Diabetes & Obesity Management

For too long, diabetes and obesity in children have been treated as failures of willpower, by the child, by the parent, by the family. In this episode, three innovators share how they are rewriting that story.

Dr. Jennifer Raymond, Division Chief of Endocrinology, Diabetes and Metabolism at CHLA, describes her community-based research with Latinx families living with type 1 diabetes, and what she has learned about the role of spirituality, peer support, language, and parental guilt in diabetes management. She also shares a striking clinical observation: that GLP-1 medications, most often discussed for their metabolic effects, are producing dramatic improvements in mental health and food anxiety in some of her young patients.

Dr. Alaina Vidmar, Medical Director of the Obesity Medicine and Bariatric Surgery Program at CHLA, makes a clear and evidence-based case: obesity is a complex chronic disease, it is not the child's fault or the parent's fault, and the toolkit for treating it, including GLP-1 medications and bariatric surgery, is more effective, more accessible, and more underutilized than most people realize. Since launching the bariatric surgery program at CHLA in August 2023, her team has completed 150 surgeries with no insurance denials.

Shireen Abdullah, founder of Yumlish, shares how she built a culturally adapted, web and text-based diabetes prevention platform for low-income Hispanic communities, after her own doctor told her to "eat healthy" without any meaningful guidance. Yumlish has achieved CDC full recognition, with at least 60% of completers achieving weight loss or A1c reduction, and recruits 95% of participants through federally qualified health centers.

Episode Resources:

Weight Management for Adults with Obesity - Wegovy®

Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS)

National Diabetes Prevention Program

When Should Kids Get Bariatric Surgery? Obesity Medicine Experts Share the Science

CHLA Bariatric Surgery Program

Peer Support Lowers HbA1c in Adolescents and Young Adults With Diabetes

Connect with Dr. Jennifer Raymond:

Dr. Jennifer Raymond CHLA

Dr. Jennifer Raymond LinkedIn

Connect with Dr. Alaina Vidmar:

Dr. Alaina Vidmar CHLA

Dr. Alaina Vidmar LinkedIn

Connect with Shireen Abdullah:

Shireen Abdullah LinkedIn

Yumlish Website

Yumlish LinkedIn

Yumlish Instagram

Yumlish: Diabetes and Multicultural Nutrition Podcast

Connect with us:

KidsX Website

KidsX LinkedIn

Children's Hospital L.A. Website

Children's Hospital L.A. Instagram

Children's Hospital L.A. LinkedIn

Transcript

SPEAKER_00 0:01

Welcome to the Dose of Optimism, where I talk to the optimists in healthcare. My name is Omkar Kulkarni, and I work at one of the world's best children's hospitals where I lead innovation. I started Kids X, which is a premier international startup accelerator for pediatric innovation, and over the years I've met thousands of startups, investors, and innovators. Every one of them has a story, and every one of them is optimistic about the problems they're solving. On this podcast, you'll meet amazing people who will share their stories and what makes them optimistic about the future of healthcare. A little note before you get into this episode. This podcast is for informational purposes only. We are not offering medical advice and we're not endorsing any products. Please talk to your own physician about your health or the health of your children. All right, let's get started. Dr. Raymond, thank you for joining us.

SPEAKER_02 1:02

Thank you so much for having me.

SPEAKER_00 1:04

So we are in such an awesome community because we have so many kids with diabetes to take care of, and many of them come from diverse backgrounds.

SPEAKER_02 1:14

So we, as far as um Latinx folks that have type 1 diabetes, we're seeing some of the largest increases in diagnoses and numbers of people living with type 1 in our Latinx community. And we also know that even with increases in technology and access, that those same individuals are having more challenges with success with their diabetes. And there can be multiple reasons for that. And that they use diabetes technology at a much lower rate. And that can be continuous glucose monitors or insulin pumps. And we know that those devices improve outcomes for anyone living with diabetes. And so we designed a project really using some of the work we'd done with adolescents and young adults to look at how do we engage the community. And that means kids and their caregivers and families in really looking at what do they need to be able to care for their diabetes and then how do we support them with moving towards diabetes technology? And it's actually CHLA, UCSF, and UC Davis. And we started with engaging the community, so individuals living with type one and their families, but also all the healthcare providers at our institutions to understand what the gaps are, what do people need? And then we kind of built an intervention from there. And so then we've really had those same communities give us guidance throughout the intervention. How do we adapt it? How do we address issues? And then really built, designed, and then iterated with the community in mind.

SPEAKER_00 2:51

There's three different things you've identified. One is there's a higher prevalence of diet type one amongst this community. There's even in addition to that, a lot of these kids are having a hard time managing their diabetes because of the variety of factors. And then the third is their use of technology, even though you know we know it's helpful in managing diabetes, their use of technology would be lower than other populations. So, what have you learned through all this work in terms of why for all those three things?

SPEAKER_02 3:19

Yeah, yeah, yeah. It's a great question for the first one. We know that actually communities of color, it I guess I should back up. We used to think of um type 1 diabetes as being for young people from Caucasian or white communities, right? However, now we know that it's happening across all ages, whether that be our under five is some of the fastest growing, under five years of age, fastest growing population, but there are also adults being diagnosed and older adults being diagnosed.

SPEAKER_00 3:47

Sorry, I so I didn't you just tell me something new. So historically it was a it was something that was largely amongst white Caucasians?

SPEAKER_02 3:54

Yeah, and that's kind of how it's thought of. And I guess I would say the largest population, our largest community of type one diabetes or prevalence rate is in has historically been in Scandinavian countries. And so that is kind of initially type one diabetes, those are Is that a genetic kind of pattern that's thoughts? Yeah, so there's a genetic tendency, but then there's also there's a we're not certain what causes type 1 diabetes or really autoimmune diseases in general. And even thinking of the Scandinavian countries, which have amazing healthcare systems where they can follow long term and also look back and see risk factors. They've looked at is it related to the pregnancy experience? Is it related to what they ate in the first year? You know, like milk versus formula versus whatever it is. Is it related to vitamin D deficiency because they're in an area where there's less sun exposure, you know, during the day? Is it specific genetics? There are some things found within that that are like this raises your risk, but nothing really stands out as being this is why, right? Um, there's some also looks uh literature looking at is it related to our hygiene and kind of our environments? Is it related to viruses and all of that? And there's nothing really that's been pinpointed, but what we know, type 1 diabetes, as with other autoimmune diseases, is increasing across the world. It's increasing in all communities. And communities of color who, again, have historically and I would say still are often misdiagnosed with type 2 diabetes or something else, have high rates of onset of type 1 diabetes. And then when you look at the entire population, under five years of age is the fastest growing population. But then we also are seeing it, you know, in 50, 60 plus year olds, type 1 diabetes, which historically it was like that would absolutely be type 2 diabetes or whatever it is because you're older and that can't be type one. But we're seeing type 1 diabetes kind of across the board now.

SPEAKER_00 5:58

Wow. Are you working with adult endocrinologists on because I imagine a lot of adult endocrinologists aren't used to dealing with uh new onset type 1 diabetes?

SPEAKER_02 6:08

Yeah, such a good question. We don't have enough PEEDS endocrinologists, pediatric endocrinologists really to care for the population in general. But then when you look at it going to the adult world, there are not enough endocrinologists on the adult side to manage all of those individuals who grow and successfully manage type one in their pediatric years. I have some amazing colleagues, Sean and Tamara Auster, who are family practice physicians. One of them lives with diabetes and then they have children that have diabetes, they're partnered. They live in Colorado and they actually work on how you train primary care physicians to be able to manage type one diabetes because it's gonna be coming, you know, into your practice. But it's tough because a lot of adults feel that you have to be able to manage it more on your own because you're not necessarily, depending on where you're getting care, you're not gonna have the same expertise potentially, um, or the focus on type one diabetes that you do with an endocrinologist. I will also say, and I was just on service last week and covering kids in the hospital and outpatient with new onset diabetes. For example, one of the families I was seeing, the kids have diabetes and at like new onset diabetes. And as I was reviewing with the parent, we realized that mom actually has a different type of diabetes than what she was being managed for, you know, like or how her diabetes was being managed or what she thought she had. And it's not uncommon for adults or even my older adolescents to young adults to be misdiagnosed with a different type of diabetes or be treated with a different type of medication under the presumption that it's type two diabetes or it's lifestyle that needs to be adjusted versus being in that.

SPEAKER_00 7:48

Wow. So you were just talking to this parent and realizing talking to them that they probably was describing her experience.

SPEAKER_02 7:56

What was um really humbling to me is that through communicating with her, we got to the understanding that part of her hesitancy and concern for her children having diabetes and needing insulin or whatever it might be was related to her own personal like trauma and experience with diabetes. And then she was like, I need to talk to my doctor. I don't think that I'm being managed like as I should be, right? Um, and it's not uncommon. And I I mean, everybody's doing the absolute best they can with, you know, the volume of patients they see and then their experiences. But I do think that diabetes, whether it be type one or type two, are genetic, monogenic forms. I think there's a lot of misclassification and we're learning much more about how to manage.

SPEAKER_00 8:40

So, what are the things that you're doing to help these populations better manage both both the technology piece, but also the lifestyle piece and the treatment piece?

SPEAKER_02 8:49

So our first phase of the work was working with all of the kids and families and then those providing care in clinics. And we realized several things. One is, and I think the strongest message was we need support, period, right? We need it to look different. We need a community. I know no one else with type one diabetes. I know no other parents caring for someone with type one diabetes, and I need that, right? So help me better understand how to do that with the support. Two is that in general, the system is difficult to navigate. And if you do not have English as your primary language or as your first language, it's much more challenging. And so, how do you navigate pharmacies or technology or even reaching out for support through your clinic if you don't have English as your first language, right? And so a lot of that we also realized, and this was the first time that it kind of come across in any work that I had done, that there was a strong spiritual component, some religious, but really more the understanding of disease compared to health and how we navigate that and how we talk about that, and really a desire for that to be incorporated and respected in families who really desperately want to understand and support their child with being as healthy as they can be. And then a lot about understanding technologies, how to understand and use diabetes technologies in limited resource areas. If you don't have access to certain things, is there a, you know, a way to do that? Or if you don't have experience with this, how do you do that? And so we used everything from that kind of first year of work to design, we're doing virtual peer groups or support online. And we do them in English and in Spanish. We do them for the kids and the parents, and they're all separate. And then our facilitators take everything that we learned from that first year of work, and then with an advisory board again of community members that either live with or care and love someone that has type one to design topics for people to be able to join online. And then our goal is to have them provide peer support with our facilitation. And so we have bilingual, bicultural leaders, we have that help facilitate the discussion. And it's anyone from like coordinators on my team that are from our community, that have their own experiences that do it, to you know, our nurses and social workers and dietitians and everyone that have experience. And we have six different topics and then offer those every few weeks in different languages and with different groups. And we're finding that it's increasing their engagement, it's increasing their uptake of technology. Kids and families are reporting that it's improving their relationships and communication at home, diabetes or not, right? Just developmentally how you do all of that. And then improving satisfaction for our team members who also worked so hard to care for kids and families living with diabetes, which is great.

SPEAKER_00 11:50

Any type of chronic disease management, particularly a life-changing one, it's a lifestyle change. And the lifestyle comes from the common experiences of a community. And so building interventions or you know, lifestyle changes that are community-based and community-oriented or influenced by people in the community, is incredibly important. And it makes sense that people be more engaged in that and find it more effective because you're talking about changing the way they the family lives, the way the family engages with technology, the family, the way they buy groceries, the way they cook food. These are things that are deeply cultural and community-oriented and not exclusively clinical. So makes a lot of sense.

SPEAKER_02 12:32

It's interesting the families also were even in that first year of work, the kids and families were like, because we wanted to do it all virtual, because it was like we don't want to add more burden to people, you know, community around Los Angeles or, you know, in San Francisco or wherever. And very strongly in the work we were doing, where kids and families were like, no, we just need time to come together and share food and community. And so every quarter we have things where we all come together in person and eat or play games or do whatever kind of is with the season and folks share with one another. Um, and really, again, kind of building on that community and how they support one another or how the kids support one another, even at different ages. And that's been good because we listened to what they said they needed and then really built around that and added what we thought would have been a burden, but it turns out they actually really want it to be part of the work.

SPEAKER_00 13:27

So you lead uh CHLA's telehealth program, and what you just said brought up a conversation that I feel like I've had a couple different times. So I think nationally we see that families that speak Spanish are often underutilizing telehealth compared to families that don't speak Spanish, right?

SPEAKER_02 13:45

Absolutely. And I think there's a place for all of that to really meet families' needs. And I think the biggest thing I think we need to consider in healthcare in general is how to be adaptable and how to understand the lived experience of what those that you're caring for, what that might look like and how that impacts what they need from a clinical standpoint, right? So I do think there are times where virtual is preferred and it will be easier for folks and it will provide excellent care, right? We have a lot of data on that. And I try to always talk with my kids and families about what feels right and most supportive to them, right? So some really feel like coming in and having that connection, whether that be respect or culture or it's that everybody comes together, that's really important. And then some know transportation's difficult, or this family member, you know, is always at home, you know, or whatever it is. And then like a virtual option is better for them. What I think we miss is that sometimes we try to generalize it and look, you know, like big picture, and we offer in this way and then this way, when I really think so much of it needs to be personalized and there needs to be an actual conversation with someone who has the trust and rapport with that kid and family to be able to talk about it. And so much of what we learn, especially from our Spanish-speaking families, is they just they want to know someone is committed to them, is showing up for them, um, is listening to what they need. And then they feel comfortable asking for that, like whether it be online part of the time or in-person part of the time or whatever it might be. And I feel like that connection is often missing. And because much of the healthcare I think that we do is like, I have to be as efficient as possible. I only have these number of slots, like you have to work around what I, as the physician, have available. But I don't necessarily think that's any more efficient because not everybody can be successful in coming to those visits, emergency things come up. So I just think there's an opportunity for us to really think outside the box as far as that goes with what folks need.

SPEAKER_00 15:49

Are you seeing as GLP ones are introduced into the potential treatment plans for patients with diabetes? Are you seeing a difference around how perhaps Spanish-speaking families may be asking questions, thinking about the pros and cons of GLP ones versus non-Spanish speaking families?

SPEAKER_02 16:09

That's such a great question. I will say I haven't done any broader research on type one or type two specific to language with that, but I do think just even clinically, the understanding or the discussion is quite different based on what um that kid or family has experienced with others in their lives that have diabetes, right? So some of my maybe English speaking, privately insured white families might come in and they've done research and then they know and this is what they want, and they know somebody that's on that, right? And then in some of the Spanish-speaking community or communities of color, they might come in with different understanding, even of diabetes in general. And then there is a different, and again, this is just my kind of clinical experience. I think there's a different concern of what that means for their child socially, emotionally, you know, how will that impact them at school? What does that look like then for our family when we have meals or celebrations or whatever, you know, that might be? How will they feel on this and those things? And I think the concerns or understanding comes a little bit differently, I guess. What I will say is I've also been, and I think of one of the first kids that had type has type 1 diabetes that I talked to the family about using a GLP1 because he has type 1 diabetes, but he also has significant insulin resistance, right? He was using maybe twice as much insulin as I would expect for someone his age and size. He felt like it was just going up and his glucose levels were higher. So I talked to them about like we could use this medication and see how it goes, right? And they had wonderful and appropriate concerns and questions. A week or two after he had started, mom, and I'm proud, we do kind of Spanish-English translator, like our interpreter as we need to, but we do sometimes just with messaging one another. And she was sharing that her child had changed so dramatically as far as like his depression or anxiety around food and guilt around his management. Like, was he doing enough? Was he eating too much? Whether his blood sugars can out of control or not, to the point that it was impacting in a positive way how he interacted with the family at home, but also how he was doing at school and participating, joining others at lunchtime, all of those things. And he's, gosh, he was one of my first kids that I started. So he's been on med GLP one to really help with that insulin resistance piece for years. And his A1C has gone down, his insulin needs have gone down, his mental health has improved dramatically, right? And I see that not infrequently in my kids and families. And so I do think there's such an opportunity for us to think about, again, personalizing it, but also thinking about what the kid and family kind of bring in as far as their concerns for management go, too.

SPEAKER_00 19:06

What are you seeing in terms of kids with diabetes, either type one or type two? What are the next couple of years going to look like? What data are you looking for?

SPEAKER_02 19:15

I really think the initial step is building a relationship with the child and the family and understanding their beliefs. So one of the things, and I say this because it kind of impacts next steps. One of the things we really realized with a lot of the focus group work we've done in adolescents and in their families, but also in our Latinx community and their kids and families is that they'll often have a belief of why this disease was, you know, why their child has this disease. For example, I had a family who the mom, after talking with her for a while, said, I know that this is happening. God is punishing me because I'm not a good enough mother, right? If I would have done more as a mom, my kid not would not have had diabetes. And it made me pause and think, wow, that could be something that actually many people are thinking, I'm not addressing that. I'm talking about insulin and I'm talking about managing diabetes, right? And so, in a lot of the work we're realizing is that the understanding of the cause behind the disease and the chronic management is very different and we're not always approaching it. So I think just first is building a trusting relationship so you can honestly have that conversation about what someone's understanding is, right? So that's first how to work on those goals together in a shared decision-making, really family and kids-centered model. And then with that, I think what I hope to see is that we have really personalized approaches, right? If someone has insulin resistance or someone has food anxiety or kind of the food chatter that makes everything about diabetes management difficult, or they're living with obesity or complications to that, we need to think about GLP ones being part of their care, right? And then for diabetes technology, can we start conversations with that earlier and support an adolescent who just wants to be like every other adolescent and not have diabetes? How do we help them connect with peers or their family connect with peers to understand others' experiences with diabetes technology, why it might be beneficial for them, and really lean into the peer support, the understanding behind the disease, and then the ability to personalize it all through insulin or GOP ones or whatever it might be, beyond all of the exciting research that's being done in different spaces for the future of a cure intervention and whatever?

SPEAKER_00 21:32

So we just talked to somebody who's got some interesting work happening in the eating disorder population. She was talking about the importance from her perspective for parents not to feel like they caused the eating disorder. How do you respond or manage parental guilt if they feel like they cause their child's diabetes?

SPEAKER_02 21:57

I'd love that you asked that. So I'll tell you um several. Things. One is we actually have a chaplain who's a sociologist who's done a doctorate who's now on our team. And she is teaching me so much. And again, it's not just religious, it's the like the spirituality or the beliefs, right? About health and medicine and everything. And really helping us be like, this needs to be part of our communication from the beginning, right? Like the health beliefs behind that. And then supporting, you know, the kids and families. And so I think we're learning from her. I also think we did some work with.

SPEAKER_00 22:33

Did she meet with the parents? I'm sorry, it's a quick question.

SPEAKER_02 22:35

Yes. No, no, no. So such good questions. So she does. And actually, we now have someone, and again, I was just on service last week. We have someone who's in the hospital that previously I had thought of our chaplains in the hospital as they were doing more end of life for karate, whatever, whatever it is. But now I'm reaching out to them at diagnosis, inpatient or outpatient side, and having them reach out to families to really like, this is a lot. Tell me how you're feeling or processing or your beliefs or understanding. And I honestly think that we need to start from there and whether it be psychology and mental health support, but also like the spiritual and kind of health belief side. And so the um Dr. Megan Weiser, who's on our team right now, she has a project actually looking in type one and type two. She's working with kids and families, really families, to understand that experience. And then Dr. Ceci Namak, one of our fellows, whose Peruvian Spanish is her first language, she's meeting with kids and families and really parents and families, anyone in that caregiver circle to understand their experience at diagnosis, what they remember, what they needed, what they've learned moving forward, and what advice they give back to the healthcare team about really considering that moving forward. And so I think there's much for us to learn and listen and consider with our kids and families at any time, including a diagnosis. And then really to use that as something that we kind of are always checking in on. Because we're looking at blood sugars and ANCs and making adjustments, but it's not really that we're thinking about the full picture of that chronic disease management and whatever that young person's lived experience is. So I think there are interesting opportunities. The other thing I would say is that in one of our focus group, or in some of our focus group work, or even in the parent groups, being able to be with other parents or other caregivers, right? Because sometimes it's aunties and uncles and whomever, right? Grandparents, and sharing that you also have that guilt and someone else feels that like this is happening because of me or this challenge is not because this is diabetes is hard and that's what it looks like, but it's because I'm not good enough, right? Or I'm not doing all I can to protect my kid. Being able to be and hear that from other people versus even hearing it from me, if I'm able to have that conversation, it's so different when it's someone who shares the lived experience and your culture or whatever it might be. So I think a lot of what we're learning is that families and caregivers, as well as the kids, need that support and understanding from others to even kind of process our work through it together. So we're hoping to keep building on that, whether it be at the diagnosis time or throughout their time with diabetes. There's a lot of opportunity.

SPEAKER_00 25:21

That's that's tough. That's really hard.

SPEAKER_02 25:24

So for type two and obesity, I definitely, and Dr. Fidmar, who runs our weight management and bariatric program, says this so beautifully. But I think both for type two diabetes and then for those living in a bigger body, the message that people get is like, this is my fault as a parent, right? When in reality, it is genetic and it's environment and it's multifactorial, and it is absolutely no one's fault. And that is not the message we're routinely saying from the beginning, right? And so, like I had a family last week, and the mom was like, I know, I knew this was gonna happen. She had a cupcake at whatever. And I was like, let's back up. It's absolutely not that you did not cause this. It is not because of anything you as a family agent. This is a chronic disease, right? And we're gonna help you learn to teach it, but we have to reinforce that over and over again because what they're gonna hear or what they're often hearing in the community or the news or the whatever is that this is your fault, you're not doing enough. And as you said, I think as a parent, all you want to do is protect your child and do as much as you can to help them be successful, right? And if the healthcare system or the community is telling you you're doing the exact opposite, I can't imagine how difficult it is to engage back in that and try to advocate for or do better if you feel like you're perpetually failing or not doing enough for your child.

SPEAKER_00 26:40

Especially if you have other kids in the family. There's younger siblings, other siblings, people that you're also taking care of, and it never stops.

SPEAKER_02 26:50

And I think I just there's such an opportunity for us to really listen to individuals' lived experience to emphasize and re-emphasize that it is no one's fault, and our job is to be here to support them, and it's not because of something they did or didn't do, and that it will be different at every stage. We're here to do that with them and ideally be able to, I think that really we need to always have the ability to weave in peer support or spiritual or psychological support, and all of that should be part of any chronic disease management.

SPEAKER_00 27:24

Multi-generational, too, because I imagine older generations and the messages they're passing on to like what grandparents are telling parents who are then feeling guilty about stuff. Yep, absolutely. Dr. Raymond, thank you so much for joining. Always fun talking and amazing work you're doing. Tell me all about Yumlish. What got you started? What's the problem you're solving, and what does it do?

SPEAKER_01 27:49

Yeah, so where where all of this started, Unkar was actually a few years ago now. I was uh diagnosed with a diet-related chronic condition at the time that I was trying to manage. I didn't quite know how to do that, turned to my doctor at that time, really tried to understand that better. And the only advice my doctor at the time could give me was something vague like eat healthy. Okay, great. What does that mean? Let me just go flip that switch on. Like, what do I what do I do? Um, I didn't quite understand that. I'm also of uh South Asian descent, grew up on South Asian foods. I cooked practically every day for myself and my family, and felt quite lost to try to navigate those types of foods and ingredients and those foods, just the meals that I was cooking. Anyways, cut to just realized that we're all just trying to do better for ourselves or families, but just not a lot of guided support available out there. The best uh that we can turn to is just googling our way and figuring that out because that was that was my default way of figuring it out. Anyways, cut to created what has now turned into Yamlish, and that's exactly what we do is we provide culturally adapted uh and web and text-based uh diabetes prevention programs in low-income populations. We really started out in diabetes in particular because there's just a disproportionate amount of diabetes in low socioeconomic communities. There's a known solution for it out there. It's this diabetes prevention program. It comes from the CDC, been around for 20, 30 years, but within its data, you quickly see that those who truly need this program, it's just not getting to them. And by the way, the efficacy for this program is already there. It's established it can cut someone's risk of developing diabetes in half. And it's just not getting to the communities it needs to. So, anyway, so that's why we provide a web and text-based version of this program. It's all online, it's digital and incredibly accessible through devices that a lot of the community has. So we do a lot of work in terms of the communities we serve today. So largely Hispanic, like Spanish-speaking populations at the moment. We're working in California and Texas, and uh there the there's this overwhelming need for Spanish speaking and culturally adapted solutions. The culturally adapted piece is such a, you know, it it's something that you have to, you can't AI your way through it. You have to make sure that you're taking the right community members and you're really taking their needs into account as you build and develop this. But for everything else that we have adapted around it, which is like a web and text-based model that we've created, a tech enabled model, uh, that has resonated quite strongly in these communities that we work in.

SPEAKER_00 30:22

I think the cultural relevance around diet and lifestyle change is something that we've all talked about for years. I remember there were cookbooks created in print 20 years ago that were focused on heart disease and diabetes and other lifestyle changes that were required, and they were culturally sensitive. But I think we need a digital way of doing that. And I love that you're focused in that space. How do you track success? Like, what is what does success look like for you, Amlish?

SPEAKER_01 30:48

Success for us looks like well, in two different things. So one is the success that the CDC kind of holds us to in terms of recognition. So we have the highest recognition, by the way, from the CDC to do this work that we do. It's called full plus recognition rendering. Um, so we have that. So success from an outcomes perspective is something that's validated by the CDC, which essentially means that at least 60% of completors going through our program seeing are seeing weight loss, are seeing a reduction in their A1Cs. So that's um, you know, that's that's the something that is a huge accomplishment for our team. And again, we do this in a very low-tech model, at least on the UI front. The other elements of success for us are things like where these participants come from. If you look at the competitor landscape today for any kind of chronic disease program and notably the diabetes prevention program, the competitors largely said in a more commercial space. So these are employer-based, you know, programs. Uh, they do well there, but they're just a different audience altogether. So when it comes to success in this population, we bring on participants from federally qualified health centers. So that's our number one recruitment sites. And in working in these communities in this population, when there's just demand for this type of work because it's such an unsaturated market and also because there's a huge need there. We're able to enroll participants, all 95% or something of our participants come from federally qualified health centers. And that to us is another another feather in our cap in that we're able to bring participants on in this web and text-based model for diabetes prevention and really access this population where other models just haven't been able to tap into. So that to us is another another one.

SPEAKER_00 32:37

I think the FQHC is such an important player in this space given the population you're looking to serve. Would you ever consider having more presence in non-health related sites? I'm thinking about community centers, churches, temples, mosques, etc.

SPEAKER_01 32:56

The the short answer to your question is absolutely. We've uh partnered with different community organizations in the past. Uh the FQ environment we found to be a more, you know, it's just resonated a little bit stronger in car. And the reason for that being is, you know, you're you're at the doctor's office, you're getting, let's say, a pre-diabetes diagnosis, or your doctor's telling you, hey, you need to do something uh about, you know, your health or your weight or whatever it may be. And much like the experience I had all those many years of bearers, like, yeah, just try to eat healthy. Now the conversation becomes a little bit more meaningful and deeper where we go, I want you to do this, and I want you to sign up for this program that can help you as well. And that coming from your provider holds a lot of weight because then your provider's also holding you accountable, right? Or something like that. So that conversation and converting from that conversation has been quite powerful. But that's not to say community other organizations, other CBOs have not worked out. They've just been great, but we've just seen the stronger sort of uptake from FQs.

SPEAKER_00 33:58

Sharine, thank you so much for joining us and talking about the Yumlish and the really important work you're doing.

SPEAKER_01 34:02

Thank you. And and thank you for this opportunity to talk to you about it, Carr. Appreciate it.

unknown 34:12

Dr.

SPEAKER_00 34:13

Vidmar, thank you for joining.

SPEAKER_03 34:14

Of course. Thanks for having me.

SPEAKER_00 34:16

Dr. Vidmarth, you've been doing amazing work in our obesity management program. Tell us more about what work you're doing and also just what the current state is. I think we read a lot about the epidemic that exists amongst kids in terms of the growing rates of obesity amongst children. What is the current state today nationally, and what are we doing here at CHLA about it?

SPEAKER_03 34:37

Yeah, absolutely. So, you know, I think there's been a big movement as we think about caring for kids living in larger bodies. One to understand how do we treat it as a complex chronic disease? Because I think as the science has unfolded, we have realized that kids living in larger bodies, this is not their fault. They are not doing something wrong. This is not their parents' fault. This is how they are made. And so we are trying to understand how do we create clinical programs that can actually help them live long, healthy lives and really take the focus away from the number on the scale and the size of their body, but really providing them a toolkit that can help prevent them from getting things like diabetes, high blood pressure, and high cholesterol. And I think what's been cool is that our toolkit is expanding. So we have more medications, we have more innovative ways to help families eat healthfully and move more, we have more access to things like bariatric surgery. So I think clinicians are trying to figure out how do we creatively and in a shared decision-making way partner with families to both break weight stigma, um, but also provide access to this treatment so that we can help kids because we know that about one in five kids is living in a larger body. So we have a lot of young people that we need to try to help, and we have a short time frame that we need to do it so that we can provide some prevention.

SPEAKER_00 36:00

And how young are these kids that are starting to seek your services?

SPEAKER_03 36:04

So we see kids as young as two. I think what's pretty interesting is there was some recent epidemiological data that just came out that actually showed that the rates of pediatric obesity are continuing to climb. So this was data looking at 2023, but it actually showed that preschoolers were having some of the highest rates. So we actually know that unfortunately, because this is probably epigenetic and happening early, um we're seeing some of these rates in younger kids. So the earlier we can intervene, probably the greatest impact we're gonna have.

SPEAKER_00 36:35

And is it still based on their growth curves?

SPEAKER_03 36:38

Yes. So we still do look at it based on the growth curve because we know that at the end of the day, the diagnosis is looking at you're gaining weight faster than you're getting taller. I think there's a lot of discussion and debate about the use of body mass index and whether that is the correct um way to look at it. I think what has been helpful probably over the last five to seven years is that we've really been thinking more about risk reduction. So that the work is not about the actual number on the scale, but the ability to use that number as a surrogate for how living with excess adiposity might be increasing someone's risk of something that could really impact their quality of life or even how long they're gonna live.

SPEAKER_00 37:24

And you mentioned uh medications that are coming out. How are GLP1 drugs and others fitting into the equation for pediatric populations?

SPEAKER_03 37:34

So I think it's been excellent to see our toolkit expand because we want to have access to as many treatments as we can. So we now have FDA-approved GLP1s. So semaglitide in the form of Logovi is FDA approved for kids living in larger bodies, ages 12 and up. And really the GLP ones have been a proof of concept that obesity is a complex chronic disease, that it's multifactorial and that it's not the kids' fault. And I think that has been a great opportunity for us to break weight stigma, but also to really see that if you don't have a part of your biology that's working and you replace it, you can actually treat that condition, which is really the crux of any chronic disease management.

SPEAKER_00 38:18

You've been saying repeatedly, and I love the way you frame it that it's not the kids' fault when you talk to parents or grandparents who may have been raised in a different generation where they may have a different perspective or or they're feeling, even if they don't outwardly express it, some feeling of responsibility or maybe guilt that the foods they provided or the activities they were or were not able to provide for the kids may have resulted in their current state.

SPEAKER_03 38:44

Yeah. So I think the weight stigma that kids and parents experience is so heavy. And I think the guilt and the shame that they're holding is really preventing them from getting help. It's preventing them from so many experiences that they want to have for themselves and their kids. And I think unfortunately, it's just something that has been bred over time, um, a lot of which is found not in factual science, but in things that we just didn't understand. So I think that we have a huge job as clinicians in this space to correct that. We have a job to say, I'm sorry, we got it wrong, and we need to think differently about it. Because I also think that we can't really treat it correctly unless we define it correctly. Um, and so I think again, we take care of so many chronic diseases in pediatrics. And in those cases, we're not mad at the kids because, for example, their beta cells don't make insulin in type 1 diabetes or in asthma, their lungs don't open and they need albuterol, right? So obesity is the same, but we just have to redefine it and we have to do a lot of education. And I think if we can break through that, we can really transform these kids' lives, but we have to do that first.

SPEAKER_00 39:53

You talk about the toolkit expanding and having new tools available at Children's Hospital in Los Angeles. I believe we've got bariatric surgery as a tool that may be used for certain kids who are ready for that intervention. Talk us through that intervention and that program at children's.

unknown 40:09

Yeah.

SPEAKER_03 40:09

So bariatric surgery is a really interesting tool in the obesity space because it's the most effective and durable treatment for severe obesity. It improves obesity, it prevents and treats obesity-related complications, but it is the most underutilized tool. We know that a few years ago, the NIH reviewed some numbers and showed that over 2 million kids in the United States qualified for bariatric surgery. And that year, only 2,000 kids got it. So if you think about that in the context of another chronic disease, we probably wouldn't allow that to be the numbers, but because of the weight stigma that exists, we can let a tool or treatment not be utilized because of our own stigmas and concerns and myths. And so I think there's a big movement in the obesity space to one, allow access to these programs and then to make sure that we educate patients about how to use this program well in their patients. And so we started the program at Children's Hospital Los Angeles in August of 2023. Um, we've actually done 150 surgeries since opening, which is a really high volume, just showing how patients are interested in this surgery, how they want access to it. And it's really transformative because the kids can lose about 100 pounds in the first year. And while we're really not looking for that number on the scale, I think what's most transformative is really what it does for their metabolic health. Because it's really one of the only treatments we have where they can consistently prevent those obesity-related complications over time and keep them off. And so I think building programs where you have a comprehensive multidisciplinary care team. So we have surgeons and endocrinologists and psychologists and dietitians who can wrap around a patient and family to really think about what their kid is experiencing, who's living with a severity of obesity that requires surgery and really get them that treatment younger, we know their outcomes are going to be better.

SPEAKER_00 42:04

Is it a similar type of procedure as what happens with adults?

SPEAKER_03 42:08

It is similar. The movement in the surgical world is that most young people and adults get a sleeve gastrectomy, which is basically taking a stomach that has expanded over time and really lost a lot of its metabolic function and returning it to sort of its native size. I think what people don't know is that a sleeve gastrectomy is really similar to getting your appendix out or your gallbladder out. It's about a 45-minute surgery. You stay in the hospital for one day. It's a very safe surgery. And so I think again, there's just a lot of myths and concerns about what is this surgery? How does it work? Why would you do it on a young person? And so we've really designed our program to be a pathway. So it's an opportunity for patients to enter, to become educated, and to really understand how this might work. And we really find that patients are so interested in this. They have thought about it, they've wanted it for their kid, and they're just waiting for a clinician to offer it to them.

SPEAKER_00 43:01

And you mentioned access. So is that insurance related or insurance companies reimbursing for these services? Are they covering these services for all kids? I know many kids are on Medicaid. How does Medicaid think about bariatric surgery?

SPEAKER_03 43:13

Yeah, so we've had no denials to date. Usually this surgery is completely covered. A lot of times there is minimal access for patients with public insurance, just the way these programs are designed, but there's actually very good coverage. Um, again, I just think it's how these programs are built. There's just not very many in the country. Um, there's an accreditation process, and there's only about eight pediatric programs across the country that are accredited. We received our accreditation in July. And I think that just it takes quite a big lift to put these together to make a thoughtful program that can support these kids and families. Um, but again, the outcome is pretty exceptional. And I think it really is an important tool when you care for this community.

SPEAKER_00 43:54

Do you have longitudinal outcomes as a data set nationally to see out some of the earliest kids who've had bariatric surgery now that they're adults, how they're doing? What does the data show?

SPEAKER_03 44:04

Yeah, so there's a really uh neat consortium that was run through the NIH that's now been following these kids for 15 years, um, called the Teen Labs Consortium. Um, and really, again, that's that's kind of where we get this data. Obviously, the numbers are growing over time, but just that this really is to date the most effective and the most durable treatment for severe obesity. Obviously, our medications are newer and we need to follow them, but surgery is definitely the most effective tool that we have to result in consistent and effective weight loss that then persists over time.

SPEAKER_00 44:38

So that in that NIH study, they they've shown that those kids are 15 years later are still having positive outcomes generally.

SPEAKER_03 44:46

Correct. Yes. So they've shown that they're able to lose the weight and keep it off. They've shown that they actually do better than the adults, which to any pediatrician is not super surprising because often when you start younger and you don't have as many complications, you have greater success. They've shown that they've been able to treat and prevent things like diabetes, fatty liver, heart disease. And then they've shown the benefits and things like quality of life, improved mental health, improved fertility. So the things that we care about when we think about setting up a young person for adulthood.

SPEAKER_00 45:16

That's great. We'll link that study in in the show notes so people can take a look if they're interested. Dr. Ridmar, thank you so much for joining us and for doing groundbreaking work. All right, thank you for joining us for your dose of optimism. Make sure to check out our show notes to get more information about our guests and the work they're doing. Visit our podcast page on the Kids X website to join our podcast community and to learn more about pediatric innovation. Thank you to our sponsors and to our presenting partner, Kids X. Please subscribe wherever you get your podcasts. And remember, it takes a village to make sure our kids grow into healthy adults. So volunteer at your local library, help out at the community center, and if you're so inspired, donate to your local children's hospital. Alright, see you next time. The content, views, opinions, and information presented on this podcast do not reflect the views of Children's Hospital Los Angeles or of the sponsors of the podcast.