Transcription:

Bill Klaproth (Host): According to the national survey of children’s health; nearly four in ten Tennessee children and teens are classified as overweight or obese. So, is the answer teen bariatric surgery or Le Bonheur’s Healthy Lifestyle Clinic which specializes in helping children and teens with obesity. Let’s find our with Dr. Ying Weatherall, Assistant Professor at the University of Tennessee Health Science Center.

This is the Peds Pod by Le Bonheur Children’s Hospital where pediatric experts explore topics affecting children’s health including complex cases and innovations on the healthcare horizon. I’m Bill Klaproth. Dr. Weatherall, thank you for your time. Let’s start with this. Can you tell us about the Healthy Lifestyles Clinic, how it got launched and what is its purpose?

Ying Weatherall, MD (Guest): Thank you for having me. The Healthy Lifestyles Clinic was launched because there was a need for some sort of treatment of pediatric obesity which is a major problem especially kind of in our area and in our neighborhood, so in west Tennessee, Memphis area. So, it was launched to address this overwhelming need of pediatric obesity and overweight.

Host: Right, so what are the different pieces of the Healthy Lifestyle Clinic?

Dr. Weatherall: The Healthy Lifestyle clinic consists of a medical provider which is either an MD or a nurse practitioner. It also has a Registered Dietician as part of the clinic as well as an exercise physiologist which is a PhD in exercise as well as a physical therapist who runs exercise classes regularly. And then also, a psychologist who is a PhD in psychology and then a surgeon who is a pediatric bariatric surgeon.

Host: So, for a child that’s obese; is the first stop the Health Lifestyle clinic?

Dr. Weatherall: Usually for a patient who has obesity or is overweight; their primary care doctor is the first stop. Just because they are normally seeing their PCP for everyday things and annual checkups. So, the first stop usually is the primary care doctor and then the primary care doctor if they feel like there’s a major concern; then they refer them directly to the Healthy Lifestyle Clinic. We also get patients from other areas of the hospital. For example, patients with comorbidities like type 2 diabetes, with obstructive sleep apnea, with joint pain, Blount Disease. So, we get patients from a variety of places, but patients are either referred directly in from their primary care physicians or from one of the physicians that’s treating their comorbidities.

Host: Got you. So, let’s switch to bariatric surgery for teens because there is some controversy surrounding this. So, when is it appropriate for a teen to undergo weightloss surgery and what other options do you try before surgery?

Dr. Weatherall: The controversy with adolescent bariatric surgery is are we doing it too early, are we stunting the patient’s growth by having them lose a lot of weight and then are we giving them enough time to try to do the nonoperative alternatives which is diet, exercise and what we call lifestyle modifications. So, that’s the controversy around this topic of adolescent bariatric surgery is if we are doing it too early and we are not giving them enough time to shed the weight nonsurgically.

Host: Okay, that makes sense. So, then what are the requirements for a teen to qualify for bariatric surgery?

Dr. Weatherall: So, for a teen to qualify for bariatric surgery; we ask them to be of a certain BMI. So, it’s either a BMI of 35 and over with a major comorbidity which we classify as type 2 diabetes, obstructive sleep apnea, really severe hypertension, pseudotumor cerebri. These are all diseases that are associated and as a result of morbid obesity. Or the other alternative is that if their BMI is over 40, they don’t need any comorbidities. It’s just straight up BMI of over 40.

In addition to the BMI we want them to be psychologically mature or have a family member that can take care of them and just have everybody be understanding that this is not just a surgery but it’s a whole lifestyle change and that they have to be very invested on all aspects of the Healthy Lifestyle Clinic or any weight management program and not just a surgical aspect.

And then they also have to be physiologically done growing which means that they are mature, that they are no longer growing in height because we don’t want to blunt their height growth as part of the surgery.

Host: So, Dr. Weatherall, this sound like it’s mainly for kids in their upper teens, is that right?

Dr. Weatherall: Right, so technically for girls; they are usually done growing as just a group; they are usually done growing around 14 and for boys around 15. So, we start talking to them around that age, around the 14 to 15 age knowing that this process takes about six months to a year so that they won’t get surgery right when we talk to them. They’ll get surgery later on. However, before we actually do surgery; they all get a bone age to make sure that their bones are fused and that they are done growing.

So, usually the age is around 14-15, that’s when we start talking to them about adolescent bariatric surgery.

Host: Okay. I understand. So, there are a lot of requirements to hit before bariatric weightloss surgery for a teenager. So, what types of bariatric surgery do you perform and how does it work to promote weightloss?

Dr. Weatherall: So, at Le Bonheur we do laparoscopic sleeve gastrectomy’s which is the most common type of bariatric surgery performed in the United States. This is for adults and for adolescents. About 60-65% of bariatric surgery done are sleeve gastrectomy’s and what that is, is essentially we make the stomach about a tenth of the size by removing the majority of the stomach with a stapling device. So, the stomach basically looks like a sleeve and that’s why it’s called a sleeve gastrectomy.

Host: Right and what are the outcomes then and what have you seen from bariatric surgery in teens?

Dr. Weatherall: So, the outcomes – the adult population have a lot of long-term studies and then in the teen population there is a three year outcome study from the Teen-LABS Group which is the major group that have done a good amount of adolescent bariatric surgery and they have three year follow-up and the – really the long-term follow-up and outcome is that they will lose about 30% of their starting body weight. So, for our patient who started at 300 pounds, they’ll lose 100 pounds. Some patients will lose more. Some patients lose less. But as an average; they should lose a third of their starting body weight to be considered a success for the bariatric surgery to be considered a success.

Host: So, you were just mentioning follow-up. What kind of research has been conducted on teen bariatric surgery?

Dr. Weatherall: So, the Teen-LABS group, Teen-LABS stands for Teen-LABS which is longitudinal assessment of bariatric surgery which actually is an adult consortium. The Teen-LABS are modeled after the adult setup and they are five institutions that started doing adolescent bariatric surgery fairly early. They started collecting data like in 2012 and those five institutions have studied various aspects of adolescent bariatric surgery starting from safety. So, they started with 30 day perioperative safety and then they went into the actual amount of weight lost and that paper is a three year follow-up and that’s published in the New England Journal of Medicine which documents about a third of weight lost. They have also looked at remission of comorbidities like type 2 diabetes, obstructive sleep apnea, hypertension, kidney function and a lot of quality of life factors they’ve looked at. And also joint pain, musculoskeletal pain, cardiac function. So, there’s all of these comorbidities that are associated with morbid obesity. They’ve studied these comorbidities independently.

So, the Teen-LABS group have published about like 20 papers in relation to their cohort of patients. They have about 242 patients that they are following longitudinally.

Host: So, do we have any results yet of the consequences of teen bariatric surgery?

Dr. Weatherall: So, the consequences are – the one bad thing about teen bariatric surgery that we have to be aware of and we have to try to avoid is nutritional deficiencies. So, after bariatric surgery; the amount of food allowed is very small because of their weightloss and their just lack of appetite which happens after a sleeve gastrectomy. So, patients don’t like to eat but you have to remind them to take vitamins. And this is the same for adults. Everybody has to take vitamins.

But for the kids; we found that there is a significant increase in iron deficiency as well as some other vitamins which we know this so, we definitely have that as part of the preoperative education for all of the patients as well is that they have to take vitamins after surgery to try to avoid this.

But otherwise, there’s really not been any bad or adverse outcomes associated with bariatric surgery in adolescents that’s been published or that we’ve found.

Host: So, you were talking about vitamins after surgery. What is the follow-up process post-bariatric surgery?

Dr. Weatherall: After bariatric surgery; we see the patients at one week to make sure that they are not dehydrated. At three weeks and then seven weeks, just regularly every month to advance their diet stages and then we see them every three months for the first two years to check their vitamin levels and make sure that they are not deficient. And then also to monitor their exercise and also their weightloss. And then after that, we see them annually.

Host: Got you. So, if you could wrap this up for us Dr. Weatherall, what is the future of bariatric surgery at Le Bonheur?

Dr. Weatherall: I hope and I envision that we will continue to do more sleeve gastrectomy’s. in the first year, we did ten. In the second year we are looking at 15 and I hope to do about 25-30 every year and then really to become accredited with MBSAQIP which is the accrediting body for bariatric centers and then hopefully to become a regional center and really also address things like disparities and access to surgery for our patient population as well as monitoring their health and just promoting their weightloss and growth as our center grows.

Host: Well that’s a great way to wrap it up Dr. Weatherall. Thank you for your time. To learn more about Le Bonheur visit www.lebonheur.org, that’s www.lebonhuer.org. And if you want to hear more, make sure you subscribe to the Peds Pod in Apple Podcasts, Google Play or wherever you listen to your podcasts. You can also check out www.lebonheur.org/podcasts to view our full podcast library. And if you found this podcast helpful please share it on your social channels. This is the Peds Pod by Le Bonheur Children’s Hospital. I’m Bill Klaproth. Thanks for listening.