Primary Care: Pediatricians Urge Greater Access to Surgery for Severely Obese Youth

As childhood obesity becomes an “epidemic within an epidemic,” new guidance from the American Academy of Pediatrics echoes Endocrine Society recommendations on bariatric surgery for severely obese young people. Aside from reducing their weight, these procedures could benefit young people well into adulthood.

Improved access to bariatric surgery is “urgently needed” for the severely obese pediatric population, according to a new policy statement and technical report from the American Academy of Pediatrics.

“The overarching message is straightforward,” says Marc P. Michalsky, MD, MBA, professor of clinical surgery and pediatrics at the Ohio State University College of Medicine, who was a primary author of the guideline. “Bariatric surgery for the pediatric population is safe, effective, and should be considered at the primary-care level sooner rather than later.”

The need for aggressive treatment has grown as “severe obesity has outpaced less severe forms of childhood obesity in prevalence, and it disproportionately affects adolescents,” the policy statement says.

Michalsky says that the AAP statement represents an evolution in practice as recognition grows that “robust data” now supports the use of weight-loss surgery among pediatric patients: “Like any clinical treatment strategy, it takes time to become adopted to the point where it is a well-accepted practice model.”

“What is very compelling about the use of bariatric surgery in the pediatric timeframe is that evidence is beginning to show that certain outcomes related to comorbidity resolution may actually be better when compared to adult patients,” Michalsky says. In addition to the weight loss itself, early improvements in conditions such as diabetes; high blood pressure; and risk of heart disease, liver disease, and kidney disease improve as much as in adults, offer the potential advantage of enlisting the physiological plasticity of youth before the effects of the chronic disease become fixed. “Furthermore, bariatric intervention during the teenage years serves to also eliminate the cumulative impact linked to such conditions, potentially resulting in significant improvement in long-term health for decades to come,” Michalsky says.

Policy Statement and Technical Report

“The guidance is based on a comprehensive review of the literature and consultation with experts in surgical and medical pediatric weight management,” according to Sarah C. Armstrong, MD, professor of pediatrics at Duke University, who chaired the guidance committee. “It includes a policy statement titled Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices to help pediatricians select appropriate patients, guide teens and families through the decision-making process, locate high-quality surgical programs, and advocate for payment. An accompanying technical report titled Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity details the evidence on procedure types, complications, and outcomes.”

The new guidance “nicely complements” the 2017 Endocrine Society clinical practice guideline on the treatment of pediatric obesity, says Dennis M. Styne, MD, a pediatric endocrinologist at the University of California, Davis, who chaired the Endocrine Society guideline committee.

“I don’t think there is any time too early to start a conversation about this, especially at the primary care level. Starting a conversation does not automatically assign someone to a bariatric intervention, but often, just having a conversation about this can allow a patient and family to have improved access to multi-disciplinary care designed to treat childhood obesity.” – Marc P. Michalsky, MD, MBA, professor of clinical surgery and pediatrics, Ohio State University College of Medicine, Columbus, Ohio

“It very closely corresponds to what we think,” Styne tells Endocrine News. “It has the same indications, the same contraindications, and recommends the same high-level, experienced, comprehensive team approach to bariatric surgery. And it confirms that children, even more than adults, are denied bariatric surgery — even when they meet the criteria that have been established.”

Indications for Surgery

The technical report notes that obesity classifications are not as straightforward among patients under 18 as with adults. In adults, class 2 (severe) obesity is defined as having a BMI of 35 or higher, but the technical report says: “Because BMI values increase over time from age 2 to 18 years, the use of absolute BMI is generally not considered an accurate surrogate for adiposity and may either over- or underestimate associated health risks.” For that reason, the report defines class 2 obesity as having a BMI that is more than 35 or that is greater than 120% of 95th percentile for age and sex. It defines class 3 obesity as a BMI greater than 40 or 140% of the 95th percentile for age and sex.

For patients with class 2 obesity, surgery is indicated if they have clinically significant comorbid conditions, including obstructive sleep apnea, type 2 diabetes, non-alcoholic steatohepatitis, idiopathic intracranial hypertension, or gastroesophageal reflux disease. Surgery is indicated in patients with class 3 obesity regardless of the presence of comorbid conditions.

In addition to the BMI and comorbidity status, the policy statement notes that patients must possess “physiologic, psychological, and developmental maturity; the ability to understand the risks and benefits and adhere to lifestyle modifications; decision-making capacity; and robust family and social supports leading up to and after surgery.”

The contraindications for surgery include a medically correctable cause of obesity; an ongoing substance abuse problem; a medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to postoperative dietary and medication regimens; and current or planned pregnancy within 12 to 18 months of the procedure.

Special Considerations for Youth

Michalsky says that one of the important differences between adult and pediatric patients is the need to assess the young patient’s ability to give informed consent. “We want to make sure that there is a certain level of cognitive maturity and decision-making ability to really comprehend what this type of therapeutic intervention entails, what is involved for their participation, and to fully understand the risks and benefits,” he says.

“[The AAP recommendation] very closely corresponds to what we think. It has the same indications, the same contraindications, and recommends the same high-level, experienced, comprehensive team approach to bariatric surgery [as the Endocrine Society’s 2017 clinical practice guideline on pediatric obesity]. And it confirms that children, even more than adults, are denied bariatric surgery — even when they meet the criteria that have been established.” – Dennis M. Styne, MD, pediatric endocrinologist, University of California, Davis; chair, the Endocrine Society’s “Pediatric Obesity: Assessment, Treatment, and Prevention” guideline committee

As with adults, candidates go through a multi-disciplinary evaluation. “It is a relatively long process, and usually takes several months to complete,” Michalsky says. “It entails not just a physiologic assessment by physicians, but also requires assessment by a behavioral specialist, as well as a number of other multidisciplinary providers.”

“Contrary to prior reports, the evidence does not clearly identify a lower age limit,” committee chair Armstrong says. “Research shows that complications were lowest and outcomes the best when individual and family-level factors drove the decision-making process. There is no evidence to suggest that watchful waiting is effective; in fact, outcomes are improved and complication rates are lower when the surgery is done sooner.”

“I don’t think there is any time too early to start a conversation about this, especially at the primary care level,” Michalsky says. “Starting a conversation does not automatically assign someone to a bariatric intervention, but often, just having a conversation about this can allow a patient and family to have improved access to multi-disciplinary care designed to treat childhood obesity.”

The policy statement calls severe obesity among youth an “epidemic within an epidemic” that “portends a shortened life expectancy for today’s children compared with those of their parents’ generation.” Although substantial evidence supports its safety and effectiveness, youth with severe obesity often lack adequate access to surgery, especially those in underserved populations.

Seaborg is a freelance writer based in Charlottesville, Va. In the September issue, he wrote about real world evidence and the possibility of virtual clinical drug trials.

 

 

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