It is clear that we are finally making some inroads in treating obesity in children. Several cities are eliminating soft drinks and other high carb choices from schools, as well as providing carbohydrate contents in restaurants and fast-food outlets. There are some promising results in terms of obesity prevention. Although, some studies find that if one becomes obese as a young child, it may be very difficult to lose the weight upon reaching adolescence (has been demonstrated in adolescent mice).
There are several tiers towards tackling obesity:
- Nutritional counseling
- Elimination of carbohydrate rich/fatty food from school lunches
- Family intervention and culture change
If all else fails, some teams are electing to consider bariatric surgery in adolescents (Bariatric surgery is offered at Children’s National Medical Center, but the adolescents are screened very carefully.)
A recent paper published in the International Journal of Obesity (online ahead of print 2012, Sept 25, doi: 10.1038/ijo.2012.160), “Two year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity” shared the results from a Swedish Nationwide study. The study successfully demonstrated sustained weight loss in adolescents. However, there were other serious considerations upon deciding upon surgery. The authors, Olbers, Gronowitz, Werling et. al, studied 81 adolescents ages 13 to 18 with a BMI 36-69 kg/m2 who underwent gastric bypass surgery in a university setting in Sweden from 2006-2009. Two-year outcomes analyzing BMI and metabolic outcomes were compared to adults who had the same type of surgery. Other metabolic abnormalities also improved (hyperinsulinemia, a precursor of diabetes).
What were the results?
In adolescents undergoing surgery, the mean BMI was 45.5 at baseline and 30.2 post surgery, which is highly significant after two years (p<0.001) resulting in a 32 percent weight loss and 76 percent loss of BMI! In addition, quality of life improved considerably. However, according to the authors surgical and psychological challenges require “careful attention.”
What is the effectiveness and cost-effectiveness of pediatric bariatric surgery?
In a review in Clinical Obesity by Aikenhead, Knai and Lobstein, published online 3, March, 2011 (doi: 10.111/j.1758-8111.2010.00003.x), the authors provide a systematic review. The authors searched PubMed, ISI Web of Science, Embase, and the Cochrane library to September 2012. The authors evaluated 37 papers on bariatric surgery effectiveness in 831 children and or/adolescents over 36 years. The majority of studies supported the previous authors with improvement or resolution of conditions associated with obesity (diabetes, metabolic syndrome, hyperinsulinemia, sleep apnea, etc.). However there was a range of post-op complications that were noted involving all types of surgical procedures that included the following:
2. Intestinal leakage
3. Wound infection
4 Anastomotic strictures
5. Nutritional deficiencies
- Bowel obstruction
- Pulmonary embolism
- Disrupted stable lines
- Band slippage
- Psychological intolerance
- Repeated vomiting
What may we conclude from these studies?
Bariatric surgery in adolescents will result in significant weight loss and improve associated metabolic derangements that occur with obesity as well as quality of life. However, post-operative complications, based on the authors’ research, may be more problematic in adolescents than adults (possibly due to adolescent related behavior in which adherence is often problematic). Unfortunately, based on the results of the study, the availability of long-term data on safety, effectiveness, and cost-effectiveness remains unknown. The authors conclude that there should be a cautious approach to child and adolescent bariatric surgery and advise that reversible techniques should be strongly considered versus surgical approaches that alter intestinal anatomy permanently.
Once again, due to the developmental considerations of adolescents, one must weigh the surgical procedures very carefully and err on the side of caution. Most bariatric surgery teams work diligently to identify ideal candidates for surgery involving a dedicated multidisciplinary team including dieticians, psychologists, and adolescent medicine specialists as well as surgeons. The first step is not surgery, rather applying behavioral approaches with support. Only after all non-surgical approaches have been exhausted will the team consider bariatric surgery. A frank discussion with the adolescent and family will ensue discussing the pros/cons and possible complications that may occur and the close follow-up that will be necessary for the adolescent’s safety.
For further information, please read about the Bariatric surgery program at Children’s National Medical Center.