Adolescent obesity is a growing problem that causes consternation for all and for which there are few if any durable treatments available.  Non-treatment, however, is no option.

Obese children, like their adult counterparts can develop metabolic syndrome with all of its attendant complications-- cardiovascular problems resulting from years of high blood sugar and lipid levels and consequent, diabetes and/or hypertension.¹

Pediatric Metabolic Syndrome May Not Be a Stable Diagnosis

The factors that comprise the metabolic syndrome in adults--large waist circumference, abnormal fasting glucose, hyperlipidemia, and hypertension have long-term stability over time (75% during 3 years) and are associated with excess risk for cardiovascular disease and type 2 diabetes. The factors in children, however, are not well defined.  Perhaps 3 or more of the following might be considered: waist circumference, systolic or diastolic blood pressure, and fasting triglycerides 90th percentile; high-density lipoprotein cholesterol 10th percentile; fasting glucose 100 mg/dL.  Regardless, even if well defined, the factors are not stable over time.  In fact, in the following study, no individual component of metabolic syndrome had either short-or long-term stability.  

Study

Short-term stability was examined in 220 obese patients (body-mass index [BMI] 95th percentile; age range, 6–17 years). Eligible children (age range, 6–11 years) also had hyperinsulinemia, and adolescents (age range, 12–17 years) had one of the following: hyperinsulinemia, hyperlipidemia, sleep apnea, elevated liver function tests, abnormal fasting glucose, or hypertension. Most participants were older than 12 years, female, and black.

At baseline, 38 patients (17%) exhibited metabolic syndrome, and, at a mean follow-up of 20 days, 70 patients (32%) showed metabolic syndrome. However, nearly one third of patients with metabolic syndrome at baseline did not meet criteria at follow-up.

Long-term stability was examined in 146 children (age range, 6–12 years) who were at risk for adult obesity because they were obese (BMI 95th percentile for age) or had one obese parent (BMI 25 kg/m2). None had comorbid conditions. Most participants were younger than 11 years, female, and white. At baseline, 39% were obese, and 8% exhibited metabolic syndrome. At a mean follow-up of 6 years, 47% were obese, and 9% exhibited metabolic syndrome. Nearly half the patients with metabolic syndrome at baseline did not meet criteria at follow-up.

Comment: This study demonstrates that not only is diagnosing metabolic syndrome in a pediatric population, even in patients at high risk for the disease difficult, but the metabolic syndrome as defined, isn't a stable finding until children are post pubertal. Until it is better defined, we need to continue to monitor obese children and adolescents for the individual facets of metabolic syndrome and treat each of them accordingly.

Reference: Gustafson JK et al. The stability of metabolic syndrome in children and adolescents. J Clin Endocrinol Metab 2009 Dec; 94:4828. 

[Medline® Abstract] 

Desperation Moves

Sustained weight loss is a goal for all, however elusive.²  We may see it in those who have a heart attack, but 'that's closing the barn door after all the horses have left their stalls.'  Bariatric surgery is a desperate move in children, but Dr. Livingston in the Feb. 10^th 2010 issue of JAMA says while it remains controversial, the evidence is mounting for its use.  Here's a recap of his important editorial:

• Gastric bypass–type operations permanently alter the stomach muscle and lining, giving pause.
• Laparoscopic adjustable banding operations are more popular apparently because they "can result in reasonable weight loss with relatively few complications and substantial potential for reversibility [but] the literature supporting the use of bariatric procedures is incomplete, causing policy makers to be hesitant in recommending this procedure for treatment of adolescent obesity."

O’Brien and colleagues³ "randomized 50 obese adolescents to either receive a laparoscopic band or enroll in a medically supervised weight loss program. All participants received free care and those involved in the medical care group were offered an unusually intense program that included the provision of a personal trainer for 6 weeks. At 2 years of follow-up, there was substantial heterogeneity in weight loss outcomes for both groups with greater average weight loss for those receiving laparoscopic banding procedures. Even though weight loss was modest in the medical weight loss group, there was substantial improvement in hypertension, hyperlipidemia, and insulin resistance, demonstrating that lifestyle interventions are worthwhile even though they did not result in the amount of weight loss achievable with surgery."

Laparoscopic Banding Devices' Complication Rate: despite being a very "experienced group" of surgeons, 7 of the 24 patients needed revision, "suggesting that these complication rates will probably be higher in actual community practice." Nevertheless, "laparoscopic banding procedures appear to be a feasible means for treating obesity in adolescents. The operation is known to require more patient compliance than Roux-en-Y gastric bypass (RYGB) surgery, and concerns have existed about the ability of teenagers to comply with the rigorous follow-up required to lose weight after laparoscopic banding placement. Because laparoscopically placed adjustable bands have fewer complications and are reversible, they represent a better alternative than RYGB for obese adolescents in need of surgical treatment for obesity."

In keeping with the theme of this column—"Reforming Healthcare & Managed " Dr. Livingston's editorial closes with: "Many insurance companies in the United States will not pay for bariatric surgeries, and their decision to not cover this treatment is based on the lack of compelling, universally accepted evidence in its favor. Studies such as the one by O’Brien et al³ go a long way toward providing the evidence necessary to evaluate the benefits and risks of bariatric surgery."

Livingston EH. "Surgical Treatment of Obesity in Adolescence."  JAMA. 2010;303(6):559-560.

1. van Dam RM, Willett WC, Manson JE, Hu FB. The relationship between overweight in adolescence and premature death in women. Ann Intern Med. 2006;145(2):91-97
2. Treadwell JR, Sun F, Schoelles K. Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Ann Surg. 2008;248(5):763-776
3. O’Brien PE, Sawyer SM, Laurie C; et al. Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. JAMA. 2010;303(6):519-526.