Tag Archives: morbid obesity

Trends in Adolescent Bariatric Surgery

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Despite increased numbers of obese adolescents, the number of inpatient bariatric surgery cases has plateaued (JAMA Pediatr 2013; 167: 126-32).  Thanks to Ben Gold for sharing this reference.

In this retrospective cross-sectional study using an administrative dataset (Healthcare Cost and Utilization Project Kids’ Inpatient Database), the authors documented the following bariatric surgery rates:

  • In 2000: 0.8 per 100,000 (328 procedures)
  • In 2003: 2.3 per 100,000 (987 procedures)
  • In 2006: 2.2 per 100,000 (925 procedures)
  • In 2009: 2.4 per 100,000 (1009 procedures)

The other observations in this study were that procedures were predominantly performed on females (75%), the prevalence of comorbidites increased (49% in 2003 vs. 59% in 2009), and complications rates were low.  68.3% had private insurance.

Take-home points:

The number of adolescents who would qualify for bariatric surgery has increased but the rates have not changed.  Why?

  1. Societal barriers.  Obesity is more common in lower socioeconomic groups with lower educational levels.  Yet, the rates of bariatric procedures is the same in low-income and high-income populations.
  2. Insurance coverage.  In many states, medicaid does not cover bariatric surgery.
  3. Physicians limiting access.  After initial enthusiasm (2000-2003), published guidelines to identify appropriate patients and to highlight recommendations prior to surgery may have led to more cautious referral patterns.

Over the past decade, there are increased numbers of qualified surgeons and there has been more use of laparascopic techniques.  The Roux-en-Y gastric bypass (RYGB) was the most common bariatric procedure in this population, accounting for 67.6% of cases in 2009 (60.6% were laparascopic, 7% were open).  Laparascopic adjustable gastric banding (LAGB) accounted for the remaining 32.1% of cases.

Since this study relied on administrative data, there are several limitations.  Billing codes may not reflect the procedures accurately.  For example, ICD-9 codes for laparascopic sleeve gastrectomy were not available until 2011.  Nevertheless, this study provides some insight into the trends with bariatric procedures in adolescents.

Related blog link:

Six year outcomes with bariatric surgery | gutsandgrowth

Outgrowing the growth charts

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Unfortunately, there is a need for extreme growth charts (Pediatrics 2012; 130: 1136-40).

The authors of this study designed growth charts for morbidly obese children.  The reason for these charts is that there are many pediatric patients who cannot be plotted using the CDC  growth chart which has a maximum BMI of 36 kg per meter-squared.  The CDC charts are based on a preobesity epidemic population data set (1963-94) and has sparse data for those above the 97th percentile.  The manuscript describes how these initial charts were derived.

These new growth charts calculate the BMI as a percentile of the 95th percentile.  For example, multiplying the BMI 95th % by 1.2 would yield a result of 120% of the 95th%.  The authors calculated 1.1 through 1.9 multiples of the 95% for all ages between 2 and 20 years.  On their curve, a BMI as high as 64 kg per meter-squared can be plotted.  This allows easier visual tracking of a patient’s progress.

Drawbacks:

  • Difficult to explain to parents due to confusing phraseology –use of two percentages
  • Many of the patients are now on the growth curve and could appear to be graphically normal despite being morbidly obese

The authors note that their growth charts were incorporated into their electronic medical record (Epic software).

Related blog entry: