Preparation of a severely obese adolescent for significant and long-term weight loss: An illustrative case

Article (PDF Available)inPediatric Surgery International 29(8) · April 2013with311 Reads
DOI: 10.1007/s00383-013-3311-y · Source: PubMed
Abstract
For severely obese patients planning bariatric surgery, many surgeons advise pre-operative weight loss which can be difficult for some to achieve. We report a 16-year-old male who was referred for weight loss surgery in a very late stage of severe obesity with a weight and BMI of 310 kg and 93 kg/m(2), respectively. He also suffered from obstructive sleep apnea and hypertension. To prepare him for laparoscopic gastric bypass, a strict pre-operative nutritional intervention with inpatient and outpatient phases was designed. He lost 22 kg pre-operatively and an additional 86 kg by 67 months post-operatively, representing a 35 % total reduction in BMI. This case illustrates the feasibility and value of a defined pre-operative dietary intervention to effectively manage the weight of an adolescent referred late in the progression of severe obesity.

Figures

Preparation of a severely obese
adolescent for significant and long-term
weight loss: an illustrative case
Andrew J. Kruger
Email: akruger43@midwestern.edu
Kathleen B. Hrovat
Stavra A. Xanthakos
Thomas H. Inge
Phone: +513-636-8714
Fax: +513-672-0250
Email: thomas.inge@cchmc.org
Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229-
3039, USA.
Abstract
For severely obese patients planning bariatric surgery, many surgeons advise pre-
operative weight loss which can be difficult for some to achieve. We report a 16-
year-old male who was referred for weight loss surgery in a very late stage of
severe obesity with a weight and BMI of 310 kg and 93 kg/m , respectively. He
also suffered from obstructive sleep apnea and hypertension. To prepare him for
laparoscopic gastric bypass, a strict pre-operative nutritional intervention with
inpatient and outpatient phases was designed. He lost 22 kg pre-operatively and
an additional 86 kg by 67 months post-operatively, representing a 35 % total
reduction in BMI. This case illustrates the feasibility and value of a defined pre-
operative dietary intervention to effectively manage the weight of an adolescent
referred late in the progression of severe obesity.
Keywords
Bariatric surgery
Gastric bypass
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Diet
Introduction
Initiating weight loss prior to bariatric surgery in severely obese patients has been
associated with improved operative safety and other health benefits [1]. In particular, a
reduction in operative time [2], intraoperative blood loss [3], and other complications [4, 5]
has been linked to pre-operative weight loss. Pre-operative weight loss can also
significantly decrease the liver size, may reduce length of hospital stay, and may lead to
more rapid weight loss following operation [6].
Very little attention has been given to optimal pre-operative weight loss strategies for
severely obese adolescents. In particular, little objective data are available about appropriate
use of inpatient resources in extreme cases. This report highlights medical decision-making
in the preparation of an adolescent with a remarkable BMI of 93 kg/m for weight loss
surgery, and illustrates 5-year results that can be obtained with surgical management.
Case report
A 16-year-old black male with a history of obesity dating back to early childhood was
referred for consideration of surgical weight loss. As early as age 4, at a weight of 57 kg, he
was >99th percentile of weight for age. His evaluation by a dietician revealed multiple risk
factors for abnormal weight gain including multiple caretakers and minimal involvement of
his parents in his diet and exercise. His intake and activity were characterized by excessive
food portions, constant snacking, very high levels of caloric intake (estimated at over
4,000 kcal/day), and only moderate physical activity. This resulted in an early onset of
accelerated linear growth (at age 6, his bone age was 10 years), acanthosis nigricans, and
elevated blood pressure for age (120/80 mmHg). Over 3 months, he was able to lose only
1 kg on a low calorie diet and an exercise regimen.
By age six, his BMI was 45 kg/m . He began a more structured weight management
program, and in the first 13 months he lost 6 kg, while increasing 6 cm in height. However,
in the last 2 months of this intervention, he regained 8 kg.
At age 16, with a weight of 294 kg and a BMI of 88 kg/m (328 % over ideal weight), he
had developed obstructive sleep apnea (apnea-hypopnea index 10 events/h) requiring
treatment with continuous positive airway pressure at night, arterial hypertension managed
with metoprolol, lisinopril, and hydrochlorothiazide, dyslipidemia treated with niacin, and
insulin resistance with normal fasting glucose. He also suffered with weight-related
arthralgias, particularly the left knee, requiring naproxen and dextropropoxyphene.
Although the patient clearly met medical criteria for weight loss surgery in adolescence
with an extreme BMI and multiple significant comorbidities, the decision to proceed with
surgery was complicated by several factors, warranting a cautious approach. He had gained
16 kg in the 6 months prior to his initial surgical consultation visit, indicating ongoing risk
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factors driving very rapid weight gain. It was unclear if he—in his social and family
environment—could be adequately prepared for a complex weight loss intervention,
especially one which requires active patient and family participation to succeed.
During 6 months of outpatient pre-operative preparation, his weight initially decreased from
310 kg to a low of 304 kg, but then increased to 311 kg, exceeding the weight at the time of
the initial assessment (Fig. 1). The patient was frustrated by his lack of sustained weight
loss. Given the failure of conventional outpatient nutrition and physical activity
recommendations to impact his weight, and his seemingly earnest desire to put adaptive
behaviors into place, a more aggressive inpatient weight loss plan was proposed. The goals
were to reduce dietary intake and promote a more structured lifestyle and physical activity
program in a controlled environment.
Fig. 1
BMI changes and associated events
The inpatient meal prescription consisted of one liquid supplement (Boost—240 kcal, 15 g
protein, Nestlé HealthCare Nutrition, Fremont, MI) at breakfast, two at lunch, two at dinner,
and one for an evening snack. Multiple flavors provided a variety of choices for his meals.
He was also encouraged to drink as much non-nutritive fluids as he desired. This high-
protein liquid regimen provided 1,440 kcal/day and 90 g/day of protein. Fiber (Benefiber,
Novartis Consumer Health, Inc., Parsippany, NJ) was added to his liquid meal, starting at
1 g of fiber per meal and gradually increasing until he received 25 g of fiber per day. Meal
times were fixed, although non-nutritive liquids were available ad libitum. Each day, his
routine consisted of three 30-min exercise sessions, dedicated time for schoolwork, and
appropriate free time.
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During his 13 day inpatient regimen, he demonstrated good compliance. Twelve days into
the exclusively liquid diet plan, one can of the protein supplement was eliminated and a
high-protein meal was added in an attempt to enhance the sustainability of the intervention
after discharge by adding solid food and variety. At discharge on day 13, the prescribed
daily intake was 4 cans of high-protein Boost (960 kcal) and one lean protein-meal
providing 225–240 kcal per serving. He was instructed to continue this diet and the daily
physical activity regimen as an outpatient. His discharge weight was 298 kg, a loss of 13 kg
in 13 days (Fig. 1; Table 1).
Table 1
Pre- and post-operative measurements
Pre-operative month Post-operative month
9 2.5 2 1.5 0.2 0 5 12 19 40 67
Weight (kg) 310 319 311 298 288 226 189 164 172 202
BMI (kg/m )
93 96 93 89 86 68 55 48 49 61
ALT (U/L) 32 38 27 22 24 21 22
Choi (mg/dL) 128 107 109 95 114 124 130
HDL (mg/dL) 44 32 36 35 55 60 55
LDL (mg/dL) 79 69 65 48 53 54 64
TG (mg/dL) 46 26 38 <30 30 <30 57
HbAlc (%) 4.1 4.8 4.8
Insulin (µU/mL) 36 26 10 5 11 9 3.8
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Glucose (mg/dL) 94 70 72 76 80 78
BUN (mg/dL) 6 8 9 8 9 11 11
Cr (mg/dL) 0.9 0.7 0.7 0.7 0.7 0.7 0.7
Ferritin (ng/mL) 81 39 40 25 22 30
Iron (µg/dL) 49 62 78 46 101 132
Hb (g/dL) 12.4 12 14 13 13.7 13
MCV (f L) 83 90 91 90 90 90.2
Alb (g/dL) 4.9 3.8 3.9 3.9 4.8 4.2 4.1
Folate (ng/mL) 512 373 351 293 321
PTH (µg/mL) 51 59 110
Vit Bl (µg/dL) 3.9 3.6 97 34
B12 (pg/dL) 447 269 381 222
Vit D (ng/mL) 5.8 11.4 8.6 5.2
Over the ensuing 6 weeks after discharge, an additional 10 kg was lost. The pre-operative
weight loss was associated with improvement in hyperinsulinemia, reductions in both LDL
cholesterol and serum ferritin. He underwent an uncomplicated laparoscopic RYGB, using a
retrocolic, antegastric reconstruction with roux limb length of 150 cm and a hand sewn, 2
layer gastrojejunal anastomosis. He had an uneventful 4-day hospital stay post-operatively.
Starting 2 weeks post-operatively, he began to walk 5 days per week for 30 min, and began
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resistance training 3 days per week. Three months following the operation, his weight had
decreased an additional 50 kg.
At 12, 40, and 67 months after surgery, his BMI was 55, 49, and 61 kg/m respectively
(Figure. 1; Table 1). Thus, following bariatric surgery, he lost 86 kg, a 30 % reduction post-
operatively. When considering combined weight loss during pre-operative and post-
operative phases, his total weight loss was 35 %. His laboratory assessments also
demonstrated significant improvements with declines in ALT, LDL cholesterol,
triglyceride, insulin and glucose levels and increase in HDL cholesterol (Table 1). He did
not experience anemia or hypoalbuminemia, but did have persistently low 25-OH vitamin D
levels at most recent measurement. He still suffered with arthralgias on a weekly basis and
low back pain monthly, but did not require analgesic medication. He was still hypertensive
but reported a remarkably improved quality of life, with ability to attend college, and to
play basketball and football with friends.
Discussion
The findings in this case report are unique as there are no similarly detailed reports of pre-
operative preparation and long-term outcome of a severely obese adolescent available. Pre-
operative very low calorie liquid meal replacement programs have been used in adults
before surgery to achieve clinically meaningful weight loss. Although an inpatient stay can
be resource intensive and costly, it may be justifiable to initiate a strict treatment plan when
outpatient treatment has been unsuccessful. An 11-week very low calorie liquid inpatient
regimen (<900 kcal/day) for adult bariatric patients resulted in an average loss of 38.9 kg
(85.8 lbs), but this occurred entirely during the supervised inpatient stay [7]. In this
adolescent patient’s 13-day inpatient stay with a 1,440 kcal/day regimen, he lost 13 kg and
went on to lose an additional 10 kg in 6 weeks after being discharged, resulting in a total of
23 kg (50.7 lbs) total loss in 8 weeks. Our case suggests that the diet and exercise behaviors
necessary for successful pre-operative, as well as post-operative, weight loss can be taught
in a significantly shorter time period, avoiding a more expensive extended inpatient stay. In
a controlled setting that eliminates social and environmental factors promoting weight gain,
greater comprehension and execution of an intensive nutritional and physical activity
prescription can be achieved. In this case, the regimen was designed to reinforce behaviors
and eating patterns that would also be useful post-operatively. The high-protein liquid diet,
a sugar-free fluid goal, and a structured meal time pattern was well tolerated and resulted in
significant weight loss prior to surgery, with maintenance of these behaviors and weight
loss post-discharge.
Maintaining dietary interventions for weight loss can be a challenge for biological reasons
that are increasingly becoming clear [8]. Not only does this case demonstrate that a
structured setting can be useful for initiating pre-operative weight loss, but it also illustrates
the sustained and significant weight loss that can be achieved following effective bariatric
procedures, even in cases of severe adolescent obesity. RYGB is believed to trigger
powerful neuroendocrine mechanisms resulting in dramatic changes in appetite [9] and
energy intake [10]. If these anatomic and physiologic responses to surgery are maintained
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long term, durable weight loss should be seen. When compared to other adolescents who
have undergone RYGB contemporaneously in this program, the subject of this case report
demonstrates similar percent weight loss results. The mean BMI of other patients in our
program has been reported at 60.2 kg/m , and the mean post-operative BMI change 37 %
[11], very similar to this patient’s loss of 40 % at 40 months post-operatively and 35 % at
67 months post-operatively. While this degree and durability of weight loss certainly
represents success on one hand, it is also true that certain comorbidities may not be
remedied when surgical therapy is applied so late in the process of severe obesity. In this
case, while some aspects of his health improved, his hypertension and arthralgias did not
resolve, possibly because his post-operative BMI value still indicated severe obesity. Thus,
“waiting” until an adolescent has an extremely high BMI (e.g., >60 kg/m ) to first consider
surgery may well preclude the satisfactory reversal of severe obesity and some related
comorbid conditions [11].
Inspite of maintaining an overall weight loss of 35 % post-operatively, our patient gained
13.6 kg (30 lbs) between his 40- and 67-month visits. He had limited phone contact with the
program in the time period between these two visits, as he had missed his 4-year annual
visit. This weight regain, as well as the persistently low vitamin D 25-OH levels, highlights
the importance of continuing annual follow-up to encourage and reinforce healthy behaviors
to maintain weight loss and to track nutritional status. This patient had persistently low
vitamin D levels at all post-operative time points, despite prescribed vitamin D
supplementation since surgery. His pre-operative vitamin D status was unknown. Bypass
procedures have been associated with vitamin D deficiency. In addition, obese as well as
black and dark-skinned individuals have a higher prevalence of vitamin D deficiency at
baseline as well [12]. Vitamin D status is clearly important for bone health, but is also
increasingly felt to be important in regulating the immune system [13]. This patient’s PTH
levels doubled and became abnormal between 19- and 67-month follow-ups indicating
development of secondary hyperparathyroidism. Supplementation with vitamin D and
achieving normal levels will be important to avoid onset of osteomalacia. Vitamin D with
calcium had been prescribed since surgery and was increased to 2,000 IU daily at his 40-
month follow-up.
In conclusion, this case illustrates that a severely obese adolescent who was unable to
manage his rapid weight gain using conventional outpatient counseling was successful with
a short-term 2-week intensive inpatient liquid diet and physical activity plan, and was able
to continue with weight loss after discharge prior to surgery. Moreover, this individual has
also demonstrated durable surgical weight loss post-operatively for the first 67 months and
in as much as one case can be instructive, would suggest that even in the worst cases of
advanced severe obesity, surgery can result in a clinically significant response.
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  • [Show abstract] [Hide abstract] ABSTRACT: Extremely obese adolescents are increasingly undergoing bariatric procedures, which restrict dietary intake. However, as yet, no data are available describing the change in caloric density or composition of the adolescent bariatric patient's diet pre- and postoperatively. Our objective was to assess the 1-year change in the dietary composition of adolescents undergoing bariatric surgery at a tertiary care children's hospital. A total of 27 subjects (67% female, 77% white, age 16.7 ± 1.4 yr, baseline body mass index 60.1 ± 14.1 kg/m(2)) were prospectively enrolled into an observational cohort study 1 month before undergoing laparoscopic Roux-en-Y gastric bypass from August 2005 to March 2008. The 3-day dietary intake was recorded at baseline (n = 24) and 2 weeks (n = 16), 3 months (n = 11), and 1 year (n = 9) postoperatively. The dietary record data were verified by structured interview and compared with the Dietary Reference Intake values for ages 14-18 years. By 1 year after surgery, the mean caloric intake, adjusted for body mass index was 1015 ± 182 kcal/d, a 35% reduction from baseline. The proportion of fat, protein, and carbohydrate intake did not differ from baseline. However, the protein intake was lower than recommended postoperatively. The calcium and fiber intake was also persistently lower than recommended. Calcium and vitamin B(12) supplementation increased the likelihood of meeting the daily minimal recommendations (P ≤ .02). At 1 year after Roux-en-Y gastric bypass, the adolescents' caloric intake remained restricted, with satisfactory macronutrient composition but a lower than desirable intake of calcium, fiber, and protein.
    Article · Dec 2011
  • [Show abstract] [Hide abstract] ABSTRACT: The goal of this study was to understand the mechanisms of greater weight loss by gastric bypass (GBP) compared to gastric banding (GB) surgery. Obese weight- and age-matched subjects were studied before (T0), after a 12 kg weight loss (T1) by GBP (n = 11) or GB (n = 9), and at 1 year after surgery (T2). peptide YY(3-36) (PYY(3-36)), ghrelin, glucagon-like peptide-1 (GLP-1), leptin, and amylin were measured after an oral glucose challenge. At T1, glucose-stimulated GLP-1 and PYY levels increased significantly after GBP but not GB. Ghrelin levels did not change significantly after either surgery. In spite of equivalent weight loss, leptin and amylin decreased after GBP, but not after GB. At T2, weight loss was greater after GBP than GB (P = 0.003). GLP-1, PYY, and amylin levels did not significantly change from T1 to T2; leptin levels continued to decrease after GBP, but not after GB at T2. Surprisingly, ghrelin area under the curve (AUC) increased 1 year after GBP (P = 0.03). These data show that, at equivalent weight loss, favorable GLP-1 and PYY changes occur after GBP, but not GB, and could explain the difference in weight loss at 1 year. Mechanisms other than weight loss may explain changes of leptin and amylin after GBP.
    Full-text · Article · Jun 2010
  • [Show abstract] [Hide abstract] ABSTRACT: Minimal acute pre-operative weight loss significantly reduces liver size and intra-abdominal adipose tissue. We hypothesize that these changes will reduce intra-operative complications and reduce the difficulty of laparoscopic Roux-en-Y gastric bypass (LRYGBP). This is a retrospective chart review of consecutive patients who had undergone isolated LRYGBP between July 2003 and March 2005. All patients participated in our institution's medically supervised Weight Management Program before surgery. 48 patients (Weight Loss Group) had an average percent loss of excess weight (%EWL) of 4.6; whereas 47 patients (No Weight Loss Group) gained an average of 4.8% of excess weight over an average period of 2.4 and 3 months (P=0.09), respectively. There were no differences between the two groups in age, gender, ASA class, co-morbidities, or BMI at operation. The Weight Loss Group had less intra-operative blood loss (102 vs 72 ml, P=.03). The surgeon was also less likely to report an enlarged liver in the Weight Loss Group (P=.02). Finally, the operation was less likely to deviate from the standard LRYGBP when patients lost weight (P=.02). No differences were seen in operative time, length of hospital stay, wound infections, or major complications. Acute preoperative weight loss is associated with less intra-operative blood loss and reduces the need for intraoperative deviation from the standard LRYGBP. A larger series with a greater reduction in excess weight is necessary to determine the maximal benefits of acute preoperative weight loss.
    Article · Nov 2005
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