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10 Articles in Volume 17, Issue #6
A Plea for Proper Opioid Tapering
Centers of Excellence in Pain Management: Past, Present, and Future Trends
Comorbid Pain and Childhood Obesity
Discussing Migraine With Your Patients: A Common Sense Guide for Clinicians
Justification of Morphine Equivalent Opioid Dosage Above 90 mg
Letters to the Editor: Dependence vs Addiction, Opioid Metabolism
Opioid Rotation From Opana ER Following FDA Call for Removal
Psoriatic Arthritis: Established, Newer, and Emerging Therapies
Sleep-Wake Disorders and Chronic Pain: Reciprocal and Interactive Effects
What are Nav1.7 inhibitors and how are they used in the treatment of neuropathic pain?

Comorbid Pain and Childhood Obesity

Interview with Melissa Santos, PhD, Connecticut Children’s Medical Center in Hartford, Connecticut.

Q: Please discuss the incidence of childhood obesity in the United States.

Dr. Santos: The incidence of childhood obesity has increased rapidly over the past few decades. We have seen leveling off in the incidence but not in how large kids are getting. So, while the overall prevalence rates haven’t dramatically changed, the level and severity of childhood obesity continue to increase. Children aren’t just becoming obese—they’re hitting our Class 3 obesity levels (high risk, or significant morbid obesity).

Q: Are there more younger children with obesity?

Dr. Santos: We are seeing younger and younger children in our clinic. In fact, I have a 90-lb 2-year-old in our clinic right now. A study by Ogden et al1 found that the prevalence of childhood obesity (body mass index [BMI] over the 95th percentile) between 2011 and 2012 was:

  • 8.4% of 2- to 5-year olds
  • 17.4% of 6- to 11-year olds
  • 20.5% of 12- to 19-year olds

We are also performing weight loss surgery more regularly on teenagers. We have always talked about a soft minimum age of 14 for this type of surgery, but we know clinics that evaluate kids even younger than that.

Q: What is food addiction?

Dr. Santos: Food addiction has been used to describe lots of different behaviors. For our kids, we see it in the kids who wake up and immediately want breakfast. Food is the first thing on their mind. When they are eating breakfast, they are wondering about their next snack or meal. Some may sneak or find ways to go to stores to purchase food—usually unhealthy food items.

Q: What is the impact of obesity on children?

Dr. Santos: Obesity affects kids from head to toe. I don’t know anybody who would want to go back to being in high school, much less do it as a 300-lb kid. As former Surgeon General Richard Carmona said, “Because of the increasing rates of obesity, unhealthy eating habits, and physical inactivity, we may see the first generation that will be less healthy and have a shorter life expectancy than their parents.”

Overall, we see poor self-esteem, depression, and anxiety in children with obesity. These children worry about basic things, such as whether the chair they’re in will support their weight or whether they’ll be able to get out of the chair. We’ve had kids get stuck behind desks. Morbidly obese children get winded walking between their classrooms.

There was a landmark study 15 years ago that showed that health-related quality of life for kids with severe obesity was comparable to that of kids with cancer on active chemotherapy, which is shocking.2

Q: What is the medical impact of obesity on children?

Dr. Santos: We are seeing young children with medical concerns that we never saw in children before. For example, type 2 diabetes used to be an adult disease, but now we’re seeing it in elementary school kids under the age of 10.

Asthma, sleep apnea, exercise intolerance, gallstones, flat feet, forearm fractures, stress incontinence, and hernia are some of the other complications of childhood obesity.3

Q: I’d like your thoughts on obesity and pain. In a study you presented, 70% of the 107 children in your clinic complained of pain. Headaches were reported in 55% of children, back pain in 54%, and knee pain in 31%.4 I was not surprised to hear about the musculoskeletal effects of obesity, but I was surprised to see the high levels of headaches among children.

Dr. Santos: We’ve been trying to figure out why we’re seeing headaches so much. The misconception is that overweight kids eat a lot throughout the day, but they actually go long periods without eating before binging at night. Would not eating regularly cause the headaches? Is it something related to the quality of food?

Children with sleep apnea often do not want to use the machine, and they wake up with headaches. We also have children who have odd weight distributions, such as having fat on their heads. Does this increase the headache risk?  We are looking into these questions.

Q: Are they traditional migraines or all types of headaches?

Dr. Santos: All types. We have kids with formal migraines, and then we have kids who just complain of headaches all the time. We see the whole spectrum.

Q: Are you seeing an increase in pain intensity?

Dr. Santos: Yes. The Pain Burden Inventory is a measure created by William Zempsky in our Pain & Palliative Medicine division at Connecticut Children’s Medical Center, and it was initially performed on kids with sickle cell disease. We used the same measure in our pain program.

We found that the pain burden scores of children with obesity are similar to those of children with sickle cell disease (5.24 vs 6.79, respectively). This really spoke to the severity of the problem.

We have also seen that obese children take longer to see a pain specialist than non-obese kids. In a study conducted in our pediatric pain program, of the 99 patients (8-18 years), 29% were obese.5 Other associations with obese children include:

  • A higher BMI percentile correlated with greater parental reports of child catastrophizing in 8- to 12-year olds  
  • A greater likelihood of higher parental Functional Disability Index scores, especially among girls  

In addition, the children with pain and obesity were more likely to have experienced pain for a longer duration (42 months) than those without obesity (17 months).

Why is it taking so long to address their pain? Part of the problem is that parents and the children themselves assume that overweight children will have pain, and thus dismiss their complaints. When we talk about pain with parents and children, they say matter-of-fact phrases like:

  • “I think his weight has an absolute effect on his knees and back. He has bad posture because he tries to hide his chest when walking. When in pain, you tend to do less.”
  • “I think my pain influences my weight because the more pain I have, the lazier I am, and my laziness goes on to my weight.”
  • “The pain and weight are in different places. Heads don’t have weight.”  

Q: How does that affect their ability to cope with the pain, if that’s the case?

Dr. Santos: One of the things we want to explore is understanding the life experience of these kids. We understand the life experience of kids with obesity, and I think we understand the experience of kids with pain—but not combined. These are 2 significant pediatric and adult health concerns. What happens when you have both, and what’s your life like then?

Q: What is your approach to treatment?

Dr. Santos: We discovered a subset of kids with chronic pain who were not doing well in the weight loss program—they were dropping out of treatment more than other kids. That makes sense, right? You’re obese and have pain, and you’re coming to a program that’s telling you to eat less and move more. Who wants to do that?

I hope to launch a cognitive behavioral therapy intervention where I can actually combine the 2 conditions. The goal is to provide good chronic pain coping skills to better engage kids in treatment. Ultimately, the program may help them lose weight, which, for at least the musculoskeletal pain, could be a good treatment for them.

Q: What is your recommendation for weight loss surgeries versus just diet? You noted that many children regain their excess weight within 2 years of completing a nonsurgical weight management program.

Dr. Santos: We know weight loss surgery is probably the most effective treatment for maintenance of weight loss, but it doesn’t work for everyone. It’s also scary to think of performing a major surgery on young teenagers. At our institution, we currently perform the Lap Band and the sleeve gastrectomy procedures. We’re moving toward performing only the sleeve gastrectomy, which is the removal of 75% of the stomach.

We recommend surgery when quality of life and physical health are so poor that the benefits outweigh the risks. The requirements for weight loss surgery are a BMI of 35 with a medical comorbidity or a BMI of 40 with no medical comorbidity. Most medical professionals also say the minimum age for weight loss surgery is 14 years. We include a multidisciplinary team, so the patient must be cleared medically and psychologically to undergo surgery. We start months before surgery to prepare patients, but it’s tough afterward.

Q: How important is a support program or network to childhood bariatric surgery success?

Dr. Santos: The nice thing about our bariatric programs is the support group. Support is considered a standard of care for people undergoing bariatric surgery. We offer a support group for kids before and after surgery. We see children who really struggled before surgery, then after surgery strive to be positive role models for younger kids. They take ownership, and they show other kids that they can do it and can be successful.

To see a video of our interview with Dr. Santas at the American Pain Society meeting, go to: https://www.practicalpainmanagement.com/meeting-summary/video-interviews.

Last updated on: November 5, 2020
Continue Reading:
Centers of Excellence in Pain Management: Past, Present, and Future Trends

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