Management of Pediatric Obesity – PediaCast 225

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Dr Ihuoma Eneli and Dr Marc Michalsky join Dr Mike in the PediaCast Studio for a comprehensive look at pediatric obesity. We cover the scope of the epidemic, reasons for the trend, genetic and environmental variables, medical management, and the role of bariatric surgery in the pediatric population.

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  • Medical and Surgical Management of Pediatric Obesity

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Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!

Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. It is episode 225 for September 5th 2012. Management of Pediatric Obesity.

So, the title, I guess it's a little clinical, isn't it? Management of Pediatric Obesity. Of course, we're going to have information geared toward clinicians, but we're also going to have lots of good material for moms and dads out there. So maybe a better title would have been what to do to prevent your children from becoming overweight or what to do when they are overweight, because we're going to talk about all of those things.

We all know that obesity is on the rise and some say it's reached epidemic proportions and I think that's true. We see it in children, in teenagers and adults, but just how big is the problem? Why have obesity rates tripled in nearly every developed country since the 1960s? And why is it that obesity is beginning to outpace malnutrition in underdeveloped parts of the world?

01:42

Today we're going to define the scope of the obesity epidemic and take a hard look at the cause, the causes because there's more than one, of this disturbing trend. We're going to break down the medical problems associated with being overweight, which will soon surpass tobacco products as the leading cause of premature death in Americans.

We'll talk about what you can do to prevent obesity in your children. And if your kids are already obese, we'll talk about the medical management of weight control, including a look at diet, exercise, healthy choices and your environment. But what if you've already tried medical management and it's not working? Especially when your child has complications like hypertension and type 2 diabetes, you've probably heard about the option of bariatric surgery for adults, procedures like gastric bypass, gastric sleeves and laparoscopic gastric banding. But, are these procedures safe for teenagers? What benefits do they serve in the short-term and the long-term? And what risks and complications exist? And the bottom line is how do you weigh the benefits versus the risks in your own child?

02:44

Who would help me answer these questions and lots more? We have two great guests joining me in the studio today, Dr. Eneli, MD, is the medical director for the Center for Healthy Weight and Nutrition here at Nationwide Children's Hospital and Dr. Marc Michalsky, MD, is the surgical director of our Bariatric Surgery Program. They'll be joining me in just a moment.

First, I want to remind you that the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, make sure that you call your doctor and arrange a face-to-face interview and hands-on physical examination. Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org.

I also want to remind you that this is very much an audience participation type of show. So if you have a topic idea or if you have a specific question for me, just head over to pediacast.org, you can click on the Contact link and let me know, I read every single one of those that pass through. Also, you can also email pediacast@gmail.com. If you go that route, make sure you mention your name and where you're from because we're nosy like that. You can also use the voice line at 347-404-KIDS. 347-404-K-I-D-S to leave a message and we'll get your voice on the show.

04:06

All right. So let's turn our attention now to our studio guests today, two of them, Dr. Eneli, first, is the medical director of the Center for Healthy Weight and Nutrition at Nationwide Children's Hospital and she's also an associate professor of pediatrics at the Ohio State University College of Medicine. As medical director of our Weight Center, Dr. Eneli oversees the assessment and medical weight management of overweight and obese children and teens. She also participates in clinical research on medical weight management interventions, particularly from the health care provider's perspective. This is Dr. Eneli's first visit to the PediaCast studio, so let's offer a warm welcome to the program, thanks for stopping by.

Dr. Ihuoma Eneli: Thank you, Dr. Mike.

Dr. Mike Patrick: And Dr. Marc Michalsky is another PediaCast newbie. He is the surgical director of the Bariatric Surgery Program at Nationwide Children's Hospital and an associate professor of surgery at the Ohio State University College of Medicine. Dr. Michalsky's team currently performs gastric sleeve, gastric bypass and laparoscopic adjustable gastric banding procedures on obese teenagers. He also serves as a clinical investigator on several national institutes of health research initiatives, examining outcomes following surgical weight reduction procedures in the morbidly obese adolescent population. So a warm PediaCast welcome to you as well.

Dr. Marc Michalsky: Good morning, Mike. Thanks for having me.

Dr. Mike Patrick: Yeah. I appreciate you stopping by. Dr. Eneli, let's start with you. If you could just give us a definition of what is meant by the term obesity? What constitutes being obese?

Dr. Ihuoma Eneli: So, obesity is defined using a Body Mass Index. Body Mass Index is really a measure of your weight given your height. We measure your weight, we get a height assessment and we plug it into a little formula and we come up with a number. In the pediatric population, we use a growth chart because that body mass index number we come up with has to be plotted against your age and your gender. If a child on the body mass index chart, which is a growth chart, is above the 95th percentile, we say they're obese. If they are between the 85th and the 94th percentile, we say they are overweight.

06:22

Dr. Mike Patrick: Now, I think this is interesting. If you look at it that way then that means 15% of the people would be obese, but we know more are obese than that and it's because these charts used kids whose measurements were taken back between 1963 and 1970. So it's kind of interesting when we come with these percentiles or sort of comparing kids to what it used to be before we saw this explosion of obesity.

What about your people talk about this being an epidemic, is it really an epidemic in your mind?

Dr. Ihuoma Eneli: I believe it is an epidemic. When you look at an epidemic it means that it's widespread disease. We've seen it more often than we would expect in a population. And that's what we've seen with obesity. At the beginning of PediaCast, you talked about the tripling rates of childhood obesity. So in the 1980s we saw rates as low as seven to eight percent in children between six and 18 years old. Now, we're close to rates that are about 18, 19%.

Dr. Mike Patrick: Wow.

Dr. Ihuoma Eneli: And that tripling rate tells us that it's definitely widespread and much more than we would expect.

Dr. Mike Patrick: Yeah. Another interesting and we do have PediaCast listeners really all over the globe and lots of different countries that tune in and so this isn't something that's just isolated to United States. We're really seeing this around the world and I had mentioned that according to the World Health Organization overweight is becoming more of an issue even than malnutrition in some underdeveloped countries. That's pretty incredible, really.

08:04

Dr. Ihuoma Eneli: It is. When you look at the history of malnutrition in the last 50 years, it's a little confounding to see how obesity's overtaken it. However, when we go to developing countries or the countries around the world we see that environment has also changed.

Dr. Mike Patrick: Sure.

Dr. Ihuoma Eneli: The expectations of children in terms of what their food should look like. The explosion of fast food restaurants around many corners of streets. All those things add up and probably to a large extent explain the rise we're seeing across the globe.

Dr. Mike Patrick: Sure. And we shouldn't assume that overweight kids in developing countries are well-nourished. I mean, they're still malnourished. You can be malnourished and obese at the same time.

Dr. Ihuoma Eneli: I agree. And actually that applies to overweight kids everywhere, including the United States.

Dr. Mike Patrick: Sure. Yeah. So what factors affect weight? I mean, how do we become overweight and obese? What factors are involved there?

Dr. Ihuoma Eneli: When we work with kids and families in our center, we tell them that weight is a scale and on one side of the scale is the energy we put in to our body. On the other side of the scale is the energy we spend and that energy is really, we're talking about calories. So we get our calories from the food we eat and what we drink. And we spend our energy by being physically active, but perhaps even more importantly we're able to spend our energy by being alive, so breathing, having your heart beat, making urine, making poop, thinking, sleeping. All those things allow you to spend energy. It's when the calories that go and the calories that come out do not balance each other. Consistently, overtime that we see weight gain happen.

Dr. Mike Patrick: Sure. Now, it is a little bit more complicated in that if you took two kids and gave them the same number of calories and the exercise the same amount, you might have a little bit of a difference in their weight. Talk a little bit about why it's so different from one person to another.

10:20

Dr. Ihuoma Eneli: So that's a great observation and sometimes in families it's puzzling because you have two siblings and one is carrying a little extra weight and the other is normal weight. We know there is an interaction between the genes and the environment. We also know that even though I talked about weight being a scale, the energy in and energy out is the bottom line and there are many processes that lead to that energy in and energy out.

Our genes are pretty much what we inherit from our parents and they are in some instances little tweaks, that's what I call them, little tweaks in our genetic material that may increase the likelihood that we can gain weight either by the way we metabolize the food or the way our energy expenditure works out.

Dr. Mike Patrick: Sure. So you'd say folks who tend more toward obesity their metabolism is actually probably better, I mean it's more efficient than kids who don't tend toward that because they can sort of, I'm kind of simplifying it a little bit, but they can use less energy to do the same thing and so more of the energy than has to get stored as fat.

Dr. Ihuoma Eneli: So, I think that right now when you look at the research that's out there there is not a definitive answer too. It would be nice to simplify but it's not that simple.

Dr. Mike Patrick: There are lots of complex interactions.

Dr. Ihuoma Eneli: There are lots of complex interactions and lots of things that happen in the prenatal period that we're still studying. So it's difficult to make it a simple equation.

Dr. Mike Patrick: Right.

Dr. Ihuoma Eneli: But I think regardless of whether we have what we call the "garden variety" obesity, which is the tiny tweaks, versus if you have a defect in a single gene. So there are some people, very few people in a population, who will have a defect in a single gene, the most common being the Prader-Willi syndrome. And in those cases we see children who have difficulty feeding and with growth in the first year or two of life.

And then they begin to gain weight dramatically. That is very rare. What we seem to have is this "garden variety" obesity that to a logic stand is determined by what we're doing with our diet and our energy expenditure.

12:39

Dr. Mike Patrick: Right. In addition to genetics, also playing a role the environment that someone's in, what kind of diet the family eats, what are the priorities for exercise in that family, that can play a role as well.

Dr. Ihuoma Eneli: Yes. Absolutely. I think that's really where we target when we look at managing childhood obesity. If you are consuming large amounts of your calories from sweetened drinks, even from excessive amounts of 100% fruit juice, you will put in more calories in most case over time than what you're spending. If you have lack of access to healthier food options; you live in a neighborhood that's unsafe and it's difficult to be active. If you have parents that are not necessarily active so they don't serve as role models. All these things are risk factors for eventually adding a little extra weight.

Dr. Mike Patrick: Sure. So we have lots of issues and factors that can contribute to this. So let's say that someone is overweight, for whatever combination of those reasons, what medical risks and the complications are associated with obesity? Why is being overweight a problem?

Dr. Ihuoma Eneli: So we worry about being overweight because of the serious comorbid conditions that go along with obesity. And we're seeing more and more kids with these conditions and this includes insulin resistance where your body really doesn't process the sugar that it gets in the proper fashion; type 2 diabetes, which previously we used to call adult-onset diabetes; sleep apnea; high cholesterol; musculoskeletal problems.

We also note that a lot of these kids have psychological problems, so they're at risk for low self-esteem and other children bullying them and they themselves being bullies. Discrimination. And all these things together increase the risk for lower quality of life for them. Perhaps, even more importantly is that obese children are at much higher risk of eventually becoming obese adults. And the older the child is carrying extra weight, the more likely they are to end up being an obese adult.

15:03

Dr. Mike Patrick: So this is really a problem you want to deal with in childhood and it can really affect that person for the rest of their life.

Dr. Ihuoma Eneli: I believe so. The best age, we always say the best age is on the five in order to address it. But every age really you can make a turn around.

Dr. Mike Patrick: Sure. Let's talk a little bit about the medical management of weight. So you have a child who is obese and the family and the child are interested in reversing this, how do you medically manage obesity?

Dr. Ihuoma Eneli: The first step is to look at their body mass index. Work with the families around the growth chart and that's what your pediatrician will do. We want to be sure that we all agree that this is a problem and that that is something that they are ready to address. Once we're able to do that, we screen for the complications we just talked about and then the American Academy of Pediatrics recommends lifestyle modifications and this is talking about eight evidence-based messages – decreasing TV viewing, increasing physical activity, decreasing portion sizes, sweetened drinks, teaching families about balanced meal, so what we now call "my plate", whether we're increasing the fruits and vegetables that they have – so these are all their lifestyle behavior changes that we work on.

Dr. Mike Patrick: Sure. So, we can't change our genetics, so that metabolism component of it there's not a lot you can do with that. But we can change the calories coming in and the calories going out and we can change aspects of the environment that cause there to be more calories in and less calories out.

Dr. Ihuoma Eneli: That was very well said.

Dr. Mike Patrick: Oh. Thanks. I like to nutshell things. Back several ago, we sort of more in vogue I think than it is now although I've been a few years out of primary care. People would talk about is there medicine. Is there some kind of medicine that you can take to lose weight? And we've heard about diet pills, is there any role for that in pediatrics?

Dr. Ihuoma Eneli: There is a role for medicine in pediatric obesity. It is a very, very small role and for a small number of patients and this is within a medically supervised program.

17:37

Dr. Mike Patrick: Sure.

Dr. Ihuoma Eneli: Just like there is a role for special diets. So for instance, for very large kids that need to lose weight because they have serious comorbid conditions like pseudotumor cerebri where you have increased pressure in the brain, we may consider special diets that spare the protein and decrease the calories and the carbohydrates for instance. We haven't discounted those two, the American Academy of Pediatrics recommends where it is necessary that it's done in a medically supervised environment.

Dr. Mike Patrick: Yeah. And I would say that a medically supervised environment with a focus on pediatrics, because there are certainly a lot of weight loss clinics out there that focus on adults, but really teenagers should be seen by a pediatric specialist not an adult specialist, would you agree with that?

Dr. Ihuoma Eneli: I absolutely agree with that and I'm sure Dr. Michalsky does too.

Dr. Mike Patrick: And speaking of Dr. Michalsky, yes he is in the studio. Let's talk a little bit about the surgical option. First, I guess let's define what is bariatric surgery.

Dr. Marc Michalsky: Sure. Thanks again, Mike. So, bariatric surgery is a general terminology used to describe a number of different operations that are designed to create a anatomic environment that promotes weight loss. And really this type of surgical application has been around and has evolved since the early 1960s and really has resulted in probably about a half a dozen different types of operations that are available to the general public.

19:15

Dr. Mike Patrick: When is someone a candidate for that kind of procedure?

Dr. Marc Michalsky: That's an interesting question. I think you really have to address a couple of different issues before you can really come up with a simple answer to that. And if you look at the adult population and a lot of what we're doing adolescent bariatric surgery is with consideration of what's going on in the adult world and has resulted in an extrapolation of adult bariatric care.

In the simplest terms, in an individual and this goes for adults and adolescent patients, to be a candidate for bariatric surgery you have to be at least 100 pounds above your ideal body weight. Dr. Eneli touched on the concept of body mass index and there are some very specific criteria for what body mass index or BMI that you need to be before you could be considered for bariatric operation and without getting into the specific details and the differences between BMI categorization for adults versus kids, generally speaking, you would not be considered for bariatric operation unless your body mass index is at a minimum 35 kilograms per metered square.

Dr. Mike Patrick: So this is not something someone picks up the phone and calls a bariatric surgeon and says hey, I want to get in and get this done. It's really done in coordination with weight loss program like we have here at Nationwide Children's.

Dr. Marc Michalsky: Yeah. That's right and it's a really good point. Dr. Eneli and I have worked together for years now and in a very coordinated manner, which is one of the benefits of our program here at Nationwide. Our typical patient that is considered for a bariatric operation is someone that has spent a considerable amount of time, minimum six months and sometimes much longer than that, working under the direction of somebody like Dr. Eneli or their primary care network to attempt to lose weight.

Really, it is a very challenging issue for many, many of these patients that if you look at the data that's available, in many situations and certainly in the adult population as well, the probability of losing weight, not only losing weight but maintaining weight loss, when you've achieved this sort of weight is very discouraging. So typically, these are not people that have just jumped in over a weekend and decided they wanted to undergo a bariatric operation.

21:53

Dr. Mike Patrick: Right. This is something they've been dealing with for a long time and they've really put the effort into the medical management of it.

Dr. Marc Michalsky: Very much so.

Dr. Mike Patrick: So what kind of surgical techniques? What are the most, there are lots of them, but what are the most common ones being used in teenagers today?

Dr. Marc Michalsky: Right. And as I mentioned, there are probably half a dozen or so operations across the board. In the adolescent population it's really trickled down to about three and those three happen to be the three most common operations that are performed not only in the United States but globally as well. They include the gastric bypass, the adjustable gastric band and laparoscopic sleeve gastrectomy, which you've mentioned.

Interestingly though, there's been sort of an evolution of the operations that we are performing since we started performing bariatric surgery here in Columbus, which has been about 10 years now, and we've seen sort of a shift from one operation to another to another. It's certainly reasonable to assume that this issue hasn't necessarily settled down on what is the one best operation. I think that it really depends upon who the patient is and the family, environment and we know we try to make a decision together as to what the optimal operation will be.

23:09

Dr. Mike Patrick: Yeah. With each of those three, can you just describe briefly what's involved with each of those?

Dr. Marc Michalsky: Sure. I start with the definition of a bariatric operation looking at the gastric bypass and the reason for that is that really is the operation that we know the most about. It's been around for the longest period of time and the results are fairly predictable. It also tends to be one of the more invasive operations.

But basically, what is done is the stomach itself is divided and made into a very small pouch, typically the size of a clenched fist, and that pouch can accommodate about an ounce of fluid at any given time. And that pouch is then connected to a portion of the small bowel and that actually is the definition of the term bypass.

We actually bypass about a third of the small intestine. And by doing so, you wind up with an operation that restricts the amount of calories that can be consumed because you have this very small pouch. And you've also limited the amount of calories that can absorbed given the amount that's been taking in because you've bypassed about a third of your small intestine and that's where many of your calories or most of your calories are actually absorbed into your system.

Dr. Mike Patrick: Sure.

Dr. Marc Michalsky: The next operation is the adjustable gastric band and that's an interesting operation. It distinguishes itself from the other two in several ways. The first is that it actually involves a device and this is a device that is wrapped around the top of the stomach like a buckle. I think that's the best way to think of it. And what that results in is that essentially creates a pouch not dissimilar to what I've just described in the gastric bypass.

The interesting thing about that buckle is on the inside of it is a balloon. That balloon is connected to some tubing, which is connected to a small reservoir or port that sits under your skin and that port can accommodate some fluid/water or saline and that can adjust or change the size of the balloon, which can tighten or loosen the size of the pouch that you've just created and in essence can modify the amount of food or calories that you can consume in any given time.

25:39

Compared to the gastric bypass, the adjustable gastric band is also effective at losing weight. It takes a bit longer to get to the ideal post-operative weight that you're aiming for. And then the other distinguishing factor is that this device can be removed. I'm often asked by patients and families if all the weight has been lost when you've had a gastric band procedure, is it then probable that you'll have your band removed and the answer to that is no.

What we do know about those operations is that if you do remove a band people tend to regain their weight. So even though it's considered removable, I'd like to describe it more as a permanent operation.

Dr. Mike Patrick: Sure. And then you don't get the non-absorptive benefit that you do with the gastric bypass?

Dr. Marc Michalsky: Well, you not only don't get the non-absorptive benefit, but you also don't get the non-absorptive complications that occur with something like a gastric bypass. And we're very upfront when we talk about these operations to describe the potential complications that can occur including vitamin and protein malnutrition and those are much less likely when you had something like an adjustable gastric band.

Dr. Mike Patrick: Sure.

Dr. Marc Michalsky: And the last operation is the laparoscopic sleeve gastrectomy or gastric sleeve. In simplest terms, what we do in that operation is we turn the stomach essentially into a long tube and that results in really excellent weight loss. That's an operation that's been gaining a lot of interest and popularity over the last five to seven years ongoing. Actually, it originated or was part of a much larger operation that is considered inappropriate for the adolescent population.

It has the benefit of having excellent weight loss. In some cases, just as robust and effective as the gastric bypass, but without many of the potential complications that I just mentioned, including vitamin and protein malnutrition.

27:43

Dr. Mike Patrick: In trying to do my research for this episode, I came across an investigational technique called the intragastric balloon that apparently is being used in some other countries but has not been approved for use by the FDA. Do you know anything about that?

Dr. Marc Michalsky: Yeah. The first thing I would say is everything old is new again. Intragastric balloon is not a new concept although we are seeing a revised or revived interest in this type of technology. It's currently not approved for the adolescent population and as you said it is even considered investigational device or procedure for the adult population although it has been used much more frequently in Europe.

I think it is an encouraging potential procedure and may ultimately trickle down to the adolescent population. Whereby, endoscopically you insert a balloon into the stomach and that essentially results in a very simplistic way of creating calorie restriction by limiting the amount of food that can be taken in. So, that's a procedure that is on a horizon potentially for the adolescent population. Something to watch out for.

29:01

Dr. Mike Patrick: So let's say someone has bariatric surgery, in terms of short-term outcomes, what can they expect?

Dr. Marc Michalsky: I would go back to some of the comments that Dr. Eneli made with regards to the degree of comorbid illnesses that we see in this population. I'd like to remind everybody when we start talking about this that these are not procedures that are really meant to be looked at from the superficial sense in terms of just the pure weight loss. And obviously, that has some legitimate cosmetic implications with regards to how people look and feel. But I think more importantly it has tremendous implications with regards to what happens to the comorbid diseases that occur.

So in the short-term, we see a dramatic change in many of the comorbid illnesses. As an example, patients that come in sometimes on anti-hypertensive medications or medications for insulin or are patients that suffer from sleep apnea and require the application of a breathing device, we see a dramatic change as early as one to two weeks after these operations. And interestingly, that's a time period where the typical patient has to lose a tremendous amount of weight and it just really I think exemplifies what we've already observed in medical weight loss that it doesn't take much weight loss to see a very significant change in many of the comorbid conditions.

So, many of these patients see a very dramatic change not only in their body but in their lifestyle based on whatever pharmacologic therapy they're required to administer as a result of their comorbid illnesses and this can be quite striking.

Dr. Mike Patrick: So, not only they lose weight, but if they had lipid problems, high-blood pressure problems, diabetes, reflux, obstructive sleep apnea, those things really do reverse in the short-term.

Dr. Marc Michalsky: Yes.

Dr. Mike Patrick: What about long-term? Do those things stay away or do we know yet?

31:08

Dr. Marc Michalsky: Yeah. Well, both good questions. So, anecdotally and in an institutional level, it does appear that many of the benefits that we're seeing are durable, meaning that they improved and remain improved. There are several studies going on right now including a large National Institutes of Health study that we're involved in looking at long-term five and ten-year results from these patients. And the data is looking promising in terms of these types of questions and there is an expanding body of literature that's available right now.

In many instances, single institutional reports of relatively small and relatively small meaning less than 100 patients showing that not only are these operations safe and effective but that the benefits are long-lasting.

Dr. Mike Patrick: Good. We talked briefly about risks and complications associated with bariatric surgery in particular with malnutrition with particular procedures. What other risks and complications are possible?

Dr. Marc Michalsky: Sure. Well, these are not small operations and there are a composite of what we call paraoperative risks, the risks of anyone undergoing any sort of major abdominal operation and we try to mitigate those risks by doing some very straightforward, well-established risk-reduction procedures. Things that I'm talking about are bleeding, blood-clots, wound infections, things like that, again that are very general and really any patient adult or adolescent undergoing any major surgical operation have to deal with.

I think the other way to look at this question goes back to the way that we assess these patients and back to where originally we're talking about in terms of the type of engagement that a patient likely has before they undergo one of these operations.

During that pre-operative period where we're working with the patient and the family, we perform a very, very thorough history examination and we work with these patients and their primary care providers so that we wind up with a very, very thorough understanding of what comorbid conditions these patients have and then work to optimize those.

As an example of what I'm talking about it for instance, occasionally, we'll find a patient that has untreated hypertension or untreated sleep apnea and those are the risks that really need to be fully understood and optimized before a patient goes to the operating room. And again, for any operation not just the bariatric procedure.

34:07

Dr. Mike Patrick: Sure. I also sort of came across in doing the research for this, there is I think a why statement and that was the rate of complications you expect them to be reduced in the hands of an experienced surgeon. So this is a sort of procedure that you want done by someone who does lots of them and manages the post-operative care of lots of these kids. Would you agree with that?

Dr. Marc Michalsky: Oh, I would. This is specialty surgery and the folks around the country and internationally that do these operations have tended to focus their practice on the surgical treatment of childhood obesity. So yeah, I'm one of two people here in Columbus that perform this operation. But I think your point is accurate and I think more importantly than that I think it's very important that there be a multidisciplinary team approach to these patients. Not just the surgeon, it's the medical director, it's the dietician, the exercise folks, the behavioral folks, really it's an orchestra of people that are required to increase the probability of success.

Dr. Mike Patrick: Yeah. Dr. Eneli, back to you, we talked about this kind of a group of people, multidisciplinary approach, tell us a little bit about this Center for Healthy Weight and Nutrition here at Nationwide Children's. What sort of professionals are involved? It's not just the doctor, correct?

Dr. Ihuoma Eneli: Yes. It's not just the doctor. So the Center for Healthy Weight and Nutrition is a comprehensive obesity center. And that means that in addition to the medical management of obesity, we're also involved in community activities and prevention and advocacy. Because the most important thing about childhood obesity is that we have to involve the community in which they live in, as well as their families. And that community includes the schools too.

An example is our center is part of a national group, the National Institute of Child Healthcare Quality, healthy weight collaborative, which brings to get a public health, community organizations and primary care to address childhood obesity. And through that effort in the last year, we've been able to work on things like your healthy lifestyle plan that involves the parents, making goals for the whole family, working on healthy weight messages

We have launched an email and text program called "Feeding Your Kids" that is totally free and it's a nutrition-based program. We have also worked very closely with the community. Nationwide Children's Hospital is actually one of probably two children's hospitals that has a community garden onsite. And that garden is a wonderful opportunity for us to work with the kids that come to our center on hands-on growing, looking at plants and healthy eating.

37:16

Dr. Mike Patrick: Sure. So we have the physicians, you have dieticians, physical therapy, sports medicine, psychology, social work, I mean really multidisciplinary access to all of these things for patients who come in and see you.

Dr. Ihuoma Eneli: Yes. Our medical program has all these disciplines which is really that's our strength and recommended by the American Academy of Pediatrics. It allows us to offer both programs within the clinic as well as programs in a community at specialized gyms.

Dr. Mike Patrick: Sure

Dr. Ihuoma Eneli: And provide the support for the bariatric surgery that are kids get.

Dr. Mike Patrick: And we'll put a link to the Center for Healthy Weight and Nutrition here at Nationwide Children's in the Show Notes so that folks can find you, because there's a lot of resources, nutrition articles, exercise plans, parent and physician resources and of course referral information there too. So there are lots of goodies at the website that moms and dads can check out.

Dr. Ihuoma Eneli: Absolutely. I also would like to add that we, another component of our center is research, so Dr. Michalsky had talked a little bit about the bariatric surgery research that we're doing. We have a National Institute of Health study around self-regulation of intake with young kids. So that's one of the areas we promote because we think that perhaps when we look at intervention with children younger than five that may be a good way to go.

Dr. Mike Patrick: Sure. And really when you switch from the medical management and over to more surgical management that's really an individualized decision and you have to weigh the benefits and the risks and it's not an easy formula. You just have to take each kid individually and the family and the medical professionals together have to come up with that plan.

39:00

Dr. Marc Michalsky: Right. I think that's a very accurate way to say it. It's a team approach and a team decision and the family is an integral part of that team.

Dr. Mike Patrick: Yeah. What about third party pairs? Does insurance cover, I mean for folks to be evaluated in the Center for Healthy Weight and Nutrition and then for bariatric surgery, do you get push back from the insurance companies?

Dr. Ihuoma Eneli: So we do. Most of the medical visits that involve the physician is covered by insurances except for a co-payment, which is typical for any medical visit. We get some push back with our dieticians if they bill or our exercise specialist. One of the ways that we address that is to be upfront with the families when they're coming in and provide the information so they can check out what the benefits are through their insurance company.

Dr. Mike Patrick: That's just crazy to me. Because you're talking about changing people's lifestyles when they're seeing dieticians and sports medicine or physical therapist. I mean we know that if you can get the weight under control as a child that there's less chance for adult obesity and then how much is that insurance company is going to have to pay to deal with your hypertension and your high lipids and coronary artery disease and all of that.

Dr. Ihuoma Eneli: Now, it's interesting. The picture is slightly different for bariatric surgery and Marc may be able to add a couple of comments.

Dr. Mike Patrick: Sure

40:23

Dr. Marc Michalsky: Well, I think that it certainly can be challenging in the bariatric world as well. I think that we certainly have had the majority of our patients have received coverage but it is by no means an easy thing. And access to care, in general, for bariatrics not just in the adolescent population but the adult population as well is a challenging issue. I think part of the reason is that it's reasonable to assume that there are national guidelines that dictate who should be getting these operations, what the outcomes are, what the results should be.

Certainly, in the adolescent population that is still in development and in an evolutionary phase. So I think that it becomes a matter of education in many instances where as an example if we have a patient that has been denied by their insurance carrier, often times it requires some input from our center to the decision-makers and the medical directors at those institutions in order to have a decision reversed.

But I think your point is well said and connects to the number of the things we've been talking about in terms of it would make sense to take care of these things before they develop and balloon, why are we seeing insurance in sort of kicking the can down the road, so to speak. And there have been a number of studies that have suggested that the cost of medical care of obesity does cross the reduction of associated cost for groups of patients that have had a bariatric operation at some point during the post-operative period.

So economically, it probably makes sense. I think this is going to continue to be a struggle as we move down the road.

42:32

Dr. Mike Patrick: We really appreciate both of you stopping by. We'll have links not only to the Center for Healthy Weight and Nutrition but in particular the Bariatric Surgery Program at Nationwide Children's in the Show Notes. And I do want to point out you guys are willing to see folks from outside of our area. So if a family don't live near a children's hospital, and this is kind of unique, isn't it? Not all children's hospitals have a weight center like this and a bariatric surgery program. In fact, a few do, is that?

Dr. Marc Michalsky: Yeah. That's true. We really are one of the few in the United States. Probably if you look at the number of centers that are doing high volume, going back to the discussion earlier with regards to the experience of a group in a center like this, there probably are only about a half a dozen centers in the United States that provide these types of services. And this is very much regionalized care. So to your point, we are very happy to see folks from the Midwest and have done so and obviously our hospital here at Nationwide is well-suited to care for patients that come from far away.

Dr. Mike Patrick: Yeah. Very lovely Ronald McDonald house that we have.

Dr. Ihuoma Eneli: Yes.

Dr. Mike Patrick: So again, if folks out there are interested in hooking up with the Center for Healthy Weight and Nutrition here at Nationwide Children's Hospital, just head over to the Show Notes for PediaCast 225 and you'll find links to get you where you need to go.

So Dr. Michalsky, thanks for stopping by. We really appreciate you taking the time.

Dr. Marc Michalsky: Thanks for having me, Mike.

44:08

Dr. Mike Patrick: And Dr. Eneli, thank you as well.

Dr. Ihuoma Eneli: Thanks for having me.

Dr. Mike Patrick: Yeah. Absolutely. Also I want to thank all of the listeners out there for taking time out of your day to join us. We really appreciate it. Also, I want to remind you that iTunes reviews are helpful as our links on your webpages and mentions in your blogs, on Facebook, in your tweets and on Google+. Be sure to join our community by liking PediaCast on Facebook, following us on Twitter, tweeting with hashtag #pediacast and hanging out with us over on Google+.

And be sure to swing by the Show Notes at pediacast.org to add your comments on today's show. We also appreciate you telling your family, friends and neighbors about PediaCast. And don't forget to talk us up with your child's doctor at your next well check-up or sick office visit. We also have posters you can download and hang-up wherever moms and dads hang-out and you can find them over at the Resources tab at pediacast.org.

Once again, if you want to get a hold of me with a show suggestion or you have a question for the program, head over to pediacast.org and click on the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody.

[Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

 

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