Allina Kids and Teens Weight Management

Transcription

1 Allina Kids and Teens Weight Management MPPOCC Jan 2018 Bradley C. Linden, M.D., FACS, FAAP, FASMBS Diplomate, American Board of Obesity Medicine Pediatric Surgical Associates Allina Health Kids and Teens Weight Management Program Minneapolis, MN

2 Disclosures Off label use of adjustable gastric bands will be discussed No financial disclosures

3 It is time to change how we think about this disease

4 The effects of severe obesity are deadly and CUMULATIVE

5 Paradigm shift time

6 OK This is one time where kids actually ARE small adults

7 The difference: Children have a short window of plasticity

8 THE CLOCK IS TICKING Only a child for a short time Cumulative effects Shortens life Severe effects on QOL Adverse effect on productivity

9 Delay in treatment is injurious

10 Age continuum of the disease of obesity

11 Increasing prevalence of severe obesity Skinner et al JAMA Pediatrics 2014

12 Obesity prevalence is increasing Girls Boys Freedman, D. S., Obesity - United States, MMWR CDC, (2011) 60 Suppl, 73-77

13 Childhood Obesity - Emotions Medical community Anxiety Public Anxiety? Ignorance is bliss?

14 An OPERATION for obesity in CHILDREN? Medical community Anxiety!!! Hope? Excitement? Public Anxiety? Ignorance is bliss?

15 You want to do WHAT to a kid???

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21 Sidney Farber, MD

22 An OPERATION for obesity in CHILDREN? Remember what you thought about BMT?

23 Childhood cancer Do we say: Oh, my, having such a big dangerous operation to remove a Wilm tumor (for cure) is so dangerous, and we wouldn t want potential renal insufficiency in adult life So we wont resect the tumor until the child reaches adulthood By then, of course, cure is out of reach

24 Complications of Obesity Severe obesity and related comorbidities worsen over time

25 Severe obesity worsens over time Princeton Cohort BMI > 40 kg/m2 BMI Baseline 1yr 2yr 3yr 4yr 5yr Year of F/U Slope +1/yr p< % Remain Morbidly Obese Dolan RO1 unpublished

26 Type 2 diabetes worsens 51 graduates of childhood diabetes clinic Age 17 at T2DM diagnosis In 2002, graduates were age yrs OUTCOME?

27 Tragedies Ahead? Death 2 sudden deaths on dialysis (age 25, 31) 2 traumatic deaths 3 deaths from unrelated illness Morbidity 3 others alive on dialysis 1 blind at age 26 1 with amputation 67% with severely high HbA1C

28 Tragedies Ahead? Pregnancy outcome 56 pregnancies 35 live births

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30 Complications of obesity worsen over time Elevated adolescent BMI is a risk factor that is independent of adult BMI Elevated BMI in adolescence increases risk for CHD in adulthood by 12% per increase of 1 unit of BMI Tirosh, A. NEJM 2011 vol. 364 (14) pp

31 Surgical Guidelines Surgical guidelines have been debated and refined over the years

32 March 1991 Gastrointestinal Surgery for Severe Obesity National Institutes of Health Consensus Development Conference Statement Bariatric operations have complications Decision making requires risk-benefit assessment Patients with BMI 40 are potential candidates for surgery if they strongly desire substantial weight loss, because obesity severely impairs QOL If BMI surgery if high-risk conditions: severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, severe diabetes mellitus, obesity-induced physical problems interfering with lifestyle Am J Clin Nutr 1992:55:615S-9S

33 March 1991 Gastrointestinal Surgery for Severe Obesity National Institutes of Health Consensus Development Conference Statement Children and adolescents have not been sufficiently studied to allow a recommendation for surgery owhen pediatric patients are developing Obstructive Sleep Apnea Syndrome, Type II DM, cirrhosis, hypertension, how much study is needed? owhen and how do we initiate effective treatment? Am J Clin Nutr 1992:55:615S-9S

34 Pediatrics 2004 vol. 114 (1) pp

35 BMI < 40, non-surgical management Surgery if BMI 40 with Type 2 DM, Obstructive sleep apnea, Pseudotumor cerebri Surgery if BMI 50 with other clinically significant comorbid conditions Dyslipidemia Hypertension Weight related psychosocial distress; Impaired ADL NASH Pediatrics 2004;114:217-23

36 Only when unsuccessful with 6 months non-surgical weight management When extremely obese (BMI greater than 40) When adult height reached (usually 13 or older for girls and 15 or older for boys), and Have serious weight-related health problems, such as type 2 diabetes, sleep apnea, heart disease, or significant functional or psychosocial impairment Patients should be referred to specialized adolescent bariatric surgery centers with a team of experts qualified to meet their unique needs Pediatrics 2004;114:217-23

37 obesity VOLUME 17 NUMBER 5 MAY 2009 Obesity (2009) 17,

38 Safety of Bariatric Interventions Adolescent bariatric surgery may be safer than adult surgery

39 Perioperative outcomes of bariatric surgery in adolescents compared with adults at academic medical centers N=55,501 Bariatric operations (UHC, ) N=55,192 Adults N=309 (<1%) Adolescents years old Varela et.al. Surg Obes Relat Dis :

40 Rate (%) 1) LABS Reporting Group N Engl J Med 2009;361: ) DeMaria et al Surg Obes and Relat Dis 2010 ;6: )DeMaria et al Ann Surg. 2007;246(4): )Buchwald et al JAMA. 2004;292: ) AHRQ, Healthcare Cost and Utilization Project (HCUP), accessed 01/13/10, 2007 data DRG 288 6) Ibid 2007 data DRG s 161 and162 7 )Ibid 2007 data DRG s 166 and167 8) Ibid 2007 data DRG s 180 and181 9) Ibid 2007 data DRG s 493 and ) Ibid 2007 data DRG s 547 and ) Ibid 2007 data DRG s 557 and Ibid 2007 data DRG 577 Safety of Surgery 2 Mortality Rate

41 Morbidity of bariatric surgery at academic centers ( ) Procedure related (%) -Wound infection -Reopening wound -Perforation/laceration -Bleeding/hematoma -GI hemorrhage/ulcer Non-procedure related (%) -Pneumonia -DVT/PE -Cardiac -Pulmonary Adults Adolescents Varela et.al. Surg Obes Relat Dis :

42 Overall 30-day morbidity of Bariatric Surgery at academic centers ( ) % * Varela et.al. Surg Obes Relat Dis : * = p < 0.05 vs. ADOL

43 Types of Bariatric Procedures Operations

44 Laparoscopic adjustable gastric band DeMaria E. N Engl J Med 2007;356:

45 Laparoscopic Roux-en-Y gastric bypass DeMaria E. N Engl J Med 2007;356:

46 Laparoscopic Sleeve Gastrectomy

47 Ann Surg Aug;256(2):266-73

48 Ann Surg Aug;256(2):266-73

49 JAMA Pediatrics January 2014 Volume 168, Number 1

50 Teen LABS JAMA Pediatrics January 2014 Volume 168, Number 1

51 Teen LABS (Longitudinal Assessment of Bariatric Surgery) JAMA Pediatrics January 2014 Volume 168, Number 1

52 Teen LABS (Longitudinal Assessment of Bariatric Surgery) JAMA Pediatrics January 2014 Volume 168, Number 1

53 Teen LABS (Longitudinal Assessment of Bariatric Surgery) JAMA Pediatrics January 2014 Volume 168, Number 1

54 Inge T, Courcoulas A, Jenkins T, et al. Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. The New England Journal of Medicine 2016;374(2):

55 Inge T, Courcoulas A, Jenkins T, et al. Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. The New England Journal of Medicine 2016;374(2):

56 Health outcomes Inge T, Courcoulas A, Jenkins T, et al. Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. The New England Journal of Medicine 2016;374(2):

57 Long-term Complications of obesity There appears to be risk associated with delaying operation

58 Inge et.al. J.Peds October year after bypass

59 Increasing BMI = increased risk Michalsky M, Inge T, Simmons M, et al. Cardiovascular Risk Factors in Severely Obese Adolescents: The Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Study. JAMA Pediatrics 2015;169(5):

60 Cardiopulmonary Benefits Sleep Apnea Left Ventricular Hypertrophy

61 Sleep apnea is prevalent in morbidly obese adolescents P< subjects (23F), mean age 17, mean BMI underwent PSG 55% had OSA 75% of those with BMI >60 Kalra M. Obesity Research 2005;13:1175

62 Sleep apnea largely resolves after bariatric surgery Baseline Post Op Weight (kg) BMI OSAS 10/10 1/10 Median AHI Kalra M. Obesity Research 2005;13:

63 Left Ventricular Hypertrophy (LVH) is an independent predictor of adult CV morbidity & mortality Indexed LV Mass LVM > 51g/m 2.7 carries up to 4 fold greater risk in adults LVM gm/m 2.7 Mean = 54 g/m 2.7 * Mean = 42 g/m 2.7 Willens, H.J., et al, Am J Cardiol 2005 vol. 95 (12) pp

64 100% 80% 60% 40% 20% Abnormal LV geometry REVERSES in ADOLESCENTS 0% CLVH Eccentric ELVH Concentric CR Normal Concentric LVH LVH Remodeling Pre-op Post-op Ippisch, et al, J Am Coll Cardiology 2008;51; Overall geometry significantly improved (p<0.0001)

65 Possible Argument for earlier bariatric intervention ADULTS Improvements in indexed LVM But no significant change in posterior wall and septal thicknesses versus ADOLESCENTS improvements in indexed LVM AND remodeling of the posterior wall and septal thicknesses Adolescent myocardium may be easier to remodel than adult myocardium Am J Cardiol. Jun ;95(12): Ippisch, et al, J Am Coll Cardiology 2008;51;

66 Psychosocial Benefits Depression IMPROVES Quality of Life IMPROVES

67 Cincinnati Adolescent psychosocial outcomes, n=31 Pre 1yr p BMI 64 ± ± 8 <0.001 Beck Depression 15 ± ± 5.6 <0.001 Peds QL 54 ± ± 12 <0.001 IWQOL kids 59 ± ± 15 <0.001 Zeller et.al. Obesity 2009

68 Conclusions Surgical weight loss is an effective treatment for adolescent morbid obesity Most complications of obesity are improved or resolve with surgical weight loss Knowing what we know now the ethics have become clear

69 The question is no longer whether it is, or isn t ethical for children to have bariatric surgery It is unethical NOT to offer this therapy to those in need

70 Conclusions Develop a sense of urgency Delay is injurious

71 So, I have a patient suffering from severe obesity disease What do I do?

72 Stage One: Prevention Plus Usually Primary Care provider Dietary Habits: Behavior Counseling: Breakfast daily, limit meals outside the home, family meals 5-6 days per week, Allow child to self regulate Goals: Weight maintenance with growth and decreasing BMI Monthly follow up- no improvement 3-6 months advance to Stage Two

73 Stage Two: Structured Weight Management Program Primary care provider with appropriate training Dietary habits and physical activity: develop action plan for nutrient dense foods, structured meal time and snacks, Supervised activity 60 minutes per day, screen time one hour or less. Goal: decreasing BMI with age, weight loss should not exceed 1 pound per month Monthly follow up: no improvement advance to Stage Three

74 Stage 3 and 4 weight management After 6 months of stage 2 therapy (Structured weight management) Stage 3 Comprehensive multidisciplinary intervention Stage 4 - Tertiary care Stage 3 + medications and/or operations

75 Evaluation includes Surgical and medical evaluation Identification and treatment of comorbidities Nutritional evaluation and education Exercise therapy 2hr/wk x 12 weeks With dietary coaching Psychological assessment and referral to maintenance therapy prn Social/family evaluation

76 Food insecurity

77 Focus on developmentally appropriate care

78 So, I have a patient that I suspect might benefit from multidisciplinary weight management What do I do?

79 Contact Phone Number Call (763)

80 Evaluation includes Surgical and medical evaluation Identification and treatment of comorbidities Nutritional evaluation and education Exercise therapy 2hr/wk x 12 weeks With dietary coaching Psychological assessment and referral to maintenance therapy prn Social/family evaluation

81 Kids, Teens & Young Adults Weight Management Susan Johnson, RN PHN MS Nurse Clinician Abbott Northwestern Hospital Jenny Reemtsma, RD, LD Bariatric Dietitian Abbott Northwestern Hospital

82 Kids, Teens & Young Adults Weight Management Jessica M. Jacklitch, PT, MPT Physical Therapist Courage Kenny Rehabilitation Institute Erin Vesey, DPT Physical Therapist Courage Kenny Rehabilitation Institute

83 Kids, Teens & Young Adults Weight Management Rachelle Hansen, Ph.D., LP Allina Health

84 Kids, Teens & Young Adults Weight Management Stacy Erstad, PA-C, MPAS

85 Kids, Teens & Young Adults Weight Management Stephanie Stanton, MD Medical Bariatrician Allina Health Weight Management Program United and Abbott Northwestern Hospitals Bradley Linden, MD Medical Director Allina Kids and Teens Weight Management Allina Health Weight Management Program

86 Kids, Teens & Young Adults Weight Management Deborah Vanderhall, RN Manager, Bariatric & Weight Loss Operations and Clinical Services Chuck Svendsen, MD Medical Director Bariatric Clinical Service Line

87 10 Pediatric Surgeons 6 Pediatric Urologists Programs Trauma Mpls, St. Paul, Duluth Fetal diagnostics and intervention Safety and outcomes Offices: Minneapolis Minnetonka Burnsville Woodbury Maple Grove Sartell Duluth St. Cloud St. Paul

88 Contact Phone Number Call (763)

89 Thank you

90 The burden of obesity Relation between mortality and BMI. Ann Intern Med Dec;103(6 ( Pt 2)):1024-9

91 The burden of obesity Table 2. Cost of Obesity in the US Disease Diabetes mellitus CHD Osteoarthritis Hypertension Gallbladder disease Colon cancer Breast cancer Endometrial cancer Direct Cost ($US billions) Total 51.6 Cost of obesity in the US. Obes Res 6:97 106, 1998

92 Obesity prevalence is increasing Skinner JAMA Pediatrics June 2014 Volume 168, Number 6