Ep 175: Childhood obesity- when to consider medication and surgery treatment options? with Dr. Alaina Vidmar and Dr. Kamran Samakar

In this conversation, Dr. Alaina Vidmar and Dr. Kamran Samakar discuss the complexities of pediatric obesity, emphasizing that it is a chronic disease influenced by genetics, biology, and environment. They highlight the importance of understanding the stigma surrounding obesity and the need for comprehensive treatment approaches that include medication, surgery, and lifestyle changes. The conversation also addresses the rising rates of childhood obesity, the challenges of weight loss, and the criteria for seeking help. They advocate for a patient-centered approach that meets families where they are and provides education on nutrition and health. This conversation explores the complexities of pediatric obesity treatment, highlighting the efficacy of GLP-1 medications, and the role of bariatric surgery. Transformative stories from patients illustrate the profound impact of these interventions on children's lives.

For more information please refer to.

https://www.chla.org/blog/experts/care-innovation/childrens-hospital-los-angeles-launches-pediatric-bariatric-surgery

https://www.chla.org/blog/experts/care-innovation/qa-when-bariatric-surgery-right-youth-obesity

https://www.chla.org/center-endocrinology-diabetes-and-metabolism/programs-and-services/healthy-weight-clinic

Instagram: @ChildrensLA

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

For more content from Dr Jessica Hochman:
Instagram: @AskDrJessica
YouTube channel: Ask Dr Jessica
Website: www.askdrjessicamd.com

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Transcript

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Welcome back to your child is normal, the podcast where we have honest conversations about kids' health and their well being. Now if you're a parent struggling to help your child with severe obesity, you are not alone. Millions of children in the US face the same challenge. Now the truth is, traditional advice like just eat less and move more often isn't enough. So what are the other options? Well, today, we're joined by Dr Elena Vidmar, a pediatric endocrinologist specializing in childhood obesity, and Dr Cameron samakar, a bariatric surgeon, and together, they co direct the obesity medicine program at Children's Hospital of Los Angeles. In this episode, they'll break down why obesity is a complex medical condition, how medications like GLP ones and bariatric surgery can be life changing, and what families need to know when seeking help. If you've ever felt at a loss for what to do next, this episode is for you, and as always, I am so grateful that you take the time to listen to this podcast, and if you are enjoying your child as normal, please take a moment to leave a five star review wherever it is. You listen to podcasts, all of these reviews really help other people find the podcast, which helps the podcast grow. Thank you so much. Now on to the episode, Dr Vidmar and Dr samakar, thank you so much for taking the time to be here today. I'm so appreciative of your time. Absolutely thanks for having us. So I would love to first tell everybody, what do you guys do? What are your credentials, and where do you work? Should we start with Dr Vidmar, yes. So I'm Elena Vidmar. I am a pediatric endocrinologist and obesity medicine specialist, and I work at Children's Hospital Los Angeles, and I have the pleasure of running our obesity medicine program there. And Dr samakar, tell us about yourself. What do you do for work? Sure, thanks for having us on today for your podcast. I think it's a great opportunity for us to share about our program. My name is Cameron samakar. I was an adult bariatric surgeon general, surgeon trained, and then I met Dr Vidmar, and her passion for pediatric obesity really sparked an interest in expanding the bariatric service line to CHLA and starting a program with her. So I co direct the program, along with Dr Vidmar, and we're super excited and passionate about the work we're doing. So I think it's well known what an epidemic childhood obesity is, and I think it's really helpful for families to know that a program like what you offer exists. And so I'm really excited to just let people know what is out there what options they have? Because I think this is, unfortunately, a problem that many people are now facing with, and they're at a loss for where to go and what to do and where to get help. So first, can you tell everybody what kind of patients do you typically see at CHLA for obesity management? I mean, I think we can back up a little bit just to start this conversation, if that's okay, and just acknowledge that children living in larger bodies or living with obesity, which is the medical diagnosis, that's not the fault of the patient or their parent, and that the work we do is not about the number on the scale or the size of one's body, but it's about helping these kids live long, healthy lives, because we know that kids living in larger bodies have a high increased risk of life, limiting complications like type two diabetes, high blood pressure, high cholesterol, and that's why Doctor Sam McCart and I do the work that we do, because we're trying to help these kids to thrive into their adulthood. It's true. It's tricky, because while there is, unfortunately, a stigma for being more overweight, for suffering from obesity, and we know that it's really hard to lose weight, it's really, really a challenge. So I think that's a nice balance that you guys strike, where you acknowledge that it's not their fault, that it is a difficult place to be in, and at the same time offering help and solutions for them and their families. Yes, that is definitely our goal, and that's why we have designed our program. And back to your first question, so we know that we can't do this, this program alone, and so we try to partner with our pediatric colleagues across this region and really try to align with the American Academy of Pediatrics clinical practice guidelines that came out in January of 2023 that kind of give us a framework for how we think about this care when we take care of a patient with a complex chronic disease, which, as you know, is not new to pediatrics, and so we really can triage based off of the severity of disease and offer treatment that matches that severity. So that's how we kind of think about how patients get referred and triaged into our program is really based off the severity of their presentation. I'm curious, from your perspective, as someone who's worked with children in larger bodies for many years, why do you think this increase in this trend in obesity is occurring? Because when you look at the numbers from 3040, years ago, the rates of obesity were much lower. And I know it's multifactorial, but maybe can you touch on the main points as to why you think this is happening absolutely so there's many factors, there's genetics and there's biology and there's the environment, but we have to. To step back to the fact that this is no one's fault. This is not about self discipline or self will. This is about biology, but we also know that our genes change over time, right? So we have epigenetic changes that are forming in these young people as they are born that are impacting how both their brain controls when they're hungry and when they're full, I like to think of it like a light switch. And it's like their light switch has syrup in it, so it's not working the way that it should. This is in the arcuate nucleus, part of the hypothalamus, as well as in their periphery, the way that their cells use the food that they consume. So when we take in our food, we want it to be used as energy. But when you're living with obesity, you take in your food and you immediately store it as adipose tissue. And those two things are happening over time. And I think what we have to acknowledge as a scientific community and a general society is that you cannot prevent something that's already happened, which is why we have to treat and care for the children living in front of us with obesity. So we know that the most recent data suggests that one in three to five young people is living with obesity, and if these rates continue by 2050, up to 60% of children will be living with obesity. So we have to treat this condition in front of us with the ultimate goal that hopefully we can get to a place where we reset these genes, and we actually get to generations where these prevalence rates go back down, but we can't prevent something that's already happened. So that's the goal of what we're trying to do here with our program. Now, when children are placed on diets, or they're on restrictive calorie diets, they do lose weight, but the trouble with that is they often regain the weight Correct, correct? So I think again, what we have to acknowledge is that you can use food as medicine, right? So just like we use any tool in our tool kit, there are ways we can help give the body what it needs. And if your body is not able to use calories efficiently, you can give less calories to use that but alternatively, and we are in a current season where we have other tools, like medication and bariatric surgery, we can understand how we actually give the body back the machinery that it needs in order to function more efficiently and prevent those complications over time. And so historically, our tool kit has been very limited. So we have been working mainly with food as medicine, which for this particular chronic disease is not very effective, which unfortunately is why we haven't had great tools, so our tool kit has expanded significantly, which has led us to a place where we can actually treat this disease more effectively and lead to outcomes that hopefully can get us to a place where we can prevent some of these life limiting complications, which is part of the mission of what Doctor samakar and I are trying to accomplish. What I was alluding to is a lot of people think, as to your point about it being too difficult to expect with willpower alone, is that, I think a lot of people know, okay, if we if we watch our diet, we can lose weight. But the tricky thing is, the body has its own barometer, right? It's like a thermometer and a thermostat in our body, that if we do lose weight, it's working against us to keep the weight off for a sustained period of time. Correct? You know that what you're referring to, Jessica, you know what bariatric surgeons have long time called, you know, the barostat. And there's good science to support the fact that adipose tissue has memory in the adipose tissue of patients with obesity who lose weight is different in where its set point is and what it's trying to return to the patients who have never had obesity. So that is why, in just zooming out to the larger context of what we're talking about, what is the approach for obesity as a chronic disease? So we have medications, we have surgery, but the framework for that is intensive, lifestyle, behavioral therapy. That's the first step of any kind of approach. The reality of that, though, is in severe obesity, the failure rate is 95 plus percent, and this has been shown time and time again. So as a medical community, we really need to move away from not acknowledging this as a chronic disease, prescribing intensive lifestyle and behavioral therapy, thinking that it may work, it doesn't work. I mean, that's the bottom line. And severe obesity. It's a failed treatment modality that's been demonstrated in multiple trials. So with that said, we like to refer to it as recurrent weight gain, because what you do when you intervene on obesity, and you not just help the number on the scale, but you actually change the trajectory of the meta. Metabolic diseases is you change the quality of life and the patient's health perspective long term. And so while there is recurrent weight gain, typically what we see in our patient population is there is recurrent weight gain over time in both adolescents and adults. If you look at all longitudinal studies, and there's Swedish studies that go out over 25 years, the weight difference with the recurrent weight gain group after bariatric surgery or interventions is much lower than the natural history of a patient with obesity that has no intervention. And so we are dealing with the chronic disease. Recurrent weight gain is an issue that we constantly are vigilant for, and we need to continue to treat over the lifetime of the patient. And I'm and I'm curious, what kind of patients do you want to come see you in your practice? I mean, obviously a lot of people are five pounds 10 pounds overweight. What meets the criteria where they should come visit you at Children's Hospital. So we have kind of two different, you know, criteria set. So at our program, we accept patients with class two obesity, which we define either based on the BMI or the BMI in excess of the 95th percentile, which is a CDC metric that helps us understand sort of weight above the 100th percentile, because that's kind of where our growth charts cap out, or class three obesity. So again, these are set by various entities specifically for us, in pediatrics, the American Academy of Pediatrics, both for which medication would be appropriate and bariatric surgery. Now, one of the things we are trying to do in our community is support general pediatricians and other healthcare clinicians for what to do with young folks living in larger bodies who don't meet those criteria. So we've created something we call reach kids, which is our kind of reverse console model, where we take our educational curriculum and integrate it into primary care, so that pediatricians have resources for those patients like you're talking about, who don't maybe meet that criteria for escalating care into our program, but need some support in the interim. So I think it's important to know where you practice, what you can use depending on what risk level the patient has, just like we would with any other chronic disease model. That's helpful to know about. And can you tell people again where they can find that information? Yes, so it's on the CHLA website, and then I'm happy to provide our contact information as well if you want to directly reach out to us. We have a tool kit. We have a prescribing guideline for obesity medication. We have triaging for getting blood testing for obesity related conditions, referral criteria for surgery and other useful resources for folks that are doing this within their clinical practice. And do you stress diet and exercise as well? So that's within our toolkit, sort of the support around it again, I would say within our program, we really emphasize the comprehensive treatment approach. So there's really been a movement away from the staged approach, which is the idea that you need to do one thing at a time and then fail it, acknowledging that we really know and have confirmed scientifically the efficacy of each of these approaches. So there's no reason for a patient with severe obesity to try something that we actually already know is going to fail. So instead, we actually want to take the menu of options approach and do everything we know is going to be effective at once, so that we make sure that we optimize our treatment approach, a multi modality approach that said we have our dedicated dietitian that works with our program. You know, surgery is a tool, medications are a tool, behavioral change, dietary change, family support and exercise are all good. The reality is that the number on the scale is largely determined by what you eat. Exercise is not going to move that needle. You can't outrun a bad diet. And so exercise is good for so many things, especially in the pediatric population, you know, bone density, muscle mass, brain health, heart health, but what's going to change the number on the scale is food, and we dive into that, and a lot of that is just education. We have to provide that education and make sure that our patients understand, how many grams of protein do we want? How many, how much hydration do we want? What are the the calorie dense nutrition poor foods that they may be consuming, because the ecosystem here that's contributing to obesity in our day and age is because there are a lot of edible non food products that are called food, but they're actually just edible products that are not actually food, so we try to limit it as much as possible, but we're just humans, and unfortunately or fortunately, you know, I don't have the genetic makeup where it's going to be seriously consequential for me, but some people do, and so we need to treat those Okay. Cases and we need to give them options. I mean, that's really well said, because I feel like there's a there's a trickiness to the conversation. Because, you know, while we say it's not the children's fault, we do also know that eating certain calorie dense foods, certain sweet foods, they work against us in terms of gaining weight with ease. But it's very challenging because, as you said, it's everywhere in our environment, and some kids can eat it and stop after a little bit of consumption, and some people, they can't stop. I mean, I think it's super important that these, these lines of attack, run in parallel, right? So the prevention, the well, the prevention is too late right at this point, we need to do a u turn in how we're living. You know, I mean, just to give you an example, when I do surveys at conferences of how many you know, people used to walk to school, probably about 50 to 70% of hands go up. And when I ask, how many of your kids walk to school now, it's less than 10% pretty much across the board, so we just live differently than we did just 2030, years ago. And our food is different. These things need to run in parallel, because we still need to treat the individuals that are suffering with this disease. And to your point about how you can't out exercise the food that you consume. I think this is so true. Because I think about, if I were to have the most challenging workout of my life, if I were to run for an hour straight, I would probably burn 500 600 calories. But if I went to McDonald's and I got a Big Mac, large fries and a soda, I don't know what is that over 1000 calories? Easy peasy, absolutely. So it's really, it's really, really hard to burn enough calories from exercise to make up for a calorie dense diet, absolutely. And then if you have the genetics where you only burn 20% of that, then there's no way that the math is ever going to equal right, which is why the narrative that living in a larger body is just because your calories in don't equal your calories out, unfortunately, no longer applies. Yes, absolutely. I think everybody listening knows that relative that can make less healthy choices, and they never seem to gain weight. And then other people in the same family or the same friend group can eat the same foods, and they it seems to never get off their bodies. So I think that's definitely true that genetics works against a large amount of people, which they say that's evolutionarily that was protective back in the day, right? To have to have calories when you never knew they were going to be around to store them, yes, and just now, we have so many food options that it's not working in our favor. So tell me. Okay. So let's say someone's listening and they're thinking about their own child, and they're considering your program, what would the experience look like for them? Tell us about what would be offered to them and the initial treatment strategies. Absolutely, we really start by acknowledging that this is a chronic disease, by acknowledging that this is not the patient or the parent's fault, and by really outlining what it means to do comprehensive obesity care. Now at our program, again, we really don't take the staged approach. So we're going to lay out our toolkit. We're going to talk about food as medicine. We're going to talk about nutrition, we're going to acknowledge the importance of exercise. We're going to talk about obesity pharmacotherapy and bariatric surgery on that first visit, if your kid qualifies. So we're going to really open up the tool kit, which we've really learned over time from our patients. We really want to take that multi modal approach. And so again, we're going to open up those opportunities for based on your your child, what their class of obesity is, their obesity related conditions, what kind of treatment they you know, would be best and most appropriate for them. We have dietitians, we have psychologists, we have obesity medicine specialists, and then we have our bariatric surgery pathway. And a lot of our patients have curiosity, and we really just want to provide an opportunity for education. There's so many myths and misunderstandings about this work, from start to finish, from it being a chronic disease to just even what is an obesity medication to what is bariatric surgery? What are we doing? How does it relate to the story I know about my aunt who had it 20 years ago. So a lot of what we do is education and the opportunity for patients to just spend time with our team and learn more about what's appropriate for their kid. And so that's really kind of how it starts, and that kind of walks them into their kind of ultimate treatment experience. So I first want to ask you about medication options, and then I want to ask you about the surgical options when it comes to medications. How old are children when they can initiate these medications, and what are the types of medications in your tool kit? I know GLP ones have gotten a lot of attention recently. Aside from GLP ones, are there other medications that you recommend as well and offer to families? We really take an individualized approach at CHLA, which is partly due. To a couple different reasons. One is that while there are FDA age minimums, a lot of the work we do in the obesity space is off label, because we just don't always have regulated medications. It's fairly new that we've had this. So we don't really have age minimums. We're thinking about the kid in front of us, their class and severity of obesity and the comorbidities and conditions that they have. We really think again about this toolkit, right? So we have injectable options, which is our GOP ones. Those are things like ozempic and wegovy and Manjaro, right? We have oral options, which are things like Topiramate and phentermine. And we're really going to lay out all of those options for the patient in front of us. We're going to talk about just some practical, pragmatic things, access logistics. Can we get it through your insurance? Can is there access to the pharmacy? Can your kid tolerate an injection or not? Can they swallow a pill? Right? We're still kind of in the access phase. We're going to talk about side effect profiles. We're going to talk about what other medications they're on, what can they tolerate? And then we're going to just talk about what the family can tolerate, right? If you have a family member that's on ozempic and doing great, you might be more open to it versus, you know, you're not interested in that at the moment. So a lot of it is really just a patient centered approach. What are those goals that you have? How does this align with the treatment that you need? And how can we best get that tool to you? And what does that look like? I love that. It sounds like meeting the family where they're at, meeting the patient where they're at. I think is a great approach. I know for the GLP ones, they're approved now down to 12. So that's so interesting that you are able to think about the child on the whole not looking at those age requirements. The other thing I would mention for your listeners, because they may not notice, you know, but, but it needs to be said, Dr bitmar really is a world expert in this, right? She, she, she's doing cutting edge therapy. We are so fortunate to have her at CHLA, because the things that she's doing and the approach that she's bringing is truly cutting edge and unique. It makes me feel extra lucky to have you on here today. It's my pleasure. And then I guess I'm curious, have you found good success with the GLP ones I know with adults, they are flourishing. Have you found that to be helpful with childhood obesity? Yes, I think overall, having a growing tool kit is very helpful. I think the GOP ones and the GLP 1g Ip, which is trizepatide, are very effective. They're certainly the most effective tool for the most young people. Again, I think we know every person is different, right? So you might take it and it might be very effective. Others might take it and it's not effective. But I also think they've been a really interesting proof of concept about obesity as a chronic disease, which is when you give the tools back to these people, and their biology has the cells that they need, has the machinery that they need, they can effectively use their calories, their appetite and satiety can be regulated. And I think that that's really important again, we have to acknowledge that they're going to be effective to a certain level, which is why we cannot forget that surgery, which is one of the most underused tools that we currently have, still remains the most effective and the most durable treatment for severe obesity. And I think one of the things that I have really come to appreciate in the last two years, since we stood up our pediatric program at CHLA, is just the importance of using the tools that are going to match the severity of the disease in front of us. And I actually think in pediatrics, we do that so well for every other chronic disease when we think about asthma, type one diabetes, but for some reason there's been a lag with pediatric obesity, so I've been really trying to think about how I was trained and how to make sure that I translate that. Because obesity is exactly the same, you can anticipate the efficacy based on what you know, and that's what you're going to see. So the medications are the same, they have a certain cap that you're going to see, and if surgery is required, that is what's going to be required to get that efficacy. So I'd love to hear more about this, because I think when people hear surgery and a child, it might sound daunting or too extreme, but I hear what you're saying, that it's a very effective tool. So tell us a little bit about the decision making process about what child would qualify. So just take one step, quick step back. You know, we identified that there's a gap, and but why is that? Well, because these conversations can be uncomfortable sometimes, and so oftentimes, I think what what ends up happening is the difficult conversation isn't had. And when you survey patients who've had bariatric surgery, the vast majority will will tell you that if someone had talked to me about this earlier, I would have done this so much sooner. And so we really need to have these conversations. And I encourage anyone who's interested in just you know, there's various, various resource. And they can contact me, and I can put them in touch. So who qualifies? Essentially, we can go by PMI or percent percentile growth charts, 120% of 95th percentile for age with with a obesity associated medical problems such as diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, the list goes on and on. Or 140% of 95th percentile in rough BMI numbers, that's BMI of 35 and above with the comorbidity, or BMI 40 and above. To answer the other part of your question, what is bariatric surgery? So bariatric surgery are surgeries designed to treat obesity and metabolic disease associated with obesity. The most common procedure we're doing at CHLA is the sleeve gastrectomy. The sleeve gastrectomy is the most common adult procedure being performed at the United States as well. It's removal of about 75% of the native stomach. The stomach anatomy essentially stays the same. The size of the stomach is decreased over time the patients can resume a regular diet. Obviously, we reinforce the the the hallmarks of a nutritious high protein, lower carb, more complex carbs, reduced sugar, diet, but essentially they can resume that, and we see about 25% total weight loss as a result of the sleeve I should add here safety. What is the safety? So to put it in perspective, the most common abdominal operations in the United States, appendectomy, cholecystectomy, gallbladder removal, these all have a higher risk profile and mortality rate than bariatric surgery done at a credit Center. In the United States, the risk of death from bariatric surgery is less than one in 1000 patients, and this is all comers. So this is patients in the pediatric population to 70 plus years of age. But to put it in perspective, are mortality rates lower than the most common no one talks about mortality rates when we're talking about appendectomy, right? But everyone talks about it when we're talking about bariatric surgery. When you talk about the leak rate from a sleeve gastrectomy, it's point two 5% so two out of 1000 cases, these are really acceptably low complication rates, and the success rate is is pretty good. So for the for the right candidate, bariatric surgery serves as a very effective and safe surgical intervention for obesity, and what is the average age that you see that you perform the surgery on? I'm sure parents are going to be asking the question, if they have a child who's obese, let's say they're eight, 910, years old, would they qualify to see you? Yeah, they would. I guess I'm thinking of patients that are younger overweight, but they have yet to go through their growth spurt, and parents are looking for help, and I'm wondering, is it advisable for them to come see you now, or should we wait until they've finished going through puberty? Right? So we've removed all age cutoffs. We view the case as a unique case every single time, and the reality is that there are patients that are very young that would benefit, and it would change their life course to intervene on their obesity for a myriad number of reasons. So we now just case by case. I think there's a misconception that if you have, for example, bariatric surgery early, it's going to affect your puberty and your height, but one of the things I think we have to understand is it's actually the exact opposite. So living with obesity actually leads to a shorter adult height, which has been well proven, because it leads to advanced bone age as well as delayed pubertal onset for boys and advanced pubertal onset for girls. So again, I think that's one of those sort of misunderstandings that we actually have the science to refute, that if you want to optimize pubertal advancement and final adult height, intervening earlier is the way to do that, is that because the adipose tissue has some hormonal properties to it. Yes. I mean, we don't know all of the mechanism, but yes, I think sort of the most simplistic, you know, hypotheses that we have is that the adipose tissue is producing estrogen, which is advancing the bone age, and then we know how that's impacting, sort of the insulin, estrogen, testosterone cycle. Now I really appreciate Dr samakar, you explained how safe the bariatric surgery is. Do you have any data on long term outcomes? How do kids look years out from the procedure? Any concerns that parents should be aware of? So when you look at the data 10 plus years I mean, there's really good data. There's. Data on longitudinal data published in the New England Journal on comparing outcomes, specifically in pediatric patients undergoing rheumatoid pass and sleep hysterectomy, and then comparing those results to the adult counterparts. And so the the weight loss, it holds. And not only that, but what those so at 10 years their weight is significantly decreased compared to baseline and very similar to the adult trajectory. So the the fundamental hormonal changes that are taking place seem to hold now. The difference is intervening on the metabolic disease early seems to confer an advantage to intervening late. And we see this all the time with our adult patients, patients that come to us, 40s and 50s who've had diabetes now for 25 years. So as soon as you perform a bariatric surgery, you're going to start seeing normalization of blood glucose. I mean, instantly, 24 hours, they've lost no weight at that point. But we also know from the adult literature that the longer you've had your diabetes, the lower your chance of remission, complete remission. So we can only mitigate, you know, so, so much so the earlier intervention not only confers the longitudinal advantage, but also confers the Early Intervention advantage. And so when you're intervening, the sooner you intervene, the greater the trajectory of the benefit that you'll have long term. So 90% of our patients prior to surgery have tried multiple medications. Everyone has engaged in intensive lifestyle, behavioral therapy. Everyone's met with a dietitian on multiple occasions. So we have a long runway before that, and then post operatively, we continue all of those things, including medication. We think that multimodal therapy is optimal therapy. So we want to have optimal weight loss, we want to have optimal comorbidity resolution. So I have sort of a question that might be difficult to answer, but I will say, as a general pediatrician, one of the biggest challenges that I have when I have children that are becoming obese, or they're starting to gain weight, and parents are looking for help and resources is figuring out how to do it in a way that doesn't break the bank, because I will for our for patients to dieticians, and it can be, honestly, very cost prohibitive. For families, hundreds of dollars to see a dietitian, or, honestly, there aren't that many dietitians available for them to meet. So something as extensive as your program, what would that look like for families? Is it covered by insurance? Is this going to be cost prohibitive? Do you have any information on that? Yeah, it's a great question. So our program is completely covered by insurance, and that was part of our goal in standing this up to increase access to all patients in our region. So we take all forms of insurance and ensure that prior to going through the program, every component of it is covered. Now you bring up a good point, though, that that you know, we can't guarantee that to All Programs, and there are certainly components that aren't, and when you think about the medications depending on your insurance, that's important. But I think that is a really important thing for clinicians to understand. What resources do you have for your payer mix, because it might look different based on the patients that you serve, and how can we really access that? Because there's a lot of good community resources in our region, and really try to understand how to tap into that, acknowledging, for example, there's not a lot of dietitians in our region. We know that that's a huge access issue. So how do we optimize that? Either through virtual resources, through resources at CHLA, you know, through other opportunities, knowing that there's a lot of creative, innovative ways to get those therapies. So Dr samakar, Dr samakar, I have a question for you. I am admittedly a pediatrician who tends to shy away from interventions. It's often not my first approach and recommendation for families. So tell me, because I want to be excited about this. What do you what do you notice from the children that have gone through bariatric surgery? Tell me about Tell me some good stories I want to hear. What is it like on the other end? Yeah, so, so let me start off by saying, when, when I when we do a surgical evaluation or consult. It's a conversation, and it's an open ended one. I think that the point I try to get across to the patient and the families, this is an option. I'm here for you today or in 10 years from now, but this is planting the seed in someone's mind that there is an option, there is an effective treatment modality that we offer and that they can use. And that's really the entire goal of that surgical consult. A lot of patients will go home and think about it, and they're, you know, the wheels will start turning. They'll be like, this is right for me. There are some patients say this is not right for me right now, and that is perfectly fine. We want to support all of those kids. So the second part of your question is. What? What are those? So in the adult population, Bariatrics, the stigma still applies bariatric surgery and seeking out bariatric surgery is one of the only patient driven portions of medicine that still exist. If you have a colon cancer, you get referred. If you have you know, if you need a mammogram, you get referred. If you need your maintenance, colonoscopy, you get referred. Bariatric patients find us patients. They're not referred. So when adults come to me, they've thought about this for some time, and they're ready to engage in that process. Pediatric population is a little different. Someone's concerned. They may be concerned that they don't have the tools to effectively communicate that we know that the two thirds of pediatric patients with obesity are bullied and have self esteem issues as a result of that, the bullying is not just from their peers, it's in their homes. And so the patients will come and they, you know, the sad parts about this is, yeah, I noticed very quickly they're, you know, withdrawn. They may not want to make eye contact, and we have multiple visits, and over time, that changes, and they come back six months a year later, and they're dynamic. They're proud of themselves. I mean, this is a major accomplishment in a 14 year old's life, to lose 80 pounds. And as a pediatrician, you know the reward for being in this career is because you get you get to make an impact, and it's those little moments that really fuel you to go on. And so we get a lot of those little moments, and it's incredibly rewarding. I'm thinking about the toolkit, how how wonderful it is that it's now expanded, because years ago, we could only offer advice on diet and exercise and so often that didn't work. So it's just nice to know that there's something out there for families that are really struggling, yeah, and I think we take for granted little things that these young people are experiencing, right? So we have patients come back and they say things like, I took a trip in an airplane to visit my grandma, and I fit in the airplane seat, or I slept all night last night, and I wasn't snoring and gasping for air in the middle of the night, right? And we assume that 12 year olds are not experiencing that, but they are every day, right? And so I think those are the moments that I walk away with that, I feel so grateful that our tool kit is expanding and that we have the privilege to do this work and help teach people about how we can expand this and make sure it is offered to every kid that needs it. I'm honestly I'm thinking now about my father in law, who's who's passed away, but he lived most of his life. He was very obese when he passed away, he was well into 400 pounds, and I wonder how his life would have been different had he been offered this tool kit. I think, you know, he lived at a time when this wasn't as readily available and it wasn't as perfected. I think people were scared about the surgeries, hearing about side effects or failed surgeries, and I think it made him nervous, but I wonder how it have been for him. Today, it's definitely a new time and a new space, and there's a lot more we can offer. So I think we have this great opportunity to do so. I wish it was available to more people. You know, even even now, with with availability that we do have, we do meet families that are engaging in medical tours and for their children's to treat their children's obesity. And so there really is, you know, the landscape is changing slowly, but it is changing. So before we close, is there anything else that you'd like to tell parents about, any message of hope or any misconceptions you'd like to clear up before we before we finish up? I mean, I will just repeat what I've already said, but I think just acknowledging for parents and pediatricians and healthcare providers, just how important it is to acknowledge that pediatric obesity is a complex chronic disease, that this is not the fault of the patient or their parents, and that we need to tell people that over and over and over again until they believe it, because we're the holders of breaking this stigma, and if we don't believe it ourselves, they're never going to believe it. And so we start by breaking the stigma, by diagnosing it and by providing the right treatment. Because every time we treat pediatric obesity, we start to break the stigma. And so I hope that pediatricians will treat it, will refer to our program and start those conversations, because that's how we start the life transformation, by actually providing access to these treatments. Thank you so much, and I will make sure to put all of the information for your program in the show notes below. And thank you guys so much for being on that. I really appreciate it. Thanks for having us. Thank you. Thank you for listening, and I hope you enjoyed this week's episode of your child is normal. Also, if you could take a moment and leave a five star review, wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr Jessica. See you next Monday.