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Stephanie Walsh, MD - 2024 Pediatric Bariatric Surgery Update Course
With Dr. Stephanie Walsh
Chapter 1 of 5 · Fundamentals
Adequate weight loss
Defining adequate weight loss and patient heterogeneity
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Expected weight loss after pediatric bariatric surgery is typically quoted as 25-35% total body weight loss.
Kids who can lose weight usually lose weight, and kids who cannot do not—this group requires focused intervention.
When adolescents start drinking sugar after bariatric surgery, it is usually because they are not eating food and the sugar makes them feel better.
Physical activity in adolescent girls is lower than in boys, and is predominantly influenced by their mothers' activity levels.
Physical activity impacts mental health in addition to physical strength.
Bupropion post-operatively helps with mood and provides additional weight loss benefit, though it is labeled for age 18 and older.
Pre-operative anti-obesity medications can provide psychological benefit by helping adolescents stabilize or lose weight, keeping them engaged in the program.
Most pediatric bariatric patients can only access phentermine and topiramate; GLP-1 agonists are not available for most patients.
When using medications that decrease hunger post-operatively after a surgery that also decreases hunger, clinicians must ensure patients are still eating adequate nutrition.
Medication availability is almost entirely determined by insurance coverage and supply constraints.
In Atlanta, phentermine is only available in 15 mg capsule form, which cannot be split.
Many families are hesitant about long-term medication use despite accepting bariatric surgery.
Novo Nordisk is prioritizing shipment of 1.7 mg and 2.4 mg semaglutide doses for patients already on therapy, with very limited availability of lower initiation doses.
Some patients do well on 1.7 mg semaglutide but not necessarily better on 2.4 mg, suggesting individualized dosing may be appropriate.
As of last year, 1.7 mg semaglutide is considered a maintenance dose, which should reduce insurance coverage barriers.
Clinicians should use the lowest medication dose that the patient can tolerate and that is effective, which varies by individual.
One protocol offers medications at 3 months for less than 10% total body weight loss and at 6 months for less than 15% weight loss; these thresholds are conservative given Teen-LABS data.
In a cohort of 750 patients, modeling showed that if a patient is off the expected weight loss curve at 3 months, they never return to that curve.
A cohort of sleeve gastrectomy patients did not achieve satiety despite standard resection; these patients were started on Vyvanse at 2 weeks post-operatively.
Studies examining medication use at 6 months or later are too late; data strongly suggest starting medications earlier and being more aggressive.
For adolescents with type 2 diabetes, there is no reason to wait for BMI 35 when diabetes will not improve differently at BMI 32.
The longer adolescents with type 2 diabetes are on insulin, the less likely intervention will help their diabetes.
In heterogeneous outcome data, one subgroup shows only 12% weight loss at 10-year follow-up while other groups are highly successful.
An unpublished study by Tom showed improvement in weight loss outcomes with phentermine and topiramate use post-operatively in approximately 12 patients.
An unpublished study by Evan showed that adolescents who lose weight successfully also lose weight well with medications, but the benefit for the highest-BMI subgroups remains unclear.