Massachusetts General Hospital | MassGeneral Hospital for Children

Alison G. Hoppin, MD, Associate Physician in Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Associate Director for Pediatric Programs, Mass General Weight Center, Assistant Clinical Professor of Pediatrics, Harvard Medical School

Obesity is a unique medical problem because it affects a large proportion of the population across the entire lifespan, causes comorbidities in virtually every organ system including mental health and social functioning, typically affects several members of the same family, and is remarkably refractory to treatment.

Accordingly, the MassGeneral Hospital for Children Weight Center is a unique program, with the following goals:

Multidisciplinary clinical care for children with obesity

• Expertise in evaluating and addressing comorbidities in each organ system, and nutritional issues.
• Assessment of psychosocial contributors to and consequences of obesity, and coordination of mental health care
• Close collaborations with subspecialists at MGHfC for patients with advanced comorbidities such as type 2 diabetes or obstructive sleep apnea
• Established and successful Weight Loss Surgery program for adolescents with severe and complicated obesity
• Expanding clinical options, including group-based programs for parents of young children and for adolescents (ENRGY, launching in fall 2012)

Lifespan approach

• Parents and other family members are included in the clinical care of pediatric patients
• The MassGeneral Weight Center for Children is closely associated with the adult programs at the MGH Weight Center. Multiple members of the same family often seek care at the Weight Center, allowing for coordinated family-centered care.
• Pediatric patients are treated with age-appropriate approaches that evolve as the patient matures.

Collaborative research

• Create a network among the clinicians and investigators in the MGHfC community who are working in the field of obesity, to increase awareness of our common resources, catalyze collaboration, and support coordinated clinical care.
• Accomplish clinical and translational research in pediatric obesity.
• Support research projects that emanate from other departments at MGHfC , MGH, or Partners’ Health Care systems.
• Collaborate with the research arm of the MGH Weight Center, which has expertise and ongoing projects examining the genetic contributors to obesity, and the neuroendocrine mechanisms involved in weight loss surgery.

Our research efforts take several different approaches, which are outlined above and detailed below.

1) Create a network:  Expertise in obesity is spread across a wide range of divisions and locations at MGHfC. Accordingly, we convened a Pediatric Obesity Collaborative Retreat in May 2012 to catalyze clinical and academic collaboration. Speakers and participants represented most pediatric subspecialties and primary care, Pediatric Surgery, Nursing and Anesthesia, the Stoeckle Center for Primary Care, MGH Community Health Centers, the Center for Community Health Improvement, the Institute of Sports Psychology, and the Newton-Wellesley Hospital Weight Management Program. The first outcome of the Collaborative Retreat is the development of a set of patient-education materials for use by clinicians throughout the MGHfC system.

2) Accomplish our own research program:  The focus of research is informed by the characteristics of our program:

• A high proportion of children and adolescents with very severe obesity  
• A subset of adolescents undergoing weight loss surgery

Clinical research from the Weight Center’s pediatric program has included a trial of a curriculum designed to attenuate the development of obesity in pre-school aged children (a collaboration with the Massachusetts WIC program). We also collaborated with Craig Canapari of the Pediatric Pulmonary and Sleep Medicine programs in his study of the relationship between sleep apnea, fat distribution and insulin resistance in obese children.

Future projects will focus on adolescents in our weight loss surgery program, addressing the physiologic and perhaps psychological changes that accompany dramatic weight loss and resolution of comorbidities.  

3) Support research projects that emanate from other departments at MGHfC:  The MassGeneral Hospital for Children Weight Center supports clinical research projects that are initiated by investigators from other divisions, by collaborating on study design and/or helping to recruit subjects from our clinical population. Ongoing projects include a study of cardiac remodeling in adolescents with metabolic syndrome using cardiac MRI (a collaboration with Michael Jerosch-Herold and Ravi Shah, of the radiology and cardiology departments).   In addition, we are helping to recruit subjects for a study examining the effects of low-dose growth hormone on visceral fat and cardiovascular risk factors in adolescent girls with obesity (principal investigator Madhusmita Misra). 

4) Collaborate with the research arm of the MGH Weight Center:   The MGH Weight Center has several active research programs that focus on 1) the pathophysiology on non-alcoholic fatty liver disease (NAFLD) in obesity and  2) physiological and molecular mechanisms of gastrointestinal regulation of body weight. While this research has largely focused on adults, the expansion of this research to include children is a top priority for the center.  As the Mass General Weight Center continues to expand its pediatric programs in medical management of obesity and pediatric surgical programs, it will also expand pediatric research endeavors.

Members of the MassGeneral Weight Center for Children Pediatric team:

• Pediatric Obesity Medicine:  Paul Boepple (Pediatric Endocrinology); Alison Hoppin (Pediatric Gastroenterology and Nutrition); Christina Scirica (Pediatric Pulmonology); Fatima Stanford and Gitanjali Srivastava (Obesity Medicine fellows).
• Bariatric Surgery:  Janey Pratt (Director, MGH Weight Center)
• Weight Center Psychology:  Mark Gorman and Stephanie Sogg
• Weight Center Nutrition:  Isadora Nogueira and Marianne Tsikitas

MassGeneral Weight Center for Children bibliography:

Adolescent Weight Loss Surgery:

1. Michalsky M, Reichard K, Inge T, Pratt J, Lenders C. American Society for Metabolic and Bariatric Surgery.Surg Obes Relat Dis. ASMBS pediatric committee best practice guidelines. 2012; 8(1):1-7.
2. Lenders CM, Gorman K, Lim-Miller A, Puklin S, Pratt J. Practical approaches to the treatment of severe pediatric obesity. Pediatr Clin North Am. 2011; 58(6):1425-38.
3. NA Kissane, R Lovett, MJ Gorman, R Kalmbach, et al.  Where should adolescents undergo weight loss surgery. Poster presentation, annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), San Antonio, 2011.
4. Pratt JS, Lenders CM, Dionne EA, Hoppin AG et al. Best practice updates for pediatric/adolescent weight loss surgery. Obesity (Silver Spring). 2009; 17(5):901-10.
5. Levitsky LL, Misra M, Boepple PA, Hoppin AG. Adolescent obesity and bariatric surgery.  Curr Opin Endocrinol Diabetes Obes. 2009; 16(1):37-44.
6. Hoppin AG, Katz ES, Kaplan LM, Lauwers GY. Case records of the Massachusetts General Hospital. Case 31-2006. A 15-year-old girl with severe obesity. N Engl J Med. 2006; 355(15):1593-602.

Collaborations with other MGHfC specialists:

1. Stanford FC, Hoppin AG. Extreme Childhood Obesity Secondary to Homozygous Melanocortin Receptor (MC4R) Mutation: A Case Report. J S C Med Assoc 2012; in press.
2. Canapari CA, Hoppin AG, Kinane TB, Thomas BJ, et al. Relationship between sleep apnea, fat distribution, and insulin resistance in obese children. J Clin Sleep Med. 2011; 7(3):268-73.
3. Kaplan LM, Gorman MJ. Addressing the big challenge of obesity: how to prevent regain of lost weight. Nat Clin Pract Gastroenterol Hepatol. 2007; 4(5):254-5.
4. Palmert MR, Mansfield MJ, Crowley WF Jr, Crigler JF Jr et al. Is obesity an outcome of gonadotropin-releasing hormone agonist administration? Analysis of growth and body composition in 110 patients with central precocious puberty.  J Clin Endocrinol Metab. 1999; 84(12):4480-8.

Basic science research:

1. Stylopoulos N, Hoppin AG, Kaplan LM. Roux-en-Y gastric bypass enhances energy expenditure and extends lifespan in diet-induced obese rats. Obesity (Silver Spring). 2009; 17(10):1839-47.