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Treating Teen Obesity: A National Leader in Bariatric Surgery on GLP‑1s vs. Surgery · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehmint, and this is Pediatrics Now.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit, depending on your topic or podcast.
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I'm here today with Dr. Richard Peterson. He's the immediate past president
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of the American Society for Metabolic and Bariatric Surgery,
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Chief of Metabolic and Bariatric Surgery at UT Health San Antonio,
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Division Chief of General and Minimally Invasive Surgery, and Surgery Quality
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Director at University Hospital.
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He's helped shape national standards for bariatric surgery and obesity care
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and is a recognized leader in treating obesity in both adults and adolescents.
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Dr. Peterson, welcome to Pediatrics Now, and thank you for being here in the podcast studio.
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Holly, thank you so much for the opportunity. And I know it took us a little
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time to align our schedules, but today is the day, and it was meant to be this
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way, so I'm glad it worked. It's great to have you here.
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Dr. Peterson, let's start with the big picture. Many centers have reported declines
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in bariatric surgery volumes since GLP-1 medications became widely available.
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Given the national vantage point you have leading the field's largest professional
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society and having led that professional society, what are you seeing across the country?
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Are we witnessing a permanent shift or are surgery and medications finding complementary roles?
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Yeah, I think that is a great question. It's really the 10,000-foot view when
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you look at everything is, yeah, there's definitely been a decline in metabolic
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and bariatric surgery over the last two to three years.
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And even we took a little bit of a hit during COVID.
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So you might remember most elective surgeries were put on hold during that time
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when ICUs and hospitals were just full of patients that time.
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We recovered from that pretty well. Didn't go back to the numbers we had prior,
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but then the GLP-1s came out.
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And so that, you know, that's not, it's not surprising that.
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When something simpler, if you will, honestly, was there, is available instead
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of something that seems so terrifying to people like surgery.
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But the truth is that surgery still remains the most durable treatment for the disease of obesity.
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I think that's one thing I want to make sure that we kind of,
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we focus on as we talk today is that we're talking about a disease.
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We're not talking about a problem, not talking about a choice,
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talking about a disease.
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And obesity is no different of a disease than cancer is a disease.
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And, you know, you're asking about the medications and I love the way you phrased
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the question is that are we getting to a point of complementary,
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you know, medicine and surgery? And we are.
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We're seeing that, and you probably watched, there's tons of ads and everything
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else, so much media about medications.
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Medications are getting better. They're getting better and better and better.
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But they are a lifelong treatment requirement. You will always have to be on
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that medication so far because nothing changes people.
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It is just an adjunct or an augment to what their body isn't doing.
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Whereas surgery has, as it alters the anatomy, it also alters the physiology
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and the metabolic rate of the patient.
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So there's definitely a benefit there.
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One of my good friends out at, actually at Yale now, Dr. John Morton said,
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you know, we were, we were GLP-1s before they were cool.
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And which is true because surgery itself has an opportunity to let the body
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naturally produce the amount it's supposed to.
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And so most patients that do have surgery do really well compared,
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you know, to, to not for sure.
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But it has always seemed so scary, I think, to people. And it's just,
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it's really not when you take the time to hear about it.
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The GLP-1, you know, as it's come out, well, it definitely brought our volumes down.
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I would say if we look at 2022 to 2024, during the annual meeting we had of
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the American Society for Metabolic and Mediatric Surgery in San Antonio this
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year, which I actually had to be the president of at that time,
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happened to be in my own town, so it was cool. I heard it went well. It was great.
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We released the numbers at that time showing from 2022.
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To 2024, we've seen a decrease of about 40% of our volumes.
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So it was a real difference. And from 23 to 24 is about a 19% difference.
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So that's cumulative for those two years. The thing is that,
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well, it's a little frustrating at first for those of us doing surgery and,
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you know, treating this disease.
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What the medications have done without a doubt that we in surgery haven't been
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able to do was raise awareness that it's a disease, right? So more people now
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say, oh, there's a pill for it or there's a shot for it.
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That's a disease now instead of it's a problem. You know, people won't treat
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problems with pills that level.
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Not obesity and not other diseases. Or they treat diseases, but don't treat
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their problems. So like, you know, hypertension, yeah, people are on medications.
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But the cost is different, right? It's a very different thing.
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I was talking to a general pediatrician the other day, and she says that she
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gets asked about GLP-1s often.
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And she tells the families, you would need to see endocrinology.
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So if it's indicated for your child, then let's go that route.
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But if it's just, if it's something your teenager wants to be a little bit more
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thin or you think that they would benefit from, I'm not going to prescribe that.
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Do you think that that's a good way to handle it?
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Yeah. So I do absolutely believe that there are specialists involved.
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Now, endocrinologists have training in the disease process for sure.
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There are those individuals who are American Board of Obesity Medicine certified, ABOM, A-B-O-M.
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And so that, and that, that is open to anyone. That's open to surgeons,
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family practitioners, endocrinologists, you know, so internal medicine,
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the whole gambit of individuals can sit for that exam.
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And, and I would say that's someone who you're probably going to do better with.
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I'm not, not to discredit any family practitioners who haven't done that.
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If they're comfortable treating the disease, that's great.
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But maybe they are uncomfortable using the entire ornamentarian of the medications.
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And there are old medicines that used to do pretty well, and they don't maybe
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compare to the new ones today, you know, and that's okay.
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But someone who has all of that in front of them and has comfort with each of
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those is probably the best person to help, you know, you through your journey
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as an adult, through your child's journey as they're going from one point to the next.
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The American Academy of Pediatrics recommends considering the full spectrum
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of obesity treatment, including metabolic and bariatric surgery.
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What specific criteria-rich BMI, thresholds, comorbidities, age should pediatricians
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be using to decide who to refer for evaluation?
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Yeah, that's a great question. So if you look at, you know, and I'll bring up
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an updated. So in 1991, the NIH released criteria on metabolic,
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it was only called bariatric surgery then.
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We added the metabolic component of it in about 2012, or 2010, I think it was.
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And so when you look at that, the BMI previously used to be a BMI of 40 or above,
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with no comorbidities, or a BMI of 35 and above with hypertension or sleep apnea or type 2 IADs.
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Well, in 2022, the American Society for Metabolic and Bersetic Surgery,
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and IFSO, which is the International Federation for Surgery of Obesity,
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released a joint statement on criteria.
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And that criteria changed the BMI to 35 and above with no comorbidities or 30 to 35.
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So we definitely lowered that down. And then in the Asian population,
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a BMI of 27 is sufficient to actually qualify for surgery.
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So if someone says 27, that's not a lot, but we're talking about a metabolic
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disease. We're not talking about a weight or a BMI, which BMI is the easiest thing to do.
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It's definitely not the most reliable, but it's what we've gone after now in the pediatric world.
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The actual criteria is looking at those, the children who are a higher percentage
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of their, of the 95th percentile.
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And so that changes when we're looking at adolescents. And, you know,
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the American Academy of Pediatrics, they support us because we worked with them
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on developing those guidelines.
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And in part is what we know is that like the Tanner staging does not,
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you know, having metabolicometric surgery does not affect that.
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So it's okay to proceed with surgery earlier because the earlier we get to the
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disease process, the more long-term effect we have on it, right?
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Many pediatricians still think of bariatric surgery as a last resort,
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and a lot of misconceptions persist among both physicians and families.
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What are the biggest misconceptions you wish they'd stop believing? Yeah.
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Well, I would say the first one you can highlight is that it's a last resort because it's just not.
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When it's a last resort, that is what we're doing to react. So it's reactive medicine.
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And reactive medicine isn't really the best medicine when we practice it.
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Preventive medicine is what everybody talks about. And that's what pediatrics
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is all about in so many ways, right?
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So when you're doing a surgery to prevent further, you know,
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decrease in, whether it be life, length of time, whether it be other conditions
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that they're going to have, I mean, you're trying to stop those.
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And why wouldn't you? I mean, we live in South Texas.
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We have a very high incidence of type 2 diabetes in the general population here.
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But additionally, one of the highest areas concentrated in adolescents.
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And with surgery, and I don't want this to be surgery-centric,
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I really don't, but obviously as a bariatric surgeon, you know,
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this is what I've done for my life for 20-something years.
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Surgery is still the most durable treatment for type 2 diabetes, period, period.
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And the earlier we get to it, the more likely we are to put it into remission. So...
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Those kids who've been dealing with diabetes, let's say, since they were 12, 13 years old,
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and they finally reach adulthood six years later, seven years later,
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and qualify potentially for surgery because people didn't want to consider it then.
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They've had at least six or seven years of diabetes just running rampant in
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their body and it is more challenging to control that at that time than it is
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to control it at a year into it,
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and so if someone had an opportunity to be off medications and not have to take
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that and all the side effects that go with all the meds,
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that would be the that would be a much better opportunity And so I think that's
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where we have to kind of help individuals get through there.
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The other thing is, I think, unfortunately, as someone who's in the media,
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you know that the media, what's out there are shows that are there for the,
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you know, what's the right word I'm looking for? Shop value, right?
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And so people see like— The worst of what's happening, or sometimes the best.
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Yeah. And so, I mean, there's a title of a show, and it's, you know,
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My 600-lb Life. I'm not advertising anything that anybody probably is not aware of.
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That's the misconception that you have to be 600 pounds before you should qualify
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for surgery. That's just not true.
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You know, I kind of told you that the criteria in terms of the BMI,
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those are low BMI's when someone would qualify for the surgery.
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And we have a much better handle on caring for individuals when we get that opportunity.
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Now, meds, as I said, they're doing really well, but the meds can't be stopped.
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Whereas surgery, if you do it early enough, maybe that's all they ever need.
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But if you kind of give me the latitude to talk about it as like cancer,
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I think most people understand if they had the disease of cancer,
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they would come to the surgeon, to the medical doctor. They would absolutely
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say, I have disease, please cure it.
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And, but when people think about obesity, it's an outward appearing disease.
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And there's been so much bias in our society that it's a blame people for having
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that disease. And that's not what it is. They didn't, they didn't ask for it
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and they didn't do it to themselves necessarily.
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So, but cancer can be treated with medication only and somebody is cured or
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at least in more mission, or they get a surgery only and it's fine, or they might eat both.
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And that's the world we live in today with the disease of obesity.
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Medications are doing really good. They can be a good bridge to get to surgery.
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They might be on a medication and just do swimmingly and not eat anything else.
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They might get surgery and never need anything again. or maybe because it's
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a really chronic, unrelenting disease, they need both. And that's okay.
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Do you have any advice for pediatricians regarding when they're getting inundated
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with parents asking about these medications and their child is not obese?
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It's a great question. So I think as, you know, the more informed they can be,
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the better off they will do.
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There is so much of a push, as you said, from the media.
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And we'll be honest with you the medication companies the pharma companies they
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have a lot of money that they can put forward to that that's why you know there's
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commercials Super Bowl commercials.
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And also it's a little unregulated to a degree right I mean not the pharma companies themselves but
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you have groups on on that you can go get these medications from with an online
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consultation with no one ever really
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watching how you're responding to the medications that's a little scary.
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I mean, if you decided to Google my blood pressure and decided to go onto some
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online site and just start picking blood pressure medications at will,
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that'd be a little scary.
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I think people would think that's crazy, but then when we talk about it with,
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you know, medications for, you know, losing weight, and so many people are learning to link it right.
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Yes. I was at dinner with one of my friends. We've been friends since third grade.
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And she looked different. I mean, she didn't look like she needed to lose any
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weight, but she had no interest in the food we were eating.
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And that's one of the things I love about her is this, like, she loves a great meal.
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And then she mentioned she's on the GLP-3s that aren't approved.
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And her functional medicine doctors prescribed them for her.
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And she just wants to lose weight with them.
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Yeah, well, that's when you're trying to keep up with all those. You're exactly right.
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So, you know, there's the GLP-1s, and then there's the combo therapies and GIPs
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and GLP, and then there's this GLP-3, which is research-owned.
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And by the way, I find it very interesting because that I think in the adolescent
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and sort of young adult area, you see that there are companies targeting people
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specifically under the guise of research.
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And actually, I was looking at this two days ago, and those research compounds,
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can't call them medication because they're not FDA approved,
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says very specifically, for research purposes only, not for human or animal use. Wow. Yet.
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Every one of them is being sold to a person who's injecting themselves with it.
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And that's a little scary. Yes. So, again, I understand, and maybe with the
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area of cancer, people might want to try.
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Other therapies, right? Other holistic options.
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And I would never tell anybody not to do it. You do everything you can to put
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your cancer remission or cure it, right?
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But here's known things. So I find it a little scary that people are treating
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themselves with sort of, there's not randomized controlled trials.
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I mean, those GLP-3s sound promising, but they're not even out.
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And also, if you're getting it from a research company, you don't even know what it is. Right.
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And she, yeah, she just talked about the food she was not interested in.
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Which was what we had in front of us. And then was so tired,
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she had to leave early, you know.
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Well, and that's one of the things I think. That's one thing that the medications
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had done that gave a term to something that we've been seeing in metabolic retic
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surgery for, you know, 30-plus years.
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When I was doing surgery way back before GLP-13, when I would do a gastric bypass
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on a patient or a sleep gastric on someone, after surgery, more than 80% of
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patients said they weren't hungry. They just didn't feel hungry.
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And I get that's a good thing. But I said, you know, we would talk about having
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a healthy diet, which meant eating about five or six small meals a day,
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giving your body the fuel it needs all day long, right?
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You don't run your car to, well, you try not to run your car until it's on the
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last fumes. You try to fill it up, fill it up.
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So you're doing that same thing with your body, but the individuals,
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so this term that came up with the GLP-1s is food noise.
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And that's what I think, surgery has been quelling this food noise for years,
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since we've been doing it. We just didn't have that term.
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But now when someone has a GLP-1, they aren't, it's not even an obsession,
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it's just they're not thinking about it.
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The food is so far from moving, which is what GLP-1 does.
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So it slows your stomach But it makes you not hear that I thought that was kind of dramatic.
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This one doctor told me that he tried the GLP-1s and that he couldn't drink
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enough water during the day and he got a kidney stone.
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And so he stopped taking it after a month. He said for him it was not good at all.
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You know, I have colleagues, you know, in our metabolic and pediatric surgery
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world who are using them and they feel good about it.
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They're being cautious and they're careful. But you're absolutely right.
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There is still data that is unknown about these, you know, medications and what
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their long-term effects are.
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And I think that's the part where we're going to see some interesting information
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over the next couple of years.
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We've definitely seen it with certain medications causing pancreatitis.
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You mentioned gallstones. I mean, there's gallstones, which certainly you can
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do too, but it's, again, you know, that's an issue.
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I'm going to talk about blindness. I don't want to talk about all the— That could be a side effect?
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Yeah, absolutely. Really? Blindness? Yeah. Didn't know that.
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So it's very interesting.
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Are there lots of reports? No. And this is the same thing. I'm sure somebody's
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like, well, surgery, you know, there's leaks and there's this.
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But the reality is that, you know, if you look at our data, here's what I think
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is a striking difference, is that the reported weight loss with medications
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currently are all off of the randomized controlled trial data. Okay.
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Well, that, and which is good. It's good data.
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But it is randomized control.
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Control is the big word right there. Whereas if you look at real world data, that's different.
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So the weight loss with individuals on those medications in the real world setting
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is less. It's different.
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Surgery, we don't have a ton of randomized control trials.
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So most of our data that we're publishing is real world data.
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And so most of the things you hear about surgery are real-world data quoted.
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And so I think that's the difference. And, you know, when we're trying to get,
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that's definitely apples and oranges. You're trying to put them together.
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So how do you determine whether an adolescence is a better candidate for GLP-1
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therapy, bariatric surgery, or both?
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You know, that's, again, great question, because I think you have to individualize
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the care for that individual.
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And in the disease of obesity, we have not yet done a good job of characterizing
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what I would say are the phenotypes of obesity.
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So in cancer, we can say you have pancreatic cancer, you have breast cancer,
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you have stomach cancer, you have different cancers, and we know kind of how
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they work and what they do.
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Right now, we're treating obesity as a disease, and there's a spectrum,
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right? Someone who's a BMI of 37 and has diabetes, high blood pressure,
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sleep apnea is different than somebody who has a BMI of 70 with no other conditions.
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They're both in a severe form, but just very different.
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So understanding what are the needs
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of that individual and how can we best support them in all those ways.
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Again, just if we don't coordinate the care, because cancer care is coordinated and people do well.
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If we don't coordinate the care in the obesity space, we're going to leave patients
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behind. And that's not right.
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What do you say to a parent who says, but my teenager's body will be permanently
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changed by this surgery, so wouldn't medication be better?
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Well, you know, great question.
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And yeah, there will be an alteration of the body, but they have a disease.
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And so when a child comes in with a tumor, like a Williams tumor or something
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along those lines, and I'm pulling from medical school stuff,
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okay? It's been a long time since I've seen that stuff, but I remember that's a kid's tumor.
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When you have a tumor like that, and surgery is going to alter their body.
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It's going to take that away.
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And no one blinks an eye because you're treating the disease.
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So this disease of obesity permanently altering the body can lead to a positive
22:33
effect that saves them from all the sequela of bad things that happen with the disease of obesity.
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And usually in adolescence, we tend not to go to the more extreme,
22:46
what I would call is a terminal operation, which is the gastric bypass.
22:50
So it's a great operation. It's the gold standard. It's what we've done doing for 60 plus years.
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When you look at it, but it is more altering, whereas the sleeve gastrectomy
22:59
just takes out a portion of the stomach, no alteration of the anatomy,
23:02
essentially, other than the removable part of the stomach, but everything else is in continuity.
23:07
We have options to do things later with the sleeve, for example.
23:10
Whereas the bypass currently today, there's not a lot of options to continue on that journey.
23:15
And so when I see patients that are younger, I lean towards that because I know
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that this chronic unrelenting disease is going to be there for their whole life.
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And I want to have options later if necessary. And the medications,
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that's just it. They're not altering anything.
23:32
You know, they're just, the medication are just providing what the body isn't doing well with anyway.
23:39
But what we don't know is that's a constant, ongoing, like, you've got the GLP-1,
23:46
so it's going all the time, all the time, because it's in your bloodstream.
23:49
Whereas with surgery, when we've done surgery, your body naturally produces
23:54
the amount of GLP-1 it needs for that moment, and then it stops it for a while.
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And then it produces and stops. But that's all your body's regulation.
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Whereas the other one is just a constant barrage of that. And will the long-term
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effect of that, what will that be?
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I don't know. I mean, I don't have that crystal ball, but I do have concerns
24:14
that either there'll be resistance because maybe the medication dosing is going
24:19
up for each individual, or maybe the body just doesn't respond to it at all anymore.
24:25
Or maybe there's a potential that, and if you look the disclaimers,
24:29
if you have certain disease processes, you shouldn't be on a GLP-1 because it
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may exacerbate it or make some of it a rotten source.
24:39
Rich, how did the outcomes compare between today's GLP-1 medications and bariatric
24:45
surgery, broadly speaking, in terms of weight loss and remission of conditions
24:49
such as type 2 diabetes, hypertension, sleep apnea, and fatty liver disease? Yeah.
24:55
So when you look at, you know, a blanket statement, surgery outperforms them all.
25:01
That having been said, and that's the general. Now, if you look at each of the
25:04
individual surgeries that we do, some outperform by a lot, and some are,
25:10
they're almost, they're not neck and neck, but they're close to each other.
25:13
The most, with the current,
25:16
most effective medications, the GLP-1 is the trisepitide, which is that combo, right?
25:23
That one does really well. And so when you look at that, that is not quite as
25:28
good as a sleeve gastrectomy, but it's close.
25:32
But then the gastric bypass or the duodenal switch or CEDES,
25:36
we call that, this is a single anastomosis duodenal ileostomy with a sleeve.
25:41
That's a very aggressive operation that if someone has bad type 2 diabetes,
25:46
I mean, that's going to aggressively treat it.
25:49
Most of our surgeries for someone whose diabetes has been five years or less,
25:53
when we do the surgery, we put their diabetes into remission.
25:57
In fact, they're off their medications the next day. So that's pretty dramatic.
26:02
And we are seeing the reduction in sleep apnea, hypertension,
26:06
cholesterol, fatty liver.
26:08
You know, it's interesting you bring up the fatty liver thing because here at
26:10
UT, we're really blessed to be working with our transplant team.
26:15
It's an incredible team. They're incredible. And we've done,
26:19
we've actually published on this now with living donor liver transplants.
26:24
We are doing sleeve gastrectomy at the same time.
26:27
And those individuals, now these are individuals whose BMI was over 35 and they came to see us.
26:32
Their disease process in their liver, their liver guff, was a fatty liver disease
26:37
that then went on to some of the newer terminology, MASH and MAFOLD,
26:41
you know, which is the metabolic associated fatty liver disease,
26:45
which then went on to cirrhosis.
26:47
So the reality is we want to prevent that new graft from getting that same disease
26:55
process. So that's why my friend Renee Hilton in Georgia, I love her. She's hilarious.
27:02
I was telling her about this program. She said, that's amazing.
27:05
It's amazing because she's like, why would you buy furniture and put it in your burning house?
27:12
Which is true. This liver is the new furniture. And if you haven't changed anything
27:17
about them, but take out the old liver and put in the new liver,
27:20
you've not changed anything about their metabolic disease that's going to make
27:23
that new liver sick again.
27:25
So let's change the paradigm.
27:28
And these patients who we've done it on, and I just saw one of them,
27:32
he was at his two-year visit last week.
27:34
He is like, he was absolutely against the idea of surgery, of rather of metabolic
27:40
surgery. until we did the sleeve.
27:42
But he was completely fine with having his liver gripped out and put in a new
27:46
one, right? But I was like, well, what are you afraid of here?
27:50
Because he had sleep apnea, hypertension, diabetes.
27:53
And the new liver doesn't change that. But the surgery we did changed that.
27:57
And so doing it together.
27:58
So now he's, I mean, oh yeah. He's like, I want to be your poster child.
28:02
I love this. This is like, it's the greatest thing I've ever done in my life. Wow.
28:06
And I would say most people, by the time they're getting to surgery,
28:10
the most common thing that's ever said to me in the last 25 years is I wish I'd done it sooner.
28:16
And that's a great analogy about the furniture. So what happens when patients
28:21
discontinue GLP-1 medications and how does that durability compare with weight loss after surgery?
28:28
You've got a lot of great questions. Oh, thank you. So that is,
28:31
when you think about the medications, if you stop them, you,
28:37
again, you haven't changed anything other than you've supplemented the individual.
28:43
So when they stop, they're going to have weight gain. And in fact,
28:46
most studies, almost all studies, people regain all the weight back.
28:51
The hard thing about the medications currently is that at about six months,
28:57
50% of people taking the medications have stopped.
29:00
And at a year, about 70% of the people have stopped.
29:05
And there's different reasons. Side effects, you and I were chatting about it a little bit before.
29:10
Cost, insurance coverage anymore. So I was doing some visits on the Hill this
29:16
last year. And we had a patient as one of our folks that were going from,
29:20
you know, senator and congressman, you know, back and forth around.
29:24
And it struck me that she had had really great success with her GOP one.
29:28
And she looked great. She was feeling great.
29:30
But she was so anxious and had so much fear because her insurance stopped covering it.
29:38
So here's a taste of great success. And now we take it away.
29:42
And so that is heartbreaking.
29:46
Drinking. We don't do that to surgery. You know, insurance company approves it to start with.
29:51
They don't get to unapprove it after you've already had it, right?
29:54
It's, so it's yours to key.
29:56
Now, hopefully it continues to give you all that you need, but,
29:59
but the durability kind of tying back to the durability of the question that you ask is with surgery.
30:05
And again, if you just lump them all together, well over 70% of patients maintain
30:11
their excess weight loss at five years.
30:15
If you break it down by surgery, sleeve is more like about 55-60% of patients
30:22
keep it off of five years.
30:24
Gastric bypass is close to 80%. And at that SATI or DS, it's more like 90-95%.
30:30
So, it's pretty dramatic.
30:32
I have another friend who, and she's lost a lot of weight on that GLP-1s.
30:38
And she says she can't keep weight on now. Like it's becoming,
30:42
her weight's becoming dangerously low.
30:44
And then I asked her, well, how about try, I mean, can you stop taking the medication?
30:49
And she said, I know I'll gain everything back the week I do that,
30:53
you know, so I'm not ever going to. Right.
30:55
Right. Yeah, it creates a, again, these are the unintended consequences of a
31:02
rapid uptake of something.
31:06
And I'm not going to call it a fad. It's way beyond a fad. And like I said.
31:10
And it's a godsend for some people, of course. Absolutely. And so there's this
31:14
fear that they've gotten something they've never had before.
31:17
You know, we like to say that people who are taking the medications are trying on surgery.
31:23
But they're getting a sense of what surgery can really do for them.
31:26
Wow. But if they have to stop it, then there's this, to your point,
31:31
there's this whole fear because the individuals who are going, they're leaving.
31:37
I would say most people, when they're leaving where they started,
31:41
they're not leaving their disease.
31:44
They're leaving from a place of bias and stigma that is so horrible that they
31:50
have an incredible fear of having to go back to that.
31:53
They're not afraid of necessarily not being able to get on the roller coaster
31:57
again. I mean, that is part of it.
32:00
They're afraid to go back to all the things.
32:05
The person who can't go through the grocery store and go to the dessert aisle
32:10
without being judged for picking
32:12
up a thing of ice cream because outwardly you can see their disease.
32:17
I mean, some people might look at someone who's buying cigarettes and say,
32:22
you know, oh, they probably shouldn't smoke, but they don't see their lung cancer
32:26
in their body versus doing that.
32:28
So it's just, it's not the same stigma. It's this disease of obesity has such a horrible stigma.
32:35
And I think that I know patients are afraid.
32:38
Are GLP-1 medications being used before surgery, after surgery,
32:43
or both? And how do you see these therapies working together?
32:46
Yeah, they are. And in fact, I think it's a great way to do it.
32:50
I alluded to the word bridge before.
32:53
So in my presidential address, this is one of the things I talked about is.
32:57
We, you know, treating a disease like obesity is, it's like this,
33:03
this book by Simon Sinek, it's called The Infinite Game. I don't know if you've
33:06
ever read it or heard about it.
33:07
It's a great book. I highly recommend people read it. It's such a,
33:10
it was such an eye-opening thing for me.
33:12
The Infinite Game is that you are in the game to play the game continuously.
33:17
You're, you're not trying to win or lose. You're just trying to keep playing.
33:20
When we were kids, I'm going to guess we're similar age, you'd go out on the
33:25
street and you'd play and you'd play until it was dark, but you wanted to keep playing.
33:29
You may not be keeping score, you just played to play and it was fun.
33:32
And so the infinite game is doing that. The finite game is trying to win and
33:38
just there's a winner and a loser there.
33:40
And in medicine, that's not the place. We need to be in the infinite game.
33:43
We need to just always trying to do better and trying to continue what we're doing.
33:48
When it comes to the medications, you know, people who play the infinite game,
33:53
they don't look at their competitors.
33:56
They can look at their competitors, but they need to learn from them.
33:59
They don't need to necessarily compete with them.
34:02
I would say that's what we have to do in our world today is we need to not fight
34:07
with the medication companies when it comes to surgery and medications.
34:10
We're not, it shouldn't have to be either or.
34:13
It's that there are choices for your disease and we can help you with that.
34:17
And now we do see there is more of this use of it before surgery, get through surgery.
34:25
And in those people who we've determined have a really severe form,
34:28
we keep going. We keep doing it.
34:30
So they need them both, just like cancer.
34:32
They call that neoadjuvant therapy.
34:35
Surgery and then adjuvant therapy. And that's exactly how we need to look at
34:39
the medications and surgery in a common, you know, in a synergistic therapeutic model.
34:45
How do you help families navigate the decision of maybe they're worrying about
34:50
surgery versus worrying about keeping their teenager on medications for years or a lifetime? Yeah.
34:57
You know, the nice thing about the care of obesity, and certainly in surgery,
35:04
we have been doing comprehensive obesity care for it. That's how we do it.
35:10
And so we work with dieticians, we work with psychologists, we work with,
35:14
you know, work the primary care doctors.
35:16
We all work together to ensure that the patient is getting the best treatment all around.
35:22
And when it comes to, you know, the little difference in the adolescence part
35:26
is that, you know, there's more counseling time spent doing that,
35:29
ensuring that everyone understands, ensuring that there's support,
35:33
getting rid of the blame, blaming the parents for, you know,
35:37
giving them junk food or blaming the parents for, you know, a more sedentary
35:41
lifestyle for their child or blaming the parents because,
35:44
turns out, interestingly enough, obesity is a, you know, hereditary disease.
35:49
And so, but people just see individuals suffering from that disease with,
35:54
you know, junk food and all these other things, whereas that's not the case.
35:58
So families are counseled and, you know, so it's the longer process when you're
36:04
in the adolescent world for surgery.
36:07
But it absolutely can be effective. And actually, oftentimes it benefits the
36:11
entire family. Brilliant.
36:14
Insurance coverage and access are often the real barrier pediatricians run into
36:19
when trying to refer a patient. What should they know about navigating that?
36:23
Yeah. So I think we've actually done a really good job in our world today,
36:29
especially from a surgery perspective.
36:32
Most insurers actually do cover surgery. Medications are still being challenged by that.
36:39
So from an access perspective, here's what I would say. I would say,
36:43
at least on the surgery side of things, just refer to the surgeons.
36:48
Let us deal with that. That's what we do.
36:50
You know, medications, getting the referrals, that can be a challenge,
36:53
or getting authorizations, rather.
36:55
In surgery now, like I said, we've done such a good job on our access to care,
37:01
so there's a lot of access.
37:02
The problem is utilization.
37:05
So everyone has Peloton.
37:09
But how often are you using it? And that's the thing. So we've given everybody
37:14
an opportunity to have that, but it's just people aren't doing it.
37:18
And there's a lot of reasons why. I do have a Peloton. And I do use it, though.
37:23
But not as often as I should. I've got an elliptical sitting in the bedroom
37:27
that it is an amazing coat rack.
37:32
It's the greatest intention, right? But it's not getting too—but that's there for people.
37:37
And I think you asked a little earlier, maybe that's a good myth,
37:40
too, is a myth that surgery is not a covered benefit is actually not accurate.
37:46
Most insurance plans are pretty good about it. Now, if you're on one of the
37:50
state, the exchange plans. Oh, exchange plans.
37:53
Those don't because currently obesity is not one of those diseases that is considered
37:59
an essential health benefit, which is crazy.
38:02
And so we're working on the national level to fight that.
38:05
In fact, that's one of the things we did all last year. We're pushing forward
38:08
this year with even more on that.
38:10
So if we can get at the federal level to change so that the disease will be
38:15
seen as the essential health benefit, that will filter down to the states that
38:19
have those exchange plans. Is that going to happen?
38:22
I believe it will. Do you want to say anything else about you mentioned it helping the entire family?
38:27
Yeah. Yeah. Well, so, you know, I mentioned my buddy, John Wharton,
38:30
he, when he was at Stanford, they did a study looking at, you know,
38:34
so those individuals who had surgery and then they followed their family, their spouses and kids.
38:39
And what they found was that those individuals who had the surgery had a pretty
38:44
good normal progression of their weight loss as expected with surgery and also
38:48
found that the families lost about 13 to 15 percent of their weight just by,
38:54
being a part of that one person's journey. Wow.
38:57
It's just that they're supporting, they're changing the ways they eat,
39:01
maybe they're exercising more as a family.
39:03
So that definitely you see that impact when you have that supportive structure
39:07
within the group. So absolutely. Okay, that makes sense.
39:12
Has the popularity of GLP-1 medications changed the surgical candidates you're seeing?
39:17
Are today's patients different than they were five years ago? They are. Yeah. Yeah.
39:24
I, again, I also address this, that the world of surgery and the treatment of
39:31
obesity, we're evolving in that way.
39:34
You know, the cardiothoracic surgeons in the 90s and 2000s dealt with,
39:40
you know, they were the all coronary artery disease. They took care of it.
39:43
And then what happened was the stents came along.
39:45
Very easy for people to do. They have cardiologists and interventory,
39:48
all these people doing it.
39:50
So they struggled, but they did define the best way. They took on more complex
39:55
disease. That's where we are today.
39:57
We're still in the metabolic and metric surgery world. We're going to still be the revision people.
40:02
We're still going to be people who take care of BMIs of 50, 60, 70, 80.
40:06
I mean, medications just don't
40:07
touch those people, just not going to make an effect for a long time.
40:11
So we're going to just own a different subset. I would say the patients,
40:15
I'm not seeing as many BMI 42, you know, with maybe high blood pressure or one thing.
40:22
I'm seeing a lot more severe disease.
40:25
And that's okay because we're still here to take care of everyone.
40:29
And I think that there will probably be a, there is, well, I'm already starting
40:32
to see a swing back in our practice of an increase in our number of referrals
40:37
in patients seeking metabolic rheumatic surgery.
40:40
So if there's one message you'd like every pediatrician listening today to remember
40:45
about treating adolescents with severe obesity, what would that be?
40:49
It's never too early to start.
40:52
Think about it. If there's questions, reach out. We'll help you.
40:57
We'll help you navigate it. Don't be burdened by the process of whether they
41:02
have a benefit or not. If they don't, we'll work with that and help you figure it out.
41:06
Maybe there are other plans that they can look at. Maybe when the next year
41:09
comes around, the family can adjust the plan that they're on or look for that
41:13
to make sure the coverage is there.
41:15
But don't be afraid to do that. You know, you just don't let that be the barrier.
41:20
And don't let obesity as a disease be a barrier to the conversation about treating
41:25
someone with a disease of obesity.
41:27
It is a disease. And so some people say, if I bring it up, it's embarrassing.
41:31
It's not embarrassing. In fact, you not talking about that it only makes it worse.
41:36
You're the individual who can actually talk about that disease actually brings
41:42
relief to the patient who knows that they have this disease. They just are way.
41:46
Actually, they don't have this problem. I'm putting air quotes here.
41:50
They have this problem, but they actually have a disease.
41:52
And so there's a there's a process there. Help them. Help them with their disease.
41:57
And I love the empathy coming through with with all this way you're talking about obesity.
42:03
I know that helps the patients that you see and the families.
42:06
We have dieticians that we work with that are just spot on on fire. They're amazing.
42:12
And they have that empathy and compassion for individuals who are dealing with
42:16
this disease. So they are able to work through that process and help them.
42:20
And some people really want the, please give me the blueprint. And then I will build.
42:28
I have this furniture from Ikea. Help me build it. And other people just need the concept.
42:34
And the people that we work with are able to cater to both.
42:38
And let's be honest, we're talking about adolescence too, but as an adult,
42:42
most adults have gone through all the diets and all the things.
42:45
Most of what you're telling them, they've already heard 100 times.
42:48
So kids, maybe they're starting to hear about it.
42:51
But also sometimes it's so restrictive that it becomes that they actually,
42:56
in fact, using the word diet, when I say diet, I'm not even talking about like
42:59
a Weight Watcher style. I'm talking about like, this is my diet.
43:03
My diet is I eat this, I eat that, I eat this. That's what I mean.
43:06
But I remember one of my dieticians was like, you're using such a bad word.
43:11
When you say diet, that is just like, it's like saying a bad word. They don't like it.
43:17
Finding another way to talk about meal plans, you know, that kind of thing,
43:22
so that individuals can focus on the good.
43:25
And pediatricians are seeing so
43:28
many patients a day. Often they see 40 patients a day. When is it time...
43:35
To say this is when you need to look at surgery. I know we've gone over this,
43:38
but just a quick review about BMI and how long they've been trying,
43:43
changing eating patterns.
43:45
Sure. I mean, the thing is, if you, you know, it's never the wrong thing to
43:51
start with someone who, if you want to start on lifestyle changes and medications,
43:57
just be aware that lifestyle,
44:00
meaning, you know, diet and exercise,
44:03
is horribly ineffective when
44:06
it comes to treating me. But it seems like that's what everybody does.
44:10
And it's just that's almost never enough.
44:14
You know, The Biggest Loser was that show that they did diet and exercise. They did great.
44:19
But that's fine if you have a personal trainer 24-7 and a chef 24-7.
44:24
What happened to all those people after The Biggest Loser?
44:27
They gained it back. And there was only one person who did it and they had surgery. Really?
44:31
So it's, so that's, that's not effective, but you can try there. You can try.
44:36
Unfortunately, you know, I get it. There's a time constraint.
44:39
Right. And so the other thing is don't, don't also feel afraid that you're going
44:44
to lose anything by sending them to a specialist whose, my entire visit is designed for this.
44:51
It's my, my visit is not trying to treat the other 10 things and that.
44:57
And also, if you're just treating their diabetes and their high blood pressure
44:59
and their sleep apnea and their cholesterol.
45:03
You're missing the one big thing that if you did this, you would at least quell
45:07
most of that or treat it better, more effectively with less medications or maybe none.
45:13
And then send them to the specialist, it doesn't have to be surgery specialist,
45:17
tell them to obesity medicine specialist. Let them take their visit,
45:20
which is designed for obesity too, help them through that.
45:24
You're not going to lose a patient. You're just going to, you're going to gain a healthier patient.
45:29
And you do surgeries at the UT Multi-Specialty Surgery Hospital and University Hospital?
45:34
Correct. Yeah. We're working on the Multi-Specialty Research Hospital.
45:39
We're in the process of getting that up and running for the metabolic and pediatric surgery.
45:43
We've been doing the metabolic and pediatric surgery at University Hospital
45:46
for quite a few years now. We've
45:48
actually, we're an accredited center for metabolic and pediatric surgery.
45:51
And so we're looking to expand that designation as well.
45:54
And you may expand to adolescent surgery. That's our plan. That's our hope is we'd like to do that.
45:59
So we're really giving the full comprehensive care. Now that that hospital has
46:03
a, you know, women's and children's swing and we're working with our pediatric
46:06
surgeons and pediatricians, we have a real positive hope to make that a redout.
46:11
Yeah, I just can't emphasize enough that there are so many options out there
46:17
for treatment for this disease.
46:19
And, you know, here at UT Health, we are here to help and we have all the components.
46:27
I would love soon, someday, to have our full comprehensive center where a patient
46:32
can walk into the front door and get all of the services in one place to take care of them in that way.
46:38
We may not have that building right now, but we have all the infrastructure
46:43
and we will get people to the right place and we will not leave anyone behind. I love it.
46:49
And here on Pediatrics Now, I love to focus on having a life outside of medicine.
46:54
Do you want to mention what you like to do in your spare time?
47:00
Well, I would say, unfortunately, the last two years has been a lot less spare
47:03
time. And you're not on the elliptical. Okay, we've crossed that off.
47:08
I really enjoy, you know, I love skiing. I love traveling.
47:12
My mom was a travel agent. So while growing up, we got to do lots of different
47:16
trips with mom on her like fam, They called them fam trips back in the day where,
47:20
you know, I was going to check out, you know, properties and stuff. Doing the work.
47:24
Someone's got to do it. She was working and we enjoyed it. Nice.
47:26
I really, but I love traveling. And actually, you know, in my,
47:30
you know, role at the ASMBS for the last couple of years, I've had a lot of
47:34
travel and I do enjoy that.
47:36
But getting the opportunity, you know, I love skiing, you know, getting outdoors.
47:40
We actually just had a retreat up in Montana. Nice. I've never been there. It was gorgeous.
47:45
My ski accident happened in Big Sky. It was so beautiful. It was a big sky.
47:48
It was. Oh, yeah. So we went to, we actually were at the summit.
47:51
It was a summertime. So we went to that summit resort.
47:54
And yeah, I mean, I saw Bozeman Hospital. Oh, you're a little stuff. Yes.
47:59
I almost went there, but I came back here for the surgery. I got to go down
48:02
in one of the, you know, emergency. Oh, boy. Yeah. Yeah.
48:06
So, you know, I like trying to do different things.
48:10
But Bozeman's beautiful and big sky is so gorgeous and I want to go back. Yeah, me too.
48:16
Nice. So skiing, what about any summer travel? Are you doing anything fun there?
48:20
The summer travel I'm doing is all for work.
48:22
You know, I'm actually, I was just down in Puerto Vallarta giving some talks. Oh, nice.
48:27
That sounds like a rough job. Yeah, it was real rough. Yeah.
48:29
I'll be going to Monterrey, Mexico coming up soon here. I'm actually going to,
48:33
we have a retreat in Lake Tahoe.
48:36
We have that IFSO group I mentioned is in Toronto.
48:39
And I'll also be giving some talks in Oxford coming up in September.
48:43
In England? Yeah. Oh, nice. Yeah, I've been a part of it. They have a bariatric
48:48
meeting that they do every year.
48:49
Oh, nice. It's last year's, but I've been there for the last,
48:51
yeah. It's kind of cool being in Oxford at Christchurch.
48:55
Yes. They have the dinners in that hall that Harry Potter was modeled after.
49:00
Oh, wow. And drinking out of silver goblets. And I studied at Brasenose College,
49:06
postgraduate study at Oxford, and studied Shakespeare in performance versus reading Shakespeare.
49:12
Speaking of Shakespeare, do you have a favorite quote?
49:15
Do you have a favorite quote from Shakespeare? Or just favorite quote,
49:18
just from Dr. Richard Peterson or someone you like, a quote. I've got a couple. Okay.
49:25
I love quotes. But I'm going to say, let's start with this one.
49:29
And so there's a surgeon by the name of Wayne Meredith who says this,
49:33
but my chairman says it more often than not. And I've lived this way for the
49:37
last, you know, seven or eight years is presume virtuous intent.
49:42
Now, what that means is that the person, so, you know, we, we had some Starbucks,
49:48
right. And they actually made my order correct today. Right.
49:51
But if they had given me this mocha with almond or something,
49:56
it wasn't that they chose to do it and were trying to hurt me.
49:59
So I presume that the person intended to do the right thing.
50:03
Now that only doesn't change the fact that I've got the wrong drink,
50:06
but it does make me not think that they're a bad person. So I,
50:10
I try to live that way, presume virtuous intent.
50:13
I think that's important. And then the other one is that if you're the smartest
50:17
person in the room, you're in the wrong room.
50:21
And, and my chairman's has a quote that it was more like, you know,
50:24
the smartest person in the room isn't smarter than the room too.
50:27
So I think those are, I just always learning and just know, I mean,
50:30
I just, I don't, I don't live by being the, I don't want to be the smartest person in the room.
50:35
In fact, it's kind of funny when I go out and if I'm traveling or whatnot,
50:39
unless I'm at a surgery meeting, I usually don't tell people what I do.
50:43
Really? It changes the dynamics sometimes. So I just like to be neat.
50:49
But being a surgeon really is, it's at my core.
50:55
And that's a great thing to think about, how the power of the intelligence in
51:00
a room and as a team, how we can work better together. It goes to that diversity
51:05
of thought, you know, the more thought that can be about something,
51:08
there's things, a lot less things will be missed.
51:11
Dr. Richard Peterson, Chief of Metabolic and Bariatric Surgery at UT Health
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San Antonio. This has been so insightful. Thank you so much for being here on Pediatrics Now.
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Don't forget to click on the link in this podcast for free credit that includes
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CME, MOC, and ethics credit, depending on our topic or podcast.
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Our website is PediatricsNowPodcast.com, and our sister podcast is Pediatrics Now for Parents.
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We'll have a shorter parent-friendly episode on that podcast.
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You can also find Pediatrics Now for Parents anywhere you get your podcasts.
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It's meant to be one less thing you have to say in the exam room.
51:51
Coming up next week you've heard about it the lettuce outbreak we'll talk to,
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our pediatric infectious disease doctor dina sutter with some advice and we
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know you're probably getting asked about this and she's also going to talk about
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the rabies and typhus in san antonio and in other states,
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i'm holly wayment thank you for listening to pediatrics now i'll see you soon.