Teen and Childhood Obesity

Sydney is an 17 year old Caucasian young woman who at the age of 16 weighed 312 pounds (BMI = 49 kg/m2). At the time of her initial assessment, she was 123% over her ideal body weight, and suffered from type 2 diabetes mellitus, high blood pressure, hypertriglyceridemia, acne and irregular menstrual periods (polycystic ovary syndrome or PCOS), and fatty liver disease (non alcoholic steatohepatitis). She had attempted to lose weight on her own, and had also participated in prolonged physician-supervised attempts organized within her endocrinologist?s office. She managed to lose 20 pounds but was not able to maintain this weight loss.

Based on her worsening obesity-related health problems, her inadequate weight loss with dietary and behavioral attempts available to her, she was referred by her endocrinologist to the Surgical Weight Loss Program for Teens at Cincinnati Children?s Hospital for consideration for weight loss (bariatric) surgery. During this assessment, she was also found to suffer from obstructive sleep apnea syndrome and had a very high insulin level of 67 micro International Units per deciliter. After careful evaluation by the comprehensive weight management team and considerable discussion about the risks and benefits of bariatric surgery, Sydney and her parents were ready to embark on a surgical solution to her weight problem. The decision was made to offer Sydney a laparoscopic gastric bypass.

The laparoscopic gastric bypass was uneventful, and she was discharged on 4 days after the operation which is fairly typical for teenagers. Her diabetes medicine (glucophage) was discontinued after the operation, since her blood glucose values had become normal! By 3 weeks after the operation, her weight had decreased by 22 pounds to 290 pounds. She was eating 4 meals per day consisting of 6-ounce protein drinks and other high protein soft foods for a total of 62 grams of protein intake per day. Her average caloric intake was estimated at 485 calories per day (less than 25% of her intake before operation), and she was not hungry!. She was taking 40-62 oz of sugar-free clear liquids per day as well, had no pain or difficulty swallowing, and was pleased with her progess

By her 3 month follow-up, her weight had decreased to 225 pounds (13% loss of excess body weight) and her BMI was 35.1. She was consuming 99 grams of protein per day and her daily caloric intake was estimated at 770 calories based on an average intake over a 4-day period. Fluid intake was 72 oz per day and she taking all vitamins and minerals without trouble. She was enjoying her ability to be physically active, and her activities included dancing three times per week, biking for 30 minutes 2-3 times per week, using weight resistance machines 2-3 times per week for her legs and arms, and doing calisthenics (i.e. 250 sit-ups 3 times per week). Her insulin level had fallen by 50% and her fasting blood glucose remained normal, so Sydney?s diabetes was essentially a thing of the past!

By 12 months following her surgery, she weighed 171 pounds for a total weight loss of 141 pounds (81% loss of excess body weight). From a nutritional standpoint her blood work showed no problems (her laboratory values at baseline and one year follow-up are shown in the table below). Although her hemoglobin was trending downward, it was still within the normal range, and normal ferritin and iron levels reassured everyone that her total body iron stores were adequate. Her stable albumin reassured us that her protein intake was adequate and her lean body mass (muscle mass) had been maintained through the period of drastic weight loss. Of course, the period of drastic weight loss is a time during which she was primarily consuming her own fat stores for energy. Indeed, her body composition analysis at 12 months following the operation demonstrated only 31% body fat, compared to 53% initially. In essence, her surgical procedure coupled with a very good dietary intake after the operation had resulted in a reduction of her initial body fat mass from 163 pounds to 53 pounds (a fat loss of 110 pounds) and a reduction in lean mass from 147 pounds to 117 pounds (a lean mass loss of 30 pounds). This ratio of fat loss to lean loss is typical for what we have seen in dozens of adolescents who have undergone gastric bypass. It is also consistent with the fact that some lean mass is required to support fat mass, and when fat mass is lost, less lean mass is required.

At her 12-month follow up visit, Sydney said that she was tolerating most foods well and eating 6 small meals a day with food volume at one cup per meal. Results of a 24-hour dietary recall indicated that daily caloric intake had increased to 1954 calories; protein intake was 92 grams and her percent of calories from fat was 43%. She continued to maintain a high level of physical activity, which has helped to compensate for this higher level of caloric intake. However there was some concern that this shift in her pattern of eating with an emphasis on high-fat foods and limited intake of fruit, vegetables and whole grains may eventually lead to weight gain in the future. When Sydney met with the dietitian, emphasis was placed on selecting high protein foods and starches that were lower in fat and she was encouraged to eat more fruit, vegetables and whole grains. So despite the limited volume of food that she was eating at any one time, her pattern of frequent high-fat meals needed to be addressed. Though this surgical tool had successfully limited the quantity of food that can be consumed at any one time, it was now her food choices and determination (e.g. goal setting, self-monitoring) that were needed for her to establish a healthier eating pattern that will sustain her weight loss.

Therefore this case demonstrates that with the surgical and dietary interventions simultaneously applied, Sydney has been prepared to enter into adulthood far more healthy overall than she was in her late adolescent years. It is our firm belief that yearly monitoring by her weight loss surgery team will be essential for long-term success.

Table: Lab values for case report (normal reference ranges provided in first column that are appropriate for age and gender; ND = not done).

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This information has been provided by Dr. Thomas Inge, Surgical Director of the Surgical Weight Loss Program for Teens at Cincinnati Children?s Hospital Medical Center, a national leader in the pediatric weight loss surgery field. Dr. Inge also serves as the chairman of Teen-LABS, the largest scientific study to date designed to learn more about the risks and benefits of surgery for teenage obesity. Click here to learn more about this study.