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STAT

An MUSC blog
Keyword: nutrition

Morbid obesity in American adolescents has been steadily rising, mirroring the rise of adult obesity in the United States and other developed countries. According to recent research, bariatric surgery can provide sustainable weight loss and other health benefits to teens with morbid obesity.

“We know that morbidly obese teenagers are at high risk for becoming morbidly obese adults. From recent research available on adolescents who underwent weight-loss surgery, we now know that they can achieve good, long-term weight loss, achieving a 30 percent reduction in BMI,” says Aaron P. Lesher, M.D., an assistant professor of surgery and pediatrics at MUSC Health who specializes in adolescent bariatric surgery.

Pediatric Obesity and Bariatric Surgery

Severe pediatric obesity can affect long-term health and quality of life, and non-operative treatments have shown little effect. It’s an issue with which South Carolina healthcare providers are especially familiar.

“The latest figures are that approximately 6 percent of children under 18 are morbidly obese or have a BMI greater than 35,” says Dr. Lesher. “South Carolina has a higher prevalence of morbid obesity than the national average, and that number is increasing.”

Bariatric surgery has proven benefits for adults with morbid obesity, and healthcare providers have been performing weight-loss surgeries for decades. Still, many providers have been hesitant to perform these procedures on younger patients due to the lack of research on the treatment’s long-term risks and benefits.

“While bariatric surgery has been shown to provide durable weight loss for patients with morbid obesity, there’s been some reticence on the part of surgeons and primary care doctors to do this in adolescents because of the lack of reliable data with long-term follow-up,” explains Dr. Lesher.

That lack of data leads to questions such as:

  • How do adolescents’ long-term weight loss compare to adults’?
  • Will adolescents adhere to the dietary restrictions necessary after surgery?
  • How might adolescents be psychologically affected after surgery?
  • Will adolescents develop the same vitamin and mineral deficiencies that are sometimes seen in adults who undergo bariatric surgery?

New Data Shows Benefits of Adolescent Weight-Loss Surgery

Recently released data, such as that from a study published in The Lancet, shows an eight-year follow-up of adolescents who received bariatric treatment for morbid obesity. The results are promising.

“In comparison to diet and exercise modification, adolescents achieved significant weight loss with bariatric surgery, approximately a 30 percent decrease in BMI,” says Dr. Lesher. “One study showed that bariatric surgery resolved diabetes in 88 percent of adolescents who had the condition prior to bariatric treatment.”

According to Dr. Lesher, this data may make primary care providers more comfortable in recommending adolescents for bariatric treatment. “As surgeons acting in the best interest of our patients, we are willing to offer this service to our morbidly obese adolescent patients because of this long-term data that shows we can provide durable weight loss,” he says.

While most of the longer-term studies for adolescents have looked at gastric bypass surgery, Dr. Lesher says MUSC Health considers sleeve gastrectomy another good option for bariatric surgery in adolescents.

“We don’t have as good long-term data in sleeve gastrectomy as we do with gastric bypass, but we can extrapolate that we will achieve similar weight-loss results. We may even improve the nutritional and vitamin and mineral deficiencies that we occasionally see with gastric bypass,” he says.

According to Dr. Lesher, sleeve gastrectomy offers a slightly lower complication profile, in the immediate postoperative period. It also has a slightly lower long-term vitamin and mineral deficiency profile, because surgeons don’t alter the length of the absorbable bowel during the procedure.

MUSC Offers Expertise in Adolescent Weight-Loss Surgery

MUSC Health’s bariatric program offers extensive expertise in this area, as surgeons have been performing bariatric surgery on adolescents since 1992. The program is accredited by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery’s Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, for both adults and adolescents. It performs the highest volume of adolescent bariatric procedures in the state.

“We were not performing many bariatric treatments on adolescents before 2007,” says Dr. Lesher. “But as we’ve seen better data, we felt that it’s increasingly safe to perform.”

Criteria for surgery mirror those for adult bariatric surgery. Ideal candidates have a BMI greater than 40, or a BMI greater than 35 with major comorbidities such as diabetes. Dr. Lesher says any teen who has a BMI greater than 40, especially those with significant comorbidities such as Type 2 diabetes and who have failed other attempts at weight loss, may benefit from bariatric surgery.

“I think that intervening earlier—before someone reaches a BMI of 50 or 60 or has more comorbidities—may give patients a better chance at long-term health improvement and better outcomes,” says Dr. Lesher.

In adolescent patients, the MUSC Health team prefers to wait until patients are at least 15, though Dr. Lesher says they consider patients as young as 13, in the cases of profound morbid obesity.

“The data suggests that we need to be performing these procedures when patients are skeletally mature,” he says. “We use X-rays to confirm that patients’ bony growth plates have fused.”

As with adults, adolescent patients benefit from MUSC Health’s comprehensive program and experienced team. “We have all of the ancillary and support staff, from pediatric surgeons to adolescent dietitians and psychologists, to achieve optimal long-term goals,” he says.

Dr. Lesher hopes pediatricians and family providers will consider bariatric surgery for young patients who might benefit from this life-changing treatment: “With this recent evidence, we can legitimately say that bariatric surgery is a safe and effective procedure. And it is, by far, the most effective way for these patients to lose weight and to keep it off. This really gives teens a chance to become healthy, productive adults and to modify their behavior and lifestyle sooner rather than later.”

For more information, contact Dr. Lesher at leshera@musc.edu.
 

Of an estimated 30 million Americans with morbid obesity, one percent or less undergo bariatric (weight-loss) surgery that could benefit them.

“There are so many patients with morbid obesity, which is a serious condition. Yet there's a huge disconnect between the number of patients who could benefit from weight-loss surgery and the number of patients who are actually receiving treatment. This surgery would significantly improve their life and reduce their comorbidities,” says T. Karl Byrne, M.D., a professor of surgery at MUSC Health.

According to Dr. Byrne, several factors, including health insurance coverage and misinformation, contribute to the low percentage of people undergoing bariatric surgery. He wants primary care physicians and patients to know that there are safe and effective bariatric surgery options.

Insurance: One Barrier to Bariatric Surgery

According to Dr. Byrne, a dearth of health insurance plans covering bariatric surgery is one key reason so few people with morbid obesity actually seek out weight-loss surgery.

Whether a health insurance plan covers weight-loss surgery (and for whom) varies with a company, policy, even state. “For example, in about half of the states in the nation, the state health plans will cover weight-loss surgery,” explains Dr. Byrne. “In the state of South Carolina, our state healthcare plan does not. Medicare and Medicaid, however, do cover weight loss surgery.”

Patients who need to self-fund bariatric surgery are significantly less likely to continue with the process. Because of that reality, Dr. Byrne says insurance status is one of the first topics broached with patients inquiring about bariatric surgery.  “If a patient’s health insurance doesn’t cover weight loss surgery, we then discuss with them a range of options for self-pay,” he says.

Lack of Information About Weight Loss Surgery Safety Advances

Another obstacle to bariatric surgery: patient education. While Dr. Byrne says family practitioners are becoming more open to discussing weight-loss surgery for applicable patients, misinformation among patients still abounds.

“There is a significant amount of myth among patients as to the safety of surgery for obesity,” he explains. “In the last several years, the mortality rates for patients undergoing surgery for obesity have dropped dramatically. Secondly, most of the cases that are performed today are being done laparoscopically, so wound complications are practically nonexistent anymore.”

When comparing data across the nation, the 30-day mortality rate after a bariatric procedure is currently zero. In fact, Dr. Byrne says weight-loss surgery today is safer than many other types of surgical procedures, such as joint replacement.

“Unfortunately, that information hasn't percolated down to our patient population yet,” he says.

MUSC Bariatric Surgery Program: A Snapshot

Strict guidelines and protocols for care as well as comprehensive bariatric surgery teams comprised of various subspecialists have helped to make these surgeries safer and more beneficial for patients. MUSC’s bariatric surgery program, an accredited center from the American College of Surgeons, offers a range of weight-loss surgery options for patients as young as 15 and as old as 75, using minimally invasive approaches.

In general, candidates for weight loss surgery include patients with a body mass index (BMI) of 40 or a BMI of 35 with a weight-related medical problem, such as diabetes. Not all patients would benefit from the same type of bariatric surgery, which is why MUSC offers options, such as:

  • Gastric bypass, previously the gold standard for bariatric surgery, a procedure that’s still common today
  • Sleeve gastrectomy, the most common weight loss surgery performed today
  • Duodenal switch, a more complicated procedure that’s shown to be beneficial for super-obese patients, or patients with a BMI of 50 or more

“The gold standard operation for weight loss has always been the gastric bypass, which is done laparoscopically now,” says Dr. Byrne. “However, that has been superseded in terms of numbers by the sleeve gastrectomy, which is now the most common weight-loss procedure performed throughout the United States.”

In sleeve gastrectomy, a surgeon removes the vast majority of the stomach, leaving a long, thin, cylindrical or sleeve-like stomach in its place. Compared to gastric bypass, Dr. Byrne says gastrectomy is more straightforward and easier to perform.

A standard laparoscopic sleeve gastrectomy procedure at MUSC today can be completed in as little as 45 minutes. Most patients stay in the hospital overnight and go home the next day. “The vast majority of patients will have that kind of experience,” says Dr. Byrne. “Likewise with gastric bypass surgery, the hospital stay has been reduced significantly. It's now a one- or two-day stay as well.”

Weight Loss Surgery’s Mounting Benefits

Increased safety, shorter hospital stays and more procedure options: Bariatric surgery has changed for the better in recent years. Still, a large percentage of patients have yet to realize it.

“That’s unfortunate,” says Dr. Byrne, “because many patients who have a bariatric procedure lose a significant amount of weight, reduce the number of medications they take and completely reverse comorbidities such as diabetes and hypertension.”

For more information, contact Dr. Byrne at byrnetk@musc.edu.
 

Nursing motherIn the October 2015 issue of Pediatrics, two MUSC Children’s Hospital faculty members—vitamin D researcher Bruce W. Hollis, Ph.D., and neonatologist Carol L. Wagner, M.D.—reported clinical trial findings definitively showing that sufficient vitamin D can be transmitted via breast milk to meet the needs of the exclusively breastfed infant, provided that the mother is adequately supplemented.

Breastfeeding is encouraged by the medical community in part because breast milk meets all nutritional needs of the child, with the glaring exception of vitamin D. Why such an essential vitamin would be missing from breast milk has always been puzzling. Many physicians erroneously believe that vitamin D simply cannot be transmitted via breast milk. To prevent deficiency in exclusively breastfed babies, the American Academy of Pediatrics recommends that they be supplemented with 400 IU/d of vitamin D3, delivered via liquid drops. Unfortunately, the drops can be difficult to administer and not all mothers adhere to this directive, leaving some infants vulnerable to rickets or fractures.

The study results reported by Hollis and Wagner suggest that a more natural and effective way to supplement the child would be to adequately supplement the nursing mother.  At the time the study was designed, the Institute of Medicine (IOM) recommended that adults, even nursing mothers, receive 400 IU/d of vitamin D3; the IOM has since increased the recommended dose to 600 IU/d. The study randomized mother/infant dyads to either 400 IU/d of vitamin D3 each or 6,400 IU/d for the mother and none for the infant. The infants in both arms of the trial achieved vitamin D sufficiency, and no adverse effects were reported for mothers receiving the 6,400/IU day dose.  The results suggest that adequate maternal supplementation—6,400 IU/d of vitamin D3 vs. the current IOM recommendation of 600 IU/d—offers a safe and effective alternative to direct infant supplementation.

photo of a box of fruits and vegetablesA recent study led by MUSC professor David P. Turner, Ph.D. finds that lifestyle habits such as diet and exercise could affect the progression of cancer and the rate of survival, but so could race. According to the study published in Cancer Research in May, our bodies have to metabolize food to obtain the sugars we need, thus leaving behind a reactive-metabolite waste product. These leftovers are referred to as advanced glycation end-products (AGE), and this study addresses the apparent correlation between AGE levels and the prevalence of age-related diseases among non-Hispanic whites and African Americans. 

High levels of AGE are associated with diabetes, cardiovascular disease, Alzheimer’s, and cancer. These levels are highest in African American men with prostate cancer—they are 1.5 times more likely to be diagnosed with this cancer and twice as likely to die from it than non-Hispanic whites. Consumption of sugar and processed food can contribute to AGE levels. Food preparation (i.e., browning) also plays a large role in these levels. They are higher in the West, where the diet commonly consists of red meat, refined grains, and high sugar and fatty foods.

 When analyzing serum from cancer patients, Turner found that AGE levels were significantly higher in patients with cancer than those without. Breast and prostate immortalized cancer cell lines grew more, migrated farther, and invaded more when treated with AGE. In conjunction with higher AGE levels, African Americans have more C-reactive protein (CRP), making them more susceptible to chronic inflammation. Chronic inflammation is one of the key factors implicated in the development of cancer, along with oxidative stress, an increased immune response, and the presence of AGE.

AGE cannot be completely eliminated, but levels of circulating AGE can be lowered. Simply changing lifestyle habits can slow down the accumulation of AGE in the body. Avoid food with high protein, sugar, and fat, as well as processed foods. Then increase your intake of natural grains, fruits, and vegetables. Change the way you prepare your food by cooking meats at a lower temperature for a longer period of time, skipping the browning step of a dish. You can also replace high-sugar, oil-based marinades with lemon juice, vinegar, and tomato juice. The last big step of lowering your AGE levels is exercise. A sedentary lifestyle only allows for more AGE to accumulate.

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