Earlier this year, the American Academy of Pediatrics updated their treatment guidelines for pediatricians and general practitioners to officially include earlier recommendations for weight loss surgery in children with obesity.
We spoke with Jeffery Zitsman, MD, director of the Center for Adolescent Bariatric Surgery about the importance of this change and how the program for surgical treatment of obesity in children and adolescents actually works.
Starting with the guidelines themselves, is this the first time the American Academy of Pediatrics (AAP) is recommending bariatric surgery for children and adolescents?
Well, in 2019, the AAP published its recommendations for bariatric surgery, and it was a very data-driven article, with several hundred articles looking at the data. It followed the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines for bariatric surgery and adhered pretty closely to it. And they basically said, gastric bypass is appropriate for people with severe obesity who meet these indications. Gastric sleeve is appropriate. Gastric band may be appropriate but is a less effective procedure.
Now, they've gone to the next step by saying these are the guidelines to treat obesity. You start here, you move to this, you move to this, you move to this...And for the first time, surgery for obesity is included in that.
20 percent of children and adolescents in the United States have obesity. Do you expect that number to continuously rise?
I think that all of the elements that exist which contribute to the rise in obesity are still present, specifically large portion sizes, difficulty obtaining healthy foods, particularly in underserved communities. The ongoing pressure from the food industry for people to consume not only large quantities but very highly caloric meals, processed foods, sugar-sweetened beverages, soda, juice. I don't think that's going to change.
It may not continue to rise at the same rate, but I think we're going to sit in the 20-22 percent range for quite some time. And children with obesity have a nine out of 10 chance or better of being adults with obesity. Right now, on average, about a third of adults in the U.S. have obesity. In some areas, it’s approaching 50 percent.
For a child with obesity, how early should they be evaluated?
The new AAP clinical guidelines really start talking about doing evaluations in preschool years. Because the earlier somebody with obesity is diagnosed and their lifestyle, behaviors, eating habits, activity levels, all of those things are addressed, the better chance they have of turning around before they get to the levels that are more serious.
As a pediatrician, the recommendations are that it be addressed in preschool years. In our program, when I ask, “When did obesity develop?” a small percentage will be very, very big babies. Probably, mom had diabetes or was on other medication/treatments that contributed to it. But the nine-pound baby, that sort of thing, they are the exception. Some will develop obesity in the first year.
Does that mean preschool years are when the majority of kids start developing obesity?
The majority actually develop it between six and eight. And that probably has to do as much with what they're consuming, how they're consuming it, where they're consuming it as anything.
It's a time for birthday parties, for snacks at school. It's a time for all of these things that can easily contribute to the calories going in. And since different people have different genetic makeups, their metabolic rates are going to vary. It's complex, but certainly, intake has a lot to do with it.
With the extensive differences between individuals and their metabolism, are genetics really what it comes down to?
The genes are really the script—what our bodies are instructed to do, what they are going to do. But epigenetics comes into it too. And perhaps an analogy would be going to see a play. So, you see Hamlet, a performance with a group of actors in one scenario, and then you go to another theater and maybe it’s an off-Broadway production. Still have the same words, same play, but the inflection is different, and the interpretation is different.
And that's the way I think of epigenetics. There are other factors that literally take the genes into account but have an impact on how they are pronounced. How they are expressed.
There's often a language model that's used. A simple phrase, “I did not take that cookie.” Depending upon which word you emphasized, “I did not take that cookie. I did not take that cookie. I did not take that cookie. I did not take that cookie or I did not take that cookie.” It's different ways of looking at the same thing.
I think that's analogous to how bodies interpret genes and express them. And certainly what a person takes in, how much they exercise, what medications they might be on, sleep, all of those things have an impact.
In these new guidelines, is the treatment approach tailored individually to each child? Some start with nutritional support, lifestyle changes and some may just start with bariatric surgery? Or is there a more generalized pathway?
First, it’s a really important thing that the American Academy of Pediatrics has accepted obesity as a chronic disease that needs treatment, regardless of when it occurs. So, you look at the symptoms. Say they’re short of breath, wheezing. The guidelines talk about ‘motivational interviewing’ at preschool age.
To the extent that a child and their parent can have the conversation and discussions about diet, lifestyle, exercise–how much time are they spending on screens? What kind of activity do they have?--that should start very early. By the time they get to our program, it may be the first introduction to treating their obesity that they've ever had. Most will have seen a nutritionist or picked up a book or tried a diet. In the past, a few might have gone to Weight Watchers or Jenny Craig. A few had even gone to some of the specialized camps. Most may have been through obesity management programs already.
But the ones who come to us are at the 99th percentile or above. These teens really have severe obesity. And part of that is because I don't accept them into the surgery program unless they're likely to be surgical candidates.
When working with children in the program you’re doing sleeve gastrectomy, is that right?
When I started the program in 2005, gastric banding was relatively unstudied in children and adolescents. And since it’s a reversible procedure, it has very low metabolic risk. I thought, let’s start here. And sleeves didn’t exist then.
My friends around the country were doing gastric bypass as a multi-center collaborative effort, Teen-LABS, when they started back then. But gastric bypass is an irreversible procedure, and I didn’t feel it was the right thing to put on a 16-year-old. If you're 45 and you want to do that, great, but if you're 16 and you're basically stuck with this for the rest of your life, that's a burden.
So we started with gastric bands. Sleeves appeared on the scene in 2008 and we started doing them in 2010. Then in 2012, we stopped doing bands entirely because sleeves were just such a better operation, and since then sleeves are all we’ve done.
A sleeve gastrectomy is not reversible, correct? What’s the benefit of that over bypass at this point?
Absolutely not reversible. So my argument for not doing bypasses, because they couldn't be reversed, disappeared. The metabolic consequences of bypasses are somewhat more severe than they are with the sleeve. Initially, with sleeves, we didn't really know what the impact was going to be on vitamins and absorption of iron, things like that. Whereas when we know with bypasses that you have to take supplements for the rest of your life, otherwise you're going to have deficiencies.
Will you explain the sleeve operation? What is the impact on vitamin absorption?
So, we remove a lot of the stomach and sort of make it into a sleeve shape. The part of the stomach that's taken out is where most of the co-factors that involve absorbing B vitamins are.
People who have sleeve gastrectomy don't feel hungry because the hormone Ghrelin is made in that part of the stomach. It's made in other places, but the signal to eat, because you're now hungry is greatly diminished. But thymine factors are made in that part of the stomach, so thiamine deficiency is a risk. Vitamin B12 has co-factors that are made in that part of the stomach. That's a risk. Folate is very important for females who may have children.
Also, we have to make sure their levels are adequate. Iron deficiency can occur, so we monitor that, and most people have vitamin D issues, which doesn't relate to that part of the stomach, but having a sleeve will decrease their intake, their vitamin D absorption isn't necessarily as good. And more importantly, losing weight. You don't just lose the fat, you lose everything. So, they're at risk for developing osteomalacia as well. Supplementing vitamin D, taking adequate amounts of calcium so that the bones remain strong is also very important.
In light of these guidelines, has there been reticence from pediatricians to recommend bariatric surgery?
In 2010, a study out of Michigan looked at pediatricians and family practitioners, and half of them at that point, in spite of quite a bit of evidence, said they would never send a child under the age of 18 for a bariatric procedure.
Six years later, with a lot more data from all around the country showing that bariatric surgery was effective and safe—even the American Society for Metabolic and Bariatric Surgery and AAP were incorporating it into their recommendations—pediatricians in Virginia were still not going to send them for surgery.
Why do you think that is?
I think pediatricians take on the role of protector and extended parent. They want to keep their patients, and their families, away from surgeons. So, the database education that we work really hard to provide is the best tool that we have.
There's another study that some colleagues did at Tufts around 2017 that showed the single most important factor in a child being referred for bariatric surgery was whether the pediatrician had brought it up or not. And the majority don’t.
Do you hope that will get better and better as these guidelines have been recognized by the Academy of Pediatrics?
Realistically, I think we're likely to still be in the margins. The obesity guidelines are an enormous benefit, a gift to the pediatricians because now they can say “I have some things I can do to help this kid who's miserable. To help this family who's beside themselves because they don't know what to do.”
“Now, I have these tools. And there are even some medicines I might be able to use if I can prescribe them in the right ways.” It's not something that's instantly going to happen. But I think we'll see more kids getting treatment, and that is probably going to include medication.
Are medications an option for most children?
We have seen an uptick in referrals to our program for kids who are already on medication. And they may have gone from a BMI of 51 to 45, and they're feeling good about that, but they still need to lose more weight and so surgery comes into play. The indications for medication are relatively limited. Most of them now are only for diabetes in younger patients so insurance won’t cover them, and it’s expensive.
Will you tell us a little bit about these medications?
Metformin, Glucophage has been on the market for some time for people who have insulin resistance or pre-diabetes. That's not a weight management medication, it helps with control. But it's not something where people can be expected to lose weight.
The new medications are the GLP-1 agonists, and these medications make the brain think that somebody's full so they don't have hunger, to put in in a simplistic way. But for some people who eat because they're hungry all the time, that can be very effective. They're only approved in cases of diabetes right now. So that's a barrier that pediatricians, endocrinologists, and obesity specialists are working on—to try to get those medications approved.
It seems there are barriers on multiple fronts, from education to access itself.
Yes. I think the main barriers are acceptance of surgery as an appropriate tool for the appropriate people, and an understanding of surgery. We're sort of preloaded with our own thinking.
With many of our own physicians who are not involved in weight management, the operations are all the same. They don't distinguish, they don't have an understanding of what the nuances of the potential care are. It gives me an important job because I get to talk to them every few years and say, “Look out for this. You don't have to worry about this.” That sort of thing. But just as I'm sure there are things in medicine that I'm ignorant about, there's a lot of absence of knowledge that we who are involved in caring for these kids think is important, but it doesn't necessarily register as important to them.
Do you have specific or personal goals you hope will be bolstered by these guidelines? From perception to practice?
Well, one other interesting thing about the guidelines is that in the first AAP position statement, they very clearly said that they could not set age limits. The AAP chose to take that a little step further and say that surgery is appropriate as young as 13. But they wouldn't make any comment on patients who were younger than 13 because they didn't feel that the level of data had met the criteria for them to include it in the guidelines.
Now, having said that, there are studies of a number of children, not thousands, but adequate numbers of children under the age of 13 who have had successful surgery. And we here have operated on probably a couple of dozen who are in the 12 and underage group. So, on the one hand, advocates for surgery, some of my colleagues, are angry that they didn't go all the way.
On the other hand, some of us say, well, this is a single, you're on base, so shut up about the home run. Let's do the work. Let's produce the studies and show them this. That work will be ongoing.
It doesn't mean that we won't do them. We have plenty of kids in the program who are 11 and 12 right now, and they'll be good surgical candidates when they get through the program in many cases.
Do you have any predictions for the future? Hopes for the next 10 years?
I think these guidelines, and medication, will probably make more people aware of both the importance of and the availability of treating severe obesity. Do I think we're going to stem the flow of obesity? No. I think that the societal issues around preventing obesity are enormous.
So, what can we do? Well, we can provide effective treatment. We have to continue to make sure that it's safe. We have to continue to make sure that individuals who have these treatments have good outcomes. And we have to be prepared if we find that things steer off in a bad direction, that we can pull back and say, okay, we don't want to do that anymore.
We have to be willing and eager to continue to learn more about it. But I think the guidelines are going to make it easier for people to accept obesity is something that needs to be treated. I think the medications are going to make it easier for people to have some tools. And that may in some instances move them a little farther along in understanding that there could be a role for surgery as well, and that surgery does a pretty good job of helping.