Melanie Cole, MS (Host): Welcome to Meaningful Medicine, a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm Melanie Cole. And today, we're exploring a compassionate approach to adolescent weight and health.

Joining me is Dr. David Voellinger. He's a bariatric surgeon and board-certified in Obesity Medicine. Dr. Voellinger, welcome. Thank you so much for being with us today as we get into this topic. You and I both know that obesity is an epidemic. And among our children, we are seeing things we never did see before, comorbidities, high blood pressure, diabetes in kids, type 2 diabetes that we did not see before. Tell us what you've seen. What's kind of happening in the trends of obesity today?

Dr. David Voellinger: Melanie, thanks for having me today and excited to talk about this subject. What we have seen in the adult world is absolutely happening to our kids. And your point is well made. We used to call it adult-onset diabetes and juvenile-onset diabetes. We can't do that anymore, because our kids are getting diabetes at earlier ages as type 1 and type 2 now. They're seeing sleep apnea. They're seeing hypertension. And in this particular group, what happens in our adolescents, it's a different type of disease because of the social-emotional effects, the peer group effects. It can really affect their lives forever starting at this early age.

Melanie Cole, MS: Well, it absolutely can. So, Dr. Voellinger—and I've been in the field a long time, and we talked about that a little bit—when I talk to parents when you talk to parents, this is a very sensitive subject. It's one thing if, you know, you're talking to adults about their weight and things to change and ways to change their lifestyle and such.

But when you are talking to parents about adolescent weight and health, please tell us how you approach this sensitive topic in a way that feels supportive. Because these kids, as you just pointed out, it's already hard enough for them. I mean, other kids, it's already hard socio and psychosocial ways. How do you talk to them about this?

Dr. David Voellinger: Great point, and we don't address it as obesity. We address it as a chronic disease like any other disease you would have, high blood pressure, diabetes. That's kind of from, one, framing this as a chronic, relapsing, lifelong disease. It's not a matter of willpower. It's not the kid's fault that they have the disease. It's also not the parents'. It's not lack of parental supervision. It's not a parent issue. It's not a child issue. It is a disease like any other. And framing it that way helps them better understand it and not have that guilt complex at recognizing, "Look, this is a disease I need help with like any other disease." That's really the key there, is that messaging. Staying away from the biased terms. We never use, words like fat or large or anything that's detrimental to the way they think about it. It is an adolescent with obesity, right? it's important. The way we talk about it is as important as the treatment itself.

Melanie Cole, MS: Wow. That was so well said. I love that that's how you approach it. We all know the teenage brain is a little bit different, so they process things just a little bit differently. Now, Doctor, what makes the Novant Health Adolescent Bariatrics Clinic different from traditional weight management approaches? Because now you have more tools in your toolbox, and it's a pretty exciting time in your field.

Dr. David Voellinger: It really is. And I think that the key is we are big believers in the comprehensive obesity care model, meaning we want lifestyle, integrative, medical, and surgical to all live under one roof. And that's what we've duplicated with our adolescents. We have adolescent specialty providers, physicians, APPs. We have behavioral health specialists that are adolescent specialized adolescent, registered dieticians, and a nurse navigator, who is an adolescent specialist who coordinates and helps us develop a program. So, we're very adolescent-specific and very comprehensive in our approach, and that's what really sets us apart.

Melanie Cole, MS: That multidisciplinary approach is just so important. So at what point should families consider seeking specialized care? What signs would you like to tell them indicate that their adolescent may benefit from these kinds of treatments?

Dr. David Voellinger: It first starts with signs and symptoms. You know, joint pain, fatigue, medical issues, diabetes, hypertension, sleep apnea, snoring, for example. Also, psychosocial issues, are they withdrawing? Are they getting bullied? Those types of issues. And then, from a numerical standpoint, is their weight in the 95th percentile, or has their BMI reached 30? And that's when we really think they need to be thinking about treatment for the disease of obesity.

Melanie Cole, MS: So once they come to you, how do you involve both the teen and the families in creating that care plan that feels realistic and sustainable? Because, I mean, the families do have to be involved, including siblings. And if there's going to be lifestyle and cooking and nutrition, how do you involve that whole family in this journey?

Dr. David Voellinger: That's very key, Melanie. As we know, the adolescent is very rarely the meal planner and the cook. They're not always preparing their own meals, buying their own groceries. So, that family buy-in is crucial. And again, it's about getting not just the adolescent healthy, but the entire family healthy.

So, what we do is we bring in the caregivers, with the adolescent. We have a conversation about what's going on in their home, how we can make improvements, to their lifestyle. It's not only about eating healthier food, lean protein, fruits and vegetables, staying away from the processed sugary drinks.

It's also eating together as a family without screens, making those kind of changes, going for walks as a family. Trying to get the entire family healthy. By working with the adolescent, we can elevate the entire family. And as you probably know, with an obese adolescent, there's probably a 70% chance that at least one parent has the disease as well. So, it's something that we really work at as certainly an individual approach, but also as a team approach as well with the entire family.

Melanie Cole, MS: Such an important point. You do typically maybe see that one of the parents does suffer from obesity as well. So, it does tend to run in the family and culturally as well. So, tell us a little bit about bariatric surgery, especially when you're considering it for adolescents and young adults. How does this conversation begin and how do you help families understand what the right option may be? Because again, you have a few different options available to you now. So, tell us how you speak to them about this, when this conversation happens, and how you address some of the common fears and myths.

Dr. David Voellinger: As we mentioned before, you know, we are definitely believers in a comprehensive multidisciplinary approach. And if we think about obesity, it is a multifactorial disease, meaning there's a lot of different things that cause it. Well, that means that there needs to be a multimodal treatment, and we need to have multiple treatment plans. There's not a one-size-fits-all silver bullet approach. So, lifestyle management, nutrition, exercise and activity, behavior change, habit change, sleep. Then, maybe an integrative approach. Are there any supplements, pharmaceutical, non-pharmaceutical approaches that we can do? More exercise physiology, again, kind of non-medicine treatments. Then, next would be medications. What are some weight loss medications we can use?

And finally, when a BMI is 35 and they've developed medical problems such as hypertension, sleep apnea, high cholesterol, those types of things, or if their BMI is already over 40, then that's when we're going to really consider surgery as a tool.

Now, what does that tool do? Surgery currently is our most durable and effective method for treating obesity. Our medicines have gotten very, very good, GLP-1s in particular. But still from a durability and long-term effectiveness standpoint, surgery is still the best thing that we have. So when that patient gets to that point that I just mentioned, we want to offer one of those tools to help them, put that disease in remission, help them with those comorbidities.

So, the sleeve gastrectomy, and the gastric bypass are the most common. In our adolescent population, we really prefer the sleeve gastrectomy. Basically, what we do is we take the stomach from a bag into a tube. We're not rearranging their intestines, rearranging their anatomy, really just changing the size of the reservoir, limiting the major changes to an adolescent's body at a young age.

But this will allow us to, A, help control their portions and, B, it takes out a lot of the hunger factor production, so they're not as hungry with smaller amounts of food. That's really where the magic is with surgery. But the foundation of everything is still that lifestyle management. They have to eat right. They have to move more. They have to change behaviors. They have to get enough sleep. Plus, the surgical tool that we will offer.

The scary part about surgery is certainly the surgical risk, right? That is why particularly adolescents stay away from surgery. But fortunately today, with our minimally invasive approaches and our vast experience in bariatric surgery today, the risks are very low, less than 1%. It's even less risky than, say, getting your gallbladder out. So, the risk of them having a major complication is very low. Obviously, this is particularly important in adolescents, but it can be a life-changing procedure at a young age so that they're not having to develop and go through the issues they would have to with that obesity. It's that balance, right? Let's balance the risk of the surgery versus the risk of doing nothing and the potential benefits of surgery.

Melanie Cole, MS: Well, as you said, and I want to emphasize that you said it's a tool, because that really is one of the biggest misconceptions. "Oh, that's the easy way out." Well, it's not. But it certainly is, as you say, so beneficial. It's the gold standard. And it really is so, so approachable.

Now, one of the things that goes along with this tool is that mental and emotional aspect. Dr. Voellinger, speak a little bit about how your team helps the teens, the adolescents, and their families deal with the emotional bit that goes with surgical decisions and with the lifestyle changes that go along with it

Dr. David Voellinger: A huge component, right? It is way more than just changing your diet. It goes for a couple of ways. One is what is the obesity doing to them from a psychosocial level already? You know, again, withdrawing, not having as many friends, staying online too much, withdrawing from life, not being active in school activities. You know, that's one component, what the obesity has done.

Then, the next is going through the stress of surgery and how they adapt to those changes. So, on one hand, it's, okay, with our behavioral health therapist meeting them where they are, working through stress management, coping skills. If there's any signs of depressions or anxieties, working with those. Certainly, we got to rule out eating disorders. You know, obviously these are common in the adolescent group. So, we want to rule out any eating disorders that may need more formal therapy before we even approach a medicine or a surgery. So, a lot of different levels go into this. And then, it's that follow-up and support where they have a safe, comfortable environment, a non-bias where they can come in, feel like they're getting the help they need without the outside peer pressure, other things that adolescents experience.

Melanie Cole, MS: That was so well said. So, this is just such important information. As we get ready to wrap up, Dr. Voellinger, what would you like teens, adolescents, young adults, and their families to hear directly about their health, their options, their future, and the work that you're doing at the Adolescent Clinic at Novant Health?

Dr. David Voellinger: This is not your fault, and we are here for you. Obesity is a disease. It is not something you were doing. It is something that is, genetically, unfortunately given to you. We want you to have a place where you can get the disease taken care of, treated, so that we can be there to help.

Our goal for you, whether it's lifestyle management, medical management, surgical management, whatever you need, we want to be able to provide that for you. At Novant Health Adolescent Weight Management, our goal is for you to live longer, live better, live healthier. That's what we want to be able to provide for you.

Melanie Cole, MS: I can hear the compassion and the passion in your voice, Dr. Voellinger, for what you do. Thank you so much for joining us today and sharing really your incredible expertise and your passion. Thank you again.

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