Pediatric obesity: impact and surgical management.

Abstract: The incidence of children in the United States who are overweight or obese is increasing at an alarming rate, and many obesity-related complications are now being described in children. There appears to be no current pharmacologic treatment or surgical procedure that is both safe and effective for millions of obese children. Bariatric surgery may be useful, however, in carefully selected obese children with associated serious comorbidities unresponsive to medical or dietary interventions. The complications of pediatric obesity are discussed, as well as current medical and surgical management of this disorder.

Key Words: pediatric obesity, overweight, hypertension, hyperlipidemia, bariatric surgery, weight loss

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One of the biggest health concerns facing the United States at the beginning of the 21st century is obesity and its sequelae. According to the National Health and Nutrition Examination Survey (NHANES III), approximately two-thirds of adults in the United States are overweight, defined as a body mass index (BMI) [greater than or equal to] 25 (kilograms per [meter.sup.2]). One third of overweight adults are obese with a BMI [greater than or equal to] 30. (1,2)

Nationally, the percentage of affected children is even more alarming, with obesity affecting 15.3% of school-age children and 15.5% of adolescents. In general, childhood obesity is defined as having a BMI [greater than or equal to] 95th percentile for gender and age. Adolescents are similar to adults in that they are generally defined as obese if their BMI is [greater than or equal to] 30. (2,3) In addition, longitudinal studies demonstrate that the rate of childhood obesity has tripled over the past 30 years, and variations of these rates occur throughout all 50 states. (3,4) For example, a recent survey of children in Texas public schools showed that 22.4%, 19.2%, and 15.5% of all 4th, 8th, and 11th grade students are overweight or obese. (4)

Complex and poorly understood genetic, societal, and dietary factors are involved in the development of this national pediatric epidemic. A genetic predisposition for obesity probably exists to some extent in many children since obese parents generally have obese children, and a high concordance for obesity exists in identical twins. (2) Rare genetic defects also have been shown to lead to early-onset obesity, including mutations of the proopiomelanocortin pathway. (5) However, genetics are only part of the disease process, which is heavily influenced by Western lifestyle. Easy access to high-calorie, low-nutrient foods, increased snacking, an increase in sedentary lifestyle, and a large carbohydrate intake illustrate many of the continuing factors. (6-8)

In addition, certain ethnic groups seem to have a disproportionately increased risk of obesity, regardless of age. In particular, African Americans, Hispanic Americans, and Native Americans have experienced a tremendous rise in obesity prevalence over the past several decades, leading to an increased rate of obesity-related complications, especially non-insulin dependent diabetes mellitus. (9,10) Further understanding of this disease, particularly its treatment and prevention, is of utmost importance. Since the complications of obesity occur over several decades, recognition of this disease in the pediatric age group is the key to decreasing subsequent health risks.

Why is the treatment of obesity important? Diseases associated with poor diet and low activity have accounted for approximately 400,000 deaths annually in the United States, ranking just behind tobacco use as the leading cause of avoidable deaths. (11) In the future, it is likely that the pediatric obesity epidemic and its complications (Table 1) will lead to an even greater disease burden and an escalation of national health care costs as these affected children progress to adulthood.

Consequences of Childhood Obesity

Hypertension and Hyperlipidemia

Long-term hypertension and hyperlipidemia during childhood increase the risk of heart disease and stroke in adulthood. Previous studies have demonstrated that obese children as young as the preschool age are at a greater risk of developing hypertension and hypercholesterolemia. This effect is especially pronounced in children who demonstrate limited physical activity. (12,13) Early appearance of childhood obesity also leads to an elevated total cholesterol and low-density lipoprotein (LDL) cholesterol in young adulthood. (14)

In addition, the risk of hypertension increases as a child's BMI increases, and hypertension is more likely to be seen in children of male gender and Hispanic ethnicity. (15) Iannuzzi et al (16) have reported that obese children demonstrate physiologic changes such as hypertension, as well as other atherogenic effects such as elevated levels of cholesterol, triglycerides, insulin, and C-reactive protein, compared with age-matched normal weight controls. These children also have increased aortic stiffness when measured by aortic Doppler ultrasound. It is unknown if these changes may be reversible. Obese children with low HDL levels have atherogenic potential in relation to their overall apolipoprotein levels, while their apo-B lipoprotein levels are less than adult patients with known coronary artery disease. These findings suggest that atherosclerosis is a cumulative process which starts in childhood and may be reversible with early and intensive lifestyle changes. (17) In particular, elevated C-reactive protein seen in obese pediatric patients may be a marker of a chronic inflammatory state that predicts atherosclerotic disease during adulthood. (18) It is important to encourage exercise and weight loss since markers of inflammation, such as the C-reactive protein and D-dimer, are elevated in obese children. Unfortunately, a short-term increase in physical activity in children improves fitness and decreases adiposity without an appreciable effect on inflammatory mediators. (19)

Insulin Resistance and Diabetes

The "metabolic syndrome" consisting of insulin resistance, hypertension, and hyperlipidemia is present in overweight and obese adults and children. Weiss et al (20) performed glucose tolerance testing and evaluated baseline blood pressure, plasma lipid, C-reactive protein, and adiponectin levels on nonobese, overweight, and obese children. Overall, 50% of the severely obese children (BMI Z-score greater than 2.5) who were studied demonstrated an increased prevalence of the metabolic syndrome. As might be expected, insulin resistance in children has been associated with other comorbidities, including asthma, upper airway obstruction, and left ventricular hypertrophy, which can lead to further impaired physical conditioning. (21)

Certain ethnic groups are also at an increased risk of obesity and insulin resistance. For example, up to 5% of Pima Indian adolescents have noninsulin dependent diabetes mellitus, although this disease is seen across all ethnicities. (22,23) In the setting of obesity, there appears to be an underlying genetic basis for insulin resistance. Eberle et al demonstrated that such patients have polymorphisms of the sterol regulatory element binding protein (SREBP) gene in the form of single nucleotide polymorphisms. Such mutations may lead to a predilection for insulin resistance and noninsulin dependent diabetes via impaired transcription of gene encoding for glycolysis and gluconeogenesis. (24)

Obesity-associated Liver Disease 

Hyperlipidemia leads to fatty infiltration of the liver with the potential for hepatic disease. The hepatic consequences of elevated lipid levels, especially hypertriglyceridemia, leads to elevated serum transaminases, elevated gamma glutamyl-transferase (GGT), and ultrasound findings consistent with hepatic fatty infiltration. (25) Indeed, NHANES III demonstrated that the majority of adolescents who were either overweight or obese had measurable elevations of serum transaminases. (26) Fat accumulation in the liver is referred to as nonalcoholic fatty liver disease (NAFLD) which defines a broad spectrum of disease ranging from benign steatosis (macrovesicular fat in hepatocytes without fibrosis) to irreversible cirrhotic changes. (27) Both insulin resistance and hypertension are associated with more severe presentations of NAFLD. (28) The wide clinical manifestations of NAFLD may be due in part to impaired hepatic recovery after ATP depletion, which leads to poor oxidative phosphorylation. The levels of hepatocyte ATP may be decreased in obese individuals during times of stress which leads to subsequent liver damage. (29) Similar findings exist in children as Schwimmer et al (30) have described advanced forms of pediatric NAFLD including portal inflammation and fibrosis in the setting of insulin resistance, increased fasting insulin level, and a high BMI Z-score.

Hepatocellular carcinoma also may occur as a complication of long-standing NAFLD which is an obvious long-term concern in patients who present with NAFLD in the pediatric age range. (31) Various medical treatments for pediatric NAFLD, including vitamin E and ursodeoxycholic acid, have been used with variable success. (32,33)

Orthopaedic Issues

Orthopaedic issues are a frequent complication of pediatric obesity. Busy primary care physicians often fail to adequately screen the musculoskeletal system in overweight children. (34) Children with slipped capital femoral epiphysis (SCFE) have a statistically higher BMI than normal-weight children. (35) Also, studies have demonstrated increased body weight in relation to bone development in overweight and obese children which may lead to mechanical injuries, such as SCFE. (36,37) A low threshold for the evaluation of SCFE in the appropriate clinical scenario (for example, the obese child with leg pain, limp, etc) should be standard practice in overweight children. (38)

Iron Deficiency Anemia 

Iron deficiency anemia is increasingly recognized as a complication of pediatric obesity, and the diagnosis can be made by measuring serum iron levels. (39,40) Anemia is seen in early childhood and is associated with prolonged bottle use, especially if associated with consumption of milk or sweet liquids. (39) The etiology of iron deficiency in obese children is unclear but may be associated with poor dietary iron intake relative to body mass or increased iron requirements due to poor nutrition. (40) The prevalence of iron deficiency increases with BMI, and NHANES III data indicates that overweight children are twice as likely to be iron deficient compared with normal-weight controls. This finding suggests that iron deficiency screening may be a necessary requirement for obese children. (41)

Sleep Disturbances

Several sleep-associated complications are associated with obesity. Gunnbjornsdottir et al (42) have demonstrated increased rates of asthma, nocturnal gastroesophageal reflux, and snoring in adults with an elevated BMI. In the pediatric population, obstructive sleep apnea (OSA) is a common sleep disturbance associated with childhood obesity, and hypopnea seems to correlate particularly well with hypertensive obese children. (43) OSA is seen in 13 to 36% of obese children, and OSA severity has a positive correlation with the degree of obesity. Multiple treatment options, including weight loss, are available. (44) However, pharyngeal lymphoid tissue can potentiate the symptoms of OSA in obese pediatric patients, and adenotonsillectomy significantly improves symptoms, regardless of postoperative BMI. Surgical intervention to relieve airway obstruction should be considered as first-line treatment in these children. (45,46)

Kidney Disease

Obesity-related kidney disease, especially in the setting of the metabolic syndrome, has been amply described in adults, and this complication is demonstrated in children as well. (47) Adelman et al (48) have described the association of proteinuria in severely obese children with hypertension and hypercholesterolemia. Renal biopsies in affected children have demonstrated a wide array of microscopic disease, including focal segmental glomerulosclerosis without an inflammatory or immune-mediated reaction. Weight reduction and use of angiotensin-converting enzyme inhibitors can prevent progression of renal disease in such patients.

Cancer Risk

An inherent long-term risk of malignancy in obese adults has been observed, including cancers involving the esophagus, colon, liver, gallbladder, kidney, and pancreas. (49) Similar literature exists in the pediatric population as seen in childhood acute lymphoblastic leukemia where obesity is a frequent complication after treatment, especially if cranial radiation has occurred. The mechanism of irradiation may affect the ability of the hypothalamus to regulate leptin via polymorphisms of the leptin receptor, and all subsequent morbidities associated with obesity in the pediatric leukemia survivor, including a possible risk of future malignancy, are theoretically possible. (50) A potential concern is that long-term exposure to abnormal hormone elevations, such as an increase in serum insulin-like growth factor-1 (IGF-1), may lead to an increased cancer risk in obese children as they progress into adulthood. (51)

Health-related Quality of Life

A combination of the obesity-related complications that have been reviewed above as well as the social stigma placed on obesity affects the psychological well-being in such children. Wake et al (52) have demonstrated that obese children are at risk of problems with mental health and self-esteem compared with normal-weight controls. Several measured parameters of health-related quality of life, including poor self-esteem, decreased physical functioning, and increased emotional problems, are more prevalent in obese children. (53) Schwimmer et al (54) have demonstrated that the quality of life measurement of obese children is comparable to children with cancer, suggesting that techniques for preventing or reversing the effects of obesity are essential in preventing long-term psychological effects of pediatric obesity.

Treatment Options

Behavioral Therapy

A safe and effective pharmacologic regimen for treating children and adolescents who are overweight and obese has been elusive. In part, this failure stems from an incomplete understanding of the factors that control appetite, satiety, and energy balance. It comes as no surprise that overweight and obese individuals often turn to unproven and unsustainable interventions for help, as obesity involves a complex interaction of genetic, behavioral, cultural and environmental influences. (55) It is unlikely, therefore, that interventions which fail to incorporate behavioral changes with changes in cultural and social environments will be successful. For example, risk factors in the development of childhood obesity, including parental obesity, lack of parental concern, temper tantrums regarding food, decreased sleep in childhood, and an increased amount of television viewing, must be addressed. (56,57) Education of the entire family should include promotion of the entire family eating together and discouragement of television viewing during meals. (58)

Like most public health problems, changes in public policies at all governmental levels will ultimately be necessary to reverse the obesity epidemic. (59) Many public schools have taken the initiative by reducing and/or eliminating foods of limited nutritional value and improving the quality of food served to children. Recently, the Department of Health and Human Services officially acknowledged obesity as a disease, rather than a self-inflicted condition. This reclassification of obesity paves the way for better acceptance and improved understanding of the inherent health risks associated with obesity by both the lay public and health professionals. In addition, this subtle yet important change in definition creates the opportunity to fund programs and services, which may lead to targeting prevention.

Historically, lifestyle change has been a key strategy in the treatment of obese children and adolescents. Despite its key role, lifestyle modification has been unable to blunt the alarming rise in obese adolescents. (3,4,60) Lifestyle intervention, including selection of healthier foods, increased daily physical activity, and avoidance or cessation of smoking, is the most difficult therapy to implement, yet it has the potential of significantly improving healthcare outcomes and reducing the cardiovascular risk of overweight and obese pediatric patients. (61) Many such interventions, especially exercise programs, can be utilized in the public school setting. (62) However, studies evaluating weight loss in children, which have included decreased caloric intake, decreased fat or carbohydrate intake, and behavioral intervention, have demonstrated only short-term weight loss. For example, behavioral modification may lead to a 20% excess weight loss at 6 months, but its long-term effects in children are unknown. (63) The lifelong issues involved with appropriate dietary choices that can occur at a young age also have not been adequately addressed. For example, infants who receive nutrition through Women, Infants, and Children (WIC) funding are more likely to consume fruit-containing beverages, desserts, and sweet candy compared with non-WIC infants. (64) Given the continued rising number of overweight adolescents, healthcare professionals increasingly are looking for therapies in addition to lifestyle modification, including pharmacotherapy and bariatric surgery.

Pharmacotherapy

Few drugs currently are approved by the Food and Drug Administration (FDA) for use in obese adolescents (Table 2). Drugs that limit food intake or absorption, alter insulin secretion, or improve insulin sensitivity have shown limited success and are both expensive and hampered by side effects during long-term treatment. (65-71) In particular, sibutramine, which inhibits serotonin, dopamine, and norepinephrine reuptake, and orlistat, which inhibits fat absorption, have been shown to cause weight loss in children. (64) Although helpful in initiating weight loss and improving patients' adherence and compliance, drug therapy alone is unlikely to be of long-term benefit. The combination of weight-loss medication with lifestyle modification has been shown to be more effective in adults with obesity than each therapy evaluated separately. (72) Successful treatment and prevention of childhood obesity will require a multidisciplinary approach, including diet, nutrition education, exercise, and behavior modification, which should include the entire family. (73) In selected cases, surgical intervention may be considered.

Surgical Therapy

The premise of bariatric surgery is to promote weight loss through limiting feeding quantity, decreasing nutrient absorptive capacity, or through a combination of both mechanisms. (71) Bariatric surgery has undergone tremendous evolution since the first such procedure with jejunoileal bypass performed by Kremen and Linner in the early 1950s. Numerous modifications have been made since that time. (74-77)

Currently, the two most popular procedures are the Roux-en-Y gastric bypass (RYGB) and the adjustable gastric band. (74,78,79) Both of these procedures have a decreased risk of postsurgical side effects and complications compared with earlier procedures. The RYGB may be performed as either an open or laparoscopic procedure and involves stapling the upper stomach to form a small pouch (generally less than a 50 mL volume) while creating an outflow tract to the distal small bowel via a Roux-en-Y loop. This procedure promotes weight loss by limiting enteric capacity, inducing mild malabsorption, and influencing hormonal activity involved with satiety. The adjustable gastric band procedure involves the laparoscopic placement of an inflatable balloon (or band) around the upper stomach, thereby limiting gastric capacity. (80) The balloon may be adjusted depending upon the changing needs of the individual patient to effectively limit feeding volume. This procedure does not interfere with absorption, thereby avoiding many of the potential nutrient deficiencies and other complications associated with RYGB. The most important aspect of this procedure is the possibility of its reversibility. The operative time, complication rate, and short hospitalization time (often same day) make this procedure very enticing to both patients and surgeons. Despite such great promise however, the gastric band can be associated with postsurgical esophageal dysmotility, dysphagia, and the potential for suboptimal weight loss. (81) The gastric band procedure has not been approved for use in adolescents by the FDA. (78)

Although much has been written about the effectiveness of bariatric procedures promoting weight loss and reducing obesity-related comorbidities in adults, there is a paucity of such data in children (Table 3). (82-89) However, bariatric surgical experience in severely obese adolescent patients has demonstrated rapid weight loss and control of comorbid conditions. (78,82-89) Sugerman et al (83) provided data on 33 adolescents who underwent several types of gastric bypass procedures. The average preoperative BMI was 52 [+ or -] 11, and there was a significant reduction of BMI at 5 years (29 [+ or -] 5), 10 years (30 [+ or -] 4), and 14 years (31 [+ or -] 2), although 5 patients regained weight at 5 to 10 years postoperatively. A significant reduction, if not resolution, of obesity-related comorbidities was seen in most patients. Early postsurgical complications included wound infection, stomal stenosis, marginal ulcers, and pulmonary embolism, while late complications included small bowel obstruction and incisional hernias. Two patients died at 2 and 6 years postoperatively; however, no autopsies were performed.

Most pediatric data involving bariatric surgery is related to the RYGB procedure. Stanford et al (84) published their experience with 4 adolescent patients who underwent laparoscopic RYGB. The average preoperative BMI in these patients was 55 with a follow-up BMI of 28 at 21 months after the procedure. Other than persistent sleep apnea in one patient, all other comorbidities resolved. Strauss et al (85) have reported similar success in a series of 10 pediatric patients with an age range of 15 to 17 years who underwent RYGB. The average preoperative weight was 148 [+ or -] 37 kg, while the postoperative mean weight loss was 53 [+ or -] 26 kg. Complications did occur, including symptomatic cholelithiasis requiring cholecystectomy (two patients), incisional hernias (two patients), and micronutrient deficiencies (8 patients). Interestingly, three patients in this series went on to have uncomplicated pregnancies after the procedure.

Few large pediatric patient series are reported in the literature. Rand and MacGregor (86) demonstrated their experience with 34 adolescent patients, of which 30 received RYGB. The average preoperative BMI was 47, and the average postoperative BMI was 32, six years after the procedure (excluding 5 patients lost to follow up). Five patients required revision, but a significant improvement in quality of life was noted with 85% of patients stating they would undergo the procedure again. Inge et al have reported preliminary data on their center's pediatric gastric bypass experience consisting of 32 RYGB procedures. The mean preoperative BMI was 56, while the 6-month postoperative BMI demonstrated a 31% decrease from baseline. (82) More data and larger pediatric patient series are expected with the maturation of bariatric services for adolescents in many academic centers across the country. (78,90)

Although gastric banding has not been approved for adolescents in the United States, some pediatric patient experience has been noted in the literature. In 2003, Dolan et al (87) published their experience with 17 patients undergoing laparoscopic gastric banding. The age range was 12 to 19 years, and the preoperative median BMI was 44.7, while the postoperative BMI was 30.2 after 2 years. Complications were relatively mild, and included one patient who experienced band slippage while another reported a subcutaneous filling port leak requiring replacement. Horgan et al (80) have reported experience with 4 adolescent patients with a BMI greater than 40 with the average weight loss after the procedure consisting of 15% at 4 months, 87% at 7 months, 34% at 12 months, and 57% at 30 months. Widhalm et al (88) have described similar findings in 8 obese adolescents with a mean preoperative weight of 156 [+ or -] 24.2 kg and a mean postoperative weight loss of 25 [+ or -] 6.5 kg at approximately 10 months with no complications noted. Abu-Abeid et al (89) also reported on 114 patients with an age range of 11 to 17 years who underwent laparoscopic gastric banding. Marked improvement of co-morbid conditions was noted, and BMI dropped on average by 14 at a mean follow up of 23 months. It is yet unknown if gastric banding will provide long-term surgical simplicity; however, it is expected that this procedure will be approved for use in adolescents in the United States in the near future.

Bariatric surgery centers have increased in numbers in the United States, and it is important for medical professionals involved with this procedure to realize the distinct physiologic differences between adults and adolescents when considering such intervention. (90) Therefore, specific guidelines have been proposed for providers of bariatric surgery to adolescents (Table 4). These guidelines have received the support of many professional medical organizations, but more questions have been raised than answers. Unfortunately, such criteria are based on adult experience or intuitive premises rather than large pediatric studies. There is additional debate as to the specific indications for operative intervention in children. (90-95) Currently, serious pediatric comorbidities which may benefit from bariatric surgery include type 2 diabetes mellitus, obstructive sleep apnea (OSA), and pseudotumor cerebri, while less severe comorbidities include a host of both medical and psychosocial problems. (78,82)

Once a patient is determined to be an appropriate candidate for surgery, intensive education about the procedure including its risks, benefits, and expectations of the patient, family, and medical team must be discussed. (78,82) This process is best accomplished with a team approach, including medical professionals with obesity expertise, psychologists, dieticians, exercise physiologists, and a surgeon with specific experience in bariatric surgery. (82,93-95) Special consideration by the anesthesiologist is necessary due to the operative risk of airway obstruction and difficult airway management throughout the bariatric procedure. In addition, radiologic limitations due to patient size are a continuing challenge. (95,96) Medical facility considerations include appropriate patient scales, as well as beds, chairs, and door width for patients with significant obesity. (90) Recommended preoperative studies include serum electrolytes, blood urea nitrogen, creatinine, serum transaminase, lipid profile, complete blood count (CBC), glycohemoglobin concentration, fasting blood glucose, thyroid stimulating hormone, and serum pregnancy test for females. In addition, sleep history screening for OSA is important, as well as a 2-hour oral glucose tolerance test to determine if the patient has diabetes mellitus. (78)

Risks associated with bariatric surgery should be discussed explicitly with the patient and caretakers. Potential intraoperative complications include bowel perforation, hemorrhage, anesthetic complications, and possible conversion from laparoscopic to an open procedure. Postoperative complications may be divided into early and late onset. Early-onset complications include gastrointestinal leakage at the staple or anastomotic site, bleeding, wound infection, deep venous thrombosis, pulmonary embolus, or respiratory insufficiency requiring prolonged assisted mechanical ventilation. Late-onset complications include stomal stenosis, bowel obstruction, incisional or internal hernia, gastric ulcers, dumping syndrome, iron deficiency, as well as death. It is important to remind the patient that weight gain may occur due to patient noncompliance or surgical failure even after a period of sustained weight loss and maintenance. (78,82) The importance of following dietary, activity, and follow-up recommendations cannot be overemphasized.

A dedicated obesity team including a dietician with expertise in bariatric surgery nutrition should guide initial postoperative dietary management. A postoperative diet initially begins with water and/or ice chips for the first few days which progresses to pureed and soft texture foods over several weeks. Solid foods are eventually added to the diet. Since gastric capacity is usually small after surgery (30-60 mL), it is recommended that patients eat slowly to allow satiety and consume foods rich in protein. (97) Postoperative success to induce successful eating includes consuming lean protein with every meal (up to 0.5-1.0 g/kg per day), drinking 64 to 96 ounces of sugar-free liquids daily, no snacking between meals, 30 to 60 minutes of exercise daily, and taking daily vitamins and mineral supplementation. (78,79) Compliance is an inherent issue, as Elkins et al (98) have shown that 44% of the adult patients were noncompliant with snacking recommendations after bariatric surgery. Following strict dietary guidelines is important as both total energy expenditure and resting energy expenditure decreases by 25% after gastric bypass. (99)

The role of physical activity following bariatric surgery is crucial. Physical activity needs to become routine to help assure continued long-term weight loss. Unfortunately, studies have shown that at least 40% of adult patients were noncompliant with their exercise plan six months after surgery. (98) Similar findings have been shown in adolescents with one study demonstrating that 47% of these patients performed some sort of exercise and only 24% of patients exercised at least once weekly after surgery. (86)

Adolescent patients should be followed for several years and perhaps for their entire life after bariatric surgery. Initially, follow up should occur weekly but eventually may be tapered to biannually. Various postoperative studies may include serum electrolytes, CBC, urine specific gravity, prothrombin time, and B-complex vitamin levels as well as other micronutrient levels. Other studies to consider include bioelectric impedance or dual energy x-ray absorptiometry (DEXA) scanning to follow body composition during the most rapid phase of weight loss. (78,82)

An important long-term care issue involves the primary care physician who should monitor for late postoperative complications, reinforce the necessity of following dietary and activity recommendations, and promote effective birth control or pregnancy evaluation in females. (78,82) The barium upper gastrointestinal series is essential in any patient who presents with signs and symptoms of anastomotic stenosis, staple breakdown, and/or fistula formation. Upper endoscopy may be required for patients who present with a suspected upper gastrointestinal bleeding event. Patients with crampy periumbilical or upper abdominal pain associated with nausea and vomiting should be evaluated for an internal hernia using computed tomography, and emergent surgical referral is necessary if such a hernia is clinically suspected. (78)

Although bariatric surgery patients require close monitoring by a dietician, physicians should be aware of possible nutritional deficiencies associated with these patients, including protein, vitamin [B.sub.12], folate, calcium, iron, fat soluble vitamins, and other micronutrients, which often require supplementation. (100,101) Patients who undergo gastric banding often develop iron and vitamin [B.sub.12] deficiencies while RYGB patients can develop iron, calcium, and folic acid deficiencies. (96) These deficiencies usually are caused by surgical bypass of normal absorption sites within the bowel but may also develop secondary to inadequate dietary intake, particularly with the gastric banding procedure. Protein deficiency can manifest as hypoalbuminemia, anemia, edema, and alopecia and is most commonly seen 1 to 2 years postoperatively. Iron deficiency is estimated to occur in as many as one-third of patients, and multivitamins (with iron in menstruating women) are often necessary. (100) Patient compliance is an issue, as previous studies have demonstrated that only 13% of bariatric surgery patients took vitamins and supplements as instructed. (84,98)

Vitamin and mineral deficiencies can be associated with health risks in patients who have undergone gastric bypass surgery. Folate supplementation is recommended for female patients to prevent fetal neural tube defects. It is of utmost importance to provide adequate calcium and vitamin D intake in adolescent patients due to ongoing bone mineralization and to prevent the risk of osteoporosis following surgery. Thiamine deficiency seems to be quite rare, but recurrent vomiting due to a decrease in gastric size may lead to a Wernicke-Korsakoff encephalopathy. Vitamin A, E, and K deficiencies also may occur although the clinical symptoms appear to be limited. (100) Patients with excessive hair loss following surgery may require maximizing protein, zinc, and iron intake. (78) Recent data also suggests that patients may be at risk of hyperinsulinemic hypoglycemia due to nesidioblastosis after gastric bypass, perhaps due to trophic factor stimulation of beta cells, and all bariatric patients should be closely monitored for signs of hypoglycemia which may present in a similar manner as dumping syndrome. (102) The financial cost of bariatric surgery also limits which patients can undergo the procedure. However, this cost has to be compared with the fact that 10% of all health care dollars are currently spent on obesity and its complications. (103) In general, the average cost for bariatric surgery ranges from $19,000 for laparoscopic RYGB to over $25,000 for gastric banding. (104) Unfortunately, these procedural costs do not necessarily reflect costs associated with complications and patient noncompliance. Interestingly, adult patients who undergo bariatric surgery have total healthcare costs that are significantly less after the procedure compared with control patients. (105) A significant reduction in expenses from obesity-related medication appears to offset initial procedure costs except for medications which address pain management, anxiety, and hypothyroidism, and studies have demonstrated a reduction in patient mortality and new medical problems following bariatric surgery compared with controls. (106,107) More follow-up studies are needed to document long-term success and failure associated with bariatric surgery in adolescents which may help distinguish predictive factors of long-term success that have not been demonstrated in adult studies. (108)

Conclusion

The obesity epidemic in the United States presents challenges for both obese individuals and the healthcare community. Obesity and its complications are numerous, and currently, there appears to be no simple pharmacologic or surgical intervention that will benefit the health of the millions of overweight and obese patients, including children, that exist in this country. Future therapies, such as promoting anorectic effects of gut hormone peptides such as peptide YY[.sub.3-36], may prove to be helpful in reducing body weight in obese patients. (109) However, healthcare providers and institutions have yet to find a treatment model that works on a consistent basis at minimal financial cost. In the meantime, healthcare professionals and society must continue to look for ways to facilitate effective societal and cultural changes. Physical activity at an early age that is developmentally appropriate and enjoyable is beneficial to the overall health of children, and combining interventions which involve proper nutrition and physical exercise may be an initial intervention that will favorably affect BMI. (62,110) While these methods may not be a panacea, such seemingly simple changes may be a stepping stone toward turning the tide of this devastating epidemic.

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Choose well, your choice is brief, and yet endless.
--Goethe

John F. Pohl, MD, Matthew Stephen, MD, and Don P. Wilson, MD

From the Sections of Pediatric Gastroenterology, Ambulatory Pediatrics, and Pediatric Endocrinology, The Children's Hospital at Scott & White, Scott & White Memorial Hospital and The Texas A & M University System Health Science Center College of Medicine, Temple, TX.

Reprint requests to John F. Pohl, MD, Section of Pediatric Gastroenterology, Department of Pediatrics, The Children's Hospital at Scott and White, Scott and White Hospital, Texas A & M Health Science Center, 2401 South 31st Street, Temple, TX 76508. Email: [e-mail]

Dr. Pohl receives grant funding for clinical research from Wyeth Pharmaceuticals and Salix Pharmaceuticals. Drs. Stephen and Wilson have no disclosures to declare.

Accepted February 22, 2006.

RELATED ARTICLE: Key Points

* Childhood obesity in the United States is rising at an alarming rate.

* There appears to be no current pharmacologic treatment or surgical procedure that is safe, effective, and economically feasible for millions of children in the United States.

* Complex and poorly understood genetic, societal, and dietary factors are involved in the development of pediatric obesity.

* Bariatric surgery may be a useful therapy in a select pediatric patient population, but it is not an effective or economically viable therapy for large-scale populations.

Table 1. Health risks associated with pediatric obesity

Hypertension
Hyperlipidemia
NAFLD (ranging from benign steatosis to steatohepatitis-associated
  cirrhosis)
Orthopaedic (especially, slipped capital femoral epiphysis)
Iron deficiency anemia
Sleeping problems (especially, obstructive sleep apnea)
Kidney disease
Increased cancer risk
Poor health-related quality of life

NAFLD, nonalcoholic fatty liver disease

Table 2. Drugs used for treatment of obesity

Medication        Action                        Side Effects

Sibutramine       * Nonselective inhibitor of   * Abnormal EKG
                    neuronal reuptake of
                    serotonin and
                    norepinephrine
(Meridia[R])                                    * Hypertension
                                                * Palpitations
                                                * Tachycardia
                                                * Seizures
Orlistat          * Inhibits intestinal lipase  * Deficiencies of
(Xenical[R])                                      fat-soluble vitamins
                                                * Flatulence
                                                * Diarrhea
                                                * Anal leakage
Metformin         * Reduces hepatic glucose     * Abdominal discomfort
(Glucophage[R])     production                    (transient)
                  * Increases insulin           * Diarrhea (transient)
                    sensitivity
                                                * Lactic acidosis (rare)
                                                * Decreased level of
                                                  vitamin B12
Octreotide        * Reduces glucose-dependent   * Abdominal pain
(Sandostatin[R])    insulin secretion             (transient)
                                                * Gallstones
                                                * Suppression of growth
                                                  hormone and thyroid
                                                  stimulating hormone
                                                  secretion

Medication        FDA approved for weight loss and obesity in children?

Sibutramine       Yes
(Meridia[R])      [greater than or equal to] 16 years of age only
Orlistat          Yes
(Xenical[R])      [greater than or equal to] 12 years of age only
Metformin         No (a)
(Glucophage[R])
Octreotide        No
(Sandostatin[R])

(a) Approved for type 2 diabetes mellitus in children but not for
obesity.

Table 3. Suggested criteria for bariatric surgery consideration in
adolescents (71,75)

Having failed at least 6 months of organized weight management.
Having attained or nearly attained maturity (generally considered at
  least Tanner stage IV).
Being severely obese (BMI [greater than or equal to] 40) with serious
  obesity-related comorbidities or BMI [greater than or equal to] 50
  with less severe comorbidities.
Demonstrate commitment to comprehensive medical and psychological
  evaluation. Commitment must be demonstrated by both patient and
  primary caretakers.
Agree to avoid pregnancy for at least 1 year postoperatively.
Be willing and able to follow strict nutritional guidelines
  postoperatively.
Be capable of providing informed assent/consent.

Table 4. Bariatric surgery literature review

                No. of patients                       Preoperative
Reference       (n)              Demographic data     findings

Gastric bypass
  reports
  Inge et       34               Females:males        Mean BMI: 57
    al (82)     All had RYGB       (Numbers not        kg/[m.sup.2]
                                   provided)
                                 Age mean: 17 years
                                   for females; 16
                                   years for males
  Sugarman et   33               19 females:14 males  Mean BMI: 52+/-11
    al (83)     17 had RYGB      Age range: 12.4-       kg/[m.sup.2]
                                   17.9 years         (Range 38-91
                                                        kg/[m.sup.2])
  Stanford et   4                3 females: 1 male    Mean BMI: 55.14
    al (84)     All had RYGB     Age range: 17-19       kg/[m.sup.2]
                                   years              (Range 45-66
                                                        kg/[m.sup.2])
  Strauss et    10               7 females:3 males    Mean Weight:
    al (85)     All had RYGB     Age range: 15-17       148+/-37 kg
                                   years
  Rand et       34               27 females: 7 males  Mean BMI: 47
    al (86)     30 had RYGB      Age range: 11-19       kg/[m.sup.2]
                                   years

Gastric
  banding
  reports
  Horgan et     4                2 females: 2 males   Mean BMI: 50.5
    al (80)     All had gastric  Age range: 17-19       kg/[m.sup.2]
                  banding          years
  Dolan et      17               14 females:3 males   Mean BMI: 44.7
    al (87)     All had gastric  Age range: 12-19       kg/[m.sup.2]
                  banding          years              (Range 31.6-70.5
                                                        kg/[m.sup.2])
  Widhalm et    8                1 female: 7 males    Mean BMI: 49.1+/-
    al (88)     All had gastric  Age range: 14.5-       5.2 kg/[m.sup.2]
                  banding          18.5 years
  Abu-Abeid et  11               8 females:3 males    Mean BMI: 46.6
    al (89)     All had gastric  Age range: 11-17       kg/[m.sup.2]
                  banding          years              (Range 38-56.6
                                                        kg/[m.sup.2])

                                 Complications         Follow-up
                Postoperative    (n = number of        (n = number of
Reference       findings         patients)             patients)

Gastric bypass
  reports
  Inge et       Mean BMI:        Data not available.   Data not
    al (82)       39.33                                  available
                  kg/[m.sup.2]
                (at 6 months
                  postop)
  Sugarman et   Mean BMI:        Early                 Improved
    al (83)     At 5             1-pulmonary embolism    self-image
                  years:29+/-5   1-major wound         1-gained back all
                  kg/[m.sup.2]     infection             weight lost
                At 10 years:     4-minor wound
                  30+/-4           infection
                  kg/[m.sup.2]   3-stomal stenoses
                At 14 years:       (endoscopic
                  31+/-2           dilation)
                  kg/[m.sup.2]   4-marginal ulcers
                                   (medically
                                   treated)
                                 Late
                                 1-small bowel
                                   obstruction
                                 6-incisional hernias
  Stanford et   Mean BMI: 35     No perioperative or   Most were
    al (84)       kg/[m.sup.2]     postoperative         physically
                (at 21 months      complications         active
                  postop)                              All tolerated a
                                                         regular diet
  Strauss et    Mean Weight      No early              3-females with
    al (85)       Loss:            postoperative         uncomplicated
                  59.9+/-25.8      complications         pregnancies
                  kg             Late                  1-regained all
                                 5-iron deficiency       initial weight
                                   anemia                loss
                                 3-transient folate
                                   deficiency
                                 2-vitamin D
                                   deficiency (distal
                                   gastric bypass
                                   patients)
                                 2-symptomatic
                                   cholelithiasis
                                   requiring
                                   laparoscopic
                                   cholecystectomy
                                 1-protein-calorie
                                   malnutriton and
                                   micronutrient
                                   deficiency
                                   requiring total
                                   parenteral
                                   nutrition 1 year
                                   postop
                                 1-small bowel
                                   obstruction 10
                                   years postop
                                   requiring surgical
                                   care
                                 1-incisional hernia
                                   requiring repair
  Rand et       Mean BMI: 32     5-Revisional surgery  No evident growth
    al (86)       kg/[m.sup.2]     to reduce stomach     retardation
                (at 6[+ or -]3     size                  postoperatively
                  years          4-cholescystectomies  Poor vitamin and
                  postop)        1-abdominal             nutrient
                                   panniculectomy        compliance

Gastric
  banding
  reports
  Horgan et     Mean BMI:        1-cholecystitis with  All patients have
    al (80)       38.75            laparoscopic          discontinued
                  kg/[m.sup.2]     cholecystectomy       use of
                (at 13.25                                medication for
                  months                                 gastric acid
                  postop)                                suppression and
                                                         analgesia for
                                                         comorbidities
                                                         described
  Dolan et      Mean BMI:        1-band slippage that  No growth
    al (87)     At 6 months:       required              retardation
                  36.1             repositioning
                  kg/[m.sup.2]   1-port leakage that
                At 1 year:         required
                  32.6             replacement
                  kg/[m.sup.2]
                At 2 years:
                  30.2
                  kg/[m.sup.2]
  Widhalm et    Mean Weight:     No complications      All reported
    al (88)       131.5            reported              satiety
                  [+ or -] 28.8
                  kg
                (at 10.5
                  [+ or -] 6
                  months
                  postop)
  Abu-Abeid et  Mean BMI: 32.1   No perioperative or   All reported
    al (89)       kg/[m.sup.2]     late complications    improved
                (at 23 months      reported              psychosocial
                  postop)        4-iron deficiency       well being
                                   anemia

BMI, body mass index; RYGB, Roux-en-Y gastric bypass