The problem of obesity
Obesity is common in children and adolescents. There are more children at risk for obesity everyday. Childhood obesity often occurs with many obesity-related conditions, such as type 2 diabetes, high blood pressure, and sleep apnea. Recent data shows that up to 80% of children with obesity will continue to have obesity into adulthood.
How does obesity affect children?
First, a child is more likely to have health issues early on in life. Second, children also face weight bias and bullying.
Children and adolescents impacted by 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 keep very open lines of communication 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. This includes behavioral and lifestyle modification, pharmacotherapy and weight loss (bariatric) surgery. We are going to focus on bariatric surgery in this section.
Why weight loss surgery?
A child’s examination by his or her pediatrician or primary care doctor will involve assessing the food a child eats, physical activity level, blood work, and more. With this information, you can begin to discuss treatment options.
Treatments such as behavioral and lifestyle modifications may work for the majority of children with obesity and help them increase their health. However, there are children with severe obesity that require more aggressive treatment such as weight loss surgery.
Bariatric (weight loss) surgery is commonly performed on 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. Currently, the most common operations being performed in children affected by severe obesity are the Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB) and vertical sleeve gastrectomy.
The goal of bariatric 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. 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 (co-morbidities) 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. Some children and adolescents affected by obesity develop T2DM early. This is a long-standing disease that tends to worsen over time. Children with diabetes are at increased risk for high blood pressure, high cholesterol and liver disease. Recent data suggests that adolescents who undergo bariatric surgery can have significant improvement or complete remission of their T2DM.
NON-ALCOHOLIC FATTY LIVER DISEASE AND NON-ALCOHOLIC STEATOHEPATITIS
Approximately 38% of children and adolescents affected by obesity have fatty deposition 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. Studies have shown that such fatty deposition and inflammation may lead to fibrosis, or scarring in the liver. This 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.
Adolescents affected by obesity often also experience depression. Adolescents who undergo weight-loss surgery often see improvement in their emotional wellbeing. Conversely, weight-loss studies suggest that adult patients seem to be at slightly increased risk for suicide after bariatric surgery. We recommend that adolescents with depression before surgery are monitored closely for signs of depression after surgery.
OBSTRUCTIVE SLEEP APNEA
Up to 22% of children and adolescents with obesity have obstructive sleep apnea. This medical problem is characterized by shallow breathing or pauses in breathing during sleep. Sleep apnea in children can cause daytime sleepiness and problems focusing at school, and behavioral problems. Obstructive sleep apnea has also been shown to improve or go away after bariatric surgery in many patients.
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 several months after bariatric surgery.
QUALITY OF LIFE
Many children and adolescents affected by obesity feel that their obesity and health issues have a negative impact on their quality of life and emotional health. Several research studies have shown significant improvement in quality of life after weight-loss.
Binge eating and purging (also known as called bulimia nervosa) has been seen in some adolescents with obesity who desire bariatric surgery. Eating disturbances are quite serious. There is limited research on outcomes following bariatric surgery in teens with eating disorders. For this reason, bariatric surgery in these adolescents is generally discouraged unless the eating disturbance has been appropriately treated and is well managed.
Who should be considered for weight loss surgery?
Recommended selection criteria for adolescents being considered for a bariatric procedure include:
- BMI 35 kg/m2 or higher with major co-morbidities (such as type 2 diabetes, moderate or severe sleep apnea, pseudotumor cerebri, or severe fatty liver disease)
- BMI 40 kg/m2 or higher with other less severe co-morbidities (such as high blood pressure, high cholesterol, mild or moderate sleep apnea)
In general, more severe obesity is associated with higher risk for medical problems. The BMI (body mass index) is an index of weight for 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 little differently for children. Most surgeons use BMI thresholds while trying to determine if an adolescent is a candidate for weight loss surgery.
In addition to BMI, physicians consider medical problems related to obesity and the potential long-term health risks associated with untreated obesity when determining a patient’s appropriateness for bariatric surgery.
Despite the above minimum BMI criteria, many insurance companies will not cover bariatric surgical procedures for adolescents under the age of 18 years. Insurance companies may also have different criteria or only cover a certain specific procedure or 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
Adolescents 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 typically include the following members:
- Bariatric 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 bariatric surgery is a serious procedure. All surgical procedures have an associated risk of complications. Having surgery earlier in life may decrease the risks of complications after surgery and of long-term complications from obesity. The risks specifically associated with the surgical procedure should be discussed at length with your surgical team.
Short term data suggest that weight-loss following bariatric surgery improves depression, eating disturbances and quality of life. However, potential negative psychosocial risks have not been well studied.
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, vitamin D and calcium are common problems after bariatric surgery. Calcium and vitamin D are crucial for bone development during adolescence. In order to prevent these nutritional deficiencies, all patients need to follow special dietary recommendations and take vitamin supplements after bariatric surgery. Adolescents 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 for bariatric surgery. Formal consent must be provided by an adolescent’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 health care team to discuss the anticipated benefits and specific risks of bariatric surgery with the adolescent and his or her parent(s) or guardian(s). An understanding of the many complex issues involved should be formally assessed as part of the consent process. Frequently, the adolescent 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 are in agreement. There should not be any inappropriate influences. Assessing an adolescent’s capacity to make an informed decision about bariatric surgery can be challenging. The clinical team must consider the adolescent’s cognitive, social and emotional development. They must also support his or her independent role in the decision-making process.
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 weight-loss procedures are performed in adults. Many of these have also been performed in 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 adolescent and his or her family.
In the United States, 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 adolescents undergoing any bariatric procedure attend all follow-up visits with their bariatric health care team. This follow-up should be at least several years.
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 mostly due to concerns for vitamin deficiencies and protein malnutrition.
VERTICAL SLEEVE GASTRECTOMY
The vertical sleeve gastrectomy involves cutting the stomach to make it into a smaller tube shape. This procedure has been performed less often in adolescents than the gastric bypass or the adjustable gastric band. However, it has been performed in increasing numbers throughout the past few years. Long term data is not yet available. Preliminary results from studies of adolescents undergoing sleeve gastrectomy demonstrate excellent weight reduction, reversal of co-morbidities, and complication rates like those found for the adult population.
Want to know more? Read Bariatric Surgery Procedures.
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