Treatment considerations for severe adolescent obesity

Effects of multidisciplinary interventions on weight loss and health outcomes in children and adolescents with morbid obesity

OBJECTIVE

Morbid obesity is the fastest growing subcategory of childhood obesity, associated with an increased health risk that persists into adulthood. There is an urgent need to develop multifaceted interventions that target initial and long-term lifestyle changes. This review investigates the effects of multidisciplinary interventions on weight loss and health outcomes in children and adolescents with morbid obesity. The influence of age, gender and family participation on health outcomes and intensive treatment alternatives are explored.

METHODS

The review includes 16 studies conducted between 1995 and 2017. Studies examined youth with morbid obesity, 4-18 years old, undergoing multidisciplinary treatment.

RESULTS

All studies found a reduction in body mass index (BMI or z-score) and if measured, cardiovascular risk factors. Physical activity, nutrition education, behavioural modification and family involvement are commonly included treatment components and have improved weight loss and health-related outcomes. However, initial weight loss was often not sustainable, despite the favourable interventional effect on cardiometabolic risk markers. Weight loss was prolonged in younger children and among the male sex.

CONCLUSIONS

There is not a 'one-size-fits-all' treatment approach, and matched care to personal needs is preferable. The integration of a chronic care approach is critical for the successful adaption of sustainable health behaviours.

Adolescent bariatric surgery program characteristics: the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study experience

The number of adolescents undergoing weight loss surgery (WLS) has increased in response to the increasing prevalence of severe childhood obesity. Adolescents undergoing WLS require unique support, which may differ from adult programs. The aim of this study was to describe institutional and programmatic characteristics of centers participating in Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS), a prospective study investigating safety and efficacy of adolescent WLS. Data were obtained from the Teen-LABS database, and site survey completed by Teen-LABS investigators. The survey queried (1) institutional characteristics, (2) multidisciplinary team composition, (3) clinical program characteristics, and (4) clinical research infrastructure. All centers had extensive multidisciplinary involvement in the assessment, pre-operative education, and post-operative management of adolescents undergoing WLS. Eligibility criteria and pre-operative clinical and diagnostic evaluations were similar between programs. All programs have well-developed clinical research infrastructure, use adolescent-specific educational resources, and maintain specialty equipment, including high weight capacity diagnostic imaging equipment. The composition of clinical team and institutional resources is consistent with current clinical practice guidelines. These characteristics, coupled with dedicated research staff, have facilitated enrollment of 242 participants into Teen-LABS.

The increasing incidence of adolescent bariatric surgery

BACKGROUND

Morbid obesity continues to be a significant problem within the United States, as overweight/obesity rates are nearing 33%. Bariatric surgery has had success in treating obesity in adults and is becoming a viable treatment option for obese adolescents.

METHODS

We studied 1615 inpatient admissions for children ≤20 years of age undergoing a bariatric procedure for morbid obesity in 2009 using the Kids' Inpatient Database (KID). Patients had a principal diagnosis of obesity and a bariatric procedure listed as one of their first 5 procedures. Procedures (open gastric bypass, laparoscopic gastric bypass, sleeve gastrectomy, laparoscopic gastroplasty, and laparoscopic gastric band) and complications were defined by ICD-9 codes.

RESULTS

There were 90 open gastric bypasses, 906 laparoscopic gastric bypasses, 150 sleeve gastrectomies, 18 laparoscopic gastroplasties, and 445 laparoscopic gastric bandings. The length of stay for each procedure was 2.44, 2.20, 2.33, 1.10, and 1.02 days, respectively (P<0.001). The complication rates were 3.3%, 3.5%, 0.7%, 0.0%, 0.2%, respectively (P=0.004).

CONCLUSIONS

Bariatric surgery is an increasingly utilized option for the treatment of morbid obesity among adolescents. The procedures can be performed safely as evidenced by low complication rates. Additional long-term follow-up is necessary.

Bariatric surgery for obese adolescents: should surgery be used to treat the childhood obesity epidemic?

The prevalence of pediatric obesity has greatly increased over the past several decades, affecting both males and females among all racial and ethnic groups, and bringing with it comorbidities that were only observed in adults in the past. Childhood obesity is the most alarming public health issue facing the world today. Lifestyle modifications to reverse obesity are considered the cornerstone of treatment, but compliance is often poor and results may be minimal. Thus, many adolescents are turning to bariatric surgery as a treatment for obesity and its complications. The long-term success rate, consequences and risks for the pediatric population are still unknown, as is the compliance rate with the necessary dietary modifications that are required after these procedures.

Recent advances and controversies in pediatric laparoscopic surgery

Children represent a unique group of patients who are likely to greatly benefit from minimally invasive surgery (MIS). The promise of less postoperative pain, smaller scars, shorter hospital stays, and a faster return to school continues to drive growth in this area. The development of pediatric-specific techniques and documentation of improved outcomes form a critical gateway to widespread application of pediatric MIS. A brief perspective on current approaches to MIS for pediatric congenital and acquired disease is provided in this report. Technical departures from standardized adult MIS and the rationale for their modification are highlighted.

Sleeve gastrectomy in a 10-year-old child

Adolescents bariatric surgery (ABS) in morbid obesity (MO), with or without comorbid conditions, is and will be more and more indicated. Restrictive operations have the advantage of no influence on absorption. Laparoscopic sleeve gastrectomy (LSG) can be an excellent alternative. A LSG was done in a 10-year-old boy, body mass index (BMI) 42, who has Blount's disease (tibia vara) with severe pain at the knee joints that made him a wheelchair-bound person. He had a LSG and gallbladder removal without incidents. Eight months later, he has a BMI 28 and almost all his knees pain is gone. No side effects have been detected. A LSG may be the ideal bariatric operation for ABS with MO.

Preferential loss of central (trunk) adiposity in adolescents and young adults after laparoscopic gastric bypass

BACKGROUND

An increasing number of young people are developing severe obesity with adult-like co-morbidities and undergoing bariatric surgery. Although a number of studies have described major weight loss after bariatric surgery, none have examined the proportions of lean body and fat mass lost or the potentially more important issue of changes in regional fat mass distribution after laparoscopic gastric bypass surgery.

METHODS

Five morbidly obese females (mean age 18) were evaluated by standard anthropometric measures and dual energy x-ray absorptiometry at baseline and 1 year after bariatric surgery. The mean and SD values for the anthropometric and dual energy x-ray absorptiometry body composition variables were calculated, and the differences were evaluated using paired t tests.

RESULTS

Significant body mass index and weight loss were seen in all subjects at 1 year, with the percentage of excess weight loss at 63.4%. Overall fat mass loss exceeded lean mass loss by threefold in this cohort (P <.01), demonstrating the relative sparing of lean mass. Their waist circumference also decreased significantly. Using dual energy x-ray absorptiometry analysis, the vast majority (83%) of central mass loss consisted of adipose tissue. Central fat loss significantly exceeded peripheral fat loss by 1.6-fold (P = .03).

CONCLUSION

These results have demonstrated the preferential loss of central adiposity in morbidly obese young women after 1 year of surgical weight loss and may be more informative than anthropometric measurements alone. Given the association between central adiposity and the risk of subsequent cardiovascular disease, these results are suggestive of reduced cardiac risk.

Predictors of patient selection in bariatric surgery

OBJECTIVE

To identify sociodemographic and clinical predictors of patient selection in bariatric surgery.

SUMMARY BACKGROUND DATA

Population-based studies suggest that bariatric surgery patients are disproportionately privately insured, middle-aged white women. It is uncertain whether such disparities are due to surgeon decisions to operate, differences among morbidly obese individuals in access to surgery, or patients' personal preferences regarding surgical treatment.

METHODS

We conducted a national survey of 1343 U.S. bariatric surgeons. The questionnaire contained clinical vignettes generated using a balanced fractional factorial design. For each of 3 hypothetical patients unique in age, race, gender, body mass index (BMI), comorbidities, social support, functional status, and insurance, respondents were asked if they would operate. Logistic regression was used to determine the odds of selection for each characteristic while controlling for the other 7 characteristics. Subset analyses were also performed using combinations of BMI and comorbidities.

RESULTS

A total of 62.5% of eligible surgeons responded (n = 820). Patient race did not influence surgeon decisions to operate. Hypothetical patient age, BMI, and social support were most influential. In the subgroup of patients who did not meet current NIH BMI and comorbidity criteria for bariatric surgery, male sex (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.14-0.76) was associated with decreased odds of selection. Overall, younger age (OR, 0.09; 95% CI, 0.07-0.11), older age (OR, 0.70; 95% CI, 0.56-0.90), limited functional status (OR, 0.66; 95% CI, 0.52-0.82), poor social support (OR, 0.37; 95% CI, 0.30-0.47), self-pay (OR, 0.72; 95% CI, 0.57-0.91), and public insurance (OR, 0.54; 95% CI, 0.43-0.67) were associated with decreased odds of selection. BMI and comorbidity criteria influenced the magnitude of these effects.

CONCLUSIONS

Patient race did not play a role in surgeon decisions to operate. Further research should examine the roles of unequal access to bariatric surgery and differing socio-cultural perceptions of morbid obesity on racial disparities. The influence of patient age, gender, insurance status, social support, and functional status on decisions to operate was mitigated by BMI and comorbidities. Policy-makers currently debating BMI and comorbidity criteria for bariatric surgery should also consider guidelines pertaining to these sociodemographic issues that influence patient selection in bariatric surgery.