Obesity
Myron YasterMD and Lynne G. Maxwell MD
I’ve probably been to more SPA meetings than most, if not all,of you. Over the years, there have been many memorable meetings and lectures. Perhaps one of the best and most important lectures ever given was by Dr. Paul Samuels, of the Cincinnati Children’s Hospital, who discussed the current and long-term health consequences of childhood obesity and the anesthetic management of bariatric surgery. One of his comments struck me and has stayed with me since that lecture. I’m paraphrasing and relying on my memory (which admittedly is never a good idea)…he said that “obesity is to the current generation what smoking was to his and his parents generation.” Today’s PAAD is based on new recommendations from the American Academy of Pediatrics. Reading the 70 page article was a tough slog and I’ve asked Dr. Lynne Maxwell of the PAAD’s executive council to assist in this review.
As an aside, as a result of his Dr. Samuels’ lecture, SPA meetings and the food choices offered at the meetings changed forever. Prior to his lecture the food choices were highly processed, sugar loaded breakfast items like sweet rolls, doughnuts, bagels, etc. There were no “healthy” choices like fruit, protein, low fat milk, or high fiber options. Thanks to Paul and his lecture this has changed for the better forever. Myron Yaster MD
Original article(1)
Sarah E Hampl, Sandra G Hassink, Asheley C Skinner, et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics. 2023 Jan 9;e2022060640. PMID: 36622115
Long stigmatized as a reversible consequence of personal choices, obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. For most children, their families, and their health care providers, the prevailing wisdom has been “wait and see”. The new guidelines released by the American Academy of Pediatrics turns this advice on its head and recommends early (preschool, school age, and adolescents) and aggressive treatment. Why? Obesity is now recognized as a complex chronic disease which results inacute and long-term health risks like diabetes, heart (hypertension) disease, dyslipidemia, and liver (non-alcoholic fatty liver) disease that will have health consequences throughout a person’s life. “Because obesity is a chronic disease with escalating effects over time, a life course approach to identification and treatment should begin as early as possible and continue longitudinally through childhood, adolescence, and young adulthood, with transition into adult care”.(1)
The AAP recommendations are based on an extensive literature review of papers published on this topic in children greater than 2 years of age. In essence, obesity starts early and doesn’t get better. Almost 14 million American children are overweight or obese. “It is more common in children who live in poverty,children who live in under-resourced communities, in families that have immigrated, or in children who experience discrimination or stigma. As such, obesity does not affect all population groups equally”. (1)
“Overweight” is defined as a BMI at or above the 85th percentile and below the 95th percentile for age and sex. Childhood obesity is typically defined as having a BMI of ≥95th percentile for age and sex. Severe obesity is defined as BMI ≥ 120% of the 95th percentile for age and sex’.(1,2)
What do the new guidelines suggest as best treatment options? The most effective behavioral treatment for children with obesity who are 6 and older is a prompt referral to an intensive health behavior and lifestyle treatment program. These programs, which aim to provide nonjudgmental care, are often based in academic medical centers, community hospitals or obesity treatment clinics. They bring together a range of specialists, including nutritionists, exercise physiologists and social workers, who teach fitness education, arrange cooking demonstrations and provide other programming. The A.A.P. recommends that children and their families receive at least 26 hours of face-to-face counseling over the course of three or more months. Unfortunately, there are very few of these programs and their long-term success is unclear.
As we do with most health care issues, American medicine relies on medicine and surgery for many acute and chronic diseases rather than life style changes (think CABG as the treatment of atheroschlerotic heart disease). “Glucagon-like peptide-1 receptor agonists, such as liraglutide, exenatide, dulaglutide, and semaglutide, decrease hunger by slowing gastric emptying and by acting on targets in the central nervous system. Depending on the medication, the formulation is either oral or a daily or weekly subcutaneous injection. Two small studies of exenatide (weekly injection) among children as young as 8 years showed BMI reduction ranging from 0.9 to 1.18 U but with significant adverse effects. Exenatide is currently approved in children 10 to 17 years of age with T2DM. A recent randomized controlled trial found liraglutide (daily injection) more effective than placebo in weight loss at 1 year among patients 12 years and older with obesity who did not respond to lifestyle treatment.”(1,3)
“It is widely accepted that the most severe forms of pediatric obesity (ie, ≥class 2 obesity; BMI ≥ 35 kg/m2, or 120% of the 95th percentile for age and sex, whichever is lower) represent an “epidemic within an epidemic.” Moreover, severe obesity is a harbinger of the establishment and cumulative progression of numerous related comorbidities, diminished long-term health status, and shortened life expectancy.”(1)
“Weight loss surgery is safe and effective for pediatric patients in comprehensive metabolic and bariatric surgery settings that have experience working with youth and their families. Laparoscopic Roux-en-Y gastric bypass and vertical sleeve gastrectomy are both commonly performed in the pediatric age group and result in significant and sustained weight loss, accompanied by improvements and/or resolution of numerous related comorbid conditions.”(1) “Similar to the adult experience, an expanding body of data shows that pediatric bariatric patients also experience durable reduction in BMI, as well as significant improvement and/or complete amelioration of several obesity-related comorbid conditions. These include HTN, T2DM, dyslipidemia, cardiovascular disease risk factors, and weight-related quality of life’.(1)
Finally, recent evidence showing that adolescents had a higher probability of remission of certain cardiometabolic risk factors (T2DM and HTN) compared with adults highlights the argument that earlier surgical intervention may impart specific advantages related to the cumulative impact of chronic obesity-related diseases.(4) The significantly lower magnitude of efficacy of intensive behavioral interventions—compared with larger and more durable improvements in BMI and comorbidity resolution after metabolic and bariatric surgery—has led to a significant increase in pediatric bariatric surgical case volume since the early 2000s.”(1)
The guidelines do not discuss the prevention of obesity, which, according to the authors will be addressed in a forthcoming AAP policy statement nor provide guidance for children younger than 2 years of age.
As discussed in previous PAADs, we routinely perform physical examinations and detailed histories prior to surgery. When pediatric patients present for surgery and meet the criteria for obesity, should we be making referrals for comprehensive behavioral and lifetime treatment programs? I’ve raised this issue before (suicide, drug use, etc.) and not all of you agree (see tomorrow’s reader response). What do you think? I’d also like reader responses on how obesity is treated in your hospital systems. For example, can severely obese patients be treated as same day surgery patients? Are they treated as a difficult airway or full stomach? Send me your thoughts and I will post in a readers response.
References
1.Hampl SE, Hassink SG, Skinner AC, Armstrong SC, Barlow SE, Bolling CF, Avila Edwards KC, Eneli I, Hamre R, Joseph MM, Lunsford D, Mendonca E, Michalsky MP, Mirza N, Ochoa ER, Sharifi M, Staiano AE, Weedn AE, Flinn SK, Lindros J, Okechukwu K. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics 2023.
2.Centers for disease control and prevention. Defining childhood obesity., 2022.
3.Kelly AS, Auerbach P, Barrientos-Perez M, Gies I, Hale PM, Marcus C, Mastrandrea LD, Prabhu N, Arslanian S. A Randomized, Controlled Trial of Liraglutide for Adolescents with Obesity. N Engl J Med 2020;382:2117-28.
4.Inge TH, Courcoulas AP, Jenkins TM, Michalsky MP, Brandt ML, Xanthakos SA, Dixon JB, Harmon CM, Chen MK, Xie C, Evans ME, Helmrath MA. Five-Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults. N Engl J Med 2019;380:2136-45.