WLS for kids?

On December 18, 2009, in Uncategorized, by Andrea

I worry.  ADULTS won’t follow vitamin requirements, will kids?  For life?

From Medscape:

Bariatric Surgery for Obese Adolescents: Should Surgery Be Used to Treat the Childhood Obesity Epidemic?

Christy H. Lynn; Jennifer L. Miller

Posted: 03/16/2009; Pediatr Health. 2009;3(1):33-40. © 2009 Future Medicine Ltd.

Abstract and Introduction


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.


Over the past two decades, pediatric obesity has been on the rise throughout the world. In the USA, the prevalence of children who are obese has increased from 4% in 1971 to more than 15% in 2007.[1] Not only has there been an increase in childhood obesity, but the severity of the obesity is greater, with an estimated 4% of children meeting criteria for extreme obesity (BMI >3 kg/m2 standard deviation score for age and gender) in the USA during 2008.[2] These trends are reflected in children around the world. Obesity in the pediatric population tracks into adulthood. Obese children have a 70% chance of becoming obese adults, and this risk increases to 80% if one or both parents are also obese.[3] Medical consequences of pediatric obesity are well documented, including premature morbidity and mortality.

As the incidence of childhood obesity has increased, so has the identification of the consequences of obesity in children, including obstructive sleep apnea, orthopedic problems, hyperandrogenism, Type 2 diabetes, hypertension, hyperlipidemia, fatty liver disease and premature cardiovascular disease.[4] Over 50% of overweight adolescents meet the criteria for the metabolic syndrome (insulin resistance, hypertension, hyperlipidemia and abdominal obesity).[5] Children with low socioeconomic status and certain ethnic/racial groups have the highest prevalence of childhood obesity. In the USA, African–Americans, Native Americans and Hispanics have the highest rates of pediatric obesity, while in Europe those of Black African and Indian ethnicity have the highest prevalence of childhood obesity.[6] Children from these ethnic/racial backgrounds also have greater insulin resistance, thus, predisposing them to a higher rate of complications from obesity.[7] The comorbidities of obesity in children persist into adulthood, thus, increasing both the medical burden on society and the risk for early morbidity and mortality. Owing to the rising prevalence of both childhood obesity and its comorbidities, it is estimated that up to a third of the US and European populations will develop Type 2 diabetes during their lifetime.[8] A twofold increased risk of mortality has been detected as early as the fourth decade of life for obese adolescents, and there has been shown to be a dose–response relationship between BMI during young adulthood and the risk of death.[9] The epidemic of obesity beginning in childhood is threatening to reverse the gains in life expectancy that were made through control of hypertension, hyperlipidemia and smoking, with this generation of children being predicted to be the first to not outlive their parents.

Prevention of obesity in children should be the first line of treatment. The cornerstone of management for childhood obesity is modification of dietary and exercise habits. Decreasing portion sizes, decreasing high calorie food and drinks and decreasing snacks are the most common dietary recommendations for obese children. Diet modification alone is often not sufficient to achieve optimal weight loss in individuals with morbid obesity. When caloric intake decreases, metabolism slows, resulting in decreased calorie utilization and difficulty achieving weight loss, typically resulting in a maximum weight loss of 5–10%, which is unlikely to be sustained.[10] Fewer than 5% of people who attempt diet and exercise modifications to lose weight actually lose a substantial amount of weight and maintain that weight loss.[10] Greater than 90% regain their weight within 1 year.[11] Although substantial, long-term weight loss is difficult to achieve, the loss of 5–10% of bodyweight results in a significant improvement in the presence of comorbidities and the risk for premature morbidity and mortality.[10] These data suggest that more effective treatments for childhood obesity should be aggressively pursued.

Available pharmacologic and behavioral interventions for the morbidly obese rarely result in the magnitude of weight loss necessary to improve health outcomes. For individuals suffering from complications associated with morbid obesity, bariatric surgery is recognized as an effective treatment to provide significant weight loss and long-term weight control. Gastric bypass surgery, which is the most commonly used surgical intervention for severe obesity in the USA, appears to overcome the compensatory responses of the body to decreased caloric intake, and results in long-term, clinically significant weight loss.[12,13] In the adult population, bariatric surgery has been shown to improve both quality of life and obesity-related conditions, such as diabetes, hypertension, pulmonary disease and hyperlipidemia.[14] However, in the adolescent population there is less evidence to make those same conclusions and, therefore, a conservative approach to this surgery is mandated.

Approach to Bariatric Surgery in Adolescents

The benefits of bariatric surgery must be carefully weighed against the risks. For morbidly obese adolescents with comorbidities of obesity, who have been unable to achieve clinically significant weight loss with conventional treatments, bariatric surgery is an option that can be considered. Several studies have demonstrated significant reductions in BMI in obese adolescents who have undergone gastric bypass surgery.[15–18] One study demonstrated an average of a 36% reduction in BMI by 5 years postoperatively with those results maintained for up to 10 years postsurgery.[18] These results are comparable to those reported in adults. All of the studies investigating the long-term effects of bariatric surgery in adolescents have included small numbers of patients with up to 10-years follow-up postoperatively, but inadequate numbers of patients followed out further than 10 years.[18] Therefore, considerable uncertainty remains regarding the incidence of weight regain and other side effects of the surgery, such as vitamin and mineral deficiencies, as these individuals enter their third decade of life.

Current recommendations suggest that adolescents who should be considered for bariatric surgery include those who:

  • Have failed greater than 6 months of organized attempts at weight management with the assistance of a multidisciplinary weight-loss program;
  • Have attained physiologic maturity;
  • Have morbid obesity with comorbidities;
  • Demonstrate commitment to psychological and medical evaluations before and after surgery;
  • Agree to avoid pregnancy for at least 1 year postoperatively;
  • Be capable and willing to adhere to nutritional guidelines postoperatively;
  • Demonstrate decisional capacity;
  • Provide informed assent;
  • Have a supportive family environment.[19,101,102]

Those who should not be considered for possible surgery include those who:

  • Have a medically correctable cause of obesity;
  • Have a substance abuse problem within the preceding year;
  • Have a psychiatric, medical or cognitive condition that would impair their ability to follow nutritional recommendations;
  • Current or planned pregnancy;
  • Whose parents or patient have the inability to comprehend the consequences of this surgical procedure and the need for lifelong medical surveillance.[19,101,102]

Preoperative education of the patient and family is essential for the success of bariatric surgery. Since obese children often have obese parents, parental recognition of the lifelong dietary recommendations and requirements must be ascertained before proceeding forward with surgery. The adolescent whose home is stocked with high calorie, high sugar foods, will not be successful postoperatively and this must be clearly communicated to the parents before a referral to surgery is made. The family must all be ready to accept the necessary dietary changes that will occur postoperatively and be willing to change their lifestyle to accommodate this.

It is not known how bariatric surgeries performed before completion of puberty and epiphyseal fusion will affect neuroendocrine, skeletal and psychosocial maturation. While the majority of puberty and skeletal maturity occurs before the age of 14 years in girls and the age of 15 years in boys, the assessment of pubertal stage and bone age must be done before surgery is considered.[20] If the bone age radiograph indicates that the individual has achieved greater than or equal to 95% of their adult stature, then there is little concern that a bariatric procedure would adversely affect the adult height.[20]

Although most childhood obesity is the result of environmental effects on a susceptible population, some individuals with obesity in childhood have a genetic or neuroendocrine cause of their weight excess.[21] These individuals have either defective feedback from the gut to the brain regarding hunger and satiety signals or a monogenic defect resulting in dysfunction of the hormones and neurotransmitters involved in brain recognition of satiety.[21] These conditions must be evaluated for and ruled out before bariatric surgery can be considered ( Table 1 ). These causes of childhood obesity are not amenable to bariatric surgery and would have a tremendously increased risk of postoperative morbidity and mortality.

Recommendations for Bariatric Surgery in Adolescents

In order to determine which adolescents should be referred for bariatric surgery, the degree to which their medical and psychologic health is being compromised by obesity must be assessed. Adolescents who are determined to be possible candidates for bariatric surgery should be referred to a center with a multidisciplinary team capable of managing the unique challenges of adolescents undergoing this surgery.[19] This team should consist of a pediatric endocrinologist who can assess for obesity-related comorbidities and determine if puberty and growth are completed, a geneticist who can evaluate for genetic causes of obesity that would not be amendable to bariatric surgery, a psychologist who can assess patient readiness and understanding of the surgery and the necessity of long-term adherence to dietary restrictions, a nutritionist and exercise physiologist and a surgeon who has experience doing this procedure in adolescents.[19] The whole family should also undergo psychological evaluation to determine factors that could either positively or negatively impact compliance. The importance of the child being mature enough to understand the consequences of this surgery and the family´s ability to maintain compliance with diet is paramount in making the decision about which children are viable candidates for this procedure.

Current recommendations are that adolescents with a BMI greater than 35 kg/m2 and comorbidities of obesity, and those with a BMI greater than 40 kg/m2, regardless of the presence of comorbidities, be considered for bariatric surgery.[19,101,102] Several laboratory evaluations should be done to assess for the presence or absence of obesity-related comorbidities, including a hemoglobin A1c, oral glucose tolerance test, liver function tests, complete blood count, thyroid function tests, screening for micronutrient deficiencies and pregnancy tests for females.[102] It may also be prudent to perform overnight polysomnography to evaluate for sleep apnea, to have a pulmonologist assess the child´s airway and breathing and to evaluate for orthopedic problems prior to surgery. Some institutions require preoperative weight loss, as the first 10% of weight loss is from visceral stores, which makes a difference in the time and ease of operation by allowing a greater intra-abdominal area when insufflated.[22]

For those candidates who meet criteria to undergo surgery, there are four operations for bariatric surgery: the adjustable gastric band, Roux-en-Y gastric bypass, gastric sleeve and biliopancreatic bypass with a duodenal switch.[23] The two most commonly used and well-studied procedures for adolescents are the adjustable gastric band and the Roux-en-Y gastric bypass.[23–25] Of these, gastric bypass is the only approved surgical option for adolescents in the USA. While both gastric bypass and banding are effective in treating the medical consequences of obesity in adolescents, gastric bypass surgery has been shown to be the most effective for optimal weight loss, while the gastric band has been found to have a lower incidence of operative and postoperative complications.[23,24] Polling of the members of the International Pediatric Endosurgery Group (IPEG; n = 125) as to the best operation for adolescents: 59% chose the gastric band, 22% chose the Roux-en-Y gastric bypass, 14% chose gastric sleeve, 1% chose biliopancreatic diversion and 3% chose other surgical treatments.[24]

Surgical Options

From 2000 to 2003, there was a threefold increase in utilization of weight-loss procedures (90% gastric bypass) in adolescents.[26,27] Estimates indicate that approximately 2700 adolescents per year undergo bariatric surgery in the USA.[26] However, only 0.7% of the 140,000–150,000 bariatric surgery cases per year are actually performed on adolescents.[28] These data underscore the fact that surgeons who will perform bariatric surgery on adolescents should undergo subspecialty training in bariatric medical and surgical care as detailed by the American College of Surgeons and the American Society for Bariatric Surgery.[28]

Gastric bypass has become the most commonly used surgical intervention for weight loss and is considered the most effective operation against which all other bariatric procedures should be judged.[25] Roux-en-Y gastric bypass dates back to the 1960s for adults and the 1980s for adolescents. The operation entails the creation of a 15–30 ml gastric pouch just beyond the gastroesophageal junction. A section of the jejunum is connected to the gastric pouch using a 1–1.5 cm anastomosis, which impairs rapid emptying of the pouch.[23,28] The pouch restricts meal size, which results in a period of negative energy balance leading to a 25–30% weight loss initially (Figures 1A & 1B).[28] Subsequently, equilibrium of the energy balance occurs and the weight is stabilized at the reduced level. This procedure is increasingly being performed through minimally invasive methods, which result in quicker recovery and fewer potential complications. Even in the hands of the most experienced surgeons, gastric bypass carries a 1% mortality rate.[29]

Click to zoom

Figure 1.Most commonly used bariatric surgical procedures in adolescents.
(A) Normal stomach. (B) Roux-en-Y gastric bypass. (C) Gastric banding.

Figure 1.

Most commonly used bariatric surgical procedures in adolescents.
(A) Normal stomach. (B) Roux-en-Y gastric bypass. (C) Gastric banding.

In 2001, the LAP-BAND® was approved by the US FDA for patients who are at least 18 years of age. A small number of facilities have approval for an investigational study of gastric banding in adolescents under the age of 18 years. Gastric banding is a restrictive bariatric procedure in which an adjustable silicone band is placed around the stomach to create a small proximal gastric pouch that enhances early satiety and consequently induces weight loss (Figure 1c).[30] The size of the gastric pouch can be adjusted by inflation or deflation of a balloon lining the lumen of the band. Small studies have demonstrated that adolescents treated with gastric banding lost 55% of their excess bodyweight in the first 2 years, had resolution or improvement of comorbidities of obesity and had minimal morbidity as compared with those undergoing gastric bypass.[24,29–31] There is growing support and evidence of the safety and efficacy of gastric banding as an adolescent procedure. Compared with other surgical procedures, gastric banding is the only operation that is reversible and it is the least invasive procedure.[30] Although gastric banding requires a commitment to return for frequent office visits for adjustment of the band, adolescents are capable of making this type of commitment. Gastric banding works the best for individuals with a BMI of less than 50 kg/m2 who are willing to change their eating habits and to increase physical activity after surgery.[31] The super morbidly obese patients (i.e., those with a BMI > 50 kg/m2) have a better success rate with gastric bypass than with gastric banding.[31] Bariatric surgery can positively change the health of a severely obese adolescent and should be considered as a treatment option for certain adolescents with morbid obesity.

Diet & Compliance After Surgery and Future Perspective

Diet & Compliance After Surgery

Before surgery, a candidate is required to meet with a multidisciplinary team that includes a dietitian. Postoperatively, dietary restrictions must be followed, and compliance with supplements and medications must be maintained to ensure a beneficial outcome. The dietitian should meet with the patient following surgery to review the expected dietary management. After surgery, patients begin a liquid diet and once tolerated, will gradually introduce small portions of solid food. On a ‘full diet´, the typical procedure is to consume meals that are less than a cup in size, contain both protein and fiber and to avoid fluids with a meal. Hydration is vital and in order to improve meal success, it is suggested to drink water only 90 min after a meal and no later than 15 min prior. Patients must chew their food slowly and thoroughly.

Following surgery, nutrient deficiencies may occur owing to poor micronutrient supplementation and poor absorption.[32] Nutritional supplements are required in order to help prevent such deficiencies, including calcium, vitamin D, iron, folate, thiamin and B vitamins (B1, B6 and B12). A total of 5–16% of gastric bypass patients who did not receive adequate vitamin B supplementation developed peripheral neuropathy.[33] In addition, after a gastric bypass procedure patients are at risk of fat malabsorption with resultant fat-soluble vitamin deficiencies (A, D, E or K). Of special concern for adolescents is the potential for suboptimal calcium and vitamin D intake following surgery, with a greater risk of deficiency with malabsorption following surgery. It is necessary to monitor bone mineral density levels over the lifespan for adolescents who have undergone bariatric surgery. Owing to the poor absorption of iron, specific iron supplementation may help prevent iron deficiency anemia; however, mild anemia may still occur despite normal vitamin levels.[32] Females are at greater risk for iron deficiency if they are menstruating or become pregnant. Although women can safely support pregnancy after bariatric surgery, it is recommended that patients use contraception to prevent pregnancy, especially within the first year following surgery, owing to the rapid weight loss.[19,101,102] Additional postoperative complications vary according to the surgical procedure. Following the gastric band procedure port-related complications, including infection and hematoma, can occur, as can band erosion and slippage.[34] After gastric bypass surgery, complications include stricture formation at gastrojejunostomy, anastomotic leak, fistula formation and leaking into the excluded part of the stomach.[34,35] The failure rate for weight loss with gastric banding is 40% at 5 years and for gastric bypass the failure rate is 10–20%.[34,35]

Factors that may increase weight loss following bariatric surgery include a daily exercise regimen of at least 20–30 min and a food diary that includes any of the mentioned side effects.[36] Postsurgical management can be overwhelming and frustrating, even for adults, and poor compliance with supplements and medications is not unique. Weight loss can fluctuate from an initial quick loss to a plateau, followed by slower weight loss. Patients need to understand that behavior modifications, medications and supplements still need to be maintained in order to continue their success of reaching a goal weight. Adolescents are at particular risk for noncompliance, especially if their maturity level is not optimal to understand the consequences of their behaviors. As such, the National Institute of Diabetes and Digestive and Kidney Diseases established a program to follow the longitudinal outcomes of bariatric surgery in adolescents (Teen-Longitudinal Assessment of Bariatric Surgery [Teen-LABS]) with the goal of obtaining a realistic estimate of the risks and benefits of bariatric surgery in this population.[37]

The current epidemic of pediatric obesity has resulted in an increasing number of adolescents with obesity-related complications and bariatric surgery provides an opportunity for significant weight loss and reversal of these complications in the most severe cases. Many surgeons believe that performing bariatric surgery in adolescence will result in decreased morbidity and healthcare costs in adulthood.[28] There is some evidence that weight loss in adolescence can preserve pancreatic β-cell function and, thus, decrease the progression from insulin resistance and glucose intolerance to Type 2 diabetes for these obese teens.[28] Although there is good evidence that adolescents can have successful weight loss following bariatric surgery, questions remain about the long-term effects of these operations for adolescents. In addition, the degree to which weight loss after bariatric surgery in adolescence can be sustained over a lifetime is unknown. The long-term follow-up of individuals who undergo this treatment during adolescence is needed to determine if there are environmental, behavioral and biologic predictors of success that can be used in the determination of who are the best candidates with the most chance of success for this surgery. At this point, recommendations for bariatric surgery in youngsters should be conservative and prior to undergoing bariatric surgery, it should be emphasized that this surgery mandates a lifetime commitment to lifestyle change.

Future Perspective

Over the next 5–10 years, physicians will gain a better understanding of the effectiveness and long-term consequences of bariatric surgery for morbidly obese adolescents. As more is learned about the genetics that contribute to obesity in our current obesogenic environment, it may be possible to determine which adolescents are the best candidates for bariatric surgery and who are destined to fail these procedures. As the consequences of childhood obesity are better understood and the public becomes better educated about the risks associated with pediatric obesity, hopefully, the current epidemic will begin to subside.

Related Posts with Thumbnails

Leave a Reply