Teen and Childhood Obesity

Behavioral weight management programs have been shown to be somewhat more effective for obese children and adolescents than adults. In cases of extreme obesity (more than 100 pounds over ideal weight) however, behavioral weight loss programs are poorly attended and weight loss is not optimal. For adolescents with BMI values more than 40 kg/m2, research suggests that ≤ 3% BMI reduction occurs one year after participation in an organized weight management program (Lawson et.al.; Levine et.al.). Poor weight loss results have also been reported for pre-adolescents with extreme obesity. Pharmacologic trials of orlistat in adolescents have shown to decrease BMI by ≤ 5%while centrally acting sibutrimine has been slightly more effective, causing an 8% reduction in weight over one year. With this said, some patients may experience cardiovascular side effects with the use of sibutrimine. Currently, there is no information assessing the ability of drug-induced weight loss beyond 1 year. While comorbidities in extremely obese youth are well documented, most evidence suggests that very few non-surgical treatment options produce significant long term weight loss.

National trends in the use of bariatric surgery to treat adolescent obesity
Bariatric surgery has been used to treat extreme obesity for nearly half a century in the United States. Bariatric surgery is a proven treatment for extremely obese adults, and several procedures were endorsed in 1991 by a Consensus Development Conference of the National Institutes of Health. Do to the clearly demonstrated adverse effects of adult obesity on all-cause mortality, bariatric surgery is recommended for those who are morbidly obese and who have failed prior non-surgical obesity management attempts. As we observe an ever rising number of physical, psychosocial and medical comorbidities in morbidly obese pediatric populations, we must consider and evaluate pediatric patients for surgical intervention.

Very little population-based research assessing the use and/or safety of bariatric surgery for youth has been conducted to date, but recently data pertaining to nationwide trends in the use of adolescent bariatric surgery and basic comparisons of early postoperative outcome between adolescents and adults have been published (Tsai et.al.). Between 1996 and 2003, nearly 3,000 bariatric procedures were performed in adolescents; during this period the annual rate climbed over threefold. The weight loss surgery of choice as of 2003, was gastric bypass surgery for both adults and adolescents, representing about 90% of all cases. Of the bariatric surgeries performed in 2003, adolescents comprised 0.7% of all patients and generally had significantly fewer comorbidities than adults. Adolescent hospital stay were slightly shorter than adults at 3.2 days vs. 3.5. Cardiac, infectious, renal and surgical complication rates occurring in-hospital were modestly lower in adolescents than in adults; complication rates were not significant different overall however. In-hospital mortality (death) rate was 0.2% of adults, while there were no adolescent deaths recorded in 2003 or any other year. This suggests that amongst the morbidly obese, youth are more fit when undergoing weight loss surgery operations.

Special considerations when adolescents are referred for weight loss surgery
When teens are considered for weight loss surgery, it should be known that despite extremely high BMI values, the comorbidities of most morbidly obese adolescents are not as severe as those of adults. It is for this reason that medical decision making will be somewhat different between adolescents and adults.

The importance of nutritional factors which infuence success following bariatric surgery (Xanthakos and Inge) should also be considered. Adolescents must be prepared for an intervention that will change eating patterns for life and may impact reproductive outcomes once bariatric patients reach childbearing age. Morbidly obese adolescents are often malnourished prior to weight loss surgery, and there are concerns about proper micronutrient intake preoperatively and the impact this may have on developing nutritional deficiencies after weight loss surgery. Furthermore, there are questions about whether or not adolescents will be compliant with vitamin and mineral supplementation after weight loss surgery. For instance, folate is crucial for normal organogenesis during pregnancy. Adolescents should participate in a conservative nutritional management program where education involves family and focuses on post weight loss surgery diet/nutrition practices early in the bariatric evaluation process. Multivitamin and mineral supplementation should also begin several weeks prior to weight loss surgery so that any preoperative micronutrient deficiencies are replenished. With the risk of beriberi occurring after gastric bypass, it is recommended that additional B1 or a B Vitamin Complex be added to the multivitamin and mineral supplementation program.

Indications for bariatric surgery in adolescents
To date, there is no strong evidence to suggest that indications for bariatric surgery in adolescents are different from those applied to adults. However, taking into consideration the often delayed health implications of pediatric extreme obesity and the fact that less is known about the long-term risks and durability of surgical therapy in youth, conservative indications for operation have been proposed. There has been debate about whether one should consider extreme obesity, in the absence of comorbidities, as an indication for operation in adolescents; however, most pediatric experts agree that candidates for surgery should have a BMI of at least 40 kg/m2 and manifest an identifiable physical or psychosocial comorbidity of obesity to justify an invasive surgical procedure with lifelong consequences. This is a contrast to the time-honored NIH guidelines for adults which indicate that a BMI ≥ 40 kg/m2 without specific comorbidities justify this surgery. As with adults, teens considering surgery should have demonstrated failure of nonoperative weight management approaches. Surgery should not represent a first-line intervention.

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This information has been provided by Dr. Thomas Inge, Surgical Director of the Surgical Weight Loss Program for Teens at Cincinnati Children?s Hospital Medical Center, a national leader in the pediatric weight loss surgery field. Dr. Inge also serves as the chairman of Teen-LABS, the largest scientific study to date designed to learn more about the risks and benefits of surgery for teenage obesity. Click here to learn more about this study.