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Bill Klaproth (Host):  The number of children and adolescents with severe obesity is increasing and affected youth are at a high risk of the development of significant weight related medical conditions like type two diabetes. In addition to ongoing dietary and other lifestyle changes; adolescents with severe obesity may benefit from the use of medications and weight loss or bariatric surgery. So, a lot has changed in this field over the past few years and Dr. Edmond Wickham is here to tell us more about the current treatment options for weight loss surgery including the benefits, who is a good candidate, the different types of surgery and what the American Academy of Pediatrics now says about the option of weight loss surgery in youth. 

This is Healthy with VCU Health. I’m Bill Klaproth. Dr. Wickham, so, what is the definition of severe obesity in children and adolescents?

Edmond “Trey” Wickham, MD, MPH (Guest):  So, we more recently have kind of defined different classes of obesity even within children and the definition that we are currently using is that for a child or adolescent, severe obesity would be defined as either having a body mass index of greater than 35 kilograms per meter squared or a BMI that’s greater than the 120^th percentile for the 95^th percentile for age and sex for that particular child. 

Host:  So, how much of the youth population is this affecting and what are the current and future health risks of severe obesity in children and adolescents?

Dr. Wickham:  Current estimates are about 10 to 14% of children ages 12 to 19 in the US would meet this definition of severe obesity. So, that’s approximately 1.5 million children. And although there have been a lot of advances in obesity prevention in children and adolescents and treatments; unfortunately the class of children with severe obesity has continued to increase and part of why that’s so important is that we know that children with severe obesity are at the highest risk of developing weight related health conditions even during their youth and certainly are at substantially increased risk over their lifetime. And these can be conditions such as type two diabetes, obstructive sleep apnea, something called nonalcoholic fatty liver disease which is an inflammation of the liver which can occasionally lead to full liver failure, high blood pressure and high cholesterol. And so, all of these things are putting the children with severe obesity at substantial risk again not just at that point in their lives, but throughout their lifetime. 

Host:  So, considering those conditions you just named off, type two diabetes, sleep apnea, nonalcoholic fatty liver disease, high blood pressure, high cholesterol; obesity in youth is a serious problem especially for future health considerations. So, what are the treatment options before you consider surgery? I’m sure you don’t go right to weight loss surgery. How do you address a treatment plan first?

Dr. Wickham:  The cornerstone of all treatments for obesity actually is lifestyle modification. So, making sustainable dietary changes and changes in physical activity to promote weight loss and why that’s so important is that without those changes; weight loss surgery and even weight loss medicines aren’t necessarily all that effective. Their effectiveness is most seen when it’s in conjunction with those core behaviors of lifestyle changes. No, that doesn’t mean that an adolescent needs to have a perfect diet or exercise at the gym for hours a day before weight loss surgery would be helpful but we definitely want those habits established and they are a part of that comprehensive treatment plan. I want to highlight that even changes in weight can have substantial health benefits. But many times, for our children with more severe obesity; the weight loss that they are able to achieve with those lifestyle changes alone might not be sufficient for the severity of illness that they have. 

Host:  So, then at that point, if the lifestyle modifications aren’t sufficient; is that where weight loss medications and weight loss surgery come in?

Dr. Wickham:  Yeah. So, for children who have the more severe forms of obesity and particularly those with health related conditions such as type two diabetes; we will often consider the role of weight loss medications and weight loss surgery in that treatment. As far as weight loss medications, in the adult population we have more and more options for pharmacotherapy for the treatment of obesity. Unfortunately, relatively few of those medicines have been effectively studied in the pediatric population and there are only actually two that have been approved by the FDA for use in kids and those are orlistat and phentermine for older adolescents. 

And although they can be effective in increased weight loss in conjunction with ongoing lifestyle changes; I really think that based on this data that we have that their role in the pediatric population is somewhat limited at this time. Where we have much more data is an exciting part of the field. It’s the data about the role of weight loss surgery in children and adolescents. I want to highlight that we actually prefer to use the term now metabolic and bariatric surgery when we talk about weight loss surgery. In the past, I think a lot of folks have considered that weight loss surgery basically works because it just restricted the amounts of food that an individual was able to eat. And we now have a lot of research data that shows although the surgeries certainly do restrict to a certain portion what people are able to eat; there are a lot of other metabolic and hormonal changes that these surgeries actually induce that really help the patient be successful long term in keeping weight off. 

So, we know that these surgeries reduce hunger hormones. They actually change metabolism in such a way that it improves the ability for patients to maintain their weight loss afterwards and it actually changes a lot of the hormones and factors that are important for some of these other weight related conditions such as type two diabetes. 

Host:  So, bariatric or metabolic weight loss surgery as you call it has an important role to play. So, can you tell us more about weight loss surgery and the types of procedures you perform?

Dr. Wickham:  It’s actually a variety of different types of surgery. I’ll just briefly explain the two that are most commonly used both in the adult population as well as the pediatric population. These are the Roux-en-Y gastric bypass and the vertical sleeve gastrectomy. So, both of these procedures can be performed laparoscopically meaning that they are done without a large major incision in the abdomen but skilled surgeons in these areas can actually use cameras to do them through several very tiny incisions in the patient’s abdomen. 

Host:  So, then what is the average weight loss someone can expect and what are some of the other benefits?

Dr. Wickham:  The benefits of metabolic and bariatric surgery, certainly the biggest one that we look at is weight loss. There have been studies that have been following adolescents who have had weight loss surgery out almost ten years and what we see is that on average adolescents who have had weight loss surgery are able to lose approximately 25% of their body weight and in many cases maintain those significant losses over the duration of five or more years. 

And what’s exciting about the impacts of that weight loss is that we know that it substantially often improves quality of life for adolescents that were experiencing severe obesity and that it’s particularly effective in actually treating some of these other weight related conditions such as type two diabetes. 

Host:  So, what’s the long term success and it sounds like surgery can help reverse weight related medical conditions. 

Dr. Wickham:  There is an exciting study that was just released from the National Institutes of Health called the Teen Longitudinal Assessment of Bariatric Surgery or Teen-LABS and what they showed is that actually the majority of youth that had type two diabetes and underwent weight loss surgery; their diabetes went into remission and it was actually again sustained for three or more years. I want to highlight that one thing that was super important about that study is that those rates were even for remission of diabetes in adolescents were even higher than what we see in the adult population, really pointing to challenging the thought that weight loss surgery doesn’t need to just wait until a patient with severe obesity becomes an adult but there actually could be an appropriately selected case benefits with intervening with weight loss surgery as part of a comprehensive treatment plan earlier in an individual’s life. 

Host:  So, it sounds like you’re saying do this procedure sooner than later then who is a good candidate for metabolic or bariatric weight loss surgery?

Dr. Wickham:  Yeah, that’s a great question. The American Society for Metabolic and Bariatric Surgery revised their criteria in 2018 to be more inclusive and actually as part of that, they removed an age range. I would say that most folks would only consider weight loss surgery in children with severe obesity that were age 10 or older but there’s no longer a specific age cut off with who might be appropriate. What is important, is that the child actually is able to participate in the care in an age appropriate way, understand the risk and benefits of surgery, and is actively involved as part of the medical decision making. 

Host:  So, what then are the specific guidelines that need to be followed before bariatric weight loss surgery is considered?

Dr. Wickham:  So our current recommendation is that weight loss surgery might be an important part of a comprehensive treatment plan for youth with severe obesity who have a BMI that’s greater than 35 and if they have other health conditions related to weight like type two diabetes or for youth who have a BMI of greater than 40 that have maybe fewer weight related comorbidities. And there are other specific criteria as far as maybe for younger kids, but I think those are the ones that are most regularly applied. 

Host:  And let’s talk about safety. Bariatric weight loss surgery is safe for adolescents?

Dr. Wickham:  Yeah, so, we again, it’s been following adolescents out for longer. As far as the risks of weight loss surgery; I mean certainly with any surgical procedure you do need to consider the risk of actually having surgery itself. And again, when performed at centers that are specialized in doing metabolic and bariatric surgery, the risk of surgery actually appears to be lower than removing a gallbladder you know a common procedure that we have. Probably the largest risk long term is that because these procedures do change absorption is that people after they’ve had weight loss surgery do need to be followed lifelong for nutritional deficiencies and if an individual follows recommendations as far as taking regular nutritional supplements and is following up with their healthcare team to make sure we’re monitoring levels; those levels are still relatively low but that is something that needs to be considered is the risk of nutritional deficiencies. So, think like iron deficiency or vitamin D deficiency, B12 or folate longer term. 

Host:  And then Dr. Wickham how does the American Academy of Pediatrics, or AAP, feel about weight loss surgery for teens?

Dr. Wickham:  So, this has been a place in the field that is really – where we’ve gotten so much more data about the safety of weight loss surgery and how even adolescents can respond to weight loss surgery and based on this robust data, the American Academy of Pediatrics late last year in 2019 came out with a very strong statement about supporting the role of weight loss surgery and the comprehensive care of youth with severe obesity when applied in the right context. I think things that were really important about that statement is that the AAP recognized that although there are these large numbers of children that actually may benefit from surgery, relatively few youth with severe obesity are actually being seen and evaluated for the role of surgery.

I’ll highlight it is certainly not for everybody, but many times families aren’t even made aware that this could be a part of an effective treatment plan. Also just to emphasize some of the barriers that also come up from insurance coverage and I’ll say practically as I work with families that are undergoing weight loss surgery; we are seeing more and more insurance companies support and cover costs of both pre-surgical care as well as the surgery itself in adolescents. But I think there are certainly still gaps there compared to what we see as coverage typically in the adult population. 

Host:  So, it’s important to let parents know that there is this option of bariatric surgery and insurance companies are increasingly covering this. So, let’s turn to Children’s Hospital of Richmond at VCU. Do you hold any special designations or certifications pertaining to adolescent bariatric surgery?

Dr. Wickham:  At Children’s Hospital of Richmond at VCU, we have The Healthy Lifestyles Center which is a comprehensive treatment program for infants, children and adolescents with obesity and their families. And that center is actually the region’s tertiary care center so, one of the services that we provide is that as a center of expertise we do have an adolescent weight loss surgery program that actually has been designated as a Center of Excellence by the Metabolic and Bariatric Surgery Association Quality Improvement Program. So, one of the things that we haven’t mentioned so far that I think is also important about the guidelines is recognizing that the AAP strongly recommends that if weight loss surgery is going to be pursued or considered in youth that it actually be done in conjunction with a team that has specific pediatric expertise about the role of weight loss surgery. So, it isn’t just having a family seeing an adult program, it’s actually seeing a specialized program that includes pediatric medical specialists, pediatric surgeons, pediatric health psychologists, all who are experienced and equipped to help the family look at the risk and benefits. 

Host:  Which is important and comforting for parents to know. So, what else makes Children’s Hospital of Richmond unique in this area?

Dr. Wickham:  Yeah so, we again have an extensive team at the Healthy Lifestyle Center. It’s really committed to meeting youth and their families where they are at. Those that have obesity, helping them come up with an individualized treatment plan that makes sense for them. And so, certainly we understand that weight loss surgery might not be in everybody’s treatment plan and so we have a lot of resources to help families making lifestyle changes, those dietary changes and physical activity changes and for those youth that are affected by more severe obesity; we have specialists that can help with considering weight loss medicines and then a comprehensive team that does offer weight loss surgery for adolescents. 

Host:  And then last question Dr. Wickham and thank you so much for your time. So, weight loss surgery for adolescents, this shouldn’t be viewed as the end all be all, right? This is just another tool to be used in the fight against obesity?

Dr. Wickham:  You know, we don’t consider weight loss surgery in a sense a magic bullet like this is something that’s done passively. But how we like to describe it is a tool or a magnifying glass where it takes the changes a family is making and increases the impact that they get from those changes. 

Host:  Well that’s a good way to look at it. And a good way to wrap up this podcast. Thank you for the wealth of information and education Dr. Wickham. We appreciate it. 

Dr. Wickham:  You’re welcome. Thanks. 

Host:  That’s Dr. Edmond Wickham and for more information please visit www.chrichmond.org, that’s www.chrichmond.org. And if you found this podcast helpful, please share it on your social channels and explore the full podcast library at www.vcuhealth.org/podcast for more health topics of interest to you. This is Healthy with VCU Health. I’m Bill Klaproth. Thanks for listening.