Bariatric Surgery for Obese Adolescents: Should Surgery Be Used to Treat the Childhood Obesity Epidemic?

Abstract and Introduction

Abstract

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.

Introduction

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.

Pediatr Health. 2009;3(1):33-40. © 2009  Future Medicine Ltd.

Cite this: Bariatric Surgery for Obese Adolescents: Should Surgery Be Used to Treat the Childhood Obesity Epidemic? - Medscape - Feb 01, 2009.