Bariatric surgery for morbidly obese adolescents: is there a rationale for early intervention?

Outcomes in morbidly obese adolescent patients undergoing laparoscopic sleeve gastrectomy in the Indian subcontinent: A retrospective review

Introduction:

There is a worldwide increase in the prevalence of obesity among the adolescent population in India from 16.3% in 2001 to 19.3% in 2010. Recent evidence suggests that bariatric surgery leads to resolution of comorbidities and associated long-term complications in adolescent patients with morbid obesity.

Aim:

The aim of this study is to determine the impact of bariatric surgery on the weight loss and comorbidities of morbidly obese adolescents.

Materials and Methods:

A retrospective review of the data of 10 adolescent patients, who underwent Laparoscopic Sleeve Gastrectomy at our institute (tertiary care hospital), from July 2009 to July 2016 was carried out.

Results:

Of the 10 patients, 4 patients had syndromic forms of obesity. The median age was 16.54 years. The median pre-operative weight and height were 112 kg and 154 cm, respectively, with a body mass index of 47.2 kg/m². There was no intra-operative or post-operative complication except for suspected methylene blue toxicity in one patient which was treated conservatively. Median follow-up period was 1 year (0–5 years). The patients had an increase in excess weight loss (EWL) of 54.5% until the end of 1 year. There was a regain of weight between the 1^st and 2^nd year, followed by a sustained weight loss achieving 44.8% EWL at 3 years and 60% at the end of 5 years (only two patients followed up at 5 years). Similar results were found in syndromic patients. Among the four diabetic patients, three had complete resolution and one had improvement in diabetes status. Among the three patients with obstructive sleep apnoea, two patients had complete resolution, while one patient had improvement in symptoms. One patient with hypocortisolism improved after surgery with a decrease in the steroid requirement. Among the hypothyroid patients, one patient had a complete resolution, one patient had improvement in hypothyroid status while two patients had no change.

Conclusion:

Bariatric surgery is effective for morbidly obese adolescents, leading to significant resolutions of comorbid illness.

Bariatric Surgery in Youth

Bariatric surgery provides a clinically effective and cost-effective means of achieving sustained weight reduction and management of associated comorbidities and has been met with increasing enthusiasm for application in obese youth. Following trends seen among obese adults, carefully selected obese youth are now undergoing bariatric surgical procedures with excellent short-term and intermediate-term outcomes. Although long-term data are not yet available, the results thus far hold great promise in the management of this population.

Development of significant disordered eating in an adolescent following gastric bypass surgery

The development of eating pathology is a concern following bariatric surgery, even in the absence of any pre-surgical psychopathology. No consistent risk factors have emerged in the literature to identify those at greatest risk. However, post-surgical guidelines encourage eating behaviors that would be considered disordered in other contexts. We present a case of an adolescent developing bulimia nervosa following gastric bypass surgery and the escalation of her symptoms from diligently following recommended food behaviors to a full-syndrome clinical eating disorder. We discuss the differences between appropriate post-surgical eating behaviors and disordered eating behaviors. We provide recommendations for clinicians to screen for eating pathology and referrals to an interprofessional treatment team to address eating disordered behaviors and cognitions.

Energetic adaptations persist after bariatric surgery in severely obese adolescents

OBJECTIVE

Energetic adaptations induced by bariatric surgery have not been studied in adolescents or for extended periods postsurgery. Energetic, metabolic, and neuroendocrine responses to Roux-en-Y gastric bypass (RYGB) surgery were investigated in extremely obese adolescents.

METHODS

At baseline and at 1.5, 6, and 12 months post-baseline, 24-h room calorimetry, body composition, and fasting blood biochemistries were measured in 11 obese adolescents relative to five matched controls.

RESULTS

In the RYGB group, mean weight loss was 44 ± 19 kg at 12 months. Total energy expenditure (TEE), activity EE, basal metabolic rate (BMR), sleep EE, and walking EE significantly declined by 1.5 months (P = 0.001) and remained suppressed at 6 and 12 months. Adjusted for age, sex, fat-free mass, and fat mass, EE was still lower than baseline (P = 0.001). Decreases in serum insulin, leptin, and triiodothyronine (T3), gut hormones, and urinary norepinephrine (NE) paralleled the decline in EE. Adjusted changes in TEE, BMR, and/or sleep EE were associated with decreases in insulin, homeostatic model assessment, leptin, thyroid stimulating hormone, total T3, peptide YY3-36, glucagon-like peptide-2, and urinary NE and epinephrine (P = 0.001-0.05).

CONCLUSIONS

Energetic adaptations in response to RYGB-induced weight loss are associated with changes in insulin, adipokines, thyroid hormones, gut hormones, and sympathetic nervous system activity and persists 12 months postsurgery.

Laparoscopic gastric plication in the morbidly obese adolescent patient

Childhood obesity is a significant problem. Due in part to suboptimal weight loss with lifestyle intervention alone, bariatric surgery, combined with ongoing lifestyle changes, has become a favorable approach in adolescents with severe obesity and weight-related comorbidities and is associated with effective weight loss and reducing weight-related comorbidities. Laparoscopic greater curvature plication is a promising new bariatric surgical procedure that has been shown to be effective in adults with severe obesity but has not been evaluated in the adolescent population. Gastric plication may be a particularly attractive approach for the adolescent patient as it is potentially reversible, does not involve the surgical removal of tissue, and is without a significant malabsorptive component. Our team has obtained approval from our Institutional Review Board to perform a laparoscopic greater curvature plication on 30 adolescent patients with severe obesity and study its effect on weight loss, metabolic effects, and psychological functioning in the setting of a multidisciplinary program. Results of this study, including comprehensive clinical and psychological data collected over a 3.5-year span, will inform larger prospective investigations comparing the laparoscopic greater curvature plication and other bariatric operations in the adolescent population.

Medical and psychosocial implications of adolescent extreme obesity - acceptance and effects of structured care, short: Youth with Extreme Obesity Study (YES)

Background

Prevalence rates of overweight and obesity have increased in German children and adolescents in the last three decades. Adolescents with extreme obesity represent a distinct risk group. On the basis of data obtained by the German Child and Youth Survey (KiGGS) and the German district military offices we estimate that the group of extremely obese adolescents (BMI ≥ 35 kg/m²) currently encompasses approximately 200.000 adolescents aged 14 to 21 yrs. Conventional approaches focusing on weight reduction have largely proven futile for them. In addition, only a small percentage of adolescents with extreme obesity seek actively treatment for obesity while contributing disproportionately strong to health care costs. Because of somatic and psychiatric co-morbidities and social problems adolescents with extreme obesity require special attention within the medical care system.

We have initiated the project “Medical and psychosocial implications of adolescents with extreme obesity - acceptance and effects of structured care, short: ‘Youths with Extreme Obesity Study (YES)’”, which aims at improving the medical care and social support structures for youths with extreme obesity in Germany.

Methods/Design

We focus on identification of these subjects (baseline examination) and their acceptance of diagnostic and subsequent treatment procedures. In a randomized controlled trial (RCT) we will investigate the effectiveness of a low key group intervention not focusing on weight loss but aimed at the provision of obesity related information, alleviation of social isolation, school and vocational integration and improvement of self-esteem in comparison to a control group treated in a conventional way with focus on weight loss. Interested individuals who fulfill current recommended criteria for weight loss surgery will be provided with a structured preparation and follow-up programs. All subjects will be monitored within a long-term observational study to elucidate medical and psychosocial outcomes. Our aim is to evaluate realistic treatment options. Therefore inclusion and exclusion criteria are minimized.

We will recruit adolescents (age range 14–21 years) with extreme obesity (BMI ≥ 35 kg/m²) (extreme group) within 24 months (120 per centre, 5 centres) as well as obese adolescents being at risk for developing extreme obesity (BMI ≥ 30 – 34.9 kg/m²) (at risk group). Follow-up evalutations will be performed biannually after inclusion for several years depending on additional funding. In sum, we aim at establishing evaluated health care structures for extremely obese adolescents.

Discussion

The results of YES will be of importance for a frequently neglected group of individuals, for whom current medicine has little to offer in terms of structured access to empirically evaluated therapeutic programs. Thus, the results will be both a help for the adolescents within the study and for others in the future given that the trial will lead to a positive finding. Moreover, it will help practitioners and therapists to deal with this neglected group of individuals.

Trial registration

Project registration numbers for each subproject: 1.) ClinicalTrials.gov: NCT01625325, NCT01703273, NCT01662271, NCT01632098; 2.) Germanctr.de: DRKS00004172, DRKS00004195, DRKS00004198, DRKS00004197.

Mental Health Evaluations for Adolescents Prior to Bariatric Surgery: A Review of Existing Practices and a Specific Example of Assessment Procedures

OBJECTIVE

Best practice guidelines for adolescents considering bariatric surgery recommend a pre-operative mental health evaluation. However, only general information about these assessments appears in the literature, which makes consistency of administration challenging. This review proposes a specific empirically-derived format for pre-surgical mental health evaluations and summarizes currently available data on the psychiatric functioning of adolescents seeking bariatric surgery.

DESIGN

Studies of mental health evaluations for adults preparing for bariatric surgery are reviewed, as is the limited literature relevant to adolescent evaluations. A specific and detailed example of an evaluation (clinical interview, self-report questionnaires, cognitive assessment) used for younger patients at a major metropolitan hospital center is presented, followed by data from an initial group of adolescents completing this evaluation.

SUBJECTS

200 adolescents (n=139 female; age: 14-18 y, BMI: 35.4-83.3 kg/m²) presenting for bariatric surgery.

RESULTS

A notable subset of adolescents reported current Axis I conditions (31.5%) and current mental health treatment (29.5%), but reports of current illicit drug use (1.5%) and regular alcohol use (0.5%) were relatively rare. Procedures for using the completed evaluation and post-surgery monitoring of psychosocial issues are discussed.

CONCLUSIONS

Adolescents considering weight loss surgery should receive comprehensive pre-surgical mental health evaluations, but additional data are needed to develop specific recommendations the use of these evaluations in post-operative care.

Bariatric surgery for obese children and adolescents: a review of the moral challenges

BACKGROUND

Bariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open and transparent decision making process.

DISCUSSION

A wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.

SUMMARY

Performing bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents.

Revisiting Childhood Obesity: Persistent Underutilization of Surgical Intervention?

Over the last two decades, the prevalence of obesity in children ages 6 to 11 years has almost tripled, and more than tripled in teenagers. The purpose of this study is to define the characteristics of hospitalized obese children and utilization of bariatric surgery. Analysis of the 1998 to 2007 Healthcare Cost and Utilization Project Nationwide Inpatient Sample was conducted with years 2000, 2003, and 2006 substituted with the Kids’ Inpatient Database dataset. Records with diagnosis of obesity were included in the analysis with major comorbidities defined as the presence of hypertension, obstructive sleep apnea, diabetes mellitus, or coronary artery disease. National estimates over a 10-year period were calculated using sampling weights. Approximately 223,700 children met the inclusion criteria, of which 20 per cent were morbidly obese, with an overall 20 per cent incidence of major comorbidity. Comorbidities were found to be significantly higher among Asian/Pacific Islander (28.3%), African-American (27.2%), and Hispanic (19.1%; P < 0.001) compared with white (15.6%) children. Only 2 per cent of morbidly obese children with major comorbidity underwent a bariatric procedure. Obesity remains a growing childhood epidemic with a disproportionate ethnic burden of comorbidities. Bariatric surgery remains a viable option and a structured guideline in children may provide equitable access across different ethnic and socioeconomic groups.

Practical approaches to the treatment of severe pediatric obesity

Pediatric obesity is a major public health threat. Obese children and adolescents are at increased risk for many medical and surgical conditions. These conditions may affect their quality of life and life expectancy. The rapidly progressive nature of type 2 diabetes mellitus within the first 5 years of obesity diagnosis is particularly concerning. Because health risk increases with degree of obesity, adolescents who may be eligible for more aggressive obesity treatment should be identified and counseled.

A latent class analysis of psychiatric symptoms among 125 adolescents in a bariatric surgery program

OBJECTIVE

The purpose of this study was to examine whether subgroups could be identified among a sample of adolescents presenting for bariatric surgery.

METHODS

Participants were 125 severely obese adolescents enrolled in a bariatric surgery program referred for a psychiatric evaluation. A latent class analysis was conducted with self-report and clinician-rated measures of depressive symptoms, total problems by the Youth Self-Report Scale, anxiety severity, eating pathology, psychiatric diagnoses, quality of life, and family functioning.

RESULTS

A 3-class model yielded the best overall fit to the data. Adolescents in the ?eating pathology? class demonstrated high levels of both eating disordered and other psychopathology. The second class, or ?low psychopathology? class exhibited the fewest psychosocial problems, whereas adolescents in the third class were intermediate on measures of psychopathology, which is consistent with ?non-specific psychopathology.?

CONCLUSIONS

The latent class analysis identified homogeneous subgroups with different levels of psychopathology among a heterogeneous sample of severely obese adolescents. The identification of clinically relevant subgroups in this study offers an important initial means for examining psychopathology among adolescent bariatric surgery candidates and suggests a number of avenues for future research.

CLINICAL TRIALS REGISTRY

Laparoscopic Adjustable Gastric Banding (LAGB) as a Treatment for Morbid Obesity in Adolescents, NCT01045499.

Best practice updates for pediatric/adolescent weight loss surgery

The objective of this study is to update evidence-based best practice guidelines for pediatric/adolescent weight loss surgery (WLS). We performed a systematic search of English-language literature on WLS and pediatric, adolescent, gastric bypass, laparoscopic gastric banding, and extreme obesity published between April 2004 and May 2007 in PubMed, MEDLINE, and the Cochrane Library. Keywords were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. In light of evidence on the natural history of obesity and on outcomes of WLS in adolescents, guidelines for surgical treatment of obesity in this age group need to be updated. We recommend modification of selection criteria to include adolescents with BMI >or= 35 and specific obesity-related comorbidities for which there is clear evidence of important short-term morbidity (i.e., type 2 diabetes, severe steatohepatitis, pseudotumor cerebri, and moderate-to-severe obstructive sleep apnea). In addition, WLS should be considered for adolescents with extreme obesity (BMI >or= 40) and other comorbidities associated with long-term risks. We identified >1,085 papers; 186 of the most relevant were reviewed in detail. Regular updates of evidence-based recommendations for best practices in pediatric/adolescent WLS are required to address advances in technology and the growing evidence base in pediatric WLS. Key considerations in patient safety include carefully designed criteria for patient selection, multidisciplinary evaluation, choice of appropriate procedure, thorough screening and management of comorbidities, optimization of long-term compliance, and age-appropriate fully informed consent.

Management approaches for pediatric obesity

Childhood obesity is a worldwide problem that has reached epidemic proportions, resulting in an increased prevalence of premature obesity-related morbidities, and, thus, probable increased health-care costs to treat children. The development of viable approaches to manage this epidemic is crucial. Most experts in the field of childhood obesity agree that the prevention of obesity in children should be the first line of management. Pediatricians must be adept at recognizing children at risk of obesity, calculating and plotting the BMI at all visits, using a change in the BMI to identify excessive weight gain, and monitoring for comorbidities associated with obesity. If obesity is present, the cornerstone of treatment is modification of dietary and exercise habits. Practice-based counseling and community-based programs that support and encourage lifestyle modifications have yielded promising short-term results. Children with severe comorbidities who are unable to achieve lifestyle modifications can be considered for either pharmacologic therapy or surgery, but these options should be considered as a last resort. Early intervention and prevention strategies are the most cost-effective methods of dealing with this issue.

Pediatric obesity: parallels with addiction and treatment recommendations

Rates of pediatric obesity have increased dramatically over the past decade. This trend is especially alarming because obesity is associated with significant medical and psychosocial consequences. It may contribute to cardiovascular, metabolic, and hepatic complications, as well as to psychiatric difficulties. The development of obesity appears to be influenced by a complex array of genetic, metabolic, and neural frameworks, along with behavior, eating habits, and physical activity. Numerous parallels exist between obesity and addictive behaviors, including genetic predisposition, personality, environmental risk factors, and common neurobiological pathways in the brain. Typical treatments for pediatric obesity include behavioral interventions targeting diet or exercise. These treatments have yielded mixed results and typically have been examined in specialty clinic populations, limiting their generalizability. There are limited medication options for overweight children and adolescents, and no approved medical intervention in children younger than 16 years old. Bariatric surgery may be an option for some adolescents, but due to the risks of surgery, it is often seen as a last resort. The parallels between addiction and obesity aid in developing novel interventions for pediatric obesity. Motivational enhancement and cognitive-behavioral strategies used in addiction treatment may prove to be beneficial.

An overview of pediatric obesity

Pediatric obesity is increasing worldwide and disproportionately affects the economically and socially disadvantaged. Obese children are at risk of developing the (dys)metabolic syndrome, insulin resistance, early-onset type 2 diabetes mellitus, polycystic ovarian syndrome, hypertension, hyperlipidemia, and obstructive sleep apnoea. Those with diabetes may have mixed features of type 1 and type 2 diabetes mellitus. Pediatric obesity is the result of persistent adverse changes in food intake, lifestyle, and energy expenditure. It may be because of underlying a genetic syndrome or a conduct disorder. Children living in urban settings often lack safe, affordable, and accessible recreational facilities. Tight educational schedules mean less free time, while computer games and television have become preferred recreational activities. More families are eating out or eating take-out meals and processed foods at home because of pressures of work and time constraints. Consumer advertising targeted at children and the ready availability of vending machines encourage unwise food choices. Some children eat excessively because they are depressed, anxious, sad, or lonely. Often families and obese children are aware of the need for healthy eating and exercise but are unable to translate knowledge into weight loss. Population-based measures such as public education, school meal reforms, child-safe exercise friendly environments, and school-based and community-based exercise programs have been shown to be successful to varying degrees, but there remain individuals who will need special help to overcome obesity. Overeating (e.g. binge eating) may be a manifestation of disordered coping behavior but may also be because of defects in the neural and hormonal control of appetite and satiety. New pharmacological approaches are targeting these areas. We need a coordinated approach involving government, communities, and healthcare providers to provide a continuum of population-based interventions, focused screening, and personalized multidisciplinary interventions for the obese child and family.

A rat model of childhood diet-induced obesity: Roux-en-Y gastric bypass induced changes in metabolic parameters and gastric peptide ghrelin

Childhood morbid obesity is reaching epidemic proportions. Roux-en-Y gastric bypass (RYGB) results in many metabolic alterations, including changes in glucose and lipid metabolism, and changes in levels of the gastric hormone, ghrelin. As more children are undergoing RYGB, an animal model would be beneficial to further study RYGB and its subsequent metabolic effects. DIO Sprague Dawley rats underwent RYGB, sham jejunojejunostomy (SH), or no operation (HFC) after 6 weeks of high-fat diet. Non-obese rats fed standard chow (SC) were a final control group. Animals were post-operatively fed standard chow for 7 days before sacrifice. At sacrifice, venous blood and gastric mucosa was collected for metabolic parameters and ghrelin determination. RYGB rats weighed less than SH and HFC (361 +/- 8.8 vs. 437 +/- 9.3 and 443 +/- 6.2 g, P < 0.05). Compared to HFC, RYGB animals had decreased plasma glucose (292 +/- 23 vs. 141 +/- 10 mg/dL), cholesterol (80 +/- 12 vs. 45 +/- 5 mg/dL), triglycerides (138 +/- 37 vs. 52 +/- 7 mg/dL), HDL (43 +/- 5 vs. 20 +/- 3 mg/dL), and free fatty acids (0.72 +/- 0.14 vs. 0.23 +/- 0.02 mEq/L), all P < 0.05. Plasma ghrelin increased in RYGB rats compared to SC and HFC (116.22 +/- 32.27 vs. 31.60 +/- 2.66 and 31.75 +/- 0.75 pg/mL, P < 0.05). In a rat model of RYGB, we demonstrated improved metabolic parameters and increased plasma and gastric mRNA ghrelin levels. The rat model for RYBG appears to be a reasonable model for future study of the cellular and molecular regulatory pathways of obesity and its surgical treatment.

Effect of bariatric surgery on obstructive sleep apnoea in adolescents

Obese adolescents, particularly those with extreme obesity (body mass index > or =40 kg/m(2)), are developing serious medical complications at an unexpectedly high rate. As non-operative approaches to weight loss have shown less than optimal results, paediatric patients are increasingly seeking bariatric surgical intervention. Bariatric surgical procedures are designed to restrict stomach size or impair macronutrient absorption. They typically result in substantial weight loss. As with adult studies, paediatric studies generally report good obstructive sleep apnoea (OSA)-related outcomes after bariatric surgery. Therefore, in patients meeting eligibility criteria, bariatric surgery can be a valuable approach for achieving significant weight loss and resolution of serious comorbidities such as OSA. Studies that focus on long-term assessment of OSA are needed to understand whether OSA resolution after adolescent bariatric surgery is sustainable over the lifetime.