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Morbid Obesity and Implications of Bariatric Surgery in the Adolescent

Population

Children’s National Medical Center Case Study Amy Bortnick

 1/22/2013

Presentation Outline

Childhood obesity and the indication for Bariatric Surgery

Bariatric Surgery in adolescents

A Case Study of nutrition counseling for an 18 year old female in the IDEAL Outpatient Clinic considering Bariatric Surgery

Clinical Analysis of the patient and her appropriateness for Bariatric Surgery

Conclusion and questions

Childhood Obesity

The Percent overweight children in the United States has almost tripled in the past 30 years.

15.5% of children are estimated to be obese.

50-77% of obese children grow up to be obese adults.

Obesity in both adolescents and adults greatly increases the risk of developing chronic life threatening diseases and can lead to premature death.

Overweight children have a reduced quality of life compared with non-overweight children (1).

Bariatric Surgery in Adolescence

For severely overweight children and adolescents who have tried and failed to lose weight for longer than 6 months through conventional weight loss methods, bariatric surgery may provide a practical alternative for achieving a healthy weight (1).

From 1996-2003, according to recent national trends, the US has seen a great increase in bariatric surgeries performed in adolescents.

There is very little data documenting long term effects of bariatric surgery in adolescents.

Bariatric Surgery in Adolescence

>14 years of age

Tanner development stage 4 or greater

BMI >40 w/ obesity related comorbidity or BMI> 50.

Documented history of obesity for 3 years

Consent

Confirmation by psychologist or psychiatrist

Inclusion Criteria

Choice of Bariatric Surgery Procedure

Laparoscopic Roux-en-Y Gastric Bypass (LGB)

Laparoscopic Adjustable gastric band (LAGB)

Laparoscopic Sleeve Gastrectomy (LSG).

Source:http://www.nationalbariatriclink.org/imgs/surgery_types.jpg

Critical Labs for Bariatric Candidates

fasting glucose hemoglobin A1c liver function lipid profile complete blood counts thyroid function Pregnancy micronutrient deficiencies. Polysomograpy ( patients with sleep apnea) Bone age assessment (younger patients)

Potential Complications

Early Complications: pulmonary embolism, wound infections, stomal stenosis, dehydration and marginal ulcers

Late Complications: small bowl obstruction, incisional hernias, and late weight regain, sub optimal vitamin intake and micronutrient deficiencies.

Gastric Bypass: intestinal leakage, thromboembolic disease, small bowl obstruction, incisional hernia, protein calorie malnutrition, micronutrient deficiencies.

Adjustable Gastric Band: port mal absorption or mal function, tubing leaks, band slippage, infection, band erosion into stomach or esophagus

Pre-Operative Bariatric Diet

Suggested full liquid diet of protein rich supplements for two weeks Been show to result in greater weight loss after

surgery Shrinks the liver, decreasing surgery time Displays ability to adhere to diet and lifestyle

changes

Post Operative Bariatric Diet

First 2-3 weeks: of a liquid diet. Mainly supplements high in protein, low in fat, and

carbohydrates

After 4-6 weeks: Pureed diet

After 6 weeks: Soft regular foods

Vitamin and Mineral Supplements: 2 multivitamin’s daily, calcium, vitamin B12, and additional vitamins/minerals as needed

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Case study

Subjective

XX is an 18 year old female presenting to the IDEAL Clinic with morbid obesity for her second follow up visit accompanied by her mother. She is currently considering bariatric surgery for weight loss. XX was pleasant and interactive during her last visit. She appears morbidly obese with a buffalo hump, acnathosis nigricans, and abnormal hirstuism present on the face.

Diet Prior to Admission

XX admits to trying several diets in the past. Prior to admission she was following a diet that involved having 8 very small-portioned meals a day. Additionally, on 7/4/12 patient became a vegetarian. XX has never seen a dietitian in the past.

PES Statements

Overweight/obesity (N.C-3.3) related to excessive energy intake, and food and knowledge related deficit as evidenced by BMI > 95%, inability to apply some nutrition related recommendations.

Physical Inactivity (NB-2.1) related to lack of value for behavior change or competing values, as evidenced by obesity >97th percentile, infrequent/ low duration exercise, large amounts of sedentary activities e.g. T.V. watching, computer, and phone use and reports of getting tired easily.

Not Ready for Diet/ Lifestyle Change (NB-1.3) related to lack of self efficacy for making change or demoralization from previous failures at change as evidenced by lack of eye contact, lack of focus, and lack of efficacy to make change or to overcome barriers to change

Anthropometrics

Anthropometrics

Height: 5’5”

Weight: 345 lbs.

BMI: 99.5%

BMI percentile: >97th

Growth Evaluation

Weight trends: 11/27: 158.8 kg, 12/18: 156.5 kg, 1/22: 156.6

BMI trends: 11/27 56.93 (>97%), 12/18: 55.38 (>97%), 1/22: 56.28 (>97%).

Height trends: 11/27:167cm, 12/18: 168.1 cm, 1/22: 166.8 cm

Notable Labs

12/44 HgA1c: 5.8 Low HDL: 26 HOMA-IR: 17.9 –elevated, insulin resistant, on

metformin Low Vitamin D: 9.5 (deficient) – on vitamin D

supplements ALT 37

Labs are significant for: impaired fasting glucose, hypertriglyceridemia, low HDL, mild elevation of ALT, and elevated HOMA-IR

Assessment

Estimated Energy Needs Kcals/kg: 31-43/kg ADBW/day: 2223-2438 kcal Grams protein/ kg: 0.8/kcal/kg = 125.8 g protein mL/day to meet maintenance fluid needs:

20/kg/day 3132 ml

Plan/ Goals

Physical Activity Goals Move at least 10 minutes 3/day a week (Tuesday,

Wednesday, Saturday). Nutrition Goals

Pre-op diet for one week (bariatric guide, RD email address provided)

Use meal replacement instead of skipping breakfast

XX and Bariatric Surgery

BMI of 56.28 meets criteria

18 YO meets maturation and bone growth

IDEAL clinic provides multi-disciplinary support (patient is seeing a physician, psychiatrist and RD)

Patient is currently trying to lose weight through nutrition and physical activity without significant success

Mother displays evidence of a supportive family member, respecting the patient’s decision.

However patient shows concern for adherence to dietary demands of bariatric surgery

Patient and mother have been receiving on going education on bariatric surgery

Case Conclusion

It is too early to tell if XX will be appropriate for weight loss surgery. Her personal desire for the surgery as well her efficacy and ability to understand and adhere to dietary restrictions will be critical. However, her current BMI status places her a substantial risk for chronic life threatening conditions, she has documented her weight has interfered with her quality of life. For now the focus is physical activity a healthful diet and the ability to follow a pre-operative diet.

Discussion

More research on bariatric surgery in adolescence is needed to determine long term impacts on overall health and well being.

Israel Study: Comparing inpatient intervention with bariatric surgery

Netherlands Study: Interventional study comparing laparoscopic adjustable band surgery and behavioral therapy

Results of such studies won’t be forth coming for several years

Questions?

Source: http://adiaryofamom.files.wordpress.com/2011/01/ist2_5853965-question-mark.jpg

References

1. Inge T et al. Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations. Pediatrics Vol 114 No. 1 July 2004 217-223.

2. Ingelfinger, Julie. Bariatric Surgery in Adolescents. N Engl Med 365;15

3. Wilson S. Tsai, MD; Thomas H. Inge, MD, PhD; Randall S. Burd, MD, PhD. “Baratric Surgery in Adolescents- Recent National Trends in Use and In-Hospital outcome”. American College of Medicine.

4. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;25:869-873. Reousce: http://www.nejm.org/doi/full/10.1056/NEJM199709253371301#t=articleTop

5. University of Michigan Health System: Adult Bariatric Surgery Program. http://www.med.umich.edu/bariatricsurgery/about/bypass/postop.shtml