Obesity in the Young: Metabolic Risks and Surgery
Published: Oct 13, 2014
The American Academy of Pediatrics Institute for Healthy Childhood hosted a forum entitled Innovations in Obesity: Prevention, Assessment, and Treatment at the academy's annual meeting in San Diego. During the forum, two posters addressed the use of metabolic measures for assessing cardiovascular risk among obese children and adolescents, and two others evaluated outcomes following bariatric surgery in these patients.
Measuring Risk
In one study of 754 patients ages 6 to 17 enrolled in a weight management program, waist-to-hip ratio was correlated with factors that typically are associated with the metabolic syndrome in adults, according toAngela Fals, MD, of the Florida Hospital for Children in Orlando, and colleagues.
"In adults, the waist-to-hip ratio is a valid assessment tool to determine risk for the development or presence of metabolic syndrome, diabetes, and cardiovascular disease. Its validity with children and adolescents is unknown or limited in availability of evidence-based research," they explained.
In a chart review, waist-to-hip ratio correlated positively with these factors:
- Triglycerides in 597 patients, r=0.192, P<0.001
- LDL in 596 patients, r=0.087, P=0.033
- Insulin in 414 patients, r=0.164, P=0.001
Moreover, on an analysis of variance that included all 754 patients, there also was a significant effect of waist-to-hip ratio on body mass index (BMI) percentile, (F=22.428, P<0.001), the researchers reported.
"These results suggest that evaluation of waist-to-hip ratio may be a useful tool to indicate risk for developing metabolic syndrome and diabetes in children and adolescents," Fals and colleagues noted.
Another study determined that, among young adolescents, a high-risk atherogenic index (AI) was associated with abdominal obesity, high blood pressure, and insulin resistance, according to Shahnawaz M. Amdani, MD, and colleagues from the Lincoln Medical and Mental Health Center in New York City.
"As the prevalence of childhood obesity is increasing, more and more pediatric patients are at risk for early atherogenesis and metabolic dysfunction," the researchers observed.
The AI represents the ratio of triglycerides to HDL cholesterol and has been shown to predict cardiovascular disease in adults.
To assess its value in a pediatric population, the researchers reviewed the electronic medical records of 82 boys whose mean age was 13 and 65 girls whose mean age was 14. Mean BMI was 33.3 for the boys and 34.3 for the girls.
The AI was considered to be abnormal in 82%, with boys being eight times more likely than girls to have this abnormality.
Prehypertension, defined as blood pressure between the 90th and 95th percentiles, was present in 13% overall and in 7% of boys and 20% of girls. Actual hypertension, which was blood pressure above the 95th percentile, was present in 23%, and in 20% of boys and 26% of girls.
A total of 26% had the metabolic syndrome, which included 22% of boys and 30% of girls.
Compared with patients who had low-risk AI, boys with high-risk AI had 13 times greater risk of being hypertensive, while girls had 34 times greater odds (P<0.0001).
All the boys and 94% of girls who had an abnormal insulin resistance index also had an abnormal AI, and a linear correlation was found between waist circumference and abnormal AI.
"Further prospective studies are required to evaluate the progression of cardiovascular disease in patients with high-risk AI," Amdani and colleagues concluded.
Surgical Results
"Adolescent bariatric surgery remains controversial despite studies showing its safety and efficacy. Many feel that medical weight management is more appropriate for this population," observed Avraham Schlager, MD, of Emory University in Atlanta, and colleagues.
To compare the results of sleeve gastrectomy with a comprehensive weight management program, the researchers reviewed chart data for 16 patients who had the surgery after participating in the weight loss program for 4 to 15 months.
Fourteen of the patients were girls, and mean age was 15.8 years.
They compared BMI at the patients' initial clinic visit (T0), at the preoperative visit following the weight management period (T1), and then 4 to 8 months after the surgery (T2).
Mean BMIs were 50 at T0, 50.4 at T1, and 42.1 at T2. Mean change in BMI between T0 and T1 was minimal, at +0.35 (P=0.58), while change between T1 and T2 was a significant -8.26 (P=2.3 x 10-7).
Mean hospitalization for the surgery was 3.3 days, and no perioperative complications were reported.
Two of the patients were readmitted within 6 months after the surgery, one for dehydration and the other for abdominal pain.
"In patients eligible for bariatric surgery, sleeve gastrectomy offers significant short-term BMI decrease as compared with medical management," Schlager and colleagues concluded.
A second study examined the effects of a different type of bariatric surgery, Roux-en-Y gastric bypass, among adolescents treated by a multidisciplinary team, according to Sigrid Bairdain, MD, of Harvard Medical School in Boston, and colleagues.
"The current estimates of the prevalence of adolescent morbid obesity and severe morbid obesity are 21% and 6.6%, respectively," the researchers noted.
As in adults, obesity in adolescents can lead to hypertension, hyperlipidemia, insulin resistance, type 2 diabetes, obstructive sleep apnea, polycystic ovarian syndrome, and anxiety and depression.
The study included 11 adolescents (10 girls), whose median BMI before surgery was 48.2.
Their median age was 17, 45% had insulin resistance, and all showed symptoms of depression and anxiety.
Median time until surgery after enrollment was 6 months. Patients averaged two visits to a surgeon, five visits to a pediatric gastroenterologist, six visits with a dietitian, and four with a social worker.
The laparoscopic surgery was accompanied by a hiatal hernia repair in five of the patients, and median time spent in the hospital was 3 days. No surgical complications occurred.
At 1 year, the median percentage excess body mass index lost was 66.7%, and insulin resistance resolved in all cases.
"Future studies on a large scale are needed to show a continued improvement in their medical and anthropometric profiles," Bairdain and colleagues stated.
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