Rapid Fire and Conclusion: Pediatric Obesity 2017

So, the next section is called rapid fire. So, we haven't done rapid fire with this group before. Uh, some of us surgeons have been involved with that with the pediatric surgery group. So, I'm gonna throw a question out there, and I know we all like to talk. You get 30 seconds to 1 minute to answer the question, and I might cut you off. So I'm not trying to be rude, just trying to get through, uh, as many of these as we can. It should be a lot of fun. I'm going to try to do some controversial stuff and we'll see. I'll start out since we're on the subject of bariatric surgery. It's going to cover all the topics from the whole day and we may even throw a few curveballs in there that we haven't even talked about yet. So, first topic, first question. Bariatric surgery. Tom, you showed, uh, you know, you showed us that you lose a fixed percentage of weight. OK. So what is the optimal BMI to intervene? Tom, let's start with you. Uh, BMIs in the 40s, I think will predictably get you to BMIs, uh, less than 30, which is what we would want to see. Victoria? I'm going to pass on this one, not being a bariatric surgeon, so I'll give my time to Alan Brown. Well, you, you refer them. So when do you think we ought to refer? I'm going to put you on the spot. I can let you off the hook. No, I'll be honest, I don't have a lot of experience on this one, so I'm gonna, I'm going to definitely pass on this one. Don't I get a pass? OK, everybody gets one pass. Lifeline. OK, yeah, exactly. Call a friend, yeah, so I'm gonna skip our clinic because I sort of know where, where we are unless any of you, do any of you have a real strong opinion, Sheeel. When do you think we ought to be doing this? I can't talk about BMIs, but I can say, um, the more I learn about it, the younger that we can intervene, it seems to just help their quality of life. Um, so sooner rather than later, but I'm not sure I would be able to speak to an exact BMI, Claudia. I would say in the 40s also, John. Uh, generally I've done above 35. Nice, nice, Alan. I think that we should work on the BMI percentiles and use that the percentile of the 90th percentile. Certainly there is overwhelming data, and Tom has repeated it repeatedly presented it, that really shows that if you operate at a lower degree of obesity, you can move people into a much healthier state. And since bariatric surgery is the best thing we have, #1 or #2, actually, #1 is that these kids are sick and their quality of life is going down. They have predictable health risks in the future and the more you scratch, they've got health effects right now. So I think we have to continue to establish goals to make them healthy, Mark. Yeah, I mean, I reiterate what everybody said, but you know, so yes, I agree in the 50s or rather in the 40s, but I want to make the point just to, just to drive it home, you know, there is data, and Tom published data back in 2009 that showed that subjects or patients above BMI 55 only have about a 14% probability of getting down to a BMI below 30. So again, You know, I think once you cross that 50 threshold, I think your probability of really mitigating the, you know, risk that's associated with these numbers of 35 and above really becomes challenging. So in the 40s for sure, or rather, don't let somebody get to 50 and over. Chris. So, as the person who does a lot, most general pediatrics, I think I, I, I start the conversation when they start getting in the 35 saying like, and it's not punitive, it's not a threat, but when they're hitting in the in the 30s, mid-30s, I'm saying, you know what, if we don't do something, we're heading that direction. And I say it's not a threat, and certainly when they're getting, if they have comorbidity. At that range, if they're getting closer to 40, I start the discussion like we can try things, but you're kind of in the zone where we're going to get better results doing this a different way. And again, it's not to be punitive, it's just letting them know what the data shows. So I start the conversation at 35. I start talking about, I start using the B word. Good. OK. So, great, great answers. Next topic, next question. Well, this is a combined topic, bariatric and medication, OK? So you have a 12 year old. BMI, let's make it, since you're worried about 50 being that we're gonna say the BMI is 49. 12-year-old, otherwise engaged, wants to make changes, has been in a, in a weight management program for 6 months, has stabilized the weight. But that's the best that they are doing. Medications or surgery, Alan? Start with medications. OK, Mark. Surgery. Chris. Surgery Tom, Yeah, the time for medication's passed, and uh, I think, you know, we, we have to realize that, that at that, at that BMI we're, we're sort of getting to the point where surgery may fail to get them out of the severely obese category. So yes, I would say you have to talk about surgery. Victoria, you, you use your pass already. Then I'll go, I'll go with surgery. It seems like surgery is the answer here. OK. Well, on my screen, you're surrounded by surgeons. Uh, Sheetel I, I, I would go with surgery, but I'm the psychologist, so I'd have to ask the patient if they do about it. Very good. What would you say, John? I had surgery and OK, and Claudia, I saved you for last. Well, I would for sure treat them with topiramate and phentermine at least for a bit and see what happens. Undoubtedly the kid's going to need surgery. If I could buy him a little bit of time to gain some maturity, assuming a 12-year-old is going to need some maturity, um, it might help for a little bit. So, so I'm gonna take, uh, I'm gonna take uh moderator privilege here and just ask you a quick follow-up question, Claudia. So, do you see medications as, you know, what's the role for medications as a bridge to surgery versus, uh, you know, the, the primary therapeutic intervention? Kind of depends on the degree of, of obesity and it also depends on the patient's preference. To me, it seems like a logical stepwise progression. Um, to start with pharmacotherapy first. If that doesn't work, they're not getting ample success, then to go on to surgery, knowing that even after surgery, some kids are still gonna need pharmacotherapy. Um, so it's not, it, just because you have surgery doesn't mean you're done. Um, but I, I, I do think it can be a bridge. It can be a A treatment on its own for some kids, but intervening sooner rather than later, regardless of what kind of um what, which of the interventions is is the key. I think Claudia is exactly right. This needs, it's a heterogeneous disease. First of all, there's a very wide range of response, whether you're talking about surgery or any other treatment form, and you need to take a continuous approach. Keep ratcheting it up and do what the individual patient needs. Very good. So, we're gonna move on to the next question. Remember, it's rapid fire. OK. Do you use drugs, that is pharmacotherapy for weight management in your patients, which ones and in whom, Alan? If the patient has been involved in the program for about 3 to 6 months and you've established that healthy living is not sufficient to control the disease in that patient, then you need to move on. So I use to use medications in your clinic. You use medications in your clinic then? Yes, and which ones do you use? Topiramate and phentermine. Oh, and, um, oh, Vyvanse, Mark. We do not. Chris, I do not. John, Uh, I have occasionally used metformin, but really more for insulin resistance than weight loss, and that's it, Tom. Yeah, we use, uh, we, we see a special population of hypothalamic obesity patients and, um, you know, often getting them ready for surgery, we will, uh, we, we will put them on dexamphetamine, uh, which is, uh, a drug that has, has an evidence base in this population. And unfortunately, we've, uh, certainly had to use, uh, dexamphetamine as well after surgery. Um, because they have a biological drive to, to gain weight and defeat the surgery that is just profoundly different than, um, our, uh, uh, our other patients that don't have brain injury. Um, sometimes we will use phentermine and topiramate as well. Victoria, Our pediatric endocrinologist, um, our pediatric endocrinologists do use, uh, medications. I'm not exactly sure for which ones and how long. And uh Claudia, you already, you, you kind of told us already, right? That was your whole talk. I, yeah, I use topiramate and phentermine, and metformin. I have a couple of kids on enetide or loraglatide. Um, I'll use a combination of separate naltrexone and bupropion in some kids, um. Yeah, stimulants. Great. The response is quite variable. Great. Yeah, no, that's, that's good, good answers. OK, so the next one is, uh, is, uh, on a completely different topic. How do you make nutrition services financially viable in a practice, or can you? Do you have any ideas for that, Alan? You spend a lot of time in the office of your state Medicaid and talking to them, presenting evidence to them, talking to them about the Preventative Health Services Task Force, etc. and we've got them under some degree of control here in Maine, and the next thing we've got to go after is the insurance companies themselves, the private insurance companies. Mark, is that something in your domain, or is it, I mean, not so not specifically in my domain, but I mean, you know, I agree with Alan's comments. I mean, I think that this requires, you know, a constant, you know, advocacy and, you know, policy support, but it's certainly an issue. So Chris, I'm assuming this was, this was Chris gets credit for this question. I'm assuming you asked it because you have it all figured out, right? No, no. So, so what we're trying to figure out both with counseling services, counseling services from psychologists and from in a private practice setting, trying to figure out ways to make their service. We're trying to figure out ways to make them available to more than just people needing obesity services, but that's the challenge to find um dietitians who can who can do a lot of different things. We, we have one who does a lot of different stuff. She also does eating disorders, but we have to really figure out a way to utilize her time in a lot of different ways. We have to get really creative. OK, let's see, Victoria. Well, I think so I'm in the same state as Alan. So, uh, in Maine, I think we have done it pretty well. I think we have still a lot more work to do on it. And so the other thing that we've, uh, I think had some success doing is, is helping, um, to have primary care providers feel comfortable providing some of these educational nutritional pieces and components to it. I, I mean, I think there's opportunities for other folks, as people have mentioned, to provide some of those services. Kristen, I'm gonna. You, you, you get this firsthand. You have any ideas? I think you're muted. There you go. I think everyone had pretty good ideas about this. OK. Tom, how do you do it in Colorado now that you just got there? Do, do you get reimbursed in Colorado? Oh, we're, we're gonna do, we're gonna do amazing things in Colorado. We, we haven't had a chance to start yet, but I concur, uh, with the, uh, with the collective here. Yeah, you got a great partner there, which, uh, So, uh, Claudia. Well, we don't have a problem with public insurance paying for dietitian services, but just this year we've had a lot of pushback from private insurers, limiting us to 3 visits in a year. And you know, if we're thinking of obesity as a chronic disease, you need more than 3 visits a year. Yeah, John, you wanna, uh, we haven't had much of an issue with our mostly Medicaid patients, but getting them actually in to see the nutritionist is another thing. I haven't quite mastered that yet. OK, so the next question actually, Kelly apologized that he couldn't, he was gonna be here for rapid fire, but he had something come up and uh he was not able to stay. But I'm gonna ask a question on his behalf, sugar tax, yes or no, Alan. Uh yes, Mark. Uncertain. Come on, you got to commit. Well, you know, I mean, you know, these are, I think like many things, it's not, it's not that black and white, you know, these can be regressive. That can be a regressive type of tax depending upon what socioeconomic class you're in. So I think in general it's a good idea to limit it. I'm just not sure taxing it is necessarily the right thing to do. Chris, Yes. Oh, I wanna hear what Tom, I wanna hear what Tom has to say. I, I, I see it as an exercise in futility. We don't get obesity because of sugar per se in and of itself. And so I think taxing a certain, you know, uh, product or products, um, is not going to have an impact that you want to have. Gellibrano showed this morning, he showed some pretty compelling data that it decreases consumption and makes a lot of money for whoever's doing it. Biologically, biologically we're wired to be where we're going to go, and I don't think so you think we'll replace it with something else, so, uh, Victoria. Yes. She, I think it's a place to start, but I also think there's probably a lot of other things that might take its place. John, yes, 100%. Claudia. Yes, but it wouldn't be my first public health policy that I'd go after. Sure. Where, where do you stop, you know, where do you stop. Jody, not letting you guys off the hook on this one. Yeah, I agree with Sheel. I mean, I, I think it could be a good thing, but I definitely don't think it's going to stop the problem, Kristen. You're muted. Yeah, it won't be the end of it for sure. It'll only be the beginning. OK, no, those are, uh, it's, so I didn't, so this one, so Stephanie, what, what do you say. And I think I'm, yes. I'm sort of like Mark. I don't know 100% for sure, even though I was trying to get him to commit. I'm, uh, I'm, I'm pretty much yes. So, eating disorder and so I wanna talk about, go back to eating disorders a little bit. And so have you ever had a patient. Who you have treated in your clinic. That was obese and developed an eating disorder and a lot of folks said that they had. Um, how did that patient end up? I mean, did they end up with, you know, chronic anorexia and bulimia, or did they end up with chronic obesity, or did they end up. Sort of norm, you know, normalizing. Alan, you had, if you haven't had anyone, you do get to pass on this one. Pass, Mark. In terms of how they wound up, I mean, we've had a number of kids, you know, with eating disorders, and I mean, I think that, you know, our take on it is that, you know, through a combination of, uh, you know, Interactions with our behavioral health folks and nutrition folks that, you know, if you can come to the point where you believe that um that it's under control, uh, you know, we've we've had a number of patients like that and they've done well. Chris, You know, they've, I've seen them kind of both go in both directions, and I think that they're both chronic diseases. Um, I, you know, I think it's hard to say that they wound up one way or the other. I think they continue to fight both um obesity and fight the eating disorder for the rest of their life. John, Um, I haven't had anyone, really. So what sheel answer for us. Sheel, yeah, we actually in our, um, early years we actually did have one young, um, Hispanic, uh, teenager who, um, it did really well in the program, came back for her last two or three visits and ended up, um, engaging in some compensatory behaviors, vomiting. But was very open about it, so it's probably, I don't even know if we'd say she qualified for an actual eating disorder, but it was something she sort of ended up doing. We talked about it. It seems like it resolved on its own after some discussion, but that's the only case that I can recall, and, and I think it says something too about there's also some underlying. Risk factors, I think family stressors and things like that, that, that it can exacerbate an eating disorder that we didn't see in her. So I think there's other factors that go into that as well. Victoria We've had a similar experience as Chris. We can think of uh 2 or 3, not, not that many. We had lots of concerns when we started doing this work in Maine that we were gonna, um, sort of be there and cover a lot of eating disorders or push folks in that direction. We only had a couple, and they, they were treated, they were managed very well, I think, in both the cases that I can think of. Um, they still struggle, but not to the extent that they had to be hospitalized, um, and they're very productive young adults right now, so. Tom, Uh, so in our, in our research population, you know, and the clinical population, very few come in with the, uh, you know, a, a, a diagnosis or label of binge eating disorder. But when you look for it objectively and have them, uh, complete the, you know, the questionnaires, uh, really that define a binge eating disorder, most of them have, have, uh, you know, it could, could be or have a case of, um, or, or, a binge eating disorder. And I've been impressed with the, the adult literature. You know, Jim Mitchell has spearheaded the, with a lot of experience in eating disorders and obesity, has spearheaded, uh, the behavioral, uh, uh, components of the labs, uh, consortium, and they demonstrate, you know, very good resolution of those, uh, same symptoms whether you come in with a diagnosis or not. I got a feeling that they that come in with a diagnosis. Probably have a lot of other, um, you know, have, have the more severe forms of disease that's been picked up before. But if you're just looking strictly, you know, at the criteria, um, I, I think that surgery is, is, uh, actually is a very good way to extinguish a lot of those, uh, behaviors. Um, and, um, and, and is successful. Uh, you have to wonder whether long term a prior diagnosis or prior criteria for binge eating disorder may, uh, pose, you know, a, a higher risk for relapse or weight regain. Claudia. I think many of our patients have disordered eating, maybe not a frank, truly diagnosable eating disorder, but for sure disordered eating that consists of restricting for much of the day and then overeating later on in the evening. We do screen routinely all of our new patients for binge eating disorder, and the, the rate of true meaning diagnostic criteria is quite low. I mean, it's under 5% that are meeting the true criteria. Um. We've had a couple of patients who have lost weight, so much weight due to fear of eating, um, so I think Chris brought this up during his, his talk or one of his questions. When it becomes sort of restricting and patients are fearful of eating, then we send them on to an eating disorders program. I think that's a great point, and I'll say it all the time. It's, we don't see quite as many, like you're saying, diagnosable eating disorders, but that term disordered eating applies to every patient that comes in. There's something going on. There's feelings or emotions around eating and food and restricting, but it doesn't quite meet those, those DSM criteria. Mhm. Well, I think our time is up. Uh, that was a lot of fun. Thank you, everybody. Uh, we had fantastic talks, lots of great discussion. We had stuff going on in the chat room. This was, uh, really, I think this was a fantastic show. And I just want to thank everybody and, uh, the show, just a couple of wrap up things. It will be available for archive and you can go online so other people can still get to it. They can still get CME for the show. Uh, was there anything? Else I need to talk to the tech folks. Is there anything else on the wrap up with the getting CME and that stuff that I need to say? OK. Under the links tab, there's a link to get your CME for the show, and uh thank you again, everybody for participating. And uh we really, uh, really want to give my heartfelt thanks on behalf of both Chris and Stephanie. I know we really are grateful for the fantastic faculty we had this year. Thank you very much. Thank you. Thank you. Thank you.