The AHRQ (Agency for Healthcare Research and Quality) released a press report in September 2008 about the success of behavioral modification programs in helping children with obesity. Concerns have been raised about the utility of pharmacology in assisting children with losing weight within these behavioral modification programs. Should weight reduction medications be prescribed to children and/or adolescents, and are they effective?
Behavioral Changes Cause Weight Loss
The AHRQ delivered a press release titled the "Effectiveness of Weight Management Programs in Children and Adolescents" which showed that working with children and adolescents to lose weight through behavioral modification programs can be successful. The study compared various types of weight loss programs. The report concluded that health-care based programs were generally better than school-based programs in accomplishing weight loss. The school-based and healthcare settings led to a small to moderate weight reduction. Although the decrease in weight was modest, the detriment from a behavioral modification program is minimal.
Several studies have investigated the usefulness of using medications in conjunction with behavioral modification in promoting weight reduction in children/adolescents. The report from the AHRQ did show that sibutramine and orlistat did improve the amount of weight lost in programs where the drugs were used in combination with behavioral modification. However, the medications had significant complications. In "Recommendations for Treatment of Child & Adolescent Overweight and Obesity"published in Pediatrics by B.A. Spear et al, it was suggested that adolescents treated with pharmacological agents for obesity should be referred to a tertiary center for more comprehensive management and oversight. In the review, it was noted that some clinicians have suggested a BMI of 99% for pharmacological candidates.
Weight Loss Program Complications
Medications used to help children and adolescents lose weight have side effects, some more problematic than others. Orlistat is a lipase inhibitor which decreases the absorption of triglycerides, cholesterol, and fatty acids. Since these fats are not absorbed from the gastrointestinal tract, they are eliminated through the gut which leads to complications. The most common complaints are abdominal cramps, flatulence, and fecal soiling. Vitamin supplementation is required with orlistat use because it impairs the intake of fat soluble vitamins. A significant difficulty with orlistat is the need to take it with each meal, which can be problematic for an adolescent attending school.
Sibutramine is a appetite suppressant. Several studies have showed the benefit of taking sibutramine in combination with behavioral modification in helping adolescents lose weight. R.I. Berkowitz et al in "Behavior Therapy & Sibutramine for the Treatment of Adolescent Obesity" in JAMA 2003 confirmed the benefit of sibutramine in a trial with adolescents. However, the complications with using sibutramine are important. Sibutramine can cause tachycardia and hypertension, both of which are common comorbidities in obese adolescents. Occasionally the tachycardia from sibutramine persisted even after the medication was discontinued. It was reported that adolescents were removed from studies using sibutramine and orlistat because of resulting complications.
Bariatric Surgery for Adolescent Obesity
The AHRQ report and several other studies have reported that bariatric surgery can result in moderate to substantial weight loss in adolescents. The concern is that long-term studies on adolescents undergoing weight loss surgery is limited. Bariatric surgery can lead to resolution of obesity comorbidities like asthma and sleep apnea. B.A. Spear et al felt that certain criteria should be met for any youth undergoing bariatric surgery:
- The adolescent should be physically mature.
- The BMI should be >50.
- The BMI should be >40 with existing critical comorbidities.
- The adolescent failed a formal 6 month weight loss program.
- The adolescent should be committed to long-term lifestyle changes.
- A psychological assessment is conducted.
- Arrangements can be made for long-term follow up.
With about 17% of American youth obese (that is a BMI > 95%), medical professionals and healthcare institutions are working aggressively to address this medical emergency. The comorbidities associated with obesity include asthma, diabetes, fatty liver disease, and sleep apnea to name a few. But we often fail to address the psychological impact obesity can have upon youth. While surgery may look like a quick fix, and medication is often thought to be an easy fix, there is no simple fix to the problem of obesity. The only way to fix the problem is to address the issue at the heart of obesity - modifying behavior toward food for a lifetime.
