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Rapid Fire and Conclusion: Pediatric Obesity 2017

Video Published 2018-09-16 Updated 2022-08-22

Timestops (8)

Rapid Fire Session Introduction

When to Refer for Bariatric Surgery

Pharmacotherapy for Weight Management

Insurance Coverage for Dietitian Services

Taxing Sugar-Sweetened Beverages

Eating Disorders After Bariatric Surgery

Closing Chat Room Questions

Session Closing Remarks

Topic Overview

A rapid-fire panel discussion concluding a pediatric obesity symposium, covering optimal BMI thresholds for bariatric surgery intervention, the role of pharmacotherapy versus surgery in severely obese adolescents, current medication use patterns in clinical practice, financial viability of nutrition services, and the relationship between obesity treatment and eating disorders. Panelists representing surgery, endocrinology, psychology, and primary care debate clinical decision points with general consensus that bariatric surgery should be considered in the BMI 40s range, that medications can serve as a bridge to surgery in select cases, and that disordered eating is common in obese youth though frank eating disorders remain relatively rare.

Key Takeaways

Bariatric surgery discussion should begin at BMI mid-30s; emphasize surgery at BMI ~40 with comorbidity for superior outcomes. (3:59)
Patients with BMI >55 have only 14% probability of reaching BMI <30 post-surgery; outcomes decline sharply above BMI 50. (3:05)
Pharmacotherapy can bridge younger patients (e.g., age 12) to surgery; some require continued medication post-operatively. (6:27)
Bariatric surgery effectively extinguishes binge eating, though prior diagnosis may increase weight regain risk. (20:40)
Disordered eating (restricting/evening overeating) is nearly universal in obese youth; frank eating disorders remain <5%. (21:18)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Speaker 2 — guest

Chapters

0:00Optimal BMI for Bariatric Surgery Intervention — Panel discusses the optimal BMI threshold for bariatric surgery, with most panelists favoring intervention in the BMI 40s range, citing data that higher BMIs reduce probability of achieving healthy weight outcomes.
3:58Surgery vs. Pharmacotherapy Decision-Making — Panel addresses treatment choice for a 12-year-old with BMI 49 who has stabilized weight in a management program, with most favoring surgery though one panelist advocates for medication trial as a bridge to gain patient maturity.
8:18Current Pharmacotherapy Use Patterns — Panelists describe their medication use in clinical practice, with topiramate/phentermine most commonly cited, along with metformin, stimulants for hypothalamic obesity, and GLP-1 agonists in select cases.
10:42Financial Viability of Nutrition Services — Discussion of strategies to make nutrition services financially sustainable, including Medicaid advocacy, creative staffing models, and challenges with private insurance limiting visits.
14:11Sugar Tax Debate — Panel split on sugar taxation as public health policy, with concerns about regressive effects and whether it addresses root causes versus potential benefits in reducing consumption.
16:47Eating Disorders in Obese Youth — Panel shares clinical experience with eating disorders developing in obese patients, noting that frank eating disorders are rare but disordered eating patterns are nearly universal, with most cases resolving with appropriate intervention.

Key claims

0:56BMIs in the 40s will predictably achieve BMIs less than 30 after bariatric surgery — Speaker 1
3:05Patients above BMI 55 have only about 14% probability of getting down to BMI below 30 after surgery — Speaker 1
3:32Once BMI crosses 50 threshold, probability of mitigating risk associated with BMI 35 and above becomes challenging — Speaker 1
3:59Conversation about bariatric surgery should start when BMI reaches mid-30s range — Speaker 1
4:17At BMI approaching 40 with comorbidity, surgery discussion should emphasize better results compared to other interventions — Speaker 1
5:34At BMI 49, the time for medication has passed and surgery must be discussed — Speaker 1
6:27Topiramate and phentermine can serve as bridge to surgery to allow 12-year-old patient to gain maturity — Speaker 2
7:20Some children will need pharmacotherapy even after bariatric surgery — Speaker 2
7:56Obesity is a heterogeneous disease requiring continuous treatment approach with escalation based on individual patient needs — Speaker 1
8:31If healthy living is insufficient to control obesity after 3-6 months in program, need to move on to medications — Speaker 1
9:32Hypothalamic obesity patients have biological drive to gain weight that defeats surgery, profoundly different from patients without brain injury — Speaker 1
13:36Private insurers are limiting dietitian visits to 3 per year, insufficient for chronic disease management — Speaker 2
14:33Sugar tax can be regressive depending on socioeconomic class — Speaker 1
15:08Obesity does not result from sugar per se, so taxing specific products will not have desired impact — Speaker 1
19:53Most severely obese patients meet objective criteria for binge eating disorder when screened, even without prior diagnosis — Speaker 1
20:40Bariatric surgery is effective at extinguishing binge eating behaviors — Speaker 1
21:03Prior binge eating disorder diagnosis may pose higher risk for weight regain after surgery — Speaker 1
21:33Rate of true binge eating disorder meeting diagnostic criteria is under 5% when screening new obesity patients — Speaker 2
21:18Disordered eating consisting of daytime restricting followed by evening overeating is common pattern in obese youth — Speaker 2
22:20Disordered eating applies to nearly every obese patient though it may not meet DSM diagnostic criteria — Speaker 1

Points of disagreement

5:16Treatment choice for 12-year-old with BMI 49
- Speaker 2: Trial topiramate/phentermine first as bridge to allow patient maturity before surgery
- Speaker 1: Multiple panelists favor proceeding directly to surgery given BMI level and risk of surgical failure at higher weights
14:22Sugar taxation as public health policy
- Speaker 1: Multiple panelists support sugar tax
- Speaker 1: One panelist views it as exercise in futility that won't address biological drivers of obesity
- Speaker 1: One panelist uncertain due to regressive nature of such taxes

Open questions

What is the optimal timing and patient selection criteria for pharmacotherapy versus proceeding directly to bariatric surgery in severely obese adolescents?
Does prior diagnosis of binge eating disorder predict higher risk for weight regain after bariatric surgery in adolescents?
What are effective strategies to make nutrition services financially viable in pediatric obesity programs given insurance limitations?
Will sugar taxation effectively reduce obesity prevalence or will consumption simply shift to other calorie sources?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Bariatric Surgery Timing and Medical Management in Adolescent Severe Obesity

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Subspecialty Exists

Adolescent bariatric surgery emerged as a distinct discipline because conventional weight management — diet, exercise, behavioral modification — fails predictably in severe pediatric obesity 7:56. When a 14-year-old presents at BMI 50, the disease trajectory is set: progressive metabolic deterioration, orthopedic complications, and near-certain adult morbidity 0:56 3:05. Medical weight management was designed for mild-to-moderate obesity; bariatric surgery addresses the reality that some adolescents have already crossed into a disease severity that demands procedural intervention 4:17.

The Core Clinical Problem

Severe obesity in adolescence is not adult obesity that started early 7:56. It represents accelerated disease progression during a critical developmental window 0:56 3:05. The central challenge is timing: intervene too early and you subject a child to irreversible anatomic change; wait too long and the surgery itself becomes less effective 3:32. The discussants frame this around a specific threshold effect: patients with BMI in the 40s achieve better outcomes after surgery 0:56, but those above BMI 55 have only 14% probability of reaching BMI below 30 3:05. Once BMI crosses 50, mitigating risk becomes increasingly difficult 3:32.

This is not a linear dose-response relationship 0:56 3:05. There is a window of surgical efficacy, and it closes as BMI climbs 3:05 3:32.

How the Approach Works

The treatment framework is explicitly continuous rather than algorithmic 7:56. One discussant describes it as heterogeneous disease requiring "a continuous approach — keep ratcheting it up and do what the individual patient needs" 7:56. In practice, this means:

Early engagement. Conversation about bariatric surgery should begin when BMI reaches the mid-30s 3:59, not as threat but as trajectory counseling 3:59. By BMI approaching 40 with comorbidity, the discussion shifts to emphasizing surgery's superior outcomes compared to other interventions 4:17.

Pharmacotherapy as bridge or adjunct. Medications serve dual roles 6:27 7:20. For a 12-year-old at BMI 49 — clearly in surgical range — one discussant advocates topiramate/phentermine as a temporizing measure "to gain some maturity" before proceeding to surgery 6:27. But pharmacotherapy is not abandoned post-operatively: medications may be needed even after bariatric surgery 7:20. The stepwise model (lifestyle → medication → surgery) is less a sequence than a toolkit, with components layered based on response 7:56.

Etiology-specific modifications. Hypothalamic obesity — obesity following brain injury or tumor — represents a biologically distinct entity 9:32. These patients have a drive to gain weight that is profoundly different from patients without brain injury 9:32. They require dexamphetamine both pre- and post-operatively 9:32, a recognition that not all severe obesity responds to the same intervention.

Escalation triggers. If healthy living is insufficient to control obesity after 3-6 months in a structured program, the recommendation is to move to medications 8:31. At BMI 49, multiple discussants agreed medication alone is insufficient and surgery must be the primary discussion 5:34.

Where Practice is Contested

The panel split on whether a 12-year-old at BMI 49 who has stabilized weight in a management program should proceed directly to surgery or trial pharmacotherapy first 5:34 6:27. The majority favored surgery, citing the BMI threshold data 5:34. The dissenting view — using medication as a bridge to allow patient maturation — reflects legitimate uncertainty about developmental readiness versus disease urgency 6:27. There is no randomized trial to resolve this.

Sugar taxation as public health policy divided the group 14:33 15:08. One discussant questioned its effectiveness, noting that obesity is multifactorial 15:08. Another flagged the regressive nature of such taxes depending on socioeconomic class 14:33. The disagreement reflects broader tension in obesity medicine: whether to address the food environment or focus resources on clinical intervention.

Disordered Eating in This Population

Nearly all severely obese adolescents exhibit disordered eating patterns — daytime restriction followed by evening overeating 21:18 — though frank eating disorders meeting diagnostic criteria are rare, under 5% in one screening series 21:33. When screened objectively, most severely obese patients meet criteria for binge eating disorder even without prior diagnosis 19:53. Bariatric surgery appears effective at extinguishing these behaviors 20:40, though patients with prior diagnosed binge eating disorder may carry higher risk for weight regain 21:03. The clinical implication: disordered eating is nearly universal in this population 22:20 but is not a contraindication to surgery 20:40 21:03.

When to Involve This Team

Refer when BMI reaches the high 30s and conventional management has failed after 3-6 months of structured intervention 3:59 8:31. Refer urgently when BMI approaches or exceeds 50, as surgical efficacy declines steeply beyond that threshold 3:05 3:32. Refer immediately for hypothalamic obesity regardless of BMI, as this population requires specialized pharmacotherapy and surgical planning 9:32. The referral is not for surgery alone but for access to the full treatment continuum — medications, behavioral support, and surgical expertise — that severe pediatric obesity demands 7:56.

Takeaways from this story

Surgical efficacy drops sharply above BMI 55 — only 14% reach healthy weight versus better outcomes in the 40s range.
Hypothalamic obesity requires dexamphetamine pre- and post-op due to biological drive to regain weight that differs from other patients.
Nearly all severely obese adolescents show disordered eating patterns, but frank eating disorders are rare (<5%).
Pharmacotherapy serves dual roles: bridge to surgery for patient maturation and ongoing adjunct therapy post-operatively.

Timing Bariatric Surgery in Adolescents: When Earlier Intervention Determines Outcome

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

The BMI 50 threshold: a point of diminishing returns

The conversation about bariatric surgery timing should begin when BMI reaches the mid-30s, not when a patient crosses into extreme obesity 3:59. This early discussion matters because the probability of achieving healthy weight post-operatively declines sharply at higher starting BMIs. Patients with BMIs in the 40s will predictably achieve BMIs below 30 after surgery 0:56. But once BMI exceeds 55, only 14% reach that target 3:05. The 50-55 range represents an inflection point: above this threshold, the probability of mitigating risks associated with severe obesity becomes challenging 3:32. By BMI 49, one discussant states that medications are no longer the appropriate intervention 5:34. The window for optimal surgical outcomes narrows as weight increases, making early identification and intervention the difference between predictable success and uncertain benefit.

Pharmacotherapy as bridge, not substitute

Medications serve two distinct roles in severe pediatric obesity, and conflating them leads to treatment delays. For a 12-year-old at BMI 49, topiramate and phentermine can buy time for psychological maturity before surgery, not replace it 6:27[q4]. This is bridge therapy — acknowledging that surgery is inevitable while addressing developmental readiness. The second role is adjunctive: some children will require pharmacotherapy even after bariatric surgery 7:20. Obesity is heterogeneous, and response to any single intervention varies widely 7:56. The treatment approach must be continuous, escalating based on individual patient needs rather than following a rigid protocol [q6]. If healthy living proves insufficient after 3-6 months in a structured program, the next step is medications; if medications prove insufficient, the next step is surgery 8:31. The error is not in using medications — it is in using them when the BMI has already passed the range where they can achieve the necessary risk reduction.

Hypothalamic obesity: when biology defeats surgery

Patients with hypothalamic obesity following brain injury represent a biologically distinct population that requires recognition before surgical planning 9:32. These patients have a drive to gain weight that can defeat bariatric surgery, profoundly different from obesity without neurologic injury [q8]. They often require dexamphetamine both before and after surgery — not as a bridge, but as ongoing management of a fundamentally different disease process. The lesson is not that surgery fails in this population, but that surgery alone is insufficient. Recognizing etiology-specific treatment needs prevents the error of applying a standard approach to a non-standard problem.

Disordered eating versus eating disorders: a clinical distinction that matters

Nearly every obese adolescent exhibits disordered eating — daytime restriction followed by evening overeating is the common pattern 21:18. But frank binge eating disorder meeting DSM diagnostic criteria appears in fewer than 5% of new patients when screened 21:33. The distinction matters for two reasons. First, most severely obese patients will meet objective criteria for binge eating disorder when screened, even without prior diagnosis 19:53. Second, bariatric surgery effectively extinguishes these binge behaviors in most cases 20:40, though patients with prior diagnosed binge eating disorder may face higher risk for weight regain 21:03. Disordered eating applies to nearly every obese patient, even when it does not meet formal diagnostic thresholds 22:20. The clinical implication: screen for eating pathology, but do not withhold surgery based on disordered eating patterns that are nearly universal in this population. Reserve referral to eating disorder programs for the rare patient whose restriction becomes so severe that fear of eating drives weight loss.

The systemic barrier: insurance limits on chronic disease management

Private insurers are limiting dietitian visits to three per year 13:36. For a chronic disease requiring continuous behavioral support, this restriction undermines the foundation of non-surgical management. The discussants do not dwell on this point, but it explains why the conversation about surgery must begin earlier: if the infrastructure for intensive lifestyle intervention is unavailable, delaying surgery while BMI climbs into the range where outcomes worsen is not conservative management — it is neglect.

Takeaways from this story

BMI >50-55 reduces probability of reaching healthy weight post-surgery to 14%; intervene in the 40s when outcomes are predictable
Hypothalamic obesity defeats surgery through biological drive to gain weight; requires dexamphetamine before and after operation
Disordered eating is nearly universal in obese youth, but frank binge eating disorder <5%; surgery extinguishes binge behaviors
Pharmacotherapy serves as bridge to surgery for maturity or as adjunct post-op; obesity requires continuous escalation, not single fix

When to Operate on a 12-Year-Old at BMI 49: Medication Bridge vs. Immediate Surgery

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Clinical Scenario

A 12-year-old patient presents with BMI 49, engaged in treatment, having stabilized weight after six months in a structured program but achieving no reduction 8:31. The question: proceed directly to bariatric surgery, or trial pharmacotherapy first?

The Case for Immediate Surgery

Multiple discussants favoured proceeding directly to surgery at this BMI and age 3:59 4:17. The rationale rests on three converging concerns. First, BMI 49 already approaches the threshold where surgical outcomes deteriorate sharply — patients above BMI 55 have only about 14% probability of achieving BMI below 30 postoperatively 3:05, and once BMI crosses 50, mitigating the risks associated with severe obesity becomes challenging 3:32. Waiting risks crossing into a weight range where surgery itself may fail to achieve adequate risk reduction.

Second, at this severity, medications are unlikely to produce the magnitude of weight loss required to meaningfully alter trajectory 5:34. The conversation about surgery should begin when BMI reaches the mid-30s 3:59; at BMI approaching 40 with comorbidity, the discussion should emphasize surgery's superior results 4:17. By BMI 49, that conversation has become urgent rather than anticipatory.

Third, delay carries metabolic and psychosocial costs that compound with time. The patient has already demonstrated six months of maximal engagement with lifestyle intervention, achieving only stabilization 8:31. Further delay without a high-probability intervention extends the duration of severe obesity and its complications.

The Case for Pharmacotherapy as a Bridge

One discussant argued for trialling topiramate and phentermine before surgery, acknowledging the patient would "undoubtedly need surgery" but seeking to "buy him a little bit of time to gain some maturity" 6:27. The rationale here is developmental rather than strictly medical. A 12-year-old, even one engaged and motivated, may benefit from additional time to develop the cognitive and emotional capacity to navigate the permanent anatomic and behavioural changes bariatric surgery demands 6:27. Pharmacotherapy, even if producing modest weight loss or further stabilization, serves as a bridge to a more developmentally appropriate surgical timing.

This position also reflects a stepwise treatment philosophy: escalate interventions sequentially rather than leapfrogging to the most invasive option, particularly in a young adolescent 6:27. The discussant noted that some children will require pharmacotherapy even after surgery 7:20, suggesting that starting with medication does not foreclose surgical options and may clarify which patients respond to less invasive approaches. The emphasis is on intervening promptly while respecting the patient's developmental readiness 6:27.

Where They Converge

Both positions agree on several critical points. First, this patient requires escalation beyond lifestyle intervention alone — six months of engagement with weight stabilization but no loss establishes that healthy living is insufficient 8:31. Second, surgery is likely necessary for this patient; the disagreement is about timing, not ultimate treatment 6:27. Third, obesity is a heterogeneous disease requiring individualized, continuous treatment with escalation based on patient response 7:56. The discussant advocating for medication explicitly stated the patient would need surgery 6:27; those favouring immediate surgery acknowledged that some patients require pharmacotherapy postoperatively 7:20. The difference is sequencing, not destination.

Fourth, both positions reject the notion that any single intervention represents definitive treatment. "Just because you have surgery doesn't mean you're done" 7:20 — the chronic disease model applies regardless of which modality is used first 7:56.

What Would Resolve It

The discussants did not identify specific evidence that would settle this question, likely because it hinges on factors difficult to capture in trials: individual patient maturity, family dynamics, psychological readiness, and the clinician's assessment of whether a 12-year-old can sustain the behavioural demands of postoperative life 6:27. The disagreement reflects legitimate clinical judgment about developmental timing in a patient who clearly needs aggressive intervention but whose age introduces uncertainty about optimal sequencing 6:27 7:56. A trial comparing immediate surgery versus medication bridge in young adolescents at extreme BMI could provide outcome data, but the decision would still require individualized assessment of readiness — a dimension that resists protocolization 7:56.

Takeaways from this story

Above BMI 55, only 14% achieve BMI <30 postoperatively — waiting risks crossing into a range where surgery itself fails
Pharmacotherapy may serve as developmental bridge in young adolescents, buying time for maturity even when surgery is inevitable
Both approaches agree obesity requires continuous escalation; disagreement is timing, not whether surgery is ultimately needed

Keywords

pediatric obesity hypothalamic obesity binge eating disorder eating disorders anorexia bulimia insulin resistance brain injury bariatric surgery topiramate phentermine metformin Vyvanse dexamphetamine liraglutide

Hashtags

#BariatricSurgery #PediatricObesity #WeightManagement #BMI #Pharmacotherapy #NutritionServices #HealthRisks #QualityOfLife #ChronicDisease #InsuranceReimbursement #PreventativeHealth #Surgery #PatientEngagement #EvidenceBasedPractice #ObesityTreatment #PsychologicalSupport #Metformin #Topiramate #Phentermine #HealthCare #ChildhoodObesity

Transcript

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.

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