Nicole Peña Sahdala, MD, internist, gastroenterologist specialist in bariatric endoscopy, ABIM certified, discusses the rise in bariatric surgery among youth, and why other forms of care, such as lifestyle changes and education, are essential before any surgery is performed.
Transcript (edited for clarity):
Hi and thank you so much for joining us. I'm Joshua Fitch of Contemporary Pediatrics®.
Nicole Peña Sahdala, MD:
Hi, I'm Dr. Nicole Peña Sahdala. I'm a US-trained gastroenterologist with a specialty in endoscopic geriatrics.
Thank you so much for taking the time. Today we're discussing bariatric surgery among obese adolescents. First, what trends are currently being observed regarding bariatric surgery in adolescents, and how does it compare to trends seen in adults?
So with adolescent teenagers, and now we see adolescent medicine going all the way from 12 years old to maybe 19 or 20 [years old], we usually try to be less aggressive at the beginning, because they're going through so many changes in their lives. They're trying to become adults, they're going through identity crisis, [so] we don't want to be as aggressive maybe as an adult who has been obese for 20 or 30 years is tried everything. So with adolescent medicine, we want to be able to offer them the appropriate care, which in their case is even more integral. You need a psychology approach, you actually need the parents to go to the psychologist as well, you need nutrition, make sure they change the dietary habits and also their physical activity. We are seeing more and more surgery for obese adolescent patients, because we're just seeing more of those patients. Unfortunately, even though we now have some FDA-approved medications, one, some are very costly, and not everybody can afford these medications, and two, they don't necessarily work for every single adolescent obese patient that we have out there.
Dr. Peña with an increasing trend in some of these surgeries, like you mentioned, what are some of the most common surgeries among this patient population that we're now seeing an increase of?
Surgery per se, I think the most common one will definitely be the gastric sleeve. In adolescence, we try to shy away from a bypass surgery, just because it's going to cause malabsorption and these adolescents are trying to increase their nutrition, and their bodies are growing and they're changing. So we shy away from bypass and we go on to a gastric sleeve. Now usually these surgeries are only for adolescent patients who have a body mass index (BMI) of 35 or over with some type of medical condition, or their BMI is above 40. That's when we start considering this. Again, it's usually not our first option, try to go through dietary changes and lifestyle modifications, we try to educate them, we try to change everything around in their homes. We also, more and more, are seeing adolescent patients getting balloons intragastric balloons because they are less invasive than a gastric sleeve, which is a surgery, this is something that is foreign material goes into your stomach, it gets filled, it causes some occupying space, so the patients feel satiety with less food, and that kind of jumpstarts the weight loss. So in that aspect, I think we're going to see a trend of these two increasing, we also have in the bariatric endoscopy world, what's the endoscopic suturing, which is basically suturing through the mouth, the stomach and reducing its size. That can actually be something helpful for an adolescent patient, who you don't have to really do something too aggressive, because you want to get them when they're still very fresh, and you can change help them change the rest of their lives. If you learn something, when you're 12, 13, or 14, it's going to impact the rest of your life vs if you try to learn this when you're 50 years old, might be a little harder. So definitely education, nutrition, help with a good psychologist. I think that's the keystone, and then moving on forward, I think the least invasive would be a balloon, and then an endoscopic gastroplasty, which is an endoscopic procedure, and then it would be the gastric sleeve. But unfortunately, because we're seeing more patients with obesity at a younger age, I think we're going to see a trending number of all of these procedures being performed more in these patients.
You mentioned the at home environment, nutrition, lessons learned. At what point is the next step taken to one of these surgeries? Is there a kind of a set threshold that health care providers deem in a visit or what is the threshold where we take a step away from those environmental aspects, so to speak, and go on to the surgery?
I think it's a case-by-case decision that you make. Again, at least in my practice, we try to be not as aggressive in the beginning in the sense of not offering them balloons or surgeries, but trying to be more supportive with the whole environment. Now, when we're talking about adolescent medicine, it's very easy to talk to an adult and say, 'Hey, you have to eat more fruits and veggies.' But 12-year-olds, 13-year-olds, 16-year-olds aren't the ones shopping at home, right? So you have to get their families involved. In some of these patients, they have families where both parents work, and sometimes they don't have a grocery store nearby, or they don't sell fresh produce nearby. So we have to be very aware, not only the patient, but everything that's surrounding them as well. School can be a good way to get some support with counselors, making sure that the patient isn't bullied at school, trying to get more support as to what their PE teachers say what they like to do, getting them to do more activities. Because it's not only calorie restriction, it's not only doing a lot more sports, it's trying to find the perfect fit for each patient, which might not be the same balance for every single person. Gender has a huge impact as well. Boys tend to be a little more active than girls, also your cultural background, we're seeing that Hispanics have a higher tendency of obesity at a younger age than other ethnicities. So it's a very complicated world, the whole adolescent obesity. So I think we have to do case by case now, you need a multidisciplinary team, this is not something that me as a bariatric endoscopy is going to do on their own, this is not a decision I take lightly. So I will definitely have involvement with nutrition, a psychologist, I might even have a family therapist, because some of these bad habits could be just learned at home. So everybody might have to change at home to be able to help this child. Now, if we're seeing that a 13- or 14-year-old has very bad, poorly controlled diabetes, is really making an effort and not, you know, achieving their goal, then you might want to be a little more aggressive with offering them some other alternative treatment with either medication or something like a balloon or an endoscopic gastroplasty, or maybe even a sleeve. If you see that the patient is maybe not losing the weight as quickly as they would like, but they are changing certain things, maybe you want to push off those decisions. So it's not that easy. It's not a cookie cutter, it's a case by case and individual families, and as I said, it has a lot of components in it. Not just the patient himself or herself for that matter.
Are these surgeries in the pediatric population, adolescent population, altered in any way compared to adult patients that received them? Are there even more risks being that it's an adolescent population, by default, in the younger population, compared to adults?
Statistically, in the literature, not necessarily. I think emotionally, we might need a lot more support in adolescent patients, you know, you might not understand that all of a sudden, your stomach can't hold the same amount of foods. But not necessarily, it's going to increase the risk. Obviously, if you have a patient who's diabetic and poorly controlled, he or she is going to have the same risks as an adult who has a poorly controlled diabetes. So are they altered? I wouldn't think so. Again, we're not trying to impact 6, 7, 8-year-olds, we're trying to impact adolescent teenagers. We're trying to push the surgery or anything invasive off as long as we can, as long as something is working and giving them the building blocks to be able to change, I think when the adolescent patient is chosen appropriately, so when it's somebody who knows what they're going through, the whole family is better prepared. The patient has gone through extensive psychological help and evaluation and assessments, I think it can actually be very beneficial in the correct patient population. I think if we can diagnose these patients in the appropriate way, and we know which patient would do best with maybe a dietary change or a specific type of procedure, or maybe more psychological support, etc., I think that would be very helpful because it would help us as physicians know what to offer and be able to tell the patients 'look, if we do this, this actually is going to improve your chances of having a positive outcome.' I think in the end, that's what everybody wants. The caretakers of these patients, not only the medical staff, but also the family members, we want to see these patients, you know, gain health and gain confidence through their achievement of the weight loss. With Phenomix Sciences, we'll do a specific testing that will let us know in what category these adolescent patients are going to fall. If they're going to be slow metabolizers, if they're going to be hungry brain, hunger, gut, etc. Depending on where they fall, the treatment is going to be directed towards that specific phenotype. So, if you are one phenotype, but you or your parents are thinking about something that won't work, I'm going to be able to tell you, 'Hey, that's not the best thing, let me guide you, and maybe what we need to do is change around your diet, or yeah, maybe actually surgery or a balloon is what you need to do.' I think it's going to impact adolescent medicine in a phenomenal way because we're going to actually be able to cut the guesswork out. We're going to be able to tell them exactly what needs to be done, depending on their phenotype. We've seen statistically how choosing the appropriate treatment actually increases the weight loss, which is what we want for these patients. Your phenotype isn't going to change. It's what you were born with, right? You only have to have this test done once, and we'll be able to tell you, 'yeah, this is how you're going to work and this is what's going to work for you.' So, we're going to be able to give them those building blocks and give them these tools that they're going to be able to use their entire lives, not just while they're teenagers, in their early 20s, or 30s, but their entire lives, to be able to keep that weight off. I'm sure as the company (Phenomix Sciences) grows, and we get more data, we're going to be able to tweak that information even more and add some more, subtract more. I think I'm very happy about how this test is going to actually positively influence this whole population. Because the sad truth is, we're seeing obesity in 5- and 6-year-olds and that breaks my heart because there's not much I can do for 5- or 6-year-old. How do you modify their diet? I mean, I have a 3-and-a-half-year-old, and I try to get her to eat veggies and it's really difficult. When you start talking to 12, 13, 14-year-olds, they're actually really aware and if you can tell them, 'hey, this is what's going to work for you' and if you can tell their parents and if you can help their pediatricians, because we're actually basically just in charge of one small part of the pediatric patient. But if you can go back to the pediatrician and say, 'I'm going to start this out, but can you please help me reinforce this with the nutritionist and psychologists and the pediatrician, and whoever's in charge of their obesity treatment,' then there's 4, 5, or 6 people on the same track, giving this patient the same tools to be able to achieve their goal. There are countless studies that actually show that the more interaction the patient has with their team, the more weight loss the patient has. So imagine if instead of being one person, you can bring in the nutritionist and the psychologist and now the regular pediatrician on top of their parents, imagine how much we can impact this person's life. I'm so grateful for this test, and how I think it's going to impact not only obesity in adults, because we're going to be able to impact this at a younger age, and hopefully start seeing less and less adults with obesity. So I think it's the way to go.