Weight Loss Surgery in Pediatrics Analisa Podgorski November 19, 2012 Nutrition 415: Clinical Nutrition I Dr.

Melissa Hansen-Petrik

Introduction Obesity among children has increased dramatically in the United States. According to CDC reports, prevalence of childhood obesity has risen approximately 17% (1). In adults, the categorization by BMI is not dependent on either the sex or the age of the individual. However, in children, the categories are sex and age specific. In pediatrics, the term overweight refers to Body Mass Index (BMI) 85th percentile and <95th percentile while the term obesity indicates a BMI 95th percentile (1). Despite its usefulness, BMI remains a screening tool and is not a diagnostic tool for the population. Obesity affects all aspects of the adolescents quality of life- physical health and mental health. Obese adolescents are prone to developing negative major health risks later in life, such as: high blood pressure, sleep apnea, liver disease, Type II Diabetes, asthma, and dyslipidaemia (2)(5). Additionally, obese individuals suffer from psychological distress such as low self-esteem, anxiety, and depression (2)(5). Obesity can be treated with weight loss. The conventional weight loss strategies include various nutrition and lifestyle interventions. For example, one-on-one counseling can allow the child to express his/her feelings in private, while a collaborated effort among a counselor, a pediatrician, and the childs parents can support the individual in his journey toward a healthy lifestyle (6). Furthermore, these nutrition programs can educate the child about a proper diet and adequate physical activity to promote weight loss. Another option of weight loss for adolescents is undergoing bariatric surgery. Generally, an adolescent can be candidate for bariatric surgery if the individual has been unsuccessful in various weight loss methods, has been enrolled in

nutrition programs, has a sufficiently high BMI, and has a determined mindset of the need for a healthy lifestyle (6)(7). Weight loss surgery falls into two categories: restrictive and restrictive malabsorptive (3). Restrictive surgery physically restricts an individuals food intake and consists of two procedures: Vertical Banded Gastroplasty (VBG) and Laparoscopic Adjustable Silicone Gastric Banding (LASGB). On the contrary, a restrictive malabsorptive procedure limits the amount of food absorbed by bypassing parts of the digestive tract i.e. the small intestine and includes Roux-en-Y Gastric Bypass (RYGB) and Biliopancreatic Diversion (BPD) (3)(4). All in all, weight loss surgery in pediatrics literature is vast, as such; this paper is not meant to be exhaustive and its intention to give the reader information regarding child obesity and one method of weight lossbariatric surgery. Expected Benefits Weight loss after surgery in obese subjects can alleviate several obesity-related comorbidities such as Type II diabetes (T2DM), obstructive sleep apnea, obesity hypoventilation, gastroesophageal reflux disease (GERD), and peripheral edema (3). Inges 2009 study examines eleven RGYB adolescent patients with T2DM and cardiovascular risk factors. T2DM is a disease characterized by the reduction of insulin sensitivity and is generally developed in adulthood. However, due to the epidemic of adolescent obesity, T2DM is now more frequent. The purpose of this study is to determine if T2DM and its correlated cardiovascular issues (hypertension, cholesterol, and dyslipidaemia) decrease or even completely subside after surgery (8). Subjects of the study are 21 years of age,

previously diagnosed with T2DM, and have a mean BMI of 50 5.9 kg/m2. One-year post operation, the mean fasting glucose reduced by 41% and HbA1C levels decreased from 7.8 2.3% to 7.1 2%. HbA1C is the measure of formation of stable hemoglobinglucose components and can be used to diagnose diabetes (levels 6.5% indicate diabetes) (14). Patients also discontinued or developed a reduced need for diabetes medication after surgery. In addition to improvements of T2DM, several cardiovascular risk factors positively progressed: blood pressure decreased (systolic: 129.6 18 to 120 16 mmHg; and diastolic: 77 9 to 62 7 mmHg) to reach the normal level of120/80 mmHg, heart rates decreased by 19%, triglyceride values decreased by 61%, and total cholesterol decreased by 29% after RGYB. In summary, the studys hypothesis was supported by the decreased risk of cardiovascular issues and the significant improvements in T2DM. Physical Risks Weight loss surgery in pediatrics is a highly debated universal issue. Bariatric surgery is generally not accepted for adolescents because of the hazardous complications that can occur during or post surgery. Other concerns about adolescent surgery include: consent from minors; timing of intervention; cost-effectiveness; healthy growth to adulthood; and support services after surgery (9). A nationwide Swedish adolescent morbidly obesity surgery (AMOS) study examined the safety of bariatric surgery for children. The study required for patients to be 13-18 years of age, a BMI 40 kg/m2 or 35 kg/m2 with obesity-related comorbidities, a Pubertal Tanner stage >III, and formerly enrolled in a year long weight

loss management program. The study compared two adolescent groups: a conventional treatment group (receiving nutrition and healthy lifestyle programs) and a surgical group (undergoing RYGB or gastric bypass surgery). Eighty-one adolescents underwent gastric bypass surgery. Two years after treatment, the mean BMI decreased significantly in the surgical group (45.5 to 30.2kgm2) in contrast to the conventional treatment groups mean BMI (42.2 to 42.6kgm2). Even though there were no deaths or intensive care required, several patients experienced postoperative complications. Thirty days post operation, two subjects had blood transfusions due to abdominal hemorrhaging and one was given antibiotics due to an infection. One to two years post operation, twelve patients underwent additional surgery (five were operated for internal hernia, five underwent cholecystomies for gallstones, one needed an laparoscopical operation for adhesions, and one had a laparotomy for abdominal pain) (10). In this study, adolescent patients who underwent surgery improved their health issues and experienced positive metabolic changes such as reduced insulin resistance and decreased levels of HbA1C. However, infection and complications did occur, indicating that patients should be closely monitored after their operation (10). Another study examined bone loss in sixty-one adolescents after bariatric surgery. Subjects met the following guidelines for laparoscopic RYGB surgery: six months of unsuccessful weight loss attempts; BMI > 35; at least one or more comorbidities; Tanner stage 4; and passed a psychological evaluation (11). The study hypothesized that patients would experience a decrease in whole-body (WB) bone mineral content (BMC) and bone mineral density (BMD) after surgery, and this loss would be related to the amount of weight lost (11). Dual-energy radiograph

absorptiometry (DXA) was chosen as the method of assessment that scanned the patients before and two years after surgery. Additionally, a daily (1000 mg calcium and 800 IU of vitamin D) multivitamin was prescribed (11). The adolescent patients experienced a 7.4% decrease in WB BMC levels, a decrease in BMD levels (1.5 to 0.1), and a 5% increase in fracture rate (11). This study reveals several limitations-most notably, the time frame. This study only examines patients two years post operation. The results give no indication of life long bone loss (11). Another limitation was that the reported bone loss might not have been a direct outcome from the RGYB surgery but rather from the general weight loss (11). In summary, adolescent patients who underwent surgery improved their quality of life and experienced positive metabolic changes such as reduced insulin. But, these patients should be closely monitored and evaluated to enhance physical maturation after surgery. Psychological Risks Physical post operation complications are not the only concern for adolescents. In fact, post-operative mental issues can be equally hazardous to the individuals well being. The most common adverse psychological effects resulting from bariatric surgery among adolescents are depression, anxiety, and low self-esteem. These issues can lead to harmful behaviors such as eating disorders (binging or bulimia) and even suicide (13). For example, excess skin resulting from dramatic weight loss after surgery can decrease self-confidence among adolescents and stimulate self-destructive behavior (13).

In the nationwide Swedish AMOS study (mentioned earlier), adverse psychological effects were observed along with physical complications. Six of the eighty-one subjects suffered psychological distress: two attempted suicide, one endured bullying, four experienced depression, and one demonstrated self-destructive behavior and expressed suicidal ideation (10). The study indicated that the majority of the adverse psychological effects was due to the lack of taking the prescribed vitamins. Never the less, the risk of psychological distress should be addressed and patients should be closely monitored and appropriately counseled after the operation (10). The AMOS study was much more developed and thorough than Kaulfers study because it evaluated both physical issues and psychological issues whereas Kaulfers findings focused primarily on the physical complications. The Procedure: Restrictive Surgery vs. Restrictive Malabsorptive Surgery As previously mentioned there are two categories of weight loss surgeries: restrictive surgery and restrictive malabsorptive surgery. Restrictive surgery is comprised of two procedures: VBG and LASGB. VGB, also known as stomach stapling, is characterized by stapling a portion of the stomach to form a small stomach sac that takes on the role of a normal functioning stomach. This small sac promotes fullness and satiety faster, limiting food intake (3). LASGB, also known as lap band, is distinguished by an inflatable band placed on the top portion of the stomach, restricting the amount of food or liquids consumed (3). In contrast, a restrictive malabsorptive surgery includes the RYGB and BPD procedures. The RYGB procedure is characterized by creating a small sac from the original stomach tissue and attaching it to the small intestine. The BPD procedure refers to the cutting of the stomach to form a

smaller stomach and connected to the end of the small intestine, bypassing the first two sections- duodenum and jejunum (3). In Treadwells 2008 meta-analysis study comprising of 352 adolescents, two different types of surgery were compared and analyzed, specifically LAGB and RGYB. After a one to three year follow-up for adolescent patients who underwent LAGB, BMI decreased substantially (approximately by 10.6 to 13.7 units). This BMI drop coincided with a dramatic weight loss due to the gastric banding (12). Along with weight loss, comorbidities such as diabetes and hypertension were significantly reduced. No death occurred post LAGB operation. However, 8% of patients had to return to the hospital for reoperations to correct various complications such as band slippage, gastric dilation, intragastric band migration, psychologic intolerance of band, hiatal hernia, cholecystitis, and tubing crack (12). After a one to six year follow up of adolescent patients who underwent the RYGB procedure, BMI had reduced by 17.8 to 22.3 units (12). The reason for this greater drop in BMI was due to the follow-up time frame, which spanned for six years rather than only three years. Along with weight loss, patients experienced a significant drop in comorbidities- sleep apnea and hypertension (12). Four patients died post operation. One patient died from severe Clostridium difficile colitis, severe diarrhea, hypovolemia, and multiple organ failure (12). The other three patients most likely died from unrelated causes of the gastric bypass surgery two to six years post operation (12). Based upon the studys findings both surgical procedures resulted in dramatic weight loss and improved rates of comorbidities. According to the study, the difference between the two procedures lies in the post operation complications. While the RGYB

subjects experienced a reduced risk of complications, the risks were more severe. On the other hand, a greater percentage of the LAGB subjects experienced complications but they were less severe. Conclusion The obesity epidemic is rapidly increasing in the United States, and is now affecting adolescents more than ever. Although obese children do not share all of the heightened health risks that obese adults have, obese children do have a high tendency to become obese adults, adding to the total number of people who are at risk for obesity-related illnesses. As poor diet and inadequate physical activity become the societal norm, obesity will take over and control an individuals quality of life. The best way for obese adolescents to control their health risks is to lose weight. Nutrition programs, lifestyle management counseling, healthy diet, and adequate physical activity will equip an individual with the skills and ability to lose weight. However, if the child has been unsuccessful with various weight loss strategies and has an extremely high BMI, bariatric surgery can be performed to induce rapid weight loss. Bariatric surgery not only reduces BMI but also improves obesity-related comorbidities such as T2DM, hypertension, sleep apnea, asthma, and etc. Never the less, young patients should be closely monitored to prevent physical issues (band slipping or bone loss) as well as mental issues (depression or anxiety). Despite the gloomy projections of reporters and investigators, hope for the health of the nation and its population does exist. First, the abundance of articles about the rise of obesity in the United States is a confirmation that the problem has been recognized. Second, the relationships between ill health and obesity have been

established and are being utilized by health professionals throughout the country. Third, the associations between obesity and poor nutrition have been identified and are being used by nutrition advisors to assist entire segments of the population as well as the individual. Fourth, the connections between obesity and poor nutrition and socioeconomic status have been focused, providing targets for government agencies to obtain the most impact on the overall problem of obesity.

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References (1) Overweight and Obesity: Data and Statistics Page. http://www.cdc.gov/obesity/data/childhood.html. Updated August 28, 2012. Accessed November 14, 2012 (2) Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander D, Stewart L, Kelnar CJH. Health consequences of obesity. Arch Dis Child. 2003; 88:748752. (3) American Medical Association. Assessment and Management of Adult Obesity: A Primer for Physicians. 2003. Chicago, Illinois. (4) John Hopkins Medicine. Gastric Bypass (Malabsorptive) Surgery Procedure. http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/g astric_bypass_malabsorptive_surgery_procedure_92,P07988/. Accessed November 14, 2012. (5) Kids Heath. Kids Health Issues: 2011. http://kidshealth.org/parent/positive/issues_2011/2011_obesity.html?tracking=P_ RelatedArticle. Accessed on November 14, 2012 (6) Childhood and Teenage Obesity. Intervention Strategies. http://www.exrx.net/FatLoss/ChildObesityIntervention.html. Accessed on November 14, 2012. (7) Lucile Packard Childrens Hospital at Standford. Bariatric Surgery Candidates. 2012. http://www.lpch.org/clinicalSpecialtiesServices/ClinicalSpecialties/centerHealthy Weight/bariatric/candidates.html. Accessed on November 16, 2012. (8) Inge T H, Miyano G, Bean J, Helmrath M, Harmon C M, Chen M K, Wilson K, Garcia V F, Brandt M L, Dolan L M. Reversal of type 2 diabetes mellitus and improvements in cardiovascular risk factors after surgical weight loss in adolescents. Pediatrics. 2009. Vol. 123 No. 1 pp. 214 -222 (doi: 10.1542/peds.2008-0522). (9) World Health Organization. Do surgical interventions to treat obesity in children and adolescents have long- versus short-term advantages and are they costeffective? 2012. http://www.euro.who.int/en/what-we-do/data-andevidence/health-evidence-network-hen/publications/2012/do-surgicalinterventions-to-treat-obesity-in-children-and-adolescents-have-long-versusshort-term-advantages-and-are-they-cost-effective. Accessed on November 16, 2012. (10) Olbers T, Gronowitz E, Werling M, Mrlid S, Flodmark CE, Peltonen M, Gthberg

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G, Karlsson J, Ekbom K, Sjstrm LV, Dahlgren J, Lnroth H, Friberg P, Marcus C. Two-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity: results from a Swedish Nationwide Study (AMOS). International Journal of Obesity (2012) 36, 13881395; doi:10.1038/ijo.2012.160. (11) Kaulfers A M, Bean, J A, Inge T H, Dolan L M, Kalkwarf H J. Bone loss in adolescents after bariatric surgery. Pediatrics. 2011. Vol. 127 No. 4 pp. e956 -e961 (doi: 10.1542/peds.2010-0785). (12) Treadwell J R, Sun F, Schoelles K. Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Medscape. 2008; 248(5):763-776. (13) Cleveland Clinic. Adolescent Bariatric Surgery. 2012. http://weightloss.clevelandclinic.org/bsurgeryadolesandteen.aspx. Accessed on November 18, 2012. (14) Nelms M, Sucher K, Lacey K, Long Roth S. Nutrition Therapy and Pathophysiology, 2nd ed. 2011.

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