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Caitlin Whyte: Welcome, you're listening to Pediatric Insights, advances, and innovations with Children's Health. I'm your host, Caitlin Whyte. Childhood obesity is a complex problem that increases the chances of children becoming overweight or obese as adults. It is a serious illness with serious side effects on physical, psychological, and behavioral health, including chronic conditions, such as diabetes, high blood pressure, liver disease, heart disease, and depression. The children's health bariatric surgical center works with adolescents and their families to address the problem of obesity. They identify candidates for weight loss surgery and provide the surgical medical, nutritional, emotional, and social support necessary for adolescents. Joining us for this conversation today is Dr. Faisal Qureshi, a Pediatric Surgeon at the Children's Health Bariatric Surgical Center, and an Associate Professor at UT Southwestern. Doctor, in 2019, the American Academy of Pediatrics changed the guidelines for pediatric bariatric surgery. Why is this so important and how did this affect the Children's Health Bariatric Surgical Center?

Dr. Qureshi: That's a very important question. The guidelines that we were previously using for children and adolescents for weight loss surgery were based along the adult guidelines that were created in 1991, where what physicians were recommending, were if you had a body mass index of greater than 35, or if you had a body mass index of greater than 40, and you had really significant metabolic problems, diabetes, high blood pressure, heart disease, and you were above the age of 14, then you would be considered for weight loss surgery. The difference that has arisen with these new guidelines is that instead of looking at the age of the child and also the body mass index of the level of obesity, what you're only going to look at, or what you should only look at is the metabolic profile. How sick is this child as a result of their obesity?

If you consider them to be ill from the problems of obesity, then you should consider referring them for weight loss surgery. And to be clear, weight loss surgery is now being redefined as metabolic and bariatric surgery. And that word metabolic is critical because it's not just about weight loss. It's about changing the way your body's behaving after you start losing that weight. This opens up children who are younger. So if you're 13, 11, 10, and you have significant complications of obesity, you should be referred for weight loss surgery. As an example, just recently, I saw a five-year-old who has significant obesity from a condition called Prater Willi Syndrome. As you can imagine, five is super young, but this five-year-old weighs 70 pounds. And is super sick from his obesity. He has high blood pressure and he has diabetes as a five-year-old. So this allows families, primary care providers, pediatricians, and surgeons to reevaluate their relationship with weight loss surgery. For these types of children,

Host: The American Academy of Pediatrics also states that severe obesity affects the health and well-being of millions of children and adolescents in the US. Bariatric surgery is an underused treatment option. Why do you think that's the case?

Dr. Qureshi: So, let's put it at numbers, the best data that we have that in the United States, which has a population of over 300 million people, of which over 70 million are under the age of 18, and of the 17 million, about 30% are obese or overweight. So 30 million kids, or 24 million children, roughly. In the United States, the best information that we have on an annual basis, only between 1,500 and 2,000 metabolic and bariatric surgeries are performed on children. And I'm going to say that again, between 1,500 and 2,000 children, only. In a state of Texas alone, there's about 300,000 kids who are either obese or overweight. Even if we say only 50% of those would qualify for weight loss surgery, that's 150,000 kids just in the state of Texas. And currently in the United States, only 2,000 kids are getting the surgery. So when you break down the reasons why this occurs, believe it or not, even in the year 2020 amongst pediatricians and primary care providers, they feel that obesity is a purely social problem.

It is not a medical problem. And they believe that families and the children and the patients should be able to lose 50 to a hundred pounds on their own. And this is documented. This has been studied. These are the attitudes of the primary care providers. And that's a challenge because you cannot expect a teenager and adolescent child to just go out and lose 50 or a hundred pounds on their own. I would challenge any adult to try and lose 50 or a hundred pounds on their own. On the adult side of things, adult providers, adult physicians, adult primary care physicians, family practitioner, internists, have learned that obesity is a disease that it should not just be treated by diet and exercise. That in appropriate circumstances, those patients who are obese should be referred for metabolic and weight loss surgery, because that's the only thing that actually works. I'll give you another example.

We know that children who have had weight loss and metabolic surgery cure their diabetes 80% of the time, whereas children who are managed under a conservative or non-surgical therapy with medications and diet and exercise, they continue to have diabetes at over 99% of the time. But sorts of question of attitudes, families can sometimes feel that they're failed in looking after their own children, by reverting to surgery, primary care providers feel that surgery could potentially be unethical or that it's an extreme measure that's been taken. But I think that's why the AAP guidelines are eye-opening because they're giving pediatricians permission to say, Hey, this is not your fault. The patient cannot lose this weight on their own. They cannot get to a healthier weight on their own. Please refer them often. Please refer them earlier for weight loss surgery.

Host: Now, what is the definition of severe obesity for adolescents?

Dr. Qureshi: So, the definition for adolescents is as follows. If you are on the growth chart and the CDC publishes growth charts for children, and it tells you for your height and your gender and your age, you're supposed to wait a certain number. But in children, because we have to do it based on percentile, you know, for example, a child could be 30th percentile for height and gender or 50th percentile. Anybody above the 85th percentile or heightened gender is considered overweight. And then if you are a hundred and 20th percentile of 95th percentile, then that's called class two severe obesity. And let me back up by saying, in order to be obese, you have to have greater than 95th percentile for your age and gender. So that's class one, class two is greater than one 20th and class three is greater than a 140th percentile and 95th percentile. So it's a complicated way that sometimes families don't understand, but I would ask our listeners to ask their pediatricians, to use the extended growth charts, which are readily available at most pediatricians offices and ask them, where am I on this chart? Am I above 85th percentile? If I am, then I'm overweight. If I'm above 95th percentile, then I'm obese. And then depending on how high above the 95th percentile you can be in class one, two or three obesity.

Host: Can you share the history of the Children's Health bariatric Surgical Center? How long has it existed and what medical professionals make the team a success?

Dr. Qureshi: So, we've been in existence since early 2016, and we are a collaboration between the surgical services and the medical services. We have a large team, which includes myself as the director of the weight loss and metabolic program. I have a physician assistant, who's the program coordinator. We have a psychologist, a social worker, and a dietician who worked directly for us. And then we have Dr. Gupta who is the medical director of the medical weight loss program. So what this gives us is a very unique way of helping children go through the process of metabolic and weight loss surgery. I'll give you a example. On the adult side, if I'm a 35 year old obese adult male, I go to a surgeon, the surgeon evaluates me, and then if I'm a good candidate, he or she books me for the procedure. On the pediatric side, because a obese child is not making decisions on their own most of the time, the family has to be heavily involved in the entire process. In order for me to assess the family structure, I rely on my social worker in order for our program to assess the psychology of the relationship between the patient and the family and the patient and their environment.

I have a psychologist. In order for me to understand, is the family willing to change the dietary habits for the entire household, my dietician helps me. And then lastly, Dr. Gupta, who's our medical director for the medical program evaluates the medical comorbid or medical complications of obesity. And we make sure that there are no other reasons for somebody to be obese. There are conditions, medical conditions that lead you to becoming obese like thyroid problems. And so we work in conjunction to make sure that we cover all the bases, make sure that the child and the family are well-prepared for the surgical intervention, work for success before the surgery and for success after the surgery. And I think that's a very unique thing that most good children's based metabolic and weight loss surgery programs need to have. I think that if you take a 13 year old or 14 year old or 16 year old to an adult surgeon who does adult operation 99.9% the time, that patient does not get the entire package that they should be getting, because we are not just concerned about the surgery, we're concerned about the results from the surgery and lifelong improvements in your overall health.

Host: So which patients are good candidates for bariatric surgery?

Dr. Qureshi: The best candidates are those with strong family support. That's critical to understand. If you have a family where you have four children and one of them is obese and requires weight loss surgery. The entire household has to shift their relationship to exercise and dieting because that's the only way the surgery is going to be successful. Now, having said that sometimes that does not happen and it often doesn't happen because a lot of the times the child comes from a diverse background and often the families struggling with weight related issues. So if your BMI, and I'm going to keep it very simple, is above 35. And you have significant medical complications of that obesity. You should be evaluated for surgery. Often pediatricians believe that, Oh, I'll only send the patient when their BMI is 45 or 50 or 55 or 60. And then I'll refer them for surgery. The issue with that is the bigger you are in terms of body mass index when I operate on you, I can only bring you down to a certain level. So let's say if you started at a BMI of 60, I can only bring you down to a BMI of 45, which still leaves you as a class three severely obese patient. So the best candidate for me is anybody above 35 with a medical problem related to obesity, send them to me because those are the ones that will have the lowest technical risk. And those are the ones which will have the longest term success.

Host: What should parents and patients expect when they are referred for an evaluation?

Dr. Qureshi: So, the biggest thing is that they're going to be seen by a lot of people. This is not a simple process. You have to be patient with us because we have to make sure that you and your family are good candidates for surgery. So from the time that a patient is referred to us to the time that they get surgery is usually between three and four months. And that's how long it takes us to evaluate the family and the patient completely get all the testing done. And then I'm sorry to say that we still have to get insurance approval. Insurance companies sometimes don't want to approve this procedure in children. And so all of that takes a fair amount of time to get done. Multiple evaluations, you will be seen by our program director two or three times. You will be seen by a dietician psychologist and social worker two or three times. And then depending on what we uncover, you may need other physicians or testing to be done.

Host: You mentioned insurance. And that leads me into my next question. Is this procedure covered by insurance?

Dr. Qureshi: It is most of the time, the insurance companies have learned that it is better to cover this as a procedure at a younger age, because it turns out that children who have, for example, diabetes, due to obesity will actually cure their diabetes at a faster rate than adults. So if you take a 50 year old adult who has diabetes and obesity and a 15 year old child who has diabetes and obesity, the 15 year old will cure their diabetes at a faster rate than the 50 year old, which makes sense, right? Because the 50 year old has probably had diabetes for much longer, has had more damage to their kidneys, to their eyes, to their joints, to their nerves. Where as a 15 year old doesn't have all those complications. And most of the time insurance companies do approve the process. I've had some insurance companies, especially if your employer does not get that benefit as part of your insurance policy, then there's nothing I can do about that. But that occurs very rarely.

Host: I noticed Children's Health offers one specific procedure. Can you explain what it is and why that is the one that is offered?

Dr. Qureshi: There are multiple procedures that you can do for metabolic and weight loss surgery in adults and children. I'll do the simplest one, which is the gastric band, where you put a piece of plastic band around the stomach to try and prevent patients from eating, that has a 10% reoperation rate. And therefore I don't offer that procedure. The next one is called a bypass procedure where you reroute the intestine and you shrink the stomach so that when the patient eats, not only are they able to eat less, but if they eat inappropriate foods, their intestine doesn't absorb any of that. The problem with that operation is that, that because the rerouting of the intestines can have significant nutritional deficiencies and can have surgical complications up to 10% for the life of the patient. And because I'm operating on 15 and 16 year olds and even younger, my concern is that that patient is going to live another 60, 70 years. And I don't want them to have to deal with those nutritional deficiencies and or surgical complications for so many years. In the United States, something called the sleeve gastrectomy where I remove 80% of the stomach is now the mainstay of weight loss surgery, both in adults, and that's the primary operation children, because it's the simplest operation. It has the lowest nutritional deficiencies, and it has one of the lowest technical complication risks. So it's a safer operation and it gives very good long-term results.

Host: Can you talk about what preparations patients need to go through before surgery?

Dr. Qureshi: So, once you go through the process of being evaluated and we need to, as a team, every two weeks to discuss all the patients who are in the pipeline, if the entire team agrees that the patient is appropriate candidate for a metabolic and weight loss surgery, then we look for a surgical date. We apply for your insurance authorization. And for about two weeks before the operation, you're put on a significantly restricted diet, which is very different than what we do for the first three months. And the reason we do that is the more weight you lose in the first couple of weeks before surgery, the smaller your liver sizes and the easier the operation is technically. So the patients do have to adhere to a very strict two week preoperative diet to maximize their weight loss during that time period. They come to the hospital, the morning of surgery, they are without food or drink for eight hours before the scheduled time of the operation, they get the surgery, the surgery lasts about two hours and 70 to 80% of the time they're home the next day. After the surgery, they should expect about a week of staying home. But within five to seven business days, you should be back at school if it's school season and then within about a month, you should be doing pretty much all the physical activity that you want.

Host: Can you share some of the outcomes that come out of these procedures? What are the proven results?

Dr. Qureshi: Of the patients that we operate on, and I'll compare the patient that we've operated on and compare the patients who are referred to us, but never go on to get surgery for one reason or another. After surgery, you can expect to lose 40 to 50% of your extra weight. What does that mean in real terms? If you are a hundred pounds overweight within the first year, our expectation is that you will have lost 40 to 50 of those pounds within the first year. Within the first six to nine months, 70% of diabetics stop taking all their medications completely. If you're hypertensive 60 to 70% of you will no longer need diabetic medication. If you have sleep apnea, you're going to not be using your sleep apnea machine 60, to 70% of the time within the first year. But the most important things, you feel better, your joints and your legs don't hurt as much. Your back doesn't hurt as much.

You have a lot more energy, you sleep better. And if I was to have you talk to any one of my patients who follows the rules, they are bouncing with confidence. They are much happier people. Patients who have for years been hiding in a shell, come out and start interacting with their peers. They're noticed by their friends. They are a lot more fun to hang out with. And parents come back and tell us my child, Jane, for example, which is a made up name, of course never went to the mall for the last three years. Now, she wants to go to the mall with me. Now, she wants to go to the restaurants with me. Now she wants to walk in the neighborhood with me. Now she wants to invite friends over. So it really changes the way they feel. It changes the way their body's behaving from a health perspective. And it changes the way they interact with other people. Their entire social circumstance changes.

Host: Now wrapping up here doctor, which patients succeed after weight loss surgery?

Dr. Qureshi: The patients who succeed are those that have the family support, who follow the rules. We have very particular do's and don'ts that patients have to follow. And patients who understand that this is a process that this is not a one stop shop that'll fix everything with one surgery. No, you have to be dedicated before the operation, and you have to be dedicated after. So dedication in the process and dedication to yourself and believing in yourself that you can make this happen, are the ones that succeed.

Host: Well, thank you so much for joining us today, doctor, and for sharing this information. And as always, thank you for listening to Pediatric Insights, you can find more information at childrens.com. I'm your host, Caitlin Whyte stay well.