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.

Browsing Medscape, I found this article about current recommendations for treating severely obese kids (ages 2-17) with both medications and surgical options.  Now, first off, being a mother to a child that is almost two, I cannot, cannot, CANNOT imagine, even if he had fat rolls on top of fat rolls, giving him medications at the age of two.  But perhaps I’d feel differently if he weighed 50lbs at 2 years old and was developing diabetes or some such comorbidity at such a young age.

In any case, the article lists suggestions put forth by the American Academy of Pediatrics (AAP) and The Endocrine Society for the treatment of severely obese adolescents with medications and bariatric surgery.  A few.. “highlights”  (if you can call anything from this report a “highlight” because I’m just terribly upset by it all thinking about how it could be MY child this report is talking about).

Pharmacotherapy and Surgery Treatment for the Severely Obese Adolescent

Teri Woo, PhD, RN, CPNP

Posted: 12/01/2009; J Pediatr Health Care. 2009;23(4):206-212. © 2009 Mosby, Inc.

Obesity is a growing problem both in the United States and worldwide, with the majority (66.3%) of U.S. adults considered overweight or obese according to a recent report from the National Health and Nutrition Examination Survey (Ogden et al., 2006). The statistics concerning children in the report are disquieting, with 17.1% of children ages 2 to 17 years considered obese based on the recommended American Academy of Pediatrics (AAP) terminology (Barlow and Expert Committee, 2007; Ogden et al.). This month’s column will review the current recommendations from the AAP and The Endocrine Society for the treatment of severely obese adolescents with pharmacotherapy and bariatric surgery (August et al., 2008; Barlow and Expert Committee).

Bariatric Surgery

Bariatric surgery is one of the fastest growing surgical procedures in the United States, growing by 400% from 1998 to 2002 (Encinosa, Bernard, Steiner, & Chen, 2005). Bariatric surgery has two main components—restriction of the size of the stomach and bypassing part of the intestines to reduce absorption of nutrients—or a combination of the two. Bariatric surgery represents a long-term solution to obesity, with a demonstrated decrease in adult rates of type II diabetes, including complete remission in 73% of study subjects of their type II diabetes in a group monitored for 2 years after adjustable gastric band surgery (Dixon et al., 2008). An overall decrease in mortality for all reasons was seen in 40% of adult patients undergoing bariatric surgery compared with control subjects in a systematic review conducted by Ferchak and Meneghini (2004).

The two procedures most commonly used in adolescents are laparoscopic adjustable gastric banding and gastric bypass surgery. Standards of care set for adolescent bariatric surgery have been developed by the International Pediatric Endosurgery Group (IPEG), including patient selection criteria, preoperative care and postoperative care guidelines (IPEG Standards and Safety Committee, 2008). The pediatric nurse practitioner (PNP) or clinician may consider referral for bariatric surgery in any patient with a BMI over 50 or a BMI over 40 with comorbidities, including type II diabetes (see Table 1). Regardless of the procedure, the adolescent should be managed by a multidisciplinary team including surgeons skilled in adolescent bariatric surgery, nutritionists, and mental health specialists. Pediatric nurses and PNPs often are an integral part of the team. Primary care of adolescent bariatric surgery patients will be discussed later in this article.

Laparoscopic Adjustable Gastric Banding

The laparoscopic adjustable band (LAP-BAND, Realize) is a silicone band that is placed via laparoscopic surgery around the upper portion of the stomach, resulting in a very small pouch available for food. The band’s diameter is adjustable, allowing controlled weight loss or “loosening” of the band for times of increased nutritional need such as pregnancy. The laparoscopic adjustable band is a restrictive procedure that does not affect food absorption. The patient needs to make multiple visits to the surgical team to have the volume of the band adjusted throughout the weight loss period and periodically afterward. In a review and meta-analysis of six laparoscopic adjustable band studies by Treadwell, Sun, and Scholles (2008), the random effects analysis of adolescent weight loss was 10.6 to 13.7 BMI units (95% CI) in patients monitored for 1 to 3 years.

Laparoscopic adjustable banding is a fairly safe procedure, with no in-hospital or postoperative deaths reported in a meta analysis of 352 operations conducted by Treadwell, Sun, and Scholles (2008). Band slippage requiring surgical correction is the most common postoperative complication, with slippage rates varying from center to center and ranging from 7% to 15% in adult patients (Ferchak & Meneghini, 2004). Band slippage requiring surgical correction was reported in 3% of adolescents in a meta analysis of adolescent studies (Treadwell et al.). Hiatal hernia, cholecystitis, and physical intolerance of the band also have been reported. While the laparoscopic adjustable band is intended for long-term treatment, the band may be removed and the stomach is returned to its normal anatomical state and function. It must be noted that adjustable gastric banding has not been approved by the FDA for use in adolescents and is considered investigational at this time.

Gastric Bypass Surgery

Gastric bypass surgery is a procedure that is both restrictive and affects absorption of nutrients. The most common procedure is the Roux-en-Y procedure gastric bypass (RYGB), where a small stomach pouch is fashioned and a bypass of the small intestine is created to decrease absorption leading to rapid weight loss. Patients have substantial and sustained loss of excess body weight, with excess body weight defined as the difference between preoperative BMI and a healthy BMI of 25 to 30 (Levitsky, Misra, Boepple & Hoppin, 2009). In a meta-analysis of four studies of RYGB surgery outcomes in adolescents, the random-effects summary statistic ranged from 17.8 to 22.3 BMI units (95% CI) lost postoperatively (Treadwell et al., 2008). The RYGB procedure leads to greater excess weight loss than does the gastric band, but it also has a higher surgical complication rate (Levitsky et al.).

Complications from gastric bypass surgery are both from the surgery itself and because of the changes in absorption of micronutrients caused by the bypass itself. Early postoperative complications include pulmonary embolism, wound infection, and anastomotic leak (Treadwell et al., 2008, Levitsky et al., 2009). There have been no reported in-hospital deaths in adolescents who underwent gastric bypass surgery (Treadwell et al.). Long-term complications include nutritional deficits because of decreased absorption of micronutrients including iron, calcium, vitamin B12, and thiamine (Levitsky et al.). Iron deficiency anemia and mild beriberi have been reported in adolescents after gastric bypass surgery (Treadwell et al.). These nutritional deficits can be anticipated and treated with a multivitamin containing iron. An understanding of normal adolescent development is key in preventing nutritional deficits, with Haynes et al. (2008) recommending that the PNP or nurse member of the bariatric team assume adolescents have problems remembering to take their multivitamin and help them develop a plan for compliance.

I’m glad to see behavior modification as the first line — and then perhaps medication..  but some of those medications are pretty harsh.  We have now seen some evidence that metformin can be used to help treat obesity in children, even in the absence of diabetes.

Kids’ cereal gets a makeover

On December 15, 2009, in General Nutrition, by Andrea

Glad to see it — kids’ cereal can cause a non-diabetic to need an insulin shot.

From MSNBC.com:

General Mills reducing sugar in kids’ cereal

Lucky Charms, Trix, Cocoa Puffs among the updated products

PORTLAND, Ore. – General Mills — the maker of Lucky Charms, Trix and Cocoa Puffs — plans to reduce the amount of sugar in its cereals marketed to children.

The move, announced Wednesday, comes as many food companies alter their products and face growing scrutiny from consumers, regulators and health groups over the nutritional value of their foods.

General Mills said it will cut the sugar in 10 of its cereals to single-digit grams of sugar per serving. It did not provide a timeline for reaching this goal, but it builds on reductions the company rolled out two years ago.

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The sugar in Cocoa Puffs, for example, could drop at least 25 percent from its original level and 18 percent from its current 11 grams per serving.

“This is a significant development across some of our biggest and longest-term brands,” said Jeff Harmening, president of the company’s Big G cereal division.

Cereal companies ‘under pressure’
General Mills, which is based in Minneapolis, said the updated products will begin to roll out in the next year. The timing will vary by product.

“The reduction … doesn’t represent perfection but it represents improvement,” said Kelly Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University.

Several cereal makers have adjusted their products to address the growing concern.

Last year, Kellogg Co. reformulated a number of its U.S. cereals including Froot Loops, Apple Jacks and Corn Pops. The changes vary according to product but decreased the sugar by 1 to 3 grams per serving. Kellogg also added fiber to some of its cereals.

Post Foods said it has cut the sugar content in both Fruity Pebbles and Cocoa Pebbles by 20 percent. And it increased the vitamin D in Pebbles and Honeycomb cereals this year.

“The cereal companies have really been under a lot of pressure,” Brownell said.

The Food and Drug Administration has been cracking down on food packaging that touts misleading health benefits. That led to one industry organization halt its “Smart Choices” labeling program, which was attacked because sugary cereals like Fruit Loops qualified for the label.

General Mills’ effort won’t change some products like Franken Berry and Boo Berry, which are generally considered children’s cereals and once had 15 grams of sugar each. General Mills has since reduced that to 12 grams, but the cereals aren’t included in the new effort because they don’t advertise on TV shows or other media aimed at children.

And some of the company’s other cereals, such as Cheerios, already meet the goal with 1 gram of sugar per serving.

The Rudd Center recently published a study that found the least-healthy breakfast cereals are the most frequently and aggressively marketed directly to children. It also found that General Mills markets to children more than any other cereal company, and six of 10 least-healthy cereals in its study were made by the company.

“Children deserve to be marketed products that are healthier to them than what is being marketed now,” Brownell said.

General Mills said the move is a reaction to consumers’ desire for less sugar, rather than a response to criticism. The company said it has taken a number of steps — including increasing whole grain and nutrients in its cereals — to improve their healthfulness.

The company wouldn’t say how the cereal’s formulas would be adjusted except for the sugar reduction but said it would not use artificial sweeteners.

Cereal makers argue that their products provide essential nutrients and are a healthy breakfast. But health experts are concerned that added sugar, which provides no nutritional value, could contribute to weight gain.

The Rudd Center found children who ate highly sweetened cereals ate roughly twice as much as those who ate low-sugar cereals. And some say children are more susceptible to the marketing by food makers.

Andrea’s note:  While there are some good figures that show positive outcomes for metformin treating obesity in non-diabetic children, the study was short-term, not as effective as behavior-modification, and was moderately effective as compared to other drugs on the market to treat obesity.  Additionally, the study was more geared towards minorities that are impacted with metabolic disorders — so yes, much much more study is needed… but I think it’s worth noting that this study was done and positive outcomes were found.

From Medscape:

Metformin for Obesity in Children and Adolescents: A Systematic Review

Min Hae Park, MSC; Sanjay Kinra, MD, PHD; Kirsten J. Ward, PHD; Billy White, MBBS; Russell M. Viner, MBBS, PHD

Posted: 12/14/2009; Diabetes Care. 2009;32(9):1743-1745. © 2009


Objective—To summarize the efficacy of metformin in reducing BMI and cardiometabolic risk in obese children and adolescents without diabetes.
Research design and methods—We performed a systematic review and meta-analysis of randomized controlled trials (RCTs). Double-blind RCTs of ≥6 months duration in obese subjects age ≤19 years without diabetes were included. Our primary outcomes of interest include changes in BMI and measures of insulin sensitivity.
Results—Five trials met inclusion criteria (n = 320 individuals). Compared with placebo, metformin reduced BMI by 1.42 kg/m2 (95% CI 0.83–2.02) and homeostasis model assessment insulin of resistance (HOMA-IR) score by 2.01 (95% CI 0.75–3.26).
ConclusionsMetformin appears to be moderately efficacious in reducing BMI and insulin resistance in hyperinsulinemic obese children and adolescents in the short term. Larger, longer-term studies in different populations are needed to establish its role in the treatment of overweight children.


Metformin has been shown to reduce weight gain, hyperinsulinemia, and hyperglycemia in adults with type 2 diabetes[1,2] and to reduce progression from impaired glucose tolerance to diabetes in those without diabetes.[3] These benefits have led to an increase in the use of metformin in obese children with hyperinsulinemia. However, obesity is not a licensed indication for metformin in the U.K. or the U.S., and its use has proceeded faster than the evidence of its benefits. We undertook a systematic review of randomized controlled trials (RCTs) investigating the efficacy of metformin for reducing BMI and cardiometabolic risk in obese children without diabetes.

Research Design and Methods

We searched Ovid MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, the metaRegister of Controlled Trials, and key journals published before December 2008 (online appendix Tables 1 and 2 available at http://care.diabetesjournals.org/cgi/content/full/dc09-0258/DC1). We included double-blind RCTs of ≥6 months duration with obese subjects age ≤19 years without diabetes and without secondary or syndromic causes of obesity. Primary outcomes of interest were BMI (weight in kilograms divided by the square of height in meters) and measures of insulin sensitivity. Secondary outcomes included fat mass, blood pressure, fasting lipids, and adverse effects.

Where three or more studies reported a common outcome, treatment effect was explored in a meta-analysis (Stata Statistical Software 10.1; StataCorp, College Station, TX), pooling data from the end of the follow-up period for trial completers. A random-effects model was selected. Sensitivity analyses were performed using fixed-effects models and by dose of metformin (1,000 vs. 2,000 mg), age of participants (12–19 vs. <12 years), co-intervention (metformin vs. metformin + co-intervention), baseline BMI (mean ≥35 vs. <35 kg/m2), and by excluding one study reporting greater treatment effects than the other studies.[4]


Five studies published between 2001 and 2008 met the inclusion criteria.[4–8] This included one crossover trial.[5]

Three studies took place in the U.S.,[6–8] and one each in Australia[5] and Turkey.[4] All trials lasted 6 months with metformin doses from 1,000–2,000 mg/day. Three studies used lifestyle co-interventions in either trial arms.[4,7,8] Two studies included adolescents (ages 12–19 years),[6,7] one looked at younger children (ages 6–12 years),[6] and the others spanned ages 9–18 years. In the U.S. and Australian studies, a large proportion of participants (45–90%) were from ethnic backgrounds with high prevalence of metabolic syndrome (African American, Hispanic, or Asian). All participants were hyperinsulinemic or insulin resistant. Sample size ranged from 28–120 participants at randomization; in total there were 365 participants and 320 trial completers. Mean attrition rates were 11% in metformin groups and 16% in placebo groups.

In the pooled analysis, metformin reduced BMI by a mean of 1.42 kg/m2 (95% CI 0.83–2.02) compared with placebo (I2 = 56.2%; n = 342) (Fig. 1). Sensitivity analyses did not reveal notable differences by age, dose, or baseline BMI. When the outlier result was excluded, metformin reduced BMI by 1.15 kg/m2 (0.73–1.57, I2 = 0%). Reduction in fasting insulin was greater in metformin than placebo groups in three studies, but evidence for a treatment effect was weak (−5.30 μU/ml [95% CI −11.96 to 1.36], I2 = 78.7%; n = 257).[4–7] Pooled metformin effect on the homeostasis model assessment of insulin resistance (HOMA-IR) score was −2.01 (95% CI −3.26 to −0.75, I2 = 49.5%; n = 234)[4,6,8] and −1.28 (−2.55 to −0.21, I2 = 0%) if the Turkish study was excluded.

Figure 1. Forest plot comparing change in BMI (kg/m2) in metformin and placebo groups.

Figure 1.

Forest plot comparing change in BMI (kg/m2) in metformin and placebo groups.

Pooled mean metformin effect on total cholesterol was −0.19 mmol/l (95% CI −0.38 to −0.01, I2 = 0%; n = 234).[4,6,7] Analyses did not provide strong evidence for a treatment effect on fasting glucose, HDL cholesterol, triglyceride levels, or blood pressure. There was insufficient data to comment on body fat outcomes. Gastrointestinal problems were the most common reported side effect (in 20–30%) and were more frequently reported in metformin than in placebo groups (risk difference 10–14%).[6,7] Only one participant reported gastrointestinal problems as the reason for leaving a study.[7]


Our meta-analysis provides some support for a beneficial metformin effect on obesity outcomes among hyperinsulinemic children and adolescents. Treatment over 6 months may be efficacious in reducing BMI by 1.42 kg/m2 (equivalent to 0.4 SD, based on SD for BMI in U.K. and U.S. adolescents) and HOMA-IR score by 2.01 (~0.6 SD).[9] Metformin use was also associated with a small reduction in total cholesterol level (~0.26 SD),[10] but these are unadjusted measures, and it is not possible to determine whether the effects are secondary to reductions in BMI and HOMA-IR or attributable to other factors. To our knowledge, the effects of metformin on BMI in obese children without diabetes have been synthesized in only one published review based on three studies,[11] which identified no treatment effect at 6 months (−0.17 kg/m2 [95% CI −0.62 to −0.28]).

Metformin may not be as effective as behavioral interventions in reducing BMI: a meta-analysis of behavioral interventions in obese adolescents reported an effect of −3.04 kg/m2 (95% CI −3.14 to −2.94) at 6 months, which was maintained at 12 months follow-up.[12] When compared with drugs that are licensed for obesity, metformin has moderate effect: meta-analyses of RCTs reported an orlistat effect of −0.76 kg/m2 (−1.07 to −0.44) and a sibutramine effect of −1.66 kg/m2 (−1.89 to −1.43) at 6 months.[12]

The results of this review must be interpreted with caution: the studies were short-term and based on small samples; participants were mainly from the U.S., and large portions were from ethnic backgrounds known to be at increased risk of metabolic disorders, limiting the generalizability of findings; and the studies presented unadjusted measures without intention-to-treat analyses, which may have overestimated treatment effects.

Metformin may be efficacious in reducing BMI and insulin resistance among obese hyperinsulinemic children and adolescents in the short term. Larger, long-term studies across different populations are needed to establish the role of metformin as therapy for obesity and cardiometabolic risk in young people.

Heavy kids my suffer from severe back pain

On December 4, 2009, in Uncategorized, by Andrea

From MSNBC.com

Add severe back pain and spine abnormalities to the list of problems overweight and obese adolescents can develop.

Among a group of young people who came to an emergency department for severe back pain, researchers found that many had abnormalities in the lower spine. Most of those abnormalities occurred within the discs, which are sponge-like cushions in between the bones of the spine.

Spinal disc abnormalities were more common in children who were overweight or obese.

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“Back pain and degenerative disc disease are yet another problem associated with obesity in children, along with type 2 diabetes,” Dr. Judah G. Burns, of The Children’s Hospital at Montefiore in New York City reported here at the annual meeting of the Radiological Society of North America (RSNA 2009).

“Disc herniation and spinal disease are generally thought of as a problem of older people, but we’re seeing it in obese youngsters, too. This is the first study to show an association between increased body mass index and disc abnormalities in children,” Burns noted.

Burns and colleagues reviewed spinal images of 188 adolescents between the ages of 12 and 20 who complained of back pain and were imaged at the hospital over a four-year period. Children with trauma and other conditions that would predispose them to back pain were excluded.

The researchers found that more than half (52 percent) of the patients complaining of back pain had some abnormality in the lower, or lumbar, spine. All but six of these patients had disc disease.

Patients who were overweight or obese were more apt to have disc trouble than their leaner counterparts.

Height and weight data, available for 108 of the patients, showed that 66 percent of those who were overweight had a spine abnormality on imaging, compared with 38 percent of those who were not overweight.

The study suggests that being overweight as a child could lead to early degeneration of the spine.

“We saw increased spine abnormalities with higher BMI,” indicating a “strong relationship” between being overweight early in life and disc disease, Burns said.

“In children, back pain is usually attributed to muscle spasm or sprain,” Burns said in a statement. “It is assumed that disc disease does not occur in children, but my experience says otherwise.”

Copyright 2009 Reuters.

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