AACE 25th Annual Scientific & Clinical Congress:

Treatment of Severe Pediatric Obesity: Is Bariatric Surgery an Option?

Morbid obesity in adolescence has little chance of remission and is associated with increased comorbidities in childhood and adulthood. Given that diet and exercise are marginally effective, and pharmacotherapy is essential absent, bariatric surgery may be a reasonable option for adolescents with a body mass index (BMI) greater than the 99th percentile, said Ilene Fennoy, MD, MPH, at the American Association of Clinical Endocrinologists (AACE) 25th Annual Scientific & Clinical Congress, May 25-29, 2016 in Orlando, Florida.
obese child cross walk style sign
Obesity rates have remained steady among children and adolescents, with rates of 17% among those ages 2 to 19 years and 20.5% among those ages 12 to 19 years, according to data from 2011-2014.1 Nevertheless, severe obesity appears to be increasing with an estimated 4% to 6%of adolescents considered to have extreme obesity (≥99th percentile), explained Dr. Fennoy, who is Clinic Medical Director, The Center for Comprehensive Adolescent Bariatric Surgery (CABS) and Director of the Program for Overweight Education and Reduction at Columbia University Medical Center in New York, NY.2,3
Morbid Obesity in Adolescence Has Little Chance of Remission
Morbidly obese children are at high risk for obesity-related comorbidities (ie, type 2 diabetes, hypertension, metabolic syndrome, hyperlipidemia, nonalcoholic fatty liver disease, and polycystic ovarian syndrome) and the vast majority of children remain obese into adulthood, Dr. Fennoy said. In addition, children in the 99th percentile of BMI also show high levels of circulating oxidized LDL as well as markers of inflammation (ie, C-reactive protein, interleukin-6).3
"These children are having all the manifestations of early cardiovascular disease in adolescence," Dr. Fennoy said. 


Treatment Options

Diet and Exercise
A variety of meal plans have been studied for weight loss in children and adolescents, including balanced hypocaloric (30%-40% reduction in intake), protein sparing modified fast, and low glycemic index. Unfortunately, Dr. Fennoy noted, these meal plans result in only minimal changes, typically less than 10 kg, after which point weigh loss plateaus.  
"For a child with a BMI of 46 who weighs close to 300 pounds, if you tell them "lose 12 pounds and you'll be better," they will look at you like, why bother?," Dr. Fennoy explained.  
In a recent systematic review and meta-analysis of randomized trials on the impact of dietary and exercise interventions at 6 months, diet only was linked to a -0.8 to -2.7 kg/m2 change in BMI and exercise was linked to  -0.3 to -1.0 kg/m2 change in BMI.4 In addition, minimal changes were found in markers of cardiovascular disease (ie, HDL, LDL, triglycerides). 
Orlistat is the only weight loss medication approved for children age 12 years and older.  Dr. Fennoy noted that the side effects of orlistat (gas, incontinence, bowel urgency) make it difficult to recommend for a child who is in school. Results of randomized trials in pediatric obesity show that orlistat is minimally effective, with an effect size of -0.7 kg/m2 after 6 months of use.5
Other weight loss medications—including liraglutide, lorcaserin, topiramate/phentermine—are only approved for patients age 18 years and older. Metformin, which is not approved for weight loss, has shown minimal effects in children.5
Bariatric Surgery
Given the minimal effects of diet, exercise, and pharmacotherapy in pediatric obesity, bariatric surgery has been tried in morbidly obese adolescents, Dr. Fennoy explained. Of the different bariatric procedures Roux-en-Y gastric bypass—which produces a combination of restriction of food intake and malabsorption—is linked to the greatest weight loss in adults.6
"However, we have no consistent outcome studies in pediatrics," Dr. Fennoy said.  Studies to date have shown significant improvements in comorbidities of hypertension, diabetes, and dyslipidemia following bariatric surgery in adolescence, but lack consistency on the impact of this improvement between studies of the different weight loss surgeries.7
"It is difficult to compare effectiveness or recommend what surgery is best for an individual patient," Dr. Fennoy said. 
In a recent study by Dr. Fennoy and colleagues, adolescents who were morbidly obese showed significant improvement in weight, body mass index, waist circumference, systolic blood pressure, as well as lipids and the inflammatory marker C-reactive protein at 12-months following laparoscopic adjustable gastric banding.8
More recently, Inge et al published long-term data on changes in dyslipidemia in adolescents at 3 years following Roux-en-Y gastric bypass (n=161) or sleeve gastrectomy (n=67).9 The investigators found a mean weight reduction of 27% in the overall group with a similar degree of weight loss between the two procedures (28% with gastric bypass and 26% with sleeve gastrectomy). In addition, remission of dyslipidemia occurred in 66% of the overall group, with little difference between the two groups. 
Recommendations for Weight Loss Surgery in Adolescents
Recommendations by Pratt et al and the American Society for Metabolic and Bariatric Surgery suggest that bariatric surgery should be used in adolescents who have reached physical maturity—95% of their adult stature based on radiographic study—and psychological maturity as demonstrated by their understanding of the surgery, having mature motivations for the operation, and ability to comply with preoperative therapy.10,11 In addition, these patients should demonstrate the ability to comply with treatment regimens and medical monitoring before surgery, including consistent attendance in a prolonged weight management program and 1-year remission of psychosis, bipolar disorder, or substance use disorders.10,11
The recommended BMI cutoff for bariatric surgery in adolescents is as follows: 10,11
  • ≥35 kg/m2 with major comorbidities (ie, type 2 diabetes, moderate to severe sleep apnea, pseudotumor cerebri, or severe NASH [nonalcoholic steatohepatitis]) 
  • ≥40 kg/m2 with other comorbidities (hypertension, insulin resistance, glucose intolerance, substantially impaired quality of life or activities of daily living, dyslipidemia, sleep apnea)
Dr. Fennoy pointed out that most of these recommendations are based on expert opinion (ie, category D) and clinical evidence is lacking. 
Bariatric surgery has a significant impact on weight loss and comorbidities in adults, and while there is less data to support use of this surgery in adolescents, success with regard to reducing comorbidities in the pediatric population in increasing. 
"The documentation in pediatrics is less clear, but it is showing the same trends. Therefore, we need to consider bariatric surgery as an appropriate intervention for the pediatric population," Dr. Fennoy concluded.

Fennoy I. S11: Treatment of severe pediatric obesity. American Association of Clinical Endocrinologists (AACE) 25th Annual Scientific & Clinical Congress. Orlando, FL. May 25-29, 2016.

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8. Conroy R, Lee EJ, Jean A, et al. Effect of laparoscopic adjustable gastric banding on metabolic syndrome and its risk factors in morbidly obese adolescents. J Obes. 2011;2011:906384.
9. Inge TH, Courcoulas AP, Jenkins TM, et al. Weight loss and health status 3 years after bariatric surgery in adolescents. N Engl J Med. 2016;374(2):113-123.
10. Pratt JS, Lenders CM, Dionne EA, et al. Best practice updates for pediatric/adolescent weight loss surgery. Obesity (Silver Spring). 2009;17(5):901-910. 
11. Michalsky M, Reichard K, Inge T, Pratt J, Lenders C, American Society for Metabolic and Bariatric Surgery. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis. 2012;8(1):1-7. 
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