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Early bariatric surgery benefits adolescents with severe obesity
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WASHINGTON — Adolescents with severe obesity should be referred to a program that can provide surgical management before BMI reaches 50 kg/m2, and treatment options should also include behavioral and nutritional counseling and medications, according to a speaker here.
“The rationale for treating obesity should be based on obesity as a debilitating disease that is caused by genetic and environmental factors,” Janey S.A. Pratt, MD, clinical associate professor of surgery at Stanford University and member of the adolescent bariatric surgery team at the Lucille Packard Children’s Hospital, said during her presentation. “It’s associated with severe and sometimes unique comorbidities, and long-term sustainable weight loss is very unlikely to be accomplished with lifestyle changes and medication alone in severe obesity.”
According to Pratt, children with severe obesity are likely to become obese as adults, and complications of obesity that arise during childhood are particularly severe over a lifetime.
“Children with obesity are going to be the sickest people with obesity as adults,” she said. “It tracks into adulthood.”
Further, health-related quality of life in children with obesity is significantly lower compared with that of children without obesity.
“The most important statement here, and I share this with parents often, is that adolescents with obesity have a health-related quality of life similar to that of adolescents with cancer,” Pratt said.
Increasing BMI during adolescence is also associated with increased cardiovascular mortality in adulthood. Data also show that adults who undergo bariatric surgery live longer.
“They live longer primarily due to decreased CV death and cancer death,” Pratt said. “If we say to a parent that their child needs to remain obese for the next 8 years because they’re 10 years old and they have to wait until they’re adults to have weight-loss surgery, we are doing a disservice to that child and to that parent.”
The newest recommendations for weight-loss surgery in childhood or adolescence are expected to be released within the coming year and will indicate that children with BMI over 40 kg/m2 or BMI 35 kg/m2 with comorbidities are eligible for weight-loss surgery, according to Pratt.
“Children with a high BMI will have a high BMI in adulthood,” Pratt said. “They need to get into a surgery program early and not when their BMI is 50, 60 or 70 kg/m2; at that point, surgery is not going to work that well. They will not lose as much weight as they need to in order to get to a normal weight. We’ll have to add medications lifelong and add behavioral modifications.”
Additionally, surgery, behavioral modifications and medications should be used together, Pratt said.
“I would say that these three work together, but we don’t know in which order we should be doing them,” she said. “Until there’s more data out there, all we can say is that right now, the three modalities that we have for treatment is that most kids who have a BMI over 35 kg/m2 are going to need all three. We don’t know the timing yet, but we do know that if we do surgery early, they’re more likely to get to a normal body weight than if we wait until their BMI is 50 or 60 kg/m2.” – by Amber Cox
Reference:
Pratt JSA. Weight loss surgery for adolescent — Should this be the ‘last resort?’ Presented at: ObesityWeek 2017; Oct. 29-Nov. 2, 2017; Washington, D.C.
Disclosure: Pratt reports no relevant financial disclosures.
Perspective
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Thomas Inge, MD, PhD, FACS, FAAP
What our long-term data demonstrate is that when adolescents who have attained a BMI of 35 kg/m2 to 45 kg/m2 undergo bariatric surgery, they are far more likely to achieve a normal body weight following surgery than the adolescents who have attained a body mass index over 50 kg/m2. In those with a BMI greater than 55 kg/m2 or 60 kg/m2, we see that the weight loss is very good, but due to the advanced nature of the disease, these adolescents will not typically achieve a normal weight after operation. We do believe that the message is very important that optimal outcomes of surgery are achieved with earlier intervention during the process of weight gain. This means that intensive efforts, including surgery, should be considered at the point of diagnosis of severe obesity to provide the best chances of fully reversing the problem of severe obesity.
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