co direct the
obesity medicine program atChildren's Hospital of Los
Angeles. In this episode,they'll break down why obesity
is a complex medical condition,how medications like GLP ones
and bariatric surgery can belife changing, and what families
need to know when seeking help.
If you've ever felt at a lossfor what to do next, this
(00:44):
episode is for you, and asalways, I am so grateful that
you take the time to listen tothis podcast, and if you are
enjoying your child as normal,please take a moment to leave a
five star review wherever it is.
You listen to podcasts, all ofthese reviews really help other
people find the podcast, whichhelps the podcast grow. Thank
you so much. Now on to theepisode,
Dr Vidmar and Dr samakar, thankyou so much for taking the time
(01:06):
to be here today. I'm soappreciative of your time.
Absolutely thanks for having us.
So I would love to first telleverybody, what do you guys do?
What are your credentials, andwhere do you work? Should we
start with Dr Vidmar, yes. SoI'm Elena Vidmar. I am a
pediatric endocrinologist andobesity medicine specialist, and
I work at Children's HospitalLos Angeles, and I have the
(01:27):
pleasure of running our obesitymedicine program there. And Dr
samakar, tell us about yourself.
What do you do for work? Sure,thanks for having us on today
for your podcast. I think it's agreat opportunity for us to
share about our program. My nameis Cameron samakar. I was an
adult bariatric surgeon general,surgeon trained, and then I met
(01:49):
Dr Vidmar, and her passion forpediatric obesity really sparked
an interest in expanding thebariatric service line to CHLA
and starting a program with her.
So I co direct the program,along with Dr Vidmar, and we're
super excited and passionateabout the work we're doing. So I
think it's well known what anepidemic childhood obesity is,
and I think it's really helpfulfor families to know that a
(02:12):
program like what you offerexists. And so I'm really
excited to just let people knowwhat is out there what options
they have? Because I think thisis, unfortunately, a problem
that many people are now facingwith, and they're at a loss for
where to go and what to do andwhere to get help. So first, can
you tell everybody what kind ofpatients do you typically see at
CHLA for obesity management? Imean, I think we can back up a
(02:37):
little bit just to start thisconversation, if that's okay,
and just acknowledge thatchildren living in larger bodies
or living with obesity, which isthe medical diagnosis, that's
not the fault of the patient ortheir parent, and that the work
we do is not about the number onthe scale or the size of one's
body, but it's about helpingthese kids live long, healthy
(02:59):
lives, because we know that kidsliving in larger bodies have a
high increased risk of life,limiting complications like type
two diabetes, high bloodpressure, high cholesterol, and
that's why Doctor Sam McCart andI do the work that we do,
because we're trying to helpthese kids to thrive into their
adulthood. It's true. It'stricky, because while there is,
(03:20):
unfortunately, a stigma forbeing more overweight, for
suffering from obesity, and weknow that it's really hard to
lose weight, it's really, reallya challenge. So I think that's a
nice balance that you guysstrike, where you acknowledge
that it's not their fault, thatit is a difficult place to be
in, and at the same timeoffering help and solutions for
them and their families. Yes,that is definitely our goal, and
(03:43):
that's why we have designed ourprogram. And back to your first
question, so we know that wecan't do this, this program
alone, and so we try to partnerwith our pediatric colleagues
across this region and reallytry to align with the American
Academy of Pediatrics clinicalpractice guidelines that came
out in January of 2023 that kindof give us a framework for how
(04:05):
we think about this care when wetake care of a patient with a
complex chronic disease, which,as you know, is not new to
pediatrics, and so we really cantriage based off of the severity
of disease and offer treatmentthat matches that severity. So
that's how we kind of thinkabout how patients get referred
and triaged into our program isreally based off the severity of
(04:27):
their presentation. I'm curious,from your perspective, as
someone who's worked withchildren in larger bodies for
many years, why do you thinkthis increase in this trend in
obesity is occurring? Becausewhen you look at the numbers
from 3040, years ago, the ratesof obesity were much lower. And
I know it's multifactorial, butmaybe can you touch on the main
(04:47):
points as to why you think thisis happening absolutely so
there's many factors, there'sgenetics and there's biology and
there's the environment, but wehave to.
To step back to the fact thatthis is no one's fault. This is
not about self discipline orself will. This is about
biology, but we also know thatour genes change over time,
(05:11):
right? So we have epigeneticchanges that are forming in
these young people as they areborn that are impacting how both
their brain controls whenthey're hungry and when they're
full, I like to think of it likea light switch. And it's like
their light switch has syrup init, so it's not working the way
that it should. This is in thearcuate nucleus, part of the
hypothalamus, as well as intheir periphery, the way that
(05:34):
their cells use the food thatthey consume. So when we take in
our food, we want it to be usedas energy. But when you're
living with obesity, you take inyour food and you immediately
store it as adipose tissue. Andthose two things are happening
over time. And I think what wehave to acknowledge as a
scientific community and ageneral society is that you
(05:57):
cannot prevent something that'salready happened, which is why
we have to treat and care forthe children living in front of
us with obesity. So we know thatthe most recent data suggests
that one in three to five youngpeople is living with obesity,
and if these rates continue by2050, up to 60% of children will
(06:19):
be living with obesity. So wehave to treat this condition in
front of us with the ultimategoal that hopefully we can get
to a place where we reset thesegenes, and we actually get to
generations where theseprevalence rates go back down,
but we can't prevent somethingthat's already happened. So
that's the goal of what we'retrying to do here with our
(06:39):
program. Now, when children areplaced on diets, or they're on
restrictive calorie diets, theydo lose weight, but the trouble
with that is they often regainthe weight Correct, correct? So
I think again, what we have toacknowledge is that you can use
food as medicine, right? So justlike we use any tool in our tool
kit, there are ways we can helpgive the body what it needs. And
(07:03):
if your body is not able to usecalories efficiently, you can
give less calories to use thatbut alternatively, and we are in
a current season where we haveother tools, like medication and
bariatric surgery, we canunderstand how we actually give
the body back the machinery thatit needs in order to function
more efficiently and preventthose complications over time.
(07:27):
And so historically, our toolkit has been very limited. So we
have been working mainly withfood as medicine, which for this
particular chronic disease isnot very effective, which
unfortunately is why we haven'thad great tools, so our tool kit
has expanded significantly,which has led us to a place
where we can actually treat thisdisease more effectively and
(07:50):
lead to outcomes that hopefullycan get us to a place where we
can prevent some of these lifelimiting complications, which is
part of the mission of whatDoctor samakar and I are trying
to accomplish. What I wasalluding to is a lot of people
think, as to your point about itbeing too difficult to expect
with willpower alone, is that, Ithink a lot of people know,
(08:11):
okay, if we if we watch ourdiet, we can lose weight. But
the tricky thing is, the bodyhas its own barometer, right?
It's like a thermometer and athermostat in our body, that if
we do lose weight, it's workingagainst us to keep the weight
off for a sustained period oftime. Correct?
You know that what you'rereferring to, Jessica, you know
what bariatric surgeons havelong time called, you know, the
(08:33):
barostat. And there's goodscience to support the fact that
adipose tissue has memory in theadipose tissue of patients with
obesity who lose weight isdifferent in where its set point
is and what it's trying toreturn to the patients who have
never had obesity. So that iswhy, in just zooming out to the
(08:58):
larger context of what we'retalking about, what is the
approach for obesity as achronic disease? So we have
medications, we have surgery,but the framework for that is
intensive, lifestyle, behavioraltherapy. That's the first step
of any kind of approach. Thereality of that, though, is in
severe obesity, the failure rateis 95 plus percent, and this has
(09:22):
been shown time and time again.
So as a medical community, wereally need to move away from
not acknowledging this as achronic disease, prescribing
intensive lifestyle andbehavioral therapy, thinking
that it may work, it doesn'twork. I mean, that's the bottom
line. And severe obesity. It's afailed treatment modality that's
been demonstrated in multipletrials. So with that said, we
(09:45):
like to refer to it as recurrentweight gain, because what you do
when you intervene on obesity,and you not just help the number
on the scale, but you actuallychange the trajectory of the
meta.
Metabolic diseases is you changethe quality of life and the
patient's health perspectivelong term. And so while there is
(10:07):
recurrent weight gain, typicallywhat we see in our patient
population is there is recurrentweight gain over time in both
adolescents and adults. If youlook at all longitudinal
studies, and there's Swedishstudies that go out over 25
years, the weight differencewith the recurrent weight gain
(10:28):
group after bariatric surgery orinterventions is much lower than
the natural history of a patientwith obesity that has no
intervention. And so we aredealing with the chronic
disease. Recurrent weight gainis an issue that we constantly
are vigilant for, and we need tocontinue to treat over the
lifetime of the patient. And I'mand I'm curious, what kind of
(10:50):
patients do you want to come seeyou in your practice? I mean,
obviously a lot of people arefive pounds 10 pounds
overweight. What meets thecriteria where they should come
visit you at Children'sHospital. So we have kind of two
different, you know, criteriaset. So at our program, we
accept patients with class twoobesity, which we define either
(11:10):
based on the BMI or the BMI inexcess of the 95th percentile,
which is a CDC metric that helpsus understand sort of weight
above the 100th percentile,because that's kind of where our
growth charts cap out, or classthree obesity. So again, these
are set by various entitiesspecifically for us, in
pediatrics, the American Academyof Pediatrics, both for which
(11:33):
medication would be appropriateand bariatric surgery. Now, one
of the things we are trying todo in our community is support
general pediatricians and otherhealthcare clinicians for what
to do with young folks living inlarger bodies who don't meet
those criteria. So we've createdsomething we call reach kids,
which is our kind of reverseconsole model, where we take our
(11:55):
educational curriculum andintegrate it into primary care,
so that pediatricians haveresources for those patients
like you're talking about, whodon't maybe meet that criteria
for escalating care into ourprogram, but need some support
in the interim. So I think it'simportant to know where you
practice, what you can usedepending on what risk level the
patient has, just like we wouldwith any other chronic disease
(12:18):
model. That's helpful to knowabout. And can you tell people
again where they can find thatinformation? Yes, so it's on the
CHLA website, and then I'm happyto provide our contact
information as well if you wantto directly reach out to us. We
have a tool kit. We have aprescribing guideline for
obesity medication. We havetriaging for getting blood
(12:38):
testing for obesity relatedconditions, referral criteria
for surgery and other usefulresources for folks that are
doing this within their clinicalpractice. And do you stress diet
and exercise as well? So that'swithin our toolkit, sort of the
support around it again, I wouldsay within our program, we
really emphasize thecomprehensive treatment
approach. So there's really beena movement away from the staged
(13:01):
approach, which is the idea thatyou need to do one thing at a
time and then fail it,acknowledging that we really
know and have confirmedscientifically the efficacy of
each of these approaches. Sothere's no reason for a patient
with severe obesity to trysomething that we actually
already know is going to fail.
So instead, we actually want totake the menu of options
approach and do everything weknow is going to be effective at
(13:23):
once, so that we make sure thatwe optimize our treatment
approach, a multi modalityapproach
that said we have our dedicateddietitian that works with our
program. You know, surgery is atool, medications are a tool,
behavioral change, dietarychange, family support and
(13:43):
exercise are all good. Thereality is that the number on
the scale is largely determinedby what you eat. Exercise is not
going to move that needle. Youcan't outrun a bad diet. And so
exercise is good for so manythings, especially in the
pediatric population, you know,bone density, muscle mass, brain
health, heart health, but what'sgoing to change the number on
(14:07):
the scale is food, and we diveinto that, and a lot of that is
just education. We have toprovide that education and make
sure that our patientsunderstand, how many grams of
protein do we want? How many,how much hydration do we want?
What are the the calorie densenutrition poor foods that they
may be consuming, because theecosystem here that's
(14:27):
contributing to obesity in ourday and age is because there are
a lot of edible non foodproducts that are called food,
but they're actually just edibleproducts that are not actually
food, so we try to limit it asmuch as possible, but we're just
humans, and unfortunately orfortunately, you know, I don't
(14:51):
have the genetic makeup whereit's going to be seriously
consequential for me, but somepeople do, and so we need to
treat those Okay.
Cases and we need to give themoptions. I mean, that's really
well said, because I feel likethere's a there's a trickiness
to the conversation. Because,you know, while we say it's not
the children's fault, we do alsoknow that eating certain calorie
(15:12):
dense foods, certain sweetfoods, they work against us in
terms of gaining weight withease. But it's very challenging
because, as you said, it'severywhere in our environment,
and some kids can eat it andstop after a little bit of
consumption, and some people,they can't stop. I mean, I think
it's super important that these,these lines of attack, run in
(15:36):
parallel, right? So theprevention, the well, the
prevention is too late right atthis point, we need to do a u
turn in how we're living. Youknow, I mean, just to give you
an example, when I do surveys atconferences of how many you
know, people used to walk toschool, probably about 50 to 70%
of hands go up. And when I ask,how many of your kids walk to
(15:59):
school now,it's less than 10% pretty much
across the board, so we justlive differently than we did
just 2030, years ago. And ourfood is different. These things
need to run in parallel, becausewe still need to treat the
individuals that are sufferingwith this disease. And to your
point about how you can't outexercise the food that you
(16:21):
consume. I think this is sotrue. Because I think about, if
I were to have the mostchallenging workout of my life,
if I were to run for an hourstraight, I would probably burn
500 600 calories. But if I wentto McDonald's and I got a Big
Mac, large fries and a soda, Idon't know what is that over
1000 calories? Easy peasy,absolutely. So it's really, it's
(16:42):
really, really hard to burnenough calories from exercise to
make up for a calorie densediet, absolutely. And then if
you have the genetics where youonly burn 20% of that, then
there's no way that the math isever going to equal right, which
is why the narrative that livingin a larger body is just because
(17:02):
your calories in don't equalyour calories out,
unfortunately, no longerapplies. Yes, absolutely. I
think everybody listening knowsthat relative that can make less
healthy choices, and they neverseem to gain weight. And then
other people in the same familyor the same friend group can eat
the same foods, and they itseems to never get off their
bodies. So I think that'sdefinitely true that genetics
(17:24):
works against a large amount ofpeople, which they say that's
evolutionarily that wasprotective back in the day,
right? To have to have calorieswhen you never knew they were
going to be around to storethem, yes, and just now, we have
so many food options that it'snot working in our favor. So
tell me. Okay. So let's saysomeone's listening and they're
thinking about their own child,and they're considering your
(17:45):
program, what would theexperience look like for them?
Tell us about what would beoffered to them and the initial
treatment strategies.
Absolutely, we really start byacknowledging that this is a
chronic disease, byacknowledging that this is not
the patient or the parent'sfault, and by really outlining
what it means to docomprehensive obesity care. Now
(18:08):
at our program, again, we reallydon't take the staged approach.
So we're going to lay out ourtoolkit. We're going to talk
about food as medicine. We'regoing to talk about nutrition,
we're going to acknowledge theimportance of exercise. We're
going to talk about obesitypharmacotherapy and bariatric
surgery on that first visit, ifyour kid qualifies. So we're
going to really open up the toolkit, which we've really learned
(18:29):
over time from our patients.
We really want to take thatmulti modal approach. And so
again, we're going to open upthose opportunities for based on
your your child, what theirclass of obesity is, their
obesity related conditions, whatkind of treatment they you know,
would be best and mostappropriate for them. We have
dietitians, we havepsychologists, we have obesity
(18:50):
medicine specialists, and thenwe have our bariatric surgery
pathway. And a lot of ourpatients have curiosity, and we
really just want to provide anopportunity for education.
There's so many myths andmisunderstandings about this
work, from start to finish, fromit being a chronic disease to
just even what is an obesitymedication to what is bariatric
(19:11):
surgery? What are we doing? Howdoes it relate to the story I
know about my aunt who had it 20years ago. So a lot of what we
do is education and theopportunity for patients to just
spend time with our team andlearn more about what's
appropriate for their kid. Andso that's really kind of how it
starts, and that kind of walksthem into their kind of ultimate
treatment experience. So I firstwant to ask you about medication
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options, and then I want to askyou about the surgical options
when it comes to medications.
How old are children when theycan initiate these medications,
and what are the types ofmedications in your tool kit? I
know GLP ones have gotten a lotof attention recently. Aside
from GLP ones, are there othermedications that you recommend
as well and offer to families?
(19:55):
We really take an individualizedapproach at CHLA, which is
partly due.
To a couple different reasons.
One is that while there are FDAage minimums, a lot of the work
we do in the obesity space isoff label, because we just don't
always have regulatedmedications. It's fairly new
that we've had this. So we don'treally have age minimums. We're
thinking about the kid in frontof us, their class and severity
(20:16):
of obesity and the comorbiditiesand conditions that they have.
We really think again about thistoolkit, right? So we have
injectable options, which is ourGOP ones. Those are things like
ozempic and wegovy and Manjaro,right? We have oral options,
which are things like Topiramateand phentermine. And we're
really going to lay out all ofthose options for the patient in
(20:38):
front of us. We're going to talkabout just some practical,
pragmatic things, accesslogistics. Can we get it through
your insurance? Can is thereaccess to the pharmacy? Can your
kid tolerate an injection ornot? Can they swallow a pill?
Right? We're still kind of inthe access phase. We're going to
talk about side effect profiles.
We're going to talk about whatother medications they're on,
(21:00):
what can they tolerate? And thenwe're going to just talk about
what the family can tolerate,right? If you have a family
member that's on ozempic anddoing great, you might be more
open to it versus, you know,you're not interested in that at
the moment. So a lot of it isreally just a patient centered
approach. What are those goalsthat you have? How does this
align with the treatment thatyou need? And how can we best
(21:21):
get that tool to you? And whatdoes that look like? I love
that. It sounds like meeting thefamily where they're at, meeting
the patient where they're at. Ithink is a great approach. I
know for the GLP ones, they'reapproved now down to 12. So
that's so interesting that youare able to think about the
child on the whole not lookingat those age requirements. The
(21:42):
other thing I would mention foryour listeners, because they may
not notice, you know, but, butit needs to be said, Dr bitmar
really is a world expert inthis, right? She, she, she's
doing cutting edge therapy.
We are so fortunate to have herat CHLA, because the
(22:03):
things that she's doing and theapproach that she's bringing is
truly cutting edge and unique.
It makes me feel extra lucky tohave you on here today. It's my
pleasure. And then I guess I'mcurious, have you found good
success with the GLP ones I knowwith adults, they are
flourishing. Have you found thatto be helpful with childhood
obesity? Yes, I think overall,having a growing tool kit is
(22:24):
very helpful. I think the GOPones and the GLP 1g Ip, which is
trizepatide, are very effective.
They're certainly the mosteffective tool for the most
young people. Again, I think weknow every person is different,
right? So you might take it andit might be very effective.
Others might take it and it'snot effective. But I also think
they've been a reallyinteresting proof of concept
(22:45):
about obesity as a chronicdisease, which is when you give
the tools back to these people,and their biology has the cells
that they need, has themachinery that they need, they
can effectively use theircalories, their appetite and
satiety can be regulated. And Ithink that that's really
important again, we have toacknowledge that they're going
to be effective to a certainlevel, which is why we cannot
(23:07):
forget that surgery, which isone of the most underused tools
that we currently have, stillremains the most effective and
the most durable treatment forsevere obesity. And I think one
of the things that I have reallycome to appreciate in the last
two years, since we stood up ourpediatric program at CHLA, is
just the importance of using thetools that are going to match
(23:29):
the severity of the disease infront of us. And I actually
think in pediatrics, we do thatso well for every other chronic
disease when we think aboutasthma, type one diabetes, but
for some reason there's been alag with pediatric obesity, so
I've been really trying to thinkabout how I was trained and how
to make sure that I translatethat. Because obesity is exactly
(23:49):
the same, you can anticipate theefficacy based on what you know,
and that's what you're going tosee. So the medications are the
same, they have a certain capthat you're going to see, and if
surgery is required, that iswhat's going to be required to
get that efficacy. So I'd loveto hear more about this, because
I think when people hear surgeryand a child, it might sound
daunting or too extreme, but Ihear what you're saying, that
(24:11):
it's a very effective tool. Sotell us a little bit about the
decision making process aboutwhat child would qualify. So
just take one step, quick stepback. You know, we identified
that there's a gap, and but whyis that? Well, because these
conversations can beuncomfortable sometimes, and so
(24:31):
oftentimes, I think what whatends up happening is the
difficult conversation isn'thad. And
when you survey patients who'vehad bariatric surgery, the vast
majority will will tell you thatif someone had talked to me
about this earlier, I would havedone this so much sooner. And so
(24:51):
we really need to have theseconversations. And I encourage
anyone who's interested in justyou know, there's various,
various resource.
And they can contact me, and Ican put them in touch. So who
qualifies? Essentially, we cango by PMI or percent percentile
growth charts, 120%of 95th percentile for age with
with a obesity associatedmedical problems such as
(25:16):
diabetes, hypertension,hyperlipidemia, obstructive
sleep apnea, the list goes onand on. Or 140%
of 95th percentilein rough BMI numbers, that's BMI
of 35 and above with thecomorbidity, or BMI 40 and
above. To answer the other partof your question, what is
(25:36):
bariatric surgery? So bariatricsurgery are surgeries designed
to treat obesity and metabolicdisease associated with obesity.
The most common procedure we'redoing at CHLA is the sleeve
gastrectomy. The sleevegastrectomy is the most common
adult procedure being performedat the United States as well.
(25:58):
It's removal of about 75% of thenative stomach. The stomach
anatomy essentially stays thesame. The size of the stomach is
decreased over time the patientscan resume a regular diet.
Obviously, we reinforce the thethe hallmarks of a nutritious
high protein, lower carb, morecomplex carbs, reduced sugar,
(26:25):
diet, but essentially they canresume that, and we see about
25% total weight loss as aresult of the sleeve I should
add here safety. What is thesafety? So
to put it in perspective, themost common abdominal operations
in the United States,appendectomy, cholecystectomy,
(26:45):
gallbladder removal,these all have a higher risk
profile and mortality rate thanbariatric surgery done at a
credit Center. In the UnitedStates, the risk of death from
bariatric surgery is less thanone in 1000 patients, and this
is all comers. So this ispatients in the pediatric
population to 70 plus years ofage. But to put it in
(27:06):
perspective, are mortality rateslower than the most common no
one talks about mortality rateswhen we're talking about
appendectomy, right? Buteveryone talks about it when
we're talking about bariatricsurgery. When you talk about the
leak rate from a sleevegastrectomy, it's point two 5%
so two out of 1000 cases, theseare really acceptably low
(27:27):
complication rates, and thesuccess rate is is pretty good.
So for the for the rightcandidate, bariatric surgery
serves as a very effective andsafe surgical intervention for
obesity, and what is the averageage that you see that you
perform the surgery on? I'm sureparents are going to be asking
(27:49):
the question, if they have achild who's obese, let's say
they're eight, 910, years old,would they qualify to see you?
Yeah, they would. I guess I'mthinking of patients that are
younger overweight, but theyhave yet to go through their
growth spurt, and parents arelooking for help, and I'm
wondering, is it advisable forthem to come see you now, or
(28:11):
should we wait until they'vefinished going through puberty?
Right? So we've removed all agecutoffs. We view the case as a
unique case every single time,and the reality is that there
are patients that are very youngthat would benefit, and it would
change their life course tointervene on their obesity for a
(28:34):
myriad number of reasons. So wenow just case by case. I think
there's a misconception that ifyou have, for example, bariatric
surgery early, it's going toaffect your puberty and your
height, but one of the things Ithink we have to understand is
it's actually the exactopposite. So living with obesity
actually leads to a shorteradult height, which has been
(28:56):
well proven, because it leads toadvanced bone age as well as
delayed pubertal onset for boysand advanced pubertal onset for
girls. So again, I think that'sone of those sort of
misunderstandings that weactually have the science to
refute, that if you want tooptimize pubertal advancement
and final adult height,intervening earlier is the way
to do that, is that because theadipose tissue has some hormonal
(29:19):
properties to it. Yes. I mean,we don't know all of the
mechanism, but yes, I think sortof the most simplistic, you
know, hypotheses that we have isthat the adipose tissue is
producing estrogen, which isadvancing the bone age, and then
we know how that's impacting,sort of the insulin, estrogen,
testosterone cycle. Now I reallyappreciate Dr samakar, you
(29:39):
explained how safe the bariatricsurgery is. Do you have any data
on long term outcomes? How dokids look years out from the
procedure? Any concerns thatparents should be aware of? So
when you look at the data 10plus years I mean, there's
really good data. There's.
(30:00):
Data on longitudinal datapublished in the New England
Journal on comparing outcomes,specifically in pediatric
patients undergoing rheumatoidpass and sleep hysterectomy, and
then comparing those results tothe adult counterparts. And so
the the weight loss, it holds.
And not only that, but whatthose so at 10 years their
(30:21):
weight is significantlydecreased compared to baseline
and very similar to the adulttrajectory. So the the
fundamentalhormonal changes that are taking
place seem to hold now. Thedifference is intervening on the
metabolic disease early seems toconfer an advantage to
(30:45):
intervening late. And we seethis all the time with our adult
patients, patients that come tous, 40s and 50s who've had
diabetes now for 25 years. So assoon as you perform a bariatric
surgery, you're going to startseeing normalization of blood
glucose. I mean, instantly, 24hours, they've lost no weight at
that point. But we also knowfrom the adult literature that
(31:06):
the longer you've had yourdiabetes, the lower your chance
of remission, completeremission. So we can only
mitigate, you know, so, so muchso the earlier intervention not
only confers the longitudinaladvantage, but also confers the
Early Intervention advantage.
And so when you're intervening,the sooner you intervene, the
(31:29):
greater the trajectory of thebenefit that you'll have long
term. So 90% of our patientsprior to surgery have tried
multiple medications. Everyonehas engaged in intensive
lifestyle, behavioral therapy.
Everyone's met with a dietitianon multiple occasions. So we
have a long runway before that,and then post operatively, we
continue all of those things,including medication. We think
(31:51):
that multimodal therapy isoptimal therapy. So we want to
have optimal weight loss, wewant to have optimal comorbidity
resolution. So I have sort of aquestion that might be difficult
to answer, but I will say, as ageneral pediatrician, one of the
biggest challenges that I havewhen I have children that are
becoming obese, or they'restarting to gain weight, and
(32:14):
parents are looking for help andresources is figuring out how to
do it in a way that doesn'tbreak the bank, because I will
for our for patients todieticians, and it can be,
honestly, very cost prohibitive.
For families, hundreds ofdollars to see a dietitian, or,
honestly, there aren't that manydietitians available for them to
meet. So something as extensiveas your program, what would that
(32:37):
look like for families? Is itcovered by insurance? Is this
going to be cost prohibitive? Doyou have any information on
that? Yeah, it's a greatquestion. So our program is
completely covered by insurance,and that was part of our goal in
standing this up to increaseaccess to all patients in our
region. So we take all forms ofinsurance and ensure that prior
(32:59):
to going through the program,every component of it is
covered. Now you bring up a goodpoint, though, that that you
know, we can't guarantee that toAll Programs, and there are
certainly components thataren't, and when you think about
the medications depending onyour insurance, that's
important. But I think that is areally important thing for
clinicians to understand. Whatresources do you have for your
(33:21):
payer mix, because it might lookdifferent based on the patients
that you serve, and how can wereally access that? Because
there's a lot of good communityresources in our region, and
really try to understand how totap into that, acknowledging,
for example, there's not a lotof dietitians in our region. We
know that that's a huge accessissue. So how do we optimize
that? Either through virtualresources, through resources at
(33:43):
CHLA, you know, through otheropportunities, knowing that
there's a lot of creative,innovative ways to get those
therapies. So Dr samakar, Drsamakar, I have a question for
you. I am admittedly apediatrician who tends to shy
away from interventions. It'soften not my first approach and
recommendation for families. Sotell me, because I want to be
(34:05):
excited about this. What do youwhat do you notice from the
children that have gone throughbariatric surgery? Tell me about
Tell me some good stories I wantto hear. What is it like on the
other end? Yeah, so, so let mestart off by saying, when, when
I when we do a surgicalevaluation or consult. It's a
conversation, and it's an openended one. I think that the
point I try to get across to thepatient and the families, this
(34:28):
is an option. I'm here for youtoday or in 10 years from now,
but this is planting the seed insomeone's mind that there is an
option, there is an effectivetreatment modality that we offer
and that they can use. Andthat's really the entire goal of
that surgical consult. A lot ofpatients will go home and think
about it, and they're, you know,the wheels will start turning.
(34:49):
They'll be like, this is rightfor me. There are some patients
say this is not right for meright now, and that is perfectly
fine. We want to support all ofthose kids. So the second part
of your question is.
What? What are those? So in theadult population, Bariatrics,
the stigma still appliesbariatric surgery and seeking
out bariatric surgery is one ofthe only patient driven portions
(35:12):
of medicine that still exist. Ifyou have a colon cancer, you get
referred. If you have you know,if you need a mammogram, you get
referred. If you need yourmaintenance, colonoscopy, you
get referred. Bariatric patientsfind us patients. They're not
referred. So when adults come tome, they've thought about this
for some time, and they're readyto engage in that process.
Pediatric population is a littledifferent. Someone's concerned.
(35:35):
They may be concerned that theydon't have the tools to
effectively communicate that weknow that the two thirds of
pediatric patients with obesityare bullied and have self esteem
issues as a result of that, thebullying is not just from their
peers, it's in their homes. Andso the patients will come and
they, you know,the sad parts about this is,
(35:56):
yeah, I noticed very quicklythey're, you know, withdrawn.
They may not want to make eyecontact, and we have multiple
visits, and over time, thatchanges, and they come back six
months a year later, and they'redynamic. They're proud of
themselves. I mean, this is amajor accomplishment in a 14
(36:18):
year old's life, to lose 80pounds. And as a pediatrician,
you know the reward for being inthis career is because you get
you get to make an impact, andit's those little moments that
really fuel you to go on. And sowe get a lot of those little
moments, and it's incrediblyrewarding. I'm thinking about
the toolkit, how how wonderfulit is that it's now expanded,
(36:39):
because years ago, we could onlyoffer advice on diet and
exercise and so often thatdidn't work. So it's just nice
to know that there's somethingout there for families that are
really struggling, yeah, and Ithink we take for granted little
things that these young peopleare experiencing, right? So we
have patients come back and theysay things like, I took a trip
in an airplane to visit mygrandma, and I fit in the
(37:02):
airplane seat, or I slept allnight last night, and I wasn't
snoring and gasping for air inthe middle of the night, right?
And we assume that 12 year oldsare not experiencing that, but
they are every day, right? Andso I think those are the moments
that I walk away with that, Ifeel so grateful that our tool
kit is expanding and that wehave the privilege to do this
(37:24):
work and help teach people abouthow we can expand this and make
sure it is offered to every kidthat needs it. I'm honestly I'm
thinking now about my father inlaw, who's who's passed away,
but he lived most of his life.
He was very obese when he passedaway, he was well into 400
pounds, and I wonder how hislife would have been different
(37:45):
had he been offered this toolkit. I think, you know, he lived
at a time when this wasn't asreadily available and it wasn't
as perfected. I think peoplewere scared about the surgeries,
hearing about side effects orfailed surgeries, and I think it
made him nervous, but I wonderhow it have been for him. Today,
it's definitely a new time and anew space, and there's a lot
more we can offer. So I think wehave this great opportunity to
(38:08):
do so. I wish it was availableto more people. You know, even
even now, with with availabilitythat we do have, we do meet
families that are engaging inmedical tours and for their
children's to treat theirchildren's obesity. And so there
really is, you know, thelandscape is changing slowly,
(38:29):
but it is changing. So before weclose, is there anything else
that you'd like to tell parentsabout, any message of hope or
any misconceptions you'd like toclear up before we before we
finish up? Imean, I will just repeat what
I've already said, but I thinkjust acknowledging for parents
and pediatricians and healthcareproviders, just how important it
is to acknowledge that pediatricobesity is a complex chronic
(38:51):
disease, that this is not thefault of the patient or their
parents, and that we need totell people that over and over
and over again until theybelieve it, because we're the
holders of breaking this stigma,and if we don't believe it
ourselves, they're never goingto believe it. And so we start
by breaking the stigma, bydiagnosing it and by providing
the right treatment. Becauseevery time we treat pediatric
(39:12):
obesity, we start to break thestigma. And so I hope that
pediatricians will treat it,will refer to our program and
start those conversations,because that's how we start the
life transformation, by actuallyproviding access to these
treatments. Thank you so much,and I will make sure to put all
of the information for yourprogram in the show notes below.
(39:32):
And thank you guys so much forbeing on that. I really
appreciate it. Thanks for havingus. Thank you. Thank you for
listening, and I hope youenjoyed this week's episode of
your child is normal. Also, ifyou could take a moment and
leave a five star review,wherever it is you listen to
podcasts, I would greatlyappreciate it. It really makes a
difference to help this podcastgrow. You can also follow me on
Instagram at ask Dr Jessica. Seeyou next Monday.
Welcome back to your child is normal, the podcast
where we have honestconversations about kids' health
and their well being. Now ifyou're a parent struggling to
help your child with severeobesity, you are not alone.
Millions of children in the USface the same challenge. Now the
truth is, traditional advicelike just eat less and move more
often isn't enough. So what arethe other options? Well, today,
we're joined by Dr Elena Vidmar,a pediatric endocrinologist
(00:23):
specializing in childhoodobesity, and Dr Cameron samakar,
a bariatric surgeon, andtogether, they co direct the
obesity medicine program atChildren's Hospital of Los
Angeles. In this episode,they'll break down why obesity
is a complex medical condition,how medications like GLP ones
and bariatric surgery can belife changing, and what families
need to know when seeking help.
If you've ever felt at a lossfor what to do next, this
(00:44):
episode is for you, and asalways, I am so grateful that
you take the time to listen tothis podcast, and if you are
enjoying your child as normal,please take a moment to leave a
five star review wherever it is.
You listen to podcasts, all ofthese reviews really help other
people find the podcast, whichhelps the podcast grow. Thank
you so much. Now on to theepisode,
Dr Vidmar and Dr samakar, thankyou so much for taking the time
(01:06):
to be here today. I'm soappreciative of your time.
Absolutely thanks for having us.
So I would love to first telleverybody, what do you guys do?
What are your credentials, andwhere do you work? Should we
start with Dr Vidmar, yes. SoI'm Elena Vidmar. I am a
pediatric endocrinologist andobesity medicine specialist, and
I work at Children's HospitalLos Angeles, and I have the
(01:27):
pleasure of running our obesitymedicine program there. And Dr
samakar, tell us about yourself.
What do you do for work? Sure,thanks for having us on today
for your podcast. I think it's agreat opportunity for us to
share about our program. My nameis Cameron samakar. I was an
adult bariatric surgeon general,surgeon trained, and then I met
(01:49):
Dr Vidmar, and her passion forpediatric obesity really sparked
an interest in expanding thebariatric service line to CHLA
and starting a program with her.
So I co direct the program,along with Dr Vidmar, and we're
super excited and passionateabout the work we're doing. So I
think it's well known what anepidemic childhood obesity is,
and I think it's really helpfulfor families to know that a
(02:12):
program like what you offerexists. And so I'm really
excited to just let people knowwhat is out there what options
they have? Because I think thisis, unfortunately, a problem
that many people are now facingwith, and they're at a loss for
where to go and what to do andwhere to get help. So first, can
you tell everybody what kind ofpatients do you typically see at
CHLA for obesity management? Imean, I think we can back up a
(02:37):
little bit just to start thisconversation, if that's okay,
and just acknowledge thatchildren living in larger bodies
or living with obesity, which isthe medical diagnosis, that's
not the fault of the patient ortheir parent, and that the work
we do is not about the number onthe scale or the size of one's
body, but it's about helpingthese kids live long, healthy
(02:59):
lives, because we know that kidsliving in larger bodies have a
high increased risk of life,limiting complications like type
two diabetes, high bloodpressure, high cholesterol, and
that's why Doctor Sam McCart andI do the work that we do,
because we're trying to helpthese kids to thrive into their
adulthood. It's true. It'stricky, because while there is,
(03:20):
unfortunately, a stigma forbeing more overweight, for
suffering from obesity, and weknow that it's really hard to
lose weight, it's really, reallya challenge. So I think that's a
nice balance that you guysstrike, where you acknowledge
that it's not their fault, thatit is a difficult place to be
in, and at the same timeoffering help and solutions for
them and their families. Yes,that is definitely our goal, and
(03:43):
that's why we have designed ourprogram. And back to your first
question, so we know that wecan't do this, this program
alone, and so we try to partnerwith our pediatric colleagues
across this region and reallytry to align with the American
Academy of Pediatrics clinicalpractice guidelines that came
out in January of 2023 that kindof give us a framework for how
(04:05):
we think about this care when wetake care of a patient with a
complex chronic disease, which,as you know, is not new to
pediatrics, and so we really cantriage based off of the severity
of disease and offer treatmentthat matches that severity. So
that's how we kind of thinkabout how patients get referred
and triaged into our program isreally based off the severity of
(04:27):
their presentation. I'm curious,from your perspective, as
someone who's worked withchildren in larger bodies for
many years, why do you thinkthis increase in this trend in
obesity is occurring? Becausewhen you look at the numbers
from 3040, years ago, the ratesof obesity were much lower. And
I know it's multifactorial, butmaybe can you touch on the main
(04:47):
points as to why you think thisis happening absolutely so
there's many factors, there'sgenetics and there's biology and
there's the environment, but wehave to.
To step back to the fact thatthis is no one's fault. This is
not about self discipline orself will. This is about
biology, but we also know thatour genes change over time,
(05:11):
right? So we have epigeneticchanges that are forming in
these young people as they areborn that are impacting how both
their brain controls whenthey're hungry and when they're
full, I like to think of it likea light switch. And it's like
their light switch has syrup init, so it's not working the way
that it should. This is in thearcuate nucleus, part of the
hypothalamus, as well as intheir periphery, the way that
(05:34):
their cells use the food thatthey consume. So when we take in
our food, we want it to be usedas energy. But when you're
living with obesity, you take inyour food and you immediately
store it as adipose tissue. Andthose two things are happening
over time. And I think what wehave to acknowledge as a
scientific community and ageneral society is that you
(05:57):
cannot prevent something that'salready happened, which is why
we have to treat and care forthe children living in front of
us with obesity. So we know thatthe most recent data suggests
that one in three to five youngpeople is living with obesity,
and if these rates continue by2050, up to 60% of children will
(06:19):
be living with obesity. So wehave to treat this condition in
front of us with the ultimategoal that hopefully we can get
to a place where we reset thesegenes, and we actually get to
generations where theseprevalence rates go back down,
but we can't prevent somethingthat's already happened. So
that's the goal of what we'retrying to do here with our
(06:39):
program. Now, when children areplaced on diets, or they're on
restrictive calorie diets, theydo lose weight, but the trouble
with that is they often regainthe weight Correct, correct? So
I think again, what we have toacknowledge is that you can use
food as medicine, right? So justlike we use any tool in our tool
kit, there are ways we can helpgive the body what it needs. And
(07:03):
if your body is not able to usecalories efficiently, you can
give less calories to use thatbut alternatively, and we are in
a current season where we haveother tools, like medication and
bariatric surgery, we canunderstand how we actually give
the body back the machinery thatit needs in order to function
more efficiently and preventthose complications over time.
(07:27):
And so historically, our toolkit has been very limited. So we
have been working mainly withfood as medicine, which for this
particular chronic disease isnot very effective, which
unfortunately is why we haven'thad great tools, so our tool kit
has expanded significantly,which has led us to a place
where we can actually treat thisdisease more effectively and
(07:50):
lead to outcomes that hopefullycan get us to a place where we
can prevent some of these lifelimiting complications, which is
part of the mission of whatDoctor samakar and I are trying
to accomplish. What I wasalluding to is a lot of people
think, as to your point about itbeing too difficult to expect
with willpower alone, is that, Ithink a lot of people know,
(08:11):
okay, if we if we watch ourdiet, we can lose weight. But
the tricky thing is, the bodyhas its own barometer, right?
It's like a thermometer and athermostat in our body, that if
we do lose weight, it's workingagainst us to keep the weight
off for a sustained period oftime. Correct?
You know that what you'rereferring to, Jessica, you know
what bariatric surgeons havelong time called, you know, the
(08:33):
barostat. And there's goodscience to support the fact that
adipose tissue has memory in theadipose tissue of patients with
obesity who lose weight isdifferent in where its set point
is and what it's trying toreturn to the patients who have
never had obesity. So that iswhy, in just zooming out to the
(08:58):
larger context of what we'retalking about, what is the
approach for obesity as achronic disease? So we have
medications, we have surgery,but the framework for that is
intensive, lifestyle, behavioraltherapy. That's the first step
of any kind of approach. Thereality of that, though, is in
severe obesity, the failure rateis 95 plus percent, and this has
(09:22):
been shown time and time again.
So as a medical community, wereally need to move away from
not acknowledging this as achronic disease, prescribing
intensive lifestyle andbehavioral therapy, thinking
that it may work, it doesn'twork. I mean, that's the bottom
line. And severe obesity. It's afailed treatment modality that's
been demonstrated in multipletrials. So with that said, we
(09:45):
like to refer to it as recurrentweight gain, because what you do
when you intervene on obesity,and you not just help the number
on the scale, but you actuallychange the trajectory of the
meta.
Metabolic diseases is you changethe quality of life and the
patient's health perspectivelong term. And so while there is
(10:07):
recurrent weight gain, typicallywhat we see in our patient
population is there is recurrentweight gain over time in both
adolescents and adults. If youlook at all longitudinal
studies, and there's Swedishstudies that go out over 25
years, the weight differencewith the recurrent weight gain
(10:28):
group after bariatric surgery orinterventions is much lower than
the natural history of a patientwith obesity that has no
intervention. And so we aredealing with the chronic
disease. Recurrent weight gainis an issue that we constantly
are vigilant for, and we need tocontinue to treat over the
lifetime of the patient. And I'mand I'm curious, what kind of
(10:50):
patients do you want to come seeyou in your practice? I mean,
obviously a lot of people arefive pounds 10 pounds
overweight. What meets thecriteria where they should come
visit you at Children'sHospital. So we have kind of two
different, you know, criteriaset. So at our program, we
accept patients with class twoobesity, which we define either
(11:10):
based on the BMI or the BMI inexcess of the 95th percentile,
which is a CDC metric that helpsus understand sort of weight
above the 100th percentile,because that's kind of where our
growth charts cap out, or classthree obesity. So again, these
are set by various entitiesspecifically for us, in
pediatrics, the American Academyof Pediatrics, both for which
(11:33):
medication would be appropriateand bariatric surgery. Now, one
of the things we are trying todo in our community is support
general pediatricians and otherhealthcare clinicians for what
to do with young folks living inlarger bodies who don't meet
those criteria. So we've createdsomething we call reach kids,
which is our kind of reverseconsole model, where we take our
(11:55):
educational curriculum andintegrate it into primary care,
so that pediatricians haveresources for those patients
like you're talking about, whodon't maybe meet that criteria
for escalating care into ourprogram, but need some support
in the interim. So I think it'simportant to know where you
practice, what you can usedepending on what risk level the
patient has, just like we wouldwith any other chronic disease
(12:18):
model. That's helpful to knowabout. And can you tell people
again where they can find thatinformation? Yes, so it's on the
CHLA website, and then I'm happyto provide our contact
information as well if you wantto directly reach out to us. We
have a tool kit. We have aprescribing guideline for
obesity medication. We havetriaging for getting blood
(12:38):
testing for obesity relatedconditions, referral criteria
for surgery and other usefulresources for folks that are
doing this within their clinicalpractice. And do you stress diet
and exercise as well? So that'swithin our toolkit, sort of the
support around it again, I wouldsay within our program, we
really emphasize thecomprehensive treatment
approach. So there's really beena movement away from the staged
(13:01):
approach, which is the idea thatyou need to do one thing at a
time and then fail it,acknowledging that we really
know and have confirmedscientifically the efficacy of
each of these approaches. Sothere's no reason for a patient
with severe obesity to trysomething that we actually
already know is going to fail.
So instead, we actually want totake the menu of options
approach and do everything weknow is going to be effective at
(13:23):
once, so that we make sure thatwe optimize our treatment
approach, a multi modalityapproach
that said we have our dedicateddietitian that works with our
program. You know, surgery is atool, medications are a tool,
behavioral change, dietarychange, family support and
(13:43):
exercise are all good. Thereality is that the number on
the scale is largely determinedby what you eat. Exercise is not
going to move that needle. Youcan't outrun a bad diet. And so
exercise is good for so manythings, especially in the
pediatric population, you know,bone density, muscle mass, brain
health, heart health, but what'sgoing to change the number on
(14:07):
the scale is food, and we diveinto that, and a lot of that is
just education. We have toprovide that education and make
sure that our patientsunderstand, how many grams of
protein do we want? How many,how much hydration do we want?
What are the the calorie densenutrition poor foods that they
may be consuming, because theecosystem here that's
(14:27):
contributing to obesity in ourday and age is because there are
a lot of edible non foodproducts that are called food,
but they're actually just edibleproducts that are not actually
food, so we try to limit it asmuch as possible, but we're just
humans, and unfortunately orfortunately, you know, I don't
(14:51):
have the genetic makeup whereit's going to be seriously
consequential for me, but somepeople do, and so we need to
treat those Okay.
Cases and we need to give themoptions. I mean, that's really
well said, because I feel likethere's a there's a trickiness
to the conversation. Because,you know, while we say it's not
the children's fault, we do alsoknow that eating certain calorie
(15:12):
dense foods, certain sweetfoods, they work against us in
terms of gaining weight withease. But it's very challenging
because, as you said, it'severywhere in our environment,
and some kids can eat it andstop after a little bit of
consumption, and some people,they can't stop. I mean, I think
it's super important that these,these lines of attack, run in
(15:36):
parallel, right? So theprevention, the well, the
prevention is too late right atthis point, we need to do a u
turn in how we're living. Youknow, I mean, just to give you
an example, when I do surveys atconferences of how many you
know, people used to walk toschool, probably about 50 to 70%
of hands go up. And when I ask,how many of your kids walk to
(15:59):
school now,it's less than 10% pretty much
across the board, so we justlive differently than we did
just 2030, years ago. And ourfood is different. These things
need to run in parallel, becausewe still need to treat the
individuals that are sufferingwith this disease. And to your
point about how you can't outexercise the food that you
(16:21):
consume. I think this is sotrue. Because I think about, if
I were to have the mostchallenging workout of my life,
if I were to run for an hourstraight, I would probably burn
500 600 calories. But if I wentto McDonald's and I got a Big
Mac, large fries and a soda, Idon't know what is that over
1000 calories? Easy peasy,absolutely. So it's really, it's
(16:42):
really, really hard to burnenough calories from exercise to
make up for a calorie densediet, absolutely. And then if
you have the genetics where youonly burn 20% of that, then
there's no way that the math isever going to equal right, which
is why the narrative that livingin a larger body is just because
(17:02):
your calories in don't equalyour calories out,
unfortunately, no longerapplies. Yes, absolutely. I
think everybody listening knowsthat relative that can make less
healthy choices, and they neverseem to gain weight. And then
other people in the same familyor the same friend group can eat
the same foods, and they itseems to never get off their
bodies. So I think that'sdefinitely true that genetics
(17:24):
works against a large amount ofpeople, which they say that's
evolutionarily that wasprotective back in the day,
right? To have to have calorieswhen you never knew they were
going to be around to storethem, yes, and just now, we have
so many food options that it'snot working in our favor. So
tell me. Okay. So let's saysomeone's listening and they're
thinking about their own child,and they're considering your
(17:45):
program, what would theexperience look like for them?
Tell us about what would beoffered to them and the initial
treatment strategies.
Absolutely, we really start byacknowledging that this is a
chronic disease, byacknowledging that this is not
the patient or the parent'sfault, and by really outlining
what it means to docomprehensive obesity care. Now
(18:08):
at our program, again, we reallydon't take the staged approach.
So we're going to lay out ourtoolkit. We're going to talk
about food as medicine. We'regoing to talk about nutrition,
we're going to acknowledge theimportance of exercise. We're
going to talk about obesitypharmacotherapy and bariatric
surgery on that first visit, ifyour kid qualifies. So we're
going to really open up the toolkit, which we've really learned
(18:29):
over time from our patients.
We really want to take thatmulti modal approach. And so
again, we're going to open upthose opportunities for based on
your your child, what theirclass of obesity is, their
obesity related conditions, whatkind of treatment they you know,
would be best and mostappropriate for them. We have
dietitians, we havepsychologists, we have obesity
(18:50):
medicine specialists, and thenwe have our bariatric surgery
pathway. And a lot of ourpatients have curiosity, and we
really just want to provide anopportunity for education.
There's so many myths andmisunderstandings about this
work, from start to finish, fromit being a chronic disease to
just even what is an obesitymedication to what is bariatric
(19:11):
surgery? What are we doing? Howdoes it relate to the story I
know about my aunt who had it 20years ago. So a lot of what we
do is education and theopportunity for patients to just
spend time with our team andlearn more about what's
appropriate for their kid. Andso that's really kind of how it
starts, and that kind of walksthem into their kind of ultimate
treatment experience. So I firstwant to ask you about medication
(19:34):
options, and then I want to askyou about the surgical options
when it comes to medications.
How old are children when theycan initiate these medications,
and what are the types ofmedications in your tool kit? I
know GLP ones have gotten a lotof attention recently. Aside
from GLP ones, are there othermedications that you recommend
as well and offer to families?
(19:55):
We really take an individualizedapproach at CHLA, which is
partly due.
To a couple different reasons.
One is that while there are FDAage minimums, a lot of the work
we do in the obesity space isoff label, because we just don't
always have regulatedmedications. It's fairly new
that we've had this. So we don'treally have age minimums. We're
thinking about the kid in frontof us, their class and severity
(20:16):
of obesity and the comorbiditiesand conditions that they have.
We really think again about thistoolkit, right? So we have
injectable options, which is ourGOP ones. Those are things like
ozempic and wegovy and Manjaro,right? We have oral options,
which are things like Topiramateand phentermine. And we're
really going to lay out all ofthose options for the patient in
(20:38):
front of us. We're going to talkabout just some practical,
pragmatic things, accesslogistics. Can we get it through
your insurance? Can is thereaccess to the pharmacy? Can your
kid tolerate an injection ornot? Can they swallow a pill?
Right? We're still kind of inthe access phase. We're going to
talk about side effect profiles.
We're going to talk about whatother medications they're on,
(21:00):
what can they tolerate? And thenwe're going to just talk about
what the family can tolerate,right? If you have a family
member that's on ozempic anddoing great, you might be more
open to it versus, you know,you're not interested in that at
the moment. So a lot of it isreally just a patient centered
approach. What are those goalsthat you have? How does this
align with the treatment thatyou need? And how can we best
(21:21):
get that tool to you? And whatdoes that look like? I love
that. It sounds like meeting thefamily where they're at, meeting
the patient where they're at. Ithink is a great approach. I
know for the GLP ones, they'reapproved now down to 12. So
that's so interesting that youare able to think about the
child on the whole not lookingat those age requirements. The
(21:42):
other thing I would mention foryour listeners, because they may
not notice, you know, but, butit needs to be said, Dr bitmar
really is a world expert inthis, right? She, she, she's
doing cutting edge therapy.
We are so fortunate to have herat CHLA, because the
(22:03):
things that she's doing and theapproach that she's bringing is
truly cutting edge and unique.
It makes me feel extra lucky tohave you on here today. It's my
pleasure. And then I guess I'mcurious, have you found good
success with the GLP ones I knowwith adults, they are
flourishing. Have you found thatto be helpful with childhood
obesity? Yes, I think overall,having a growing tool kit is
(22:24):
very helpful. I think the GOPones and the GLP 1g Ip, which is
trizepatide, are very effective.
They're certainly the mosteffective tool for the most
young people. Again, I think weknow every person is different,
right? So you might take it andit might be very effective.
Others might take it and it'snot effective. But I also think
they've been a reallyinteresting proof of concept
(22:45):
about obesity as a chronicdisease, which is when you give
the tools back to these people,and their biology has the cells
that they need, has themachinery that they need, they
can effectively use theircalories, their appetite and
satiety can be regulated. And Ithink that that's really
important again, we have toacknowledge that they're going
to be effective to a certainlevel, which is why we cannot
(23:07):
forget that surgery, which isone of the most underused tools
that we currently have, stillremains the most effective and
the most durable treatment forsevere obesity. And I think one
of the things that I have reallycome to appreciate in the last
two years, since we stood up ourpediatric program at CHLA, is
just the importance of using thetools that are going to match
(23:29):
the severity of the disease infront of us. And I actually
think in pediatrics, we do thatso well for every other chronic
disease when we think aboutasthma, type one diabetes, but
for some reason there's been alag with pediatric obesity, so
I've been really trying to thinkabout how I was trained and how
to make sure that I translatethat. Because obesity is exactly
(23:49):
the same, you can anticipate theefficacy based on what you know,
and that's what you're going tosee. So the medications are the
same, they have a certain capthat you're going to see, and if
surgery is required, that iswhat's going to be required to
get that efficacy. So I'd loveto hear more about this, because
I think when people hear surgeryand a child, it might sound
daunting or too extreme, but Ihear what you're saying, that
(24:11):
it's a very effective tool. Sotell us a little bit about the
decision making process aboutwhat child would qualify. So
just take one step, quick stepback. You know, we identified
that there's a gap, and but whyis that? Well, because these
conversations can beuncomfortable sometimes, and so
(24:31):
oftentimes, I think what whatends up happening is the
difficult conversation isn'thad. And
when you survey patients who'vehad bariatric surgery, the vast
majority will will tell you thatif someone had talked to me
about this earlier, I would havedone this so much sooner. And so
(24:51):
we really need to have theseconversations. And I encourage
anyone who's interested in justyou know, there's various,
various resource.
And they can contact me, and Ican put them in touch. So who
qualifies? Essentially, we cango by PMI or percent percentile
growth charts, 120%of 95th percentile for age with
with a obesity associatedmedical problems such as
(25:16):
diabetes, hypertension,hyperlipidemia, obstructive
sleep apnea, the list goes onand on. Or 140%
of 95th percentilein rough BMI numbers, that's BMI
of 35 and above with thecomorbidity, or BMI 40 and
above. To answer the other partof your question, what is
(25:36):
bariatric surgery? So bariatricsurgery are surgeries designed
to treat obesity and metabolicdisease associated with obesity.
The most common procedure we'redoing at CHLA is the sleeve
gastrectomy. The sleevegastrectomy is the most common
adult procedure being performedat the United States as well.
(25:58):
It's removal of about 75% of thenative stomach. The stomach
anatomy essentially stays thesame. The size of the stomach is
decreased over time the patientscan resume a regular diet.
Obviously, we reinforce the thethe hallmarks of a nutritious
high protein, lower carb, morecomplex carbs, reduced sugar,
(26:25):
diet, but essentially they canresume that, and we see about
25% total weight loss as aresult of the sleeve I should
add here safety. What is thesafety? So
to put it in perspective, themost common abdominal operations
in the United States,appendectomy, cholecystectomy,
(26:45):
gallbladder removal,these all have a higher risk
profile and mortality rate thanbariatric surgery done at a
credit Center. In the UnitedStates, the risk of death from
bariatric surgery is less thanone in 1000 patients, and this
is all comers. So this ispatients in the pediatric
population to 70 plus years ofage. But to put it in
(27:06):
perspective, are mortality rateslower than the most common no
one talks about mortality rateswhen we're talking about
appendectomy, right? Buteveryone talks about it when
we're talking about bariatricsurgery. When you talk about the
leak rate from a sleevegastrectomy, it's point two 5%
so two out of 1000 cases, theseare really acceptably low
(27:27):
complication rates, and thesuccess rate is is pretty good.
So for the for the rightcandidate, bariatric surgery
serves as a very effective andsafe surgical intervention for
obesity, and what is the averageage that you see that you
perform the surgery on? I'm sureparents are going to be asking
(27:49):
the question, if they have achild who's obese, let's say
they're eight, 910, years old,would they qualify to see you?
Yeah, they would. I guess I'mthinking of patients that are
younger overweight, but theyhave yet to go through their
growth spurt, and parents arelooking for help, and I'm
wondering, is it advisable forthem to come see you now, or
(28:11):
should we wait until they'vefinished going through puberty?
Right? So we've removed all agecutoffs. We view the case as a
unique case every single time,and the reality is that there
are patients that are very youngthat would benefit, and it would
change their life course tointervene on their obesity for a
(28:34):
myriad number of reasons. So wenow just case by case. I think
there's a misconception that ifyou have, for example, bariatric
surgery early, it's going toaffect your puberty and your
height, but one of the things Ithink we have to understand is
it's actually the exactopposite. So living with obesity
actually leads to a shorteradult height, which has been
(28:56):
well proven, because it leads toadvanced bone age as well as
delayed pubertal onset for boysand advanced pubertal onset for
girls. So again, I think that'sone of those sort of
misunderstandings that weactually have the science to
refute, that if you want tooptimize pubertal advancement
and final adult height,intervening earlier is the way
to do that, is that because theadipose tissue has some hormonal
(29:19):
properties to it. Yes. I mean,we don't know all of the
mechanism, but yes, I think sortof the most simplistic, you
know, hypotheses that we have isthat the adipose tissue is
producing estrogen, which isadvancing the bone age, and then
we know how that's impacting,sort of the insulin, estrogen,
testosterone cycle. Now I reallyappreciate Dr samakar, you
(29:39):
explained how safe the bariatricsurgery is. Do you have any data
on long term outcomes? How dokids look years out from the
procedure? Any concerns thatparents should be aware of? So
when you look at the data 10plus years I mean, there's
really good data. There's.
(30:00):
Data on longitudinal datapublished in the New England
Journal on comparing outcomes,specifically in pediatric
patients undergoing rheumatoidpass and sleep hysterectomy, and
then comparing those results tothe adult counterparts. And so
the the weight loss, it holds.
And not only that, but whatthose so at 10 years their
(30:21):
weight is significantlydecreased compared to baseline
and very similar to the adulttrajectory. So the the
fundamentalhormonal changes that are taking
place seem to hold now. Thedifference is intervening on the
metabolic disease early seems toconfer an advantage to
(30:45):
intervening late. And we seethis all the time with our adult
patients, patients that come tous, 40s and 50s who've had
diabetes now for 25 years. So assoon as you perform a bariatric
surgery, you're going to startseeing normalization of blood
glucose. I mean, instantly, 24hours, they've lost no weight at
that point. But we also knowfrom the adult literature that
(31:06):
the longer you've had yourdiabetes, the lower your chance
of remission, completeremission. So we can only
mitigate, you know, so, so muchso the earlier intervention not
only confers the longitudinaladvantage, but also confers the
Early Intervention advantage.
And so when you're intervening,the sooner you intervene, the
(31:29):
greater the trajectory of thebenefit that you'll have long
term. So 90% of our patientsprior to surgery have tried
multiple medications. Everyonehas engaged in intensive
lifestyle, behavioral therapy.
Everyone's met with a dietitianon multiple occasions. So we
have a long runway before that,and then post operatively, we
continue all of those things,including medication. We think
(31:51):
that multimodal therapy isoptimal therapy. So we want to
have optimal weight loss, wewant to have optimal comorbidity
resolution. So I have sort of aquestion that might be difficult
to answer, but I will say, as ageneral pediatrician, one of the
biggest challenges that I havewhen I have children that are
becoming obese, or they'restarting to gain weight, and
(32:14):
parents are looking for help andresources is figuring out how to
do it in a way that doesn'tbreak the bank, because I will
for our for patients todieticians, and it can be,
honestly, very cost prohibitive.
For families, hundreds ofdollars to see a dietitian, or,
honestly, there aren't that manydietitians available for them to
meet. So something as extensiveas your program, what would that
(32:37):
look like for families? Is itcovered by insurance? Is this
going to be cost prohibitive? Doyou have any information on
that? Yeah, it's a greatquestion. So our program is
completely covered by insurance,and that was part of our goal in
standing this up to increaseaccess to all patients in our
region. So we take all forms ofinsurance and ensure that prior
(32:59):
to going through the program,every component of it is
covered. Now you bring up a goodpoint, though, that that you
know, we can't guarantee that toAll Programs, and there are
certainly components thataren't, and when you think about
the medications depending onyour insurance, that's
important. But I think that is areally important thing for
clinicians to understand. Whatresources do you have for your
(33:21):
payer mix, because it might lookdifferent based on the patients
that you serve, and how can wereally access that? Because
there's a lot of good communityresources in our region, and
really try to understand how totap into that, acknowledging,
for example, there's not a lotof dietitians in our region. We
know that that's a huge accessissue. So how do we optimize
that? Either through virtualresources, through resources at
(33:43):
CHLA, you know, through otheropportunities, knowing that
there's a lot of creative,innovative ways to get those
therapies. So Dr samakar, Drsamakar, I have a question for
you. I am admittedly apediatrician who tends to shy
away from interventions. It'soften not my first approach and
recommendation for families. Sotell me, because I want to be
(34:05):
excited about this. What do youwhat do you notice from the
children that have gone throughbariatric surgery? Tell me about
Tell me some good stories I wantto hear. What is it like on the
other end? Yeah, so, so let mestart off by saying, when, when
I when we do a surgicalevaluation or consult. It's a
conversation, and it's an openended one. I think that the
point I try to get across to thepatient and the families, this
(34:28):
is an option. I'm here for youtoday or in 10 years from now,
but this is planting the seed insomeone's mind that there is an
option, there is an effectivetreatment modality that we offer
and that they can use. Andthat's really the entire goal of
that surgical consult. A lot ofpatients will go home and think
about it, and they're, you know,the wheels will start turning.
(34:49):
They'll be like, this is rightfor me. There are some patients
say this is not right for meright now, and that is perfectly
fine. We want to support all ofthose kids. So the second part
of your question is.
What? What are those? So in theadult population, Bariatrics,
the stigma still appliesbariatric surgery and seeking
out bariatric surgery is one ofthe only patient driven portions
(35:12):
of medicine that still exist. Ifyou have a colon cancer, you get
referred. If you have you know,if you need a mammogram, you get
referred. If you need yourmaintenance, colonoscopy, you
get referred. Bariatric patientsfind us patients. They're not
referred. So when adults come tome, they've thought about this
for some time, and they're readyto engage in that process.
Pediatric population is a littledifferent. Someone's concerned.
(35:35):
They may be concerned that theydon't have the tools to
effectively communicate that weknow that the two thirds of
pediatric patients with obesityare bullied and have self esteem
issues as a result of that, thebullying is not just from their
peers, it's in their homes. Andso the patients will come and
they, you know,the sad parts about this is,
(35:56):
yeah, I noticed very quicklythey're, you know, withdrawn.
They may not want to make eyecontact, and we have multiple
visits, and over time, thatchanges, and they come back six
months a year later, and they'redynamic. They're proud of
themselves. I mean, this is amajor accomplishment in a 14
(36:18):
year old's life, to lose 80pounds. And as a pediatrician,
you know the reward for being inthis career is because you get
you get to make an impact, andit's those little moments that
really fuel you to go on. And sowe get a lot of those little
moments, and it's incrediblyrewarding. I'm thinking about
the toolkit, how how wonderfulit is that it's now expanded,
(36:39):
because years ago, we could onlyoffer advice on diet and
exercise and so often thatdidn't work. So it's just nice
to know that there's somethingout there for families that are
really struggling, yeah, and Ithink we take for granted little
things that these young peopleare experiencing, right? So we
have patients come back and theysay things like, I took a trip
in an airplane to visit mygrandma, and I fit in the
(37:02):
airplane seat, or I slept allnight last night, and I wasn't
snoring and gasping for air inthe middle of the night, right?
And we assume that 12 year oldsare not experiencing that, but
they are every day, right? Andso I think those are the moments
that I walk away with that, Ifeel so grateful that our tool
kit is expanding and that wehave the privilege to do this
(37:24):
work and help teach people abouthow we can expand this and make
sure it is offered to every kidthat needs it. I'm honestly I'm
thinking now about my father inlaw, who's who's passed away,
but he lived most of his life.
He was very obese when he passedaway, he was well into 400
pounds, and I wonder how hislife would have been different
(37:45):
had he been offered this toolkit. I think, you know, he lived
at a time when this wasn't asreadily available and it wasn't
as perfected. I think peoplewere scared about the surgeries,
hearing about side effects orfailed surgeries, and I think it
made him nervous, but I wonderhow it have been for him. Today,
it's definitely a new time and anew space, and there's a lot
more we can offer. So I think wehave this great opportunity to
(38:08):
do so. I wish it was availableto more people. You know, even
even now, with with availabilitythat we do have, we do meet
families that are engaging inmedical tours and for their
children's to treat theirchildren's obesity. And so there
really is, you know, thelandscape is changing slowly,
(38:29):
but it is changing. So before weclose, is there anything else
that you'd like to tell parentsabout, any message of hope or
any misconceptions you'd like toclear up before we before we
finish up? Imean, I will just repeat what
I've already said, but I thinkjust acknowledging for parents
and pediatricians and healthcareproviders, just how important it
is to acknowledge that pediatricobesity is a complex chronic
(38:51):
disease, that this is not thefault of the patient or their
parents, and that we need totell people that over and over
and over again until theybelieve it, because we're the
holders of breaking this stigma,and if we don't believe it
ourselves, they're never goingto believe it. And so we start
by breaking the stigma, bydiagnosing it and by providing
the right treatment. Becauseevery time we treat pediatric
(39:12):
obesity, we start to break thestigma. And so I hope that
pediatricians will treat it,will refer to our program and
start those conversations,because that's how we start the
life transformation, by actuallyproviding access to these
treatments. Thank you so much,and I will make sure to put all
of the information for yourprogram in the show notes below.
(39:32):
And thank you guys so much forbeing on that. I really
appreciate it. Thanks for havingus. Thank you. Thank you for
listening, and I hope youenjoyed this week's episode of
your child is normal. Also, ifyou could take a moment and
leave a five star review,wherever it is you listen to
podcasts, I would greatlyappreciate it. It really makes a
difference to help this podcastgrow. You can also follow me on
Instagram at ask Dr Jessica. Seeyou next Monday.
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