Weight Loss Surgery and Kids Part 1

Laparoscopic sleeve gastrectomy in children younger than 14 years: refuting the concerns - Alqahtani et al.

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This series is part of the work I did with Weight Inclusive Nutrition and Dietetics (WIND) to create a comprehensive response to the disastrous American Academy of Pediatrics (AAP) guidelines for higher-weight children. I was part of the team that analyzed the research that, the AAP claims, supports their recommendations, and I’ll be publishing my breakdowns here as well.

You can find the other studies here:
Part 2
Part 3
Part 4

Today’s study is Laparoscopic sleeve gastrectomy in children younger than 14 years: refuting the concerns
Aayed Alqahtani, MD, FRCSC, FACS, Mohamed Elahmedi, MBBS, and Awadh R. Al Qahtani, MD, MSc, FRCSC

General observation:

While the AAP Guideline authors cite this study to back up their recommendations of surgery for children as young as 13, they don’t mention that it refutes all their behavioral weight loss interventions, saying “there is no effective solution for treating ob*sity and its associated comorbidities in children. Nonsurgical weight management (NSWM) programs achieve modest weight loss results at best.”

Author conflicts of interest:

The authors declare “no conflicts of interest”

Aayed Alqahtani:

Has significant personal investment (and profit potential) in the recommendations of this study:

• CEO and Owner – Innovative Care Co/New You Medical Center, Riyadh, KSA (a weight loss company)

• Professor and Consultant of Minimally Invasive and Ob*sity Surgery at College of Medicine King Saud University & King Khalid University Hospital (KKUH), Riyadh

• Chair of the Membership Committee, Saudi Arabian Society of Metabolic and Bariatric Surgery (SASMBS)

• Director and Ob*sity Chair at King Saud University

• Founder and Supervisor of King Saud University Multidisciplinary Ob*sity Clinic

• Former Director of the Bariatric Surgery Program at King Fahad Medical City

• Past President – Pan Arab Society for Metabolic & Bariatric Surgery (PASMBS)

• Immediate Past President – International Pediatric Endosurgery Group (IPEG)

• Founder and Past President Middle East Chapter International Pediatric Endosurgery Group (IPEG)

Mohamed Elahmedi

• Has based his career on this paradigm as the “Ob*sity Chair, King Saud University”

Awadh R. Al Qahtani

• Has based his career on these surgeries

Note: The parts in italics are quotes from the study. They contain weight stigma and may be triggering. You can skip them and just read my analysis.

Introduction:

The results of weight loss surgery in children and adolescents are still scarce, despite recent studies suggesting favorable short- and intermediate-term outcomes that are comparable to those in adults.7–10

First, as this surgery creates a lifelong disease state, long-term outcomes are incredibly important and their seeming lack of care about them concerns me greatly. Here are the studies they cite to support this claim:

7 – Study (Laparoscopic sleeve gastrectomy in adult and pediatric ob*se patients: a comparative study) by the same authors. It only offers a 24-month follow-up and found complications in 6% of 108 pediatric patients (defined as aged 21 years or younger.)

8 – Study (Laparoscopic sleeve gastrectomy in 108 ob*se children and adolescents aged 5 to 21 years, 2012) by the same authors of 108 pediatric patients – defined ages 5 through 21 years old. 10% of the patients failed to achieve weight loss even in the short-term. They report no adverse effects, but the vast majority of the study population was lost to follow-up (beginning: n=108, 3 months n = 88, 6 mos n = 76, 12 moss n= 41 and 24 months n = 8)

9 – Study (Bariatric surgery in monogenic and syndromic forms of ob*sity, 2014) by the same authors.

This study’s introduction also refutes the AAP’s other recommendations, saying “In all forms of ob*sity, dieting and physical activity do not result in significant weight loss and is associated with a high rate of weight regain.” This study looks specifically at the small population of children with “monogenic ob*sity” (ie – body size is due to mutation or deficiency of a single gene) and syndromic (a term used to describe higher-weight children and adults with cognitive delay, dysmorphic features, organ-specific abnormalities, hyperphagia, and/or other signs of hypothalamic dysfunction. May be inherited in either an autosomal or an X-linked pattern and can be caused by de novo genetic mutation). This isn’t extrapolatable to typical pediatric populations and, again, this study also repeatedly cites their own research and offers no long-term follow-up information.

10 – Study (Co-morbidity resolution in morbidly ob*se children and adolescents undergoing sleeve gastrectomy, 2014) by the same authors. This study had 226 total subjects, 37 of whom were 18 and older. They include three years of follow-up, but lost a significant number of subjects ( year one 4.2%, year two 7.6%, and year three 15.3%.) About 2/3 of health improvements occurred in the first 3 months (when patients had lost almost no weight) and health improvements stopped after 2 years. They claim “few complications” but they only assessed “major complications” of leak, pulmonary embolism, bleeding, reoperation, mortality,) and “minor complications” of readmission, pneumonia, wound infection, nausea and vomiting, and gastroesophageal reflux. This is far from a full list of complications and notably absent here are issues of malnutrition, especially micronutrient deficiencies and hypoglycemia which are well-known side effects in adults. There is also no data on psychological impacts, and issues with disordered eating and eating disorders.

Methods

In this study, patients who underwent surgery were “matched” with patients in the “non surgical weight management” (NSWM) program at the same hospital to compare “weight loss, complications, comorbidities, growth, and metabolic changes” It should be noted that these are both “intervention” groups and there is no control group (patients who were not subjected to any intentional weight loss methodologies,) nor was there an intervention group who were provided with weight-neutral health-supporting interventions, and thus the only conclusions that can be drawn are comparing these surgeries to interventions that the study authors themselves admit are typically unsuccessful.

Weight Change Assessment

They chose to use the International Ob*sity Task Force cut-offs, rather than the World Health Organization. While there is general agreement between the two, their choice to highlight the work of a trade group (comprised of and funded by those with a profit interest in these surgeries) rather than, for example, the WHO definition (which, while driven by a similar organization at least gives a measure of propriety) should be noted.

Preoperative Characteristics

116 were children 14 years or younger, 158 were adolescents (age, 14.01–21 years), 1:1 “control” (again, note that there is no true control group, the “control” here is just a different intervention group) of patients on NSWM was drawn from the cohort and matched for age, sex, and height z-scores at baseline. Nineteen (6.9%) patients were in the age group 5 to 8.99 years, 56 (20.4%) were in the age range 9 to 12.99, 115 (42.0%) were in the age group 13 to 16.99, and 84 (30.7%) were between 17 and 21 years of age, respectively (Table 2). (Note that this study, by its own title, seeks to refute concerns in populations 14 and younger, and only 42% of those in this study actually meet that criterion.)

Post-operative growth and height change

They offer only 5 years of follow up which does not account for the full growth stage, especially for younger adolescents. Further, they are comparing the growth and height change of kids who had surgery to those who underwent a program including food restriction and exercise which may also have impacted growth and height change. They did not compare them to a control group who were not subjected to weight loss attempts.

Discussion

Bariatric surgery remains the most effective solution for morbid ob*sity, with an estimated worldwide increase exceeding 240% between 2003 and 2011.

This ignores the near-total lack of data after 10 years and the severe paucity of even mid-range data, as well as the failure of follow-up in existing studies to (attempt to) capture physical and psychological adverse events and outcomes, as well as a lack of comparison to weight-neutral interventions.

Children are still not provided access to bariatric surgery because of concerns related to safety, efficacy, and impact on growth

Their paper fails to fully alleviate even the concerns that they investigate, beyond which they are ignoring concerns that they fail to address around the possible long-term adverse outcomes of creating a lifelong disease state in a child creating forced restriction (including long-term issues with malnutrition) as well as the psychological impact of forcing observable, atypical eating on a child, and the development of eating disorders (made more difficult to determine as this surgery purposefully creates many of the symptoms of disordered eating and eating disorders.)

Some of these concerns may be valid; however, none have been proven by evidence to date, whereas the comorbidities suffered by ob*se children in this age group continue to rise at an alarming rate

A lack of data does not justify a radical surgery on a child. Further, this fails to include that these “comorbidities” have treatments that are better researched and far less invasive and risky than surgery (including weight-neutral, health-supporting options, medications, and other non-surgical management) In populations of higher-weight youth, the discussion of these conditions as “co-morbidities” is part of a focus on “treating” the child’s size first, rather than addressing any symptomology and ignores the fact that these comorbidities may be a result of weight loss interventions (and ensuing weight cycling) as well as the experience of weight stigma among higher-weight kids.

Experience with bariatric surgery in other age groups has been successful; in adolescents, reports have confirmed that it results in safe and significant weight loss and improvement in major comorbidities.8,10,32

8 – Study (Laparoscopic sleeve gastrectomy in 108 ob*se children and adolescents aged 5 to 21 years, 2012) by the same authors of 108 “pediatric” patients – defined ages 5 through 21 years old.) 10% of the patients failed to achieve weight loss even in the short-term. They report no adverse effects, but the vast majority of the study population was lost to follow up (beginning: n=108, 3 months (n = 88), 6 mos (n = 76), 12 (n = 41), and 24 (n = 8))

10 – Study (Co-morbidity resolution in morbidly ob*se children and adolescents undergoing sleeve gastrectomy, 2014) by the same authors. This study had 226 total subjects, 37 were 18 and older. They include three years of follow up, but lost a significant number of subjects ( year 1 4.2%, y2 7.6%, and y3 15.3%.) About 2/3 of health improvements occurred in the first 3 months and Health improvements stopped after 2 years. They claim “few complications” but the study is behind a paywall and it is unclear what they actually assessed in terms of complications. Also, three years is still within what is considered the “honeymoon” period in adult populations.

32 – Study (Laparoscopic adjustable gastric banding in adolescent: safety and efficacy, 2007) by one of the same authors) that looks at gastric banding which the AAP Guidelines explain has fallen out of favor due to limited efficacy and high complication rates.

there are numerous concerns pertaining to the use of medications in treating ob*sity-associated comorbidities suffered by children. For instance, there are increased risks of toxicity and reduced therapeutic effect because of the limited understanding of drug pharmacokinetics in ob*se children.46 Furthermore, the significant drug noncompliance observed in pediatric patients leads to dosing errors and omissions, improper intervals, and premature discontinuation, and strategies to improve pediatric compliance to medication did not lead to significant results.

Here again, the study cited by the authors of the AAP guidelines contravenes their recommendations for pharmacotherapy in pediatric populations. Also, these surgeries require significant “compliance” in terms of amount and type of food eaten and nutritional supplements and, unlike with weight loss drugs, lack of compliance can be health and life-threatening, so the same legitimate criticisms by which the authors dismiss pharmacotherapy for children are also an indictment again the surgeries they recommend.

The speculation that LSG might cause neurocognitive impairment in ob*se children is a concern that warrants further evaluation

It is concerning that this was not reason enough for the authors and the AAP to delay a wide-scale recommendation of these surgeries to children.

Given the afore-stated evidence and the potentially life-threatening comorbidities that may reach poorly reversible stages, we believe that postponing bariatric surgery does not favor children’s health and may endanger their lives

Note here the use of “potentially” and the repeated use of “may” as well as the total lack of long-term outcome data and the ignored existence of far less risky interventions for these co-morbidities in order to recommend a surgery that takes a child’s healthy, perfectly functioning digestive system and surgically creates a lifelong disease state. In fact, if this state happens to a child because of injury or disease it is considered a tragedy. For higher-weight children, they are trying to call it “healthcare.”

Conclusions

This study answers most of the current concerns related to the safety and effect of LSG on children younger than 14 years. It demonstrates that growth is, in fact, improved following LSG, weight loss is significant and sustained, and comorbidities are resolved

This is a gross overstatement of their findings. It should also be noted that they failed to include a “limitations” section which should include, at the very least, the very small sample size, the relatively short-term follow up of 5 years, and the massive loss during the follow-up period, the failure to have a control group or a weight-neutral intervention group, the failure to capture physical and psychological adverse events.  This study in no way supports a recommendation of weight loss surgery for children.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.