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Ahead of new childhood obesity guidelines, doctors say surgery is an important option

Earlier intervention recommended with medication or surgery after failed efforts at behaviour change
A pediatrician involved in creating new treatment guidelines for obese children in Canada says an “alarming” rise in obesity has led to a greater need for surgery as an intervention for teens whose mental and physical suffering typically worsens into adulthood. A close-up of a beam scale in New York, Tuesday, April 3, 2018. THE CANADIAN PRESS/AP-Patrick Sison

A pediatrician involved in creating new treatment guidelines for obese children in Canada says an “alarming” rise in obesity has led to a greater need for surgery for teens whose mental and physical suffering typically worsens into adulthood.

Dr. Mélanie Henderson, a pediatric endocrinologist and researcher at Sainte-Justine Hospital in Montreal, said guidelines expected to be published later this year will go beyond obesity determination measures such as body mass index to include kids’ overall quality-of-life experiences.

New guidelines published in the American Academy of Pediatrics last month recommend earlier intervention with medication for children 12 and older and bariatric surgery for those 13 and up and severely obese after multiple failed efforts at intensive behaviour changes.

The Canadian guidelines will also focus on interventions without delay due to growing obesity rates and the risk of major health consequences, said Henderson, a co-director of the pediatric hospital’s family-focused program. It includes various specialists that work with children to improve their physical fitness and nutrition and provide counselling.

“We don’t have a lot of data on what are the best interventions to improve some of the mental-health issues and quality of life,” she said, adding a review of studies over the last decade suggests evaluations of anxiety and depression, for example, are lacking even though those issues are addressed in various intervention programs.

“All of this will be highlighted in the actual guidelines,” she said.

Henderson is part of a group of clinicians and researchers across the country that came together in 2019 to create new guidelines with research support from Obesity Canada and the University of Alberta.

She said there’s greater acceptance that medication and bariatric surgery should be offered early as options for a subset of children because obesity is a chronic disease versus a risk factor for other illnesses.

“We have honest discussions about this in that subgroup of kids who have severe consequences from their obesity. We’re talking about earlier cardiovascular disease, earlier Type 2 diabetes, earlier hypertension. All these elements that lead to earlier mortality. So, these are not minor complications.”

An estimated 27 per cent of children in Canada are overweight or obese. Of those, about 10 per cent are obese, triple the amount compared with 30 years ago, Henderson said.

“It’s quite alarming that we’re seeing these very important increases in pediatric obesity,” she said, adding that while genetic factors are a strong component, reduced physical activity at school and more sedentary lifestyles at home account for part of the problem. To address these issues, behaviour change is required — and that’s the caseeven for kids who are prescribed medication or get surgery, which requires committing to a healthy diet.

“We used to think that obesity in childhood wasn’t a big deal, that they’ll outgrow it,” she said. “But in fact, that’s been disproven. So, very young children grow up to be adolescents with obesity and adults with obesity.”

Obese children are at three times the risk of depression compared with their non-obese peers due to the stigma and shame that extends beyond the schoolyard to health professionals, who can have their own biases toward those who are severely overweight, Henderson said.

Among the medications used to treat childhood obesity in Canada is Orlistat, which inhibits fat absorption at the gut level, is particularly effective for adolescents but is not usually prescribed due to side-effects that include digestive issues.

Another medication, Metformin, is mainly used for management of Type 2 diabetes in adults and is prescribed off label. However, a lack of data means it’s difficult for doctors to know who would respond well to it.

A class of drugs called GLP-1 agonists are given by injection, and have been approved for use in children aged 12 and up, said Henderson, adding they are probably the best option in reducing hunger but cost almost $400 a month.

Bariatric surgery, which involves shrinking the stomach to reduce food intake, was introduced in Canada for adolescents in 2010 as part of the two-year SickKids Team Obesity Management Program, or STOMP, at Toronto’s Hospital for Sick Children.

“We need to be offering all possible treatment options and we have good data that bariatric surgery is effective,” Henderson said. “It’s effective in children, and in fact, it’s effective at reversing some of those complications. In particular, for high blood pressure and Type 2 diabetes it’s more effective in the teenagers than it is in adults.”

Dr. Julius Erdstein, director of the adolescent medicine division at Montreal Children’s Hospital, said bariatric surgery, starting at age 15, is a “no-brainer” for teens enrolled at the Centre of Excellence in Adolescent Severe Obesity and struggling with issues such as failing kidneys, injections for diabetes and sleep apnea.

“If we get five kids a year undergoing surgery, which probably represents about 10 per cent of the patients that are referred to us, that would be a big amount,” Erdstein said, adding an operation is offered after two years of behavioural intervention.

“There’s a lot more kids who need it. We don’t have the capacity, and it takes a long time to prepare someone for surgery,” he said of the clinic for those with a body mass index above 35 and a major complication, or a BMI above 40. A BMI is a measurement based on height and weight, and obesity is defined as a BMI at or above the 95th percentile for those of the same age and sex.

“This is about people with life-threatening, life-altering medical conditions that we really haven’t had in the past,” Erdstein said. “If the medical community didn’t have the tools, there are lots of people out there selling snake oil. Behaviour and lifestyle interventions form the core of what we do but most of the evidence shows that the result of that, even with intensive interventions, is not very big.”

He said a 15-year-old who weighs 400 pounds could, after about six months of medical support, lose 20 to 40 pounds, but that’s not a significant enough difference compared with surgery, which could result in a loss of half that weight. A variety of surgeries is available, some requiring adherence to strict rules, such as limiting portions and avoiding carbonated beverages, but the intervention is “unparalleled” in improving overall health, Erdstein said.

A lot of education goes into preparing kids for surgery, he noted. “You have to be very careful about what you eat and the timing of what you eat. So it’s it’s a big thing. You are making a commitment to vitamin supplementation for the rest of your life.”

Dr. Tom Warshawski, a pediatrician and chair of the Childhood Obesity Foundation, said the American recommendations for medication and surgery are “reasonable” for Canada but the primary intervention beyond new guidelines would be a policy shift to restrict marketing of unhealthy food and beverages to children.

“We know, without a doubt, that a major driver for the epidemic of unhealthy weight worldwide is the consumption of ultra-processed foods. And a big driver of kids’ consumption, why they are often lured to these foods, is marketing.”

Warshawski said it’s time that legislation in Quebec prohibiting commercial advertising directed at children under 13 be extended to the rest of Canada as obesity-related health-care costs rise, most recently due to more screen time and less physical activity during the pandemic.

—Camille Bains, The Canadian Press