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State-of-the-Art Pediatrics

August, 2018

Identification of Candidates for Weight Loss Surgery

 

Author: Brooke Sweeney, MD, FAAP | Medical Director Internal Medicine-Pediatrics/General Academic Pediatrics/Weight Management | Medical Director / Center for Children’s Healthy Lifestyles & Nutrition Children’s Mercy Kansas City | Associate Professor UMKC School of Medicine

Column editor: Amita R. Amonker, MD | Physician Scheduler, Division of Pediatric Hospital Medicine | Pediatric Hospitalist | Assistant Professor of Pediatrics, UMKC School of Medicine

Obesity is a disease with a complex pathophysiology that is treatment resistant. In the earlier stages of the disease, overweight and Class 1 Obesity (BMI 95th percentile to 120 percent of the 95th percentile), and at younger ages, intensive lifestyle intervention, has a reasonable chance for effectiveness. However, for children with severe obesity, ≥120% of the 95th percentile or a BMI of 35 or above in children 15 years old and older, the likelihood they will remain obese as an adult is almost 100 percent.1 Treatments for obesity are most often based on changes in the external environment with lifestyle modification and/or behavioral therapy, including reducing calorie excess, activity deficit and behavioral contributors.2 

Once a certain level of adipose tissue is established, however, efforts to force the body to reverse the process of increasing adipose tissue are unlikely to respond to external treatments alone. As calories are restricted, the internal physiology adjusts metabolism to conserve energy and maintain homeostasis, resulting in stable or even continued increase in weight.3 Primary care providers may recognize this process when encountering a child with severe obesity whose family has attempted to implement recommendations and found them either not possible to implement (e.g., due to increased hunger and food seeking with calorie restriction) or ineffective in bringing about a change in the weight trajectory. When families have attempted change and have not been successful, this sets up a cycle of increased frustration, decreased trust in medical recommendations and feelings of futility for implementing future recommendations. Therefore, in cases of severe obesity, successful sustained weight loss will likely require treatment of both the external factors and the internal physiology. 

The treatments specifically targeting internal physiology for weight loss are medications, devices and weight loss surgery. Weight loss surgery has now come into its own as an adjunct to behavioral weight management to result in significant, durable weight loss in adults and children with severe obesity. Weight loss surgery has been performed in adolescents in significant numbers since 2000 and is increasingly safe and effective for assisting in weight loss. 

The ASMBS (American Society of Metabolic and Bariatric Surgery) released updated guidelines in August 2018. A significant amount of data has been published on long-term outcomes, resolution of comorbidities, and specifically treatment of Type 2 diabetes mellitus, which informs these new guidelines. Candidates for weight loss surgery are children 10 years of age and older with: a BMI ≥120% of the 95th percentile with an additional comorbidity including: hyperlipidemia, HTN, insulin resistance, T2DM, decreased HRQoL (Health Related Quality of Life), OSA, GERD, NAFLD, orthopaedic complications, or IIH (idiopathic intracranial hypertension) qualify as comorbidities in children.4 A BMI ≥140% of the 95th percentile, or a BMI of 40+ with or without any additional comorbidity, is also a qualifying state.4 

Further, surgery can be considered even in children seen previously as having “contraindications” such as intellectual and developmental disabilities, syndromic obesity, hypothalamic obesity (including Prader Willi), family dysfunction, history of maltreatment, mental health disorders and loss of control eating.4 The only true contraindications are active psychosis, suicidality or substance abuse. Bone age and Tanner stage should not be an indication or contraindication to surgery as typically patients have better growth post-surgery. Additionally, with the recent three-year outcome data showing resolution of comorbidities, weight loss surgery should be considered a treatment option for the mentioned comorbidities associated with obesity, especially type 2 diabetes mellitus.
 

These new guidelines are a call to action for those of us in primary care and medical weight management.

  • Aggressively and consistently intervene with families and children who are increasing weight and becoming overweight. 

    • This is the time when intensive lifestyle interventions alone can be effective: in younger children and those who are overweight with less severe obesity. 

    • Resources such as those found on the AAP’s Institute for Healthy Childhood Weight can be helpful. See https://ihcw.aap.org/Pages/default.aspx

  • Refer children 10 and older with severe obesity (BMI ≥120% of the 95th percentile) for evaluation in a Tertiary Care Weight Management Center. Let them know they are a possible candidate for weight loss surgery.

  • For older teens (>15) who have a BMI 35 or above, think about offering a referral for evaluation for weight loss surgery sooner. 

  • The optimal window for weight loss surgery is a BMI of 35-45. As the BMI increases past 50, the child will likely still have severe obesity even after surgery, and the operative complication rate increases. 

References:

1. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and Adolescents: The Bogalusa Heart Study. Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. 1, 2007, J Pediatrics, Vol. 150, pp. 12-17.
2. Pediatric Obesity Pharmacotherapy: Current State of the Field, Review of the Literature and Clinical Trial Considerations. Kelly AS, Fox CK, Rudser KD, Gross AC, Ryder JR. 7, Jul 2016, Int J Obes (Lond), Vol. 40, pp. 1043-1050.
3. Biology's Response to Dieting: The Impetus for Weight Regain. Maclean PS, Bergouignan A, Cornier MA, Jackman MR. 3, Sep 2011, Am J Physiol Regul Integr Comp Physiol, Vol. 301, pp. R581-600.
4. ASMBS Pediatric Metabolic and Bariatric Surgery Guidelines. Pratt JSA, Browne A, Browne NT, Bruzoni M, Cohen M, Desai A, Inge T, Linden BC, Mattar SG, Michalsky M, Podkameni D, Reichard KW, Stanford FC, Zeller MH, Zitsman J. 7, Jul 2018, Surg Obes Relat Dis, Vol. 14, pp. 882-901.