Childhood & Adolescent Obesity and Bariatric Surgery: What do we know?

Transcription

1 Childhood & Adolescent Obesity and Bariatric Surgery: What do we know? Jessica Gonzalez Hernandez MD Pediatric MIS Fellow Wednesday, December 7, 2016 Outline Background Prevalence Consequences of Obesity Causes Treatment options Benefits, Risks and Outcomes Types of Bariatric Surgery 1

2 Background Obesity isa major global problem Direct costs aresignificant, but particularly difficult to quantify. 1.9 to 27% of healthcare expenditure In adults, obesity is defined using the BMI > 25 kg/m 2 = overweight > 30 kg/m 2 = obesity However, in childhood, such definitions are more controversial owing to the changes in the growing child and variation in the rates of growth and development. Aligning BMIto growthpercentiles has been used to overcome this difficulty. - Odegaard K, Borg S, Persson U, et al. The Swedish cost burden of overweight and obesity evaluated with the PAR approach and a statistical modelling approach. Int J Pediatr Obes. 2008;3(Suppl. 1): Anderson lh, Martinson BC, Crain Al, et al: Health care charges associated with physical inactivity, overweight, and obesity. Prev Chronic Dis. 2005;2:9. Definition Overweight BMI 85 th to 95 th Obese BMI 95 th to 99 th Severe obesity BMI 99 th %ile BMI 1.2 x 95 th %ile = Class 2 (BMI 35 to 39.99) 2

3 12/22/16 Prevalence Estimates of the prevalence of obesity Latin America 35.8% England 18.3% in 11- to 15-year-olds United States - have tripled across two decades to reach 16.5% 20.5% of adolescents (12 to 19yrs old) are considered obese (BMI 95th %ile) in % of adolescents considered to have extreme obesity ( 99th %ile) Recent data shows that up to 80% of children affected by obesity will continue to be affected by obesity into adulthood. Bariatric surgery for children as young as 5 years old has been reported. - Rivera JA, De Cossio TG, Pedraza ls, et al: Childhood and adolescent overweight and obesity in Latin America: A systematic review. Lancet Diabetes Endocrinol 2014;2: The NHS Information Centre. Health Survey for England: child trend tables, 2011, PuB Hedley AA, Ogden cl, Johnson CL, et al: Prevalence of overweight and obesity among US children, adolescents, and adults, JAMA 2004;291:

4 Consequences of Obesity Psychosocial Most common consequences Systematic discrimination, poor selfesteem, and depression each of which can persist into adulthood Lower academic achievement, as recently observed in obese adolescents, may be related to these issues. Medical consequences Hyperlipidemia Childhood hypertension Rare at <1% but has been estimated to be 9 times more common in the obese. Type 2 Diabetes Mellitus increased by 9-fold in children over a 15- year period, at the same time when levels of overweight and obesity have increased. - Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics 1998;101: Booth LN, Tomporowski PD, Boyle JM et al: obesity impairs academic attainment in adolescence: Findings from AlSPAC, a UK cohort. Int J Obes. - Pinhas-Hamiel O, Zeitler P. The global spread of type 2 diabetes mellitus in children and adolescents. J Pediatr 2005;146: Ebbeling CB, Pawlak DB, ludwig DS: childhood obesity: Public-health crisis, common sense cure. Lancet 2002;360: Others Obstructive sleep apnea Pseudotumor cerebri Orthopedic complications Polycystic ovarian syndrome Consequences of Obesity Psychosocial Most common consequences Systematic discrimination, poor selfesteem, and depression each of which can persist into adulthood Lower academic achievement, as recently observed in obese adolescents, may be related to these issues. Medical consequences Hyperlipidemia Childhood hypertension, rare at <1% but has been estimated to be 9 times more common in the obese. Type 2 Diabetes Mellitus increased by 9-fold in children over a 15- year period, at the same time when levels of overweight and obesity have increased. - Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics 1998;101: Booth LN, Tomporowski PD, Boyle JM et al: obesity impairs academic attainment in adolescence: Findings from AlSPAC, a UK cohort. Int J Obes. - Pinhas-Hamiel O, Zeitler P. The global spread of type 2 diabetes mellitus in children and adolescents. J Pediatr 2005;146: Ebbeling CB, Pawlak DB, ludwig DS: childhood obesity: Public-health crisis, common sense cure. Lancet 2002;360: Others Obstructive sleep apnea, Pseudotumor cerebri Orthopedic complications Polycystic ovarian syndrome 4

5 Weight Bias & Bullying Weight Bias by Peers Negative attitudes begin as early as preschool. Children are teased by kids and chosen less as playmates. Stigmatization continues through high school and college, where they are viewed as self-indulgent, lazy and are excluded from social activities. Peer Victimization Overall, as many as 63% of girls and 58% of boys report peer victimization. Having excess weight predicts future peer victimization. Biasby Educators Teachers report that students affected by obesity are perceived as: Untidy More emotional Less likely to succeed at school More likely to have family problems The Obesity Action Coalition, a nonprofit dedicated to educating and advocating for those affected by obesity, provides valuable resources on weight bullying. Causes Increased access to processed and refined, high-energyfood and drink. Regular consumption of fast food high in saturated and trans fats and low in essential fiber, micronutrients, and antioxidants Children are vulnerable to food advertising even if exposure is brief, and heavy television use has been associated with higher reported junk food consumption Slight increases in calorific consumption or small reductions in energy expenditure can lead to marked body mass increases in the long term Genetic variations causing leptin resistance shown to cause an excessive appetite and early obesity in childhood. - Dixon HG, Scully Ml, Wakefield MA et al: the effects of television advertisements for junk food versus nutritious food on children s food attitudes and preferences. Soc Sci Med 2007;65: Montague Ct, Farooqi IS, Whitehead JP et al: congenital leptin deficiency is associated with severe early-onset obesity in humans. nature 1997;387:

6 12/22/16 Treatment Options 1. Dietary and Lifestyle Interventions 2. Pharmacological Interventions 3. Surgical Intervention Dietary and Lifestyle Interventions Reports on such interventions have illustrated the inevitable relapse in most patients who achieve weight loss by these methods. Up to two-thirds of patients regain more weight than was initially lost. In adolescents, modest reductions in obesity have been achieved by intensive interdisciplinary and multimodal dietary/lifestyle approaches. - Norris Sl, Zhang X, Avenell A et al: Long-term non-pharmacological weight loss interventions for adults with prediabetes. Cochrane Database Syst Rev Mann T, Tomiyama AJ, Westling e et al: Medicare s search for effective obesity treatments: diets are not the answer. Am Psychol 2007;62: Doak CM, Visscher TL, Renders CM et al: the prevention of overweight and obesity in children and adolescents: A review of interventions and programmes. Obes rev 2006;7:

7 Prevention (BMI 5 to 85 th %ile) Dietary Intake Limit consumption of sugar sweetened beverages Encourage 5-a-day fruits and vegetables Physical Activity Limit screen time to 1-2 hrs/day starting age 5 yrs No TV/computer screens in bedroom Encourage 60 min moderate to vigorous physical activity/day Eating behaviors Daily breakfast Limit restaurant eating Encourage family meals Limit portion size Stage 1: Prevention + Protocol (BMI 85 th %ile) Same as prevention (5 th to 85 th %ile), plus Monthly follow-up Target: weight maintenance with decreasingbmi as height increases If no improvement in 3 to 6 months, start a structured weight management program 7

8 Stage 2: Structured Weight Management Program (BMI 85 th %ile) Balanced macronutrient diet emphasizing low amounts of energy dense foods Structured meals Supervised active play for 60 min/day Screen time 1 hr/day Increased monitoring of screen time, physical activity, meal logs by patient, family, provider Target: Weight loss = 1 lb/month 2-11yrs or 2 lbs/week in older obese/overweight children and adolescents If no improvement in 3 to 6 months, move to Stage 3 Stage 3: Comprehensive Multidisciplinary Protocol (BMI 85 th %ile Eating and activity goals same as stage 2 Structured behavioral modification program Food and activity monitoring Setting of short-term diet and activity goals Involvement of primary care givers for children under 12yrs of age, and training of care givers for all children Target: Weight maintenance or gradual weight loss till BMI 85 th %ile not to exceed 1lb/month in children 2-5yrs or 2lbs/week in older obese children/adolescents For children unsuccessful with BMI 95 th %ile and with significant comorbidities or with BMI 99 th %ile, go to Stage 4. 8

9 Stage 4: Tertiary Care Protocol Referral to pediatric tertiary care center with expertise in pediatric obesity which operates under a designed protocol Diet and activity counseling Consideration to: Meal replacement Very low calorie diets Medication Surgery Diets #1 Balanced Hypocaloric (30-40% reduction in intake) Low fat (25-30% of calories) High complex carbohydrate (50-55% of calories) Adequate protein (20-25% of calories) Considered safe with normal growth expected #3 Low Glycemic Index (GI) 45% to 50% Carbohydrates 30% to 35% Fat Increased non-starchy vegetables, legumes, fruits, nuts Decreased bread, potatoes, rice, refined flour and sugar #2 Protein sparing modified fast Low calorie ( /day) Much water Multivitamin/mineral supplement Increased intake of low-starch vegetables Considered experimental/high risk Complications: nitrogen loss, orthostatic hypotension, cardiac arrhythmias, impaired growth, hair loss,gallstones Williams CL et al. Ann NY Acad Sci 699:207, 1993 Epstein LH et al. Am J Dis Child 147:1076,

10 Pharmacological Interventions Limited value in attempting to achieve significant and sustained weight reduction. Orlistat The only broadly available obesity drug (>12 yr) Intestinal lipase inhibitor MOA: inhibit GI fat absorption by up to 30% Modest BMI reductions kg/m 2 at best Metformin Shown to result in moderate weight and BMI reductions in overweight adolescents Reports on reductions in BMI kg/m 2 - Bogarin R, Chanoine JP: Efficacy, safety and tolerability of orlistat, a lipase inhibitor, in the treatment of adolescent weight excess. Therapy 2009;6: Rogovik Al, Chanoine JP, Goldman RD: Pharmacotherapy and weight-loss supplements for treatment of Paediatric obesity. Drugs 2010;70: Surgical Intervention The vast body of the literature relates to adult populations, in which surgery has been the most successful intervention for obesity. Achieving considerable weight loss Enabling maintenance of weight loss in the longterm Induction of remission of comorbidities Improvement in long-term mortality - Buchwald H, Avidor Y, Braunwald e et al: Bariatric surgery: A systematic review and meta-analysis. JAMA 2004;292: DeMaria EJ: Bariatric surgery for morbid obesity. N Engl J Med 2007;356: Sjostrom l, Lindroos AK, Peltonen M et al: Lifestyle, Diabetes, and Cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:

11 Bariatric Surgery First attempts 1950s Classification Restrictive (e.g. bandingprocedures) Malabsorptive (e.g. jejunoilealbypass) RYGB is to many the gold standard bariatric procedure with excellent outcomes for excess weight loss, comorbidity resolution, and eating function, with acceptable rates of morbidity and mortality. Adolescent Bariatric Surgery Currently, the most common operations being performed in children affected by severe obesity are Roux-en-Y gastric bypass Adjustable gastric banding Vertical sleeve gastrectomy The goal of bariatric surgery is to provide the most benefit possible with the lowest risk. 11

12 Benefits of Bariatric Surgery Type 2 Diabetes Long-standing disease that tends to worsen throughout time à increased risk of developing high BP, high cholesterol & liver disease Adolescents who undergo bariatric surgery can have significant improvement or complete remission of their T2DM. Obstructive Sleep Apnea Up to 22% of obese children and adolescents have obstructive sleep apnea à cause fatigue, moodiness and difficulties with paying attention and completing tasks. Obstructive sleep apnea has been shown to improve or go away after bariatric surgery. Benefits of Bariatric Surgery Non-alcoholic Fatty Liver Disease & Nonalcoholic Steatohepatitis Pseudotumor Cerebri ~38% of obese children and adolescents have fatty deposition in their livers vs 5% of normal-weight individuals, and about 9% have associated inflammation vs 1% of lean children. Condition caused by increased pressure inside the skull, and symptoms can include headache, visual changes, ringing in the ears, nausea and vomiting. Fatty deposition and inflammation may lead to fibrosis, or scarring in the liver. This has been shown to improve in adolescents who have undergone bariatric surgery. No obvious cause for this condition, but it has been associated with obesity and symptoms frequently improve several months after bariatric surgery. 12

13 Benefits of Bariatric Surgery Cardiovascular Disease Although we are still learning about risk factors for heart disease in obese children à may lead to increased risk of heart and vascular diseases in adulthood. Weight-loss from bariatric surgery has been shown to improve several risk factors in adults; however, for children and adolescents these effects would take many years to measure, and studies are still ongoing. Quality of Life Many obese children and adolescents feel that their obesity and health issues have a negative impact on their quality of life and emotional health. Several studies have shown significant improvement after weight-loss. Benefits of Bariatric Surgery Depression Obese adolescents often find themselves affected by depression as well. Adolescents who undergo weight-loss surgery often see improvement in their emotional wellbeing. Weight-loss studies suggest that adults seem to be at slightly increased risk for suicide after bariatric surgery. Adolescents with depression before surgery should be watched closely for signs of depression after surgery. Eating Disorders Binge eating and purging has been seen in some obese adolescents who desire bariatric surgery. Eating disturbances are quite serious, and outcomes following bariatric surgery in teens with eating disorders have not been studied. Because of this, bariatric surgery in these adolescents is generally discouraged unless the eating disturbance has been appropriately treated and is wellcontrolled. 13

14 Risks and Outcomes PSYCHOSOCIAL RISKS Potential negative psychosocial risks have not been well studied. However, suicide can be a risk after bariatric surgery in adults, and it is important that adolescents with preoperative depression be monitored for recurrence of depression postoperatively. NUTRITIONAL RISKS Vitamin and other nutritional deficiencies Low levels of iron, vitamin B12, vitamin D and calcium are common problems after RYGB. Calcium and vitamin D are crucial for bone development during adolescence. In order to prevent these nutritional deficiencies, all patients need to follow special dietary recommendations and take vitamin supplements after bariatric surgery. Adolescents preparing to undergo bariatric surgery are carefully assessed for their ability to follow the recommended regimens and come to scheduled appointments. AAP Guidelines Have failed > 6 months of organized attempts at weight management Have attained or nearly attained physiologic or skeletal maturity. This generally occurs at age 13 or older for girls and at age 15 or older for boys. BMI > 40, with serious obesity-related problems; or have a BMI > 50 with less severe obesity-related problems. Be committed to comprehensive medical and psychological evaluations that should occur before and after surgery Agree to avoid pregnancy for at least 1 year after surgery. Be capable of and willing to adhere to a strict bariatric surgery nutrition program following your operation. Provide informed consent to surgical treatment. Demonstrate the ability to make sound decisions. Age is not necessarily the limiting factor here. Have a supportive family environment 14

15 ASMBS Selection Criteria BMI > 35 kg/m 2 with major comorbidities such as type 2 diabetes, moderate or severe sleep apnea, pseudotumor cerebri, or severe fatty liver disease BMI > 40 kg/m 2 with other less severe co-morbidities such as high blood pressure, high cholesterol, mild or moderate sleep apnea Despite the minimum BMI criteria, many insurance companies will not cover bariatric surgical procedures for adolescents < 18 years old, or they may have different criteria or only cover a certain specific procedure. - Pratt JS, Lenders CM, Dionne EA, et al. Best practice updates for pediatric/adolescent weight loss surgery. Obes Silver Spring 2009; 17: Initial Evaluation Evaluation detailing the child s food intake, physical activity level, blood work, etc. Behavioral and lifestyle modifications Pharmacological Interventions Surgical Intervention EXPERIENCED MULTIDISCIPLINARY TEAM Qualified and experienced pediatrician Surgeon Adolescent/child psychologist Pediatric nutritionist Exercise physiologist or physical therapist Nursing support staff Patient coordinator Social worker - Lennerz BS, Wabitsch M, Lippert H et al: Bariatric surgery in adolescents and young adults Safety and effectiveness in a cohort of 345 patients. Int J obes 2014;38:

16 Informed Consent Individuals < 18 years of age cannot legally provide consent for bariatric surgery; formal consent must be provided by an adolescent s parent orguardian. complex process important to discuss in detail with the adolescent and parents/guardian the anticipated benefits and specific risks understanding of the many complex issues involved should be formally assessed as part of the consent process Frequently, the adolescent and parent have differing ideas about the effect that obesity has on their lives, and may disagree about bariatric surgery. While a child cannot consent to surgery, it is important that they are in agreement (called assent) without inappropriate influences assessing an adolescent s capacity to make an informed decision about bariatric surgery can be challenging consider the adolescent s cognitive, social and emotional development and support their independent role in the decisionmaking process - Caniano DA. Ethical issues in pediatric bariatric surgery. Semin Pediatr Surg 2009;18: Types of Bariatric Surgery Current data shows that bariatric surgery in adolescents is as safe and effective as bariatricsurgeryin adults. A number of different weight-loss procedures are performed in adults, and manyof these have also been performed in adolescents. The decision regarding which procedure is appropriate for an individual patient is a complex one that is made by the surgical team, in conjunction with the adolescent and his or her family. 16

17 Only randomized trial between lifestyle intervention and bariatric surgery (laparoscopic gastric banding) for morbid obesity It demonstrated favorable weight loss and improvements in cardiovascular risk factors, as well as improved quality of life in the surgically treated group. - O Brien PE, Sawyer SM, Laurie C, et al. Laparoscopic adjustable gastric banding in severely obese adolescents: A randomized trial. JAMA 2010;303: It includes studies involving children with 6-18 years of age and examines outcomes across RYGB, sleeve gastrectomy and adjustable gastric band. Provides good initial evidence in support of surgical intervention. Mean change in BMI at 12 months was 13.5 kg/m 2 (95% CI 15.1 to 11.9). Authors were unable to provide summary estimates for complications, but data from the currently available reports show complication rates of 22 33% for RYGB, 4.3% for SG and 10 48% for AGB. - Black JA, White B, Viner RM et al. Bariatric surgery for obese children and adolescents: A systematic review and meta-analysis. Obes Rev 2013;14:

18 Included subjects aged 5 21 years Offered insight into outcomes following SG in young patients, with the vast majority of subjects experiencing resolution of OSA (91%), prediabetes (100%), T2DM (94%), prehypertension (83%), hypertension (75%), and dyslipidemia (70%). - Alqahtani Ar, Antonisamy B, Alamri H et al: laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years. Ann Surg 2012;256: A longitudinal observation of 76 adolescents aged mean 16.8 (range 14 18) years for a mean duration of 11 (range 2 23) years Revealed that prolonged weight loss was achievable, with 78% excess weight loss at longest follow-up. Comorbidity resolution was impressive, with 100% resolution of diabetes and dyslipidemia and >80% resolution of hypertension. - Papadia FS, Adami GF, Marinari GM et al: Bariatric surgery in adolescents: A long-term follow-up study. Surg Obes Rel Dis 2007;3:

19 Roux-n-Y Gastric Bypass In the US, first performed in adults in the 1960s and in adolescentsin the 1970s. Provides lasting weight-loss in adolescents, with complication rates similar to those seen in adults. Severe complications, although rare, have been reported. It is very important that adolescents undergoing this or any bariatric procedure attend all follow-up visits with their bariatric health care team, and that this follow-up should be long-term (at least several years). Laparoscopic Adjustable Gastric Banding Not yet approved by FDA in children under the age of 18 years some institutions perform this procedure as off-label use of the banding device Studies of adolescents demonstrate it to be an effective and safe procedure, and associated with fewer nutritional complications than RYGB. Weight-loss and improvement in obesity-related co-morbidities appear similar to those seen in adults, though long-term data has not yet been published. Most complications are device-related and not life threatening. 19

20 Sleeve Gastrectomy Performed less often in adolescents than the RYGB or the LAGB, but has been performed in increasing numbers throughout the past few years. Long term data is not yet available, but preliminary results from ongoing studies of adolescents undergoing VSG demonstrate excellent weight reduction reversal of co-morbidities complication rates similar to those of the adult population Comparison Type of Surgery RY Gastric Bypass Gastric Banding Sleeve Gastrectomy Longevity Since 1970s Since approved as a 1ary procedure Weight loss 55-70% 40% 50-60% Reversible Yes Yes No Average OR time 1-3 hours 1-2 hours 1-2 hours Hospital stay Mortality Risk 0.4% 0.1% 0.1% Pros Rapid and more total weight loss Most commonly studied procedure Rapid improvement or resolution of weight related comorbidities 85% remission of diabetes Cons Potential for nutritional and vitamin deficiency Dumping syndrome Least invasive No stomach stapling or intestinal rerouting Fast recovery time Weight loss is modest in 20% of patients Foreign body No device is implanted Simpler than gastric bypass No intestinal rerouting Acid reflux may develop later Not reversible Long term data is limited 20

21 12/22/16 Genetic Syndromes A number of endocrine and other genetic syndromes can cause obesity in the adolescent commonest being Prader Willi syndrome (PWS) these must be considered in any assessment program for surgical obesity intervention, although reports of successful surgery in PWS have begun to emerge - Singhal v, Schwenk WF, Kumar S: evaluation and management of childhood and adolescent obesity. Mayo clin Proc 2007;82: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) MBSAQIP ACS + ASMBS = combined their national bariatric surgery accreditation programs into a single unified program to achieve one national accreditation standard for bariatric surgery centers works to advance safe, high-quality care for bariatric surgical patients through the accreditation of bariatric surgical centers A bariatric surgical center achieves accreditation following a rigorous review process during which it proves that it can maintain certain physical resources, human resources, and standards of practice. All accredited centers report their outcomes to the MBSAQIP database. 21

22 CENTER OF EXCELLENCE in Pediatric and Adolescent Metabolic & Bariatric Surgery 1. Institutional Commitment to Excellence 2. Surgical Experience 3. Program Directors & Interdisciplinary Team 4. Consultative Services 5. Equipment and Instruments 6. Surgeon Dedication & Qualified Call Coverage 7. Clinical Pathways & Standardized Operating Procedures 8. Weight Management, Surgical & Support Staff 9. Patient Support Groups 10. Long-term Patient Follow-up & Outcomes Data CENTER OF EXCELLENCE in Pediatric and Adolescent Metabolic & Bariatric Surgery 1. Institutional Commitment to Excellence 2. Surgical Experience 3. Program Directors & Interdisciplinary Team 4. The Consultative applicant maintains Servicestwo program Co-Directors 5. for the Equipment program, anda Instruments Pediatrician Medical Director 6. and Surgeon a Surgical Dedication Director, & that Qualified both Call havecoverage program 7. oversight. Clinical Pathways & Standardized Operating Procedures 8. Weight Management, Surgical & Support Staff The Surgical Director must be designated, or in the 9. Patient Support Groups process of becoming designated, as a Center 10. and/or Long-term Surgeon Patient of Excellence Follow-up in & Outcomes Metabolic Data and Bariatric Surgery. 22

23 CENTER OF EXCELLENCE in Pediatric and Adolescent Metabolic & Bariatric Surgery 1. Institutional Commitment to Excellence 2. Surgical Experience 3. Program Directors & Interdisciplinary Team 4. Consultative Services 5. On-site Equipment within 30 min andof Instruments request: Endoscopist, IR, Critical 6. Care Surgeon physician Dedication & Qualified Call Coverage 7. Clinical Pathways & Standardized Operating Cardiologist Procedures Nutritionist/dietitian 8. Psychiatrist/mental Weight Management, health provider Surgical & Support Staff 9. Pulmonologist Patient Support Groups 10. Endocrinologist Long-term Patient Follow-up & Outcomes Data Infectious disease specialist Nursing program manager CENTER OF EXCELLENCE in Pediatric and Adolescent Metabolic & Bariatric Surgery 1. - Anesthesia Institutional & Perioperative Commitment care, including to monitoring Excellence & airway management 2. - DVT Surgical preventionexperience 3. - Identification Program& evaluation Directors of & early Interdisciplinary signs of complications Team 4. - Preoperative Consultative multidisciplinary Services evaluation, education, preparation, admission workup/evaluation & informed consent 5. - Preoperative, Equipment postoperative and Instruments & long-term nutrition regimen 6. - Pain Surgeon management Dedication & Qualified Call Coverage 7. Clinical Pathways & Standardized Operating Procedures 8. Weight Management, Surgical & Support Staff 9. Patient Support Groups 10. Long-term Patient Follow-up & Outcomes Data 23

24 BENEFITS of SRC Accreditation Short & Long-Term Career Plans UT Southwestern Dallas, TX Bariatric Surgery Fellowship ??? Pediatric Surgery Fellowship Pediatric Bariatric Surgeon EXPERIENCED MULTIDISCIPLINARY TEAM Qualified & experienced pediatrician/internist Adult Bariatric Surgeon Adolescent/child & Adult psychologist Pediatric & Adult nutritionist Exercise physiologist or physical therapist Nursing support staff Patient coordinator Social worker Bariatric Surgery Center of Excellence for Families Multidisciplinary approach Early intervention Better adolescent perioperative care Improve long-term weight loss Prevent obesity in younger generations 24