As clinicians, we are concerned about the health of our young patients with obesity and frustrated by the lack of reliable therapeutic interventions. Likewise, parents and the affected adolescents are understandably discouraged by the lack of long-term success of prescribed lifestyle changes (diet and exercise) and search instead for a quick remedy.
When our young patients’ weight has reached the point where the consequences are beginning to appear, we must work together to design strategies that can benefit them. To facilitate that conversation, it’s worthwhile first reminding them and ourselves of the considerable toll that adolescent obesity can have.
The Significant Consequences of Adolescent Obesity
The prevalence and severity of obesity in adolescents continues to increase worldwide. Childhood obesity is a serious health problem that predicts adult obesity, liver and cardiometabolic disease, and early mortality.
Nonalcoholic fatty liver disease (NAFLD) has become the most common etiology of chronic liver disease in children and adolescents in most industrialized countries, approaching 10% of the general pediatric population. In the United States, end-stage liver disease due to NAFLD is a leading cause of liver transplants in adults.
Stavra Xanthakos, MD, my colleague at Cincinnati Children’s Hospital, documented the health consequences from the progression of NAFLD to nonalcoholic steatohepatitis (NASH). She and her co-authors reported that approximately one third of children with NAFLD enrolled in the NASH Clinical Research Network had histologic features of progression within 2 years, in association with loss of glucose homeostasis and resulting in the development of type 2 diabetes (T2D).
This was taken by us as a clarion call for early intervention in adolescents with severe obesity.
What Can Be Done?
Pharmacotherapy for pediatric NASH is lacking. Randomized trials have shown that bariatric surgery may offer benefits by promoting glycemic control and remission of T2D more reliably than medical therapy. Although bariatric procedures are efficacious and relatively safe, whether to proceed requires a shared decision-making conversation about the risks and benefits of surgery compared with continuing usual lifestyle changes and medical treatment. There are downsides to bariatric surgery. For example, in a prospective study of adolescents who underwent this surgery, nutritional deficiencies (eg, iron, vitamin B12) were common by 5 years after the procedure.
It is therefore understandable why an article by Yoshino and colleagues generated such significant discussion among my colleagues. In it, the investigators asked an important question: For those with T2D, does Roux-en-Y gastric bypass have therapeutic effects on metabolic function that are independent of weight loss?
Their study set out to determine whether surgical procedures that involve bypass of the upper gastrointestinal tract offer unique therapeutic effects on glycemic control, allowing remission of T2D. They cited previous, often conflicting, studies of the effects of gastric bypass on several factors involved in the pathogenesis of T2D: multiorgan insulin resistance, altered metabolic response to meals, and inadequate beta-cell function.
This classic clinical research investigation was designed to determine whether weight loss attained via gastric bypass bestowed therapeutic metabolic effects beyond those brought about by weight loss induced by a low-calorie diet alone. They enrolled 33 people with obesity and T2D (18 in the diet group and 15 in the surgery group), although 7 participants in the diet group and 4 in the surgery group were not included in the final analysis because they did not achieve the target weight loss. Notably, all meals were provided to the diet cohort in the form of liquid shakes and prepackaged entrees.
At the end of the study period, the mean weight loss was 17.8% in the cohort adhering to diet alone and 18.7% in the cohort who underwent bariatric surgery. The similar metabolic benefits of bypass surgery and diet were ascribed to the weight loss. The authors stated that there were “no evident clinically important effects independent of weight loss.” They also reported similar weight loss benefits induced by gastric bypass or diet alone on multiorgan insulin sensitivity, beta-cell function, 24-hour plasma glucose and insulin profiles, and body composition.
Guiding Our Children to a Healthier Future
Clearly, standard lifestyle counseling may not bring about the desired effect of sustained weight loss. The daily temptations of fast foods and sugar-sweetened beverages result in high caloric intakes and poor diet quality. Data from the National Health and Nutrition Examination Survey indicated that during 2015-2018, 36% of children and adolescents consumed fast food on a given day, accounting for an average of 14% of their daily caloric intake.
The study reported by Yoshino and colleagues bypassed this real-world issue that limits the sustained success of diet alone by supplying prepackaged foods. However, if a committed patient or family can avoid these risk factors, weight loss and metabolic improvement can ensue. For example, Schwimmer and colleagues documented that in adolescent boys with NAFLD, the provision of a diet low in free sugar content resulted in significant improvement in hepatic steatosis.
For children who do not respond to standard lifestyle counseling and are experiencing worsening disease, multidisciplinary interventions may be more effective. However, these intensive multicomponent lifestyle modification programs are not easily accessible and require considerable financial resources and time. Therefore, referral to an interdisciplinary team of experts — including registered dietitians, exercise physiologists, psychologists, among others — is not feasible for all patients.
Bariatric surgery will probably benefit the most severely affected patients with incipient serious complications. Unfortunately, insurers are often reluctant to pay for this intervention for individuals younger than 18 years, owing to the relative paucity of long-term outcomes data.
Combined with the alarming data on prognosis supplied by Xanthakos and colleagues, the data from Yoshino and colleagues allow us a scientific basis for our recommendations to patients and their parents. Although we can now say that surgery works because it leads to weight loss, we should continue to first recommend achieving that weight loss without surgery.
William F. Balistreri, MD, is the Dorothy M.M. Kersten Professor of Pediatrics; Director Emeritus, Pediatric Liver Care Center; Medical Director Emeritus, Liver Transplantation; and Professor, University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center. He has served as director of the Division of Gastroenterology, Hepatology and Nutrition at Cincinnati Children’s for 25 years and frequently covers gastroenterology, liver, and nutrition-related topics for Medscape. Dr Balistreri is currently editor-in-chief of the Journal of Pediatrics, having previously served as editor-in-chief of several journals and textbooks. He also became the first pediatrician to act as president of the American Association for the Study of Liver Diseases. In his spare time, he coaches youth lacrosse.