Key points

Introduction

The need for effective treatment of obese children and adolescents is increasingly agreed on. Clinicians now recognize that a significant percentage of children and adolescents with obesity become obese adults. They also have significant psychosocial and medical comorbidities while they are children as well as when they become adults. As the physiology and biochemistry of obesity is being unraveled, it becomes apparent that obesity is not a voluntary behavior problem on the part of the pediatric patient or their parents. Obesity is the energy regulatory system of the body gone awry and driving unhealthy behavior. Obesity is the root cause of many comorbidities. These comorbidities prevent a healthy life, a high-quality life, and a productive life. Comorbidities result in massive health care costs throughout the lifetime of the patient. There is now strong evidence of the effectiveness of a multidisciplinary approach to obesity leading to an improved quality of life, resolution of comorbidities, improved economic productivity, and decreased health care costs.

This article:

• 1.
  

  Discusses the goals of therapy when treating pediatric obesity

  
  
• 2.
  

  Presents the basic cornerstones of diet, activity, and behavior that need to be provided to all pediatric patients with obesity and their families

  
  
• 3.
  

  Presents bariatric procedures that have been shown to help adolescent and pediatric patients with obesity

  
  
• 4.
  

  Speculates how weight loss medications might be used to help pediatric patients with obesity

  
  
• 5.
  

  Speculates how weight loss devices might be used to help pediatric patients with obesity

  
  
• 6.
  

  Speculates how endoscopic weight loss procedures might be used to help pediatric patients with obesity

  
  
• 7.
  

  Speculates how some theoretic techniques might be used to help pediatric patients with obesity

Gastroenterologists might be involved in pediatric weight management in many ways:

• 1.
  

  As obesity medicine specialists directing the multidisciplinary weight management program

  
  
• 2.
  

  In the care of obesity-related comorbidities such as nonalcoholic fatty liver disease

  
  
• 3.
  

  Using endoscopic skills to revise bariatric procedures

  
  
• 4.
  

  Performing endoscopic versions of bariatric procedures

  
  
• 5.
  

  Placing, adjusting, and removing weight loss devices

Introduction

The need for effective treatment of obese children and adolescents is increasingly agreed on. Clinicians now recognize that a significant percentage of children and adolescents with obesity become obese adults. They also have significant psychosocial and medical comorbidities while they are children as well as when they become adults. As the physiology and biochemistry of obesity is being unraveled, it becomes apparent that obesity is not a voluntary behavior problem on the part of the pediatric patient or their parents. Obesity is the energy regulatory system of the body gone awry and driving unhealthy behavior. Obesity is the root cause of many comorbidities. These comorbidities prevent a healthy life, a high-quality life, and a productive life. Comorbidities result in massive health care costs throughout the lifetime of the patient. There is now strong evidence of the effectiveness of a multidisciplinary approach to obesity leading to an improved quality of life, resolution of comorbidities, improved economic productivity, and decreased health care costs.

This article:

• 1.
  

  Discusses the goals of therapy when treating pediatric obesity

  
  
• 2.
  

  Presents the basic cornerstones of diet, activity, and behavior that need to be provided to all pediatric patients with obesity and their families

  
  
• 3.
  

  Presents bariatric procedures that have been shown to help adolescent and pediatric patients with obesity

  
  
• 4.
  

  Speculates how weight loss medications might be used to help pediatric patients with obesity

  
  
• 5.
  

  Speculates how weight loss devices might be used to help pediatric patients with obesity

  
  
• 6.
  

  Speculates how endoscopic weight loss procedures might be used to help pediatric patients with obesity

  
  
• 7.
  

  Speculates how some theoretic techniques might be used to help pediatric patients with obesity

Gastroenterologists might be involved in pediatric weight management in many ways:

• 1.
  

  As obesity medicine specialists directing the multidisciplinary weight management program

  
  
• 2.
  

  In the care of obesity-related comorbidities such as nonalcoholic fatty liver disease

  
  
• 3.
  

  Using endoscopic skills to revise bariatric procedures

  
  
• 4.
  

  Performing endoscopic versions of bariatric procedures

  
  
• 5.
  

  Placing, adjusting, and removing weight loss devices

Goals of therapy

The goals of therapy for pediatric patients with obesity include improving the quality of life, resolution and/or prevention of comorbidities, improving economic productivity when patients become adults, and reducing lifetime health care costs.

Identification and objective measurement of childhood obesity are accomplished by calculating body mass index (BMI) for age and gender. Although percentage body fat is a better measure of obesity and the accompanying visual, metabolic, and physiologic issues, it is more difficult and expensive to do, and thus is not commonly done.

BMI charts for age and gender are readily available. Using the child’s height, weight, age, and gender, the patient can be categorized on the appropriate growth chart ( Table 1 ).

With a child increasing in height and age, keeping a stable weight may result in an improvement in the classification of the obesity. Calculating the predicted ultimate adult height for a child with obesity provides information on whether weight loss will be necessary or how much weight loss might be necessary to reach a normal BMI. The raw BMI or the BMI percentile for age and gender when the BMI is more than the 95th percentile is no longer appropriate. The categorization system mentioned earlier allows better monitoring. How aggressively to attempt to return a given patient to a normal BMI percentile is still an open question, but BMI percentile for age and gender is very useful to follow each patient’s progress.

Although BMI is convenient and useful, evaluation of psychosocial and clinical comorbidities is ultimately more important. There are pediatric weight-related quality-of-life scales that can be used to identify and follow psychosocial comorbidities and the progress of the patient. Monitoring children for bullying and stigmatization episodes, depression, and other mental health issues is standard of care ( Box 1 ).

Evaluation for clinical comorbidities involves testing for subclinical and clinical disease as well as risk factors for clinical comorbidities ( Table 2 ).

When abnormalities are found, they need to be monitored. In addition, a general evaluation should be performed at regular intervals to screen for additional clinical and psychosocial comorbidities. Reaching the goal of improving or eliminating psychosocial and clinical comorbidities is more important than reaching a normal BMI.

Diet, activity, and behavior: healthy living

Healthy living is the cornerstone on which all other weight management therapies and tools are based. A pediatric weight management program providing various advanced therapeutic options must have personnel who are trained and skilled in the management of diet, activity, and behavior.

The blueprint for the application of diet, activity, and behavior is outlined in the 2007 AAP recommendations, “Expert Committee Recommendations Regarding the Prevention, Assessment and Treatment of Child and Adolescent Overweight and Obesity: Summary Report.” These recommendations show an increasing frequency and intensity of assessment and education from stages 1 through 4. Stages 1 and 2 are delivered in primary care offices. Stage 3 involves specialists in the treatment of children with obesity and brings up the possibility of pharmacotherapy. Stage 4 continues the work by specialists in obesity medicine and brings up the possibility of bariatric surgery. In the advanced stages (3 and 4), a multidisciplinary team that includes a dietitian, an activity specialist, and a behavior health specialist is advised. The progression from one stage to the next is based on response to therapy. The weight goals vary with the age of the patient and the stage of disease.

In general, the success of healthy living practices is marginal. However, measurements of success are hampered by lack of agreement on goals. Some studies emphasize BMI, others emphasize comorbidities, whereas others try to extrapolate to future risk of disease. There is general agreement that advanced therapies such as weight loss medications, weight loss devices, and weight loss procedures should not be performed without a foundation of diet, activity, and behavior education and support, which should continue after the initiation of the advanced therapeutic modalities. Obesity should be approached as a chronic, incurable disease.

Healthy living practices should be applied to the whole family unit and supported by the school and community. Consistency in the child’s environment is essential. The adoption of healthy living activities is beneficial to all family members without regard to their individual weight status.

Which diet to advise is controversial. Even agreement on what is a healthy diet is difficult. Appreciating cultural and ethnic background is important to improve the acceptance and continuation of a healthy diet. Ketogenic diets, very-low-calorie diets, and meal replacement systems may be useful at the initiation of weight management, but eventually a healthy everyday diet should be attained, and this may involve considerable creativity on the part of the team’s dietitian, depending on the cultural and ethnic background of the patient and family.

Dr Robert Lustig observes: “Parents won’t change until you show them:

• 1.
  

  Their kid will eat the food;

  
  
• 2.
  

  Other people’s kids will eat the food;

  
  
• 3.
  

  They themselves like the food; and

  
  
• 4.
  

  They can afford the food.”

Obesity is a heterogenous disease and there is variation in how different patients handle different caloric sources. The macronutrients and micronutrients need to be calculated to avoid starvation; achieve modulation to a healthy body composition; and support health, growth, and development.

Activity is important for health and for maintenance of a healthy body composition. It is not efficient or effective as a stand-alone therapeutic technique to attain a healthy body composition. Children with obesity frequently have orthopedic and mechanical difficulties in performing the usual activities for their age. Because of the difficulties children with obesity can have with certain activities, a physical therapist should be part of the weight management team. The activity portion of healthy living has to be fun, safe, and available. Current activity guidelines use time and level of exertion as markers. Time is difficult because of the spontaneous nature of activity in children. Level of exertion is highly subjective without complex monitoring. Evaluation and monitoring of the fitness level of children with obesity can be done with the Harvard Step Test, the 6-minute walk/run, or the Bruce Protocol, although these are not designed for children with obesity.

Bariatric surgical procedures

Reports over the last 20 to 25 years have established that bariatric surgical procedures can be safely and effectively performed in children and adolescents with obesity. Unique concerns about children and adolescents with obesity being treated with bariatric surgical procedures have included:

• 1.
  

  Would weight management with surgical procedures cause problems with growth and development?

  
  
• 2.
  

  Would children, adolescents, and families be able to adapt to the dietary and behavioral requirements before and after a bariatric surgical procedure?

  
  
• 3.
  

  Would weight management with surgical procedures for children, adolescents, and families result in resolution or prevention of the medical and psychosocial comorbidities of obesity?

  
  
• 4.
  

  Would the risks and complications of bariatric surgical procedures be balanced out by the improvements in quality of life and resolution or prevention of the medical and psychosocial comorbidities of obesity?

  
  
• 5.
  

  Would the cost of bariatric surgical procedures, including ensuing complications and revisions, be balanced out by the improved economic productivity of children or adolescents with obesity as they move on into adulthood?

The most common bariatric surgical procedures currently being performed for weight management of children and adolescents with obesity include the laparoscopic sleeve gastrectomy (LSG), the Roux-en-Y gastric bypass (RYGB), and the adjustable gastric band (AGB). There has been a small, published experience with the biliopancreatic diversion and duodenal switch, but possible nutritional consequences have steered surgeons away from using these procedures for weight management in children and adolescents.

The longest experience in the pediatric population has been with the RYGB, which is usually performed laparoscopically. When performing the RYGB, the surgeon creates a small proximal gastric pouch attached to a Roux-en-Y limb of jejunum, resulting in bypass of the mid and distal stomach, the duodenum, and the proximal part of the jejunum. RYGB was originally thought to be effective because of the restriction caused by the small proximal gastric pouch and because of malabsorption caused by the bypass of portions of the stomach, the duodenum, and the proximal jejunum. Newer understanding of the energy regulatory system, including the importance of the vagus nerve and hormones secreted by the stomach, duodenum, and small intestine, shows that most of the RYGB effects are physiologic. These effects include stimulation of afferent signals from the stomach to the hypothalamus via the vagus nerve, and the altered stimulation of hormones secreted by the duodenum, jejunum, and ileum. There is a bell-shaped curve to the responses to the RYGB with nonresponders and super-responders. The average response is about a 50% to 60% excess weight loss over the first 6 to 12 months after the procedure with good maintenance of a healthier body composition for at least 3 years.

Five to 10 years ago, there was considerable experience using the AGB for weight management of obese adolescents. The AGB is an adjustable silicon ring placed around the upper stomach to create a small proximal gastric pouch. The mechanism for weight loss is decreased hunger mediated by the vagus nerve responding to the pressure in the small proximal gastric pouch. Adjustment of the ring size is achieved by injecting or removing fluid from a balloon on the inner surface of the ring. The average response is about 40% to 50% excess weight loss over 3 years. There is little response immediately after placement of the AGB. Response depends on the AGB being adjusted to the point at which the patient’s hunger is resolved with a small portion of food. This point seems to depend on the size of the orifice through the ring, which changes in response to the thinning or thickening of the stomach passing through the ring. Therefore, repeated adjustments are often necessary. The AGB requires continued management by a weight management program to support the mechanical nature of the patient’s diet, the necessary adjustments of the AGB, and the potential management of food impaction and proximal pouch dilatation. Several factors have resulted in decreased use of this modality in the United States, including slower or minimal response to therapy, and the need for long-term management of the patient.

The newest weight loss procedure is the LSG, which involves the removal of 80% to 90% of the stomach by resecting longitudinally along the lesser curve and creating a tubular stomach. The procedure results in signals to the ERS by several mechanisms: (1) pressure in the proximal stomach; (2) reduction of ghrelin production through removal of most of the ghrelin-producing cells in the stomach; and (3) shortened gastric emptying time, resulting in faster stimulation of the distal small bowel and leading to increased levels or peptide YY (PYY) and glucagon-like peptide-1 (GLP-1) (satiety signaling mechanism). The weight loss with LSG is approximately 50% of excess weight loss and occurs over the first year after the operation. The simplicity, safety, and effectiveness of the LSG has resulted in it becoming the most common weight loss procedure performed in the United States.

At present, the responses to the previous unique concerns regarding children and adolescents and bariatric surgical procedures are as follows:

• 1.
  

  Would weight management with surgical procedures cause problems with growth and development? There has been no evidence that weight management with surgical procedures causes problems with growth and development. Weight management with surgical procedures usually results in a healthier body composition but does not result in a normal body composition, underweight, or malnutrition.

  
  
• 2.
  

  Would the children, adolescents, and families be able to adapt to the dietary and behavioral requirements before and after a bariatric surgical procedure? All the published experience has shown that the results from weight management with surgical procedures for children and adolescents with obesity is at least as good as the results in adults and does not produce any unique complications.

  
  
• 3.
  

  Would weight management with surgical procedures for children, adolescents, and families result in resolution or prevention of the medical and psychosocial comorbidities of obesity? The early results are encouraging, but there are no large, long-term studies.

  
  
• 4.
  

  Would the risks and complications of bariatric surgical procedures be balanced out by improvements in quality of life and resolution or prevention of the medical and psychosocial comorbidities of obesity? The early results are encouraging, but there are no large, long-term studies.

  
  
• 5.
  

  Would the cost of bariatric surgical procedures, including ensuing complications and revisions, be balanced out by the improved economic productivity of children or adolescents with obesity as they move on into adulthood? The authors currently do not know the answer. This question will require long-term, comprehensive studies.

In spite of the answers to these concerns, support for weight management with bariatric surgical procedures for children and adolescents with obesity from clinicians, policy makers, and payers has been slow to develop. In the adult world, the use of weight management with bariatric surgery occurs in less than 1% of the candidates. The limited use of bariatric surgical therapy has created a gap between healthy living techniques to treat obesity and the use of bariatric surgery. Obese adults who fail to adequately respond to managing their obesity with healthy living are offered pharmacotherapy, weight loss devices, and bariatric surgery. The treatment gap is wider for children and adolescents because of the greater reluctance to use bariatric surgery, even more limited pharmacotherapy options, and the lack of other options. In addition, the decision-making process for obese children and adolescents is more complicated than for adults because it involves their parents and their primary care physicians. The recent advent of safe, effective, US Food and Drug Administration (FDA)–approved devices for obese adults has the potential to fill the gap between healthy living techniques and bariatric surgery. Additional studies investigating the safety and efficacy of weight loss medications and devices in children and adolescents are needed.