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Best Practice Guidelines in Pediatric/Adolescent Weight Loss Surgery Caroline M. Apovian,* Christina Baker,† David S. Ludwig,‡ Alison G. Hoppin,† George Hsu,§ Carine Lenders,* Janey S.A. Pratt,† R. Armour Forse,* Adrienne O’Brien,* and Michael Tarnoff§

Abstract APOVIAN, CAROLINE M., CHRISTINA BAKER, DAVID S. LUDWIG, ALISON G. HOPPIN, GEORGE HSU, CARINE LENDERS, JANEY S.A. PRATT, R. ARMOUR FORSE, ADRIENNE O’BRIEN, AND MICHAEL TARNOFF. Best practice guidelines in pediatric/adolescent weight loss surgery. Obes Res. 2005; 13:274 –282. Objective: To establish evidence-based guidelines for best practices in pediatric/adolescent weight loss surgery (WLS). Research Methods and Procedures: We carried out a systematic search of English-language literature in MEDLINE on WLS performed on children and adolescents. Key words were used to narrow the field for a selective review of abstracts. Data were extracted, and evidence categories were assigned according to a grading system based on established evidence-based models. Eight pertinent case series, published between 1980 and 2004, were identified and reviewed. These data were supplemented with expert opinions and literature on WLS in adults. Results: Recommendations focused on patient safety, reduction of medical errors, systems improvements, credentialing, and future research. We developed evidence-based criteria for eligibility, assessment, treatment, and follow-up; recommended surgical procedures based on the best available evidence; and established minimum guideline requirements for data collection. Discussion: Lack of adequate data and gaps in knowledge were cited as important reasons for caution. Physiological

The costs of publication of this article were defrayed, in part, by the payment of page charges. This article must, therefore, be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. *Department of Medicine, Surgery, and Pediatrics, and Section of Endocrinology, Diabetes and Nutrition, Boston University Medical Center, Boston, Massachusetts; †Weight Center and Departments of Surgery, Pediatrics, and Psychiatry, Massachusetts General Hospital, Boston, Massachusetts; ‡Boston Children’s Hospital, Boston, Massachusetts; §Departments of Surgery and Psychiatry, Tufts-New England Medical Center, Boston, Massachusetts. Address correspondence to Caroline M. Apovian, Boston University Medical Center, 88 East Newton Street, Robinson Building, Suite 4400, Boston, MA 02118. E-mail: [email protected] Copyright © 2005 NAASO

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status, comprehensive screening of patients and their families, and required education and counseling were identified as key factors in assessing eligibility for surgery. Data collection and peer review were also identified as important issues in the delivery of best practice care. Key words: pediatric, adolescent, gastric bypass, bariatric surgery, overweight

Introduction The prevalence of overweight in pediatric age groups has nearly tripled in the last 30 years (1). Today, an estimated 16.1% of adolescents (12 to 19 years old) in the United States are overweight (BMI ⱖ 95th percentile for age) (2) (Appendix 1). Studies indicate that 50% to 77% of those adolescents will become obese adults; 80% of those with one obese parent will do so (3– 6). Data show significantly lower quality-of-life scores for obese children compared with children of normal weight (7). They also show increased risk of obesity-related comorbidities, including degenerative joint disease (8,9) and type 2 diabetes (3,10 –12). For severely obese adults, weight loss surgery (WLS)1 is a safe and effective option with well-defined risks (13–15). However, very little information has been published on the subject of obesity surgery in adolescents (16), and few reports have addressed their unique metabolic, developmental, and psychological needs (17). This paper addresses those needs in the context of best practice recommendations for patient safety, evaluation, selection, surgical treatment, and follow-up.

Research Methods and Procedures We searched MEDLINE for articles on pediatric WLS published from January 1980 to February 2004. These in-

1 Nonstandard abbreviations: WLS, weight loss surgery; RCT, randomized controlled trial; RYGB, Roux-en-Y gastric bypass; LAGB, laparoscopic adjustable gastric banding; BPD, bileopancreatic diversion; BPD-DS, BPD with duodenal switch; JIB, jejunoileal bypass; VBG, vertical banded gastroplasty.

Pediatric Weight Loss Surgery Guidelines, Apovian et al.

cluded prior systematic reviews on the subject, randomized controlled trials (RCTs), prospective cohort studies, crosssectional surveys, case reports, and existing guidelines on pediatric WLS. Inclusion and exclusion criteria were developed for each major search area (18). The system used to grade the quality of the evidence was based on models used by the U.S. Preventive Services Task Force (19) and other established agencies and organizations (20). No RCTs on pediatric and adolescent WLS were found. Recommendations were based on extracted evidence (Category C) and expert opinions and literature from WLS in severely obese adults (Category D).

Results Potential Benefits Sugerman et al. (16) have reported that WLS in adolescents is safe and associated with significant weight loss, correction of obesity-related comorbidities, and improved self-image and socialization. Those data are consistent with outcomes from other studies (1,21–23). Evidence Statement. WLS can be a safe and effective treatment modality for carefully selected adolescents with severe obesity and major obesity-related comorbidities (Category C). Patient Safety Reasons for Caution. Timing of surgical treatment for clinically severe obesity in adolescents is controversial and often depends on the severity of obesity-related comorbidities for individual patients (17). Factors to consider before recommending WLS in adolescent patients (i.e., 12 to 19 years old) include: pubertal development and growth, psychological maturity, the potential for as-yet-unknown chronic complications, and pregnancy or plans to become pregnant. Evidence Statement. Surgery should be used after careful deliberation (24) to treat intractable severe obesity and its medical complications in affected adolescents (Category D). Because limited information is available to guide patient selection and predict long-term risks, centers engaging in WLS in this age group should be committed to rigorous collection of data to enhance knowledge in this field.

inations should include evaluations of sexual maturation. The linear growth spurt generally occurs before Tanner stage IV in both boys and girls. The majority of skeletal maturity is attained by girls at ⱖ13 years of age; boys, at ⱖ15 years of age (17). Although maximizing adult height may be of lesser concern than the medical consequences of severe obesity, it would seem prudent to exclude adolescents who have not attained Tanner stage IV and 95% of adult height based on estimates of bone age. In cases of uncertainty, the patient should be referred to a specialist in pediatric endocrinology, and radiographs of the hand and wrist should be performed to assess bone age. Evidence Statement. Adolescents who have not attained Tanner stage IV and 95% of adult height based on bone age should be excluded as candidates for WLS (Category D). BMI BMI is a useful screening tool for assessing and tracking the degree of obesity among adolescents (25,26), but direct application of adult BMI criteria for WLS (20) to younger age groups could lead to specious clinical decision making. Until further information is available, more conservative selection criteria should be applied to adolescent candidates for WLS. Many comorbidities of obesity can be documented in childhood and adolescence, but the severity of these comorbidities for the majority of those adolescents with BMI ⱖ 30 kg/m2 does not warrant surgical intervention (17). Data also show that behavior therapy approaches can be more effective in children and adolescents than in adults (27) and that a proportion (20% to 30%) of obese adolescents may not become obese adults (4). Evidence-Based Statement. Inclusion criteria: ●

● ● ●

BMI ⱖ 40 kg/m2 with one serious comorbidity (such as type 2 diabetes, obstructive sleep apnea, severe or complicated hypertension, or pseudotumor cerebri); BMI ⱖ 50 kg/m2 with less serious comorbidities (17); Failure of nonsurgical treatments for obesity; Adolescents with lower BMI (⬍35) and life-threatening comorbidities should be considered for WLS on a caseby-case basis (Category D).

Exclusion criteria: Criteria for Eligibility Physiological Maturity. Neuroendocrine and skeletal maturation are accelerated during adolescence, and it is not yet known how these processes are affected by restrictive or malabsorptive WLS procedures (17). Failure to attain physiological maturity before WLS may delay or affect achievement of potential growth and sexual development due, in part, to postoperative nutrient deficiencies. Height and pubertal maturity are reasonable markers of adult metabolic and physiological maturity. Physical exam-

● ● ●

Patient has not attained Tanner stage IV (Category D); Patient has not attained 95% of adult height based on estimates from bone age (Category D); Female adolescents who are pregnant, breast-feeding, or plan to become pregnant within 2 years of surgery (Category D).

Pregnancy The effects of WLS on fertility, pregnancy, and the health of offspring are of particular importance for female adolesOBESITY RESEARCH Vol. 13 No. 2 February 2005

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cents. Adult experience indicates that fertility increases after WLS. After weight stabilization, wellness during pregnancy is also improved, with fewer incidences of maternal and fetal complications, such as preeclampsia, gestational diabetes, macrosomia, and neural tube defects. Evidence Statement. Female adolescents who undergo WLS must be counseled on the need to postpone pregnancy until at least 2 years after surgery to avoid potential birth defects from nutrient deficiencies. Family planning, including methods of contraception, should be offered to fertile female patients (Category D). Syndromic Obesity Syndromic obesity, such as Prader-Willi syndrome, should be excluded or diagnosed before WLS. In questionable cases, consultation with a specialist in genetics should be obtained. If syndromic obesity is diagnosed, there must be a reasonable expectation, based on careful review of available literature, that the syndrome will not adversely affect the outcome of WLS. Informed Consent Consent in the case of a minor requires full consent of the legal guardian and the patient. Complete understanding of surgical and nonsurgical alternative treatments for obesity, possible short- and long-term complications, and behavior changes required to achieve a successful outcome should be documented. Tests used to document education should be administered to the guardian and the patient. Legal guardians and/or patients who are unwilling or unable to provide documented informed consent should be considered ineligible for WLS. Psychological Maturity Each adolescent and family should be extensively evaluated by a multidisciplinary team with experience in pediatric WLS and specialized knowledge in the treatment of overweight adolescents. The team should consist of the surgeon, a pediatrician, a behavioral clinician (i.e., pediatric psychiatrist or psychiatrist), and a registered dietitian. Knowledge, motivation, and compliance should be assessed by interview and written examination of the adolescent and at least one parent or legal guardian; exam content should evaluate understanding of the planned procedure, the potential risks and benefits, the nature of potential complications, and responsibility for self-care (Category D). Psychological maturity should be evaluated to determine whether the patient is able to understand the consequences of WLS, provide informed consent, and comply with medical care and lifestyle changes required before and after surgery (Category D). Specific tools that can be used to carry out the psychological evaluation are shown in Table 1. Psychological factors that present a contraindication to WLS or that could interfere with treatment, such as eating 276


Table 1. Goals of psychological evaluation prior to WLS for adolescents A. Evaluate ability to consent; assess family agreement/ support or coercion (use interview, mental status exam, visual analogue scales). B. Evaluate motivation, compliance, knowledge about procedure and postoperative requirements and expectations (use repeated interviews, homework between appointments, and test of knowledge/understanding). C. Evaluate psychological factors that could interfere with treatment or negatively impact surgical outcome or adjustment (talk with counselor or therapist, if available). 1. Eating disorder symptoms (use interview and selfreport instruments such as the Eating Disorder Examination, Eating Disorder Inventory-II subscales, or Questionnaire of Eating and Weight Patterns for adolescents) 2. Mood (use interview and self-report instrument such as the Child Depression Inventory) 3. Smoking, substance abuse (use interview and selfreport questions) 4. Psychosis, borderline personality disorder (use interview, treatment, and symptom history; also talk with current/past clinicians, if possible) 5. Abuse, posttraumatic stress disorder (use interview) D. Assess family environment, school environment, social support, barriers to adherence (use interviews with patient, parents, and other family members living in home; and teacher or coach, if an appropriate reference is available)

and/or mood disorders, psychosis, borderline personality disorder, sexual or physical abuse, cigarette smoking, substance abuse, and posttraumatic stress disorder should be evaluated and appropriately treated (Category D). Evidence Statement. Eligibility for WLS should be based on comprehensive assessments and testing of the patient and at least one legal guardian. Decisions to proceed with surgery should be based on documented knowledge, motivation, and understanding of the planned procedure, its risks and benefits, and potential complications; capacity for compliance and self-care; psychological maturity; and contraindications (Category D). Choice of Procedure The optimal procedure for adolescent WLS has yet to be identified. Data are scant but still allow for some general


conclusions to be drawn. They also underscore the importance of performing WLS only in the context of an intensive multidisciplinary evaluation and treatment program. Recent data show that ⬃150 adolescents have undergone WLS since 1985 (28). Studies published since 1974 indicate variable outcomes in adolescent patients for short- and long-term morbidity, mortality, and efficacy from all well-tested procedures except biliopancreatic diversion (16,22,23,29 –33) (Category C). There are several limitations to this body of literature, including small sample sizes; lack of consistency across programs, surgeons, and procedures; and a short average length of follow-up. However, larger series from adult WLS populations have been reported (34 –50), and selected components of data from these studies can be safely extrapolated to the adolescent population. Roux-en-Y Gastric Bypass (RYGB) Data suggest long-term efficacy and safety of RYBG in adolescent patients (16,22,23,30 –32). Similar outcomes have been reported from larger series in adult populations (34 –37). To date, there have been no negative reports surrounding the use of RYGB in adolescent populations. Limited data suggest that long limb and distal gastric bypass can also be safe and effective in adolescents (16), but they increase the risk of nutrient deficiency and protein energy malnutrition and seem to be most appropriate in superobese adolescents who have reached skeletal maturity. More aggressive malabsorptive procedures should be viewed with great caution in the adolescent population (Category C). Their irreversible nature mandates meticulous patient selection and commitment to lifelong follow-up (Category C). Laparoscopic Adjustable Gastric Banding (LAGB) LAGB is approved by the FDA for use in properly selected patients between the ages of 18 and 65. We identified one published series on the use of LAGB in an adolescent population (33,51). The majority of data come from Australia and Europe, with growing evidence from experience in the United States (46 –50). Data show that in adults, LAGB yields long-term excess weight loss of 40% to 50%, which is comparable with that achieved with gastric bypass (52). Further, resolution or improvement of associated comorbid conditions after LAGB placements occurs with the same frequency as is seen after gastric bypass (53). Approximately 10% of LAGB patients undergo revisional surgery (46 –50). Longterm success of LAGB in adolescent patients is still unknown, but the low morbidity and reversibility of the procedure make it an attractive alternative for severely obese adolescents. Evidence Statement. Limited available data suggest that RYGB and LAGB are generally safe and produce durable

weight loss in adolescents. Evidence is from eight Category C studies (Table 2) and large-scale adult case series reports. The panel recognizes RYGB as the procedure with the best long-term data and LAGB as the procedure with the least apparent risk for adolescent patients. Because there are currently no criteria to determine which of the two procedures (RYGB or LAGB) is best for any given patient, the decision should rest with the patient, his or her parents or guardians, and the surgeon and other members of the WLS team (Category D). Bileopancreatic Diversion (BPD) and BPD with Duodenal Switch (BPD-DS) Much data exist on the effectiveness and safety of BPD and BPD-DS (43) in adult populations (40 – 45,54). Studies report durable excess weight loss of 70% to 80% after 14 years (40). These procedures enable patients to eat a more normal diet without the effects of caloric restriction or dumping. However, these are complex operations, with greater risk of nutrient deficiency and protein calorie malnutrition. The American Society of Bariatric Surgeons currently recommends that BPD and BPD-DS be performed only by experienced surgeons with a commitment to longterm follow-up (55). Evidence Statement. The affects of BPD and BPD-DS in adolescents are unknown. Until reliable long-term data are available, this malabsorptive procedure is not considered an appropriate option for adolescent WLS patients (Category D). Jejunoileal Bypass (JIB) and Vertical Banded Gastroplasty (VBG) Limited data exist on the use of JIB in adolescent patients (29). The procedure is no longer performed because it was associated with severe nutrient, protein calorie malnutrition, liver failure, and death (55). VBG has been displaced by RYGB (38,39) and LAGB. Surgeon Credentialing Pediatric surgeons should be eligible for credentialing in WLS under the same criteria as surgeons who perform weight loss procedures on adults (56). Likewise, surgeons who provide WLS to adults should be eligible for credentialing to operate on pediatric patients who meet the criteria for WLS (Category D). Program Credentialing In the future, programs with demonstrated expertise in WLS and dedicated pediatric teams for evaluation and longterm care of adolescent patients may apply for special credentialing in pediatric WLS. They should demonstrate the capacity to comply with the best practice guidelines in this supplement, participate in the peer review process, and collect long-term data. They must modify their plant and OBESITY RESEARCH Vol. 13 No. 2 February 2005

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278

15 to 17 years; 7 girls, 3 boys; total ⫽ 10

17 to 19 years; 3 girls, 1 boy 13 to 17 years; total ⫽ 19

11 to 17 years; 8 girls, 3 boys; total ⫽ 11 12 to 18 years; 19 girls, 14 boys; total ⫽ 33

12 to 19 years; total ⫽ 17

Strauss (31)

Stanford (22)


Abu-Abeid (51)

Dolan (33)

42.2

52

46.6

49

55.1

52.4

47

154 kg; no BMIs listed

Initial mean BMI

LAGB

1 horizontal gastroplasty; 2 VBG; 17 RYGB; 10 LL GB; 3 days GB

LAGB

VBG-RYGBP

Laparoscopic RYGB

RYGB

30, RYGB; 4, VBG

JIB

Type of surgery

Postoperative BMI ⫽ 30

77% weight loss

Postoperative BMI ⫽ 33.1

Postoperative BMI mean ⫽ 28

87% weight loss

62% weight loss

BMI average, 32; 66% weight loss

Average weight 107 kg

Results

GB, gastric bypass; LL GB, long limb gastric bypass; PE, pulmonary embolus; SBO, small bowel obstruction.

Sugerman (16)

Capella (23)

Rand (30)

11 to 22 years; 8 girls, 3 boys; total ⫽ 11 11 to 19 years; 27 girls, 7 boys; total ⫽ 34

Subject age and gender

Silber (29)

Reference

Table 2. Case series reports of adolescent WLS reported since 1980 (Category C)

One PE, one wound infection, three stomal stenoses, four marginal ulcers, two deaths, one SBO, six incisional hernia

Two gastrogastric fistulas; two cholelithiasis; one ulcer; three anemias Four iron-deficient anemia

Three deaths; hepatic failure, renal failure, sepsis One staple line failure; three inadequate weight loss; revision hypoglycemia; anemia; gallbladder disease Three pregnancies; one protein calorie malnutrition; two cholelithiasis One persistent sleep apnea

Complications

2 months

14 years

23 months

10 years

4 to 22 months

1 year

6 years

10 years

Follow-up period



Table 3. Minimum requirements for data collection 1. Preoperative assessments a. Anthropometrics, including past measurements to determine age of onset of overweight if available b. Medical comorbidities and laboratory screening to include: TSH, BUN/Cr, LFTs, total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fasting glucose or 2-hour oral glucose tolerance test, insulin, PTH, 25-OH Vit D, pregnancy test c. Psychological measures (standardized written measures and expert assessment, as described elsewhere in this document) d. Family history of obesity and the major obesity-related comorbidities in first and second degree relatives 2. Perioperative data a. Surgical procedure(s) b. Intraoperative findings and complications c. Postoperative recovery time and setting 3. Short-term outcomes (0 to 1 year postoperative) a. Weight change, height velocity pre- and postsurgery, symptoms (vomiting, pain, other complaints), menstrual patterns b. Surgical complications c. Cosmetic complications: assessment of pannus formation d. Medical complications: laboratory assessment of micronutrient deficiencies (iron studies, vitamin B12 folate, 25hydroxy vitamin D, prothrombin, calcium, PTH, thiamine) and periodic bone density measurements. e. Status of medical comorbidities (repeated measures) f. Compliance with prescribed supplements, follow-up visits, eating and exercise requirements, and contraception g. Social adjustment (return to school, repeat written measures of depression, eating attitudes and eating disorders, selfesteem, and body image; assessment of substance abuse) 4. Long-term outcomes a. All of the above plus: b. Pregnancies i. Timing, laboratory assessment during, complications ii. Long-term follow-up of offspring, whenever possible: anthropometrics, medical problems, school performance c. Male reproductive function, erectile function d. Social outcomes i. Further education ii. Stable relationships iii. Employment TSH, thyroid stimulating hormone; BUN/Cr, blood urea nitrogen/creatinine; LFT, liver function test; PTH, parathyroid hormone; 25-OH Vit D, 25 hydroxy vitamin D.

equipment to accommodate the physical and psychological needs of severely obese adolescent patients (Category D) (57). Future Research: Prospective Data Collection Current literature on pediatric WLS is insufficient to determine how outcomes in adolescents may differ from those in adults who undergo WLS. Prospective collection of high-quality data is imperative to advance the field and improve our ability to predict outcomes and manage ado-

lescent WLS patients. Strong and ongoing efforts to collect short- and long-term data should be a requirement for certification. A centralized data collection system should be created. Programs with their own databases will be encouraged to use systematically defined data elements and procedures to collaborate with other programs using the centralized system. Only data from patients who go through an appropriate informed consent process will be included in the database. Databases that combine adolescent with adult patient data OBESITY RESEARCH Vol. 13 No. 2 February 2005

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are recommended (58); however, adolescent data should be easy to extract. Minimum requirements for data collection are outlined in Table 3. Task Group Recommendation Data collection is essential for improving patient safety and conducting medical research on WLS. Thus, all programs offering WLS to adolescents should be vigorously engaged in collecting short- and long-term data on their adolescent patients. Follow-Up Data collection systems should have clearly defined procedures to ensure long-term patient follow-up, including: scheduled annual appointments, multiple pathways of contacting patients over time, and active efforts to find patients who fail to return for follow-up appointments or are lost to follow-up. Strategies for Medical Error Reduction: Peer Review Process Current literature justifies WLS for selected adolescents with high-risk obesity but is insufficient for setting firm protocol for all aspects of care. Evolving standards of care call for particularly careful decision-making, the highest quality care, and careful long-term follow-up. Programs offering WLS to adolescents should undergo a peer review process on a regular basis to ensure the implementation and maintenance of the high standards of care defined in this supplement and to ensure collaboration and updating of standards. Details of the process will need to be determined by a representative group from pediatric WLS programs. Task Group Recommendation We recommend a biennial peer review process for all programs offering WLS to adolescents, with ongoing collaborative discussion, sharing of techniques, and updating of standards among all programs.

Discussion An epidemic increase in adolescent obesity in the United States has resulted in significant obesity-related comorbidities previously seen only in adults. Although WLS is an acceptable alternative for weight loss in severely obese adults, no conclusions have been made about the appropriateness of WLS for individuals younger than 18 years of age. Nonetheless, WLS is increasingly being performed on adolescents with clinically severe obesity (24). Application of the principles of adolescent growth, development, and compliance is essential to avoid adverse physical, cognitive, and psychosocial outcomes after weight loss operations (24). A multidisciplinary team of pediatric 280


specialists is needed for optimal preoperative decision making and postoperative management (1). Strategies for medical error reduction and systems improvement should include a peer review process in which all programs offering WLS to adolescents participate on a biyearly basis. The goals of the process will be to ensure that the high standards of care outlined in this document are met and maintained and also to ensure collaborative discussion, sharing of techniques, and updating of standards among all programs. Research needs for the future should include prospective data collection and interpretation of long-term outcomes of adolescents undergoing WLS, especially for the newer, less invasive procedures such as the LABG.

Acknowledgments We thank George Blackburn and Frank Hu for manuscript preparation, Barbara Ainsley for administrative assistance, and Rita Buckley for editorial services. Manuscript preparation was supported, in part, by the Center for Healthy Living at Harvard Medical School and by the Boston Obesity Nutrition Research Center Grant P30DK46200. This report on WLS was prepared for the Betsy Lehman Center for Patient Safety and Medical Error Reduction (Department of Public Health, Boston, MA). References 1. Inge TH, Garcia V, Daniels S, et al. A multidisciplinary approach to the adolescent bariatric surgical patient. J Pediatr Surg. 2004;39:442–7. 2. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA. 2004; 291:2847–50. 3. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics. 2001;108:712– 8. 4. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337:869 –73. 5. Guo SS, Huang C, Maynard LM, et al. Body mass index during childhood, adolescence and young adulthood in relation to adult overweight and adiposity: the Fels Longitudinal Study. Int J Obes Relat Metab Disord. 2000;24:1628 –35. 6. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med. 1993;22:167–77. 7. Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289:1813–9. 8. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. 1998;101:518 – 25.


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