Efficacy of Intragastric Balloon Treatment for Adolescent Obesity

Successful Weight Loss in Adolescents with Overweight or Obesity Using a Swallowable Intragastric Balloon and Nutritional Oversight

PURPOSE

Medical devices benefit patients living with overweight or obesity, but studies in the adolescent population are lacking. The goal of this study was to collect information on the performance and safety of a swallowable intragastric balloon program (SGBP) in adolescent patients.

MATERIALS AND METHODS

Data were collected retrospectively on patients aged 15 to 17 years with body mass index (BMI) ≥ 27 kg/m2 who received the swallowable intragastric balloon (SGB) and associated lifestyle and nutritional change program. Patients had not responded to previous dietary and behavioral modification weight loss treatments and elected to undergo SGBP. The SGB was swallowed and filled with 550 mL of distilled water in an outpatient setting, and a multidisciplinary team delivered a lifestyle/nutritional change program. Mean % total body weight loss (%TBWL) was calculated for each patient compared with baseline.

RESULTS

A total of 91 patients, 69 (75.8%) female and 22 (24.2%) male, underwent SGBP and completed follow-up through SGB passage at 4 months. Baseline mean ± SD age, weight, and BMI were 16.4 ± 0.77, 99.70 ± 21.33 kg, and 35.60 ± 5.59 kg/m2, respectively. After 4 months, mean weight and BMI were 86.37 ± 18.83 kg and 30.86 ± 5.16 kg/m2 respectively; %TBWL was 13.05 ± 7.64 (1-sided t-test, p < 0.0001). Most (80, 87.9%) reported no adverse events; 11/91 (12.1%) experienced an adverse event. Of these, 9/91 (9.9%) experienced nausea and/or vomiting; 1/91 (1.1%) reported abdominal pain only; 1/91 (1.1%) reported flatulence only. There were no serious adverse events or premature device removals.

CONCLUSION

The SGBP provides safe and effective short-term weight loss in adolescents living with overweight and obesity.

Approach to the Treatment of Children and Adolescents with Obesity

Pediatric obesity continues to be an omnipresent disease; 1 in 5 children and adolescents have obesity in the United States. The comorbidities associated with youth-onset obesity tend to have a more severe disease progression in youth compared to their adult counterparts with the same obesity-related condition. A comorbidity of focus in this study is metabolism-associated steatotic liver disease (MASLD), which has rapidly evolved into the most common liver disease seen in the pediatric population. A direct association exists between the treatment of MASLD and the treatment of pediatric obesity. The current evidence supports that obesity treatment is safe and effective.

Type 2 diabetes in children and adolescents: Exploring the disease heterogeneity and research gaps to optimum management

Over the past 20 years, the incidence and prevalence of type 2 diabetes mellitus (T2DM) in children and adolescents have increased, particularly in racial and ethnic minorities. Despite the rise in T2DM in children and adolescents, the pathophysiology and progression of disease in this population are not clearly understood. Youth-onset T2DM has a more adverse clinical course than is seen in those who develop T2DM in adulthood or those with T1DM. Furthermore, the available therapeutic options are more limited for children and adolescents with T2DM compared to adult patients, mostly due to the challenges of implementing clinical trials. A better understanding of the mechanisms underlying the de-velopment and aggressive disease phenotype of T2DM in youth is important to finding effective prevention and management strategies. This review highlights the key evidence about T2DM in children and adolescents and its current burden and challenges both in clinical care and research activities.

Adolescents with Type 2 Diabetes: Overcoming Barriers to Effective Weight Management

The prevalence of type 2 diabetes (T2DM) among children and adolescents has remarkably increased in the last two decades, particularly among ethnic minorities. Management of T2DM is challenging in the adolescent population due to a constellation of factors, including biological, socioeconomic, cultural, and psychological barriers. Weight reduction is an essential component in management of T2DM as weight loss is associated with improvement in insulin sensitivity and glycemic status. A family centered and culturally appropriate approach offered by a multidisciplinary team is crucial to address the biological, psychosocial, cultural, and financial barriers to weight management in youth with T2DM. Lifestyle interventions and pharmacotherapy have shown modest efficacy in achieving weight reduction in adolescents with T2DM. Bariatric surgery is associated with excellent weight reduction and remission of T2DM in youth. Emerging therapies for weight reduction in youth include digital technologies, newer GLP-1 agonists and endoscopic procedures.

Caring for US Children: Barriers to Effective Treatment in Children with the Disease of Obesity

In 2020, impediments to pediatric obesity (PO) treatment remain pervasive, even though these barriers are clearly documented in medical literature. Providers must invest considerable resources to overcome these barriers to care. Notable barriers include gaps in medical education, misperceptions of the disease, weight bias and stigma, exclusion of coverage in health plans, and thus an unsustainable financial framework. Hence, this review offers an updated social-ecological framework of accessibility to care, wherein each barrier to care or variable is interdependent on the other and each is critical to creating forward momentum. The sum of all these variables is instrumental to overall smooth function, configured as a wheel. To treat PO effectively, all variables must be adequately addressed by stakeholders throughout the health care system in order to holistically comprehend and appreciate undertakings to advance the burgeoning field of PO medicine.

Obesity Treatment Among Adolescents: A Review of Current Evidence and Future Directions

Importance

Obesity in adolescence has reached epidemic proportions around the world, with the prevalence of severe obesity increasing at least 4-fold over the last 35 years. Most youths with obesity carry their excess adiposity into adulthood, which places them at increased risk for developing obesity-driven complications, such as type 2 diabetes and cardiovascular disease, and negatively affects social and emotional health. Given that adolescence is a unique transition period marked by significant physiologic and developmental changes, obesity-related complications can also negatively affect adolescent growth and developmental trajectories.

Observations

Provision of evidence-based treatment options that are tailored and appropriate for the adolescent population is paramount, yet complex. The multifactorial etiology of obesity along with the significant changes that occur during the adolescent period increasingly complicate the treatment approach for adolescent obesity. Treatment practices discussed in this review include an overview of evidence supporting currently available behavioral, pharmacologic, surgical, and device interventions for obesity. However, it is important to note that these practices have not been effective at reducing adolescent obesity at the population level.

Conclusions and Relevance

Because adolescent obesity requires lifelong treatment, effectively addressing this disease will require significant resources, scientific rigor, and the provision of access to quality care similar to other chronic health conditions. Effective and less invasive therapies, effective adjuncts, and comprehensive centers that offer specialized treatment are critical. This considerable need for increased attention to obesity care calls for dedicated resources in both education and research for treatment of obesity in youths.

Impact of Intragastric Balloon Treatment on Adipokines, Cytokines, and Metabolic Profile in Obese Individuals

BACKGROUND

Obesity is accompanied by adipose tissue remodeling characterized by increased production of tumor necrosis factor-alpha (TNF-α), interleukin (IL)-6, leptin and resistin and reduced secretion of adiponectin, which favors inflammation, metabolic disorders, and cardiovascular diseases. Although intragastric balloon (IGB) can be considered safe and effective for weight loss, its effect on serum levels of these biomarkers has been evaluated only in a few studies, while no previous study evaluated its effect on circulating levels of resistin, TNF-α, and IL-6. The aim of this study was to evaluate the changes in serum levels of metabolic and inflammatory biomarkers in obese patients submitted to IGB treatment.

METHODS

A prospective observational study involving 42 patients with obesity using IGB for 6 months. The patients were evaluated, on the day of insertion and withdrawal or adjustment of IGB, for the following: anthropometric measures and serum levels of adiponectin, leptin, resistin, TNF-α, IL-6, high-sensitivity C-reactive protein (hs-CRP), glucose, insulin, uric acid, triglycerides, and total cholesterol and fractions.

RESULTS

The body mass index decreased from 35.15 ± 0.41 to 29.50 ± 0.54 kg/m². There was a reduction (p < 0.05) in leptin, hs-CRP, glucose, insulin, HOMA-IR, and triglycerides, while the adiponectin/leptin ratio increased (p < 0.05). Moreover, weight loss presented (1) a positive association with the decrease in leptin, hs-CRP, glucose, insulin, HOMA-IR, uric acid, and total cholesterol and (2) a negative association with the reduction in adiponectin/leptin ratio.

CONCLUSIONS

The present study suggests that 6 months of IGB treatment in obese individuals reduce serum leptin and hs-CRP and improves insulin resistance and lipid profile which may decrease cardiovascular risk.

Changes in Body Adiposity, Dietary Intake, Physical Activity and Quality of Life of Obese Individuals Submitted to Intragastric Balloon Therapy for 6 Months

BACKGROUND

Obesity is an important risk factor for several chronic diseases and also is associated with worse quality of life. Intragastric balloon (IGB) is an effective method for weight loss. Although changes in lifestyle are critical to weight loss during and after IGB therapy, only a few studies evaluated dietary intake and none evaluated changes in physical activity with a validated questionnaire during the treatment. The aim of this study was to evaluate changes in total and central body adiposity, dietary intake, physical activity, and quality of life of patients with obesity submitted to IGB treatment for 6 months.

METHODS

Prospective observational study involving 42 patients with obesity using IGB for 6 months. The patients were evaluated, on the day of insertion and withdrawal or adjustment of IGB for total and central body adiposity (anthropometry and bioelectrical impedance), dietary intake, physical activity (Baecke questionnaire), and quality of life (SF-36 questionnaire).

RESULTS

There was a significant decrease in total and central body adiposity. The mean % total weight loss and % excess weight loss were 15.88 ± 1.42 and 56.04 ± 4.90, respectively and waist circumference decreased 13.33 ± 1.39 cm. There was a reduction in energy intake, an increase in physical activity, and an improvement of quality of life during IGB treatment.

CONCLUSION

The present study suggests that IGB treatment during 6 months in individuals with obesity is effective for decreasing total and central body adiposity being associated with reduction in energy intake, increase in physical activity, and improvement in quality of life.

Endoscopic intragastric balloon: a gimmick or a viable option for obesity?

Worldwide, the prevalence of obesity has doubled since 1980 in 70 countries. More than one in three adults now suffer from overweight or obesity. Health problems related to obesity include orthopedic problems, psychiatric conditions, metabolic and cardiovascular diseases, and of increasing concern, cancer. Thus, obesity has an enormous impact on the individual’s wellbeing as well as on society’s workforce and health care expenses. Medical efforts are ongoing to find safe and effective treatment options for obesity and its metabolic implications. At present, available treatment options include lifestyle interventions, pharmacotherapy, endoscopic applications, and bariatric surgery. Within the range of endoscopic treatment options, the intragastric balloon is the most widely used device. The idea is simple: the gastric volume is reduced by a balloon that is in most cases implanted by an endoscopic procedure similar to a gastroscopy. During the past decades, different models have been developed, which we will briefly introduce in this review. We aim at reviewing the pathophysiology underlying the effect of endoscopic intragastric balloon on weight loss and metabolic changes. We will assess expected short-term and long-term benefits for the patient, and we will discuss common side effects as well as rare complications. We will compare endoscopic intragastric balloon to conservative treatment options with or without pharmacological support on the one hand and to the spectrum of bariatric surgery on the other hand. In most patients, obesity must be considered a chronic disease that requires a lifelong treatment concept. In view of current treatment options for obesity, we will discuss whether endoscopic intragastric balloon is a viable treatment option, and who may be the right patient to benefit from it.

Endoscopic Sleeve Gastroplasty in 109 Consecutive Children and Adolescents With Obesity: Two-Year Outcomes of a New Modality

OBJECTIVES

Endoscopic sleeve gastroplasty (ESG) uses full-thickness sutures that restrict the stomach to a sleeve-like configuration. There is no published evidence on endoscopic tissue apposition techniques in pediatric patients. In this article, we report our ESG experience with the first 109 pediatric patients with obesity who underwent ESG under our care.

METHODS

ESG was offered as a day-case procedure under a standardized protocol and clinical pathway that included surgical, medical, and endoscopic modalities for the treatment of pediatric and adult obesity. ClinicalTrials.gov Identifier: NCT03778697.

RESULTS

The 109 patients in this study had a baseline body mass index and age of 33.0 ± 4.7 and 17.6 ± 2.2 (range: 10-21) years, respectively. Ninety-nine (90.8%) were females. The mean procedure time was 61 ± 19 minutes. The mean % total weight loss at 6, 12, 18, and 24 months was 14.4% ± 6.5%, 16.2% ± 8.3%, 15.4% ± 9.2%, and 13.7% ± 8.0%, respectively. Fourteen adolescents visited the ambulatory clinic for analgesia. One patient (aged 19.8 years) requested removal of endoscopic stitches due to abdominal pain, and another underwent Redo-ESG for insufficient weight loss. There were no blood transfusions, emergency admissions, mortality, or significant morbidity.

DISCUSSION

In this first study to date on ESG in pediatric patients, we observed that the procedure is safe and effective in children and adolescents with obesity. Significant weight loss occurs during the first 2 years without mortality or significant morbidity, and this weight loss seems to be maintained.

Insights on Obesity in Children and Adults: Individualizing Management

For the management of obesity in childhood and adolescence, nonoperative approaches have limited efficacy, including community-based and behavioral interventions and pharmacotherapy approved for use in adults. Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy are efficacious in reducing weight, body mass index, and comorbidities in adolescents. Understanding the phenotype associated with obesity provides an opportunity to individualize patients' treatments directed at the brain-gut axis. These phenotypes include rapid gastric emptying, increased fasting gastric volume, reduced postprandial incretins, and central mechanisms that impact appetite and satiation including hedonic eating and affective disorders. Further studies are required in adolescents. Identifying phenotypes could enhance the efficacy of behavioral, dietary, and pharmacotherapeutic interventions alone or in combination in children and adolescents.

Working toward precision medicine approaches to treat severe obesity in adolescents: report of an NIH workshop

Adolescent severe obesity is a prevalent, chronic, and serious disease with few effective and safe treatment options. To address this issue, a National Institutes of Health-sponsored workshop entitled "Developing Precision Medicine Approaches to the Treatment of Severe Obesity in Adolescents," was convened, bringing together a multidisciplinary group of experts to review the current state of the science and identify (1) what is known regarding the epidemiology and biopsychosocial determinants of severe obesity in adolescents, (2) what is known regarding effectiveness of treatments for severe obesity in adolescents and predictors of response, and (3) gaps and opportunities for future research to develop more effective and targeted treatments for adolescents with severe obesity. Major topical areas discussed at the workshop included: appropriate BMI metrics, valid measures of phenotypes and predictors, mechanisms associated with the development of severe obesity, novel treatments informed by biologically and psychosocially plausible mechanisms, biopsychosocial phenotypes predicting treatment response, standardization of outcome measures and results reporting in research, and improving clinical care. Substantial gaps in knowledge were identified regarding the basic behavioral, psychosocial, and biological mechanisms driving the development of severe obesity and the influence of these factors on treatment response. Additional exploratory and observational studies are needed to better understand the heterogeneous etiology of severe obesity and explain the high degree of variability observed with interventions. Tailored treatment strategies that may be developed by achieving a better understanding of individual differences in genetic endowment, clinical, metabolic, psychological, and behavioral phenotypes, and response to environmental exposures need to be tested. It is anticipated that these recommendations for future research, including strategies to enhance methodological rigor, will advance precision medicine approaches to treat severe obesity in adolescents more effectively.

Treatment Options for Severe Obesity in the Pediatric Population: Current Limitations and Future Opportunities

OBJECTIVE

Severe obesity is the only obesity classification increasing in prevalence among children and adolescents. Treatment options that produce meaningful and sustained weight loss and comorbidity resolution are urgently needed.

METHODS

The purpose of this review is to provide a brief overview of the current treatment options for pediatric severe obesity and offer suggestions regarding future opportunities for accelerating the development and evaluation of innovative treatment strategies.

RESULTS

At present, there are three treatment options for youth with severe obesity: lifestyle modification therapy, pharmacotherapy, and bariatric surgery. Lifestyle modification therapy can be useful for improving many chronic disease risk factors and comorbid conditions but often fails to achieve clinically meaningful and sustainable weight loss. Pharmacotherapy holds promise as an effective adjunctive treatment but remains in the primordial stages of development in the pediatric population. Bariatric surgery provides robust weight loss and risk factor/comorbidity improvements but is accompanied by higher risks and lower uptake compared to lifestyle modification therapy and pharmacotherapy. New areas worth pursuing include combination pharmacotherapy, device therapy, identification of predictors of response aimed at precision treatment, and interventions in the postbariatric surgical setting to improve long-term outcomes.

CONCLUSIONS

Treating pediatric severe obesity effectively and safely is extremely challenging. Some progress has been made, but substantially more effort and innovation are needed in the future to combat this serious and ongoing medical and public health issue.