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Shehata MA, Elhaddad A, El-Attar AA, Shehata SM. The Effect of Antrum Size on Weight Loss, Glucagon-Like Peptide-1 (GLP-1) Levels, and Glycemic Control Following Laparoscopic Sleeve Gastrectomy in Adolescents with Obesity and Type 2 Diabetes. Obes Surg 2021; 31:4376-4385. [PMID: 34355337 DOI: 10.1007/s11695-021-05590-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/22/2021] [Accepted: 07/09/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE The aim of this study was to compare the effect of antral resection versus antral preservation sleeve gastrectomy on the post-operative GLP-1, glycemic control, and weight loss in adolescents suffering from severe obesity and type 2 diabetes (T2D). MATERIALS AND METHODS This study included 36 adolescents. Patients were randomly divided into 2 groups: group (A) and group (B). Each group included 18 patients who underwent LSG, starting transection at 2 cm or 5 cm from the pyloric ring in group (A) and group (B), respectively. They were followed up at 1, 3, 6, 12, and 24 months post-operatively. The outcomes were the post-operative GLP-1 response, glycemic control, weight loss, and safety. RESULTS The improvements in the body mass index and the percentage of excess weight loss (%EWL) were statistically significant within each group. The mean GLP-1 levels showed significant increase at the 1, 3, and 6 months but not in the 12 and 24 months in all the studied samples within each group. The mean HbA1c levels and post-prandial serum C-peptide significantly improved within each group (P < 0.05). No statistical differences in the weight loss, %EWL, GLP-1, HbA1c, C-peptide changes, and complication rates were observed between both groups. Diabetic remission was significantly higher (88.9%) in group (A). CONCLUSIONS LSG resulted in generalized significant GLP-1 initial response that decreased over time. The reduced antrum size did not influence the GLP-1 response, glycemic control, or insulin resistance, but resulted in significantly better T2D remission. Since the study examines a small number of patients, further studies are needed. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04388059.
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Affiliation(s)
- Mohamed A Shehata
- Department of General Surgery, Pediatric Surgery Unit, Faculty of Medicine, Tanta University, El-Geish Street, Tanta, 31257, Egypt.
| | - Ahmed Elhaddad
- Department of General Surgery, Pediatric Surgery Unit, Faculty of Medicine, Tanta University, El-Geish Street, Tanta, 31257, Egypt
| | - Ashraf A El-Attar
- Department of General Surgery, Pediatric Surgery Unit, Faculty of Medicine, Tanta University, El-Geish Street, Tanta, 31257, Egypt
| | - Sherif M Shehata
- Department of General Surgery, Pediatric Surgery Unit, Faculty of Medicine, Tanta University, El-Geish Street, Tanta, 31257, Egypt
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Pyle L, Kelsey MM. Youth-onset type 2 diabetes: translating epidemiology into clinical trials. Diabetologia 2021; 64:1709-1716. [PMID: 34075436 DOI: 10.1007/s00125-021-05480-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/10/2021] [Indexed: 12/17/2022]
Abstract
Globally, the proportion of new diagnoses of youth-onset diabetes represented by type 2 diabetes is increasing, and youth with type 2 diabetes commonly have complications and comorbidities, as well as a higher rate of mortality. In this review, we summarise what is known about the natural progression of youth-onset type 2 diabetes from published clinical trials and large-scale prospective epidemiological studies. It is important to note that the robust pathophysiological and treatment data specifically related to individuals with a diabetes onset at ≤20 years of age largely hails from the USA. Youth-onset type 2 diabetes is characterised by pathophysiological heterogeneity and inadequate glycaemic control, highlighting the need for new treatment approaches and innovative study designs in populations of varied genetic and cultural backgrounds.
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Affiliation(s)
- Laura Pyle
- Section of Paediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Megan M Kelsey
- Section of Paediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA.
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Bjornstad P, Drews KL, Caprio S, Gubitosi-Klug R, Nathan DM, Tesfaldet B, Tryggestad J, White NH, Zeitler P. Long-Term Complications in Youth-Onset Type 2 Diabetes. N Engl J Med 2021; 385:416-426. [PMID: 34320286 PMCID: PMC8697255 DOI: 10.1056/nejmoa2100165] [Citation(s) in RCA: 232] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The prevalence of type 2 diabetes in youth is increasing, but little is known regarding the occurrence of related complications as these youths transition to adulthood. METHODS We previously conducted a multicenter clinical trial (from 2004 to 2011) to evaluate the effects of one of three treatments (metformin, metformin plus rosiglitazone, or metformin plus an intensive lifestyle intervention) on the time to loss of glycemic control in participants who had onset of type 2 diabetes in youth. After completion of the trial, participants were transitioned to metformin with or without insulin and were enrolled in an observational follow-up study (performed from 2011 to 2020), which was conducted in two phases; the results of this follow-up study are reported here. Assessments for diabetic kidney disease, hypertension, dyslipidemia, and nerve disease were performed annually, and assessments for retinal disease were performed twice. Complications related to diabetes identified outside the study were confirmed and adjudicated. RESULTS At the end of the second phase of the follow-up study (January 2020), the mean (±SD) age of the 500 participants who were included in the analyses was 26.4±2.8 years, and the mean time since the diagnosis of diabetes was 13.3±1.8 years. The cumulative incidence of hypertension was 67.5%, the incidence of dyslipidemia was 51.6%, the incidence of diabetic kidney disease was 54.8%, and the incidence of nerve disease was 32.4%. The prevalence of retinal disease, including more advanced stages, was 13.7% in the period from 2010 to 2011 and 51.0% in the period from 2017 to 2018. At least one complication occurred in 60.1% of the participants, and at least two complications occurred in 28.4%. Risk factors for the development of complications included minority race or ethnic group, hyperglycemia, hypertension, and dyslipidemia. No adverse events were recorded during follow-up. CONCLUSIONS Among participants who had onset of type 2 diabetes in youth, the risk of complications, including microvascular complications, increased steadily over time and affected most participants by the time of young adulthood. Complications were more common among participants of minority race and ethnic group and among those with hyperglycemia, hypertension, and dyslipidemia. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; ClinicalTrials.gov numbers, NCT01364350 and NCT02310724.).
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Affiliation(s)
- Petter Bjornstad
- From the University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (P.B., P.Z.); George Washington University, Rockville, MD (K.L.D., B.T.); Yale University, New Haven, CT (S.C.); Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland (R.G.-K.); the Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston (D.M.N.); the University of Oklahoma Health Sciences Center, Oklahoma City (J.T.); and Washington University School of Medicine, St. Louis (N.H.W.)
| | - Kimberly L Drews
- From the University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (P.B., P.Z.); George Washington University, Rockville, MD (K.L.D., B.T.); Yale University, New Haven, CT (S.C.); Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland (R.G.-K.); the Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston (D.M.N.); the University of Oklahoma Health Sciences Center, Oklahoma City (J.T.); and Washington University School of Medicine, St. Louis (N.H.W.)
| | - Sonia Caprio
- From the University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (P.B., P.Z.); George Washington University, Rockville, MD (K.L.D., B.T.); Yale University, New Haven, CT (S.C.); Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland (R.G.-K.); the Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston (D.M.N.); the University of Oklahoma Health Sciences Center, Oklahoma City (J.T.); and Washington University School of Medicine, St. Louis (N.H.W.)
| | - Rose Gubitosi-Klug
- From the University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (P.B., P.Z.); George Washington University, Rockville, MD (K.L.D., B.T.); Yale University, New Haven, CT (S.C.); Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland (R.G.-K.); the Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston (D.M.N.); the University of Oklahoma Health Sciences Center, Oklahoma City (J.T.); and Washington University School of Medicine, St. Louis (N.H.W.)
| | - David M Nathan
- From the University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (P.B., P.Z.); George Washington University, Rockville, MD (K.L.D., B.T.); Yale University, New Haven, CT (S.C.); Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland (R.G.-K.); the Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston (D.M.N.); the University of Oklahoma Health Sciences Center, Oklahoma City (J.T.); and Washington University School of Medicine, St. Louis (N.H.W.)
| | - Bereket Tesfaldet
- From the University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (P.B., P.Z.); George Washington University, Rockville, MD (K.L.D., B.T.); Yale University, New Haven, CT (S.C.); Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland (R.G.-K.); the Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston (D.M.N.); the University of Oklahoma Health Sciences Center, Oklahoma City (J.T.); and Washington University School of Medicine, St. Louis (N.H.W.)
| | - Jeanie Tryggestad
- From the University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (P.B., P.Z.); George Washington University, Rockville, MD (K.L.D., B.T.); Yale University, New Haven, CT (S.C.); Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland (R.G.-K.); the Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston (D.M.N.); the University of Oklahoma Health Sciences Center, Oklahoma City (J.T.); and Washington University School of Medicine, St. Louis (N.H.W.)
| | - Neil H White
- From the University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (P.B., P.Z.); George Washington University, Rockville, MD (K.L.D., B.T.); Yale University, New Haven, CT (S.C.); Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland (R.G.-K.); the Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston (D.M.N.); the University of Oklahoma Health Sciences Center, Oklahoma City (J.T.); and Washington University School of Medicine, St. Louis (N.H.W.)
| | - Philip Zeitler
- From the University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (P.B., P.Z.); George Washington University, Rockville, MD (K.L.D., B.T.); Yale University, New Haven, CT (S.C.); Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland (R.G.-K.); the Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston (D.M.N.); the University of Oklahoma Health Sciences Center, Oklahoma City (J.T.); and Washington University School of Medicine, St. Louis (N.H.W.)
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Elhag W, El Ansari W. Durability of Cardiometabolic Outcomes Among Adolescents After Sleeve Gastrectomy: First Study with 9-Year Follow-up. Obes Surg 2021; 31:2869-2877. [PMID: 33840011 PMCID: PMC8175305 DOI: 10.1007/s11695-021-05364-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/12/2021] [Accepted: 03/19/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Long-term durability of weight loss and comorbidity resolution beyond 7 years after laparoscopic sleeve gastrectomy (LSG) among adolescents is completely lacking. METHODS Retrospective review of adolescents aged ≤ 18 years who underwent primary LSG at our institution between 2011 and 2015 (N = 146). We assessed anthropometric and cardiometabolic outcomes at 1, 3, 5, 7, and 9 years. RESULTS Follow-up rates were 57.53%, 82.87%, 85.24%, 83.92%, and 83.33% at the five time points. The preoperative mean body mass index (BMI) (45.60 ± 6.50 kg/m2) decreased at year 1 (30.04 ± 4.96 kg/m2, P=0.001) and was maintained up to 9 years (30.20 ± 3.92 kg/m2, P = 0.001). Remission rates were triglycerides, 100% (11/11) at 5 years, and 100% (1/1) at 9 years; high density lipoprotein, 89.4% (17/19) at 5 years, and 100% (3/3) at 7 years; low density lipoprotein, 71.4% (11/14) and 100% (3/3) at 5 and 7 years; total cholesterol, 70% (7/10) at 5 years, and 100% (2/2) at 9 years; uric acid, 100% (3/3) at 5 years. Remission of liver enzymes was 84.6-100% (22/26-2/2) at 5-9 years. Prediabetes remission was 87.5% (14/16 and 7/8) at 5 and 7 years and 100% (3/3) at year 9. Type 2 diabetes complete remission was 50% (3/6, 1/2) at years 5 and 7, with all cases resolved at 9 years. The only case of hypertension completely resolved. CONCLUSIONS LSG achieved substantial weight loss and remission of cardiometabolic risk factors that were sustained on the long term. This is the first study among adolescents to assess such outcomes beyond 7 years.
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Affiliation(s)
- Wahiba Elhag
- Department of Bariatric Surgery/Bariatric Medicine, Hamad General Hospital, 3050 Doha, Qatar
| | - Walid El Ansari
- Department of Surgery, Hamad General Hospital, 3050 Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
- Schools of Health and Education, University of Skovde, Skovde, Sweden
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Perez NP, Stanford FC, Williams K, Johnson VR, Nadler E, Bowen-Jallow K. A framework for studying race-based disparities in the use of metabolic and bariatric surgery for the management of pediatric obesity. Am J Surg 2021; 222:49-51. [PMID: 33288224 PMCID: PMC9909247 DOI: 10.1016/j.amjsurg.2020.11.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Numa P Perez
- Massachusetts General Hospital, Department of Surgery, 55 Fruit St, GRB 425, Boston, MA, 02114, USA; Massachusetts General Hospital, Healthcare Transformation Lab, 50 Staniford St, 7(th) Floor, Boston, MA, 02114, USA.
| | - Fatima Cody Stanford
- Massachusetts General Hospital, Department of Medicine - Division of Endocrinology-Neuroendocrine, Department of Pediatrics - Division of Endocrinology, 50 Staniford Street, 4th Floor, Boston, MA, 02114, USA
| | - Kibileri Williams
- Children's National Hospital, Division of Pediatric Surgery, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Veronica R Johnson
- Center for Obesity Medicine and Metabolic Performance, Department of Surgery, McGovern Medical School, 6700 West Loop South, Suite 500, Bellaire, TX, 77401, USA
| | - Evan Nadler
- Children's National Hospital, Division of Pediatric Surgery, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Kanika Bowen-Jallow
- University of Texas Medical Branch, Department of Surgery, 301 University Boulevard, Galveston, TX, 77555, USA
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Calcaterra V, Cena H, Pelizzo G, Porri D, Regalbuto C, Vinci F, Destro F, Vestri E, Verduci E, Bosetti A, Zuccotti G, Stanford FC. Bariatric Surgery in Adolescents: To Do or Not to Do? CHILDREN (BASEL, SWITZERLAND) 2021; 8:453. [PMID: 34072065 PMCID: PMC8204230 DOI: 10.3390/children8060453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 01/19/2023]
Abstract
Pediatric obesity is a multifaceted disease that can impact physical and mental health. It is a complex condition that interweaves biological, developmental, environmental, behavioral, and genetic factors. In most cases lifestyle and behavioral modification as well as medical treatment led to poor short-term weight reduction and long-term failure. Thus, bariatric surgery should be considered in adolescents with moderate to severe obesity who have previously participated in lifestyle interventions with unsuccessful outcomes. In particular, laparoscopic sleeve gastrectomy is considered the most commonly performed bariatric surgery worldwide. The procedure is safe and feasible. The efficacy of this weight loss surgical procedure has been demonstrated in pediatric age. Nevertheless, there are barriers at the patient, provider, and health system levels, to be removed. First and foremost, more efforts must be made to prevent decline in nutritional status that is frequent after bariatric surgery, and to avoid inadequate weight loss and weight regain, ensuring successful long-term treatment and allowing healthy growth. In this narrative review, we considered the rationale behind surgical treatment options, outcomes, and clinical indications in adolescents with severe obesity, focusing on LSG, nutritional management, and resolution of metabolic comorbidities.
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Affiliation(s)
- Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy;
- Pediatric Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (E.V.); (A.B.); (G.Z.)
| | - Hellas Cena
- Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, 27100 Pavia, Italy; (H.C.); (D.P.)
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (F.D.); (E.V.)
| | - Debora Porri
- Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, 27100 Pavia, Italy; (H.C.); (D.P.)
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Corrado Regalbuto
- Pediatric Unit, Fond. IRCCS Policlinico S. Matteo and University of Pavia, 27100 Pavia, Italy; (C.R.); (F.V.)
| | - Federica Vinci
- Pediatric Unit, Fond. IRCCS Policlinico S. Matteo and University of Pavia, 27100 Pavia, Italy; (C.R.); (F.V.)
| | - Francesca Destro
- Pediatric Surgery Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (F.D.); (E.V.)
| | - Elettra Vestri
- Pediatric Surgery Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (F.D.); (E.V.)
| | - Elvira Verduci
- Pediatric Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (E.V.); (A.B.); (G.Z.)
- Department of Health Sciences, University of Milan, 20146 Milan, Italy
| | - Alessandra Bosetti
- Pediatric Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (E.V.); (A.B.); (G.Z.)
| | - Gianvincenzo Zuccotti
- Pediatric Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (E.V.); (A.B.); (G.Z.)
- “L. Sacco” Department of Biomedical and Clinical Science, University of Milan, 20146 Milan, Italy
| | - Fatima Cody Stanford
- Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA;
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Serbis A, Giapros V, Kotanidou EP, Galli-Tsinopoulou A, Siomou E. Diagnosis, treatment and prevention of type 2 diabetes mellitus in children and adolescents. World J Diabetes 2021; 12:344-365. [PMID: 33889284 PMCID: PMC8040084 DOI: 10.4239/wjd.v12.i4.344] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/31/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
During the last two decades, there have been several reports of an increasing incidence of type 2 diabetes mellitus (T2DM) in children and adolescents, especially among those belonging to minority ethnic groups. This trend, which parallels the increases in prevalence and degree of pediatric obesity, has caused great concern, even though T2DM remains a relatively rare disease in children. Youth T2DM differs not only from type 1 diabetes in children, from which it is sometimes difficult to differentiate, but also from T2DM in adults, since it appears to be an aggressive disease with rapidly progressive β-cell decline, high treatment failure rate, and accelerated development of complications. Despite the recent research, many aspects of youth T2DM still remain unknown, regarding both its pathophysiology and risk factor contribution, and its optimal management and prevention. Current management approaches include lifestyle changes, such as improved diet and increased physical activity, together with pharmacological interventions, including metformin, insulin, and the recently approved glucagon-like peptide-1 analog liraglutide. What is more important for everyone to realize though, from patients, families and physicians to schools, health services and policy-makers alike, is that T2DM is a largely preventable disease that will be addressed effectively only if its major contributor (i.e., pediatric obesity) is confronted and prevented at every possible stage of life, from conception until adulthood. Therefore, relevant comprehensive, coordinated, and innovative strategies are urgently needed.
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Affiliation(s)
- Anastasios Serbis
- Department of Pediatrics, University Hospital of Ioannina, Ioannina 45500, Greece
| | - Vasileios Giapros
- Department of Child Health, University of Ioannina, Ioannina 45500, Greece
| | - Eleni P Kotanidou
- Department of Pediatrics, Medical School, Aristotle University Thessaloniki, Thessaloniki 54636, Greece
| | | | - Ekaterini Siomou
- Department of Pediatrics, University Hospital of Ioannina, Ioannina 45500, Greece
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Abstract
Childhood obesity can lead to comorbidities that cause significant decrease in health-related quality of life and early mortality. Recognition of obesity as a disease of polygenic etiology can help deter implicit bias. Current guidelines for treating severe obesity in children recommend referral to a multidisciplinary treatment center that offers metabolic and bariatric surgery at any age when a child develops a body mass index that is greater than 120% of the 95th percentile. Obesity medications and lifestyle counseling about diet and exercise are not adequate treatment for severe childhood obesity. Early referral can significantly improve quality and quantity of life.
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Affiliation(s)
- Adi Steinhart
- Department of Pediatrics, Stanford University School of Medicine, 1017 Paradise Way, Palo Alto, CA 94306, USA
| | - Deborah Tsao
- Stanford University School of Medicine, 227 Ayrshire Farm Ln (Apt 203), Stanford, CA 94305, USA
| | - Janey S A Pratt
- Division of Pediatric Surgery, Stanford University School of Medicine, Lucille Packard Children's Hospital, M166 Alway Building, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Stroh C, Luderer D, Meyer F. Transition of care in a case of obesity with metabolic surgery. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:250-254. [PMID: 33684957 DOI: 10.1055/a-1348-2378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The World Health Summit 2011 confirmed the epidemic-like occurrence of diabetes mellitus and obesity. In Germany, 62.7 % and 21.9 % of the population have a BMI of more than 25 kg/m² and more than 30 kg/m2, respectively. Currently, 10.5 obese people per 100 000 German inhabitants undergo bariatric surgery, while 86 and 114.8 per 100 000 in France and in Sweden, respectively, favor bariatric surgical interventions. AIM By means of a scientific case report, the instructive case of a young patient with morbid obesity is illustrated based on 1) selective references from the medical literature and 2) insights from the daily clinical practice in the case-specific medical and perioperative management after successful surgery for malformation in his childhood and, thus, the limited therapeutic options of metabolic surgery. CASE REPORT (CASE-, DIAGNOSTIC-, AND TREATMENT-SPECIFIC ASPECTS) 35-year-old patient with morbid obesity. Medical history: Status after surgical intervention for gastroschisis as a newborn (surgery report not available). Clinical findings: Super obesity characterized by 234 kg and 174 cm (→ BMI: 77.3 kg/m²), hypogonadotrophic hypogonadism. Approach & course: · Initial treatment with gastric balloon followed by a weight reduction of 46 kg within the first 6 months; however, despite weight reduction, development of an insulin-dependent diabetes with insulin resistance from a diet-based diabetes;. · Repeat gastric balloon therapy for "bridging" but with no further weight reduction despite additional administration of GLP-1 analogues.. · Surgical intervention: Removal of the balloon - termination because of excessive adhesions to the liver and spleen as well as filiforme hepatic lesions (histopathology: liver hamartoma). Open surgery: extensive adhesiolysis because of previous pediatric surgery for gastroschisis, including associated non-rotation of the intestine with complete right-sided position of the intestine (left side: colon; right flexure: at infralienal position) prompting single-anastomosis duodeno-ileostomy (SADI)-procedure, leaving the stomach in situ with simultaneous cholecystectomy and herniotomy in sublay technique.. Outcome (early postoperative and mid- to long-term): The patient tolerated the intervention well. Postoperative course was uneventful with regard to mobilization, beginning of oral nutrition, and wound healing; there was a subsequent weight reduction due to a "common channel" of 250 cm. CONCLUSION While the increase of obesity prevalence in adults has currently stopped, incidence in children and teenagers is rapidly rising. The consequence might be that children and young adults who have undergone bariatric surgery in childhood and adolescence can develop complications from these former interventions as adults. Therefore, it is reasonable to recommend follow-up investigations within specialized centers according to well-established standards. On the other hand, the increasing prevalence of obesity in childhood leads to the possibility that adults who underwent pediatric surgery because of embryonal malformations may require an appointment with a bariatric surgeon at some point. For these patients (as a representative example of the transition of care phenomenon), the risk of metabolic surgical intervention is increased; such operations require the appropriate knowledge and expertise of the bariatric surgeon on embryonal malformations and their approach by pediatric surgery.
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Affiliation(s)
- Christine Stroh
- Dept. of Obesity and Metabolic Surgery, Municipal Hospital ("SRH Wald-Klinikum"), Gera, Germany
| | - Daniel Luderer
- Dept. of Obesity and Metabolic Surgery, Municipal Hospital ("SRH Wald-Klinikum"), Gera, Germany
| | - Frank Meyer
- Dept. of General, Abdomina, Vascular and Transplant Surgery, Otto-von-Guericke University with University Hospital, Magdeburg, Germany
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Ogle SB, Dewberry LC, Jenkins TM, Inge TH, Kelsey M, Bruzoni M, Pratt JS. Outcomes of Bariatric Surgery in Older Versus Younger Adolescents. Pediatrics 2021; 147:peds.2020-024182. [PMID: 33526606 PMCID: PMC7919111 DOI: 10.1542/peds.2020-024182] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES In this report, we compare weight loss, comorbidity resolution, nutritional abnormalities, and quality of life between younger and older adolescents after metabolic and bariatric surgery. METHODS From March 2007 to December 2011, 242 adolescents (≤19 years of age) who underwent bariatric surgery at 5 clinical centers in the United States were enrolled in the prospective, multicenter, long-term outcome study Teen-Longitudinal Assessment of Bariatric Surgery. Outcome data from younger (13-15 years; n = 66) and older (16-19 years; n = 162) study participants were compared. Outcomes included percent BMI change, comorbidity outcomes (hypertension, dyslipidemia, and type 2 diabetes mellitus), nutritional abnormalities, and quality of life over 5 years post surgery. RESULTS Baseline characteristics, except for age, between the 2 cohorts were similar. No significant differences in frequency of remission of hypertension (P = .84) or dyslipidemia (P = .74) were observed between age groups. Remission of type 2 diabetes mellitus was high in both groups, although statistically higher in older adolescents (relative risk 0.86; P = .046). Weight loss and quality of life were similar in the 2 age groups. Younger adolescents were less likely to develop elevated transferrin (prevalence ratio 0.52; P = .048) and low vitamin D levels (prevalence ratio 0.8; P = .034). CONCLUSIONS The differences in outcome of metabolic and bariatric surgery between younger and older adolescents were few. These data suggest that younger adolescents with severe obesity should not be denied consideration for surgical therapy on the basis of age alone and that providers should consider adolescents of all ages for surgical therapy for obesity when clinically indicated.
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Affiliation(s)
- Sarah B. Ogle
- Children’s Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Lindel C. Dewberry
- Children’s Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Todd M. Jenkins
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and
| | - Thomas H. Inge
- Children’s Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Megan Kelsey
- Children’s Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Matias Bruzoni
- Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| | - Janey S.A. Pratt
- Lucile Packard Children’s Hospital Stanford, Palo Alto, California
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The role of gut microbiota and amino metabolism in the effects of improvement of islet β-cell function after modified jejunoileal bypass. Sci Rep 2021; 11:4809. [PMID: 33637880 PMCID: PMC7910448 DOI: 10.1038/s41598-021-84355-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 02/15/2021] [Indexed: 12/23/2022] Open
Abstract
The change in gut microbiota is an important mechanism of the amelioration of type 2 diabetes mellitus (T2DM) after bariatric surgery. Here, we observe that the modified jejunoileal bypass effectively decreases body weight gain, fasting blood glucose, and lipids level in serum; additionally, islet β-cell function, glucose tolerance, and insulin resistance were markedly ameliorated. The hypoglycemic effect and the improvement in islet β-cell function depend on the changes in gut microbiota structure. modified jejunoileal bypass increases the abundance of gut Escherichia coli and Ruminococcus gnavus and the levels of serum glycine, histidine, and glutamine in T2DM rats; and decreases the abundance of Prevotella copri and the levels of serum branched chain amino acids, which are significantly related to the improvement of islet β-cell function in T2DM rats. Our results suggest that amino acid metabolism may contribute to the islet β-cell function in T2DM rats after modified jejunoileal bypass and that improving gut microbiota composition is a potential therapeutic strategy for T2DM.
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Molinari AM, Shubrook JH. Treatment options and current guidelines of care for pediatric type 2 diabetes patients: a narrative review. J Osteopath Med 2021; 121:431-440. [PMID: 33694353 DOI: 10.1515/jom-2020-0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 11/03/2020] [Indexed: 11/15/2022]
Abstract
CONTEXT Type 2 diabetes (T2D) mellitus, which was once considered a disease affecting adults, is a growing problem among youths. Research now shows that T2D in youths is more progressive and associated with earlier onset of complications than adult-onset T2D. OBJECTIVES To update practicing clinical physicians on what is currently known about pediatric T2D and share current guidelines to care for these patients. METHODS The authors conducted a literature review through the MEDLINE/PubMed, Google Scholar, and clinicaltrials.gov databases in July 2019 using the following search phrases: "youth-onset type 2 diabetes," "pediatric type 2 diabetes," "diabetes in youth," and "FDA-approved pediatric diabetes medications." Items published between 2010 and 2019 and written in English were included. RESULTS A total of 65 items were included after database review, including 44 articles, 10 FDA product inserts, six clinicaltrials.gov listings, three position statements/guideline documents, one website, and one FDA announcement. CONCLUSIONS There are very limited treatment options available to manage pediatric T2D. Prevention of pediatric T2D is paramount, which requires a high index of suspicion, routine screening of children and adolescents, and willingness to engage in family-based interventions for those at risk for prediabetes and T2D. Osteopathic physicians have a unique opportunity to help by applying the osteopathic principles to the whole person - including environmental, societal, and lifestyle factors - to help patients achieve their health and wellness goals.
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Affiliation(s)
- Antonia M Molinari
- College of Osteopathic Medicine, Touro University California, Vallejo, CA, USA
| | - Jay H Shubrook
- College of Osteopathic Medicine, Touro University California, Vallejo, CA, USA
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Long-term impact of bariatric surgery on glycemic control and glucose-lowering therapy for people with type 2 diabetes: population-based cohort study. Surg Obes Relat Dis 2021; 17:1049-1056. [PMID: 33753008 DOI: 10.1016/j.soard.2021.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/11/2021] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) have demonstrated that bariatric surgery improves glycemic control among people with diabetes. However, evidence from RCTs may not be generalizable to real-world clinical care with unselected patients in routine clinical practice. OBJECTIVES To examine long-term glycemic control and glucose-lowering drug regimens following bariatric surgery for people with type 2 diabetes (T2D) in unselected patients in routine clinical practice. SETTING Population-based cohort study using linked routinely collected real-world data from Ontario, Canada. METHODS Individuals with T2D who were assessed for bariatric surgery at any referral center in the province between February 2010 and November 2016 were identified and divided into those who received surgery within 2 years of the initial assessment and those who did not. RESULTS There were 3674 people who had bariatric surgery and 1335 who did not. By 2 years, people who had undergone surgery had a significantly lower HbA1C (6.3 ± 1.2 % versus 7.8 ± 1.8 %, P < .0001), and this difference persisted at 3, 4, 5, and 6 years. Even by 6 years, half of those who had undergone surgery remained on no glucose-lowering drugs, and they were nearly 6 times less likely to be on insulin than those who had not undergone surgery. CONCLUSIONS In real-world clinical care, bariatric surgery was associated with large and sustained improvements in glycemic control.
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Current Perspectives on Management of Type 2 Diabetes in Youth. CHILDREN-BASEL 2021; 8:children8010037. [PMID: 33435250 PMCID: PMC7826614 DOI: 10.3390/children8010037] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/01/2021] [Accepted: 01/06/2021] [Indexed: 12/16/2022]
Abstract
The prevalence of type 2 diabetes mellitus (T2DM) in children and adolescents is on the rise, and the increase in prevalence of this disorder parallels the modern epidemic of childhood obesity worldwide. T2DM affects primarily post-pubertal adolescents from ethnic/racial minorities and those from socioeconomically disadvantaged backgrounds. Youth with T2DM often have additional cardiovascular risk factors at diagnosis. T2DM in youth is more progressive in comparison to adult onset T2DM and shows lower rates of response to pharmacotherapy and more rapid development of diabetes-related complications. Lifestyle modifications and metformin are recommended as the first-line treatment for youth with T2DM in the absence of significant hyperglycemia. Assessment of pancreatic autoimmunity is recommended in all youth who appear to have T2DM. Pharmacotherapeutic options for youth with T2DM are limited at this time. Liraglutide, a GLP-1 agonist, was recently approved for T2DM in adolescents 10 years of age and older. Several clinical trials are currently underway with youth with T2DM with medications that are approved for T2DM in adults. Bariatric surgery is associated with excellent rates of remission of T2DM in adolescents with severe obesity and should be considered in selected adolescents.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Zenno A, Nadler EP. Surgical Treatment of Type 2 Diabetes Mellitus in Youth. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1307:321-330. [PMID: 32200501 PMCID: PMC8489511 DOI: 10.1007/5584_2020_511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bariatric surgery is currently the most effective weight loss treatment of severe obesity and its associated comorbidities and is being increasingly used to treat children and adolescents with severe obesity, including those with Type 2 Diabetes (T2D). This review focuses on the conventional management of T2D in children and adolescents, comparison of various types of bariatric surgeries, effect of bariatric surgery on gastrointestinal physiology and metabolism, current literature on the use of bariatric surgery to treat youth with severe obesity and T2D, and the potential complications of bariatric surgery in this population.
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Affiliation(s)
- Anna Zenno
- Division of Endocrinology, Children's National Health System, Washington, DC, USA.
| | - Evan P Nadler
- Division of Pediatric Surgery, Children's National Health System, Washington, DC, USA
- The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
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Gow ML, Pham-Short A, Jebeile H, Varley BJ, Craig ME. Current Perspectives on the Role of Very-Low-Energy Diets in the Treatment of Obesity and Type 2 Diabetes in Youth. Diabetes Metab Syndr Obes 2021; 14:215-225. [PMID: 33500642 PMCID: PMC7822089 DOI: 10.2147/dmso.s238419] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/06/2021] [Indexed: 12/21/2022] Open
Abstract
In both developed and developing countries, pediatric obesity and type 2 diabetes are an increasing public health concern: globally 5.6% of girls and 7.8% of boys aged ≥5 years have obesity. The incidence of type 2 diabetes has increased in youth in recent decades and disproportionately affects those from ethnic/racial minority groups and disadvantaged backgrounds. For the treatment of both conditions, conventional lifestyle intervention is frequently ineffective, access to bariatric surgery is very limited and many young people are unsuitable or unwilling to undergo surgery. A very-low-energy diet (VLED) provides a viable alternative and may be effective for weight reduction and improved glycemic control in youth, based on one systematic review. In particular, in the treatment of type 2 diabetes, a chart review and a pilot study both demonstrated that a VLED can reduce the requirement for medications, including insulin, and lead to the remission of diabetes. However, long-term follow-up and safety data remain limited and therefore a VLED is inconsistently recommended by clinical practice guidelines for the treatment of pediatric obesity and type 2 diabetes. In clinical practice, VLED use in children and adolescents is uniquely challenging due to intolerance of expected side effects, difficulty adhering to the highly restrictive diet and difficulty with behaviour change within the current social context and environment. Ultimately, more research, including larger, longer-term trials with comprehensive safety monitoring are required to strengthen the evidence base. This would inform clinical practice guidelines, which may facilitate more widespread utilization of VLED programs in the management of obesity and type 2 diabetes in youth.
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Affiliation(s)
- Megan L Gow
- The University of Sydney Children’s Hospital Westmead Clinical School, Sydney, NSW, Australia
- Correspondence: Megan L Gow The University of Sydney Children’s Hospital Westmead Clinical School, Sydney, NSW, AustraliaTel +61 2 9845 0000Fax +61 2 9845 3170 Email
| | - Anna Pham-Short
- Institute of Endocrinology and Diabetes, The Children’s Hospital at Westmead, Sydney, NSW, Australia
| | - Hiba Jebeile
- The University of Sydney Children’s Hospital Westmead Clinical School, Sydney, NSW, Australia
| | - Benjamin J Varley
- The University of Sydney Children’s Hospital Westmead Clinical School, Sydney, NSW, Australia
| | - Maria E Craig
- School of Women’s and Children’s Health, University of New South Wales, Sydney, NSW, Australia
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Savic Hitt TA, Katz LEL. Pediatric Type 2 Diabetes: Not a Mini Version of Adult Type 2 Diabetes. Endocrinol Metab Clin North Am 2020; 49:679-693. [PMID: 33153674 PMCID: PMC7772966 DOI: 10.1016/j.ecl.2020.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Pediatric type 2 diabetes mellitus (T2DM) is increasing in incidence, with risk factors including obesity, puberty, family history of T2DM in a first-degree or second-degree relative, history of small-for-gestational-age at birth, child of a gestational diabetes pregnancy, minority racial group, and lower socioeconomic status. The pathophysiology of T2DM consists of insulin resistance and progression to pancreatic beta-cell failure, which is more rapid in pediatric T2DM compared with adult T2DM. Treatment options are limited. Treatment failure and nonadherence rates are high in pediatric T2DM; therefore, early diagnosis and treatment and new pharmacologic options and/or effective behavioral interventions are needed.
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Affiliation(s)
- Talia Alyssa Savic Hitt
- Division of Endocrinology & Diabetes, Department of Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Boulevard, Buerger Building -12th Floor, Philadelphia, PA 19104, USA.
| | - Lorraine E Levitt Katz
- Division of Endocrinology & Diabetes, Department of Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Boulevard, Buerger Building -12th Floor, Philadelphia, PA 19104, USA
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Ryder JR, Xu P, Nadeau KJ, Kelsey MM, Xie C, Jenkins T, Inge TH, Bjornstad P. Effect of surgical versus medical therapy on estimated cardiovascular event risk among adolescents with type 2 diabetes and severe obesity. Surg Obes Relat Dis 2020; 17:23-33. [PMID: 33071178 DOI: 10.1016/j.soard.2020.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/08/2020] [Accepted: 09/02/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) remains the leading cause of mortality in type 2 diabetes (T2D). Better interventions are needed to mitigate the high lifetime risk for CVD in youth T2D. OBJECTIVE To compare 30-year risk for CVD events in 2 cohorts of adolescents with T2D and severe obesity undergoing medical or surgical treatment of T2D. SETTING Longitudinal multicenter studies at University hospitals. METHODS A secondary analysis of data collected from the participants with T2D enrolled in the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS, n = 30) and participants of similar age and racial distribution from the Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY, n = 63) studies was performed. Teen-LABS participants underwent metabolic bariatric surgery (MBS). TODAY participants were randomized to metformin alone or in combination with rosiglitazone or intensive lifestyle intervention, with insulin therapy given for glycemic progression. A 30-year CVD event score developed by the Framingham Heart Study was the primary outcome, assessed at baseline (preoperatively for Teen-LABS), 1 year, and 5 years of follow-up. RESULTS Participants with T2D from Teen-LABS (n = 30; mean ± SD age = 16.9 ± 1.3 yr; 70% female; 60% white; body mass index (BMI) = 54.4 ± 9.5 kg/m2) and TODAY (n = 63; 15.3 ± 1.3 yr; 56% female; 71% white; BMI 40.5 ± 4.9 kg/m2) were compared. The likelihood of CVD events was higher in Teen-LABS versus TODAY at baseline (17.66 [1.59] versus 12.11 [.79]%, adjusted P = .002). One year after MBS, event risk was significantly lower in Teen-LABS versus TODAY (6.79 [1.33] versus 13.64 [0.96]%, adjusted P < .0001), and sustained at 5 years follow-up (adjusted P < .0001). CONCLUSION Despite higher pretreatment risk for CVD events, treatment with MBS resulted in a reduction in estimated CVD event risks, whereas medical therapy associated with an increase in risk among adolescents with T2D and severe obesity.
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Affiliation(s)
- Justin R Ryder
- University of Minnesota Medical School and Center for Pediatric Obesity Medicine, Minneapolis, Minnesota, United States
| | - Peixin Xu
- University of Cincinnati, Cincinnati Children's Medical Center, Cincinnati, Ohio, United States
| | - Kristen J Nadeau
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado, United States
| | - Megan M Kelsey
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado, United States
| | - Changchun Xie
- University of Cincinnati, Cincinnati Children's Medical Center, Cincinnati, Ohio, United States
| | - Todd Jenkins
- University of Cincinnati, Cincinnati Children's Medical Center, Cincinnati, Ohio, United States
| | - Thomas H Inge
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado, United States
| | - Petter Bjornstad
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado, United States.
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Abstract
PURPOSE OF REVIEW Knowledge regarding postoperative outcomes after bariatric and metabolic surgery continues to evolve. This review highlights key findings in outcomes research over the last 5 years related to weight loss, remission of obesity-related disease, reflux, revisional surgery, robotic-assisted surgical platforms, and adolescent populations. RECENT FINDINGS Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) produce similar weight loss patterns at 5 years, while duodenal switch (BPD/DS) and related procedures are associated with maximal weight loss overall and optimal resolution of obesity-related comorbidities. Remission of type 2 diabetes mellitus (T2DM) following surgery is more likely in patients who are not insulin dependent prior to surgery. Bariatric and metabolic surgery offers a significant protective effect against coronary artery disease (CAD) and associated interventions in both diabetic and nondiabetic patients, as well as heart failure (HF). Gastroesophageal reflux disease (GERD) and dysphagia following SG are common, and routine endoscopic surveillance for Barrett's esophagus may be of significant utility. Robotic-assisted laparoscopic platforms concur similar outcomes to laparoscopic intervention, with a potential benefit in high BMI patients. Revisional surgery is most commonly performed for weight regain and/or inadequate weight loss following an index procedure, or reflux, and generally characterized by higher postoperative complication rates and longer inpatient lengths of stay (LOS). Surgical intervention in adolescent populations has similar weight loss and postoperative complication profiles to those seen in adult populations, with improved outcomes related to T2DM. Bariatric and metabolic surgery continues to evolve as a treatment for obesity and obesity-related comorbidities. While effective for weight loss and remission of obesity-related disease, SG is associated with high rates of postoperative GERD.
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Affiliation(s)
- A E Roth
- Department of General Surgery, Banner University Medical Center - Phoenix, University of Arizona, 1441 N 12th Street, 1st floor, Phoenix, AZ, 85006, USA.
| | - C J Thornley
- Department of General Surgery, Banner University Medical Center - Phoenix, University of Arizona, 1441 N 12th Street, 1st floor, Phoenix, AZ, 85006, USA
| | - R P Blackstone
- Ira A. Fulton Chair in Bariatric Surgery and Metabolic Disorders, Institute for Obesity and Metabolic Disorders, Banner University Medical Center - Phoenix, University of Arizona, 1441 N 12th Street, 1st floor, Phoenix, AZ, 85006, USA
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Di Figlia-Peck S, Feinstein R, Fisher M. Treatment of children and adolescents who are overweight or obese. Curr Probl Pediatr Adolesc Health Care 2020; 50:100871. [PMID: 33097417 PMCID: PMC7576185 DOI: 10.1016/j.cppeds.2020.100871] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Stephanie Di Figlia-Peck
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, NY 11042, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States.
| | - Ronald Feinstein
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, NY 11042, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Martin Fisher
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, NY 11042, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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Zuo D, Xiao X, Yang S, Gao Y, Wang G, Ning G. Effects of bariatric surgery in Chinese with obesity and type 2 diabetes mellitus: A 3-year follow-up. Medicine (Baltimore) 2020; 99:e21673. [PMID: 32846783 PMCID: PMC7447381 DOI: 10.1097/md.0000000000021673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The incidence of obesity and type 2 diabetes mellitus is growing, and bariatric surgery was applied as a new therapy in the past few decades. However, bariatric surgery started rather late in China, and the number of surgeries and the follow-up data is limited.We assessed body weight, glucose, lipid levels, and blood pressure at baseline and 6-month, 1-year, 3-year in patients who underwent bariatric surgery. Vitamins and trace elements were investigated at 3-year after surgery. The quality of life was assessed at 3-year and compared with the control group.In total 20 patients were recruited in the study, and all the 20 patients underwent surgery and completed all follow-ups. Results showed that the body weight, body mass index, glycated hemoglobin (HbA1C), glucose, and insulin level were decreased, and islet function improved significantly in 6-month and 1-year (P < .001), and the changes were more obvious in the first 6 months. However, all the indexes rebound significantly at the 3-year (P < .05), but still better than baseline (P < .05). Weight regain was 50% after 3 years, and the mean weight regain rate was 31.45%. Besides, blood pressure and lipid levels decreased significantly compared with baseline (P < .001). At the 3-year follow-up, we found that 100% of the patients showed vitamin D deficiency, 50% calcium deficiency, 20% vitamin B12 deficiency, 20% iron deficiency, and 15% suffered from anemia. Compared with the control group, the quality of life was better in patients who underwent surgery, especially in the physical health (P < .05).The current study showed that the body weight, glucose and islet function improved significantly after bariatric surgery, and the indexes changed mainly in the first 6 months, but there seemed to be a rebound after 3 years. Furthermore, the surgery may improve the blood pressure, lipid profile, and the quality of life. However, some patients may suffer anemia, calcium deficiency, iron deficiency, vitamin D, and vitamin B12 deficiency after 3 years.
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Affiliation(s)
- Didi Zuo
- The First Hospital of Jilin University, Changchun, Jilin Province
| | - Xianchao Xiao
- The First Hospital of Jilin University, Changchun, Jilin Province
| | - Shuo Yang
- The First Hospital of Jilin University, Changchun, Jilin Province
| | - Yuan Gao
- The First Hospital of Jilin University, Changchun, Jilin Province
| | - Guixia Wang
- The First Hospital of Jilin University, Changchun, Jilin Province
| | - Guang Ning
- The First Hospital of Jilin University, Changchun, Jilin Province
- Shanghai National Clinical Research Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University, Shanghai, China
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Abstract
PURPOSE OF REVIEW The prevalence of pediatric obesity and its associated complications is increasing around the world. Treatment of obesity is challenging and metabolic and bariatric surgery (MBS) is currently the most effective treatment for this condition. At this time, vertical sleeve gastrectomy (VSG) is the most commonly performed bariatric procedure in adolescents. However, knowledge regarding the efficacy, safety, and durability of VSG in adolescents is still evolving. This review summarizes the most recent updates in the field of MBS particularly VSG in adolescents. RECENT FINDINGS MBS is recommended to treat moderate to severe obesity, especially when complicated by comorbidities. The use of VSG for weight loss is increasing among adolescents and produces similar weight loss at five years in both adolescents and adults. The physiologic mechanisms causing weight loss after VSG are multifactorial and still being investigated. The complication rate after VSG ranges between 0 and 17.5%. SUMMARY VSG appears to be a well-tolerated and effective procedure in adolescents. However, it continues to be underutilized despite the increasing prevalence of moderate to severe obesity in adolescents. It is thus important to educate providers regarding its benefits and safety profile.
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Affiliation(s)
- Vibha Singhal
- Pediatric Endocrinology, Massachusetts General Hospital for Children
- Neuroendocrine Unit, Massachusetts General Hospital
- MGH Weight Center
| | | | - Madhusmita Misra
- Pediatric Endocrinology, Massachusetts General Hospital for Children
- Neuroendocrine Unit, Massachusetts General Hospital
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Vidmar AP, Goran MI, Naguib M, Fink C, Wee CP, Hegedus E, Lopez K, Gonzalez J, Raymond JK. Time limited eating in adolescents with obesity (time LEAd): Study protocol. Contemp Clin Trials 2020; 95:106082. [PMID: 32682994 DOI: 10.1016/j.cct.2020.106082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/22/2020] [Accepted: 07/06/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Time limited eating (TLE) has been shown to be effective for weight loss and improvement of glycemic control in adults with obesity and type 2 diabetes (T2D), but has not been well studied in adolescents. TLE may be a more feasible, flexible and effective dietary intervention for adolescents because it removes the need for intensive counting of calories or macronutrients, and emphasizes eating during a specified time period. OBJECTIVES The aim of this study is to assess the feasibility of a TLE approach in adolescents with obesity using a continuous glucose monitor (CGM) to promote adherence to the intervention. METHODS We propose a prospective, randomized controlled trial, in 60 adolescents (ages 14-18) with obesity (BMI% ≥ 95th percentile). Youth will be randomized to one of three treatment groups for a 12-week intervention: Group 1) Low sugar and carbohydrate education (LSC, 5% of total daily calories from sugar (<35 g)/day; <90 g carbohydrate (CHO)/day) + blinded CGM (used to monitor adherence and glycemic outcomes without real time feedback), Group 2) LSC + TLE (16-h fast/8-h feed for 5 days per week) + blinded CGM, and Group 3) LSC + TLE+ real time feedback via CGM (to evaluate effect of providing CGM data on intervention efficacy). Outcomes will include change in total body fat (TBF) percentage measured on DEXA scan, BMI status and fasting blood glucose at 12 weeks compared to baseline. CONCLUSIONS TLE is a potentially powerful lifestyle intervention that could be readily integrated into pediatric weight management programs to optimize their impact and accelerate healthy changes. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03954223.
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Affiliation(s)
- Alaina P Vidmar
- Diabetes & Obesity Program, Center for Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine of USC, Los Angeles, CA, United States of America.
| | - Michael I Goran
- Diabetes & Obesity Program, Center for Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine of USC, Los Angeles, CA, United States of America
| | - Monica Naguib
- Diabetes & Obesity Program, Center for Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine of USC, Los Angeles, CA, United States of America
| | - Cassandra Fink
- Diabetes & Obesity Program, Center for Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine of USC, Los Angeles, CA, United States of America
| | - Choo Phei Wee
- CTSI Biostatics Core, Saban Research Institute, Los Angeles, CA, United States of America
| | - Elizabeth Hegedus
- Diabetes & Obesity Program, Center for Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine of USC, Los Angeles, CA, United States of America
| | - Kelleen Lopez
- Diabetes & Obesity Program, Center for Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine of USC, Los Angeles, CA, United States of America
| | - Janelle Gonzalez
- Diabetes & Obesity Program, Center for Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine of USC, Los Angeles, CA, United States of America
| | - Jennifer K Raymond
- Diabetes & Obesity Program, Center for Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine of USC, Los Angeles, CA, United States of America
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The role of preoperative upper endoscopy in adolescents undergoing laparoscopic vertical sleeve gastrectomy. Surg Obes Relat Dis 2020; 16:1212-1217. [PMID: 32576512 DOI: 10.1016/j.soard.2020.04.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/17/2020] [Accepted: 04/21/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Vertical sleeve gastrectomy (VSG) has been associated with gastroesophageal reflux symptoms and, in adults, with a development of Barrett's esophagus. Adults with Barrett's esophagus identified at baseline before bariatric operation are generally advised against VSG operations. The role of preoperative esophagogastroduodenoscopy (EGD) in adolescents preparing for bariatric surgery is not clearly defined. OBJECTIVE The goal of this study was to report the frequency of abnormalities identified on EGD performed at baseline in adolescents undergoing VSG for severe obesity. SETTING Free-standing academic children's hospital. United States. METHODS A retrospective chart review was conducted to describe findings of EGD performed just before VSG in a cohort of 40 adolescents and young adults (age range 14-25 yr) immediately before VSG. Review of findings from gross and histopathological evaluation of the esophagus, resected stomach, and duodenum was performed. RESULTS Five individuals reported preoperative symptoms of gastroesophageal reflux. Anatomic findings at EGD were normal in 98% of individuals. Histopathology of the esophagus, stomach, and duodenum was normal in 88%, 70%, and 95%, respectively. Abnormal findings of gastritis (18%), esophagitis (13%), and/or Helicobacter pylori (10%) infection were most common. Those with evidence of H. pylori in gastric resection specimens were treated appropriately with eradication therapy postoperatively. With the exception of 2 patients with incidentally detected esophageal mucosal eosinophilia, EGD findings did not lead to additional changes in medical or surgical management. There were no complications of the EGD procedure. CONCLUSIONS Routine EGD at the time of VSG was safe but resulted in low yield of abnormal findings requiring a change in clinical management.
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76
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Peña AS, Curran JA, Fuery M, George C, Jefferies CA, Lobley K, Ludwig K, Maguire AM, Papadimos E, Peters A, Sellars F, Speight J, Titmuss A, Wilson D, Wong J, Worth C, Dahiya R. Screening, assessment and management of type 2 diabetes mellitus in children and adolescents: Australasian Paediatric Endocrine Group guidelines. Med J Aust 2020; 213:30-43. [PMID: 32578226 DOI: 10.5694/mja2.50666] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The incidence of type 2 diabetes mellitus has increased in children and adolescents due largely to the obesity epidemic, particularly in high risk ethnic groups. β-Cell function declines faster and diabetes complications develop earlier in paediatric type 2 diabetes compared with adult-onset type 2 diabetes. There are no consensus guidelines in Australasia for assessment and management of type 2 diabetes in paediatric populations and health professionals have had to refer to adult guidelines. Recent international paediatric guidelines did not address adaptations to care for patients from Indigenous backgrounds. MAIN RECOMMENDATIONS This guideline provides advice on paediatric type 2 diabetes in relation to screening, diagnosis, diabetes education, monitoring including targets, multicomponent healthy lifestyle, pharmacotherapy, assessment and management of complications and comorbidities, and transition. There is also a dedicated section on considerations of care for children and adolescents from Indigenous background in Australia and New Zealand. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINES Published international guidelines currently exist, but the challenges and specifics to care for children and adolescents with type 2 diabetes which should apply to Australasia have not been addressed to date. These include: recommendations regarding care of children and adolescents from Indigenous backgrounds in Australia and New Zealand including screening and management; tighter diabetes targets (glycated haemoglobin, ≤ 48 mmol/mol [≤ 6.5%]) for all children and adolescents; considering the use of newer medications approved for adults with type 2 diabetes under the guidance of a paediatric endocrinologist; and the need to transition adolescents with type 2 diabetes to a diabetes multidisciplinary care team including an adult endocrinologist for their ongoing care.
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Affiliation(s)
- Alexia S Peña
- Robinson Research Institute, University of Adelaide, Adelaide, SA.,Women's and Children's Hospital, Adelaide, SA
| | | | | | | | | | - Kristine Lobley
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW
| | | | - Ann M Maguire
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW.,University of Sydney, Sydney, NSW
| | - Emily Papadimos
- Queensland Children's Hospital, Brisbane, QLD.,Menzies School of Health Research, Darwin, NT
| | - Aimee Peters
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW
| | | | - Jane Speight
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, VIC.,Deakin University, Geelong, VIC
| | - Angela Titmuss
- Menzies School of Health Research, Darwin, NT.,Royal Darwin Hospital, Darwin, NT
| | | | - Jencia Wong
- University of Sydney, Sydney, NSW.,Diabetes Centre, Royal Prince Alfred Hospital, Sydney, NSW
| | | | - Rachana Dahiya
- Queensland Children's Hospital, Brisbane, QLD.,University of Queensland, Brisbane, QLD
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77
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Perez NP, Stanford FC, Chang DC. Comment on: Socioecological factors associated with metabolic and bariatric surgery utilization: a qualitative study in an ethnically diverse sample. Surg Obes Relat Dis 2020; 16:795-797. [PMID: 32305318 PMCID: PMC9128536 DOI: 10.1016/j.soard.2020.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Numa P Perez
- Healthcare Innovation Research Fellow, Healthcare Transformation Lab, Department of Surgery, Massachusetts General Surgery, Boston, Massachusetts
| | - Fatima Cody Stanford
- Division of Endocrinology-Neuroendocrine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Division of Endocrinology, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - David C Chang
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts
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78
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Abstract
Through diverse mechanisms, obesity contributes to worsened cardiometabolic health and increases rates of cardiovascular events. Effective treatment of obesity is necessary to reduce the associated burdens of diabetes mellitus, cardiovascular disease, and death. Despite increasing cardiovascular outcome data on obesity interventions, only a small fraction of the population with obesity are optimally treated. This is a primary impetus for this article in which we describe the typical weight loss, as well as the associated impact on both traditional and novel cardiovascular disease risk factors, provided by the 4 primary modalities for obtaining weight loss in obesity-dietary modification, increasing physical activity, pharmacotherapy, and surgery. We also attempt to highlight instances where changes in metabolic risk are relatively specific to particular interventions and appear at least somewhat independent of weight loss. Finally, we suggest important areas for further research to reduce and prevent adverse cardiovascular consequences due to obesity.
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Affiliation(s)
- Sean P. Heffron
- Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, NY,NYU Center for the Prevention of Cardiovascular Disease, NYU Grossman School of Medicine, New York, NY,Corresponding author: Sean P. Heffron, 227 East 30 St., #834, New York, NY 10016, 646-501-2735 ,
| | - Johnathon S. Parham
- NYU Center for the Prevention of Cardiovascular Disease, NYU Grossman School of Medicine, New York, NY
| | - Jay Pendse
- Department of Medicine, Division of Endocrinology, NYU Grossman School of Medicine, New York, NY,Medical Service, Veterans Affairs New York Harbor Healthcare System, New York, NY
| | - José O. Alemán
- Department of Medicine, Division of Endocrinology, NYU Grossman School of Medicine, New York, NY
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79
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Abstract
PURPOSE OF REVIEW Through its direct adverse effects on the kidney and via associated intermediate disease states like type 2 diabetes and hypertension, obese has arguably become the master risk factor for chronic kidney disease (CKD). The purpose of this review is to critically evaluate bariatric surgery, which is the most effective weight reduction strategy available, as a renoprotective strategy. RECENT FINDINGS Recent randomized studies confirm that bariatric surgery is effective at improving or even remitting major CKD risk factors such as type 2 diabetes and hypertension. In addition, observational studies performed primarily in patients without preexisting CKD report improvements in estimated glomerular filtration rate and albuminuria after bariatric surgery. Yet this literature is limited by study design, participant selection, statistical power, and measurement issues that must be overcome to better define kidney-related benefits, especially with regard to harder kidney-related and other clinical endpoints. SUMMARY Encouraging data exist on the renoprotective effects of bariatric surgery. However, important knowledge gaps still remain. Future research should focus on studying, ideally in randomized fashion, the renoprotective effects of bariatric surgery in patients with preexisting CKD to better define the benefit-risk ratio for each patient.
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Affiliation(s)
- Allon N Friedman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ricardo V Cohen
- The Center for Obesity and Diabetes, Oswaldo Cruz German Hospital, São Paulo, Brazil
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80
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Haymond MW, Chung ST. Commentary on the Impact of Obesity and Puberty on Insulin Sensitivity. J Clin Endocrinol Metab 2020; 105:5802416. [PMID: 32154566 PMCID: PMC7341160 DOI: 10.1210/clinem/dgaa104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/07/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Morey W Haymond
- Baylor College of Medicine, Houston, Texas
- Correspondence: Morey W. Haymond, MD, Baylor College of Medicine, Houston, TX. E-mail:
| | - Stephanie T Chung
- Co-Director of the Metabolic Research Unit, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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81
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Nutritional Risks in Adolescents After Bariatric Surgery. Clin Gastroenterol Hepatol 2020; 18:1070-1081.e5. [PMID: 31706057 PMCID: PMC7166172 DOI: 10.1016/j.cgh.2019.10.048] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/11/2019] [Accepted: 10/29/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Little is known about prevalence and risk factors for nutritional deficiencies in adolescents after metabolic bariatric surgery. We performed a 5-year prospective cohort study of these. METHODS Adolescents who had Roux-en-Y gastric bypass (RYGB, n = 161) or vertical sleeve gastrectomy (VSG, n = 67) were enrolled at 5 tertiary-care centers from March 2007 through February 2012. The final analysis cohort included 226 participants (161 who had RYGB and 65 who had VSG). We measured serum levels of ferritin; red blood cell folate; vitamins A, D, B1, B12; and parathyroid hormone at baseline and annually for 5 years. General linear mixed models were used to examine changes over time and identify factors associated with nutritional deficiencies. RESULTS The participants were 75% female and 72% white, with a mean age of 16.5 ± 1.6 years and mean body mass index of 52.7 ± 9.4 kg/m2 at surgery. Mean body mass index decreased 23% at 5 years, and did not differ significantly between procedures. After RYGB, but not VSG, serum concentrations of vitamin B12 significantly decreased whereas serum levels of transferrin and parathyroid hormone increased. Ferritin levels decreased significantly after both procedures. Hypo-ferritinemia was observed in 2.5% of patients before RYGB and 71% at 5 y after RYGB (P < .0001), and 11% of patients before VSG and 45% 5 y after VSG (P = .002). No significant changes in serum levels of folate or vitamins A, B1, or D were found between baseline and 5 y after either procedure. By 5 y, 59% of RYGB and 27% of VSG recipients had 2 or more nutritional deficiencies. Risk factors associated with specific deficiencies included surgery type, female sex, black race, supplementation intake, weight regain, and for females, pregnancy. CONCLUSIONS In a prospective study of adolescents who underwent RYGB or VSG, we observed nutritional deficiencies by 5 y after the procedures-particularly in iron and B12 after RYGB. Ongoing nutrient monitoring and supplementation are recommended for all patients, but surgery type, supplementation intake, sex, and race might affect risk. (Clinical trial registration: Adolescent Bariatrics: Assessing Health Benefits and Risk [also known as Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS)], NCT00474318.).
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82
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Abstract
The purpose of this review is to provide an update on the changing face of paediatric type 1 diabetes and type 2 diabetes. Paediatric diabetes is on the rise, with extensive research dedicated to understanding its pathophysiology, comorbidities and complications. As obesity continues to increase among all youth, differentiating between type 1 diabetes and type 2 diabetes has become increasingly difficult but remains important for optimising treatment, anticipating complications and predicting disease risk. Novel treatments are emerging, with the ultimate goal being to achieve glycaemic control, limit weight gain, improve quality of life and reduce comorbidities. In this review, we focus on updates regarding the epidemiology, clinical presentation, comorbidities and complications of paediatric type 1 diabetes and type 2 diabetes and conclude with current and emerging treatments.
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Affiliation(s)
- Amy S Shah
- University of Cincinnati, Department of Pediatrics, Cincinnati, OH, USA.
- Cincinnati Children's Hospital Medical Center, Division of Endocrinology, 3333 Burnet Ave, ML 7012, Cincinnati, OH, 45229, USA.
| | - Kristen J Nadeau
- University of Denver, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Division of Endocrinology, Aurora, CO, USA
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83
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Ahn SM. Current Issues in Bariatric Surgery for Adolescents with Severe Obesity: Durability, Complications, and Timing of Intervention. J Obes Metab Syndr 2020; 29:4-11. [PMID: 32183507 PMCID: PMC7118002 DOI: 10.7570/jomes19073] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/16/2020] [Accepted: 02/20/2020] [Indexed: 02/06/2023] Open
Abstract
Conventional nonsurgical management of severe obesity in the pediatric population and adolescents has focused on a multidisciplinary approach involving diet, exercise, behavioral modification, and to some extent, pharmaceuticals. Although nonsurgical strategies provide a certain degree of effective weight reduction, most of the severely obese adolescents suffer from a high relapse rate. In recent studies, long-term outcomes of bariatric surgery for severely obese adolescents have shown sustainable effects on weight loss and resolution of related comorbidities, such as hypertension and type 2 diabetes mellitus in this vulnerable age group. Notably, the role and practical benefits of bariatric surgery as a multidisciplinary therapeutic approach to adolescent obesity is gaining attention and acceptance. However, a surgical approach has many obstacles that prevent the timely evaluation and optimal intervention for adolescent obesity and its comorbidities. In the present review, the latest data on long-term outcomes after bariatric surgery for severely obese adolescents in terms of durability, effects on metabolic risk factors, complications, and optimal timing were summarized. The results showed the sustainability of weight loss and comorbidity resolution in adolescents following bariatric surgery. In addition, earlier surgery in patients without an extremely high body mass index increases the likelihood of a healthier life in adulthood. This review can help clarify the beneficial effects of bariatric surgery on weight reduction and resolution of comorbidities in severely obese adolescents and remove the barriers to referral of adolescents for bariatric surgery.
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Affiliation(s)
- Soo Min Ahn
- Department of Surgery, Bariatric and Metabolic Surgery Center, Pediatric Specialized Center, Hallym University Sacred Heart Hospital, Anyang, Korea
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84
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Parks EP, Finnerty DD, Panganiban J, Frasso R, Bishop-Gilyard C, Tewksbury CM, Williams NN, Dumon KR, Cordero G, Hill DL, Sarwer DB. Perspectives of adolescents with severe obesity on social Media in Preparation for weight-loss surgery: a qualitative study. BMC Pediatr 2020; 20:96. [PMID: 32122314 PMCID: PMC7050129 DOI: 10.1186/s12887-020-1992-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 02/20/2020] [Indexed: 01/01/2023] Open
Abstract
Background Currently the most effective treatment for severe obesity in adolescents is weight-loss surgery coupled with lifestyle behavior change. In preparation for weight-loss surgery, adolescents are required to make changes to eating and activity habits (lifestyle changes) to promote long term success. Social media support groups, which are popular among adolescents, have the potential to augment preoperative lifestyle changes. The purpose of this study was to qualitatively assess the perceived role of social media as a support tool for weight-loss, and to identify motivators and constraints to lifestyle changes and social media use in adolescents preparing for weight-loss surgery. Methods Thematic analysis of social media comments from 13 (3 male, 10 female) adolescents aged 16 ± 1.3 years with a body mass index (BMI) 45 ± 7.3 kg/m2 enrolled in a weight-management program preparing for bariatric surgery and who participated in a 12-week pilot social media intervention was performed. Participants commented on moderator posts and videos of nutrition, physical activity, and motivation that were shared three to four times per week. Social media comments were coded using NVivo 11.0 to identify recurrent themes and subthemes. Results 1) Social media provided accountability, emotional support, and shared behavioral strategies. 2) Motivators for lifestyle changes included family support, personal goals, and non-scale victories. 3) Challenges included negative peers, challenges with planning and tracking, and time constraints. Conclusion Adolescents considering bariatric surgery identified social media as a tool for social support and reinforcement of strategies for successful behavior change. Important motivators and challenges to lifestyle changes were identified.
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Affiliation(s)
- Elizabeth Prout Parks
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104-4399, USA. .,The Healthy Weight Program, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104-4399, USA. .,Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, 1139 Blockley Hall, Philadelphia, PA, 19104, USA. .,Children's Hospital of Philadelphia, 2716 South Street, Room 14361, Philadelphia, PA, 19146, USA.
| | - Darra D Finnerty
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104-4399, USA.,Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, 1139 Blockley Hall, Philadelphia, PA, 19104, USA
| | - Jennifer Panganiban
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104-4399, USA
| | - Rosemary Frasso
- Center for Public Health Initiatives at the University of Pennsylvania, 144 Anatomy Chemistry Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Chanelle Bishop-Gilyard
- The Healthy Weight Program, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104-4399, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Colleen M Tewksbury
- Penn Metabolic Bariatric Surgery Program, Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Noel N Williams
- Penn Metabolic Bariatric Surgery Program, Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kristoffel R Dumon
- Penn Metabolic Bariatric Surgery Program, Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Gaby Cordero
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104-4399, USA
| | - Douglas L Hill
- Pediatrics Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - David B Sarwer
- College of Public Health, Center for Obesity Research and Education, Temple University, 3223 N. Broad St., Suite 175, Philadelphia, PA, 19140, USA
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85
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Perez NP, Westfal ML, Stapleton SM, Stanford FC, Griggs CL, Pratt JS, Chang DC, Kelleher CM. Beyond insurance: race-based disparities in the use of metabolic and bariatric surgery for the management of severe pediatric obesity. Surg Obes Relat Dis 2020; 16:414-419. [PMID: 31917198 PMCID: PMC7058484 DOI: 10.1016/j.soard.2019.11.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/28/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND It is unknown whether previously noted racial disparities in the use of metabolic and bariatric surgery (MBS) for the management of pediatric obesity could be mitigated by accounting for primary insurance. OBJECTIVES To examine utilization of pediatric MBS across race and insurance in the United States. SETTING Retrospective cross-sectional study. METHODS The National Inpatient Sample was used to identify patients 12 to 19 years old undergoing MBS from 2015 to 2016, and these data were combined with national estimates of pediatric obesity obtained from the 2015 to 2016 National Health and Nutrition Examination Survey. Severe obesity was defined as class III obesity, or class II obesity plus hypertension, dyslipidemia, or type 2 diabetes. RESULTS A total of 1,659,507 (5.0%) adolescents with severe obesity were identified, consisting of 35.0% female, 38.0% white, and 45.0% privately insured adolescents. Over the same time period, 2535 MBS procedures were performed. Most surgical patients were female (77.5%), white (52.8%), and privately insured (57.5%). Black and Hispanic adolescents were less likely to undergo MBS than whites (odds ratio .50, .46, respectively; P < .001 both), despite adjusting for primary insurance. White adolescents covered by Medicaid were significantly more likely to undergo MBS than their privately insured counterparts (odds ratio 1.66; P < .001), while the opposite was true for black and Hispanic adolescents (odds ratio .29, .75, respectively; P < .001 both). CONCLUSIONS Pediatric obesity disproportionately affects racial minorities, yet MBS is most often performed on white adolescents. Medicaid insurance further decreases the use of MBS among nonwhite adolescents, while paradoxically increasing it for whites, suggesting expansion of government-sponsored insurance alone is unlikely to eliminate this race-based disparity.
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Affiliation(s)
- Numa P Perez
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Maggie L Westfal
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Sahael M Stapleton
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Fatima Cody Stanford
- Department of Medicine - Division of Endocrinology-Neuroendocrine, Department of Pediatrics - Division of Endocrinology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cornelia L Griggs
- Department of Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Janey S Pratt
- Department of Surgery, Lucille Packard Children's Hospital, Palo Alto, California
| | - David C Chang
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts
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86
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Five-year kidney outcomes of bariatric surgery differ in severely obese adolescents and adults with and without type 2 diabetes. Kidney Int 2020; 97:995-1005. [PMID: 32229096 DOI: 10.1016/j.kint.2020.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/09/2019] [Accepted: 01/02/2020] [Indexed: 12/17/2022]
Abstract
Bariatric surgery improves markers of kidney health in severe obesity, yet it is unclear if kidney disease outcomes differ according to age at surgery. Therefore, we examined health effects of Roux-en-Y gastric bypass between 161 adolescents and 396 adults participating in two related but distinct studies. Primary outcomes were elevated urine albumin-to-creatinine ratio (UACR) of 30 mg/g or more and hyperfiltration (an estimated glomerular filtration rate of 135 ml/min/1.73m2 or more). Analyses were stratified by the presence of pre-operative type 2 diabetes. Adolescents with pre-operative type 2 diabetes had a significantly increased prevalence of elevated UACR prior to surgery compared to adults (22.5 vs. 9.0%). Resolution of elevated UACR following surgery differed between adolescents and adults with type 2 diabetes, with adolescents experiencing a significantly earlier improvement following surgery. Adolescents without pre-operative type 2 diabetes demonstrated a significantly increased prevalence of UACR prior to surgery compared to adults (9.4 vs. 4.5%), with no improvement occurring in either group post-operatively. Adolescents with pre-operative type 2 diabetes had a significantly increased prevalence of hyperfiltration that remained throughout the study period, whereas hyperfiltration prevalence was similar among those without type 2 diabetes. Thus, adolescents with pre-operative type 2 diabetes experienced earlier attenuation of elevated UACR compared to adults with pre-operative type 2 diabetes in response to gastric bypass.
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87
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Ogle SB, Inge TH, Campbell EG. Comment on: Beyond insurance: race-based disparities in the use of metabolic and bariatric surgery for the management of severe pediatric obesity. Surg Obes Relat Dis 2020; 16:419-421. [PMID: 32007434 DOI: 10.1016/j.soard.2020.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Sarah B Ogle
- University of Colorado, Denver, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Thomas H Inge
- University of Colorado, Denver, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Eric G Campbell
- University of Colorado, Denver, Colorado; Center for Bioethics and Humanities, University of Colorado, Denver, Colorado
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88
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Bjornstad P, Nehus E, van Raalte D. Bariatric surgery and kidney disease outcomes in severely obese youth. Semin Pediatr Surg 2020; 29:150883. [PMID: 32238288 PMCID: PMC7125208 DOI: 10.1016/j.sempedsurg.2020.150883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bariatric surgery, an emerging treatment for severely obese youth with and without T2D, provides marked improvement in insulin resistance, beta-cell function, and central adiposity. Further, preliminary data suggest that bariatric surgery also results in significant improvement in markers of obesity-related nephropathy and DKD, beyond that which can be achieved with current medical interventions. Yet, the mechanisms whereby bariatric surgery attenuates kidney disease remain unclear. This review summarizes the data on the effects of bariatric surgery on obesity-related nephropathy and DKD in youth with and without T2D, in addition to potential mechanisms underlying the nephroprotective effects of weight loss surgery and how these may differ in Roux-en-Y gastric bypass vs. vertical sleeve gastrectomy. Finally, we discuss potential future non-surgical therapies to mitigate kidney disease.
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Affiliation(s)
- Petter Bjornstad
- Section of Endocrinology, Department of Pediatrics, Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, United States.
| | - Edward Nehus
- Section of Nephrology, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Daniel van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, location VUMC, Amsterdam, the Netherlands
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89
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Shah AS, Nadeau KJ, Helmrath MA, Inge TH, Xanthakos SA, Kelsey MM. Metabolic outcomes of surgery in youth with type 2 diabetes. Semin Pediatr Surg 2020; 29:150893. [PMID: 32238292 PMCID: PMC7125189 DOI: 10.1016/j.sempedsurg.2020.150893] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Youth-onset type 2 diabetes (T2D) is a formidable threat to the health of obese adolescents because of its potential for early-onset and aggressive co-morbidities and complications. The physiology of youth-onset T2D differs from T2D in adults and is associated with a greater degree of insulin resistance, a more rapid decline in pancreatic β-cell function, and a poorer response to medications. Medical management in youth is focused on combining lifestyle intervention and pharmacological treatment, but these therapies have yet to demonstrate improvements in disease progression. Metabolic bariatric surgery (MBS) is now recommended for the treatment of T2D in adults largely because of the beneficial effects on weight, ability to improve glycemic control, and, in a large proportion of people, induce diabetes remission. MBS is now being performed in adolescents with severe obesity and T2D, with initial results also showing high rates of T2D remission. Here, we review the state of medical management of youth-onset T2D and the outcomes of MBS studies in youth with T2D published to date.
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Affiliation(s)
- Amy S Shah
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Kristen J Nadeau
- Denver and Children's Hospital Colorado, Division of Pediatric Endocrinology, University of Colorado, Aurora, CO, United States
| | - Michael A Helmrath
- Department of Pediatric Surgery, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Thomas H Inge
- Denver and Children's Hospital Colorado, Division of Pediatric Surgery, University of Colorado, Aurora, CO, United States
| | - Stavra A Xanthakos
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Megan M Kelsey
- Denver and Children's Hospital Colorado, Division of Pediatric Endocrinology, University of Colorado, Aurora, CO, United States
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90
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Ammori BJ, Skarulis MC, Soran H, Syed AA, Eledrisi M, Malik RA. Medical and surgical management of obesity and diabetes: what's new? Diabet Med 2020; 37:203-210. [PMID: 31850536 DOI: 10.1111/dme.14215] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2019] [Indexed: 12/19/2022]
Abstract
We conducted a narrative review of the medical and surgical management of people with obesity and diabetes. Results of this review showed that a 5-10% loss in body weight can be achieved with a change in lifestyle, diet and behaviour and with approved pharmacological therapies in people with obesity and diabetes. New targeted therapies are now available for patients with previously untreatable genetic causes of obesity. Compared to medical treatment, metabolic and bariatric surgery is associated with significantly higher rates of remission from type 2 diabetes and lower rates of incident macrovascular and microvascular complications and mortality. The National Institute for Health and Care Excellence and the American Diabetes Association endorse metabolic and bariatric surgery in obese adults with type 2 diabetes and there may also be a role for this in obese individuals with type 1 diabetes. The paediatric committee of the American Society for Metabolic and Bariatric Surgery have recommended metabolic and bariatric surgery in obese adolescents with type 2 diabetes. Earlier and more aggressive treatment with metabolic and bariatric surgery in obese or overweight people with diabetes can improve morbidity and mortality.
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Affiliation(s)
- B J Ammori
- Department of Surgery, King Hussein Cancer Centre, Amman, Jordan
| | - M C Skarulis
- National Obesity Treatment Centre, Hamad Medical Corporation, Doha, Qatar
| | - H Soran
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - A A Syed
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
| | - M Eledrisi
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - R A Malik
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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91
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Bjornstad P, Hughan K, Kelsey MM, Shah AS, Lynch J, Nehus E, Mitsnefes M, Jenkins T, Xu P, Xie C, Inge T, Nadeau K. Effect of Surgical Versus Medical Therapy on Diabetic Kidney Disease Over 5 Years in Severely Obese Adolescents With Type 2 Diabetes. Diabetes Care 2020; 43:187-195. [PMID: 31685489 PMCID: PMC6925577 DOI: 10.2337/dc19-0708] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 09/30/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare diabetic kidney disease (DKD) rates over 5 years of follow-up in two cohorts of severely obese adolescents with type 2 diabetes (T2D) undergoing medical or surgical treatment for T2D. RESEARCH DESIGN AND METHODS A secondary analysis was performed of data collected from obese participants of similar age and racial distribution enrolled in the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and the Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY) studies. Teen-LABS participants underwent metabolic bariatric surgery (MBS). TODAY participants were randomized to metformin alone or in combination with rosiglitazone or intensive lifestyle intervention, with insulin therapy given for glycemic progression. Glycemic control, BMI, estimated glomerular filtration rate (eGFR), urinary albumin excretion (UAE), and prevalence of hyperfiltration (eGFR ≥135 mL/min/1.73 m2) and elevated UAE (≥30 mg/g) were assessed annually. RESULTS Participants with T2D from Teen-LABS (n = 30, mean ± SD age, 16.9 ± 1.3 years; 70% female; 60% white; BMI 54.4 ± 9.5 kg/m2) and TODAY (n = 63, age 15.3 ± 1.3 years; 56% female; 71% white; BMI 40.5 ± 4.9 kg/m2) were compared. During 5 years of follow-up, hyperfiltration decreased from 21% to 18% in Teen-LABS and increased from 7% to 48% in TODAY. Elevated UAE decreased from 27% to 5% in Teen-LABS and increased from 21% to 43% in TODAY. Adjusting for baseline age, sex, BMI, and HbA1c, TODAY participants had a greater odds of hyperfiltration (odds ratio 15.7 [95% CI 2.6, 94.3]) and elevated UAE (27.3 [4.9, 149.9]) at 5 years of follow-up. CONCLUSIONS Compared with MBS, medical treatment of obese youth with T2D was associated with a higher odds of DKD over 5 years.
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Affiliation(s)
- Petter Bjornstad
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO
| | - Kara Hughan
- University of Pittsburgh and UPMC Children's Hospital Pittsburgh, Pittsburgh, PA
| | - Megan M Kelsey
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO
| | - Amy S Shah
- University of Cincinnati, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Jane Lynch
- The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Edward Nehus
- University of Cincinnati, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Mark Mitsnefes
- University of Cincinnati, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Todd Jenkins
- University of Cincinnati, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Peixin Xu
- University of Cincinnati, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Changchun Xie
- University of Cincinnati, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Thomas Inge
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO
| | - Kristen Nadeau
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO
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92
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Sarno LA, Lipshultz SE, Harmon C, De La Cruz-Munoz NF, Balakrishnan PL. Short- and long-term safety and efficacy of bariatric surgery for severely obese adolescents: a narrative review. Pediatr Res 2020; 87:202-209. [PMID: 31401646 DOI: 10.1038/s41390-019-0532-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 07/16/2019] [Accepted: 07/25/2019] [Indexed: 12/27/2022]
Abstract
The selection criteria, safety, and efficacy of bariatric surgery are well established in adults but are less well defined for severely obese adolescents. The number of severely obese adolescents who could benefit from weight loss surgery is increasing, although referral rates have plateaued. Surgical options for these adolescents are controversial and raise several questions. Recent studies, including the prospective Teen-Longitudinal Assessment of Bariatric Surgery Study and the Adolescent Morbid Obesity Surgery Study, help answer these questions. Early bariatric surgical intervention improves body mass index but, more importantly, improves cardiovascular and metabolic co-morbidities of severe obesity. A review of the medical, psychosocial, and economic risks and benefits of bariatric surgery in severely obese adolescents is a step toward improving the management of a challenging and increasing population. We describe the current knowledge of eligibility criteria, preoperative evaluation, surgical options, outcomes, and referral barriers of adolescents for bariatric surgery.
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Affiliation(s)
- Lauren A Sarno
- Division of Pediatric Cardiology, East Carolina University, Brody School of Medicine, Greenville, NC, USA.
| | - Steven E Lipshultz
- Department of Pediatrics, John R. Oishei Children's Hospital, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Carroll Harmon
- Division of Pediatric Surgery, John R. Oishei Children's Hospital, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | | | - Preetha L Balakrishnan
- Division of Cardiology, Children's Hospital of Michigan, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
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93
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Roberts CA. Physical and Psychological Effects of Bariatric Surgery on Obese Adolescents: A Review. Front Pediatr 2020; 8:591598. [PMID: 33585363 PMCID: PMC7873639 DOI: 10.3389/fped.2020.591598] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/31/2020] [Indexed: 12/18/2022] Open
Abstract
The worldwide obesity crisis is not isolated to adults; rather, obesity in adolescents has reached epidemic levels as well. Bariatric surgery continues to be one of the most effective treatments for obesity, both in adults and adolescents, with new evidence continually emerging; however, research surrounding outcomes of these procedures in younger patients is limited in comparison with data available for adults. Further, it is important to examine psychological aspects of obesity in adolescents, as well as effects of surgery on mental health endpoints. Conditions such as anxiety, depression, anger, and disruptive behavior show increased prevalence among obese adolescents, but minimal research exists to examine changes in such conditions following bariatric surgery. Additionally, there is growing evidence of a bidirectional relationship between sleep (quality; disorders) and the development of obesity, and the effects of this relationship are particularly pronounced in the vulnerable adolescent population. This review aims to compile and discuss the results of literature within the last 5 years with regard to overall efficacy of bariatric surgery specifically in adolescent patients in terms of weight and body mass index (BMI) reduction, hormonal changes, and co-morbidity resolution, as well as data surrounding sleep and psychological outcomes. Race, ethnicity, and socioeconomic status were also examined. From this review, we conclude that current research supports bariatric surgery in adolescents as an effective method of treatment for obesity and related co-morbidities; however, minimal long-term data exists to adequately assess efficacy and trends into adulthood. These areas are ripe for future study.
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Affiliation(s)
- Cherie A Roberts
- Department of Nutrition, Columbia University, New York, NY, United States.,Department of Biomedical Sciences, Touro College of Osteopathic Medicine-Harlem, New York, NY, United States.,Department of Osteopathic Medicine, Touro College of Osteopathic Medicine-Harlem, New York, NY, United States
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94
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Armstrong SC, Bolling CF, Michalsky MP, Reichard KW. Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices. Pediatrics 2019; 144:peds.2019-3223. [PMID: 31656225 DOI: 10.1542/peds.2019-3223] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Severe obesity among youth is an "epidemic within an epidemic" and portends a shortened life expectancy for today's children compared with those of their parents' generation. Severe obesity has outpaced less severe forms of childhood obesity in prevalence, and it disproportionately affects adolescents. Emerging evidence has linked severe obesity to the development and progression of multiple comorbid states, including increased cardiometabolic risk resulting in end-organ damage in adulthood. Lifestyle modification treatment has achieved moderate short-term success among young children and those with less severe forms of obesity, but no studies to date demonstrate significant and durable weight loss among youth with severe obesity. Metabolic and bariatric surgery has emerged as an important treatment for adults with severe obesity and, more recently, has been shown to be a safe and effective strategy for groups of youth with severe obesity. However, current data suggest that youth with severe obesity may not have adequate access to metabolic and bariatric surgery, especially among underserved populations. This report outlines the current evidence regarding adolescent bariatric surgery, provides recommendations for practitioners and policy makers, and serves as a companion to an accompanying technical report, "Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity," which provides details and supporting evidence.
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Affiliation(s)
- Sarah C Armstrong
- Departments of Pediatrics and Population Health Sciences, Duke Center for Childhood Obesity Research, and Duke Clinical Research Institute, Duke University, Durham, North Carolina;
| | - Christopher F Bolling
- Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marc P Michalsky
- Department of Pediatric Surgery, College of Medicine, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio; and
| | - Kirk W Reichard
- Division of Pediatric Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
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95
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Bolling CF, Armstrong SC, Reichard KW, Michalsky MP. Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity. Pediatrics 2019; 144:peds.2019-3224. [PMID: 31656226 DOI: 10.1542/peds.2019-3224] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Severe obesity affects the health and well-being of millions of children and adolescents in the United States and is widely considered to be an "epidemic within an epidemic" that poses a major public health crisis. Currently, few effective treatments for severe obesity exist. Metabolic and bariatric surgery are existing but underuse treatment options for pediatric patients with severe obesity. Roux-en-Y gastric bypass and vertical sleeve gastrectomy are the most commonly performed metabolic and bariatric procedures in the United States and have been shown to result in sustained short-, mid-, and long-term weight loss, with associated resolution of multiple obesity-related comorbid diseases. Substantial evidence supports the safety and effectiveness of surgical weight loss for children and adolescents, and robust best practice guidelines for these procedures exist.
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Affiliation(s)
- Christopher F Bolling
- Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| | - Sarah C Armstrong
- Departments of Pediatrics and Population Health Sciences, Duke Center for Childhood Obesity Research, and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Kirk W Reichard
- Division of Pediatric Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; and
| | - Marc P Michalsky
- Department of Pediatric Surgery, College of Medicine, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio
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96
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Reddy YNV, Obokata M, Testani JM, Felker GM, Tang WHW, Abou-Ezzeddine OF, Sun JL, Chakrabothy H, McNulty S, Shah SJ, Lewis GD, Stevenson LW, Redfield MM, Borlaug BA. Adverse Renal Response to Decongestion in the Obese Phenotype of Heart Failure With Preserved Ejection Fraction. J Card Fail 2019; 26:101-107. [PMID: 31618698 DOI: 10.1016/j.cardfail.2019.09.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/17/2019] [Accepted: 09/28/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with heart failure (HF) with preserved ejection fraction (HFpEF) and obesity display a number of pathophysiologic features that may render them more or less vulnerable to negative effects of decongestion on renal function, including greater right ventricular remodeling, plasma volume expansion and pericardial restraint. We aimed to contrast the renal response to decongestion in obese compared to nonobese patients with HFpEF METHODS AND RESULTS: National Institutes of Health heart failure network studies that enrolled patients with acute decompensated HFpEF (EF ≥ 50%) were included (DOSE, CARRESS, ROSE, and ATHENA). Obese HFpEF was defined as a body mass index ≥ 30 kg/m2. Compared to nonobese HFpEF (n = 118), patients with obese HFpEF (n = 214) were an average of 9 years younger (71 vs 80 years,< 0.001), were more likely to have diabetes (64% vs 31%, P< 0.001) but had less atrial fibrillation (56% vs 75%, P< 0.001). Renal dysfunction (glomerular filtration rate < 60 mL/min/1.73m2) was present in 82% of patients, and there was no difference at baseline between obese and nonobese patients. Despite similar weight loss through decongestive therapies, obese patients with HFpEF demonstrated greater rise in creatinine (Cr) and decline in glomerular filtration rate, with a 2-fold higher incidence of mild worsening renal function (rise in Cr ≥ 0.3 mg/dL) (28 vs 14%, P = 0.008) and a substantially greater increase in severe worsening of renal function (rise in Cr > 0.5 mg/dL) (9 vs 0%, P = 0.002). CONCLUSIONS Despite being nearly a decade younger, obese patients with HFpEF experience greater deterioration in renal function during decongestion than do nonobese patients with HFpEF. Further study to elucidate the complex relationships between volume distribution, cardiorenal hemodynamics and adiposity in HFpEF is needed.
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Affiliation(s)
- Yogesh N V Reddy
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Masaru Obokata
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey M Testani
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - G Michael Felker
- Deparment of Cardiovscular Medicine, Duke University, Durham, NC
| | - W H Wilson Tang
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Deparment of Cardiovscular Medicine, Duke University, Durham, NC; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Deparment of Cardiovscular Medicine, Vanderbilt University, Nashville, TN
| | | | - Jie-Lena Sun
- Deparment of Cardiovscular Medicine, Duke University, Durham, NC
| | | | - Steven McNulty
- Deparment of Cardiovscular Medicine, Duke University, Durham, NC
| | - Sanjiv J Shah
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Deparment of Cardiovscular Medicine, Duke University, Durham, NC; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Deparment of Cardiovscular Medicine, Vanderbilt University, Nashville, TN
| | - Gregory D Lewis
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Deparment of Cardiovscular Medicine, Duke University, Durham, NC; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Deparment of Cardiovscular Medicine, Vanderbilt University, Nashville, TN
| | - Lynne W Stevenson
- Deparment of Cardiovscular Medicine, Vanderbilt University, Nashville, TN
| | | | - Barry A Borlaug
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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97
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Kyler KE, Bettenhausen JL, Hall M, Fraser JD, Sweeney B. Trends in Volume and Utilization Outcomes in Adolescent Metabolic and Bariatric Surgery at Children's Hospitals. J Adolesc Health 2019; 65:331-336. [PMID: 31196785 DOI: 10.1016/j.jadohealth.2019.02.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/25/2019] [Accepted: 02/25/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE As the prevalence of obesity increases in adolescents, the rate of metabolic and bariatric surgery (MBS) is also rising. Little is known about MBS rates at children's hospitals. This study describes trends in adolescent MBS volume and examines hospital resource utilization among patients undergoing MBS at children's hospitals. METHODS We performed a retrospective cohort study using a large pediatric hospital database (Inpatient Essentials database) to identify adolescents aged 10-18 years who underwent MBS from 2012 to 2016. Procedures were identified based on the presence of diagnosis codes for obesity and bariatric surgery. Our primary outcome was annual MBS volume, and secondary outcomes included cost, length of stay (LOS), and 30-day readmission rates. RESULTS A total of 859 adolescents from 39 children's hospitals underwent MBS during the study timeframe. Included patients were typically aged >16 years (49.7%), female (73.3%), and non-Hispanic white (50.5%). The number of bariatric surgeries increased 1.8-fold, from 126 in 2012 to 220 in 2016 (p = .004). There was considerable variation in the number of procedures by hospital, ranging from 1 to 159, with a median of 4 (interquartile range: 1-18) procedures per hospital. As the annual number of surgeries increased, LOS decreased by 1 day (p = .028) and cost decreased by 22% (p < .001), without a change in readmission rates (p = .925). CONCLUSION MBS rates are increasing in children's hospitals, whereas LOS and cost are decreasing, without affecting readmission rates. These findings may be useful for development of quality benchmarks for developing and existing MBS programs within children's hospitals.
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Affiliation(s)
- Kathryn E Kyler
- Division of Hospital Medicine, Children's Mercy Kansas City, Kansas City, Missouri.
| | | | - Matthew Hall
- Division of Hospital Medicine, Children's Mercy Kansas City, Kansas City, Missouri; Children's Hospital Association, Lenexa, Kansas
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Brooke Sweeney
- Center for Children's Healthy Lifestyles & Nutrition, Children's Mercy Kansas City, Kansas City, Missouri
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98
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Upper Gastrointestinal Endoscopy in Adolescents With Severe Obesity Before Vertical Sleeve Gastrectomy. J Pediatr Gastroenterol Nutr 2019; 69:287-291. [PMID: 31436669 DOI: 10.1097/mpg.0000000000002371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Esophagogastroduodenoscopy (EGD) is often performed to evaluate for mucosal and anatomical abnormalities before vertical sleeve gastrectomy (SG). Little is known, however, about how prebariatric EGD in adolescents influences clinical management or outcome. Our aim was to assess if an abnormal prebariatric EGD resulted in interventions or modification of bariatric surgery. METHODS We performed a retrospective cohort study of adolescents undergoing evaluation for bariatric surgery. We obtained demographic and anthropometric data in addition to EGD findings, biopsy pathology, gastrointestinal symptoms, and surgical outcomes. An EGD was considered abnormal if either abnormal gross findings or abnormal pathology was reported. Patients were followed until a 6-week postop visit. RESULTS Of 134 patients presenting for evaluation, 94 (70%) underwent preoperative EGD. Fifty-one (54%) had a normal EGD and 43 (46%) had EGD abnormalities including 7 with an anatomical abnormality and 36 with mild mucosal abnormalities. Among patients with EGD abnormalities, 22% received medical intervention including proton pump inhibitor (PPI) administration (n = 10) and Helicobacter pylori eradication (n = 11). GI symptoms were the only predictor of EGD abnormalities (odds ratio [OR] 4.9: 95% confidence interval [CI] 1.6-15.0; P < 0.001). No factors predicted likelihood of a post-EGD intervention. An abnormal EGD did not correlate with any postoperative complications. CONCLUSIONS In this cohort of adolescents undergoing evaluation for SG, 46% had an abnormal EGD, of which 22% received a medical intervention. Symptoms were the only predictor of EGD abnormalities. Abnormal EGD findings were not associated with modification of the surgery or any adverse outcome.
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99
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Progress in understanding youth-onset type 2 diabetes in the United States: recent lessons from clinical trials. World J Pediatr 2019; 15:315-321. [PMID: 31077083 DOI: 10.1007/s12519-019-00247-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/20/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Due to the dramatic increase in the rates of childhood obesity and youth-onset type 2 diabetes (T2D) in the late 1990s in the United States, the US government, through the National Institute of Diabetes, Digestive Disease, and Kidney (NIDDK) and the Centers for Disease Control, funded a series of large studies and trials which, together, have formed the basis for much of what we currently understand about youth-onset T2D. DATA SOURCES The review focus on the recent results and implications of the treatment options for Type 2 Diabetes in Adolescents and Youth (TODAY) study and the Restoring Insulin Secretion (RISE) study. RESULTS AND CONCLUSIONS Both TODAY and RISE studies have provided critical insight into the unique aspects of the pathophysiology of youth-onset type 2 diabetes and also provided the evidence base for our current approach to the management of this disorder.
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100
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Chu L, Howell B, Steinberg A, Bar-Dayan A, Toulany A, Langer JC, Hamilton JK. Early weight loss in adolescents following bariatric surgery predicts weight loss at 12 and 24 months. Pediatr Obes 2019; 14:e12519. [PMID: 30843377 DOI: 10.1111/ijpo.12519] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/01/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Growing evidence supports the efficacy of paediatric bariatric surgery. However, there is a paucity of data examining adolescent outcomes post surgery. Among adults, studies have shown that early weight loss is associated with long-term weight loss. Therefore, the aim of our study was to investigate the association between early weight loss at 3 months with longer-term weight loss at 12 and 24 months in adolescents post surgery. We hypothesized that patients who have greater weight loss within the first 3 months will have greater weight loss at 12 and 24 months post surgery. METHODS A retrospective chart review of bariatric surgery patients (n = 28) was conducted. Anthropometric measurements at baseline and 3, 12, and 24 months were analysed. RESULTS Percent of excess weight loss (%EWL) at 3, 12, and 24 months were 33.6 ± 11.3%, 55.0 ± 20.5%, and 55.1 ± 27.1%, respectively. %EWL at 3 months was positively associated with %EWL at 12 and 24 months (P < 0.05). Receiver operating characteristic curve results identified a cut-off of greater than or equal to 30%EWL at 3 months predicted successful weight loss, defined as greater than or equal to 50%EWL at 12 and 24 months. CONCLUSION These findings demonstrate that majority of weight loss among adolescents occurs within the first postoperative year. Greater %EWL by 3 months post surgery predicts successful and sustained weight loss over time.
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Affiliation(s)
- Lisa Chu
- SickKids Team Obesity Management Program, Division of Endocrinology, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Brooke Howell
- SickKids Team Obesity Management Program, Division of Endocrinology, The Hospital for Sick Children, Toronto, Canada
| | - Alissa Steinberg
- SickKids Team Obesity Management Program, Division of Endocrinology, The Hospital for Sick Children, Toronto, Canada
| | - Alisa Bar-Dayan
- SickKids Team Obesity Management Program, Division of Endocrinology, The Hospital for Sick Children, Toronto, Canada
| | - Alene Toulany
- SickKids Team Obesity Management Program, Division of Endocrinology, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Jacob C Langer
- Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Jill K Hamilton
- SickKids Team Obesity Management Program, Division of Endocrinology, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
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