Pre- and postoperative imaging of adolescents undergoing laparoscopic adjustable gastric banding surgery.

BACKGROUND: As childhood obesity rates rise, laparoscopic adjustable gastric banding (LAGB) is being investigated as a bariatric surgical option in adolescents. OBJECTIVE: To examine pre- and postoperative imaging in adolescents undergoing LAGB, describe the most common abnormal preoperative imaging findings, and illustrate the typical appearance and variants on postoperative upper-gastrointestinal (UGI) examinations. MATERIALS AND METHODS: A retrospective chart review was performed of all adolescents from 2008 to 2010 undergoing LAGB at a single tertiary-care pediatric hospital. The picture archiving and communication system was queried for all imaging obtained before and after surgery. Postoperative UGI studies were analyzed for common patterns. RESULTS: Twenty-seven obese adolescents who underwent LAGB were identified. Twenty-five had preoperative imaging, most commonly a UGI study (81.5%). Eight UGI studies were abnormal but did not impact surgery. Preoperative chest and neck radiographs were also common. Intraoperative imaging was rare. Seventy-three postoperative UGI studies were performed on 22 children (range, 2-12 studies). A common postoperative imaging pattern was observed in 19/22 (86%) children. No complications were observed. CONCLUSION: The most common pre- and postoperative imaging studies in adolescents undergoing LAGB are UGI studies. Pediatric radiologists should be familiar with the imaging of LAGB as this procedure becomes increasingly common.

Integrating childhood obesity resources into the patient-centered medical home: Provider perspectives in the United States.

Pediatric primary care providers play a critical role in managing obesity yet often lack the resources and support systems to provide effective care to children with obesity. The objective of this study was to identify system-level barriers to managing obesity and resources desired to better managing obesity from the perspective of pediatric primary care providers. A 64-item survey was electronically administered to 159 primary care providers from 26 practices within a large pediatric primary care network. Bivariate analyses were performed to compare survey responses based on provider and practice characteristics. Also factor analysis was conducted to determine key constructs that effect pediatric interventions for obesity. Survey response rate was 69% ( n = 109), with the majority of respondents being female (77%), physicians (67%), and without prior training in obesity management (74%). Time constraints during well visits (86%) and lack of ancillary staff (82%) were the most frequently reported barriers to obesity management. Information on community resources (99%), an on-site dietitian (96%), and patient educational materials (94%) were most frequently identified as potentially helpful for management of obesity in the primary care setting. Providers who desired more ancillary staff were significantly more likely to practice in clinics with a higher percentage of obese, Medicaid, and Hispanic patients. Integrating ancillary lifestyle expert support into primary care practices and connecting primary care practices to community organizations may be a successful strategy for assisting primary care providers with managing childhood obesity, especially among vulnerable populations.

Electronic Gaming Characteristics Associated with Class 3 Severe Obesity in Youth Who Attend the Pediatric Weight Management Programs of the COMPASS Network.

BACKGROUND: The prevalence of severe obesity and electronic game use among youth has increased over time. METHODS: We administered a survey assessing gaming and psycho-demographic characteristics to youth aged 11-17 attending five weight management programs. We conducted chi-square and logistic regression analyses to describe the association between class 3 severe obesity and gaming characteristics. RESULTS: Four hundred twelve youth (51% female, 26% Black, 25% Hispanic, 43% White, and 44% with class 3 severe obesity) completed the survey. There was a stepwise relationship between time spent gaming and class 3 severe obesity, with 28% of those playing 2 to <4 hours a day, 48% of those playing 4 to <6 hours a day, and 56% of those playing ≥6 hours a day having class 3 severe obesity (p = 0.002). Compared to youth without class 3 severe obesity, youth with class 3 severe obesity were more likely to have a TV in the bedroom (76% vs. 63%, p = 0.004) and play games on a console (39% vs. 27%, p = 0.03) and were less likely to report parental limit setting on type of games played (7% vs. 16%, p = 0.006). Youth who played games ≥4 hours a day were 1.94 times (95% confidence interval 1.27-3.00) more likely to have class 3 severe obesity than those who played <4 hours a day, after adjustment for demographic, behavioral, and academic variables. CONCLUSIONS: Our study demonstrates a clear association between gaming characteristics, especially time spent gaming, and severe obesity in youth. Further research testing family-based interventions that target gaming behaviors in youth are needed.

A Narrative Review of Medical and Genetic Risk Factors among Children Age 5 and Younger with Severe Obesity.

Severe obesity defined as an age- and gender-specific body mass index ≥120% of the 95th percentile in children younger than 5 years is well recognized as a significant challenge for prevention and treatment. This article provides an overview of the prevalence, classification of obesity severity, patterns of weight gain trajectory, medical and genetic risk factors, and comorbid disorders among young children with an emphasis on severe obesity. Studies suggest rapid weight gain trajectory in infancy, maternal smoking, maternal gestational diabetes, and genetic conditions are associated with an increased risk for severe obesity in early childhood. Among populations of young children with severe obesity seeking care, co-morbid conditions such as dyslipidemia and fatty liver disease are present and families report behavioral concerns and developmental delays. Children with severe obesity by age 5 represent a vulnerable population of children at high medical risk and need to be identified early and appropriately managed.

Feasibility of Using a Commercial Fitness Tracker as an Adjunct to Family-Based Weight Management Treatment: Pilot Randomized Trial.

BACKGROUND: Fitness trackers can engage users through automated self-monitoring of physical activity. Studies evaluating the utility of fitness trackers are limited among adolescents, who are often difficult to engage in weight management treatment and are heavy technology users. OBJECTIVE: We conducted a pilot randomized trial to describe the impact of providing adolescents and caregivers with fitness trackers as an adjunct to treatment in a tertiary care weight management clinic on adolescent fitness tracker satisfaction, fitness tracker utilization patterns, and physical activity levels. METHODS: Adolescents were randomized to 1 of 2 groups (adolescent or dyad) at their initial weight management clinic visit. Adolescents received a fitness tracker and counseling around activity data in addition to standard treatment. A caregiver of adolescents in the dyad group also received a fitness tracker. Satisfaction with the fitness tracker, fitness tracker utilization patterns, and physical activity patterns were evaluated over 3 months. RESULTS: A total of 88 adolescents were enrolled, with 69% (61/88) being female, 36% (32/88) black, 23% (20/88) Hispanic, and 63% (55/88) with severe obesity. Most adolescents reported that the fitness tracker was helping them meet their healthy lifestyle goals (69%) and be more motivated to achieve a healthy weight (66%). Despite this, 68% discontinued use of the fitness tracker by the end of the study. There were no significant differences between the adolescent and the dyad group in outcomes, but adolescents in the dyad group were 12.2 times more likely to discontinue using their fitness tracker if their caregiver also discontinued use of their fitness tracker (95% CI 2.4-61.6). Compared with adolescents who discontinued use of the fitness tracker during the study, adolescents who continued to use the fitness tracker recorded a higher number of daily steps in months 2 and 3 of the study (mean 5760 vs 4148 in month 2, P=.005, and mean 5942 vs 3487 in month 3, P=.002). CONCLUSIONS: Despite high levels of satisfaction with the fitness trackers, fitness tracker discontinuation rates were high, especially among adolescents whose caregivers also discontinued use of their fitness tracker. More studies are needed to determine how to sustain the use of fitness trackers among adolescents with obesity and engage caregivers in adolescent weight management interventions.

Psychological contributors to noncompletion of an adolescent preoperative bariatric surgery program.

BACKGROUND: Noncompletion of preoperative bariatric programs is a significant problem among adolescents. Adult studies suggest that psychological factors contribute to noncompletion of preoperative bariatric programs. OBJECTIVE: The aim of this study was to determine the association between adolescent psychological functioning and completion of the preoperative phase of a bariatric program. SETTING: The study was conducted at a tertiary care children's hospital affiliated with a university medical center. METHODS: Seventy-four adolescents and their parents completed an assessment measure of psychological functioning with the Behavior Assessment System for Children, Second Edition. We compared these scores between adolescents who completed the preoperative phase of the bariatric program and proceeded to surgery (completers) to those who did not (noncompleters) using multivariate analysis of covariance and logistic regression analyses, adjusting for demographic characteristics and baseline body mass index. RESULTS: The mean age was 16.0 (1.1) years, most were female (79.8%), and the group was diverse (48.6%, Caucasian; 33.8%, black; 17.6%, other, including Hispanic, Asian, and biracial). Average body mass index was 50.5 (7.6) kg/m2. Forty-two percent of participants were noncompleters. Noncompleters were reported by parents to have more clinically significant externalizing and internalizing behaviors and fewer adaptive behaviors. Noncompleters self-reported more clinically significant internalizing symptoms, emotional problems, and poor personal adjustment. CONCLUSION: Adolescents who did not complete the preoperative phase of a bariatric surgery program had more clinically significant psychological symptoms across multiple domains compared with those who successfully proceeded to bariatric surgery. Early identification and treatment of psychological symptoms may be important in helping adolescents successfully proceed to surgery.

Problem Video Gaming Among Children Enrolled in Tertiary Weight Management Programs.

Prior studies show seven percent to nine percent of children demonstrate gaming behaviors that affect a child's ability to function (e.g., problem gaming), but none have examined the association between problem gaming and weight status. The objective of this study was to determine the prevalence of problem gaming among children enrolled in tertiary weight management programs. We administered a computer-based survey to a convenience sample of children aged 11-17 years enrolled in five geographically diverse pediatric weight management (PWM) programs in the COMPASS (Childhood Obesity Multi-Program Analysis and Study System) network. The survey included demographics, gaming characteristics, and a problem gaming assessment. The survey had 454 respondents representing a diverse cohort (53 percent females, 27 percent black, 24 percent Hispanic, 41 percent white) with mean age of 13.7 years. A total of 8.2 percent of respondents met criteria for problem gaming. Problem gamers were more likely to be white, male, play mature-rated games, and report daily play. Children in PWM programs reported problem gaming at the same rate as other pediatric populations. Screening for problem gaming provides an opportunity for pediatricians to address gaming behaviors that may affect the health of children with obesity who already are at risk for worsened health and quality of life.

Weight Trajectory in Refugee Children after Resettling in the United States: A Pilot Study.

BACKGROUND: The objective of this study is to describe the weight trajectory of refugee children after resettlement in the US. METHODS: A pilot study was conducted, utilizing longitudinal data obtained from the electronic health record of 129 children between 2 and 18 years of age (54% female, mean age 10 years) from the 3 primary countries of origin presenting to a refugee clinic (Bhutan, N = 71; Burma, N = 36, and Iraq, N = 22).. Mixed effects model analyses were utilized to characterize weight trajectory with calculation of a per year change in BMI-z score, adjusting for baseline BMI-z score, age, and time. RESULTS: There was a significant increase in BMI-z (mean 0.15 units/year, p=0.04) among refugee children during their initial period after resettlement. Female children from Bhutan demonstrated the most rapid increase in weight, with a mean BMI-z gain of 1.00 units/year. CONCLUSION: Female children from Bhutan demonstrated rapid weight gain after resettlement in the US. Further studies are needed to describe weight trajectory trends and evaluate possible reasons for rapid weight gain in this population.

Social/Electronic Media Use of Children and Adolescents Who Attend the Pediatric Weight Management Programs of the COMPASS Network.

BACKGROUND: Obesity is a major healthcare problem in youth and their social/electronic media (SEM) use has been described as a risk factor. Though much is known about the newer technologies youth use to communicate, little is known about what is used by those in weight management programs. The aim of this study was to determine what types of SEM, including sedentary and active video games, youth in weight management programs use and which they prefer for communicating with healthcare providers. METHODS/DESIGN: This was a multisite study using a 24-question online SurveyMonkey® questionnaire. Youth, 12-17 years old, attending pediatric weight management programs at seven participating centers in the Childhood Obesity Multi Program Analysis and Study System network were eligible. RESULTS: There were 292 responders with a mean age of 14.2 years. Fifty-four percent were female, 36% Caucasian, 35% African American, and 33% were Hispanic. Ninety-four percent had access to a computer, 71% had Internet access, and 63% had smartphones. Whereas 87% had at least one gaming system at home, 50% reported they never played sedentary video games (71% of females vs. 25% males; p < 0.0001) and 63% never played exercise video games during the week. The preferred method of communication with a healthcare provider was face to face (60%), with few indicating a preference for communication by texting (13%), phone (12%), or social media (6%). CONCLUSIONS: Face-to-face communication with healthcare providers is the preferred method for youth in pediatric weight management programs. They self-reported video game use less than previously described.

Characteristics of Youth Presenting for Weight Management: Retrospective National Data from the POWER Study Group.

BACKGROUND: There are no existing multisite national data on obese youth presenting for pediatric weight management. The primary aim was to describe BMI status and comorbidities among youth with obesity presenting for pediatric weight management (PWM) at programs within the Pediatric Obesity Weight Evaluation Registry (POWER). METHODS: Data were collected from 2009-2010 among 6737 obese patients ages 2-17. Patients were classified in three groups by BMI (kg/m(2)) cutoffs and percent of the 95th percentile for BMI: (1) obesity; (2) severe obesity class 2; and (3) severe obesity class 3. Weighted percentages are presented for baseline laboratory tests, blood pressure, and demographics. Generalized logistic regression with clustering was used to examine the relationships between BMI status and comorbidities. RESULTS: Study youth were 11.6 ± 3.4 years of age, 56% female, 31% black, 17% Hispanic, and 53% publicly insured. Twenty-five percent of patients had obesity (n = 1674), 34% (2337) had severe obesity class 2, and 41% (2726) had severe obesity class 3. Logistic regression revealed that males (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.0), blacks (OR, 1.7; 95% CI, 1.5-2.0), age <6 years (OR, 2.0; 95% CI, 1.5-2.6), and public insurance (OR, 1.8; 95% CI, 1.5-2.0) had a higher odds of severe obesity class 3. Severe obesity class 3 was associated with higher odds of laboratory abnormalities for hemoglobin A1c (OR, 1.7; 95% CI, 1.3-2.2), alanine aminotransferase ≥40 U/L (OR, 1.9; 95% CI, 1.3-2.6), and elevated systolic blood pressure (OR, 2.5; 95% CI, 2.0-3.0). CONCLUSIONS: Youth with obesity need earlier access to PWM given that they are presenting when they have severe obesity with significant comorbidities.

Evaluation of intelligence in an adolescent bariatric population.

BACKGROUND: The use of bariatric surgery as treatment for morbid obesity in adolescents has nearly tripled in recent years. Intelligence is an important component to a patient's assent of surgery and maintenance of a healthy lifestyle. The objective of this study was to describe the intelligence testing performance of a cohort of adolescents seeking laparoscopic adjustable gastric banding (LAGB). Twenty-nine patients (93% female, 62% white) with a mean age of 16 years and mean body mass index (BMI) of 49 kg/m(2) were enrolled in an adolescent bariatric program in the United States. METHODS: We conducted a cross-sectional analysis, evaluating patient intelligence at a single preoperative time point using the Weschler Intelligence Scale for Children-IV or Weschler Adult Intelligence Scale-IV. Intelligence quotient (IQ) scores were analyzed descriptively and in relationship to patient anthropometric measurements and characteristics. RESULTS: Mean IQ was average for age (95, SD 16), although 21% of patients had an IQ<80 and no patients had an IQ>120. There was no significant association between IQ and BMI, weight, or waist circumference. Mean IQ was lower in patients who had failed a grade compared with those who had not failed a grade (P<.01) and in patients whose parents had not graduated college compared with those whose parents had (P< .05). CONCLUSION: In our cohort of adolescents seeking LAGB, mean IQ was average for age, suggesting capability to understand the procedure and healthy lifestyle concepts. Patients who exhibit deficits in intellect prior to surgery may benefit from educational resources and clinician support tailored to their reasoning abilities.

Evaluation of weight loss on a low-calorie meal replacement diet as a potential predictor of weight loss after laparoscopic adjustable gastric banding surgery in adolescents.

BACKGROUND: Predicting weight loss after laparoscopic adjustable gastric banding (LAGB) from preoperative factors has been challenging. This study aimed to determine the relationship between weight loss from a preoperative low-calorie meal replacement diet (LCMRD) and weight loss after LAGB in a cohort of morbidly obese adolescents. METHODS: Fifty-one subjects (86 % female, 61 % Caucasian, mean age 16 years, mean weight 140.1 kg) received 2 weeks of LCMRD prior to LAGB. We utilized Pearson's correlation coefficients to test the relationship between weight loss on a LCMRD and weight loss at 3, 6, and 12 months after LAGB. RESULTS: Mean weight loss was 5.7 kg (standard deviation (SD) 2.5) during the LCMRD period and 17.4 kg (SD 12.4) at 1 year postoperatively. Having a higher baseline weight (p < 0.01) and losing less weight prior to LCMRD (p < 0.05) was associated with more weight loss during LCMRD. Weight loss during LCMRD was not significantly associated with postoperative weight loss at any time point. CONCLUSIONS: Weight loss during LCMRD was not significantly associated with postoperative weight loss in our study. Less variability in adherence, less influence of genetic and biological potential, and more diuresis during a short course of LCMRD compared to in the postoperative period may explain this lack of association.

Does body mass index accurately reflect body fat? A comparison of anthropometric measures in the longitudinal assessment of fat mass.

OBJECTIVE: To determine which anthropometric measure best correlates with change in fat mass (FM) over time. METHODS: The authors performed a retrospective cohort study of 76 obese patients (mean body mass index [BMI] 38 kg/m(2) and mean age 13 years) presenting to an obesity clinic between 2005 and 2010. For each patient, during 2 visits, FM was measured by bioelectrical impedance analysis and the following measures obtained: BMI, waist circumference, hip circumference, and neck circumference. Correlation coefficients and linear regression analyses were calculated to examine the relationship between each measure and FM. RESULTS: Change in BMI correlated better with change in FM than any other measure and had the strongest effect on change in FM (P < .01, R (2) = .887). The best regression model included BMI only (R (2) = .891); without BMI, the model was significantly worse (R (2) = .521). DISCUSSION: In the clinical management of obese children, BMI is an adequate measure of change in FM.