Should Surgery Be Used to Treat the Childhood Obesity Epidemic?

Diet & Compliance After Surgery and Future Perspective

Diet & Compliance After Surgery

Before surgery, a candidate is required to meet with a multidisciplinary team that includes a dietitian. Postoperatively, dietary restrictions must be followed, and compliance with supplements and medications must be maintained to ensure a beneficial outcome. The dietitian should meet with the patient following surgery to review the expected dietary management. After surgery, patients begin a liquid diet and once tolerated, will gradually introduce small portions of solid food. On a 'full diet´, the typical procedure is to consume meals that are less than a cup in size, contain both protein and fiber and to avoid fluids with a meal. Hydration is vital and in order to improve meal success, it is suggested to drink water only 90 min after a meal and no later than 15 min prior. Patients must chew their food slowly and thoroughly.

Following surgery, nutrient deficiencies may occur owing to poor micronutrient supplementation and poor absorption.^[32] Nutritional supplements are required in order to help prevent such deficiencies, including calcium, vitamin D, iron, folate, thiamin and B vitamins (B₁, B₆ and B₁₂). A total of 5–16% of gastric bypass patients who did not receive adequate vitamin B supplementation developed peripheral neuropathy.^[33] In addition, after a gastric bypass procedure patients are at risk of fat malabsorption with resultant fat-soluble vitamin deficiencies (A, D, E or K). Of special concern for adolescents is the potential for suboptimal calcium and vitamin D intake following surgery, with a greater risk of deficiency with malabsorption following surgery. It is necessary to monitor bone mineral density levels over the lifespan for adolescents who have undergone bariatric surgery. Owing to the poor absorption of iron, specific iron supplementation may help prevent iron deficiency anemia; however, mild anemia may still occur despite normal vitamin levels.^[32] Females are at greater risk for iron deficiency if they are menstruating or become pregnant. Although women can safely support pregnancy after bariatric surgery, it is recommended that patients use contraception to prevent pregnancy, especially within the first year following surgery, owing to the rapid weight loss.^[19,101,102] Additional postoperative complications vary according to the surgical procedure. Following the gastric band procedure port-related complications, including infection and hematoma, can occur, as can band erosion and slippage.^[34] After gastric bypass surgery, complications include stricture formation at gastrojejunostomy, anastomotic leak, fistula formation and leaking into the excluded part of the stomach.^[34,35] The failure rate for weight loss with gastric banding is 40% at 5 years and for gastric bypass the failure rate is 10–20%.^[34,35]

Factors that may increase weight loss following bariatric surgery include a daily exercise regimen of at least 20–30 min and a food diary that includes any of the mentioned side effects.^[36] Postsurgical management can be overwhelming and frustrating, even for adults, and poor compliance with supplements and medications is not unique. Weight loss can fluctuate from an initial quick loss to a plateau, followed by slower weight loss. Patients need to understand that behavior modifications, medications and supplements still need to be maintained in order to continue their success of reaching a goal weight. Adolescents are at particular risk for noncompliance, especially if their maturity level is not optimal to understand the consequences of their behaviors. As such, the National Institute of Diabetes and Digestive and Kidney Diseases established a program to follow the longitudinal outcomes of bariatric surgery in adolescents (Teen-Longitudinal Assessment of Bariatric Surgery [Teen-LABS]) with the goal of obtaining a realistic estimate of the risks and benefits of bariatric surgery in this population.^[37]

The current epidemic of pediatric obesity has resulted in an increasing number of adolescents with obesity-related complications and bariatric surgery provides an opportunity for significant weight loss and reversal of these complications in the most severe cases. Many surgeons believe that performing bariatric surgery in adolescence will result in decreased morbidity and healthcare costs in adulthood.^[28] There is some evidence that weight loss in adolescence can preserve pancreatic β-cell function and, thus, decrease the progression from insulin resistance and glucose intolerance to Type 2 diabetes for these obese teens.^[28] Although there is good evidence that adolescents can have successful weight loss following bariatric surgery, questions remain about the long-term effects of these operations for adolescents. In addition, the degree to which weight loss after bariatric surgery in adolescence can be sustained over a lifetime is unknown. The long-term follow-up of individuals who undergo this treatment during adolescence is needed to determine if there are environmental, behavioral and biologic predictors of success that can be used in the determination of who are the best candidates with the most chance of success for this surgery. At this point, recommendations for bariatric surgery in youngsters should be conservative and prior to undergoing bariatric surgery, it should be emphasized that this surgery mandates a lifetime commitment to lifestyle change.

Future Perspective

Over the next 5–10 years, physicians will gain a better understanding of the effectiveness and long-term consequences of bariatric surgery for morbidly obese adolescents. As more is learned about the genetics that contribute to obesity in our current obesogenic environment, it may be possible to determine which adolescents are the best candidates for bariatric surgery and who are destined to fail these procedures. As the consequences of childhood obesity are better understood and the public becomes better educated about the risks associated with pediatric obesity, hopefully, the current epidemic will begin to subside.

Reprint Address

Jennifer L. Miller, Division of Pediatric Endocrinology, University of Florida, Box 100296, JHMHC, Gainesville, FL 32610-0296, USA; E-mail: millejl@peds.ufl.edu

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

Known Genetic and Neuroendocrine Causes of Obesity Not Amenable to Bariatric Surgery
	Prader–Willi syndrome	Leptin deficiency	Leptin-receptor mutation	Melanocortin-4 receptor mutation	Proopiomelanocortin	Pseudohypo-parathyroidism
Phenotype	Hyperphagia, food-seeking behavior, short stature and small hands/feet	EMO, hyperphagia and decreased T-cell function	EMO, hyperphagia and aggressive food-seeking behavior	EMO, tall stature and increased lean muscle mass. Phenotype improves with time (adults report less intense hunger and have decreased insulin resistance)	EMO, hyperphagia and red hair	EMO, hyperphagia and can have tall stature
Laboratory abnormalities	Growth-hormone deficiency, hypogonadotropic hypogonadism. Central hypothyroidism and central adrenal insufficiency possible	Hypogonadotropic hypogonadism, hyperinsulinemia and hypothyroidism	Central hypothyroidism, low growth hormone and IGF-1 and absence of puberty	Hyperinsulinemia	Hypocortisolism and hypoglycemia	Primary hypothyroidism

EMO = Early-onset morbid obesity.

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

My Alerts