Narrow Window of Opportunity to Reverse Obesity with Surgery in Teens

Thursday, October 01, 2009

According to a recent study of clinical characteristics of teens who underwent laparoscopic Roux-en-Y gastric bypass surgery from 2002 until 2007, doctors may have a much narrower window of opportunity to reverse morbid obesity in teens than previously thought.

The study, conducted at Cincinnati Children’s Hospital Medical Center, appears in the current online edition of the Journal of Pediatrics.

The study focused on 61 teens who underwent laparoscopic Roux-en-Y gastric bypass at Cincinnati Children’s, most of whom were in a super-obese weight range (more than 250% over ideal weight for age). The results of the study showed that one year after surgery, weights (and body mass index [BMI]) of the group as a whole decreased by 37%. However because of their extremely high starting weights (average 375 pounds), most of the teens were still obese, and many still remained morbidly obese.

Lead author of the study, Thomas Inge, MD, PhD, Associate Professor of Surgery and Pediatrics, explains that "Current guidelines for adolescent weight loss surgery suggest that we begin to consider surgery only after a teen is 80-100% overweight. Our new data show that when we intervene when a patient is between 100 and 150% over ideal weight, we can expect successfully resolution of obesity. But by the time the teen is 200% over their ideal weight for age, the surgery will reduce their weight substantially, but many of the patients will still remain morbidly obese.

This study, like others, found that after surgery, patients generally show significant improvement or resolution of cardiovascular risk factors such as blood pressure, cholesterol, and triglyceride levels. But this is the first study in adolescents to specifically show that the postoperative weight is strongly influenced by the starting weight. This finding raises a valid concern that waiting until children are super obese to begin to think of surgery may result in major weight loss, but not resolution of obesity and certain medical problems than intervening at an early stage of the disease. For instance, in those who remain significantly obese following surgery, this excess weight can have negative effects on joints and mobility; the long-term risks of remaining seriously overweight are unknown.

Co-author Dr. Stavra Xanthakos, Assistant Professor of Pediatrics and pediatric gastroenterologist feels that “we [doctors] have to do a better job of identifying teens who are gaining enormous amounts of weight quickly and get help for them earlier.” Dr. Xanthakos says that when doctors or parents notice that a teen is beginning to gain weight rapidly, there should be a staged approach to managing the weight problem. “If the weight gain is not effectively stopped with initial nutritional or exercise measures, then even more intensive treatments or programs are indicated, and ultimately some very serious thought has to be given to surgery,” said Dr. Xanthakos.

Prior to weight loss surgery, teens with extreme obesity present with the most significant and global impairments in quality of life relative to other pediatric chronic illness populations and rates of depressive symptoms that are 3-4 times higher than national rates, says pediatric psychologist and co-author Dr. Meg Zeller, Associate Professor of Pediatrics. “We cannot underestimate the psychological impact on the adolescent when obesity progresses to such extreme levels and is not durably treated.” In fact, Zeller’s recent data (published in the journal Obesity) from the same group of teens demonstrated significant psychosocial improvements following surgery at one-year. “As we learn more about the benefits of surgery in this age group, it pushes the medical community to ask when is the optimal time to intervene surgically and potentially change a young person’s developmental course in a more positive direction?”

Mary L. Brandt, MD, Professor and Vice Chair of the Michael E. DeBakey Department of Surgery and a pediatric surgeon at Texas Children’s Hospital worries about these results as well. “We are trying to help teenagers who are at high risk for preventable but life-threatening diseases such as diabetes or obesity induced liver disease. Bariatric surgery will improve the medical condition of obese teenagers regardless of the starting weight of the patient. But our ability to help these children prevent or reverse their life-threatening diseases will be even greater if our patients are able to approach a normal weight.”

According to Brandt, “There is one other major implication of this new data. Many insurance companies will delay surgery for years, usually by requiring documentation of multiple attempts at weight loss. Severely obese teenagers only rarely respond to these kinds of treatments and, despite intense efforts to lose weight, often will gain weight during these efforts. Although it is ethically important for these children to have a least one well supervised attempt to lose weight without surgery, this report shows us that delaying the surgery while trying multiple times may not be in their best interest.”

These findings certainly indicate that families and communities need to take childhood weight problems seriously, and aggressively pursue the best treatment options available for them before the weight problem gets out of hand. “As doctors who take care of kids, we have an obligation to identify those at highest risk and start explaining treatment options to families far earlier, before the a child or teen gets to be two or three times his or her ideal weight, when even the most intensive of treatments may be less effective than we’d like" said Dr. Inge.

About Cincinnati Children’s

Cincinnati Children’s Hospital Medical Center is one of 10 children’s hospitals in the United States to make the Honor Roll in U.S. News and World Reports 2009-10 America’s Best Children’s Hospitals issue. It is #1 ranked for digestive disorders and is also highly ranked for its expertise in respiratory diseases, cancer, neonatal care, heart care, neurosurgery, diabetes, orthopedics, kidney disorders and urology. One of the three largest children’s hospitals in the U.S., Cincinnati Children’s is affiliated with the University of Cincinnati College of Medicine and is one of the top two recipients of pediatric research grants from the National Institutes of Health.

President Barack Obama in June 2009 cited Cincinnati Children’s as an “island of excellence” in health care. For its achievements in transforming health care, Cincinnati Children’s is one of six U.S. hospitals since 2002 to be awarded the American Hospital Association-McKesson Quest for Quality Prize for leadership and innovation in quality, safety and commitment to patient care. The hospital is a national and international referral center for complex cases. Additional information can be found at www.cincinnatichildrens.org.