Bariatric surgery is one of the few strategies shown to be effective in treating severe obesity in children. The American Academy of Pediatrics (AAP) issued a December 2019 policy statement that called for greater access to this life-changing and potentially life-saving intervention. We asked Elizabeth Parks Prout, MD, MSCE, to answer seven key questions about bariatric surgery in children and teens.
According to the American Society for Metabolic and Bariatric Surgery (ASMBS), bariatric surgery is recommended for children age 10 years and older. The average age of children who actually receive a bariatric surgical procedure in most centers, however, is 13 years or older, which is also the age endorsed by the AAP.
The ASMBS guidelines list two categories of children for whom surgery should be considered:
Children or teens with severe obesity, defined as a body mass index (BMI) that is at or above 120% of the sex-specific 95th percentile on the BMI-for-age growth chart (the equivalent of a BMI 35 kg/m2 in an adult) and who also have type 2 diabetes, hypertension, dyslipidemia, polycystic ovarian syndrome, or other severe comorbidities.
Children or teens with a BMI above 140% of the 95th percentile (the equivalent of a BMI of 40 kg/m2 in an adult) and without additional comorbidities.
Surgical intervention, in combination with lifestyle changes of diet and exercise, is the most effective strategy for children and teens for both initial weight loss and maintenance of weight loss.
Weight loss of up to 30% is typically achieved with bariatric surgery. This degree of weight loss has been found to result in improvements in cardiovascular parameters, type 2 diabetes, nonalcoholic fatty liver disease, and obstructive sleep apnea. In addition, the improvements in psychosocial well-being are substantial.
Lifestyle management alone typically results in minimal weight loss, with limited evidence of sustained weight loss beyond 12 months. Weight loss with medication is generally greater than that with lifestyle changes alone, though research examining the efficacy of pharmacotherapy is of variable quality.
Currently, the most common procedure performed is the laparoscopic sleeve gastrectomy, in which approximately 80% of the stomach is removed. What is left looks like a shirtsleeve, hence the name. With this procedure, all of the intestines are left intact.
The Roux-en-Y gastric bypass (RYGB) is the oldest surgical procedure for the treatment of obesity and considered to be the gold standard. In the RYGB, the stomach is reduced to about 30 mL, or the size of a whole walnut. The remainder of the stomach along with the duodenum are bypassed and reconnected to a lower Y limb and the jejunum. This results in carbohydrates and fats not being absorbed, with the potential for greater nutritional deficiencies compared with sleeve gastrectomy.
Carbohydrates, fats, and most vitamins are still absorbed after sleeve gastrectomy, which is one of the reasons it is the preferred procedure for adolescents. Although the risk for nutritional deficiencies is minimal, if they do occur, the most common nutrients affected are vitamin B12 and iron.
We know that the most effective person to refer a child for this intervention is the primary care provider (PCP). Families often need the endorsement and support of a trusted PCP before they will even consider this option. It's also important that families know that bariatric surgery is not a shortcut. A lot of work goes into preparing for the procedure and instituting the necessary postoperative lifestyle changes.
At our center, teens spend about 6 months preparing for surgery. They meet with a pediatrician who specializes in obesity medicine; a dietitian; and an exercise physiologist who can educate them about the necessary lifestyle changes that must happen before surgery and, even more important, after surgery. They also meet with a psychologist who can assess readiness and provide ongoing support throughout the entire process.
It is critical that the family is involved so that these adolescents aren't on their own. Part of our goal during the presurgical period is to ensure that families are able to provide the proper foods, help their teen adhere to exercise guidelines, and assist with tracking weight and diet. We provide a workbook with guidelines that adolescents need to follow before they undergo surgery.
Adolescents are monitored very closely for the first few years after surgery. At our center, children are typically seen by an obesity medicine specialist at least four times in the first year, three times in the second year, and then yearly thereafter so that vitamin and mineral levels can be checked.
Changes in body composition, appetite, food cravings, and metabolic parameters are the most dramatic in the first 9-18 months after surgery. It is essential that these teens remain engaged in a bariatric program to be able to stay the course and experience the most weight loss possible. This helps jump-start successful weight maintenance that persists later in life. A psychologist is particularly critical at this time. Teens can experience dramatic changes to their physical appearance and body image, which can lead to changes in their peer interactions.
Social changes. Many of our patients have increased absenteeism and are often home-schooled before surgery for any number of reasons, ranging from bullying at school to difficulty staying awake and concentrating as a result of sleep apnea. However, after surgery, they are typically back in school. And that can result in peer interactions that are new territory. Parents need to be prepared; their PCP can help educate them about normal adolescent behavior (eg, dating, sexual exploration, substance experimentation) and assist them with strategies for supporting their teen while setting reasonable expectations and limits.
Nutritional changes. A study conducted by the Teen Longitudinal Assessment of Bariatric Surgery Consortium concluded that the risk for nutritional deficiencies persists for at least 5 years after surgery. The biggest deficiencies are found in kids who had some deficiencies before surgery as well as those who are not taking their vitamins postoperatively. A trusted PCP who can talk with the child and parents to remind them of the importance of adhering to daily vitamin intake can be the difference between success and failure.
Bariatric surgery significantly reduces the production of ghrelin; therefore, many patients report that they are just not hungry after surgery. They may also experience changes in how food tastes. Foods once enjoyed may no longer taste good, whereas foods that were previously not liked may become preferred. Adolescents who undergo bariatric surgery are less likely to experience disordered eating compared with their overweight peers who receive only lifestyle management. However, as their food intake changes postsurgery, including the quantity of food consumed, the quality of nutrition should continue to be monitored.
Elizabeth Parks Prout, MD, MSCE, is a board-certified nutrition pediatrician; a childhood obesity researcher; and medical director of the Adolescent Bariatric Surgery Program, part of the Healthy Weight Program at Children's Hospital of Philadelphia (CHOP).
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Bariatric Surgery in Teens: 7 Things Every PCP Should Know - Medscape
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