Adolescent Obesity and Bariatric Surgery with Dr. Janey Pratt

Clinical Professor Dr. Janey Pratt shares her passion for working with children and discusses the pressing issue of childhood obesity. As an adolescent bariatric surgeon, Dr. Pratt emphasizes that obesity is a disease. Although GLP1s — like Wegovy and Ozempic —offer some help, Dr. Pratt describes a multitude of evidence indicating surgery is a safe and more effective solution. In addition to surgery, Dr. Pratt also sheds light on Stanford’s comprehensive preoperative process for adolescent bariatric surgery, including necessary testing and evaluations to ensure patient safety as well as diet and exercise education for the whole family.

Rachel Baker: [00:00:00] Welcome to Scrub Cast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today, we're speaking with Dr. Janey Pratt. Welcome to the show.

Janey Pratt: Thank you.

Rachel Baker: It is great to have you here. Thank you so much for joining us. Dr. Pratt, you are a clinical professor in our division of pediatric surgery.

Why did you choose peds?

Janey Pratt: I love kids. I've always loved kids. I had four of my own, but mostly I love talking to kids and taking care of kids.

Rachel Baker: Wonderful. Well, September is National Childhood Obesity Month, and you serve as our director of Adolescent Bariatric Surgery here at Stanford Medicine. So I imagine, you know, a little something about childhood obesity.

Uh, I feel like we've been hearing about this topic for years upon years. I mean, Michelle Obama was planting a garden at the White House in [00:01:00] 2009. Jamie Oliver tried to revolutionize America's school lunches in 2010. What is the status of childhood obesity today? And have we managed to move the needle at all?

Janey Pratt: Um, no. The answer is no, it's bad. Um, you know, in 1975 there was almost no obesity in children. It was like less than 1%. Now it's 20%. 20% of our children, more than 20% have obesity or have overweight. Both of those conditions are serious and lead to other complications. There's over 200 other conditions that are caused by obesity, diabetes type two fatty liver disease, sleep apnea.

All of these conditions are a result of severe obesity. And so it's not just that kids have obesity and 20% of them have it. That these [00:02:00] kids have obesity and they're sick from it.

Rachel Baker: So I, I guess that's where bariatric surgery comes in.

Janey Pratt: Yes. So we treat sort of the extreme, but there's over 6 million kids in the United States who qualify for bariatric surgery.

And all of those children are going to have obesity as adults, but they already have a lot of those conditions. And it's really key that we treat the kids when they get obesity, when it starts to become a problem, even before it's causing severe complications like diabetes, we can prevent diabetes by treating it with surgery.

Rachel Baker: One of the most common procedures you do as a bariatric surgeon, uh, is a gastric sleeve, which is you go in minimally invasively, uh, and you remove part of the stomach. So. At 17, the biggest procedure I ever had was, uh, having my wisdom teeth removed. So, uh, this is, you know, anatomy changing surgery and the patients are so young, why not wait?[00:03:00]

Janey Pratt: Because it's actually not a seriously dangerous operation. It's a very safe procedure. We use anatomy changing procedures all the time in kids and don't think twice about it. We take their tonsils out, we take their appendix out, we take their gallbladders out. Many of the kids I see have already had those removed.

Uh, in fact, a lot of them have had tonsillectomies and a lot of them have had their gallbladders removed. And honestly, those operations have more complications and less benefit to a child with obesity than taking out part of their stomach. So the operation, it's like you said, it's minimally invasive. It takes an hour.

It's very straightforward. The complication rate is less than 1%, and it really is a very safe procedure, and it doesn't work by restricting how much they can eat. So a lot of people think that that's how it works. It doesn't. It works by changing their gut hormones. To signal their brain that they're full or that they're not hungry, [00:04:00] and it's these hormones that are responsible for the weight loss.

So if you take something like the GLP ones, you know, um, we ovy, ozempic, you see them on TV all the time, right?

Rachel Baker: Mm-hmm.

Janey Pratt: Those medications are one of the hormones that are affected by surgery.

Rachel Baker: We have Wegovy. We have Ozempic. They're the miracle drug, aren't they? You should be out of a job.

Janey Pratt: I should be, right?

Well, the problem is that those medications act on the brain, okay? Mm-hmm. So when a patient has obesity, they generally have low levels of GLP one, so their levels are lower than the average person. When you give them wegovy, you're giving them a very high dose. And what we're seeing with it is that they are getting a decrease in hunger, uh, increase in feeling fullness, and their body is metabolizing glucose and insulin differently, bringing their insulin levels down, bringing their weight down.

Okay? But it, you get about a 16% total body weight loss in [00:05:00] children with Wegovy or semaglutide. That's not the same as surgery. So surgery doesn't just affect the GLP one pathway. It also affects GIP bile salts, oxy, modlin, ghrelin. So it affects multiple hormones that then improve the weight loss. So we get about 25 to 30% total body weight loss, which is twice what you get with medications.

The other problem is that these medications are expensive. They're hard to get. So they sometimes have shortages, but also you have to go to the pharmacy, you have to pick them up, they have to be refrigerated. Uh, you have to inject it in as a shot. Some kids don't like shots once a week and you have to have insurance to pay for it.

So most of the kids who suffer from obesity or majority also have difficulty with food security or with financial abilities to pay for medications. [00:06:00] Many of them are on Medi-Cal, so if Medi-Cal doesn't cover it, they can't get it. So in many states, California is actually a little different, but in many states they don't even have access to these medications.

Children with obesity and adults with obesity don't have access. But if you look overall at the cost effectiveness, mm-hmm. There've been multiple studies in the last five years showing that surgery is far more cost effective and a far increased, improved quality of life compared to medical treatment, even with a GLP one.

So we know that we can operate on a patient and it'll provide sustained weight loss for over 10 years. Whereas if we do medications, they have to stay on those medications the rest of their life. And we're talking 70 years of treatment in these kids, right? Right. So that's very expensive. Even if the cost of medication comes down, just the, the trouble of being on those medications.

Right. So, well,

Rachel Baker: [00:07:00] and I was also thinking to myself about how these kids are, you know, maybe going off to college or are wanting to travel, and how that would just, is another thing. Try and keep it refrigerated, sticking yourself, remembering all, you know, it's, it's a lot of… work.

Janey Pratt: Yes, It's a lot of work to be on a medication. You know, taking a vitamin once a day is very different than traveling with a pen that you have to inject yourself with. Right. And if you go off these medications, we have shown again and again, you regain the weight. Obesity is a disease. It's, it's a condition that is caused by an imbalance of those gut hormones affecting the hypothalamus by blocks in the hypothalamus pa hypothalamic pathways.

For, uh, satiety and for the metabolism of glucose and insulin. And it's a breakdown of those pathways and we know that there are genes that code for it. So the kids, it's not the kid's fault, it's not the parent's fault. [00:08:00] It simply is that they have a gene that makes their GLP one below and their GIP be low and their, their, their gastric emptying be low.

And, and it, it just, all of these things combined causes them to store food as fat. What I tell the kids is I say, do you have a friend who can eat as much candy and soda and junk food and pizza as they want? And they are pencil thin? Mm-hmm. All of them know someone like that. I said, but for you, if you look at a piece of pizza, you put on 10 pounds, and that's what it feels like to have obesity.

That's what it's like. That's the experience for these kids. Most of them eat fewer calories a day than I do, but I don't have obesity, so I don't gain weight. It's really, it's very much a physiologic disease, and the operation operates physiologically. It changes their response to food.

Rachel Baker: Okay, well, so you've convinced me, I'm a 15-year-old and I've listened to Dr.

Janie Pratt, and I'm like, okay, [00:09:00] I'm ready. Sign me up. How does this process work? I mean, do I just come in and I say I volunteer as tribute, or, um, is there like a, a process that we need to go through? Is there education is what, what do we, what do we do?

Janey Pratt: So we have a very robust program and we do a lot of testing preoperatively to make sure the kids are gonna be safe.

Undergoing the procedure and to diagnose underlying conditions. So our blood work, we look for, for example, uh, thyroid conditions. We look for insulin resistance, which is the most common thing that we see. And we look for sleep apnea, which is the second most common thing we see. So almost 70% of the kids are in our clinic, have sleep apnea and insulin, re, and or insulin.

Yeah.

Rachel Baker: So if they're not even sleeping, that's awful for kids.

Janey Pratt: Exactly. And sleep apnea is associated with decreased grades at school. It's associated with lots and lots, very poor health related quality of life, falling asleep, [00:10:00] issues with friends and socialization has a tremendous number of issues. Okay?

And it's often undiagnosed and untreated when they come to us. So very often we are making those diagnoses. We also diagnose fatty liver disease or metabolic associated steatohepatitis and metabolically associated. Ketotic liver disease, which is what they're called now. Okay. Um, it's a lot easier to say fatty liver, but whatever.

Rachel Baker: I agree Rolls off the tongue a little easier.

Janey Pratt: It is very common. It's over, it's about 50% of our patients. We see diabetes and pre-diabetes, also pre-diabetes, and about 30% and diabetes and about 10%. Wow. And we've watched some of these kids who come in and they want surgery, but then they're scared and they stop.

We followed these kids and they do go on to develop diabetes. They do not lose weight. Like they'll lose weight on initially and then they regain it and then they lose it again. Then they regain it. We have [00:11:00] watched this pattern multiple times in kids who come into our program and then leave our program.

We recently had a kid rejoin our program who came in with A BMI of 48 when he was 14. He's now back, he's 16, and this BMI is 62. Oh, okay. And it's not that he didn't lose weight in that time period. It's two years. He did lose some weight and then he regained it and he gained

Rachel Baker: more and more.

Janey Pratt: Yes. Oh, and so the problem is that if we wait, this is what we get.

We get a patient who has a higher weight, and at A BMI of 62, I can't use surgery alone. To get that patient to a healthy weight, I'm gonna have to use surgery. And then GLP one, the semaglutide or the Wegovy. So that child is gonna be committed to medications and surgery. So if I can see the child when their BMI is 40, then with surgery alone, I can get them down to a normal weight and then all they have is a vitamin the rest of their life.

They don't have to take a shot that they have to [00:12:00] keep in refrigerated. Yeah. So it it, it's important that we see them before their BMIs are 60 and 70 and 80.

Rachel Baker: Yeah. Absolutely. I had a friend, he was an adult when he had his bariatric surgery, but I remember when he, when he was in recovery, he had to like drink shakes and soft foods and there was a whole diet plan.

He was an adult. He, you know, lived on his own. When we're talking about teenagers, how do we prepare? The patients and their families for this huge lifestyle change.

Janey Pratt: So we do family-based therapies. We invite the parents and the child to attend regular teaching sessions. They come once a month. We have an expedited program where they come twice a month for about two months, or they come once a month for four.

And what happens during that education program is that our dieticians teach them everything they need to know about what is a protein, what is a carbohydrate, how to read a [00:13:00] label. The plate method, which is using a smaller plate to eat your food off of. We get them to stop all sodas and juices, so no sugary beverages.

And then we get them to follow a very simple rule. First of all, we want them to eat three meals a day. So in order for the sleeve to work. You have to eat and you have to eat three to five times a day. 'cause if you eat something every four hours, it turns on that GLP one mechanism. So when you have a sleeve, every time you eat, you get a shot of GLP one.

Nice. So we teach them that. We teach them to eat regularly, to stop drinking sugary drinks and how to read a label,

Rachel Baker: all the things that we probably should be teaching in public education.

Janey Pratt: Of course, of course. And then we have them all start what we call our Stanford 360. Um, 60, 60, 60 rule, and it's a very simple lifestyle change that the whole family can do safely unless they're on dialysis.

And then I have 'em talk to their, their dialysis doctor. But [00:14:00] other than that, everybody can do it safely and it's basically eating 60 grams of protein and you eat the protein first. Protein is an appetite suppressant, and it reduces the risk of losing muscle weight as they're losing weight rapidly. Then we have them drink 60 ounces of fluid, so that has one water, exactly 60 ounces of water.

We actually give them a water bottle, 60 ounces of water. And the purpose of the 60 ounces of water is one to counteract the protein. So if you just eat that much protein and you don't drink water, you're gonna get kidney stones. So it counteracts the protein, but it also acts to replace sodas and juices.

And it prevents dehydration after surgery, which can be common because as your body is burning fat, it takes two molecules of water for every molecule of fat that you burn. Interesting. So you need extra water after surgery. So that's the protein in the water. And then the third 60 is 60 minutes of physical activity.

[00:15:00] So it's 60 grams of protein, 60 ounces of water, and 60 minutes of physical activity. And it can be walking for some of the kids walking's very painful. So it's just get two 30 ounce water bottles and, and do some weightlifting. Mm-hmm. Um, it can be playing a VR game, it can be anything that is active. And in fact, one of the things I tell most of the teenagers to do is I say, get a job.

Yes. Don't join a gym. Don't join a gym, get a job. Because if you get a job bagging groceries or restocking, stocking shelves. Exactly. And then you're getting paid to exercise, picking vegetables or working in the garden. I don't care what you're doing, as long as it's not a computer job. Get a job. Mowing lawns.

Any, any selling things, you know, just even if, if you're standing at a cash register, you are getting exercise and it's better than a gym because one, you get paid. Right. They don't, you don't pay them. You get paid. Two, you're expected to be there, so you're gonna go,

Rachel Baker: oh yeah. But then

Janey Pratt: you're like, ah, I don't feel like it's, [00:16:00] you're expected to be there.

You're gonna go and two, you usually are working more than an hour. It's an hour of gym, but when you're working it's two or three or five or eight hours. Mm-hmm. So my biggest recommendation, kids over 14 or so, I say, you know, get a job and if they're under 14, do some chores. You know? But really the point is that physical activity doesn't have to be the gym.

It doesn't have to be lifting weights. It can be if that's what they want. If they like that, that's great. Mm-hmm. But it has to be something they want to do or they're willing to do. And so we have one kid that worked at the local vet. Rooming animals. Loves animals, great job. Right? We've had kids just working at McDonald's, which is fine 'cause you see that food, you don't want to eat it.

So, you know, it's just a matter of exercise. The only job that I kind of is a little off on is the ice cream shop. Oh. That's, yeah. Although I have had kids who've worked at the ice cream shop and they're like, I can't eat it anymore.

Rachel Baker: My sister worked at a [00:17:00] bakery for a little while and she came home and she was like, I will never eat a pastry ever again.

That sound means that it is time for our lightning round. On each episode of Scrub Cast, we ask our guests the same two questions. Oh, sorry. The same three questions. We added a third one. Very exciting. The first one is. Who is a surgeon you admire and why?

Janey Pratt: Susie Briggs and because she was a nurse and she decided she wanted to be a surgeon, and she went through residency at a time when there were no women in residency and she has gone around the world doing trauma and global surgery for years and just has infinite energy and infinite love and caring for all people.

Rachel Baker: Amazing. I'm gonna have to look her up.

Janey Pratt: Mm-hmm.

Rachel Baker: The second question is, what is the best advice you have received in 10 words or fewer? Ask for what you want. Ooh, [00:18:00]

Janey Pratt: I like that one. Oh, that's going on the wall. Yeah. If you wanna work 50% time, ask for it. You're not gonna just get it. Nobody's gonna give it to you.

Ask for it. Absolutely. I've worked part-time my whole life. I love it. What's the worst they're getting to say No. Exactly. Exactly. Ask for what you want.

Rachel Baker: Okay, perfect. The third question is, what is your preferred or music?

Janey Pratt: Hmm. I like to ask the nurses in the room what they wanna listen to and listen to it.

So I get to listen to lots of different things. But if I have my choice and nobody wants to make a decision, I listen to Ed Shean.

Rachel Baker: Oh, very nice. Yeah. I'm in love with that new song, Sapphire. So good.

Janey Pratt: Oh, it's so good. I love all of, it's just a wide variety, but I love it.

Rachel Baker: Yep. Well, it's been pleasure chatting to you, but before we go, I wanna ask one final question, and that is what is next for Dr. Pratt?

Janey Pratt: Um, more of the [00:19:00] same and then eventually retirement.

Um, yeah, I love it. I'm teaching a lot of, uh, junior surgeons to do bariatric surgery so I can leave my program in good hands.

Rachel Baker: That's perfect. Well, thank you so much for joining us on the show. I am. Just a huge fan.

Janey Pratt: Thank you.

Rachel Baker: And thank you to our listeners for tuning into this episode of Scrubcast. Until next time, stay sharp.

Scrub Cast is a production of Stanford University's Department of Surgery. Today's episode was produced by Rachel Baker. The music is by Midnight Rounds, and our chair is Dr. Mary Hawn