The problem of obesity
Obesity is the most common chronic disease in childhood. It is a complex disease with few successful treatment options. A combination of genetic and environmental factors contribute to childhood obesity. Associated health problems are common and include type 2 diabetes, high blood pressure, sleep apnea, non-alcoholic fatty liver disease, sleep apnea, poor quality of life, and mental health issues. Many children with obesity will continue to have obesity into adulthood. Childhood onset obesity, when untreated, significantly decreases life expectancy.
How does obesity affect children?
First, a child with obesity is more likely to have health issues early on in life. Second, children also face discrimination and bullying because of their weight.
Children and adolescents with obesity often find themselves the target of bullying. This bullying can take place in the classroom, in your neighborhood, and even in your own home. It is very important to recognize this type of behavior and address it quickly. The Obesity Action Coalition (OAC), a nonprofit organization dedicated to educating and advocating for those affected by obesity, provides valuable resources on weight bullying.
How do we treat childhood obesity?
You may be thinking to yourself, “I know my child is affected by obesity, but I don’t know what to do.” This is not uncommon. Treating childhood obesity is similar to treating obesity in adults; however, it is important to communicate with your children about treatment. Children will often not share their feelings as they fear disappointing you as their parent.
There are various treatments available for childhood obesity. These include: behavioral and lifestyle changes, pharmacotherapy and bariatric surgery. We are going to focus on bariatric surgery in this section. Children with severe obesity, a body mass index (BMI) of 120% above the 95th percentile, usually require a combination of all three of these treatments in order to reach a healthy weight.
Why metabolic and bariatric surgery?
A child’s examination by his or her pediatrician or primary care doctor will evaluate the food a child eats, physical activity level, sleep habits, blood work, and more. With this information, you can begin to discuss treatment options.
Treatments such as behavioral and lifestyle changes may work for children with overweight or mild obesity and can result in improved health. However, there are children with severe obesity who also require metabolic and bariatric surgery and/or medications to achieve lasting results. In 2019, the American Academy of Pediatrics recognized metabolic and bariatric surgery as the most effective treatment for severe childhood obesity when used in combination with lifestyle modification.
Metabolic and bariatric surgery, commonly referred to as weight loss surgery, is the most effective treatment for adults affected by severe obesity. This surgery has been shown to produce long-lasting weight-loss and improvement in many obesity-related conditions such as type 2 diabetes, high blood pressure, and sleep apnea, poor quality of life, and premature death. Currently, the most common operations being performed in children affected by severe obesity are the laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic vertical sleeve gastrectomy (VSG). The goal of pediatric weight management and surgery is to provide the most benefit possible with the lowest risk. Many research studies have been done and are continuing to evaluate outcomes following bariatric surgery in adolescents and children. The information and recommendations below are based on a recent review of the medical literature and extensive discussion by a panel of experts in this area.
Obesity-related health problems (comorbidities) in children and adolescents
TYPE 2 DIABETES MELLITUS (T2DM)
Compared with Type 1 (or juvenile) diabetes, T2DM usually develops later in life, and is associated with obesity. Insulin, the hormone that controls blood sugar, is produced but the tissues that normally break down and store sugar are not as sensitive to insulin, leading to both high insulin levels and high sugar levels. Some children and adolescents affected by obesity develop T2DM early. This is a chronic disease that tends to worsen over time. Children with diabetes are at increased risk for high blood pressure, high cholesterol and liver disease. Uncontrolled T2DM can cause early heart disease, kidney failure, vision loss, and early death. Research suggests that adolescents who undergo bariatric surgery can have significant improvement or may no longer have T2DM, and bariatric surgery is significantly better than treatment with medications alone.
NON-ALCOHOLIC FATTY LIVER DISEASE AND NON-ALCOHOLIC STEATOHEPATITIS
Approximately 38% of children and adolescents affected by obesity have fat that builds up in their livers. This is higher than the 5% of normal-weight individuals. Also, about 9% of youth with obesity have associated inflammation which is called steatohepatitis. This is higher than the 1% of lean children and adolescents. Studies have shown that such fat and inflammation in the liver may lead to damage, also known as cirrhosis, fibrosis, or scarring. This damage has been shown to improve in adolescents who have undergone bariatric surgery.
We are still learning about risk factors for heart disease in children affected by obesity. Research shows that childhood obesity may lead to a higher risk for heart and vascular diseases in adulthood. Weight-loss from bariatric surgery has been shown to improve several such risk factors in adults. However, for children and adolescents, these effects would take many years to measure. Research studies are still ongoing in this area.
Children and adolescents with obesity often also experience depression. Adolescents who undergo metabolic and bariatric surgery often see improvement in their emotional wellbeing. Conversely, studies suggest that adults seem to be at slightly increased risk for suicide after bariatric surgery. We recommend that children with depression before surgery are treated and stable before surgery and monitored closely for signs of depression after surgery.
OBSTRUCTIVE SLEEP APNEA
Up to 22% of children and adolescents with obesity have obstructive sleep apnea (OSA). This medical problem is characterized by loud snoring or pauses in breathing during sleep. Sleep apnea scan cause daytime sleepiness and problems focusing at school, as well as behavioral problems. Children and adolescents often undergo surgery to remove the tonsils to help treat sleep apnea, but if obesity is not treated, it will likely return. Obstructive sleep apnea has been shown to improve or go away after bariatric surgery in many patients as the obesity improves.
IDIOPATHIC INTRACRANIAL HYPERTENSION
Idiopathic intracranial hypertension (IIH), formerly known as pseudotumor cerebri, is a medical problem caused by increased pressure inside the skull. Symptoms can include headache, visual changes, ringing in the ears, nausea and vomiting. There is often no obvious cause for this condition, but it has been associated with obesity and symptoms frequently improve within months of undergoing bariatric surgery.
QUALITY OF LIFE
Many children and adolescents with obesity feel that their obesity and health issues have a negative impact on their quality of life and emotional health. This may be due to teasing, bullying, and the physical challenge of carrying extra weight. Several research studies have shown significant improvement in quality of life after metabolic and bariatric surgery in children and adolescents.
Binge eating and purging (also called bulimia nervosa) has been seen in some adolescents with obesity who desire bariatric surgery. There is limited research on outcomes following bariatric surgery in teens with eating disorders. For this reason, metabolic and bariatric surgery is only recommended once the child is stable and receiving ongoing treatment for this disorder.
Who should be considered for metabolic and bariatric surgery?
Recommended selection criteria for children and adolescents being considered for a bariatric procedure include:
- BMI 35 kg/m2 or 120% of the 95th percentile for age and sex (whichever is lower) with serious medical conditions (type 2 diabetes, sleep apnea, idiopathic intracranial hypertension, or severe fatty liver disease).
- BMI 40 kg/m2 or 140% of the 95th percentile for age and sex (whichever is lower).
In general, more severe obesity is associated with higher risk for medical problems. The BMI (body mass index) is a number based on a person’s weight and height that is commonly used in the medical profession. It classifies adults into 4 categories: underweight, overweight, obesity and severe obesity. BMI is typically used a differently for children. Most surgeons use BMI thresholds while trying to determine if a child is a candidate for metabolic and bariatric surgery. In addition to BMI, health professionals consider medical problems related to obesity and the future risks of untreated obesity when deciding if surgery is right for someone.
Despite the above minimum BMI criteria, some insurance companies will not cover bariatric surgical procedures for adolescents under the age of 18 years. Insurance companies may have different criteria or only cover certain procedures. If you are considering bariatric surgery for your child, it would be helpful to contact your insurance company to see if these procedures are covered under your plan.
Team approach to bariatric surgery in children and adolescents
Children who have bariatric surgery should be evaluated and cared for by a team of expert individuals. The makeup of this team may vary among institutions, but may include the following members:
- Bariatric and/or Pediatric Surgeon – experienced in performing bariatric procedures.
- Pediatric specialist – a pediatrician with special training in endocrinology, gastroenterology, nutrition and/or adolescence, or an internist or family practitioner with special experience caring for adolescents.
- Registered dietitian – should be experienced in treating obesity and working with children and families. It is helpful if the dietitian is also experienced in caring for patients undergoing bariatric surgery.
- Mental health specialist – psychiatrist, psychologist, or other qualified and independently licensed mental health specialist with specialty training in pediatric, adolescent and family treatment. The specialist should also be trained in the treatment of eating disorders and obesity and have experience with evaluating patients and families for bariatric surgery.
- Coordinator – typically a registered nurse, social worker, or another team member who coordinates the evaluation and follow-up care for each child.
- Exercise specialist – exercise physiologist, physical therapist, or other individual trained to provide safe physical activity prescriptions to adolescents affected by severe obesity.
Risks and Outcomes
When considering bariatric surgery for your child, it is important to recognize that obesity is a serious condition and bariatric surgery may be the only effective treatment. All surgical procedures have an associated risk of complications. However, having surgery earlier in life may decrease the risk of complications after surgery and of long-term complications from obesity. The risks specifically associated with the surgical procedure should be discussed with your surgical team.
Short term data suggest that weight-loss following bariatric surgery improves depression, eating disturbances and quality of life.. Surgery may also not produce significant weight loss in as many as 20% of children undergoing these procedures. This can be difficult for a child who is hoping for improvement in their obesity. However, potential negative psychosocial risks have not been well studied.
As many at 96% of children with overweight and obesity also have vitamin D deficiency even before bariatric surgery. Depending on the type of bariatric surgery, certain vitamin and other nutritional deficiencies have been reported in adolescents after bariatric surgery. In particular, low levels of iron, vitamin B12, thiamine, vitamin D and calcium are common problems after bariatric surgery. Calcium and vitamin D are crucial for bone development during childhood. Folate deficiency during pregnancy is associated with birth defects. In order to prevent these nutritional deficiencies, all patients need to follow special dietary recommendations and must take vitamin supplements after bariatric surgery. Children preparing to undergo bariatric surgery are carefully assessed for their ability to follow the recommended supplement regimens and come to scheduled appointments.
Individuals under the age of 18 years cannot legally provide consent (permission) for bariatric surgery. Formal consent must be provided by a child’s parent or guardian. However, informed consent for bariatric surgery is a complex process. This process involves much more than simply signing a consent form for the surgical procedure. It is important for the healthcare team to discuss the anticipated benefits and risks of bariatric surgery with the child and their parent(s) or guardian(s). An understanding of the complex issues involved should be formally assessed as part of the consent process. Occasionally, the child and parent have differing ideas about the effect of obesity on their lives. They may disagree about bariatric surgery. While a child cannot consent to surgery, it is important that they “assent” to surgery or are in agreement with it. There should not be any inappropriate influences. Assessing a child’s capacity to make an informed decision about bariatric surgery can be challenging. The clinical team must consider the child’s cognitive, social and emotional development. They must also support his or her independent role in the decision-making process. When a child has developmental delay or is very young and may not be cognitively able to agree to surgery, then an ethics team and the bariatric team may work together to recommend for or against surgery for that child.
Types of Bariatric Surgery
Current data shows that bariatric surgery in adolescents is as safe and effective as bariatric surgery in adults. A number of different metabolic and bariatric procedures are performed in adults. Many of these have also been performed in children and adolescents. The decision regarding which procedure is appropriate for an individual patient is a complex one that is made by the surgical team as well as with the child and his or her family.
Involves making a small pouch out of the top of the stomach and then bypassing the majority of the stomach and the first few feet of small intestines. In the United States, Roux-en-y gastric bypass surgery (RYGB) for weight loss was first performed in adults in the 1960s and in adolescents in the 1970s. Recent data shows that this procedure provides lasting weight loss in adolescents. The complication rates in adolescents are similar to those seen in adults. Although it is rare, severe complications have been reported. It is very important that children undergoing any bariatric procedure attend all follow-up visits with their bariatric team. This follow-up should last at least several years and include transition to an adult bariatric team over time.
VERTICAL SLEEVE GASTRECTOMY
The vertical sleeve gastrectomy involves cutting the stomach to make it into a smaller tube shape. This procedure has been performed since 2002 and has been the most common operation in both adults and children since 2014. Long term data is not yet available. Five-year follow-up data from studies of adolescents undergoing sleeve gastrectomy demonstrate better weight reduction, improvement in medical conditions, and lower complication rates than those found for the adult population.
Other bariatric procedures, such as the biliopancreatic diversion and duodenal switch (both of which involve intestinal bypass), have been performed in adolescents. However, outcome data is scarce. These procedures are less commonly performed in the pediatric population than the others. This is mostly due to concerns for vitamin deficiencies and protein malnutrition.
Want to know more? Read Bariatric Surgery Procedures
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