29. Childhood Obesity | Evan Nadler, MD, MBA

Learn all the things you didn't know about childhood obesity from Evan Nadler, MD, who co-directed the nation's largest childhood obesity practice at Children's National in Washington, DC, for 20 years.

Dr. Nadler brings a unique, non-judgmental approach to what he considers a fundamentally different disease from adult obesity.

Key Topics Covered:

The Science Behind Childhood Obesity

• Why childhood obesity differs dramatically from adult obesity in both cause and progression
• The role of genetics, epigenetics, and prenatal factors in early-onset weight gain
• How obesity-related diseases advance more aggressively in children

Breaking Down Blame and Stigma

• Why neither children nor parents should be blamed for childhood obesity
• The minimal role of behavioral factors in pediatric cases
• How genetic predisposition often overrides environmental influences

Treatment Approaches and Outcomes

• Why children show better long-term outcomes from surgical intervention than adults
• The importance of treatment-agnostic care and mental health support

Evan Nadler, MD, MBA, is the past Co-Director of the Children's National Obesity Institute, built & directed the nation's largest pediatric weight management program by nearly twofold, treating thousands of children and adolescents with obesity.

He & his partners recently opened ProCare TeleHealth, "The country's first pediatric-only telehealth weight management practice".

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Transcript

Jollie (02:04)
Hey, everyone, welcome back to the Move Eat Give podcast. I'm Bill Jollie with Interrupt Hunger. Thanks for joining us we've got back Dr. Evan Nadler. Thanks for joining us again, Oh, my pleasure, Jollie Anytime.

Evan P Nadler MD, MBA (02:16)
⁓ My pleasure, Jollie. Anytime.

Jollie (02:18)
We

had a really good deep dive into sick fat and adipose opathy and all kinds of topic that really went into, I mean there was plenty of science in that, but also went into the healing aspects of obesity and helping folks. thanks for that and thanks for joining us again.

Evan P Nadler MD, MBA (02:41)
Yeah, well, I think the more we talk about these topics, the better people will understand them, hopefully. And hopefully, the less stigma, the less bias, the more, and the less frankly self-blaming, shaming, so we can just move on to dealing with the problem at hand rather than, you know, I used to tell my patients all the time, I don't really care how you got.

to my office or how you got here or how you got to this weight or size or degree of disease or whatever, however you want to describe it. I only care about what we're going to do from now moving forward. Like, let's just, let's just go. Like, yes, stuff happens and it sucks that it happened to you, but time for us to just move on. And I don't mean move on in a bad way. Like, obviously, like, I'm not going to ignore your past, but I mean like,

I think it used to give people, people, you know, as you can imagine, children and families didn't love coming to a surgeon's office to talk about obesity. So it gave them sort of like a, listen, I'm not going to judge you at all kind of backdrop. And we're just going to, you know, talk about how we can move forward and get, and hopefully get you healthier together. anyway.

Jollie (03:54)
Yeah.

So today we're going to talk about childhood obesity, which you've spent most of your professional career focused on and helping folks. So I think a good place to jump off might just be, childhood obesity or adult obesity.

Seems very different. So why don't we just start there.

Evan P Nadler MD, MBA (04:18)
Sure. And because I'm getting old and can't remember things I say, and I say a lot of the same stuff from time to time, if I repeat myself, just stop me or just smack me, reach out through the screen and bop. But I like to make the sort of, I've made the joke before and I like to make the sort of tongue in cheek joke that.

Jollie (04:30)
You got it.

Evan P Nadler MD, MBA (04:39)
I would change the name of obesity as a disease to something like weight gain spectrum disorder or some like catch-all phrase because not only is developing obesity in childhood likely different than getting to that stage as an adult, but even within sub-sets, even within adults, within kids, people get there.

in different ways. to like, obesity is what's called a phenotype, which means it, the way it looks on the outside. So it looks on the outside the same to all of us, right? We look at a person, they look like they're at an unhealthy weight. We then immediately judge them and think that we know what they should do to make themselves healthier, which is totally wrong. But the reality is, is that there are different ways that people get to that point, whether it be...

things like radiation to your hypothalamus to your brain because you had a brain tumor. Or it could be that you have such a high genetic predisposition that it didn't really matter what your behavior was, you were gonna be sunk from the get-go. Or there are mental health reasons like adverse childhood experiences that can lead to obesity. So I think the main difference, getting back to your original question, between childhood obesity and adult obesity is that

Children with obesity generally have a much smaller influence of their behavior, their eating behavior or their exercise behavior. They're much more likely to be, have a high genetic or epigenetic predisposition or be the child of a mother who gained excess weight during her pregnancy or had gestational diabetes because

Jollie (06:11)
You

Evan P Nadler MD, MBA (06:12)
know, most of my kids,

Jollie (06:12)
know what I'm

Evan P Nadler MD, MBA (06:13)
when I would see them in the office, it wasn't like they were having a diet that was different than the average kid their age or didn't exercise initially until they got to a point where they couldn't, any less than the average kid. Like It just was very clear to me that this was not an environmental.

or a post-birth environmental disease, this is something that they were fighting from the get-go. And then the second major difference, which may be even more important, is that the obesity-related diseases progress faster in childhood, there's some diseases in childhood from excess weight that don't even exist in adults. So it is...

I don't know if it's different disease altogether, but it's either a more aggressive form of the disease or some people like to say it's a purer form of the disease because of the lack of environmental impact on it. But it's a thing. it's, think, unfortunately, it's what most of the current sort of, quote unquote, pundits or experts

who haven't had that experience taking care of children don't understand. They just have no concept of how there's a huge chunk of the American public where what they eat and how much they exercise has almost no bearing on their obesity risk.

Jollie (07:25)
Why is, you said it's more aggressive or faster onset. So why do you think that is?

Evan P Nadler MD, MBA (07:31)
It's good question. I think, so when I say that, mean, as an example, child with insulin resistance due to their weight is likely to develop type two diabetes in a shorter period of time than an adult with that exact same degree of insulin resistance and maybe the exact same size or BMI.

Why? Again, it's probably due to the genetic drivers. They're only, you know, we don't know exactly, but my guess is that the fat cells themselves either...

more dysfunctional and thus they...

that you have a bigger impact on what's going on in terms of health-wise or something in that.

sort of thing because, you know, in general diseases that are caught earlier should be easier to treat because they've had less time to do end organ damage. And that's, that is true in kids too, but if you don't treat it in kids early, then they get to, you know, they get to the bad places more quickly, which again is kind of weird, but it's, it's a,

Jollie (08:23)
Yeah.

Evan P Nadler MD, MBA (08:26)
You know, this isn't just me. This is something that like the whole pediatric obesity community knows about and has published about. And again, I think, you know, there are 140 million adults with obesity. There are 15 million children with obesity. So the 140 million are 10 times more, more or less. So they get more of the air time and the more of the attention. But in my view, the 15 million are actually more informative because they're the ones who

gotten this disease earlier and can be sicker and thus I think in many ways they're more interesting to study and then if we can understand what's going on with them then I think we can understand that can be generalized to the adult population.

Jollie (09:09)
Yeah, it's, you know, I know you're really big on blame and making sure we don't blame. Well, the inverse of that. You're quick to out blame. even if it's it's self induced or whatnot.

Evan P Nadler MD, MBA (09:17)
Thanks. I know you like to blame your patients.

Jollie (09:26)
So an adult, we see an adult that has obesity and we put the blame on them, their willpower, their discipline. And of course, there's countless reasons why we shouldn't do that. With kids, though, we seem to put the blame on the parents.

Evan P Nadler MD, MBA (09:43)
For sure. And that's unfair as well, obviously. Again, it's not, I can't remember. So I've probably taken care of thousands of children with obesity, or maybe certainly over a thousand, I think thousands, plural. And zero, probably.

maybe one, maybe two, are related to bad parenting. And yes, occasionally there's a parent who is giving their child, know, soda in their daily, know, sugar soda in their daily diet at a young age. you know, that's usually due to external forces like... ⁓

Jollie (10:10)
or something.

Evan P Nadler MD, MBA (10:17)
cost or, you know, there's usually a reason for that. And again, I wouldn't call that bad parenting. I would call that, you know, like sometimes it's lack of education, sometimes it's lack of access. There are socioeconomic factors. But in general, parenting contribution is small. There was one study actually when I was back at NYU 15 years ago, 20 years ago.

that showed that a parenting intervention had nothing to do with obesity at all, but just teaching people how to sort of deal with kids who are acting out or whatever had an impact on that child's risk of obesity, which was really interesting because the study had nothing to do with weight.

Jollie (10:58)
Wow.

Evan P Nadler MD, MBA (11:01)
That was one of the outcomes that they found. So it's not obviously completely irrelevant. Like if every time your baby cries, you stick a bottle in their mouth, that's probably not a good habit to start and probably not going to.

good in the long term. But again, it's that's usually because the parents are stressed out or don't have support or whatever. So yeah, I don't blame anybody. I think that's not a useful way to treat people or patients. And I try to get past that and sort of just, you know.

And there's often an emotional catharsis when I make that very clear to the families who are in my office seeing me. Usually there's a, you know, you can feel the burden lifting off the parent or the kid or both. occasionally, depending on how the room is going, I might blame the genetics, which blames the parents, but, you know, that's not...

Jollie (11:54)
for the parent or the kid.

Evan P Nadler MD, MBA (12:07)
I don't usually start there because I usually want folks to feel good about themselves in my office and then...

It just makes her, think, what's that, what's it called? The model. Anyway, it makes her a good care model where everybody's involved and can come together and make suggestions that everybody feels good about.

Jollie (12:24)
Yeah, sure. And they're there. I mean, they brought, so let's see here. What about ages? What's a what's a typical age and age range? And then like how young would you see patients?

Evan P Nadler MD, MBA (12:36)
Yeah. So, you know, the youngest

patients I've ever done bariatric surgery on are in the four and five age range, which usually makes people go, what? But those kids generally have what's called monogenic obesity. So they actually have a single gene defect that causes them to gain weight. And I learned, what was that? think 20.

Jollie (12:50)
actually.

Evan P Nadler MD, MBA (12:55)
10 years ago or more where I saw my first patient with this, with monogenic obesity. And at that time I wasn't really willing to do surgery on a five year old. And then I waited two years and that same kid went from being fairly functional, although having severe obesity, to being wheelchair bound due to her weight and not being able to take care of herself. And so I finally did her surgery and she's done really well.

But I said to myself, well, if I ever see this kind of thing again, I'm not going to make that same mistake. I'm going to just do it. so thinking I would probably never see a patient like that again, because they're pretty rare. But then I saw, then a family came over from the Middle East that had several kids with the same sort of gene defect. And I ended up tackling them earlier. And similarly, they did pretty well. Now, even kids.

without a single gene defect, I've seen as young as eight or nine with type two diabetes from their weight. And so I have another, in fact, before I stopped a couple years ago, I had the country and probably still do, because no one probably is as aggressive as I was. But I published my experience of ⁓ kids younger than 12 and under, preteens. And I have done more of those than anybody in the country.

And they actually do really well for the most part, although again, they have the strongest genetic drive to gain weight because if they need bariatric surgery at such a young age, they got something else going on than the average person.

Yeah, and then would see up to age 25 or so with, especially if they have diseases that are more commonly treated in childhood, like Down syndrome or autism spectrum disorder. I've published a lot on autism spectrum disorder. So I like to think of myself as the doc who will take care of the kids that everyone else is somewhat.

Jollie (14:23)
So.

especially if they have.

Evan P Nadler MD, MBA (14:41)
apprehensive to take care of. Like I just, I'm a, I'm just a guy from New Jersey who just wears his emotions on his sleeve and basically is willing to try, I'd rather try something and fail than not try at all because you don't try at all, what have you accomplished? And we know for most of obesity care, if you don't do something, it's going to get worse. The obesity is going to get worse. So.

I always just explain the risks and benefits to each patient and family and let them make the choice. And actually when I first, you know, with the four and five year olds, I would tell those families, I listen, no one knows whether this is going to work for your kid or not. I'm willing to try it because I know I can get your child through the operation safely, but honestly, I have no idea whether this is going to work.

And then over time, I figured out that it actually can work and can work pretty well in the right circumstances with the right support and everything else. And again, I'm not saying that that's what everybody in the country should do, but I am saying that for some specialists, it's actually a thing to go with, to try.

Jollie (15:50)
Yeah.

So, ⁓

So for the younger kids, it's easy. The parents are going to be the driver to come in and see you. But when kids start getting a little bit older, 14, 15, 16, 18, it can go either way. So for those older teens, who's usually?

pushing the visit to you.

Evan P Nadler MD, MBA (16:17)
Yeah. So it's been really interesting to watch over the 20 years of my career. So in the early, early days, when it first started, my typical patient was the child of someone who underwent bariatric surgery. And that parent, often the mom, but sometimes the dad, and sometimes both, would just come in and say,

my child is going through the same thing I went through at 13 or 14 or whatever age. And I just don't want them to have to go through their adolescence the way I did. And, you know, I didn't know bariatric surgery was an option in teenagers, but we found you on the internet and, you know, can you tell us about it? So that was my, that was, that was my typical patient for, I don't even know, let's say five years.

until words started to get around. And I've never advertised my program,

Jollie (17:04)
and I've never advertised my program ever.

Evan P Nadler MD, MBA (17:07)
guys who was like, you know, selling something. And so, as you can imagine, a lot of those teenagers posted their positive experiences online. So as my program progressed, it would be, you know, more coming from the medical docs because they would see these patients post-op and how well they would do. And they were skeptics in the beginning too, because everybody was a skeptic. So I get more referrals from them.

But then also there would be a lot of teenagers who would find me first doing their own internet search for help. And then they would have to convince their parents that it was okay to come see me. So I actually did sort of start a lot of my, like as things progressed, I would start a lot of my visits with, so tell me how you found me. Who directed you?

Jollie (17:37)
for help.

Evan P Nadler MD, MBA (17:51)
to me because if the kid said, well, I found you online, but this parent over here, they're not sure that this is a good idea. That actually would change how I, ⁓ how I would approach the visit or vice versa. Like if it was the parent, but the kid was kind of reluctant cause that happens too. ⁓ I would, you know, sort of, you know, that, that sort of is like, okay, well no one's deciding about surgery today. Like this is just a purely an informational visit. And, ⁓

Jollie (18:07)
Yeah.

Evan P Nadler MD, MBA (18:17)
you know, if you're speaking to the kid, if you're not interested, that's fine. Don't worry, you're not gonna hurt my feelings. We're just here to chat. ⁓ And then if it was the other way around, it was the kid who found it and the parents were skeptical.

Jollie (18:19)
If you're not feeling it, that's fine. Don't worry, you're not gonna hurt my feelings. We're just here to chat.

And then if it was the other way around, it was the kid who found it, and the parents were skeptical.

Evan P Nadler MD, MBA (18:32)
That would be the room where I'd be like, well, you know, it's actually your parents fault that you're, that you're like this because they gave you the genes.

Jollie (18:32)
That would be the room where I'd be like, well, know, it's actually your parents' fault that you're like this because they gave you the kid.

Evan P Nadler MD, MBA (18:39)
They give you the genes that puts you in this situation and you're just playing the hand you were dealt. Like you got no choice in this matter. So if you're going to, you know, so feel free to, to on the ride home, give your parent a bunch of grief, of course, joking. And, again, just to, you know, trying to take the tension out of the room is always a key.

Jollie (18:43)
Yeah.

That's awesome. Yeah.

Evan P Nadler MD, MBA (18:57)
was always a key piece of every visit with me, is just trying to get past that, that I don't want to be here, you know, moment, because almost everybody comes in, except for when the parent and the kid were on the same page before they got to me, and then were both excited to get to me because they both were...

just happy that someone would treat their disease as real and as not a lifestyle choice and just give them options on how to move forward. that was, those are sort of like the, obviously the quote unquote easiest visits because the folks would come in sort of together with the same idea for game plan. And so there wasn't a lot of time spent like necessarily convincing or breaking the attention or whatever. It was more like just.

down to business. But I can never miss an opportunity to tell bad dad jokes or bad obesity doctor jokes. So I still throw them in there just because they entertain me. yeah, you they roll their eyes.

Jollie (19:43)
Yeah.

And the kids love it. yeah,

that's good stuff. Does what about the socioeconomics of of your patients you saw because a lot of people still don't realize that like our most vulnerable, the ones that have the most social determinants of health stacked against them are ⁓ struggle with them.

much, much higher rates of obesity and chronic disease. The ones that need it, like does Medicaid or cover this for us?

Evan P Nadler MD, MBA (20:17)
Yeah, so, right,

so that's a great point. And first I want to make sure that everybody understands that obesity crosses all age, crosses all socioeconomic strata, it crosses all races and genders and ages. So yes, people of color and people with...

socioeconomic challenges have a higher incidence of obesity, but it can happen to anybody. And I've seen the richest of the rich and the poorest of the poor. But.

It has progressed over time and I spent a lot of time in my early days in DC working with the DC Medicaid, Maryland Medicaid and Virginia Medicaid to make sure they did pay for it and not all states do, especially in the under 18 age group. But it was always part of my sort of advocacy work that I would either talk to the medical directors or even

Jollie (20:45)
and I spend a lot of time in the early days.

did pay for it.

Evan P Nadler MD, MBA (21:10)
I have a couple of big wins from my early days where a couple of private insurers, I got them to change their policies to include children under 18 in their coverage. Even the military, got to change their ⁓ policy towards the end. That is obviously the hardest to do, as you can imagine. The federal government's always the hardest to convince of anything. But yes, and the reason that I think the Medicaid's

Jollie (21:21)
a change there.

Evan P Nadler MD, MBA (21:35)
at least in the DC area, were quick to adhere or quick to cover it, is explain to them the finances of how it all works. So in adults, the break-even point for bariatric surgery is about three years. So if bariatric surgery costs, let's say $25,000.

That's similar to three years worth of expenditures for someone with obesity who's not getting treated. So if you do bariatric surgery and their comorbidities resolve, after three years, it's actually a financial win for the, well, I guess the Department of Health for the state and the taxpayer. In kids, it's probably not three years. In kids, it's probably closer to five to seven, depending on how sick they are. But...

Another one of the pieces of data that I think that the Medicaid's do understand, at least some of them do, but maybe not everybody, is that people with obesity tend to have hurdles in their job, career, advancement in general. And so they end up

either staying on Medicaid longer or staying in jobs that don't offer healthcare benefits longer. So there's this whole hidden morbidity of obesity that people don't talk about. again, the Medicaid's, so they sort of know that if you're a 17-year-old, 15-year-old with obesity,

you're likely still going to be on that Medicaid when you go past 25. So they want to intervene sooner rather than later because their cost savings will start sooner rather than later.

so you know, think, Medicaid's, again, Medicaid's coverage varies from state to state. I'm actually sitting in Pennsylvania right now, and the bariatric surgeons I've spoken to in this state say that while Medicaid does cover it, they don't reimburse the hospitals at a significant enough rate to make it worth the hospitals to want to have bariatric surgery programs for people on Medicaid. ⁓

So it's all, you know, it's completely variable. Some states didn't cover it. Some states didn't cover it under 18. It's all moving and same thing actually goes for the weight loss medications, right? So some states will cover the GLP-1 agonists. Some states won't. Some states won't cover them under 18. Some states will only cover them for diabetes, but not for weight management. So it's just a mixed bag.

I actually had an administrative person whose job it was for every patient who came to see me to actually figure out what their insurance benefits were because it's such a hurdle and it's probably one that they introduce on purpose because they don't want people to get access to care, which is a whole other advocacy effort.

Jollie (24:11)
Yeah.

Yeah, yeah, no, no, a lot

about that. What about. So I've heard you say several times that your treatment agnostic, which I love that approach. think some folks might see.

might hear that you're a bariatric surgeon and you know so you have a hammer everything needs a hammer right and that that's that's not the case at all so talk to me about success rates for different treatments for kids compared to adults if you could

Evan P Nadler MD, MBA (24:49)
Yeah,

I mean the first key point in that is how do you define success? And the success for let's say the insurance companies is different than success for patients, right? So I would say success, and each patient has their own, each person has their own definition of success as well. Like if you start a GLP,

You started GLP-1 medication and your A1C gets to be completely under control, but you don't lose a ton of weight. Is that a success or is that not a success? Sort of depends on the person who is taking that medication and what they were hoping to get from it. So, and in bariatric surgery, because a lot of surgeons are...

numbers oriented. There's a, you people use 20 % total body weight loss as a cutoff for quote unquote success, which again, to me is sort of, I don't know, to me it's, it's arbitrary because if you lose 15 % only, but all of your medical issues have gotten better. Why isn't that? Why isn't that okay? Right. Or

Jollie (25:49)
Sounds like a win.

Evan P Nadler MD, MBA (25:53)
if you lose more than 20%, but we didn't fix your dyslipidemia or some other thing that was really.

important to you.

is that on the flip side. Now actually, you know, they're definitely patients. The sort of the, among the saddest patients for me would be the kids who would come in with mental health issues in addition to their obesity and physical health issues. And I would explicitly say to them, you know, the surgery might fix all your physical issues, but it may not help your mental health issues at all. They may, but it may not.

But everybody, including teenagers especially, don't always hear exactly. They hear what more they want to hear sometimes than what you're telling them. So I'd have kids who would come back and they would have lost a fair amount of weight, but would be even maybe more depressed because they really thought that the weight loss was going to fix their lives. it didn't. And those were amongst the most heartbreaking patients.

You know, so I worked with an awesome child psychologist when I was in DC. She's still there. And we would have a lot of conversations about the different kids we would see and how we can best help them all because, you know, it's such a... High school is hard enough. Adolescence is hard enough. And then going through it with chronic disease like obesity is hard. And then even when...

get bariatric surgery, let's say, and you start losing a lot of weight, it sometimes gets harder because everybody wants to talk to you about your weight. Everybody wants to say, oh my God, you look so great. How did you do it? And you may or may not need to want to share that. And so that was another thing we learned along the way was like, we had to prepare, we had to tell our kids before surgery, listen, this is going to happen to you and you have to decide.

yourself and it's a personal decision, who you want to tell, who you don't want to tell, what you're going to tell people. And then there's the whole, especially when we first started, there was this whole concern about the increased sort of social attention, dating attention that especially the girls would get when they would lose weight and they might never have had any attention before and now they're getting all this attention. And there were...

pregnancies along the way in the early days. In fact, one of the programs used to birth control when they first started, which is draconian if you think about it, but that was part of an NIH-funded study, so they could do that. But in the real world, you can't really tell people, you know, have to get some sort of birth control or I'm not gonna operate on you. That doesn't really work. luckily, we've come a long way in the sort of 20...

Jollie (28:05)
Yeah.

Evan P Nadler MD, MBA (28:18)
plus since we've been doing bariatric surgery in children. We've learned a lot and things are getting better for sure.

Jollie (28:27)
So ⁓ mention a couple of things that you worked so closely with a child psychologist. I'm a huge proponent of mental health therapy. We've all got issues. Just some of them choose to deal with them and some don't. There's been a...

I don't know if stigma is the right word, maybe, but that insurance required you to get counseling before you went through surgery. Is that still the case or has that changed?

Evan P Nadler MD, MBA (28:55)
Yeah, it's an interesting, it's an interesting topic because in the beginning of bariatric surgery, yes, every patient had to get a mental health clearance for surgery. And that clearance was supposed to assess, you know, like readiness for change, readiness for surgery, make sure the patient wasn't...

using any illicit substances, make sure there wasn't a suicide risk, all these things. And in the adult world, the American Society for Metabolic and Bariatric Surgery has been fighting that requirement because it's somewhat, as you said, stigmatizing. It's the only procedure or treatment that I know of that...

you have to get cleared by a psychologist or psychiatrist in order to get seems kind of a

Jollie (29:36)
I had major ankle surgery in January.

It was almost three hours. I mean, just picturing, like, well, before you get your ankle surgery, you need to go talk to a counselor. Like, that's just dumb.

Evan P Nadler MD, MBA (29:45)
Yeah.

I mean, maybe it's good because maybe everybody should talk to a counselor anyway. But that's not the point. So it remains a hurdle. I mean, remains something that insurance companies require. I do think it's important to have conversations again, especially with children, about how you're going to deal with the aftermath of your weight loss or while you're losing weight or what are you going to do if you don't lose weight?

coping strategies. So I think there's value to it. I wouldn't necessarily advocate for it being a hard requirement, but I would probably, you know, and a lot of people, to be honest, would do what they needed to do to get to surgery and then whether they followed up with the mental health professional or not, you know.

And so a lot of people didn't, and there's no way, once you get your surgery, there's no taking it back. So it's not like we could chase them down and say, we're going to put your stomach back in unless you go see your psychologist. But yeah, think, you know, it's a, it's, um.

It's probably gonna be there forever because that's how it started and it's gonna be too hard to get it removed. But whether that's fair.

⁓ is a complicated question. But like you, think everybody, I mean, if you're undergoing major health issues, you a chronic disease, you're gonna potentially undergo a therapy that will change how you eat. It helps talking to people. And the way our team worked was really...

Jollie (30:58)
Yeah.

going.

Evan P Nadler MD, MBA (31:16)
We almost never said no to a patient who wanted surgery. We might say not yet, but we would almost never say no. It would almost always be, listen, you're not ready right now because you're dealing with...

But if we can get you to a place where you're stabilized, then we can...

So again, that's sort of more my philosophy is just, it is important to make sure people are ready, people are best prepared, but I don't like to say no. So we work together to try to say yes.

Jollie (31:41)
Yeah.

Were there certain behaviors, certain things that could increase the the likelihood of that quote unquote success? I don't know. Maybe we need to phrase that differently. But yeah, more positive outcomes.

Evan P Nadler MD, MBA (31:58)
Yeah.

Yeah. So I think it's easier to predict the negative outcomes. Although one of the reasons my psychologist and I work so well together is that when I got to DC from New York, I'd already been doing bariatric surgery for five years. And I told her and everybody else that nothing preoperatively predicts post-operative outcomes. So we should stop using those criteria as a...

again as a hurdle or something. Like if you're not exercising, like saying to somebody, you have to exercise three times a week or you're not gonna get surgery. Like none of that mattered. And we've studied. So I let my psychologist was like, okay, I believe you, but I wanna study them all again because you were doing lap bands at the time and we're gonna do a surgery and we should study. I was like, okay, fair enough. And so after like three or five years when all the data came out and again, nothing preoperatively predicted post-operative outcome.

Jollie (32:30)
Yeah.

Evan P Nadler MD, MBA (32:51)
It built a lot of trust because obviously I didn't say I told you so, but I wanted to say I told you so. Maybe I did say it. the, certainly people who already have made dietary changes and who are already exercising a lot, one would logically think would do better after surgery.

Jollie (32:57)
Yeah.

Evan P Nadler MD, MBA (33:09)
And they possibly do. I think the reason the data don't necessarily show that is that you need such a huge number of patients to, you know, if you have just one patient who doesn't do well, it can skew the whole data set. But on the flip side, you know, like we did try to tell, like if somebody was continuing to drink sugar sweetened soda, that might be a patient where I might be like, listen.

I'll get you approved for surgery, but I'm not going to actually do the surgery until you've at least made an attempt to stop drinking smoothies every day or, you know, Coke every day or whatever. But the reality is that again, like they could do that just to get surgery and then you have no control over what they do after surgery. but similar to the GLP-1 agonists, bariatric surgery,

is weird in that it changes your sense of smell and it changes your sense of taste and it changes your food cravings to a degree. So I have patients who...

after surgery, their dietary patterns changed drastically. And it wasn't just because they had surgery, it was because they're, you know, like I had one, one I like to talk about is a patient who was really mad at me because before surgery she loved crawfish and after surgery she hated them. And I was like, I don't know what to tell you. Sorry. And then, you know, other patients who like, I remember a patient who said that.

Jollie (34:27)
Bye.

Yeah.

Evan P Nadler MD, MBA (34:34)
She couldn't even stand to be in the room with someone who was drinking milk after surgery because the smell of it would make her nauseated. Again, I mean, I have no idea why. it's real. mean, like people have studied it. It's like a real phenomenon. And it probably speaks to the gut-brain axis and a whole bunch of things we don't understand. It probably is part of the reason why surgery is more sustainable.

weight loss from surgery is more sustainable than medications because we probably do something more permanent to alter the gut brain access than is done with medications. But it's a whole, it's still totally unknown and we've been doing bariatric surgery pretty much for 30 plus years now and we still don't really know.

Jollie (35:20)
The two things, of both sides of it. What is the success rate? I still don't like that word, yeah, what is the, I'll go with it. I don't know what else to use right now. What's the success rate for bariatric surgery versus GLP-1s and lifestyle?

Evan P Nadler MD, MBA (35:29)
No.

Sure. So most of the data are from adults. So I'll give you those numbers first because that's where it's mostly been studied. So in adults, about 20 % of people after bariatric surgery will regain some or a large fraction of the weight they've lost from the surgery unless you do something to stop it.

So about, quote unquote, 80 % do well, 20 % have weight regain. With meds, the numbers are sort of flipped. About 80 % of people who stop a medication regain weight, and only 20 % are able to keep it off long term.

And then diet and lifestyle is the least successful of them all, which is 95 % of people who stop their diet and exercise intervention regain their weight. So those are from adults and those are pretty big numbers and pretty well established numbers. And it's why, you know, in many people's opinion, surgery is still the most effective long-term weight loss solution. Now in kids,

The lifestyle data are basically the same, 95 % regain their weight. The

weight regain rates are lower. And then there's some really interesting data that the Teen Labs Consortium recently published and they're working on longer follow-up. But at 10 years post-surgery,

Jollie (36:48)
weight regain rates are lower. And then there's some really interesting data that the Tino Labs Consortium recently published and they're working on.

I 20 years of surgery.

Evan P Nadler MD, MBA (37:03)
in their cohort still had a health benefit and were able to keep the weight off but the and they had a lower 10-year recurrence rate of diabetes in their cohort was lower than seven to twelve year recurrent diabetes recurrence rate in adults

And that was true even if people regained some of their weight. So the data suggests in kids that they have longer benefit and more benefit than bariatric surgery in adults. And they're actually working on their 15-year follow-up data now. And in my personal experience, nowhere near 20 % of my patients regained weight. I I did 750.

cases in DC over the 15 years I was there and so that would mean that 20 % would be what 150 of those patients would have had to

Jollie (37:52)
Yeah.

Evan P Nadler MD, MBA (37:53)
weight and there was no way we were near that.

Jollie (37:53)
Yeah.

Why do you think that is? Why do you think kids are more successful at keeping the health issues in check than adults? Is that, like you were saying, a five-year-old doesn't really have the behavioral aspects, like the habits, the environmental isn't ingrained?

Evan P Nadler MD, MBA (38:14)
Yeah.

Yeah, I mean, think for sure.

Well, short answers, I no idea. The longer answer is I can speculate and give you my.

Jollie (38:19)
That's easy.

Evan P Nadler MD, MBA (38:23)
some positions and I assume that, so one of the things that's been shown recently is that fat cells have memory and that they get, basically get ⁓ epigenetically modified so that even after you intervene with surgery or medication, they may work against you in the long term.

And so my scientific guess is that when you get to surgery sooner rather than later, those epigenetic modifications are fewer and thus the benefit is more long-lasting because the memory of the fat cells, and probably other cells in the body too, it's probably just not the fat cells, aren't working against you. So that's my sort of potential scientific explanation. ⁓

From a behavioral standpoint, may certainly be that, so when I was at NYU doing lap bands, I think they'd had an interesting study where the people who did the best with bands were the people who had the most to benefit socially, whether it meant new job or new spouse or something like that. And it's possible that it's the same thing with kids, right? Like a kid who...

gets their life back because they're now healthier and closer to normal weight and can participate in all the social activities that every other kid gets to participate in. They may have a more, they may have more of a social imperative or drive or desire to keep that weight off, so they may work harder to do it. I'm not sure that that's true, but one could sort of see why that could be true.

Jollie (39:53)
Kind of makes sense. Yeah.

Evan P Nadler MD, MBA (39:55)
⁓ So, you know, it's probably like everything else, a combination of those things. I do think that, at least in our program, we did a pretty good job of finding the kids who were falling off the curve and getting them back into care and intervening either with, usually with medications after surgery, if they started to regain any weight. And I think the adult community is going that direction as well, where people are starting to understand that the meds and the surgery actually work better together than they do separately.

So it could also just be an evolution of care in general that we're seeing that we're starting to understand more about it and starting to work together better. Like it's no longer surgeons versus non-surgeons in terms of the medical care of obesity. So yeah, but I'll go back to my first answer.

Jollie (40:37)
Yeah. Partnership.

Yeah. So, taking a little bit different direction, you kind of touched on this earlier, but it was interesting. So when I was editing our last conversation on adiposopathy, you were talking about weight regain from the different treatments, surgery versus meds and then

Lifestyle like exercise and diet and it just hit me like I think that's the most beautiful response I'm gonna start using it every time I hear somebody say well if you stop taking GLP 1s You're gonna gain the weight back well. Yeah, if you're exercising and eating right and then you stop What what's gonna happen?

Evan P Nadler MD, MBA (41:26)
Right. Or I mean that what a lot of advocates say is if you stop taking your blood pressure medicine, what's going to happen? Or if you stop taking your statin for your cholesterol, what's going to happen? Like why again, why is it that obesity has this threshold that's different? Like, of course, any, almost any disease you have that is treated with a medication, if you stop taking the medication, the likelihood

Jollie (41:37)
Yeah.

Evan P Nadler MD, MBA (41:51)
is that the disease is going to come back, like, duh. But yeah, it's like a... Obesity stigma and bias is so pervasive. It's not only socially, obviously, with the people who have the disease, have to suffer on the day to day, living their lives. But then, you know, they get it in the provider's office when providers keep saying the same thing over and over again.

just don't listen to the patient and don't offer either referral to specialists or some other option. But then also, again, like the insurance companies and the medical community and like, again, like no one would ever say about high blood pressure or diabetes or, you know, high cholesterol. Well, if you stop taking your medication, you know, you should be able to stop taking your medication. Like no one argues that.

And the silly thing is that obesity leads to all those diseases. So, like, of course you should take your obesity medication maybe forever because you would take your high blood pressure medicine forever or your high cholesterol medication forever. So what's the difference? What's the big deal? But haven't quite gotten there yet.

Jollie (42:58)
Yeah, it's pretty wild.

had a conversation last year. I don't think it's changed that much. But I did not realize obesity is not a protected class of ⁓ discrimination.

Evan P Nadler MD, MBA (43:12)
No, that's for sure. It's the last accepted, well, maybe not the last current environment where we're getting to discriminate against more and more people again. It's like we're returning to the dark ages of society. yeah, and I think the, so what I sort of hope or maybe even envision.

So first of all, most of the obesity medications were initially approved only to treat people with obesity. So if you lost weight on the medication and you no longer had obesity, some insurance companies would take away the coverage for that medication, which again, makes no sense whatsoever. But I'm hoping with the oral GLP-1 agents that are coming out in the next year or so, I could see a world where...

You take your GLP-1 medication and injection because it's probably easier to take once a week. Or you take the pill, whatever you want.

you've lost enough weight and you're going toward weight maintenance. People in the community have already been sort of like dialing back the doses or like doing things that are not quite FDA approved. But I'm hoping that maybe that's where the oral GLP-1 agents will have a real role is that like you take the injectable until you get down to whatever weight is the healthy weight you're trying to achieve. And then you switch over from the injectables which I think still are gonna have higher

weight loss and probably higher side effects than the pills. But maybe that's when you switch over to the pill and that becomes your statin that you take forever.

Jollie (44:34)
Yeah.

Evan P Nadler MD, MBA (44:35)
medication. Luckily I'm not on one of those that's knocking on wood. I'm not on a blood pressure medicine so I don't know what the most common ones are but yeah. So maybe that's where we're headed. That'd be great because I do think that would make sense and the oral GLP ones are gonna be a lot cheaper. So maybe that's where we're headed. least I'm hoping that's where we're headed.

Jollie (44:58)
Well, we'll eventually get there. I don't know if it'll be in the next year or two, I mean, just people are hungry to be healthy. And I think they're just much more open-minded looking at things.

Evan P Nadler MD, MBA (45:10)
Yeah, I think it's sort of the double-edged sword of the internet and social media and stuff like that. Now, you know, people are all definitely more self-advocating because they have more information to at their fingertips and can...

sort of go over options that they might be interested in before they even see a doc. But there's also so much misinformation out there that people come in with all kinds of things that are not based in science. And then even some people who run government agencies espouse things that aren't based in science. So it's like the whole world is like a...

of misinformation and it's really just like how do you sort through? How do you sort through what's real and what's not?

Jollie (45:49)
Yeah. So I've got, ⁓ I got one more question to, to, ⁓ two more questions to finish this off, but it leads into your next endeavor. So you've got this, ⁓ unique telehealth program that you and some partners started. ⁓ tell us about that, but as you do, if you don't mind lead into, or lead into that with when should somebody reach out to

obesity medicine specialist when should they talk to their primary care when should they reach out to your new company Procare?

Evan P Nadler MD, MBA (46:22)
Sure. Well, first, you should reach out to your primary care doc or primary provider. Whenever you perceive or your child perceives that the weight is becoming an issue, whether it's a mental health issue or a physical health issue, doesn't matter. If it's bothering you, talk to your provider because they hopefully will be.

open to discussing it and then if they don't really know what to do, they can at least refer you to an obesity medicine specialist. So, our unique, practice that we just started, actually last week. If you look at pediatric weight management programs, they are clustered in the northeast and the west some, but they're huge swaths of America that have no access to

pediatric weight management in large part because most of pediatric weight management programs are located in urban centers and ⁓ generally academic centers and they are nowhere near meeting the need of the number of people who could use some help.

Like for instance, my program in DC before I left was the busiest program in the country surgically and among the busiest medically. But we had a 300 patient waiting list because the demand was so high and there was basically nowhere else for these patients to go. So my partner and I, and my partner is a pediatrician from Children's Hospital of Atlanta. She and I initially formed a company to try to hospital systems build programs because

We wanted just to teach others how to do it. And we spent a year trying to convince hospital systems to hire us to help them to build access to care. And maybe not surprisingly, although I was surprised, no one hired us. No one cared. No one cared at all. Not even like lip service cared. So then we were like, what do we do next? Like if we can't get hospitals to expand access to care, how do we do it?

And so we came up with this telemedicine only practice and it's pediatrics only. So, and that goes up to maybe 25 or 26 and certainly we'll talk to families as well. but the, know, but there are a growing number of adult telemedicine weight management practices and some are now actually even seeing teenagers, or maybe even younger, but we're the first in the country that's only.

pediatrics like that's all we do and it's not that we don't know adult obesity medicine it's just that we feel like those adults have a lot of places they can turn to kids basically have almost nowhere to go so we're just starting but we're and we're only starting in Georgia and Florida for now just because of getting medical licenses in all 50 states is a thing we want to make sure that this is something that the people want I mean we think it's what the people want and I've been

Jollie (48:34)
Yeah.

Evan P Nadler MD, MBA (48:49)
Patients have told me that this is what they want, but you never really know until you actually do it. But if it's successful in those two states, the plan is to roll it out to all 50 states. And that way, access to care for all kids struggling with their weight and all families struggling with weight issues have somewhere to go. So that's the hope. And then the hope is to take that and then go to hospital systems and say,

you guys gotta start to support this because we can't do it by ourselves. But if you as a hospital, you know, you guys could do the same thing. Either you could hire us to do it or we could help you do it similarly so that, it's actually more cost effective than bringing people into brick and mortar clinics. It's better for the patients cause they don't have to drive. They don't have to take a day off from work. But it's also frankly better for the hospital systems cause they don't have to pay.

academic clinicians fringe benefits and all the other things the high salaries and that so it actually should be a very cost-effective way of delivering care but I guess the proof is in the pudding we got to make sure we can do it and do it well before anybody's gonna take us take us seriously but that's the plan

Jollie (49:51)
So

it's not just surgery.

Evan P Nadler MD, MBA (49:53)
no,

yeah, sorry, I didn't. It's actually, it's not surgery at all. Well, I shouldn't say that. If people want surgery, we can get them prepped for surgery and then help them find places to get surgery. Right now, I'm personally not doing any bariatric surgery anywhere in the country, although that could change depending on how this practice goes. But let's say you're in Atlanta.

Jollie (49:55)
That's all right.

Evan P Nadler MD, MBA (50:13)
We know surgeons, I know surgeons, pediatric bariatric surgeons in Atlanta that I can refer you to. Or if you're in Florida, I know people in Florida who I can refer you to who have programs that I have vetted and trust. So we're almost.

functioning even as a patient navigator kind of thing. Because it's so hard to care and good care out there. So we're trying to not only provide the care, like writing prescriptions for meds, getting the lifestyle stuff, behavioral treatments, lifestyle treatments, dietitians, psychologists, providing all that stuff as well. But.

Also, being a patient navigator, if you need something more, we can help point you in the direction where you can get more than.

do and then from the clinician standpoint like the surgeons I talked to I said listen I will get your patients ready for surgery. I've done more of it than anybody else in the country. I can definitely provide you patients who are well prepared to undergo a procedure and then you don't have to do that. You can focus just on doing the cases and

And in theory, your volumes can increase because you won't spend as much time in the prep, because I'll be doing that for you. that's another. know, again, whether the business model works or not, I don't know yet. I'm pretty sure, I mean, I know there's a need out there, too. I know that people will come.

their care with us, I don't. But I think we just have to work on getting the word out there to folks so they know that it's an option. like I said, we just started last week, so we got some work to do. But I'm not.

Jollie (51:39)
Yeah. Well, most,

most practices that have anything to do with, with, with, with weight manager right now are backed up six months. So I don't think there there's definitely not a lack of need. So I'm excited to follow your journey with you.

Evan P Nadler MD, MBA (51:54)
Yeah, well, as I said earlier, know, there are 140 million adults and 15 million children with this disease. So I don't even know how many providers you would need to address all those people. But it's certainly not going to be, I think, again, as we evolve, it's going to have to be primary care docs who deal with this disease because the specialists...

Jollie (51:59)
Yeah.

Yeah, sure.

Evan P Nadler MD, MBA (52:15)
just aren't going to be able to handle the volumes of need once people realize that they should, you know, like right now, maybe 5 % of people who have obesity actually seek out care. So it's a totally, it's still what, well, I'm using that number, that number's from, from GLP-1 for medication. that's, that's about the uptick of the GLP-1 medications. About 5 % of people who could get it do get it. ⁓

Jollie (52:27)
5 % ⁓ my goodness

Evan P Nadler MD, MBA (52:41)
So that may not, so it might be slightly higher for behavioral treatments, I don't know. It's not a lot. It's certainly not, it's certainly not 14 million, certainly not 10 % of people. There aren't 14 million people out there who getting, who are trying to deal with their health with obesity medicine specialists, at least not that I'm aware of, so.

Jollie (52:44)
But still, it's not a lot. Yeah.

Yeah.

As the bias and stigma start falling around treatment, that'll do nothing but improve as the cost of treatment comes down. The oral options, yeah, more options we have. yeah.

Evan P Nadler MD, MBA (53:10)
And that's the goal, right? That's what we're all trying to do is make it more accessible, more

affordable, less stigmatized and just get, you know, at the end of the day, and I've said this before and it totally sounds sappy or corny or cliche, but it really is just about helping people get healthier. you know, that is the goal. Like I'm trying to do, I'm trying to think out of the box in ways to make it happen because I'm a sort of out of the box kind of guy.

But at end of the day, the goal is the same. It's just we want people to be able to get care and get care that they like and get better, get healthier. And that's why I'm treating agnostic because I don't really care. Yes, I have opinions about which options might work better or not as well. But at the end of the day, you're the patient. You got to decide what you want to do. And I'll help you get to a decision. And then hopefully, as the patient, you will have an open mind if option one doesn't work.

Jollie (53:41)
Yeah.

Evan P Nadler MD, MBA (54:00)
Option two, if option two doesn't work, option three, there lots of options. So you just gotta keep at it.

Jollie (54:06)
Very good. ⁓

Evan P Nadler MD, MBA (54:06)
So, but

that's my Jersey roots again. Just doesn't matter how many times you run into the brick wall, keep running into it until you can break it down. Maybe take a different path. Don't go to the same spot. Maybe

Jollie (54:17)
Yeah.

Well, this has been fantastic, Dr. Nadler. Thank you so