Pediatric gastroenterologist and obesity expert Patrika Tsai, MD, MPH, presents major points from the American Academy of Pediatrics’ 2023 guidelines on care of overweight and obese children, including how to assess the condition's severity. With obesity affecting almost 20% of U.S. kids ages 2 to 9, earlier and more aggressive interventions are indicated, and Tsai breaks down screening essentials, medication options (explaining how to dose and what to expect), considerations and techniques for bariatric surgery, and keys to positive long-term outcomes.
What I'm gonna do today is spend the next 45 minutes talking about the treatments for obesity. So I thank you all for joining. Ok. As far as disclosures, I don't have any financial disclosures. I will be discussing some off label use of medication. Uh And I will let you know when I am doing that, I will mention brand names when they are relevant, but I don't endorse any particular brand. As far as the game plan for today, our objectives are gonna be that we'll review the 2023 A AP guidelines which were just released uh earlier this year. I'm also going to outline some different pharmacotherapy options for weight loss and I'll also identify considerations for bariatric surgery. So I'd like to start off with some definitions and we'll look at BM I and BM I percentile. Um As many of you are aware, overweight is defined as having A BM I that's greater than or equal to the 85th percentile up to the 95th percentile. Obesity is going to be greater than the eight, sorry, greater than or equal to the 95th percentile and then severe obesity is now going to be uh put into two different categories. So there's class two, which is greater than or equal to 120th percentile of the 95th percentile or greater than or equal to 35 kg per meter squared. And then for class three obesity, that's going to be greater than or equal to the 140th percentile of the 95th percentile or greater than equal to 40 kilometer kilograms per meter squared. So the reason that this is important is because uh this is now alignment with the adult definitions of obesity. So it does make things a little bit um easier to talk about when we're discussing childhood obesity versus adult obesity. I want to give a little bit of background too. Uh I think it's important to think about, you know, how uh impacted our population is with regard to obesity. What we know is that about 19 or 20% of Children who are um 2 to 19 year old, they are obese and this affects about 14.7 million Children in adolescence. And this also is different when you look at um different uh demographic groups. So for example, we can see that 26% of Hispanic Children um are affected. Uh and then 20 about 25% of non-hispanic black Children. And when we look at uh non-hispanic white Children, it's about 16%. And then the lowest group is going to be non-hispanic Asian Children at 9%. And then in parentheses on the right, I have the numbers for our adult population, uh which is also highly concerning um as you can tell, uh uh since there is a high prevalence of obesity there too, uh in terms of taking a look at the maps, I wanna show this one because I think it's uh very telling to see how obesity has changed over the course um of of the past uh several decades, you know, these maps, I'll just start them at 2011. And what you can see here is that uh there's, you know, still some green, uh there is, you know, a fair amount of yellow and then orange is the highest color here in orange represents about 30 to 35% of uh self reported obesity among us adults. Now, if we fast forward this by about five years and we go to 2016, uh what we see is that unfortunately, there is a new color that's added to the uh picture. And so here we see that there's a, a brighter orange color and this represents 35 to 40% of people reporting obesity. And we see that the number of states that are green has really diminished um since the previous slide and then, uh this unfortunately, uh continues as a trend when we go into the next one is gonna be in 2021. So here we see, uh, this, you know, bright red color, uh, where 40 to 45% of, uh, adults report, uh, obesity. Uh, we see that there's one holdout with the green here at 20 to 25% in DC. Uh, but really the number of people who identify as being obese, um, really increases, you know, even over this past, uh, decade. Now, how does this affect us in terms of, um, the, um, state of the world? One of the interesting things is that only about two in five young adults are actually late eligible for basic military training, uh which is concerning from a national security perspective. Uh The other uh financial impact of this is that the US ends up spending about 100 and 45 sorry, 100 and $47 billion on obesity related health care, which is, you know, just astounding um from an economic perspective. So now that, you know, we've talked about the scope of the problem, how do we tackle that? So this brings us now to our A AP guidelines uh which were released earlier this year and that came out in January. And what's interesting is that this is the first set of clinical practice guidelines um that have been issued by the A AP on obesity. So the last A AP expert committee recommendations were published in December of 2007. And then there was the A AP Institute of A healthy childhood weight algorithm uh that was uh released in 2016. So, you know, these clinical guidelines are definitely a welcome update. So the guidelines are great in that they give a good overview of pediatric obesity. And what we know is that obesity has been framed as a matter of personal responsibility. But we really know that it's multifactorial and lifestyle interventions including diet and activity are still the basic tenets of managing weight and health. And what we see though in terms of these guidelines is that there is some shift. Uh the guidelines move from a more watchful waiting stance uh of seeing whether the kids grow out of obesity to treating a lot earlier and more aggressively. So the guidelines I recommend considering pharmacotherapy and bariatric surgery as appropriate. Uh What I see is the controversy is that uh there is um some concern for increasing risk of eating disorders. Uh And then there's also the use of the medications and bariatric surgery at an earlier age. So the guidelines go over several different topics. So these topics include things like health equity, racism, bias and stigma, adverse childhood experiences, uh epidemiology, it also goes over things like risk factors, the evaluation of obesity, any comorbidities, uh most importantly, treatment, uh it also touches on systems of care and barriers to treatment. So what I wanna do is go over the takeaway points um which are really um uh distilled quite nicely. Um regarding assessment and treatment. And so they've put them in as key action statements. Uh I'd like to uh take the next couple of slides to review those. And so there are 13 key action statements. The first is that, you know, we should assess via Micro Center at least annually. Uh for those who are ages 2 to 18 to screen for uh overweight and obesity. And in terms of evaluating for these things, we'd want to take a look at history, uh mental and behavioral health screening, social determinants of health evaluation, physical exam and diagnostic studies. For those that are greater than are equal to 10 years of age um that are overweight. Uh We can evaluate for any abnormal glucose metabolism or like liver function, um especially if there is the presence of any risk factors for type two diabetes or for an apples. And then those that are 2 to 9 years of age that have obesity, then we can also evaluate for some lipid abnormalities in terms of treatment. Um Those who are overweight and obese should be treated for the uh uh overweight and obesity as well as their comorbidities. Concurrently with regard to testing for uh dyslipidemia, we should look at a fasting lipid profile for those who are greater than or equal to 10. And then we consider that in those who are 2 to 9, in terms of looking for prediabetes or diabetes, the uh testing of choice would be fasting glucose, og tt or hemoglobin A one C. In order to check for an OL, we should take a look at an A LT and then we should also take a look at hypertension with a blood pressure at each visit starting at age three, if overweight or obese. Uh The next uh key statement would be that in terms of treating uh for overweight obesity, we should always be careful to look at the principles of the medical home and chronic care model with family centered and a non stigmatized uh approach to acknowledging obesity. Uh and the different drivers which may include biologic, social and structural issues with regard to motivational interviewing. That's something that's actually also really important uh in order to be able to engage the families uh and the patients so that they can uh make a good changes in terms of their lifestyle. Uh If you look at the A EP website and go under a patient care tab uh under the Institute for Healthy childhood Weight, there is a nice professional education module uh that goes over motivational interviewing if you'd like some more information on that in terms of thinking about um intensive health behavior and lifestyle treatment. One thing that has come out in the guidelines is that they're actually uh very prescriptive in saying that they would ideally recommend uh greater than equal to 26 hours over 3 to 12 months, um which you know, uh many of us, I think when we read that, um I thought that was AAA big Lift. Um and given how, uh challenging it may be uh to uh uh access some of these services. And then I think, uh these last two points are the things that have met with a lot of, um, you know, uh controversy um in the, in the press. Uh and then also, you know, amongst uh health care providers in general. Uh, so now the recommendation is that there should be weight loss pharmacotherapy offered, uh, for those who are, uh, at least 12 years of age and up with obesity. And then, uh, a referral offer should be made for bariatric surgery for those who are, uh, greater than, or equal to 13 years of age who have severe obesity. So, in my next part of this talk, I'd like to move into medications and, uh, what I'd really love to try to accomplish with this next section is to, uh, go over, you know, the different medications that are available for pharmacotherapy, uh, for weight loss. And these are medicines that I think are ok to start in a general pediatrics office. Um, I don't think that they, they need to wait until they come to a, um, tertiary care center, um, or be seen in a weight management clinic, uh, before getting started on these medications. Um, you know, I, I know that, uh, you know, oftentimes, uh, these medicines are, are new to, to us, um, in, in general pediatrics. But, uh, these things are, are definitely things that could be started, um, prior to, uh, coming in and just to give a, a guideline, we, we have about 10 meds that I'll go over some, I'll spend a little bit more time on than others. The first one is gonna be Metformin. Uh, this one is an off label one and this has been FDA approved for those who are greater than 10 for type two diabetes. And the way that it works is it inhibits gluco agenesis and enhances insulin, media, glucose consumption in peripheral nerve tissues. Uh I'm sorry, peripheral tissues uh like the muscle and liver. Now, in terms of the mechanism for weight loss itself, the effect is, you know, not totally understood. Uh but we do know that um it will give about 5 to £10 of weight loss and the cost is actually relatively cheap compared to a lot of the other medications. So it's about $20 per month if this were out of pocket. And this is a medicine where we would hydrate it up uh by about 500 mg a week. And we would want to consider this particularly for those patients who uh may be on some meds like antipsychotics. Uh for example, uh you know, OLANZapine or Spiridon, um or ARIPiprazole. Uh those are things where we do see that there can be a pretty significant weight gain. And so Metformin might be helpful in trying to offset some of that. Uh When we give it, it's usually about 500 to 2000 mg divided twice daily. And the side effects of this are gonna be bloating uh gas diarrhea or lactic acidosis. Uh So usually I do check uh bum and creatinine uh to make sure that uh there are no renal issues before starting. Uh It can lower vitamin B 12 levels. So I often recommend uh being on a multivitamin that has uh B 12 in it. The next medicine to consider would be Lidex Amett amine. Uh This is uh marketed as Vance. Uh This also is off label and uh as you know, it is uh uh uh approved for those who are six and up for a DH D um as well as Binge Eating Disorder in adults. It's a pro drug for Dexter amet amine and it works by decreasing dopamine and noradrenaline rate uptake in the nucleus accumbens and then it decreases the uh he he hedonic um or reward based uh eating behaviors. So the side effects of this um are that there, it's gonna increase your blood pressure and then heart rate and then it may worsen psychiatric behavior. Uh contraindication would be any cardiac abnormalities and sudden death has been reported. Now, in terms of how well it works, might be about 5 to £10 of weight loss. Uh cost uh may be prohibitive if it's not covered by insurance because it could be about 3 50 to $530. And, uh, with, uh, with this one, we'd start at 3 mg, um, daily for a week and then go to 50 mg and then increase to 70 mg. Uh, another one to consider might be something like, um, Adderall, which is a combination of amphetamine and dextro amphetamine. Uh, you know, I know that, uh, lately there's been a shortage for many of the A DH D medications. And so, you know, I know that's been a, a challenging one, for, uh, many patients with a DH D to get. And so in terms of, you know, thinking about when would I recommend using this one, if there are patients who have any, um, thoughts about going on medications for treatment of A DH D, uh, then definitely, um, I, I do encourage some of the families to think, um, about, you know, going ahead and, and starting it if they're kind of on the fence. Uh, and I've definitely seen some families who, you know, um, they were, they were considering whether they should treat the A DH D and then once they started on the medication, um, they were pretty happy with the, um, the dual effect on the A HD as well as on the weight. So, the next medication is orsat and this one is FDA approved for those who are greater than or equal to 12. And this is actually marketed uh in um the pharmacies as an over the counter medication. Uh and that's as Ali A LL I, this was approved in 1999. So it's been around for a good while and it's about $80 for a four month supply. And the way that this one works is it inhibits uh pancreatic and gastric lipase and therefore decreases lipid absorption. The prescription strength is gonna be 100 and 20 mg three times a day with meals. Uh whereas over the counter it's half. Uh and so, you know, when families are thinking about this one, then oftentimes, I may uh suggest that they consider trying the over the counter one first. Uh because the dose is a little bit lower and then depending on how they do with that one, then we think about, you know, what we want to try the prescription one. And the reason is because the side effects uh are uh gonna be oily stools. Uh There can also be some abdominal pain or fecal urgency. Uh There can also be gas uh and then gas soal vitamin deficiency is something to consider as well. Uh contraindications for this would be chronic malabsorption, cholest stasis of pregnancy. And so we would uh recommend also that, you know, they take a multivitamin uh that has, you know, fat soluble vitamins if they're on the prescription one. And you know, in terms of um you know, the, the patients taking it, some of them, you know, they, you want to just stay at the over the counter dose of this. Um Others, you know, may decide that they'd like to try the, the prescription one. So, uh I, I will let you know, families know that uh it is something that they can, they can easily get um uh without a prescription. The next one is gonna be topiramate and CYM is off label. Uh It is FDA approved for epilepsy for those that are greater than or equal to two. And uh for migraine prophylaxis for those who are greater than equal to 12. Uh This one works by blocking neuronal sodium channels and it antagonizes glutamate receptors. Uh It inhibits carbonic anhydrase and then we think it suppresses appetite by augmenting uh the gabba activity. So the dose on this 1 may be uh starting at 25 but going up to about 100 mg per day. The side effects here are gonna be some potential brain fog and, and you know, that's uh gonna be this reversible cognitive dysfunction. There can be some metabolic acidosis, there is risk for kidney stones and then also some uh parasthesia. So maybe some funny tingling, it is a teratogen. So we do um want to make sure that we counsel our teenagers uh about, you know, different methods of contraception uh particularly because it can decrease the efficacy of uh birth control pills. And so you would want to consider uh doing some serial pregnancy testing. And then in anybody that has a uh risk of seizures, you would want to be sure to wean slowly. Uh if you're coming off of the pyramid, the next one I'm gonna talk about is phentermine. So this one is approved for those who are 16 and up uh for up to 12 weeks. And this one reduces the reuptake of norepinephrine stimulating um the palsy hypothalamic neurons and it affects serotonin and dopamine reuptake, inhibiting appetite. The doses here are gonna be 15, 30 or 37.5 mg daily. So the side effects here are gonna be irritability. Uh There can be some insomnia. So do you wanna, you know, take this early in the day? There can be some changes in mood. Uh There can be some dry mouth. Uh It is a stimulant, you know, there can be some dizziness or tremor uh or headaches. You know, we may see some heart rate or blood pressure elevations and then as with, you know, all of these weight loss medications, you know, they can also have the G I symptoms too. So, contraindications here would be any um concerns for uh cardiovascular disease, particularly if it's uncontrolled um hyperthyroidism, glaucoma or any use of MA O inhibitors. This one was approved in 1959. Uh it is a controlled substance and uh in terms of weight loss, it's maybe about 3% of weight at about three months and then 5 to 7% at about six months. So, you know, thinking about someone who maybe starting at £200 for example, uh then maybe weight loss of about 10 to 14. And in terms of the cost, it's also relatively cheap. This is gonna be at around 10 to $40 per month. Putting those together though, there is a medication that's a combination of phentermine and two pyramid. Uh that's an extended release. Uh This is marketed as Qsymia, uh Qsymi A and the uh medications approved for greater than or equal to 12 years old. This one can be a little bit uh challenging to get, um you do have to get insurance approval. Usually for this one, the efficacy of venturing into pyramid uh together is more than each component alone. And then the side effects are gonna be the same as each one alone and it's just dependent. And so in terms of monitoring, uh you'd want to even watch the heart rates and the blood pressure. And we also wanna watch the electrolytes and uh creatinine at the beginning and periodically, especially during the dose adjustment. So usually what you do is you start with the um low dose and so that's going to be 3.75 of the phentermine uh component and then topiramate is 23 mg. So that starts off for the first two weeks and then you move up to double the dose for weeks, three and 12. And then uh if uh things are not, you know, um uh continue to improve in terms of the weight, then you can go up uh at weeks 14 and 15 to the next higher dose and then uh considering going up to the max do um if uh if things have not improved, so decreasing the dose here, um you would wanna consider if um we're losing more than £2 a week in terms of um the approval on this, it was approved for adults back in 2012. And then it was approved for adolescence in June of 2022. So it's not been around for adolescence for very long. Um And in terms of the amount of weight loss could be about £30 or so and the cost on this one is gonna be 1 50 to 300 per month. Now, the other thing to think about is that uh if insurance is not covering it, uh both of these medications that be in and the two could be prescribed separately. And usually those are gonna be covered by insurance and uh the the cost, you know, for those even if out of pocket um is not, that is, is not as high. So, moving on into some of these um really exciting um G LP uh one receptor agonist, these are the injections that uh you know, we're seeing and hearing about in the media. Uh and that, you know, many of our patients are asking about. So the first one here is gonna be La aqui Tide and that one is um marketed as a couple of different ways. Uh One is as Victoza. Uh This was approved in 2010 for adults with diabetes and then, um for those who are 10 and up with diabetes in 2019, uh it was then approved in a SUA uh for weight loss in adults in 2014 and then uh approved for those who are 12 and up in December of 2020. Uh So this is also pretty recent too. Uh in terms of the approval, it is um noted that the weight should be at least 100 and £32 and you know, BM I should be at least greater than or equal to the 95th percentile. And so as a GOP one receptor agonist, the way that this works is uh these are incretins that enhance insulin secretion and they increase the tidy by slowing gastric emptying. Uh This is given as a daily subcutaneous injection. And so uh depending on how comfortable the patients are with this, uh there are some who will immediately say no to an injection and then there are others who are uh game to try uh with the injections. You do start at a low dose and we start at 0.6 mg increasing by about 0.6 mg each week. And then you move up to a target dose of 3 mg. The thing to keep in mind uh with the lag tide is that uh you do have to order the novo fine needles um with that and you have to make sure that the family knows that they need to um dispose of the needles, the sharps appropriately in a, in a sharps container. Uh, the sharps container could be, um, you know, uh, uh, like a one that's from the pharmacy, but it doesn't have to be, it can also be a, uh, laundry detergent as long as it's very clearly marked as sharps and, you know, each, um, municipality should have a place, um, where the Sharps can be returned. Um, many pharmacies will take the Sharps, um, some, uh, places that may be like the, um, fire stations. Uh, and then, you know, every, um, place usually will have some website, um, that can direct you to where, uh, there may be some other places uh, to dispose of the sharps appropriately in terms of, um, instructing people on how to use this medication. The website is actually really nice in that. There is a good video that explains how to do the medication. It's pretty easy. Uh, once you watch the video and, you know, many of my families have not had any issues, um, with, you know, understanding how to give the medication after seeing the video. Um There are also um videos in Spanish as well uh for families um that uh need assistance with the Spanish video with regard to the side effects. Um, people can feel fatigue. There may be some headache or dizziness. Uh You can have some heart rate, um increases as well. Uh, some palpitations. Uh, there is a risk of cal uh pancreatitis, uh and gallbladder issues and G I symptoms like uh nausea or um, some diarrhea can happen too. I've definitely seen that, uh, there may be some issues with um, kidney problems. Uh One thing that I have also seen is that there can be some uh mood swings. Uh, there can be some increase in depression, um, carefulness. Uh, there is some increased risk of suicidal litigation as well, uh, as well as um hypoglycemia and there can be different, um, injection site, um, or allergy reactions to, with regard to contraindications. Um There are some studies that suggest that there is increased risk for thyroid cancer. And so if there is any um history um of thyroid cancer in the family, particularly majorly thyroid carcinoma. Um, or if there is um, multiple endocrine aplasia syndrome too, uh, then those are uh definite contraindications for using this medication in terms of the weight loss, it's about £21 of weight loss. And, um, you know, that's, you know, pretty significant. Um, in terms of the, um, EC, this slide is gonna show, uh, just, you know, in the absolute here, you can see this is placebo. Uh, and then this is just showing like BM I standard deviation with the LRA guide that you can see quite a, a nice response there. And then, you know, here are some other, um, figures that also show here's the placebo. Um, and then here is, uh, with the little alo tide, one thing you'll notice is the, the study that was done, they gave treatment for 66 weeks. And so with stopping medications, um, we do see that, you know, weight will increase again. Uh, and I'd say that that's, you know, true of most, uh, medications that you would give, uh, for weight management. So, our next GOP, uh, when agonist is gonna be, uh, semaglutide and this one is marketed as we go, uh, and it's also, um, given as, uh, aic, uh, and V doses which are, um, approved for adults with GOVI is approved for, uh, adolescence, uh, just recently since December of, uh, last year, whereas it was approved for adults, um, in 2021. So the difference on this one, is that you don't need to have a separate needle. Uh, the way that this one works is that they, they come in, um, boxes with four, injection pens. And so the medication is, um, already, um, you know, dosed out in, in each pen. And so you would use um uh one box per month and each month the dose will increase, there are five doses to go through. And so uh you would have to write in for um a new box uh with a higher dose for each month up until you get to the doll uh the goal uh dose. And so it starts at at 0.25 mg for the first month and then moves to 0.5 mg 1 mg 1.7 and then 2.4 mg at 95. So unfortunately, uh what's been challenging is that there have been shortages of this one. What is different about this one compared to the ride is that it is weekly sub QE dosing. Uh It's, it's a long acting GOP, one doctor agonist and has decreased degradation by um DPP four. And so since it is weekly sub dosing, as you can imagine, um most uh patients and families uh prefer having the weekly sub Q dosing as opposed to the daily dosing. And in terms of side effects and contraindications, it's gonna be the same um as uh for the, the ride. OK. And similarly to um the, the ride we can see here, this is a placebo and here's the SEMO guide. Uh the uh there is a significant drop in weight um over the course of this study. Um and they gave their treatment um dosing over 68 weeks. And so the weight loss here was about £35 or about 15% of weight loss. And so, you know, certainly, you know, uh, quite significant. Now, uh, when you're thinking about weight loss in general for, um, improvement in metabolic health, I just want to give perspective to that. Even 10% drop in weight is associated with improvements, um, in metabolic health. And so that's why I think these medications, um, are, you know, really exciting uh in terms of being able to make some, you know, changes um in um the metabolic parameters for our patients. This medication I'm just gonna mention briefly is, is uh set Melano tide. Uh This one is uh for those who have certain genetic uh disorders. And so that might be for uh Barie Beetle syndrome, um or Palmy, um or P CS K one leptin receptor um issues. So these are more genetic things. Um Definitely, I think these patients would be, um, those who would be seen in a um tertiary care uh weight management clinic. Uh And so, um I wouldn't necessarily expect uh anyone in, uh JP S office to be starting this one. The last one that I'll mention. Um, also just briefly is that there is Naltrexone and buPROPion. Um This one is FDA approved for adults. Um So, you know, uh most of us would not be using this one in terms of comparing the different medications. Uh This is a nice graph that just shows you in terms of the BM I changes, you know, how some of the different ones compare to each other. Uh, so to Pyramid here is, uh, the lowest one. and then, you know, Phentermine and Metformin, uh, would be next or the stamp goes up and then the Libo Tide is gonna show you the, uh, most improvement. So I wanna switch gears. Now, um, after, uh, having gone through some of the different medications that would be available, uh I'd like to move on into bariatric surgery, which I think is an important one to talk about. And for the indications here, BM I is gonna be greater than, or equal to the 120th percent top 95th or greater than, or equal to the 35 kg per meter squared with a comorbidity. Um for those who um don't have a comorbidity, but they have a BM I, that's greater than 100 and 40th percentile than 95th percentile, um, or greater than, or equal to the 40 kg per meter squared. Uh Those patients would also be um potentially eligible for bariatric surgery as well. So thinking about the comorbidities, uh there are several uh that we would consider and so these would include things like obstructive sleep apnea. Uh kids who have type two diabetes, uh Those with idiopathic intracranial hypertension, which used to be known as Pseudotumor cerebri, uh anyone with NASH or non-alcoholic hepatitis, uh blancs disease, skippy slap, slipped, capital femoral epis, uh, reflux and hypertension in terms of contraindications. Uh, if there's any kind of medically correctable cause of obesity, then we wouldn't want to pursue bariatric surgery. Uh, if there's any issues with substance abuse problem, particularly in the preceding year, uh bariatric surgery um should not be performed. And then the other thing would be thinking about, um, if someone has any medical, psychiatric psychosocial, uh or cognitive conditions that would keep them from adhering, um, to post op dietary medication regimens, um, or impair their decision making capacity. Uh We also give us pause, um, for offering bariatric surgery, um, patients who, uh, want to pursue surgery also, um, can't be pregnant uh, or plan on having a pregnancy within a year and a half of the procedure. And then finally, um, it's really important to make sure that the patients and caregivers are able to comprehend the risk and the benefits of a surgical weight loss procedure. And if there's any question of that, then, um, that might not be a good surgical candidate, but there are different bariatric surgery, uh, procedures that are available. Um, the first one would have been the ruin y gastric bypass, um, which is around for several decades now, then came the adjustable gastric band. But lately, the one that's become the most popular is gonna be the vertical sleeve gastrectomy. And what happens here is that there's removal of about 80% of the stomach, the stomach, you know, is usually about a liter or so of capacity. What's happening with the gastrectomy is that we're cutting down that capacity really drastically. And so it's coming down to 60 to 100 mL. Uh So quite a change. And what's nice about the sleep gastrectomy is that there are much fewer complications uh compared to the ru ny gastric bypass. And so that's really um become uh the reason for its popularity. Now, there can still be complications, of course. Um And so those things that we tend to see would be stuff like staple line uh leaks. Uh there can be strictures or bleeding. One thing that's really important to think about is that there can be micronutrient deficiencies. So, for example, iron deficiency anemia, um or uh vitamin B 12 deficiency and that's because of decreased intrinsic factor from uh loss of the gastric fundus. Uh there can be some short term complications which would be within 30 days of the surgery. So, uh what would happen there is there might be some surgical site infections, uh bleeding, uh lee constrictors, as we mentioned before, there can be problems with pulmonary embolism. Uh And also there may be a need for read. One thing that can be a challenge is that, you know, after surgery, um there, there is such a limited capacity, it may be really hard for uh patients to be able to stay hydrated. Um since they're having difficulty being able to drink, uh, enough to stay hydrated, given how small the stomach has become. And so there is potentially a risk for readmission, um, or development of things like, you know, um, uh kidney stones too. And, uh, there can be a chance for the operation in terms of long term complications. As I mentioned earlier, nutritional deficiencies are definitely something that we worry about. Uh, weight regain is not uncommon. Uh And so it's certainly possible, you know, to lose all of the weight and then regain all of it back. Uh depending how, how families are able to help, you know, support uh patients in terms of their lifestyle um interventions that also need to happen. Um in terms of activity uh and nutrition, there can be issues with the gallstones. Uh There can be adhesions or hernias, uh reflux um may last for a while for some patients. Um This often can resolve. Um But, you know, there may be some reflux symptoms um for at least the first couple of months. Uh and then also the nausea um because of the small stomach capacity, people may feel bloated. Uh and then they may also have problems with diarrhea and Down syndrome with regard to the outcomes, the gastric bypass and the vertical sleeve, they tend to have similar weight loss outcomes. And there was a multi center study that was done with 100 and 77 teens uh who had the gastric bypass and then 306 that had the sleeve and the three year post op average BM I uh, percent loss was about 29% for those with the, uh, gastric bypass and then 25% with the sleeve. And so given that the sleeve has a much better, um, complication profile compared to the gastric bypass, you know, definitely, I think the sleeve is, um, the way to go uh in terms of any adolescent that's considering any bariatric surgery. And there's definitely improvement in comorbidities here. Uh This is just a graph that's showing a comparison between the gastric band here on top. And then this is showing um the, the sleeve and the gastric bypass. And you can tell that the change in BM I percentile is, is really, you know, pretty close uh for the two of them with regard to the comorbidities. Uh What we see is that, uh if you're looking at three years, post op, uh there can be diabetes remission in about 95% which is really dramatic. Uh and and life changing for these, you know, teenagers, uh there's improvement in the kidney function and so there can be a remission of about 86%. So the vast majority uh the same uh as well for prediabetes. So, remission of 76% there. Uh in terms of blood pressure, 74% showed improvement and then a 66% for dyslipidemia and the thing with surgery though is that it really is a lifelong commitment. Uh, and that is one thing that, you know, has definitely been a challenge with, uh, the patients that we, you know, had to go through, um, with bariatric surgery. You know, many of them once, you know, started to lose the weight, you know, they feel like, well, maybe I don't need to take, you know, some of these vitamins or, you know, supplements anymore. Uh and uh it's hard for them to stick to taking a daily uh routine of micronutrient supplementation. But, you know, this really is important um to try to avoid any nutritional deficiencies and complications from them later on. Uh it's also important to have them be aware that, you know, they do need to have annual lab monitoring um for these nutritional deficiencies. Uh And so, you know, I've listed here, you know, some of the different, you know, things that um may need to be checked uh later on. Uh and then there's also a concern for bone health uh because uh there is concern for uh decreased bone density in those who have had a bariatric surgery. Uh And so, uh they will uh eventually need Dexa scan. Uh There are also now um adult guidelines that recommend doing an upper gastro intestine endoscopy uh to monitor uh Barrett's esophagus, which is um a concern as a risk factor for uh esophageal cancers. And so, you know, bariatric surgery, um, is not without its, you know, potential, um, uh, long term complications. Uh, and, you know, there is a need to continue to do monitoring afterwards. Um, bariatric surgery. It's tool, uh, and, you know, patients, you know, often, um, uh, may be surprised, you know, when we talk to them about it that, you know, just because they've had surgery, it doesn't necessarily mean that they are now allowed to eat whatever they want. Um, they do need to continue to work on um, healthy nutrition and uh a good physical um activity. Now, in conclusion, um I just wanna summarize that uh the updated A AP guidelines advocate for a much more aggressive treatment of childhood obesity. Um We are fortunate that we are now in an era where we have uh several different medications that are available for weight loss, which I think is really exciting and there are more that are, you know, eventually going to be coming down. The pike bariatric surgery is another option that we have for those that have severe childhood obesity. Uh, but it does require lifelong adherence to guidelines including supplementation and testing. I also have some references here for anyone that might be uh interested in reading a little bit more uh about some of the different things that I went over in this slide set and I thank all of you for your attention uh, this afternoon.