Traci Williams, MD - 2024 Pediatric Bariatric Surgery Update Course

Hello, everybody. Welcome back and thank you again to our sponsors, Medtronics and Teleflex. We really appreciate your support. And now, I have the pleasure of introducing Doctor Tracy Williams. She is a board-certified clinical Psychologist and she works at the Strong for Life Program at Childrens. Healthcare of Atlanta. She's done many presentations on mental health both nationally and internationally and has done some amazing work with the patients at the Strong for Life clinic, and she's gonna talk to us about post-operative behavioral health concerns. Welcome, Tracy. Thank you. All right. So, I wanted to share a little bit of my experience with the patients and also what the literature says um that would be helpful for us all to be aware of. So, As we know, uh, kids and teens who are experiencing obesity are at higher risk for a wide variety of psychosocial concerns, including the mood disorders and mood disorder symptoms like depression and anxiety. Um, they are obviously prone to having difficulties with their body image and experiencing body dissatisfaction. Um, And that can obviously then lead to issues with self-esteem, experiencing difficulties with their peer relationships. So, difficulties making friends. I see that a lot. Um, being bullied and teased at school, that is fairly common, um, as well as just in general, having difficulties with maintaining the relationships that they do have. And as a result, you tend to see lower resilience. So, these all play a part uh of the picture of obesity and you can see how they are all interconnected. And the reason why I like this graphic is that it shows that there is a reciprocal relationship. So, let's say for instance, if you have poor sleep, your poor sleep is clearly going to impact your mood. It's also going to impact your attention, which is not included here. And we know that kids and teens who experience obesity tend to be at risk for ADHD as well. Um, And if you are experiencing, say, ADHD and the sleep disturbance, that then is going to impact how you feel about yourself and so on. So, all of these things are interconnected. And it is important for us to remember that this is an, uh, a crucial component of the population that we serve. Even after surgery, we need to be keeping eyes on all of these aspects of their life. So, uh, this quote, I wanted to include bariatric surgery has a significant and positive impact on the psychological comorbidities of obese teenagers. What we are doing is we are helping the teenagers in their quality of life as well as with their health. Overall, the research shows that Um, their symptomatology when it comes to psychosocial concerns for the most part tend to remit, uh, uh, or improve. Uh, and then if you do see, um, psychosocial concerns, it's typically things that were in occurrence before they had surgery. You're less likely to see new symptoms emerging. So, for instance, just one patient who comes to mind experienced depression prior to surgery. After surgery a few months later, we're recognizing that there is a resurgence of the symptoms of depression. Generally speaking, that is what we tend to see. So, all in all, long-term mental health care is advised, uh, particularly post-operatively. Um, including assessment. So for instance, in our clinic, I, uh, do a 3-month screen for depression and anxiety. You can also add on to that. Uh, some places recommend doing screens for, uh, body dysmorphia, which I will discuss in just a second. So, like I said, um, bariatric surgery can have positive impacts on the qualities of these kids' lives. And in follow-up research that has been done, we do see a decrease in the mood disorder symptoms. So symptoms of anxiety, depression, uh, anger, disruptive behavior, uh, improvements in their social isolation. And of course, if you think about it, if they are Feeling better about themselves, then they are likely to experience an improvement in their mood and an improvement in their relationships as well. Um, there's also a connection with the quality of their physical health. So as your physical health improves, the quality of your moods, emotions, and relationships are likely to improve as well. So, um, one of the things that is important to address postoperatively is the, um, lifestyle changes that will come. So, when I am doing pre-surgical evaluations with patients, I tend to talk with them about how their life will look different they have had surgery. Because with teenagers, if you think back to your teens, you're probably not spending a whole lot of time thinking future tense. And so, it's important for the teens to bring that up and discuss some of the ways where their life may look different. For instance, your eating is going to look different. Um, the habits that you have in your life are going to look different, particularly if we want to experience success. And so having those conversations preoperatively is really important and then postoperatively checking in and making sure that not only they're doing the things that they're supposed to be doing. But also how are they managing these changes, uh, their lifestyle, particularly since they're still at a young age. And that leads me to talk about developmentally, we also need to consider what teenagers are going through around the same time that we are, um, performing bariatric surgery. So, developmental transitions are also important to consider with this population. Uh, a lot of our teenagers are trying to finish up high school. They are stressed out about their grades and their academic performance. And we know that stress has a connection with our relationship with food. And so, that is something that comes up in our conversations. We also know that at this age, some of them may be getting ready to launch. So, if you are preparing for launching away from your home, whether it's going to college or uh you are moving out on your own, And you have had your parents' support to help you, making sure that you are following your nutrition plan and doing your physical activity and all of those things. What's going to happen once you move out on your own? Um, and then also just in general, remembering that it is a stressful time being a teenager. And so, it is common for these things to come up for them emotionally. Um, I did want to mention dysmorphia, and this is the last topic that I wanted to cover. So, our allocentric view of ourselves is what we feel inside and our lived experience. I know that I feel comfortable within my body. I know what my body feels like. I am connected to all of my parts. When you do something like a mindful practice like yoga, you learn how to become connected to yourself. What we do know is that people who experience obesity tend to have disconnection from their body are not fully connected to their sense of physical self. And so what can happen is after surgery, once physical changes are happening really rapidly, The change in how patients view themselves is not happening as quickly as the physical changes. So, people tend to see uh the changes that are happening to the teenagers and they're bringing it to the teenagers's attention, or you, you're losing weight, uh, you look so great, whatever comments that they say, whether they, they're helpful or not. And for the teens, what tends to happen is that they are not recognizing that they are changing. They are not seeing it and there's no way for us to force them to see it that will come with time. Um, but they can have emotional reactions to people saying that they are changing and they're not necessarily seeing it. Also, in terms of um, Physical satisfaction, bodily satisfaction, positive body image that continues to be a work in progress even postoperatively. That is something that has subconsciously take place that will not just happen as a result of having surgery, whether it's bariatric surgery or subsequent cosmetic surgery. So, that being said, I wanted to just say that it was, it is important to take precautionary measures having these types of conversations prior to having surgery. Uh, and these are conversations that I have with my teens. Bothin clinic um during their pre-surgical evaluation and post-surgically. And also encouraging the members of the cosmetic surgery teams to assess for dysmorphia. All right. Uh, Doctor Walsh, do you want to take over for questions? Yep, there we go. Yeah, great. Thank you, Tracy. So I wanted to ask you a couple of questions, and it's something we sort of talk about is these kids who experience obesity, certainly even more severe, not really going through all those developmental stages and coming out post- bariatric surgery, looking and feeling different and maybe not having gone through some of those social changes. How, how do you suggest we sort of look for that or help support these kids? So how to support them in what way? I'm sorry. In the sense that like, I, I've really, because I was bullied, I've been homeschooled since I was 12 and now I'm 16. I just had surgery. I've lost weight and I'm going back into the world kind of. Yes, um, and so that is, that is honestly scary from the psychologist's perspective. Um, one patient comes to mind, uh, she had been bullied her whole teen life, poor self-esteem, has surgery, loses the weight, and then suddenly is receiving a lot of male attention that then puts her at risk. Um, and so, what we need to do is even preoperatively, making sure that if there are any social concerns that those are being addressed, whether if they are mild. Giving them, um, basic tools for managing conflicts with peers or having difficult conversations with other teenagers and if they are more severe, so, uh, difficulties forming friendships, keeping friendships, uh, any dating issues because we see that in the mid to late teens referring out so that those things are being addressed in tandem with their bariatric journey. And, and tell me a little bit because, and again, these are things we kind of do more on a case to case basis when it shows up, but there are some kids who want to tell all their friends that they're having surgery and some that don't. And, and how can we sort of make sure we're getting enough support for those kids who sort of aren't telling their friends and therefore don't really necessarily have The same social support or what, what are your thoughts about that and what that says maybe about the kid and their comfort and things to be on the lookout for? Yes, absolutely. So I have seen the wide range. One, some of them want to shelter from the mountaintop and some do not want anybody but their mother and father to know. Um, and so what I do in the pre-surgical evaluation is I bring that up and we have a discussion about it. I asked them specifically, who knows that you have been coming to our clinic? Who is supporting you in this journey? Uh, how do you feel about their support? Because some people may be supporting, but the quality of their support is not great. They may not be as helpful as they think they might be helpful. Um, and also for those who do not feel supported, uh, with their family members, how to address that. So, for instance, just an idea that comes off the top of my head, a patient had, uh, mom tell the extended family that they were going through this process, which is understandable, but the teenager did not want that to happen and so people were making comments and making suggestions that they did not appreciate. Um, another thing is if they are going to go back to school, particularly for high schoolers, I talk with them about what is your response going to be when your body looks different and people start making comments, particularly if you have not told anyone. And they usually come up with Ways that they want to address it and that can range from saying one person said I went to a weight loss program, another person said I had surgery, and then another person said it's none of your business. So just having those conversations openly with them so that they're prepared for when they do have fun, right? And there's a question about, um, does anybody have a lot of people have conversations with the teens. Alone, does anybody have conversations with the parents alone? And then what are your thoughts on that? That would be great. I would be. Does anybody do that? I know, I know our psychologist actually, when she does her initial evaluation, she actually talks to them separately, like the parent for a period of time and um the patient. Yeah, yeah, that's a good idea. I think that that is a crucial component um of this piece for sure. Our psychologist also talks about, uh, covers that in her, um, evaluation. Oh, perfect, good. And what about sort of Eating disorder screening? Cause that with the new CPG everybody's sort of in a, what, what sort of, are the general screenings you think people should use, tools you really like, anything in particular? Yeah, we are still trying to figure out what is the right answer to that question, um, and I am more than happy to receive any feedback from other programs. The difficulty here is that in the world of bariatric surgery and obesity, we, our kids don't quite look Like the typical eating disorder kids, and we would also need to be screening for disordered eating behavior which is different from eating disorder symptoms. So if anyone knows of anything that's absolutely working great, then please let me know. I, I think that that's a really important point in terms of like future advocacy. You know, our patients have, they have disordered eating, um, but they're not welcome in a lot of disordered eating outpatient programs because their BMI doesn't meet the criteria or their symptomatology doesn't meet the criteria for inclusion. But yet, you know, it's all a spectrum and it's, it's really hard. I mean, Again, access to any mental health service is, is hard, um, anywhere, but I, I think that that is a really, really important point that, that our patients actually are excluded often from, from, you know, targeted disordered eating treatment because they technically, because of their BMI status, don't meet criteria. Um, yeah, and I can say in the mental health world. There is not a good understanding of obesity, how obesity develops, and the general thinking is you are experiencing obesity because you are binging or binge eating. And that is not typically the case. Yeah, lots of, I mean, a lot, so many of our patients have restrictive eating patterns and, you know, and everyone just assumes that they all have binge eating. Um, so, yeah. Yeah, that's one of the things we're starting to do at ProCare and Stephanie and I, or I'll talk about more what we even are, it's trying to potentially um bridge some of these gaps in the care nationally, um, with, as you guys know, as Tracy knows, and Stephanie probably knows, and Karen maybe know, knows is that SIPact allows for telemedicine visiting, uh, across multiple states, 40 states, I believe. So you don't actually have to be a locally, um, Licensed psychologists to help with this. So, uh, You know, I think, um, in our experience back in DC before I left there, You know, obviously, we saw the same stuff, and we, frankly, unless they had a, a true BED diagnosis, couldn't get them in to see anybody. Um, so we just had to sort of deal with them post-op, uh, and pre-op as best we could. But it's a, a major gap, and I think that, um, There is opportunity for folks in the mental health, behavioral health, obesity world to try to come together and, and, um. Provide better care than what we're doing at our individual centers currently. Yes, I absolutely agree. That's great, and thank you, Tracy. Um, I also wanted to say that the AAP sub course that's gonna be in the end of April. We're actually gonna have a big section on that and actually planning to have a patient panel of some of our patients who have experienced an eating disorder as well as obesity.