Under Right Circumstances, Bariatric Surgery Good for Obese Teens

Marlene Busko

June 07, 2019

Primary care providers should consider referring "appropriate" obese adolescent patients for bariatric surgery, according to a new review article published in the medical progress section of the Journal of Pediatrics

"Obesity and associated comorbid conditions are a major threat to our youth" and "the question remains, 'Are we doing enough to manage obesity?'" Ahmed Khattab, MD, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, and Mark A. Sperling, MD, Icahn School of Medicine at Mount Sinai, New York City, write.

They identified three studies in obese adolescents who had bariatric surgery, which showed that the patients benefited from durable weight loss along with improved comorbid conditions, including remission of type 2 diabetes — which suggests that "primary care providers should consider referral of obese adolescents to bariatric surgical procedures in recognized centers of excellence."

Khattab and Sperling acknowledge, however, that surgical complications, the need for post-surgery lifelong vitamin supplements, the risk of osteoporosis, and the possible need for a repeat operation are "reasonable concerns."  

But, "the benefit of bariatric surgical procedures in youth appears to outweigh the risks" for certain patients, they surmise.

And in a press release from Rutgers University, Khattab adds: "The objective evidence shows that, under the right circumstances and with the right patients, bariatric surgery is an effective treatment for adolescents with obesity." He and his coauthors also note that it is an "economically justifiable therapeutic intervention."

Pediatricians Are Reluctant to Refer

"Unfortunately," Khattab and Sperling continue in their article, "many pediatricians are reluctant to refer adolescents for bariatric surgery, in part because of lack of knowledge and concerns regarding the safety and efficacy of these procedures."

Unlike for adults, there is "sparse" published literature of studies of bariatric surgery in adolescents.

They identified three main studies:

  • A 3-year study in five US centers in adolescents who had a mean age of 17 and a mean body mass index (BMI) of 53 kg/m2, of whom 161 had Roux-en-Y gastric bypass and 67 had a gastric sleeve operation (N Engl J Med. 2016;374:113-123).

  • An 8-year US study in which 58 adolescents with a mean age of 17.1 years and a mean BMI of 58.5 kg/m2 had Roux-en-Y gastric bypass (Lancet Diabetes Endocrinol. 2017;5:165-173).

  • A 5-year Swedish study in which 81 adolescents with a mean age of 16.5 years and a mean BMI of 45.5 kg/m2 had Roux-en-Y gastric bypass (Lancet Diabetes Endocrinol. 2017;5:174-183).

The surgeries resulted in a durable 28% to 29% reduction in BMI, a 95% to 100% remission of type 2 diabetes, and a 48% to 83% remission of dyslipidemia.

However, patients also had nutritional deficiencies that had to be addressed and some patients needed a re-operation (13% of patients in the five-center study).

They say their findings are consistent with another recently published study, in the New England Journal of Medicine, as reported by Medscape Medical News, which concluded that the decision on whether to recommend bariatric surgery for adolescents with severe obesity, or postpone it to adulthood, needs to be made after careful consideration of harms versus benefits.

Guideline for Bariatric Surgery in Youth

Khattab and Sperling point to a joint guideline funded by the Endocrine Society and cosponsored by the European Endocrine Society and Pediatric Endocrine Society, issued in 2017 (J Clin Endocrinol Metab. 2017;102:709-757), which states bariatric surgery should only be considered if the adolescent patient has:

  • A BMI of 40 kg/m2 (or 35 kg/m2 plus major comorbidities).

  • Reached puberty (Tanner 4 or 5) and final or near-final adult height.

  • Persistent extreme obesity and comorbidities despite adhering to a formal lifestyle modification program, with or without pharmacotherapy.

  • No underlying psychiatric illness.

  • A stable family unit.

  • The ability to adhere to a healthy diet and regular physical activity.

  • Access to an experienced surgeon in a pediatric bariatric surgery center of excellence that has a team that provides long-term follow-up care of the bariatric surgery patient and his or her family. 

The guideline also advises that bariatric surgery should not be performed in an obese pediatric patient who:

  • Is preadolescent.

  • Is an adolescent who is pregnant or breastfeeding or planning to become pregnant within 2 years.

  • Has a substance abuse problem or an eating disorder or a psychiatric disorder.

  • Is unable to follow a healthy diet and be physically active.

Micronutrient deficiencies resulting from altered food absorption after bariatric surgery can affect the skeletal system (vitamin D, parathyroid hormone) and nervous system (vitamin B1, B12, iron), as well as the blood (hypoferritinemia).

Therefore, following bariatric surgery, patients need to take vitamins such as A, B12, C, and D, as well as iron supplements and must be monitored regularly for potential dietary and micronutrient deficiencies.

More Data Needed for Preadolescent Obese Kids

Khattab and Sperling also observe, "With the obesity epidemic continuing to involve younger and younger individuals, great caution remains with the implementation of surgical procedures in prepubertal and growing children especially regarding long-term bone mineralization."

Thus, "more data in this age group are needed," they advise.

They predict that "bariatric surgery [for adolescents] is likely to become increasingly available as more data on long-term outcomes in larger cohorts become known."

The authors have reported no relevant financial relationships.  

J Pediatr. 2019;207:18-22. Full text

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