Anyone dealing with pediatric obesity knows that there is now an increasing number of massively obese kids for whom behavioural and/or medical weight management will simply not cut it. It is therefore no surprise that an increasing number of kids and their families are now looking to surgeons for help.

To address this demand, Toronto’s Hospital for Sick Children last week announced the creation of a centre for pediatric and adolescent bariatric surgery (see report on CTV).

While to some readers this may seem shocking, extreme, drastic, and will likely provoke much head shaking amongst people who simply do not get that calling for more prevention efforts will be of no benefit to these kids, the reported outcomes for pediatric obesity surgery (at least in the short term) are actually quite good.

Thus, Ai Xuan Holterman and colleagues from Rush University, Chicago, IL, recently reported their experience with bariatric surgery in morbidly obese adolescents in the Journal of Pediatric Surgery.

This looked at the more than one year outcomes in twenty 14-17 year olds undergoing plaparoscopic adjustable gastric banding (LAGB). BMI at baseline was around 50 and was associated with hypertension (45%), dyslipidemia (80%), insulin resistance (90%), metabolic syndrome (95%), and biopsy-proven nonalcoholic steatohepatitis (88%).

At mean follow-up of 26 months, mean excess weight loss was around 30% and the metabolic syndrome was resolved in 63% and 82% of the patients at 12 and 18 months, respectively. Hypertension normalized in all patients, along with improvement in lipid abnormalities and quality of life scores.

LABG is relatively safe with few perioperative complications. Nevertheless, long-term complications including band slippage, erosions, and other problems remain a concern. Furthermore, LABG patients have to follow stringent dietary regimens to be successful. Despite these reservations, LABG certainly currently appears to be the procedure of choice both because it is theoretically reversible and has such low perioperative complication rates.

While we of course all wish that there was no need to reach for such drastic treatments in kids, the reality is that an increasing number of severely obese adolescents and kids will no doubt benefit and will get a real chance at regaining control over their weight and lives.

I predict that Toronto’s Sick Kids is very unlikely to remain the only place in Canada that performs pediatric bariatric surgery for long.

AMS
Edmonton, Alberta

Dr. Geoff Ball, University of Alberta

What do these adolescent kids and their parents expect of an obesity program? What are the barriers they face in terms of improving their lifestyles? What issues are relevant at the level of the family, peers, the health care system, and a policy and program level?

These are questions addressed by Nicholas Holt and colleagues from the University of Alberta, in a study just out in Qualitative Health Research. For this study led by Geoff Ball (picture), data were collected via 41 interviews with parents and children from the wait-list of the pediatric weight-management clinic and analyzed using grounded theory methodology.

While the study provides numerous insights into the familial and other circumstances faced by these families, I believe the following quotes from the paper speak for themselves:

On parental overprotection:

“Ever since [our daughter] was little, being the first grand daughter in the family . . . everybody watched her like a hawk. We were so afraid, like all of us, not just [my wife] and I . . . but it was the whole extended family . . .because she [daughter] was the first . . . we were so afraid that she’d get hurt . . . it’s probably that we have sheltered her a bit too much . . . [from physical activity].”

or

“I have been extremely overprotective [of my son] . . . like [I tell him], ‘Don’t go out in the cold.’ I don’t want him outside. We haven’t encouraged him that way [to be physically active].”

(not exactly a helpful recommendation in a city like Edmonton, where Winter lasts 5 months a year.)

On family meals:

“My husband has just changed jobs; he’s on shift work. So, sitting down together at 5 o’clock doesn’t happen at our house anymore . . . I go sit at the counter top and he’ll sit in front of the TV and eat and I’ll sit in front of the other [TV] and eat.”

On the importance of TVs in general:

“I think we have like five TVs in our house and four of them are just . . . well two of them are movie player ones. OK, there’s one in my brother’s room and it’s one that’s a DVD and movie player, but that’s all. And then the one in my dad’s room you can, it’s watching satellite from downstairs. And then there’s one downstairs and it’s a big screen TV and it’s just a satellite. And then we have two TVs in our toy room. And one of them is supposed to be for “GameCube” and the other one is supposed to be for “PlayStation.” But for some reason both of them are hooked up to one TV. And then we have a computer . . . well, we have two computers . . . a laptop and a computer.”

On how not watching TV cripples social life:

“[My daughter’s schoolmates] all get together and talk about . . . oh there’s One Tree Hill, Gilmore Girls, um Grey’s Anatomy . . . and they almost have one everynight that they could look at. . . . I don’t know about cutting back [TV time] much more . . . I don’t know. That would be hard . . . she’d still be able to talk about some of the shows . . . it wouldn’t cripple [her social life] . . . well [it might].”

On medical care:

“Usually the medical community, you know, they do the thyroid test and those type of things and then very little else happens, and then so it’s rested on [our] shoulders.”

Anyone interested in pediatric and adolescent obesity needs to read this fascinating study on what actually happens in families challenged by obesity and the obstacles they face in trying to change behaviour.

I can only agree with the authors, who conclude: “It is fundamentally important for program planners and health care providers, the individuals who are charged with developing and providing the best service possible, to be mindful of the personal experiences of overweight children and their families who seek weight management care.”

As with adults, overeating and “undermoving” are symptoms of underlying familial, cultural, societal and environmental challenges faced by kids, adolescents and their families. Simply telling them to “eat less and move more” is about as effective as telling them to “have a great day”.

AMS
Edmonton, Alberta

Yes, there’s a childhood and adolescent obesity epidemic out there. The word on the street now is that “this is the first generation of kids, who will not outlive their parents”.

But is this really true? Where is the data showing that childhood obesity is really a risk factor for early death?

This question is now answered by perhaps the largest study on this issue to date published by Tone Bjørge and colleagues from the University of Bergen, Norway, in the American Journal of Epidemiology.

Bjørge and colleagues studied the relationship between BMI (measured height and weight) and mortality in 227,000 adolescents (aged 14-19 years) recruited in Norwegian health surveys in 1963-1975. During follow-up (8 million person-years), 9,650 deaths were observed. Cause-specific mortality was compared among individuals whose baseline BMI was below the 25th percentile, between the 75th and 84th percentiles, and above the 85th percentile in a US reference population with that of individuals whose BMI was between the 25th and 75th percentiles.

Risk of death from endocrine, nutritional, and metabolic diseases and from circulatory system diseases was increased in the two highest BMI categories for both sexes. Relative risks of ischemic heart disease death were 2.9 for males and 3.7 for females in the highest BMI category compared with the reference. There was also increased risk of death from colon cancer (males: 2.1; females: 2.0), respiratory system diseases (males: 2.7; females: 2.5), and sudden death (males: 2.2; females: 2.7).

The authors conclude that adolescent obesity is related to increased mortality in middle age from several important causes.

Clearly not a good sign for what awaits our sons and daughters unless we get a hold on the obesity crisis.

AMS
Edmonton, Alberta

Several months ago I blogged about the results from a Finnish twin study that found lower mitochondria numbers and disturbed mitochondrial energy metabolism activity in fat cells from identical twins who were leaner than their genetically identical co-twins. These impairments correlated with critical clinical measures of obesity including liver fat accumulation, reduced whole-body insulin sensitivity, hyperinsulinemia, hypoadiponectinemia and adipocyte hypertrophy.

In this month’s issue of OBESITY, Tomas Gianotti and colleagues from the University of Buenos Aires, Argentina, report a significantly lower mitochondrial-to-nuclear DNA ratio (mtDNA/nDNA) in insulin resistant (IR) adolescents recruited out of a subset (n=175) of a cross-sectional, population-based study of 934 high school students. In this study, the mtDNA/nDNA ratio was also inversely correlated with HOMA index, a crude but simple measure of insulin resistance.

This study is very much in line with the notion that obesity-prone individuals may have impaired mitochondrial number and/or function resulting in increased risk for obesity.

From the aforementioned twin study, we know that the decreased number and function is not corrected by weight loss.

Indeed the question is whether or not mitochondrial number and function can be increased by prescribing higher activity levels? If yes, how much activity will be needed to reverse these changes? And most importantly, will people with impaired mitochondrial function actually be able to enjoy exercise enough to actually stick with this prescription?

Perhaps it is not obesity that causes impaired mitochondrial function but rather impaired mitochondrial number and/or function that predisposes to obesity. This impairment could be genetic but also due to intrauterine programing or perhaps simply luck of the draw (remember - all mtDNA comes from your mom).

Of course this is not an “excuse” for obesity as is often misinterpreted when data on the genetics and biology are presented. However, it is clear that if you have impaired mitochondrial number and/or function you are much more likely to become obese in an environment that promotes sedentariness than if you were dependent on physical activity to meet your basic needs for survival.

Remember, there were times, not too long ago, when people were actually paid to be physically active. Today, choosing to be physically active actually costs money (not to mention time).

AMS
Edmonton, Alberta

Now here is a counter intuitive finding from Catherine Sabiston, of McGill University, and P.R.E. Crocker, of the University of British Columbia (UBC) published in the Journal of Adolescent Health earlier this year.

In their study of 900 Vancouver-area 16-18 year-old teenagers in Grades 10 through 12, neither was there a link between body mass index (BMI) values and levels of physical activity nor did the physically active teens eat a markedly healthier diet than their less-active counterparts.

If anything, the heavier teens were actually the ones making healthier food choices while the teens with “healthier” BMI values were no more likely to be physically active than those with higher, “unhealthier” values.

According to Dr. Sabiston (quoted in a press release from McGill University)

“A lot of people are surprised, but when you think about it, BMI doesn’t have a huge impact on physical activity. And in terms of diet, it actually makes sense that someone who is not happy with their body might try to eat more healthily. What this study really says, is that one cannot assume that someone who is physically active necessarily eats a healthy diet – or the reverse, that someone who is more sedentary or has a high BMI by definition eats a diet of junk food.“

To me the findings aren’t all that surprising. I have always maintained that health cannot be simply deducted from the number on your scale and that for every overweight kid who eats mostly junk food and spends every spare minute on his Xbox, there’s a skinny kid out there who’s no better.

The simple truth is that eating healthy and exercising is important at any weight!

On the other hand, just as simply eating poorly and not exercising by no means guarantees weight gain - simply eating healthy and exercising does not guarantee a so-called “healthy” weight.

When everyone eats too much and no one moves, it’s likely the poor kids with the “wrong” genes that pack on the pounds - the kids with the “right” genes are simply lucky and can apparently get away with their lousy lifestyles - who says life has to be fair!

Of course, the words “wrong” and “right” in the previous sentence refer to these genes in today’s world. Until not all too long ago in the history of mankind, the “wrong” genes would have been just “right” and vice versa (talking of thinking in circles).

AMS
Edmonton, Alberta

[Hat tip to Michael Dwyer of CIHR for sending me the McGill press release]