Obesity: Advanced Practice Providers

your slides fine. Oh, you do? Yeah, I think it must be your computer there. So, uh, do you have a printout of your slides? Yeah. Perfect. So why don't you go ahead and we'll advance your slides for you. OK, we'll just start with the cover slide then. Um, I've entitled this talk The Compassionate Care of the Child Affected by Obesity and, uh, how health, how healthcare providers can improve. And if you've been expecting, um, an update on bariatric surgery, you're certainly gonna get that with this presentation, but I'll be coming at it from a different slant. Because we tend to overlook um the profound effect that this disease has on our children, and I'm going to attempt to take you inside the life of a child affected by obesity. I can see the slides now so that you can understand why we, why they seek surgery, and I want you to understand what is offered, and I want you to understand is offered. Before we go into um further into the slides, I do want you to uh realize that I wanna be, um, try to get you to think about what personal biases may be related to the treatment of of children affected by obesity and identify some barriers that might affect children affected by obesity in a clinical setting, uh, especially in the bariatric surgery clinic. There's some um definitions that I would like to go over with you. One is that, um, obesity is a condition characterized by the excessive accumulation and storage of fat in the body, as we all are aware of. The measurements that we use to um. For these children are based on percentiles for age and gender. They're classified as overweight if they're greater than or equal to the eighty-fifth percentile. They are obese if they are greater than or equal to the 95th percentile for age and gender, and severely obese if they're greater than or equal to the 99th percentile for age and gender. In our clinic, I've never seen anybody that's less than the 99th percentile, so they're all severely obese and they're very sick. Bias. I want to I want you to to pay attention to this. It's an inclination to form unreasoned judgments with prejudice as a possible outcome. Stigma is a social devaluing sign carried by the individual who's a victim of prejudice. Prejudice is a preconceived judgment or opinion that's possible with a possible outcome of bias. And discrimination is a treatment of or making a distinction in favor of or against a person based on a group, class, or category to which that person belongs rather than their individual merit, and I want to show you today, if I can, how this applies to teens seeking weight loss surgery. Back up one. I'm sorry, my slides are advancing a little bit slowly. Before we go into the incidents though, I would like to read a case study, um, to sort of set the stage for this. DW is an 18 year old scheduled for ruin Y gastric bypass. She's a very pleasant girl and excited about her upcoming operation. She's very bright. She makes straight A's, although she is homeschooled. She's been admitted to the same day surgery unit, and her parents are with her. DW has a body mass index of 65 despite having been in an intensive weight loss program at a local medical center for over a year. She's had slow but steady weight loss during her time in the program, but not enough to reverse her comorbidities. DW has been diagnosed with the following obesity-related comorbidities obstructive sleep apnea, insulin-dependent type 2 diabetes mellitus, and hypertension. She wears CPAP at 8 centimeters of water pressure and is on two hypertensive medications. You have written all the admission orders and spoken with the lead nurse on the same day unit and was assured that there will be a bariatric bed in the room and that proper equipment is readily available. However, you get a call at 6:30 that morning that there's a problem. Once you arrive in the room, you notice that the bed is not a bariatric bed and that the side rails cannot be raised and locked with DW in the bed. You also learn from the mother before you go that the medical assistant had to look for a blood pressure cuff that would fit around DW's arm because there was not one on the unit that morning. When you return to the room after trying to find the bed, you find that DW has been instructed to change into a hospital gown, but the only available gowns are standard sizes. The nurse is laughing as she cuts the gown with her bandage scissors in order to make it fit, and DW looks very embarrassed. CW finally rolls off to the operating room and just as the doors closed behind her, you overhear the nurse that was assigned to her that morning say she hated to take care of those fat kids, that they were always dirty. Did you see the dirt on her neck? Do they never wash? And before you can even recover from shock, you also hear her say, I can't believe we operate on those kids. If they would just get up and do something and quit eating, they wouldn't even be in that shape. And I want you to think about as we go through this talk what we can do to improve a setting like this so these kids feel empowered and not judged when they come into our practices. And by the way, uh, none of this was fictional. This was not all happening in one setting, but it, it is not fictional. The incidence of obesity is quite alarming. There's over 43 million children under the age of 5 that are affected worldwide. They're 5. 170 million under 18 are affected worldwide. More than a third of the children in the US are affected, and I think most of them are in Alabama right now. And I think 1 in 8 preschoolers are affected by obesity already at preschool age. There's not just one cause for obesity. It's a complex relationship between genes and environment and behaviors. It's not just an issue of eating less and exercising more. It yeah, it all comes down eventually to an energy imbalance, but the way it happens is not the same for everyone. And if you look at this, you can see that there are genetic issues that come into play. Uh, our genes tell us what to do. They tell us how to process the food. They tell us when to eat, when to move. So our genes do come into play and behavioral settings, community settings, there may not be a safe place for the kids to go out and play. They may have to come home and simply sit in the house until mama gets home because mama doesn't want them to go out because it's not safe. There may be transportation issues. They don't have a way to get to a green area where they can play, a park that is safe so they can go walk or run or jump or anything. And there may be social issues, social values that come into play. Some cultures may want to have different foods that are made value different foods that are high in fat. Living here in the South, we have a lot of, uh, we cook with a lot of, um. Um, fat back and fry a lot of things and although many of us have learned that that's not healthy for us, it's still pretty common in the weight management clinic to hear that most of the foods are fried and that this is what they really have always done and that's what they like to do, so it's very cultural too. This cartoon I'm sure you're familiar with because it's been in a lot of journals, but this one has a few more um parameters to it than some of the other ones that I've seen, but you can see from this that just that every single body system is affected by obesity. And the prevalence of the obesity related comorbidities is increasing in our child and adolescent groups. Things that we normally are used to, which you see in adults, are now being seen very frequently, very commonly in um in our clinic anyway in adolescents and even children, young children, for, and I'll give you an example. Um, in over 50% of the children we're seeing cardiovascular and metabolic risk factors like fatty liver disease in 29% of children, dyslipidemia in 32%, and obese 5 to 10 year olds, 61% of them already have one or more cardiovascular risk factors. And 25% already have two or more cardiovascular risk factors, very serious. We had one child that was, we were trying to get him through the weight management program, died of a heart attack at age 12, so this is very serious. Um, and there's a cumulative effect. The earlier they have, um, they become affected by obesity, the more likely they are to have complications, and the longer they have complications, the more likely they are to have early mortality and morbidity. Of children who are overweight or obese as preschoolers are 5 times more likely to be overweight and obese as adults and have all those complications that go with it. So to address this. The American Academy of Pediatrics has devised uh an algorithm so that pediatricians can assess children as they come in for the well child visit and uh put them in on a track to stay healthy, um, or get healthy. Go to focus on today. are um The stage 3 and 4 that are down here at the very bottom of the screen. And let me, I'll try to see if I can get my. Little clicker to go up here. At the bottom right hand um part of the screen, there we go. Stage 3. is where the pediatrician recommends them to be seen in a comprehensive multidisciplinary weight management center, and they recommend that the players in the center be a psychologist or a counselor, a dietitian, um, PT, or some sort of, some sort of exercise specialist, a primary care provider who can monitor the medical issues. And then here at Children's of Alabama we have the bariatric nurse, it's me. We have a nurse practitioner that works really closely with the younger, um, I would say under 12 age group, but the social worker and our surgeon sees patients monthly, the ones that are, uh, seeking bariatric surgery. The stage 4 recommendations are where we, we offer not only the weight management but we also offer medications, very low calorie diets, um, those are very difficult, and surgery if they haven't been successful in any of the other stages. This is very intensive. We treat the comorbidities and we um try to get them to as healthy a state as possible before we even consider bariatric surgery, and our, our rules and recommendations for surgery are very strict. We don't, we don't bend them for somebody who just wants to get cute for the prom, uh, or look good for their senior pictures or because mom and dad don't like the way they're. Their child looks. I don't know why this is not showing up, but the indications for surgery, um, are that the BMI has to be greater than or equal to 40 with weight-related comorbidities. They have to be physiologically mature, at least at 10 or stage 4. They have to be committed to being evaluated um very closely before surgery and after surgery. They have to avoid pregnancy for a year or agree to avoid pregnancy for a whole year after surgery if they're female. And they have to have a supportive and committed family, and sometimes that's one of the hardest parts because these teens just don't have a good family. Um, they don't understand that it's their whole family problem and it's not just the teen's problem and if that even happens in some of the younger children too. Parents will come in and say, you know, I just can't do anything with them. So we don't have, they just don't have a, a good home situation and those never make it to surgery. I apologize. This is not advancing like it should. Another thing that we have to do is to show that they have the decisional capacity and maturity to give us informed consent, and this is a lot of times where our psychologists will come in, they will do some testing on them and tell us that if they think that they really can give us informed consent, so they're just a very valuable asset to our clinic too. Contraindications besides what I just said about the uh the fact that they may want this because so they can look cute for the prom or they can be a cheerleader or what have you we've heard everything is that they have to have a medically correctable cause of obesity. Um, sometimes we have had children come in and we work and work and work and work and something's just not right and we find out that they may have a pituitary tumor. So that's uh That's, you know, that's something that we wouldn't take them to the OR and do a gastric bypass on them for that. Most of the families come in and say that it's, it's simply a thyroid problem, but it is rarely a thyroid problem. They can't have an active substance abuse problem and we will not operate on them if they are using tobacco. They can't have a medical or psychiatric problem that impairs their ability to adhere to what we try to teach them if they're not going to be able to to stop what they're doing or if they're not going to be able to function well postoperatively, we just have to wait for them to get well or we just have to say, well, we'll just put this off. They can't be currently breastfeeding. They can't be pregnant, and they can't plan to have a baby within the first year after surgery because it would just be dangerous for the baby, uh, and we have had several families we've had, they just would not want to comply with recommendations and disastrous. So what I'm going to do right now is try to, um, for those of you who are not familiar with weight loss surgery, I'll go over the three major types that we offer. There are, there are more than these, but these are usually the ones that you hear most about. There's um ruin my gastric bypass. Uh, it's the most common. It's a restrictive and malabsorptive procedures, been done in adults since the 60s and in teens since the late 70s. Um, the stomach is divided into two parts, and you can see up here that, um, there's a little bitty pouch that is separated from the main portion of the stomach. And then the roe limb is brought up after the duodenum is divided down here to that pouch. And there's a tiny little hole that's made between the um the stomach pouch and this limb here. I'm trying to get the pointer up and I can't seem to get the pointer up here. But Anyway, this makes it restrictive because this will only hold about 2 ounces and then the, the small opening keeps um the food in that little pouch for a long time so they keep feeling full for a while and don't want to just keep eating. And the other part, the malabsorptive part comes when this part is reattached to the real limb way down here so that there's not the absorption of the fats and sugars and stuff that normally would happen in here. It happens further down to have the opportunity to absorb the fats and sugars that it usually does. So portions are controlled, weight loss is good and um it's still um um the surgery that we perform most here, uh, the problem comes when the the teams are not compliant with their supplements and they become nutritionally, um, malnourished and we have uh we do have some problems with that. The next one is the vertical sleeve gastrectomy, and we've just started doing those here at this site, um, mainly for because of the insurance, um, reluctance more than anything. This surgery, this procedure reduces the size of the stomach. Uh, dramatically this portion over here, the portion that is separated stomach is just removed part of the stomach is just removed. It's just taken out, so all you have is the little bitty. From the esophagus, but the, the rest of the anatomy is not altered at all. So one of the good things that happens is that when the stomach pouch is removed, that, um, the graylin that drives us to eat is also gone too for the most part. I don't know if all of it's gone, but we know that the graylin is usually concentrated in that stomach that's gone, so that would help you not want to eat too. Applications are a staple line leak along that long, long staple line, and it's not reversible at all, although. If there's a not good weight loss and the person still has complications, this can be converted to a gastric bypass. Uh, there are fewer nutritional complications seen with this, and so we're starting to think it may be a better thing for our team than the ruin why gastric bypass, but we don't know yet. The next one that is used um is the laparoscopic adjustable gastric band. It's been used since the 90s. This is um a ring. With an inflatable balloon inside it, you can see that ring around the upper part of the stomach up there. Uh, it's inflated by a port just like a central line port that's attached right under the stomach wall, and it can be filled or can have the the solution removed from it so that it loosens it and tightens it. Um, there's more gradual weight loss, but there is weight loss. The problem with this is that it's not FDA approved for anybody that's under the age of 18 yet, and we've not put in any of those because of this. You can never get them past insurance companies. And there's a few complications like the band may slip. It may erode into the stomach, can herniate. There can be, uh, some infections at the port site, uh, and abdominal pain. Now the problem with um with the kids that we're seeing is that they are very, very sick. We don't have any, I don't think that are coming in that are not um already having some sort of comorbidity and are already sick. We are involved in a study called Teen labs. And it is an NIH NIDDK funded study to observe adolescents who are going to go undergo bariatric surgery anyway. The surgery itself is not part of the study, but the observation about what happens to these teens pre-op and post-op is what we're looking at. We want to determine the risk and benefits of performing these operations in the teen years rather than having them wait till they're adults. Um, we're basing this on a parent study called labs that is looking at the same thing. We're just trying to see if there's um, uh, a benefit to doing this earlier. Uh, we're now in our 8th year of the study, and so far the results are very good, and I'll, um, share those with you in a few minutes. We have 5 centers involved in this. Patients are from 13 to 19 years old, and like I said, we wanna address some knowledge gaps about these kids. If you can see up here I say 6, 50% of our teens have, um, maybe 1 to 3 comorbidities. 39% have 4 to 5 comorbidities and 12% have more than 6 comorbidities. These are seriously sick, sick kids. Now we spent a lot of time talking about the medical side of the obesity. Now I wanna focus on the psychological effects. Um, I'd really like for you to pay some attention, close attention to this, because I've learned that these kids are not going to readily tell you how badly they're being treated, how they've been hurt, and what's going on inside of them. They're going to come into your office and say everything's great, that they have friends, that they are just fine. That is rarely, rarely the case. So when you're seeing a child with obesity, keep this in mind, please. Psychologically, these kids come to us with a lot of baggage. They don't like the way they look. They don't feel very valued. They are depressed and too many of them are suicidal. They may be cutting. They may have attempted suicide more than once. In school they have a very hard time. They, and this may show up by their drops in grades. They may just not show up for school. Often they've been pulled out of school or they've dropped out of school and decided to be homeschooled. Bullying in these situations is usually pretty awful. There's um a lot of relationship problems at school and even at home. They're socially isolated and rejected, um. They people may talk about them behind their backs. They may talk about them to their face. They may throw food at them. They may trip them. Studies have shown that children affected by obesity are chosen dead last as a friend, even compared to children with disabilities, children in wheelchairs. That as a result, they may be lonely. They may not date. They usually go to the prom with a brother or a cousin or as a with a bunch of girls. Uh, if they're on sports teams, they may sit on the bench a lot even when they have better skills than than thinner players. Teachers may be culprits, and they, if they tell the teachers, the teachers either may not stop the bullying or they may participate in, participate in it themselves. These children a lot of times have binge eating disorders because food is their best friend. They're BFF, they're, you know, the only person or the only thing they can turn to. Their quality of life has been shown to be similar or even lower to that of kids with cancer. They may not be picked for a prestigious college um because of the way they looked and they may not be hired for a job because of the way they look and so this can lead them to um a socioeconomic status where they're making lesser income, they're not doing as well as they had expected to, which just leads to more depression and more lack of self-worth. As far as the um Weight-based stigma stigmatization that we're talking about, 64% of the teens that are affected by obesity report being victims, and I would say that that's probably true in my clinic. Um, just about every person that does an intake reports some sort of bullying or teasing. That's the number one reason for teasing and bullying now. It's the most popular reason to tease or bully somebody. Perpetrators are their peers, their teachers, their parents, and sadly health care professionals, and this is where I want us to all pay attention dietitians, psychologists, nurses, medical students, physicians, everybody has been, had been questioned. A studied and every single group of us has shown that we are biased in some way. For the dietitians, the studies shows that these, um, the RDs are negative about the patient who's struggling with obesity. Don't expect them to be compliant. I think it's all related to some emotional problem, and the dietetic students pick up on this too, and they think that they have a problem with weight because they overeat. They don't have any willpower, and I think of them as ugly, insecure, and slow. Psychologists, people you would think would know better, um, assign a greater sickness or greater pathology to these groups of people, and they have lower expectations of them being able to overcome or improve their diagnosis. Nurses, for those nurses of us, that the rest of us out here that are nurses, sadly we see patients as lazy, lacking in self-control, noncompliant, don't want to be assigned to them, feel very repulsed by them, and don't want to touch them. Um, this week I just heard a nurse refer to one of my patients. Um, as a little boy, but then she stopped and started laughing and said, our big boy, and we were standing right outside the room, and I was stunned and embarrassed and just praying that he didn't hear any of that, but it, it just continues to go on. Medical students. When they have very poor ideas or expectations of those with obesity, they think that they have poor self-control, that they're not inherent, that they're sloppy, awkward, unsuccessful, and unpleasant. And sadly, this doesn't change as they become medical doctors. They looks like they just add to the list, but if, if our patients, those affected by obesity are seeing a medical professional, a nurse, a doctor, somebody in the medical profession for help, and they pick up on these attitudes. It would not empower them. It would not help them become able to overcome this or be successful at weight loss. It would just make them feel defeated and unable to move forward. But the good news, the good news is that most health care professionals who work with children really want to help them, but they just feel inadequate. They don't know what to do. So the things that they have studied and found the the best starting place, there's not uh enough time for me to go over everything but what I'm gonna start with today is communication. And um parents ask that we not use certain words. They are offensive and they don't want them to be used around them or their children. These are obese, heavy, chubby, fat, things of that nature. There are those in the medical profession that still promote the idea that if we use a graphic word that it will shock somebody into wanting to make changes in their health or their weight. But this is not true. And instead what we find is that using words like this just turn them off. So what they ask us to use instead is something that focuses on the, the medical aspects of it and not be judgmental. So use terms like weight, unhealthy weight, high BMI, weight problems. Don't ask them, um, don't act like they're dirty. Go ahead and feel free to touch them, to hug them. Um, don't make fat jokes thinking it's going to just, um, diffuse, uh, a tense, um, situation. It doesn't help. Don't grunt if you're helping pick them up or helping lift them out of a wheelchair or something. Don't act. Bev, can you hear me? This is Jenny. I want. To interrupt and ask you a quick question about this because this is burning in my mind. So you've given a couple of examples of when you were a witness to a nurse or another healthcare provider make an untoward comment about an overweight child, and you said you were embarrassed, but what did you do? What, what, what do we do about it? I mean, what is a positive way to sort of reframe it right in the moment and put a stop to that kind of thing when you're a witness? We need to, we need to just take them aside and say this is not appropriate when and that happens sometimes in clinic, but a lot of times when even when I'm on the floor, it's a very hurry up situation and I'm stunned and appalled by it and don't say anything either, so that more often that happens in clinic rather than it does on the floor for me, but that's something that I too have to work on. Um, and I know that I'm just about out of time now, so I'm going to go through this and quickly now and just go to say that we have made some tremendous gains in the health of children who have metabolic. Metabolic, uh, or weight loss surgery, um, they've improved their metabolic parameters, lost a lot of weight, diabetes improved so they don't have to be on diabetic medications anymore. Sleep apnea is cured. Um, And that was not coming up. But The dyslipidemia is is um improved. And The psychological outcomes are vastly improved. Studies are showing on our preliminary patients that these children vastly improve their, their psychological outcomes. What starts out as a lower quality of life and even those children with cancer suddenly becomes better than the norm, and this. Last it's a lasting thing it doesn't just uh happen as they begin to lose weight and then it goes back down to um a bad quality of life again it does last. So anyway, I just wanna thank you for listening to me and um hope that you can take away something that will help you in your practice with these children. Thanks a lot, Beth. Thanks for the presentation. It's, it's a huge topic and, and I appreciate the way you've tried to break it down. I think, you know, at least here in the US we're all very aware of all the society wide changes that are underway to try to address this problem from. Sugar sweetened beverages to more exercise and more PE classes and everything we can do, but I think in terms of our own practice elimination of bias and, and, uh, learning how to treat these kids the best we can is very beneficial. Thanks.