Changing the Conversation Around Childhood Obesity | with Dr. Evan Nadler

Dr. Inyang Takon welcomes Dr. Evan Nadler, an internationally recognised paediatric surgeon and childhood obesity specialist, for an honest conversation that challenges many of the assumptions surrounding childhood obesity.

Drawing on more than two decades of clinical experience, Dr. Nadler explains why obesity should no longer be viewed as a personal failure or lack of willpower. 

The discussion explores why many families become trapped in an exhausting cycle of diet and exercise programmes that produce limited long-term results, often leaving parents feeling blamed and children feeling ashamed. 

The episode goes on to explore obesity in children with neurodevelopmental differences, who often face additional barriers to receiving appropriate treatment. Dr. Nadler explains why obesity should not be placed on the "back burner" while other conditions are managed, but instead addressed alongside them through multidisciplinary care and shared decision-making with families. 

Rather than advocating a single treatment, Dr. Nadler presents a balanced discussion about lifestyle interventions, medications, and bariatric surgery, emphasising that the best approach depends on the individual child and should always involve informed family choice—not paternalistic medicine. 

Whether you're a parent, healthcare professional, educator, or policymaker, this conversation will challenge long-held beliefs and encourage a more compassionate, evidence-based approach to supporting children living with obesity.

🎯 What You'll Learn

•  Why childhood obesity is a chronic disease—not a lifestyle choice 
•  The genetic, biological and environmental drivers of obesity 
•  Why diet and exercise alone often aren't enough 
•  How obesity affects children with neurodevelopmental differences 
•  Why early intervention matters more than "waiting to see" 
•  How stigma in healthcare can harm children and families 
•  When medications and bariatric surgery may be appropriate 
•  Why families should be partners in treatment decisions 
•  The long-term health risks of delaying intervention 
•  How clinicians can support children without judgement 

⏱️ Chapters

00:00 Introduction to Early Intervention Matters Podcast

02:39 The Growing Concern of Childhood Obesity

04:40 Understanding the Challenges in Treating Obesity

08:16 The Importance of Medical Intervention

11:31 The Complexity of Childhood Obesity

15:06 The Psychological Impact of Obesity on Children

17:24 Stigmatisation in Medical Settings

18:57 Defining Obesity as a Disease

22:17 The Urgency of Addressing Childhood Obesity

Evan P. Nadler MD served as Co-Director of the Children’s National Obesity Programs and Director of the Child and Adolescent Weight Loss Surgery Program at Children’s National Hospital from 2009 until 2023. He was also a tenured Associate Professor of Surgery, and Pediatrics, at The George Washington University School of Medicine & Health Sciences and continues there as an Adjunct Associate Professor.   His current pursuits include pediatric obesity treatment program development, authoring a book on obesity, and educating the public about obesity via his YouTube channel, website, and media appearances.   Dr. Nadler is an international leader in the field of child and adolescent obesity, has authored multiple publications and textbook chapters on the topic of pediatric bariatric surgery, and was one of the founding members of the Childhood Obesity Committee of the American Pediatric Surgery Association.  

Obesity Explained | Evan P Nadler MD, MBA

www.youtube.com/@obesityexplained

Evan Nadler MD, MBA | LinkedIn

Transcript

SPEAKER_00 0:03

Welcome to Early Intervention Matters, the podcast that helps parents, teachers and health professionals understand the diagnosis, treatment, care and support of children with autism, ADHD, threats, and other neurodevelopmental challenges. Your host, Dr. In Yang Takon, is a consultant neurodevelopment pediatrician, and she will provide insights through interviews, answering questions, and breaking down complicated topics. By sharing stories from parents and professionals in the field, we hope to make sense of what can be an overwhelming topic. Early intervention is crucial for children with developmental difficulties. Yes, early intervention matters. And now, here's your host, Dr. Inyan Takon.

SPEAKER_02 0:56

Hello everyone. You're welcome once again to the Early Intervention Matters podcast. We're really happy to have you here. This is a podcast that's dedicated to transforming the way we understand, identify, and support children's development from the earliest moments. And I'm Dr. Iang Takon. I'm a consultant neurodevelopmental pediatrician. I practice in the UK and have done so for over two decades. So this is a platform. We have clinicians, researchers, families, young people with lived experience. They come together because every voice matters when it comes to supporting children. And we built something really rich here with one episode after the other, going deeply into the matters that really affect children. So today I'm so pleased to have Dr. Nadler with us, and he's going to talk a lot more about himself. He's going to tell us about his work and introduce himself. But I was so pleased to meet Dr. Nadler on the Podmatch platform. And one of the things that made me very keen on his work and his profile was he seemed very passionate about one of the main issues that I do see with the community of children I see, and that is obesity. In the UK, it's a growing problem. It's really growing problem, which we haven't been able to get a handle on. We still struggle with pathways to be able to get help for the children. And families have been stuck in this wheel of diet, exercise, and sometimes families really feel isolated and feel frustrated because the amount of work they're putting into getting results, it doesn't show up. And they get stuck because the professionals time after time look at them to say what's really going on with your child. So I was so pleased to read all some of the work that Dr. Nadler has done. So thank you so much, Ivan, for coming over to and joining us on the podcast today.

SPEAKER_01 3:03

It's my pleasure, and thanks for reaching out to me and thanks for inviting me and thanks for having me. Super important topic. Childhood obesity in general is a global issue. Used to be mostly a US issue, but uh now it's all over the world, including countries you wouldn't even necessarily think of having obesity problems. And uh they're especially important, as you just mentioned, in the in the uh children with neurodevelopmental differences. And those families, I'm sure, in the UK are similar to the ones in the US. They really struggle to find resources. They they struggle to find people who understand their situation, who are willing to tackle it head on. And uh, I don't profess to have all the answers, but I can definitely share some that I've learned over the last couple of decades. And I guess to introduce myself, people should know that I'm a pediatric surgeon and have devoted the better part of two decades, or actually, I guess I finished my training in 2004. So whatever that is, 22, 22 years to childhood obesity. And specifically in the early days, bariatric surgery for children with obesity, although now I've done a lot more in the uh pharmacotherapy or medication prescription for children with obesity, and have a special place in my heart for the children with neurodevelopmental differences. Uh, again, because the families struggle so much, all the families struggle, but these families generally struggle a bit more. Because in large part there are folks who are just a little bit reluctant to provide the same care for obesity to children with childhood with uh neurodevelopmental differences, even though that's really what we should do is treat everyone exactly the same. But we'll get more into that, I'm sure, as the Yes, we will. Yes.

SPEAKER_02 4:42

And you're right, when people are making care plans and planning management plans, it's almost like a different take when it comes to how far they go with children with neurodevelopmental differences.

SPEAKER_01 4:57

I'll start with an anecdote that people might find interesting. And as I'm sure your listeners will come to understand, I'm a little bit of a um, I don't know if I want to say instigator, but I'm a I stir the pot a little bit. I do things that I think are right, whether or not other folks may think they're right. And so early in my pediatric bariatric surgical practice, there was a patient who came to me with Down syndrome. And she was actually a young adult. But in the US, the young adults, the adults with Down syndrome or um autism spectrum disorder, the adult surgeons won't take care of them. So they came to me. And the family had, you know, had custody and all the paperwork, et cetera. And they wanted diariatric surgery for their child because I can't remember, maybe the mom had bariatric surgery or maybe the dad or both. And they knew it could help their child. She had bad sleep apnea, diabetes, you know, those things that come with obesity. And this was, again, early in my surgical practice. And so I decided that because it was somewhat outside of the typical patient, that I'd bring it to the ethics committee. I'd have the ethics board discuss whether a patient with Down syndrome was an appropriate candidate for bariatric surgery. Because in the old days, and maybe still now, there's this uh hurdle that the patient must be able to understand and uh adhere to the postoperative dietary plan. And some patients with Down syndrome are very high functioning can do that, and some aren't. So I brought it to the ethics committee. And to make a long story short, the ethics committee came back to me 50-50 split. So the chair of the ethics committee sat me down and said, you know, half the people on the committee thought it was okay to have for this woman to have surgery, and half the committee did not. So in the end, it's a medical decision that you have to make. And a light bulb went off above my head. And I was like, yes, it's always a medical decision. There's nothing ethical, unethical about it. It's a medical decision. And if I think that this could help the patient and the family agrees, then I should do the surgery. And if we don't, then we shouldn't. And in fact, I flip it now on the ethics committee type people, and they say, I would argue that it's unethical not to offer it to someone because of so anyway, that was actually like 15 years ago or some long time ago. But there are still many pediatric surgeons in the US who feel that ethics committee input is important in certain cases, and and it probably is in certain cases, but truly it was like the epiphany moment where I was like, I don't need to ask the ethics committee for permission and what's medically appropriate if the family is in agreement. It just has to be appropriate.

SPEAKER_02 7:27

So anyway, I didn't mean to take up too much time with my stories, but no, but that's a really good point you've raised because I think medicine as a whole, sometimes if we're not careful, we become stuck on the letters rather than actually looking at the patient and the child in front of us.

SPEAKER_01 7:42

You know, I think the Hippocratic oath, which all doctors take, which is first do no harm. A lot of people interpret that as don't try something new. But in the case of childhood obesity, not intervening actually does harm, right? We know what happens to children over time. So again, I sort of flip the Hippocratic Oath and tell people, listen, you're doing harm by not referring the patient or not trying a medication or not doing something that's within your medical uh yeah degree and comfort. It's not baby fat that people are going to grow out of. It's actually a disease that is gonna get worse with time.

SPEAKER_02 8:16

Yeah. And I think that's the thing that a lot of people need to think about that what's the long-term impact of not doing something. And thank you for taking that angle as well to hear somebody actually putting the child at the center is is great.

SPEAKER_01 8:31

Well, you you said that I'm passionate. You got from my work online that I'm passionate about childhood obesity. Uh that word might be a a slight understatement. I might be obsessed with it or something more more than just passionate about it. Because I think about it all the time.

SPEAKER_02 8:45

It's like it's a it's good obsession. Yeah. So can you tell them why did you decide to start to specialize in obesity? Right.

SPEAKER_01 8:55

Yeah. Nobody, or at least not uh 20 actually, I did my first bariatric surgery on a child in 2004. So nobody 22 years ago went into pediatric surgery to take care of obesity or take care of children with obesity or 300, 400 pound or 150 kilo teenagers. You know, we go into it to take care of little babies with congenital disorders, and because we think of the babies as the most vulnerable patients. And I was actually at a meeting, a pediatric surgery meeting, presenting data that was from my time in the research lab uh that I was working in. And so I was still a trainee at this time. And I was actually at a pool uh in the Disney resorts in Florida and the U.S. And I looked around the pool, and you know, most of the people at the pool were struggling with their weight. And um, there was a boy across the pool from me who particularly caught my eye because he was about 12, and uh he clearly had a weight issue, and he had like a two-liter bottle of Coke, a one-pound bag of potato chips, uh, or crisps, as he would say in the UK, um, and a greasy hamburger. And I I leaned over to my wife and I said, somebody in this country has to do something about the obesity problem, and uh especially in children. And that sort of started me on the path. And at that time, naively, I kind of thought it really just meant educating the world about the perils of childhood obesity and that changing the diet of children would be all that we needed. Um, because again, this was this was in like 2001 or something, so 25 years ago. Since that time, I've learned there are a lot of biological drivers. There's genetics and epigenetics, and even the brain telling the child to eat food that they choose is probably part of the disease and not a willpower issue. It's not that the child or family thinks that those are healthy options. They may either not have the economic means to have other options, or again, I believe there's some degree of a biological drive to seek out these hyper palatable foods, the salty, sugary foods. Uh and that it wasn't gonna just be as simple as, you know, changing food back to the way it was in the 1950s or 60s or whatever. It was gonna take a bigger lift. And so that's sort of where I am now, which is trying to like those things are important. Don't get me wrong. Like we need to work on food quality and food accessibility and food affordability and all those things are super important, but but by themselves, they're just not gonna change the equation enough.

SPEAKER_02 11:32

Thank you so much. It just I'm just sitting and thinking of children coming to our clinics where everyone has been kind of hung up on the lifestyle modifications. So when the families come, you know, the lifestyle, that's the message that keeps getting drummed into I'll never forget one of the children I see in my epilepsy clinic. The saying, no, there's nothing we're doing that's different, but the there's still lots of weight gain and all that.

SPEAKER_01 12:01

So many So the data and people all of my cutting edge, let's say, we'll use that because it's a nice euphemistic word for my out-of-the-box thinking, but all of it is based in science. There's nothing unscientific about what I preach. And if you look at the data from the most intensive lifestyle programs that we have in the US, they're called uh intensive IHBLTs, intensive healthy behavior and lifestyle treatment programs. And they're supported by the Center for Disease Control in the United States and also by the American Academy of Pediatrics in the United States. And what those programs entail is 26 contact hours. So that's an hour a week, every other week, learning about diet and exercise and participating in diet and exercise programs. And at the end of all that, the patients get on average 5 to 7% total body weight loss. So if you do the math for a 300-pound or 150 kilo patient, times 15 kilos, half of that is uh seven and a half kilos. Anyway, it's a small fraction. Uh, I could do it easier with pounds. 300 pounds, 7% is 21 pounds. And so at the end of 26 weeks, that patient now weighs 279 pounds. Who is going to enroll in that kind of program? Who's gonna who's gonna put in that kind of effort for that little benefit? And yet it is actually still on the CDC website and the AAP websites as the uh primary recommendation for children with obesity. I mean, I wouldn't do that. I wouldn't put in 26 weeks of and for children, obviously, it's different, right? Not only is it the child an hour every other week, but it's the parent taking them to the visit. So it's two hours out of the parent's time at least.

SPEAKER_03 13:41

Yeah.

SPEAKER_01 13:42

And it's really hard for a lot of families, especially families whose parents can't afford to take two hours out of their time every other week. Like it's it's just it's expecting too much out of our parents and families and patients.

SPEAKER_02 13:55

Yeah, who are already dealing with quite different things.

SPEAKER_01 13:58

They've already got a lot enough on their plate. So again, diet and exercise are super important, and I don't want to minimize that. And I don't want people to criticize me and say that I don't care about those things because I do. They're important, but they're not enough. And and frankly, a lot of those changes that are needed are easier after a medication is started or after a surgery. And then again, I should mention in your patient population, some of the medications that we give to help children actually cause them to gain weight. So then asking them to do more work because of a medication weight to them. We we did this to them. Again, it doesn't make it doesn't make a lot of sense to me. But uh but sometimes sometimes I feel like I'm the only one shouting from the treetops or from the mountaintops about it. But that's what I'm here to do.

SPEAKER_02 14:47

Uh I think that's why we need to get the message across because sometimes it can be quite traumatic for the children years and years. Some of them have developed low self-esteem because of their looks and just being teased at school and all that.

SPEAKER_01 15:02

A lot of them have been stopped and preferred to be home educated and so the data from the US are somewhere between 40 to 70 percent of uh children uh with obesity have an associated mental health disorder at some point.

SPEAKER_02 15:17

40 to 70 percent.

SPEAKER_01 15:18

Yeah. And it depends obviously, um, you know, which study you're studying and the different how you define it all. But but I I would imagine that if you ask them the simple question, have you been teased about your weight? That would be about 100% or 99% or something else. And I think the take-home message for your listeners and for everybody is that obesity is a disease and not a lifestyle choice. And so you wouldn't tease a child or tease a parent or shame a family if their child had childhood cancer or had asthma or had whatever else. Uh so we need to get over the uh tendency to blame and shame parents and their children uh for the disease of obesity. Like it's not that simple. It's a disease. That same 40 to 70 percent is actually also the degree of obesity that's thought to be heritable or that you can inherit from your parents. I would say in children it's higher. It's probably a higher number, maybe as high as 80 to 90 percent. But again, I make the uh analogy that uh maybe a decade or two ago, we used to think alcoholism was a disease of of weak willpower. And then when we learned that it was genetically driven, the whole, the the entire field changed, and we understood that it was a disease that needed treatment. And obesity gets to that same point where we understand that it's not a person's fault. It's a disease that has genetic drivers, it has environmental drivers, it has societal drivers. We know lack of sleep and uh childhood childhood trauma, adverse childhood events all lead to a higher risk of obesity. So it's multifactorial, but it's not due to willpower. That's the one thing we can agree upon. No parents chose to have a child with obesity, no child ever chose to be obese.

SPEAKER_02 17:02

Yeah, that's right. I think what you have stressed for the audience is really important because you have, you know, a a lot of these families sometimes are so scared going into the doctor's office because the minute they tell the child to stand on the scales, the parents are petrified and they're anxious on almost like taking the weight, you know, religiously and asking, you know, how many pounds they gain. That whole period of building up to that, they have been trying to do their best. And then it's not shifting on the weights. So it is something that uh we have to be very professionals as well. We need to be very careful because the kind of message that comes through during the consultation can affect them.

SPEAKER_01 17:49

Yeah. So I'm I'm writing a book on childhood obesity, which is part of the reason I'm out here doing podcasts and trying to spread the message. And in it, I relay a couple of patient stories that would shock most MDs or or providers and a lot of families as well. But the amount of stigma and bias that children with obesity face in the doctor's office is it's crazy. I mean, we're supposed to be a place of healing and help, and we are actually stigmatizing our patients more. It's totally unacceptable and it's our own fault for not doing a better job of educating our colleagues. But it it it's that probably makes me the most angry of all of it is when I hear about a doc or a provider who stigmatizes their patients because of their weight. Like that to me is just a lack of understanding about the disease and a lack of empathy, really. I don't know why we feel the need to judge anybody with any problem that they come to us for help uh with.

SPEAKER_02 18:44

So And Dr. Sadner, just going back for the purpose of our audience, could you talk a bit more about obesity itself as a disease and why you said it's a disease and what is obesity?

SPEAKER_01 18:58

Seems like a simple question. But the reality is that in the in the adult world, especially right now, there's a lot of ongoing debate about how to define it. The Lancet Commission out of the UK put together all these experts to come up with a disease definition. And after like five years and all these meetings, they failed. They published their findings, but there was still no like universal agreement on how to define the disease. So we use a calculation called the body mass index, which is a ratio of your weight to your height, and it's actually your height squared to be technical. But that's a screening tool. And it's a screening tool that was developed uh actually in like the 19th century for nothing to do with medical use. And then in the 1970s in the US, it gained popularity as a uh a way to define obesity. So currently we define it in the medical community as a BMI of 30 or more in adults. In children, we use percentiles for age and sex because the children are growing and the boys and the girls grow at different rates. But it's important to understand that it's just really a screening tool because certain populations, for instance, Southeast Asians, will have disease from or complications from their weight at a lower BMI than Caucasians, for instance. And the numbers that were originally used to make the BMI calculations, as no one is too surprised about, was based on white males. So it really is not necessarily applicable to lots of other populations. So it is how we define it right now, and it's the best we have, but it doesn't correlate with health. So it is important to also understand how a weight is impacting a person. But their data actually from children, which are concerning, and it has led me to one of my new campaigns, which is trying to actually define pediatric obesity as its own entity. It's a different disease than adult obesity. But there are data that were published that show that adolescents with obesity, even if they have a metabolic problem at the time of the diagnosis, they are much more likely. They're 40 times more likely to have type 2 diabetes as a young adult than the average population. But even if you don't have a metabolic derangement at the time of diagnosis, you are still, I think, 20 times more likely to have diabetes than the average population. And you are definitely more likely to have a cardiovascular event as a young adult than the general population. So in children, at least, there are data that have been published that show that obesity defined by BMI, even what they termed in this paper as metabolically healthy obesity, which I don't really believe is the term, but even those who did not have a metabolic problem at the time of diagnosis were still at higher risk for having a cardiovascular event as a young adult. So the screening test is still pretty good in kids. And I would argue that the diagnosis of obesity, even by the um eye alone, is often worth treating. So you shouldn't necessarily ignore it just because there is no obvious related complication at the time of diagnosis. And it doesn't get that way. You know, like in kids, 80% of toddlers with obesity go on to be adults with obesity, and 95% of teenagers with obesity go on to be adults with obesity. There's not really much benefit to delaying intervention.

SPEAKER_02 22:17

Yeah.

SPEAKER_01 22:18

And you would think that for something that has a long-term risk, that we would be more aggressive to So I That's another one of my soapbox issues, which is childhood obesity is actually more aggressive than adult onset obesity in terms of the complications and how quickly they progress. Yet we treat it less aggressively, which again is a dichotomy that doesn't make sense to me personally. And all these things were trying to just try to change the way everybody thinks about this disease, and hopefully someday uh people will start to change the way they deal with patients.

SPEAKER_02 22:49

Thank you, Evan. It's been really good having that explanation because I think it's really good for our audience to understand obesity and understand what classes as obesity and the hung up on BMI sometimes can get very rigid with people without actually looking at other aspects as well. So it's good to have that discussion. And with children with uh neurodiversity or differences, what happens in why do you think they are more at risk? Because up to one in three children who are neurodivers end up with being obese. So what's the uh course? What does this get attributed to?

SPEAKER_01 23:33

Well, certainly there could be a genetic component, and I've done a lot of genetic type work in my research days. But I also think sometimes when there are children with neurodiversity, it's really hard for parents and they can only pick so many battles. And so let's say a child has a texture issue and will only eat french fries or chips, as they say in the UK, then the family just will continue to feed that child those healthy foods. And it's not, again, I'm not blaming parents for that, but I do think there could be children that have they might have textural issues. Some they there's talk about the beige diet where kids will only eat chicken tenders and uh other things that are beige. And those are not the healthiest options and and can sometimes be difficult. And then on the flip side, exercise can be difficult because it's can be hard to get children with neurodevelopmental differences adequate exercise. But that being said, I actually think it's in large part because the pediatricians taking care of them or the primary caregivers don't necessarily pay as much attention to that issue because they have the other issues that are going on. And so they might push the weight issue to the back burner until they get some of the behavioral issues better under control, which I understand as well. Although I would say you should try to take care of both at the same time because neither issue is going to get better without being addressed. So the kids who I would see initially with neurodevelopmental disorders who ended up coming to see me for surgical opinion were usually kids of parents who had issues themselves and maybe even had had bariatric surgery themselves because they would sort of think about the obesity and behavioral issues. Like they knew that the obesity was going to cause a problem at some day. So they didn't want to wait for the behavior situation to be perfect before they came and saw me. And so again, I I have lots of great success stories from children with uh neurodivergence, but not everybody's a success, and I'd be remiss if I said it was some magic boat kind of thing. Definitely challenges, and and the cohort that seemed to have the best success in my group were the boys with autism spectrum disorder, but because the sometimes if the behavior differences can be used to your advantage, for instance.

SPEAKER_03 25:50

Yeah.

SPEAKER_01 25:51

So but, you know, like again, it's not all sunshine and roses or unicorns or whatever they say. I certainly don't advocate that every child with obesity gets surgery or every child with nordevelopmental differences and obesity gets surgery, but I do think it should be offered to people and they should be able to get the information. Like I'm very much a the paternalistic provider role, I think it's long past its usefulness. I think everybody needs to know all the information that you have about everything that's out there and then be helpful to make the best decision for them. And if we don't spin in as as providers or MDs to give that information, people are gonna get it from the internet and it may or may not be accurate. Yeah, exactly. But rather than myself and and just give it to people straight and then just let them come to whatever decision they think is best for them.

SPEAKER_02 26:41

Yeah. And you said one important thing. You said sometimes people are waiting for the behavior to get better before addressing the other thing. And one of the things is that this is a reflection for me as a uh a clinician as well, and I hope for other clinicians listening to this, is that what you said is sometimes we are seeing the weight creeping, but because we are so focused on other things, we're really not tackling that at that time. We are looking at all the other things and waiting for that to be sorted, which we can't put a timeline on when on all the things we're waiting for.

SPEAKER_01 27:18

Right. And I don't blame clinicians for doing it that way, especially here in the US, where the amount of time we can spend with each patient is short. And a lot of clinicians try to address the most pressing issue first. I worked very closely with my child psychologists over the years, as we would do my program in general, but especially with the kids with differences, um, neurological differences. And uh a lot of even let's say some of the eating disorder kids, binge eating disorder or kids with suicidal audiation, we would have lots of discussions about like, okay, what's really the best timeline for these kids? Because yes, you need the binge eating disorder to be under control before you want to do anything else. But it doesn't need to necessarily be perfect. It can just be on its way to being, you know, like you don't want to doing things sequentially isn't always in the patient's best interest. And like with the uh suicidal ideation kids, so suicidal ideation for your listeners, it's basically wanting to commit suicide. Suicidal thoughts. And we would have discussions about these kids, like when so it's a contraindication for surgery to have active suicidal thoughts to go into surgery. But when's the right time? Like how long should you be after that before it's okay? Like, does that mean you should never get bariatric surgery, or does that mean you have to wait a year, six months, or whatever? Which there's no right answer to, but the psychologists and I decided that probably the best time was while they were still in treatment for their suicidal audiation, is then we would be assured that they had a mental health professional as part of their care. I use that thinking the same way I think about eating disorders or neurodevelopmental disorders or whatever, is that maybe the best time to intervene is while everybody's all involved in the care and not when they're quote unquote better, because that's when people aren't paying attention necessarily as much. So anyway, I'm not trying to say it's a perfect time or perfect answer, but it's just mostly I want it to be thought-provoking so that providers out there who are listening might think, okay, maybe I should change how I'm dealing with this problem. Uh, maybe I should try something slightly different because maybe it'll uh turn out to be a better approach, you know. Again, I don't know. But I've always been one to be more willing to make an error of commission, trying something new, than to stick to something that I know that doesn't work.

SPEAKER_02 29:35

So can you tell us what at what point do you decide this young person or this child is suitable for bariatric surgery?

SPEAKER_01 29:43

So the easy answer is that I don't decide. The family decides and the patient decides.

SPEAKER_03 29:48

Okay.

SPEAKER_01 29:49

Uh the more complicated answer, which is what you're sort of alluding to, yeah. Is how do I, as a surgeon, approach the patient? And and joking aside, it is really in large part driven by family acceptance of the idea. And you can imagine a lot of patients, when I they first come to my office, the kid is driving the bus. Like the kid found me online and it's like, I want surgery. This guy has all this experience and has all these great outcomes, and I want to be like that. And the parents come in very skeptical. And then the opposite is also true. I have times where the parents really want their kid to get surgery, but the kid has no interest whatsoever because you know, the kid isn't there yet. So again, my approach is that I really just try to give people the information that's available. Before the GLP1s were approved in children, the discussion was different because there really weren't a lot of good medications for children. Mm-hmm. Now there's at least one in the US that's approved for children. So Which one is that? Uh that's Symagletide. Okay. Or Wagovi is the brand name, but I like to use the generic name.

SPEAKER_03 30:50

Yeah.

SPEAKER_01 30:50

But that's the only one in the US that's approved of the GLP1. Uh in the US, Cusimia, which is a combination of penteramine and topiramate, is also approved on age 12, but most of the insurance companies don't cover it, so it's not an option often. So we actually break medications apart and prescribe them separately, because as generics, they're actually affordable. But so, so to me, if your weight is impacting your mental or physical health, then it's worth addressing. And whether you address it with medication or surgery is obviously more nuanced. But if you have type 2 diabetes, probably surgery is uh going to be a better long-term solution. I sort of look at it sometimes opposite to other folks. But if you're struggling with your weight, the younger you are struggling with your weight, I also sometimes think that surgery is a better option because that means your genetic drive and your epigenetic drive is that much stronger. Like if you're eight or nine and you already have prediabetes, let's say, or akanthosis and agricans, which is uh So it's setting earlier. Yeah. If it's starting with if you have that at eight or nine, you know, in my mind, that means you your likelihood of having a healthy adulthood is even less. So, you know, when you're ready, we should talk about surgery because you're most likely going to need both, to be honest. You're gonna need medication and surgery. And and so I also try to get that discussion out in front because I think for too long, people in the obesity world have sort of argued surgery versus medication. But the reality is that it's a lot of people are gonna need medication and surgery, or surgery, then medication, or medication, then surgery, and then more medication. I mean, it's a chronic disease, it doesn't get cured in many people. So again, I try to I like to call myself an intervention agnostic, meaning I don't really have any like just because I'm a surgeon doesn't mean I want to operate on everybody. I I want to operate on people who want it and need it and who will benefit from it. But I'm not looking to, you know, I'm not looking to to perform surgeries just because I enjoy it or it may and I actually don't make any more money if I operate more or less. So that's not a consideration. It is a combination of things. And there are criteria that are set forward by the our insurance companies and the NHM. And those are, again, sort of starting criteria. But sometimes I I think the family decision has a lot to do with it. I don't want to, again, it's it's not a cop-out, like Yeah.

SPEAKER_02 33:13

I think that's what I'm getting from our discussion that the family are taken into the decision-making process about what pathway they want to follow rather than letting Right.

SPEAKER_01 33:26

And in in most diseases, disease processes, I think that that's appropriate, right? We're talking about the the IHBLTs or the lifestyle programs. If a family just cannot make that happen, there's no point in prescribing it or recommending it.

SPEAKER_02 33:40

I mean, even for me, it's the it sounds like torture to to do an open twenty.

SPEAKER_01 33:47

I mean, I I often say that, yes, I should eat less and exercise more personally. Like I would be healthier if I did that. Could I commit to an hour a week every other week? Maybe. But not always, not every week. And so it's a lot to ask of people. I think if people have tried medications and don't get enough weight loss or tried diet and exercise and don't get enough weight loss, or if they have a very severe comorbidity that like live like metabolic association, metabolic dysfunction associated statohepatitis or mash, then I would be more aggressive in re in my recommendations. Or if someone has severe obesity that runs in both sides of the family where where you know the genetics are not working in the patient's favor. Those might be times where I sort of push a little bit more, but you know, no intervention works if the person doing the intervention or or having the intervention performed on uh hasn't born into it, right? So it's not gonna work. Surgery is not gonna work if the patient hasn't born into it.

SPEAKER_02 34:44

Yeah.

SPEAKER_01 34:44

Just like medications won't work if the patient has to do.

SPEAKER_02 34:47

Exactly.

SPEAKER_01 34:47

So I think that's a good thing.

SPEAKER_02 34:49

So you talked about having um some success stories. Do you want to tell us what, apart from the physical part, of obviously they would lose some weight and feel better. Are there any striking s success stories? I mean, you're doing your book, so yeah, I'm sure you've got a lot in your book.

SPEAKER_01 35:08

Yeah. And and again, it's there are tons. And like obviously, I'm happy when my patients get healthier, but the most rewarding stories are the stories of the lives that are changed. One that comes to mind is a boy from my early, early days who was sort of a social outcast who, after losing weight, was able to join a sports team and had friends for the first time in his life. Stories of one of my female patients who actually was a cancer survivor and then underwent periodic surgery. And after all that and and getting better, she's gone on to medical school to pay a phone. I have kids, I have lots of kids who participate in sort of lived experience advocacy groups uh for obesity, um, which also like I love it when the kids get back and like want. I used to actually have a peer mentoring program that I put together where um a kid who had had surgery, I would pair with a child who was maybe going starting the process. So they had someone who'd been through it to help guide them, guide the new patient through that process. And you know, large majority of my kids were willing to be part of that. I had a whole cohort of American football players who were actually like mentoring each other because they were all going through the same thing. And and so those are the things that I mean, that's the I'm sure it's the same way for you. Like the the patients who go on to help other patients, like that to me is the best. That's the ultimate win.

SPEAKER_03 36:30

Yeah.

SPEAKER_01 36:31

You know, like anyone who pays it forward for me, like those are the stories that I I love the most. When a kid loses a hundred kilos and goes from being super unhealthy to being very healthy, that makes me feel good for sure. But the things that make me feel the best are when that same kid then goes and says, How can I help someone else get the same outcome I did? Or or how can I help you?

SPEAKER_02 36:53

It must be very rewarding for you to see children's lives being transformed, literally.

SPEAKER_01 36:59

When I first started doing this in the early in the 2000, I guess like eight or nine era, there was an adult bariatric surgeon who was basically helping train me. He was from Australia. So I'm not gonna try to I'm not gonna try to mimic his accent. But he did say to me, he's like, Listen, mate, these patients are gonna be your most grateful patients that you will ever see.

SPEAKER_03 37:20

Whoa.

SPEAKER_01 37:20

And I said to him, I was like, I didn't say this to him, but I'm thinking in my head, what is he talking about? I take care of babies with deadly diseases and I save children's lives and children who were shot and this and that, and I do all this stuff. What does this guy know? But he was right. These children who like get to uh experience their adolescence in a healthy fear place are super grateful.

SPEAKER_02 37:45

And it's just very rewarding because already they've got a lot to contend with when they're going through transition into adulthood and finding employment, and it would give them a another lease of life and self-esteem to actually be able to. So we actually underestimate all the things that it would be of benefit for them.

SPEAKER_01 38:08

Yeah, and there are data that show that adults with obesity have uh lower earning potential. They get passed over for uh promotions.

SPEAKER_03 38:17

Wow.

SPEAKER_01 38:17

And actually, there are data from my kids. We did a study on executive functioning, and children after weight loss have better executive functioning and actually have structural changes in their brain than the children with obesity before weight loss. And so there are all these mental benefits, mental health and physical brain benefits that go into it that we we totally underestimate.

SPEAKER_03 38:40

Yeah.

SPEAKER_01 38:41

And again, it it to me, you know, like I this uh was an argument I used to have with the endocrinologists when I first started doing bariatric surgery on on preteens, on 12-year-olds and 10-year-olds. They would obviously have concerns about it because it when I was doing it, it really hadn't been done before. But I said to them, like, even in uh mental health or physical health, either way, do you think it's healthier to go through adolescence and puberty with 50 kilos of extra weight on board? Or after a paratric surgical procedure that might get rid of those 50 kilos? And they would say, Well, what about vertical growth? I was like, I don't know, but I can't imagine that 50 kilos. Again, back then I didn't know. Now we know it doesn't impact vertical health, vertical growth. But back then I'd say, I don't know, but I do know what'll happen if I don't do something, which is they might grow taller, but they're gonna grow sicker. And I'd rather take a chance that they'll be a little bit shorter, but a lot healthier. And it turns out they don't, they're not any shorter. So that it was just a theoretical argument. But again, the point was like it goes back to sort of my first do no harm flipping the script on that. I was like, I know what's gonna happen if I don't do anything, and it's gonna hurt this job.

SPEAKER_02 39:54

I like the way you flip the script. I've taken that one from you today. I've taken that one from you today.

SPEAKER_01 40:00

So the uh yeah, your listeners in the US will know about New Jersey, which is where I'm from. Your listeners in the Europe may not know as much, but we in New Jersey are like fighters and we're like uh instigators. We're sort of like maybe your typical football hooligan, by the way. Uh so that's why I flip the scripts because I try to take the words that people say, and I say, okay, I'll take that. Let me show you what it means to me.

SPEAKER_02 40:24

The other way.

SPEAKER_01 40:25

Yeah. So I'm not necessarily gonna not a pugilist. I'm not gonna fight you that way, but I am gonna fight you uh, you know, worse.

SPEAKER_02 40:33

Yeah. Oh, even it's been such a wonderful time just having this conversation with you. I'm definitely going to invite you back because I think this is this is a really important topic. And I've been reflecting on our practice here in the UK. And I think this is something that people need to hear. Because sometimes we get fixated on the wait part and the immediate, not thinking about the long term, the metabolic aspect, the journey for that person. Yeah.

SPEAKER_01 41:03

And what we could do, any clinician or any family for dealing with the way they do. I'm just hoping to open a few minds to doing something slightly differently or approaching the problem slightly differently.

SPEAKER_03 41:15

Yeah.

SPEAKER_02 41:16

So what what what's the message you have today for parents and then clinicians as well?

SPEAKER_01 41:21

Well, again, the the number one message, which I said before, but I say it over and over again, which is that obesity is a disease and not a lifestyle choice, and especially childhood obesity. There is no lifestyle choice piece of childhood obesity. So that needs to just go away completely. And the corollary, let's say, or the second bit of the tagline is that there's something you can do about it, right? You don't have to just do diet and exercise forever and ever and then have it fail and then get frustrated and and not want to see doctors anymore. There are medications and surgery that are that have been shown to help. And they might not be right for everybody and may not be right for your listeners, but it might be right for some. And so it's more again about just opening minds and and people knowing what options are out there and then and then having parents and families hopefully find a clinician who can help them discuss those uh different options and the pros and cons in a in an empathetic and comprehensive way.

SPEAKER_02 42:18

Where can people find you? Where can our guests find you?

SPEAKER_01 42:21

Yeah. So I'm actually not hard to find, and I actually am very responsive, in fact, probably too responsive to emails. So the easiest way to find me, if you really want to contact me directly, is my email, which is my first name.my last name, and then at my initials, which are epnmd.com. But my website is called obesity explained, my YouTube channel is obesity explained, Instagram, obesity explained, they're all the same. Again, I'm just out here to help and you know, hit me up, no worries. You know, if we need to get more people in in the UK interested in this problem because there's some and it's starting to take hold. But the childhood obesity epidemic is it's in the UK, it's in India, it's in Asia, other Asian countries. It's making its way through the Middle East, actually.

SPEAKER_02 43:10

A lot of the Middle Eastern countries are it's in the Middle East now. We definitely in the last few years, it's problem. Yeah. Yeah.

SPEAKER_01 43:17

So we need we need a little bit more global outreach. So I'm I'm certainly happy to be on this uh podcast and start that discussion outside of the US as it continues in the US.

SPEAKER_02 43:27

Thank you. Thank you so much for spending your time with us. Thank you for all the information you've shared. We really appreciate it. And it's been an insightful session. Um I personally, you know, I have taken on board quite a lot because, as you said, when we are seeing the children we see, sometimes we get very focused on the immediate concerns. And sometimes we're probably not tracking that weight and looking at things the way we should. So again, it's a a call to my fellow pediatricians out there and other clinicians that we need to be more responsive and at be more proactive, looking at options and looking at what we are asking our children to do and and what challenges they're going through with the with the dietary and the lifestyle choice. And when do we review that? When do we look at other options? So thank you so much. It's my pleasure.

SPEAKER_01 44:26

And we still need to fight policymakers and the food industry and all those other things at the same time. But uh, yeah, we have a lot of work to do as a community. When is your book coming out? I think it's probably gonna be fall of 2027. I actually just signed my contract like a week or two ago. And now I have to write the rest of it, which is so I gotta do that first. But it's coming, it's all up here. It just hasn't been typed out yet. I gotta get that. That's uh that's for sure.

SPEAKER_02 44:55

Yeah, let us know, definitely, please. Yeah, we we'll invite you back to talk about that. Thank you so much. And I hope you enjoy the rest of your time away.

SPEAKER_01 45:03

Uh my pleasure. And uh good luck, and thank you for doing what you do because you take care of a lot of kids that need help. And then you're out here on uh social media trying to spread the good word. So thank you for that.

SPEAKER_02 45:16

Well, thank you. Thank you so much. Thank you. Yeah. As we always say, early intervention leads to better outcome. And early intervention can only be achieved by early diagnosis. So thank you for listening into the series today. Um, I know some of the things we've talked about today would probably have generated some questions or need to seek clarification. So I'm happy to take questions, and I'll invite you to send your questions to eim at drtakon.com. Thank you for listening in.