Transcript
Jollie (02:04)
Hey everyone, welcome back to the Move, Eat, Give podcast by Interrupt Hunger. Thanks for joining us Today we’ve got Evan Nadler. He’s a doctor with extensive experience in childhood obesity. And today we’re going to start talking about something called sick fat. We’re trying to change the messaging around obesity.
and sick fat, also known as adiposopathy. There’s just so much misperceptions out there and stigma, bias. And the reason why I’ve got Dr. Nadler on here, I told him I have him on today both for his brain and his heart because there’s, man,
Evan P Nadler MD, MBA (02:45)
Heh.
Jollie (02:47)
Just like any kind of hot topic issue, folks are very dogmatic. And it doesn’t matter where your experience lies, folks tend to hold onto that so tightly and can’t see the other side. And so what I like about Dr. Nadler is he cuts through all the BS and he just says, what’s the science say? What’s the facts? What’s the data say? But the cool thing about it is he wraps his messaging.
and just a lot of heart. So, Dr. Nadler, thanks for joining us today. It’s gonna be a neat discussion. I’ve been looking forward to this.
Evan P Nadler MD, MBA (03:18)
Thanks, thanks, Jollie And I was hoping you were going to say that you were having me on for my brain and my good looks, but we’re on a podcast, so maybe the good looks aren’t as important. But then you went with my heart, which is obviously super nice of you to say. hopefully what you’re saying is felt by my patients, which I think it is, but hopefully the rest of the community can see it as well because
You know, as you said, like, I don’t, I want everybody to be as happy and healthy as they can be through whatever means they choose as a patient or as a person. Like I’m not here to be the old school paternalistic, you know.
Doctors of old who used to just like tell their patients you need to do this It’s much more at least my style has always been listen. Here’s how I can help you. Here’s the information I can give you and You know, I want you to do what you feel is right for you because that’s what’s gonna be the most successful In the in the long term right and that’s what we’re all trying to you know achieve
So thanks for having me. Happy to talk about this topic. Something that has been a big part of my research to date and really has informed me in my thinking about the disease because once you realize that how it works at sort of a cellular level, which is kind of boring for most people, but once you see that, it really takes a lot of the other negative messaging away.
because it really is, sort of as you said, it’s just for me, it’s about the science and I’m really, there’s no real disputing the science, although.
Jollie (04:51)
Yeah.
And I think once you get this, this, science message out there, like the, all that other crap just falls away. The stigma, the bias, the misperceptions, and then, and hopefully we can come in with a bunch of community after that and support people like the way they should. ⁓ before we get started, why don’t, why don’t you tell folks like why you’re here and, and, and all the experience you’ve had? Cause, over the years, I don’t know if there’s a lot of people that have treated more.
Evan P Nadler MD, MBA (05:05)
Yeah. Yeah.
Jollie (05:18)
pediatric patients with obesity than you have.
Evan P Nadler MD, MBA (05:21)
Yeah, well, so I certainly have the country’s largest experience with bariatric surgery in children. And that’s something I’ve been doing for 20 years and had the biggest program in the country by almost twofold. By the time I quit two years ago to write my book and to try to take the messaging and the education.
straight to the patients as opposed to beating my head against the brick wall of academic medicine, which is how I lost all my hair. had a full head of hair before I started doing this. Just kidding. But the. Yeah, so I’ve treated children with obesity in partnership with a great pediatrician who studied weight management, so I call her a pediatric bariatrician, although that’s not really.
a word, and she’s retired now, but she and I basically had shared the idea or the concept that this is really a complex chronic disease that requires aggressive treatment. And so she was aggressive with medications, I was aggressive with surgery, and together we treated, you know, I would say thousands of children.
and with great results for the most part, although obviously not everybody. And at the same time, I was doing science on the fat cells themselves. So I would actually, during the surgery of the children, I would actually take pieces of fat from inside their abdomen and from underneath their skin and look at what was actually going on at the cellular level.
And we even got to compare some samples with children who were normal weight to see the differences and see how the body changes as excess weight is put on. So I feel like I have a unique perspective on the disease in general because I’ve seen
know, children who are four or five years old with obesity. I’ve seen children weighing 500 pounds, BMIs in the 80s and 90s, all as adolescents or younger. And, you know, most people, most people like to blame the patient, right? They blame people with weight issues on that person not being…
dedicated enough or eating unhealthy or not exercising enough or whatever shame and blame they want to drop on someone. But it’s hard to do that with kids, right? Like, you know, what five year old was like not exercising enough to get obesity. And then, so then it became like parental blame. And then, people like shift the blame. you must be a bad parent if you let your child get obesity by nine. And so like there was a, mean, it was.
Jollie (07:38)
Yeah.
Evan P Nadler MD, MBA (07:46)
The number of times I’d see people and their parents in my office where I would bring them to tears by just saying, listen, this isn’t your fault. This isn’t about you. This is a disease. It’s genetically inherited. So there’s nothing really you could do about the hands you were dealt. You just got to play it as best you can.
And you know, whether it was the kid who would start crying, usually it was the parent who would start crying because there’d be so much self-hate because their kid had a weight issue at such a young age.
Jollie (08:15)
Yeah.
Evan P Nadler MD, MBA (08:19)
In the older kids, could be sometimes the kids, but it’s just so sad. I used to tell the haters, and believe me, there have been tons of haters who I’ve come across in my career and still do, I used to tell them to spend one day, one day in my clinic and it’ll change your life forever because it’s easy to blame and to say all this stuff and to think of these people as quote unquote, you know,
failures or you know, no willpower, whatever you want to say. But if you speak to them face to face, you just realize that that’s so far from the truth. And that’s what I sort of wish everybody could see and everybody could learn because I think that would help us all just take a step back and really treat people with empathy.
Jollie (09:03)
Yeah, this is
so ingrained in our society. You you’ve got a friend, Angela Fitch, who she made a great statement one time and said, our bodies weren’t built to lose weight. I’ve had conversations with multiple highly educated people and I tell them like studies show.
Like if you have somebody that’s trying to lose 20 % body weight or more and trying to do it on their own without any kind of support, medical or surgery there’s a 95 % failure rate. that means only 5 % of the time, I think it’s probably less than that, 5 % of the time are they successful. And then…
There’s this wall that’s up there that they’re not hearing what I’m saying at all. they’re just instantly, it’s like, yeah, but. Yeah, but. Like, no, there’s no yeah, but. Like this is an environmental community, societal issue. So, yeah.
Evan P Nadler MD, MBA (09:51)
Yeah. Yeah.
Yeah. Yeah. Yeah, I don’t want to
pitch. I don’t want to pitch the Netflix documentary on The Biggest Loser, but it’s worth and I haven’t seen it, but they published studies about what happened to the contestants on The Biggest Loser when they left the show and the vast majority of them gained all their weight back or if not more. And the extremes that they went to on that show.
weren’t even as televised as, you know, that’s what the documentary is about. It’s sort of like an expose of like what they actually were doing. And it’s just like, even those people gain their weight back. to try to say this is all about lifestyle and don’t get me wrong, lifestyle is super important for all of us. And we should all eat better and we shall all move more. Like, of course.
And I struggled doing it, although I’m better now that I don’t work full time in an academic hospital. But it’s struggle for everybody. So to think that that’s gonna cure the world, just changing food policy or food quality is naive. And again, it sort of sets people up for failure and sort of stigmatizes, you the administration says that if I just eat better, I’ll lose weight. And then…
You do what the administration says and you don’t lose weight and it’s just another negative experience for you. So I really want to, I’ve been on sort of a mission lately to try to combat that messaging because I want people, 140 million adults who have obesity understand that what’s being discussed in the food is medicine movement or the.
the HHS secretaries movements, like that’s not going to help 140 million Americans. We have tons of data that shows that already. So yes, do that. So to help you be healthier, but don’t expect weight loss to come from it. You still need to get access to care and get compassionate care and comprehensive care. And even with medications, know, 80 % of people who stop taking their medications gain some weight back. So
Again, I’m an advocate for medications, but it’s a, they’re all part, they’re all like arrows in your quiver or part of the armament terrier, whatever cliche or metaphor you want to use. But it really, it puts a bee in my bonnet that we can’t work together. Like the people who are the medication people in general work with the surgical people and that’s better than it used to be.
But there’s just still this huge chunk of people who have no understanding or willingness to understand or who just don’t want to accept that obesity requires more than just lifestyle changes for the vast, vast majority of people. that’s sort of the goal here is to try to help change that narrative. Although in my 20 years of trying to change that narrative, I’m not sure how far I’ve…
Jollie (12:42)
Yeah, we’ll dive into the science here in just a second. I’ve heard you say at least a couple of times that you’re treatment agnostic and that goes to your toolbox. It’s not gonna take just one thing. It’s a whole person.
Evan P Nadler MD, MBA (12:44)
you
Yeah.
Yeah, and you know, think the more… So just like I think any clinician or anybody in this world, you learn as you go along when you do things more and more. And I have to admit, in the beginning of my surgical career with bariatric surgery in children, I thought this is going to be the cure-all. Like, I’m going to operate on these kids and they’re going to be better forever. And it’s going to be amazing. And no one’s ever going to need anything else other than surgery. And…
that turned out not to be true. And I learned that relatively early on in my career that there are people who don’t respond to surgery and there are people who respond to surgery initially and then regain weight. And so it became clear to me early on how complex the disease was and that all the different pieces of the puzzle are worth exploring and discussing and using. Like…
you know, what’s the end goal? The end goal is to make people as healthy as possible. So why for far too long, it really was sort of like surgery versus meds or surgery versus lifestyle or meds versus lifestyle. was really almost very little collaboration. And I think that’s actually what set our program apart in D.C. early on is that my co-director, a woman by the name of Nazareth Mirza, she got it from the early days that she and I had to work together because
There were some kids that she took care of that needed more help. And then there’d be kids that I took care of that needed her help either before or after surgery. So again, it’s been an uphill battle trying to convince everybody to play in the same sandbox. But I’m hopefully getting a little bit more of that. opportunities like this are part of that. Like I just want…
even if there are only a handful of listeners who are like, oh yeah, maybe that makes sense that it should be a team effort with all the different potential players, then we’ve achieved something. So that’s the goal.
Jollie (14:45)
All right.
How about you? Love this attitude. Okay. With that, let’s, let’s dive into the science. So, uh, there is a, uh, a doctor, uh, Harold Bayes MD. He’s actually president of the obesity medicine association now, uh, all the way back in 2005, coined this term SICK FAT in a paper adipose opathy. So, so for far too long, we have, uh,
we have made the assumption that our fat or adipose tissue is benign, but that’s not the case at all. Yeah, so why don’t you start walking us through this process? Why is it not good for folks to have overweight or obesity and how does that lead to chronic disease?
Evan P Nadler MD, MBA (15:19)
Nah, it’s not.
Sure, and you know, I was about to say, do I have like a semester of classes I can give on this topic? that’s what it, and then it’ll take more than that. at least a semester, one of my soapbox issues is getting med schools to have a basically a semester of obesity teaching in their education because it’s, you know, it’s the number one disease in America right now.
Jollie (15:33)
That’s a big question.
Evan P Nadler MD, MBA (15:58)
They don’t, medicines don’t learn about it as a disease entity in and of itself. They learn about it in like their endocrinology rotation or something else. But anyway, getting back to your question. So it’s complicated, but the, you know, fat cells or adipose tissue are designed to store excess energy as fat. And there are two different types of fat, brown fat and white fat.
We’re talking about white fat here. Brown fat actually can create some energy, and it’s how some babies stay warm, and some other species use it to stay warm. But we’re not talking about that. So first of all, The physical issues with carrying extra weight. You may…
Jollie (16:30)
for them.
Evan P Nadler MD, MBA (16:37)
Some people who have sleep apnea, it’s really a fat infiltration of the back of their mouth that leads to that snoring that keeps them up at night. And then obviously joint pain and arthritis and things like that. And in pediatrics there’s something called Blount’s disease where your legs actually bow from the weight you’re carrying during your growth spurt. But outside of the physical attributes of carrying excess weight.
What it ends up happening as the fat cell exceeds its capacity, it starts to leak byproducts, for lack of a better term, into the circulation or bloodstream. And so you start getting fat accumulation in other tissues, like your liver or your muscle or your pancreas. And that
leads to inflammation in those cells themselves. So people may have heard of metabolic dysfunction associated steatohepatitis or MASH, M-A-S-H or MASLD. But it also, but the fat cells also contain, this is what my lab studied, the fat cells also actually contain
gene products or micro RNAs. Again, you don’t need to know the specifics of the science, the genes, what we showed is that the genes in the fat actually change when you go from lean to having obesity and…
those genes get released into the bloodstream as well and cause insulin resistance in the different organs like the muscles and the pancreas, et cetera, and even the brain, which might be how Alzheimer’s disease is connected to weight issues. So it’s complicated, but I would sum it up by saying that when your storage capacity is exceeded, your fat cells misbehave for lack of a better word.
And that can cause, depending on who you are, that can cause either liver problems or diabetes problems or heart problems or blood pressure problems. And I used to joke or I still joke that I’m just a simple surgeon. And so I think about things in a very simplistic way. So, you know, two patients of equal weight issues, equal size.
One gets diabetes, the other gets liver disease. Why? There only two explanations. Either the fat’s different or the end organs are different. And that was sort of what got me started in this research. And that, again, dials back to genetics and genetic predisposition because, you know, like one of the… I’ve seen lots of remarkable patients in my days.
But one of my most remarkable patients was a 15-year-old boy who weighed about 500 pounds, BMI of 82, and truly seemed like he had no complications in his weight. And I just like, it blew my mind. I was like, how is this person walking around like this? And then I’d see the next day, let’s say another 15-year-old, his BMI was 40 and weighed 250 pounds, and that person already had type 2 diabetes. And so again, I’d be like, this disease is confounded.
It is not linear because that would make, know, that like, how does this boy get to be 500 pounds and truly like walking around like nothing’s bothering him? Like, how does that even happen? And so anyway, I haven’t figured that out, but I’m still trying. But it’s really like, and again, I think that’s what makes, I think that’s why as a child, a pediatric obesity or childhood obesity treatment sort of pioneer.
It changed my perspective on things because I think the adult world, see sort of this very similar patients most of time, because that’s who looks, who goes for care. You know, they see, you know, 30s, 40s, whatever with, you know, BMIs in the 40s and 50s and, you know, with type 2 diabetes or whatever else going on. And so they sort of don’t think about the outliers as much because they don’t see them. So.
Anyway, think that’s why, I mean, it’s one of the reasons I’m writing my book is because I’ve seen so many outliers and it’s changed my understanding of the disease to really understand that it’s not, I like, I have lots of sort of taglines or cliches. People are gonna get sick of hearing them, but one of them is that obesity is a phenotype, meaning that’s what it looks like on the outside. So looks the same on the outside to everybody.
But it comes from many different genotypes, meaning you can get obesity from radiation to your hypothalamus because you had a brain tumor, or from childhood trauma that leads to mental health issues that leads to fever disease. Or in utero exposure, as you were developing fetus, your mom had gestational diabetes or had obesity herself.
So it’s like all these different things that can contribute to the development of the disease. And so the folks who look at it.
sort of.
simplistically like it’s one thing or a combination of two or three things. It’s just far more complex.
Jollie (21:13)
Yeah, it’s pretty fascinating. The deeper I dive into this, the more questions I have.
Evan P Nadler MD, MBA (21:19)
yeah, I’ve been doing it for 20 years. I’ve been doing
it for 20 years and I still have like more questions than ever.
Jollie (21:25)
That makes me feel better, thanks. eight out of 10 of the leading causes of death in the country are…
Evan P Nadler MD, MBA (21:27)
Ha
Jollie (21:35)
a similar process just manifested in different ways. Right. we could spend a very long time on each of these, but at a surface level, when I tell folks I’m a 13 year, leukemia survivor. And I remember sitting in the infusion chair back in 2012, I
watching poison drip into my veins, literally, and thinking like, why did I allow myself to do this? A common retort from people is, well, you didn’t actually cause yourself to have cancer.
Well, I certainly didn’t help it.
Evan P Nadler MD, MBA (22:07)
Well, you know I’m not gonna let you self blame because you know that’s not my thing. Like I do not let people blame themselves for anything. And whether or not the poor dietary habits and the weight gain contributed to your cancer or not, I think the science is still somewhat, not 100 % directly cause and effect.
Jollie (22:12)
Yep. Yep.
Evan P Nadler MD, MBA (22:32)
And again, there are probably hundreds or thousands of people who ate the exact same stuff as you and weighed the exact same amount as you who didn’t get cancer. So I’m going to continue to go back to it’s not your fault. You had a genetic predisposition that you didn’t know about or couldn’t predict or whatever. But I think the point you’re trying to raise is that many cancers are
indeed thought to be related to obesity and the chronic inflammatory state that obesity puts people in, which I think those data are pretty strong, at least the association. And actually there was a recent study which you may have seen that showed that exercise for colon cancer reduced recurrence rates. Like, holy crap, like what a great, yeah, like wow.
Jollie (23:19)
A lot. Yeah.
Evan P Nadler MD, MBA (23:21)
Like totally wow, like that was a, when I saw that I was like, that is like an amazing display of how just some.
you know, not I wouldn’t say minor lifestyle changes, but you know, lifestyle changes can really have a huge impact. So by no means am I a lifestyle medicine hater like that’s not me.
Like, yeah, like lifestyle stuff helps a lot. And you should do it if you can.
Jollie (23:42)
So what, again, just like a surface level, like walk me through how obesity adiposopathy might lead to cancer.
Evan P Nadler MD, MBA (23:53)
So I know I keep getting, you keep trying to steer me back, bring me back in, because I get on tangents, because I talk about this stuff all the time. ⁓ And am passionate, and I also have a little bit of ADD. So sometimes I get started down a pathway that I need to just be ringing it in, ringing it in. But anyway, and when I say a little bit of ADD, I mean a lot. So how could it work?
Jollie (23:57)
That’s all right, that’s my job.
You’re passionate about it. I love it.
You’re good.
Evan P Nadler MD, MBA (24:20)
Chronic inflammation. So we now know that obesity is an inflammatory disease. So people with obesity, if you just measure their serum markers for inflammation, just generalized inflammation, they often are elevated. So that means that their body is just in a chronic inflammatory state. And what that can do is lead to basically increased cell turnover. So what does that mean? let’s use the liver, for instance, because it’s a fairly straightforward example.
So you can start with what’s called just mass LD metabolic dysfunction associated steatotic liver disease. So that just means fat is getting into your liver and that is stored both in the fat cells themselves, so the hepatocytes, you can see fat actually in them. I used to do biopsies of livers during some of my surgeries and we would look at them under the microscope and you would see fat cells or fat.
droplets in the cells themselves. But then there would also be inflammation starting once the fat cells would, I guess, get enough fat. I mean, once the hepatic cells, once the liver cells, get enough fat in them, they would switch from being just steatotic, meaning having fat, to having steatohepatitis, which meant that
basically white blood cells, inflammatory cells, we’re now infiltrating the liver and starting to attack the cells themselves. So once the cells start to turn over, again, it’s more complicated than you really, the most people need to know, but every time a cell sort of like divides or replicates or changes, there are chances for errors in the replication process. And once that happens, if there’s an error,
then you might get a pre-cancerous cell and then that starts to replicate more and then you get a cancerous cell and that starts to replicate more. So chronic inflammation in general can cause cancers in any number of organs. And it’s probably actually how the exercise in colorectal cancer reduces recurrence rates because it probably…
decreases the overall chronic inflammatory state of that person, which then sort of helps the cancer that’s been treated stay calm or stay quiet. But it’s not such a, it’s not an exactly linear pathway. It’s, if we knew,
exactly how it worked and knew exactly the pathway we could try to interrupt the pathway. just, it’s not quite as clear as, you know, A leads to B and B leads to C. Nothing is in the body, frankly.
Jollie (26:52)
Yeah.
Yeah, sure. So, I I wish we had time to do each one of these, but a couple that might make hurt people’s brains hurt. Like the idea that obesity could lead to chronic inflammation, could lead to cancer. I think a lot of people don’t make that connection. The other big one that folks really have no clue about.
is Alzheimer’s disease and dementia. And we’ve been hearing the term for a few years now of like type three diabetes. And I’ve gone way down this hole, which it’s fascinating. so how might obesity lead to Alzheimer’s or depression or dementia?
Evan P Nadler MD, MBA (27:26)
Totally fascinating.
Yeah, so that’s actually another thing we were studying in our lab,
in partnership with the University of Washington, we were looking at, again, these same sort of fat cells and the genetic material and fat cells and the little carrying bodies that the genetic material and fat cells, the carrying bodies and the microRNAs they released can cross the blood-brain barrier and we could find them in the cerebrospinal fluid or the CSF of the brain.
And we basically were hypothesizing that the fat cells were causing insulin resistance in the brain and that insulin resistance in the brain is manifest as Alzheimer’s or dementia, which is why it’s called type three diabetes, because it’s insulin resistance and that’s type two diabetes. And when we were studying this, what, 10 years ago, people thought we were nuts because they were like, what are you talking about?
I like how could that possibly be? But, you know, now we’re sort of validated or becoming more validated because it’s it is a likely contributor. Now is it the beyond and all? No. Again, I think there’s a high degree of genetic predisposition and there are probably other factors that are involved and whether those turn out to be like the microplastics or the forever chemicals or whatever else.
I think that’s an interesting field for people to start thinking about. But it’s clear again that, you know, just that exercise and improving your diet and getting enough sleep are good for you, which we already knew. But it turns out they also, you know, protect your brain health, which is, think, again, you sort of like, it makes some intuitive sense. But when you think about it, as you were describing that it’s, you know, it’s more than just
you feel good and you sleep enough and your brain likes that. It’s actually like a real physiological phenomenon where you are decreasing your overall body insulin resistance and that is helping your brain stay healthy as you age. yeah, it’s, I think the GLP-1 medications,
are helping people understand all of this because of the quote unquote side effects, which are not actually side effects. But the fact that the GLP-1 medications are showing possible benefits in addiction or in Alzheimer’s and other dementias, it really, again, speaks to the fact that this is insulin resistance, at least for Alzheimer’s, maybe not for addiction, that is a key player.
obesity causes insulin resistance, insulin resistance causes Alzheimer’s. So that is sort of a more linear connection that is worth interrupting if you can.
Jollie (30:00)
So think, you know, the original idea of, creating a sick fat campaign was we’ve been fighting the wrong enemy. We’ve been putting billions and billions of dollars in untold amounts of, of agony and stress, fighting willpower and discipline. Right. And I’m hoping that we get.
you voices like yours out to start breaking that. you know, just like with exercise, what I tell people is like, we know that like you can’t lose weight with exercise. Your body pushes back unless you exercise a lot. I mean, amount. But to your point where you just make there’s so there’s countless reasons to exercise for your general health. There’s so many incredible.
benefits, like our bodies were built to move. I mean, that’s how we evolved, right? That’s why we’re the top of the food chain. One of the many reasons.
Evan P Nadler MD, MBA (30:53)
Sure. Yeah, I hope it’s not.
As
far as we know, there could be alien life that comes in and they’re actually the top of the food chain. We’re just living. Now guess now I’m going to be confused of being a conspiracy theorist or a Scientologist or something. you have to edit that out of the room. ⁓
Jollie (31:03)
Could help this out a little bit, sure.
You’re gonna, no, we’ll leave that
in. We’ll leave that in, that’s good. That’s good stuff. So this is all, these, I really used to think, and you helped educate me, you’ve taught me a lot. Like I thought the general problem was inflammation. And you said some of the fact like, you know, don’t put all your eggs in the inflammation basket. It seems, if we’re focused on inflammation for a moment, these are all different diseases. Alzheimer’s from heart disease.
to liver disease, joint pain, they’re all different diseases, but it’s all basically the same process, just manifesting in different organs in different places in the body. besides inflammation, what did you mean by don’t put all of your eggs in one basket? You talked on like epigenetics and genes stuff, but hormonal and there’s ⁓ a lot of mechanisms.
Evan P Nadler MD, MBA (32:02)
Yeah,
right. So inflammation surely certainly plays a huge role in many of the diseases and the you know, the GLP one medications to potentially have a little bit of an anti-inflammatory effect. it may they may help with the inflammation. But again, like
With Alzheimer’s, for instance, you don’t see necessarily inflammation of the brain when people, you know, like when they talk about the tau protein that accumulates with Alzheimer’s disease. That’s not necessarily from inflammation. In fact, I saw an interesting study the other day that I guess babies have a lot of tau protein in their brains and then they somehow clear it. And so now researchers are trying to figure out how babies clear it because maybe that could be potentially
translated to how adults could clear the tau proteins. But I think it’s just, again, it’s more complex. Like anytime we try to boil a body process down to one sort of mechanism or pathophysiology, the body’s just built with redundant systems to keep doing what it thinks is best for you. So like, again, our…
our studies looking at these microRNAs that are released into the bloodstream, they’re not necessarily pro-inflammatory. They might be more directly related to insulin resistance without going through the inflammatory pathway. And so while, for instance, we can show, we have shown in cell cultures that the microRNAs from our fat cells from children or adolescents with obesity
can change fat cells from just being normal fat cells to being ones that want to make fibrosis, which leads down to cirrhosis and then cancer and liver failure. It may be that the microRNAs from the fat cells, when they go to the liver, cause insulin resistance and then insulin resistance in the liver manifests with inflammation and then inflammation, you know…
takes the process in that direction. But I think it’s, you know, if we’re just inflammation, then we could treat everybody with anti-inflammatories, you know, Advil. Everybody could take Advil every day and that would be all they need. And it is probably why aspirin is in part a protective against both heart disease and colorectal cancer. But again, it’s not, the body’s too smart, has too many redundant systems.
for it to be sort of messed with with just one pathway like anti-inflammatories or stopping inflammation. So I think and I think inflammation is hugely important. I just, I always caution people just, know, keep an open mind to other potential pathways also being important. So I do like the term.
Although it’s super hard to say, adiposopathy, because I think it’s more, I think it’s really, fat cell dysfunction that is the root cause of most of the problems. And whether that dysfunction leads to inflammation or other dysfunction in other organ systems, again, sort of just depends on the organ and depends on the person. So.
I think we’re actually, again, I think the new GLP1 medications will help some of the science evolve, because we’ll start to understand a little bit more when we use these receptor agonists or receptor blockers, depending on the med. But we still have a lot to learn.
Jollie (35:10)
So I’m gonna ask you to touch on a very hot topic, but I don’t think you mind too much. ⁓
Evan P Nadler MD, MBA (35:18)
Thank
Jollie (35:19)
So let’s talk about the health at any weight movement. my take is it’s a pushback from all the bias and stereotypes and stigma and and just fat shaming. But I don’t think to me I don’t think it’s it’s good. I don’t think it’s No, we shouldn’t shame people.
Evan P Nadler MD, MBA (35:22)
Mm-hmm.
Jollie (35:39)
No, we shouldn’t blame, obviously. But there’s some reasons to still…
seek treatment or help educate me.
Evan P Nadler MD, MBA (35:47)
Yeah, no, think, you know, again, my sort of feeling about all of health is that people should do what they want to do. you know, no one should force you to get treatment. Similarly, I don’t think anyone should force you to accept your size if you don’t want to be that size.
If you can be healthy at any size, which people can be, I did a documentary actually with an Australian news magazine now probably two years ago. And they had a representative from the Fit as Any Size movement as part of the documentary where she said, you know, she’s whatever size she is, but she…
you know, does ballroom dancing three times a week. She eats right and, or eats healthy, I shouldn’t say right, because that’s pejorative. She eats healthy foods, at least that she thinks are healthy, and is very active and keeps active and doesn’t care about her weight. And that’s great. And I actually commend her for that. But the reality is she’s actually treating her obesity.
She’s just treating it with lifestyle changes. And we do know that lifestyle changes can make you healthier and not have you lose any weight. So good for her. And she should definitely do that if that’s what makes her feel good and makes her healthier. Now, if that doesn’t work for you, like you can’t get healthy, then in my opinion, you should at least consider getting more treatment. But most importantly, you shouldn’t get shamed for or blamed for seeking more treatment.
If you’re struggling with your weight and can’t control your health or can’t get your health in order by mechanisms you’ve tried already and want medication or want surgery, that’s great. Those things work. And you shouldn’t feel bad about that. And you certainly shouldn’t have a group of people who don’t know you telling you you should feel bad about that.
And so that’s my issue with the fit as any size movement is they’re they’re actually, you know, they’re sort of shaming and blaming people the way they were likely shamed and blamed, which led them to push for the fit as any size movement. So I get it and I support what they’re doing because I think there are people who can live perfectly healthy lives at a bigger size. And if that’s what makes sense for them, then that’s what they should do.
But I just want them to be a little more open-minded for those who can’t because again, as you said, the numbers don’t lie. There aren’t that many people who can achieve optimal health at a BMI of 40 or above or whatever number you want to choose.
Jollie (38:02)
The 15 year old you
mentioned earlier with that BMI up in the eighties 500 pounds, but then the next day you saw another 15 year old with a much lower BMI that it had all sorts of problems.
Evan P Nadler MD, MBA (38:12)
Yeah.
Yeah. And even the kid with the BMI of 80, like when we looked hard enough, he did have some, you know, like he was had chronic inflammation and he did have some other beginnings of sort of what I call subclinical disease. So he wasn’t going to go to he wasn’t going to live to 50.
without having some health issues and probably he wouldn’t have lived to 30 without having some health issues. So he ended up getting surgery. But at the time I saw him, it was truly like, I mean, I, you know, so it was, I don’t know, maybe a couple of years into my practice, I was just like, what the heck? Who, what is this? Like, where did this, this patient’s something I’ve never seen before. Like, how does this, how does this exist? So again, like, so you can do it. Like, and maybe if he had 12, when his BMI, let’s say it was 40 or 50, you know.
started working out every day and watching everything that went into his body strictly. Maybe he could live the long healthy life with the BMI in the 40s or 50s, but it’s hard to do. And so it’s just not for everybody. So again, I’m for, I’m treatment agnostic. just want to give people the information so that they can make the choice that’s right for them. And then I want practitioners and people.
not to judge each other for whatever decision they choose to make. It’s what’s supposed to make this country great is that we all have the right to do whatever really we want to do, other than yell fire in a movie theater or shoot somebody in the street. There a few exceptions, but for the most part, we have the freedom of choice, and that’s sort of what I’m pushing for.
Jollie (39:26)
Mm-hmm.
Yeah, I love that. Do you have a little bit more time or do need to go? Okay. So, so one topic that we haven’t talked on, and definitely a solid form of treatment is, seeking, counseling from a, from a therapist who is, who’s trained, in, in obesity medicine and, you’re, you’re close with some friends. You’ve got colleagues in this space.
Evan P Nadler MD, MBA (39:47)
Yeah, I think I’m okay.
Jollie (40:05)
You’ve got exercise, you’ve got nutrition, you’ve got GLP-1s, you got surgery. Talk to me about another form of therapy and how that fits in and where, like when that might fit in.
Evan P Nadler MD, MBA (40:16)
The child psychologist who worked with me at DC Children’s when I started my program in 2010, and who’s still there, she and I used to joke about how I was a wannabe child psychologist. That was like a, that’s really what I wanted to do, not surgery.
So, yeah, you know, and obviously we had, it was great because she and I, you know, when I first got to DC Children’s, I said to her, you know, super excited to have you on board. I know you’re not going to believe me, but nothing, no lifestyle changes preoperatively impact postoperative outcomes in kids. But
you know, but that’s what I’ve seen in New York when I was there for five years. And I’m hoping that I’ll be able to show that to you. And she was like, sure, but I’m going to study it all again myself before I believe you. So we did that. And once, once basically she realized I actually knew what I was talking about, we really bonded and became buddies and partners in crime. But the point is, that
Mental health is such a hugely important part of all obesity, but specifically childhood obesity. there’s something called the adverse childhood experiences, which runs the gamut of physical trauma, mental trauma, sexual abuse, all kinds of things that actually do have a link to developing obesity later on.
And there are, you know, I think it’s important. Those are super important things to deal with. Whether or not you’re seeking medical treatment or surgical treatment, like I think the mental health treatment goes hand in hand with all of it. I was actually trading LinkedIn messages today with a guy who has a residential school for children with obesity.
who seems to have great results. And which is sort of contrary to what most people would think because it’s, you know, he’s not really doing anything that everybody else hasn’t tried somewhere else. And I texted him this morning, I said, maybe it’s just the mental health component. Maybe you’re just getting these kids out of mental health or social situations that are…
predisposing to their weight gain and you’re just protecting them from that environment and teaching them a new set of skills and regulating their sleep and doing a bunch of sort of, you know, lifestyle medicine things that we know can help, but you’ve selected.
a group that can particularly benefit because this is the group that’s looking for residential schooling outside of the home. So maybe there’s, I asked him whether he had data on that, like what the life experiences were before they entered his school. He hasn’t texted, he hasn’t gotten back to me. But I do think that, you know, everything’s a bell curve. So no matter what,
intervention, including mental health interventions, there will be people who respond to it and do great with it. So I advocate for all, anyone struggling with their weight, regardless of age, to seek out mental health support. Again, it’s not a…
It’s another stigmatized piece of our healthcare system where like, my God, you’re seeing a therapist or you must have something that’s wrong with you or something, you must not be able to deal with it yourself or you must be weak-willed or whatever. But we gotta get over that because everybody in this field or arena has something to contribute.
and the mental health people especially. Happens to be a shortage of them around the country, which is unfortunate, especially in the pediatric side, but they can help a ton. I think that they, I have a huge respect for the mental health professionals. There’s a book, I’m gonna pitch one of my friend’s books called The New Food Fight. The lead author is a woman by the name of Mary Antonovsky Craft.
who’s a friend and a colleague. she basically, this book is about how the eating disorder community and the obesity treatment community need to get over themselves and work together to help the patients. And it’s a great book. So.
You know, again, I have a lot of respect for those folks and it’s really hard and I hope people seek out that piece of the puzzle while they’re looking for other pieces of help or other people to help.
Jollie (44:09)
So this is, so obesity is insanely complex, but I’m starting to get the.
the understanding that there, if you think of like different components, there’s different causes that have come together. It’s not just one thing that has caused obesity or chronic disease. So if you open up your toolbox you mentioned earlier and use a GLP-1, that’s gonna help reverse our…
treat some of the causes but then over here you’ve got some mental health aspect of it. And so you bring that on board and then so you’re going to address some of the causes that way. You might need surgery and that’s going to help some of those things. We’ve got this is kind of going off on a tangent, but I mean, studies show bariatric patients that have successfully maintained weight loss have developed.
much lower rates of cancer. there’s all these systems that are having the effect on the obesity and that’s why it’s not gonna take just one.
Evan P Nadler MD, MBA (45:15)
Yeah, so using the cancer analogy, because I actually like to use it often because I think it makes a good point. It’s that the medical oncologists and the surgical oncologists have worked together to actually figure out what diseases, what cancers are best treated with which, you know, with chemotherapy before surgery.
after surgery instead of surgery, both before and after surgery. Like they understand that the two things are synergistic and not one or the other. so, ⁓ right, and radiation, to mention the radiation people piece of the puzzle. But like, yeah, like they’ve spent years, figuring out with clinical trials, okay, if you have colorectal cancer, stage three.
Jollie (45:43)
and throw in radiation.
Evan P Nadler MD, MBA (45:57)
what’s your best treatment algorithm as far as we understand it today? And that’s going to probably include surgery and chemotherapy and radiation. And nobody complains about it. Nobody says, you should just have radiation or you should just have surgery. Everybody’s just like, yeah, that’s what you need. And that’s where we need to get to with obesity is I’m not sure we’ll ever be able to as clearly delineate how to treat.
each individual cause of obesity with an algorithm that’s as clean as chemotherapy and surgery and radiation for cancer. But I think that’s where a lot of the science is moving is like…
One of our studies showed that if you didn’t respond that well to surgery, your likelihood of responding to a GLP-1 agonist, albeit one of the older ones, after surgery was also decreased. So there’s something about your biology that just makes you less likely to respond to the particular treatment. So do we need to come up, like, does that patient need?
one of the new biagonists or triagonists and whether that patient should get surgery and the biagonist or triagonist like immediately after surgery as opposed to six months or a year. Like those are the questions I think is where we’re going. And again, you know, where does exercise and mental health and all those other things fit in with that puzzle so that we can stop talking about, you know, X versus Y.
We could stop talking about, the oral GLP ones going to be better than the injectable GLP ones? It’s not really that important. What’s important is what is going to help people sustain their health the longest. And maybe the pills will be that because people are more willing to take a pill every day than inject themselves once a week. Or maybe not. And maybe that’s a study that needs to be done. And maybe the pills become weight maintenance medications. Maybe you get surgery.
And when you get to your nadir lowest weight, you start taking an oral GLP-1 and you take it the rest of your life or you take it per year or you don’t take it and then if you regain some weight, you start taking it or whatever. it’s just, those are, that’s the science I think that needs to get done because I think that’s what really matters is like, how do we have the best 10, 15, 20 year outcomes for people with obesity who walk into our office today? Like what, what is it really gonna?
What is really going to make the biggest impact for you as a person? Not, a surgeon so I’m going to recommend surgery. That’s just not helpful in my opinion.
Jollie (48:23)
How do you know what treatment to start with? GLP-1 or surgery or therapy? I mean, it’s a loaded question, I know, huh?
Evan P Nadler MD, MBA (48:26)
the
It’s easy.
It’s easy. The patient tells me. I don’t, you know, I give them, you know, again, I obviously have my experience and my biases in terms of what I think will work and I’ll tell the patient, listen, 80 % of people who start a anti-OBC medication regain their weight after they stop it. 20 % of people who get bariatric surgery regain weight between years one and two after they…
have surgery. 95 % of people who stop lifestyle intervention regain their weight. The most intense lifestyle programs lose about 5 to 7 % of total body weight. You have 20 % you need to lose. The only intervention that gets 20 % as of the year 2025 is surgery. So I just give people the facts, the data.
and then sort of talk to about what they’re ready to, what they think they’re ready for, what they think is right for them. And, you know, and I tell them, sort of like we said earlier today, it’s like, you know, just keep an open mind. Like you may be in the bell curve of people who are super responders to medications and you might take a medication, it might work like gangbusters and you might need nothing else. And you might just be able to, you know, make some lifestyle changes after you lose all the weight and be able to keep it off.
And if that works for you, good for you because your genetics are working in your favor and that’s great. But you also might be the other end of the bell curve where you’re a non-responder and you might be a non-responder to meds and you might be a non-responder to surgery. And if you’re a non-responder to both of those things, then we got to be really aggressive and start with like, how do we maximize the combination therapy? Um, because you’re not a responder. Um, and so
You know, and I tell people like, just because you don’t want surgery today doesn’t mean I’m gonna like, not like you or not let you come back and see me or, you know, talk smack about you on the internet. Like you just weren’t ready. Good for you. I’m here. Come back and see me when you’re ready. And the surgery works better when people are ready. So the last thing I want to do is operate on you if you’re not ready. Like I want you in your head to be like, yeah, at times now I’m ready to commit to what surgery means. And the same thing, frankly, true for
the GLP-1s because they’re, you know, similar to surgery, which everybody says surgery is an easy way out. But people are now saying that about the GLP-1 medications. Oh, it’s an easy way out. Try taking one. See how easy it is. See how that nausea and that, you know, the fact that you’re like, can’t tolerate more than a bite or two of stuff. See how easy that is. The dehydration, the headaches that some people get.
Jollie (50:52)
Yes.
Evan P Nadler MD, MBA (51:04)
See how easy that is and then tell people it’s an easy way out. Nothing’s easy. Nothing’s easy about weight control. Nothing. So that’s another myth that desperately needs busting.
Jollie (51:14)
There’s a lot of mess. Well, I think for everybody listening, what you’ve just listened to for the last four or five minutes is one of the best examples of shared decision-making you can have when a provider has an open mind and does not tie themselves to one treatment modality. you know, when the relationship between the provider and the patient
is at its finest is, hey, here’s your options. This is what the data thinks. Where are you? And what do you think is gonna be a good place for you to start? That’s fantastic.
Evan P Nadler MD, MBA (51:47)
Yeah,
and then there are these newer sort of procedures and devices and all this experimental stuff. And so I often get asked, well, what do you think about the endoscopic sleeve gastrectomy? Or what do you think about when the lap band came out? And again, I used to go and tell people, I listen, we should be supporting any treatment that works. And yeah, the balloon, let’s say.
So the balloon only works for six months and then when it comes out, most people regain their weight. So that doesn’t mean it doesn’t work. It just means people need to know that that’s likely the scenario. So if they want to try it again, go ahead, try it. know, like, wouldn’t be what I would necessarily recommend for somebody because I don’t think it’s going to last you forever. But, you know, prove me wrong. Try it. See if it works. If it works and then you can maintain your weight loss without any other procedure.
Good for you. You’ve accomplished the long-term health goal and I could care less if you didn’t go with the surgery I was recommending or whatever else. Why should that bother me? I’ve got plenty of patients who want my services, who need my services. I’m happy. used to, again, my kids always say I’m so boring because I say the same things over and over again. So I’m trying hard not to be boring.
But I used to say, one of my soapbox things was like, really want to put myself out of business. If I could figure out how to treat everyone’s obesity and health without needing surgery, that would be awesome. I’ll find something else to do with my time. I won’t go idle hands or the devil’s work. But like, great, like that’d be great. Like, I don’t care. Like surgery is fun, but yeah, like.
I’m not like in this to, you know, to do anything other than help people get healthier. Like, so if I can find a better way that’s, or a different way that might be less, you know, less invasive, less lifestyle changing or whatever, you know, awesome. You know, I’m all for it. I haven’t gotten there yet and I may never, but I’m certainly…
interested and willing and hopeful that the newer and better therapies come along so that we can do better for people. Because again, that’s all, in theory, that’s all any provider should want is to do best by our patients. Like it sounds sort of syrupy and cheesy and lame, but it’s really like, it’s really how I feel. Like I really just want people to be healthier and happier and…
It just so happens I chose surgery as a profession and pediatric surgery as a subspecialty and then pediatric bariatric surgery because I thought it was a field where no one was helping these kids and if no one was helping these kids, someone had to. So I decided it should be me. But in the end, it just still comes back to just helping people and helping people get healthier, hopefully happier and, you know, again, sort of corny or whatever.
It is really how I feel.
Jollie (54:36)
Yeah, that’s cool. I love that. Love that. Well, we’re to have you back and dive into pediatric obesity and as many topics as you’re willing to share with us. This has been fantastic. Why don’t we finish up by telling folks your next big endeavor? It’s pretty exciting.
Evan P Nadler MD, MBA (54:50)
I got a bazillion thing. Again, I think I mentioned earlier about my ADD and I am, definitely in that ADD is my superpower. I’m one of those people who talks about that, I guess, disease disorder, whatever you want to call it, positively, like it’s been, it’s how I’ve been able to do what I do. So,
And it’s not great for my relationship with my wife. She can’t stand it, but it’s good for most other things, or at least academic things. But anyway, so today actually, as of this recording, we’re seeing our very first patient in our pediatric-only, telemedicine-only weight management program with a woman by the name of Stephanie Walsh, who used to be the director of the…
childhood obesity programming at Children’s Hospital of Atlanta. It’s called ProCare Telehealth and our website is ProCareTelehealth.com and she sees our first patient today and the goal of that is really just to expand access to kids who don’t have access. And we’re piloting that in Georgia and Florida for now. So if you live in one of those two states and you want to be seen, we can see you tomorrow because she has openings on her schedule because I know that.
And then we hope to prove to ourselves and everybody else that it’s worth rolling out to all 50 states, which we’ll then do. And I guess when I come back at some point, we could talk about the disparities in healthcare access and how pediatric rate management programs are woefully underrepresented across the country, certainly not only in urban centers.
rural kids have basically no access to weight management and how telehealth might help address some of those doubts. But that’s the next immediate.
big thing. And that, hopefully combined with the I’m writing and my YouTube channel and my website and podcasts like this and people like you, are all baby steps to try to help move the needle in the right direction. But my sort of New Jersey upbringing just can’t allow me to quit. just keep, I’m going to keep fighting this fight.
Jollie (56:39)
Yeah.
Love it.
Evan P Nadler MD, MBA (56:49)
until I can’t fight any longer.
Jollie (56:53)
I that.
You mentioned YouTube channel. What’s your YouTube channel?
Evan P Nadler MD, MBA (56:55)
Yeah.
Obesity Explained. So, and that’s on my website too. And I’m always looking for comments and feedback about, you know, like right now it’s sort of a vacuum. Like I make videos about things that I think are important. And then I try to judge what people think by the number likes, the number of views and those sorts of things. But, and you know, I do get some comments now and then usually from trolls, but that’s okay, because at least they’re watching.
But it’s like, again, I have no idea sort of what people really want to hear or really want to know. if people go into my YouTube channel, you know, leave a message saying this was helpful. Do more of this. Like my little I have a 14 year old, I guess my wife’s goddaughter. So I don’t know what that makes me. I don’t want to say I’m the godfather because that’s a movie that has negative connotations. But anyway.
She likes my blooper reel. I have one blooper reel. She’s like, you should make more blooper reels. I’m like, blooper reels don’t like, you just can’t make blooper reels. It’s not how they happen. But you know, like, but at least it’s feedback. She’s like, that’s what I like the best. She’s like, the rest of the things you say are boring. It’s okay. But she likes the blooper reel. So whatever, you know, so trying to be more, I’ll keep trying to be more entertaining. That’s my, that’s my goal. Cause maybe that’s how you get the message across. People like year.
Jollie (57:52)
Yeah.
That’s great. Yeah.
There you go.
Evan P Nadler MD, MBA (58:11)
style or the way you say stuff or whatever maybe they’ll actually listen to what you’re saying too.
Jollie (58:15)
Yeah, it’s been
good stuff. Dr. Nadler, this has been fantastic. We’re just, like as much as we got into, man, we’re just skimming this. Yeah.
Evan P Nadler MD, MBA (58:22)
⁓ Scratching the surface.
It’s a super complex topic that we could spend hours and hours and hours talking about, but then we would definitely bore people. So we’ll take a break for today and then come back and talk more about something else next time. Happy to do it. Happy to do it whenever.
Jollie (58:33)
Yeah, no.
All right.
Thank you so much. This has been fun. We’ll definitely have you back soon. All right. Thanks.
Evan P Nadler MD, MBA (58:41)
Yeah, my pleasure. Take care.
***
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