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Surgeons Address Adolescent Obesity with Bariatric Surgery
Matthew Fox, MSHC
May 10, 2023
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The global obesity epidemic, along with its significant patient comorbidities and cost to health systems, continues to grow.
In the US, more than 40% of adults are classified as obese, with nearly 10% classified as severely obese.1 As prevention and treatment paradigms evolve, metabolic and bariatric surgery has become known as a safe and effective option to induce significant, durable weight loss in adults with severely obese.2
Modern acceptance regarding the utility and safety of bariatric surgery in adults has been hard won, taking decades of research and documentation of positive long-term outcomes. Over the past 2 decades, however, a debate has emerged on the use of bariatric surgery in an even more vulnerable population—adolescents with severe forms of obesity.
Despite data and statistics on obesity often being framed in terms of adults, this chronic condition does not discriminate by age. The epidemic is moving through children and adolescents ages 2 years to 19 years, with nearly 20% of minors in the US classified as obese or severely obese.3
Although metabolic and bariatric surgery has been an option for adolescents meeting specific criteria, the treatment has not, historically, been widely recommended by primary care physicians.
The corpus of research showing positive outcomes for this younger age group has been growing, and leading health authorities for children and adolescents have created guidelines that suggest bariatric surgery is a viable, effective treatment option for select patients. Among the data and recommendations is the reality that adolescents have unique challenges when it comes to addressing obesity.
This article reviews recent developments in outcomes studies on bariatric surgery in adolescents, a clinical practice guideline for managing obesity in this vulnerable population, and how surgeons and care teams must meet adolescent patients’ needs outside of the operating room.
State of the Science
As a treatment for a chronic condition, some of the most important data to determine the effectiveness and safety of metabolic and bariatric surgery is in investigating long-term outcomes. Statistics are widely available for adult patients, but there has been a relative paucity of comparable findings for adolescents.
Within that context, a 2022 study featured in the Journal of the American College of Surgeons (JACS), “Long-Term Outcomes after Adolescent Bariatric Surgery,” provides valuable data, particularly because the outcomes were measured many years after surgery.4
Nestor F. De la Cruz-Muñoz Jr., MD, chief of bariatric surgery at the University of Miami Miller School of Medicine in Florida and lead author in the JACS study, said there haven’t been many studies that look at outcomes up to 10 years after bariatric surgery, which is partially because it can be difficult to track patients—especially adolescents—for follow-up.
To fill this research gap, Dr. De la Cruz-Muñoz and his team tracked down 96 patients of the 130 on whom he had operated between 2002 and 2010. “We ended up finding that the majority were still doing incredibly well,” he said.
Most patients received Roux-en-Y gastric bypass, he said, and at 2 years postsurgery, weight loss was at about 44% of total body weight—and notably, at almost 15 years postsurgery, weight loss remained high at 32%.
“One way to define success in bariatric surgery is by looking at the percentage of patients who have greater than 20% total body weight loss at 5 years or greater, and we found that 80% of our bypasses met that criterion,” Dr. De la Cruz-Muñoz said. “And we didn’t just have 5 years postoperative data—we had up to 15, and they reported significant reduction in comorbid conditions.”
Importantly, there were low rates of long-term complications, as well as high rates of satisfaction. The patients had largely found success in their lives, with most having received college or postgraduate degrees, gotten married, and had children.
“More than 90% of the patients we spoke with were happy with their outcomes and would do bariatric surgery again. Even a patient who had regained much of their weight told me that the weight loss during that period was instrumental in their development into a well-functioning adult,” Dr. De la Cruz-Muñoz said.
The JACS study offers a compelling argument that bariatric surgery can not only be effective, but also safe for adolescents over a long timescale. It is an important addition to a growing body of research and experiences showing similar positive results.
Expanding Outcomes Research
The ongoing Teen-LABS (Longitudinal Assessment of Bariatric Surgery) study, a National Institutes of Health-sponsored prospective, observational study initiated in 2007, follows nearly 250 adolescents who have undergone bariatric surgery and found clear improvements in weight, reductions in type 2 diabetes and blood pressure, and few long-term complications.
Together with studies like Dr. De la Cruz-Muñoz’s, clear takeaways are emerging.
“First and foremost is that these operations are safe,” said Marc P. Michalsky, MD, MBA, FACS, FAAP, FASMBS, a pediatric bariatric surgeon and surgical director of the Center for Healthy Weight and Nutrition at Nationwide Children’s Hospital in Columbus, Ohio—the first freestanding adolescent bariatric surgery center in the US to be accredited by the ACS Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.
“And they are effective, leading to the types of clinical outcomes that are very similar to what we see in the adult world,” he said.
The loss of total body weight and resolution or reduction of certain comorbidities has important implications for health outcomes that extend through adulthood, Dr. Michalsky suggested. In addition, there is compelling evidence that there may be advantages to operating on patients in this earlier age group—performed in adolescents decades before it typically is in adults.
“What we’ve seen is that certain comorbidities, like hypertension and type 2 diabetes, appear more likely to resolve when comparing clinical outcomes among participants from the Teen-LABS study to a matched cohort of adult patients from the larger LABS (Longitudinal Assessment of Bariatric Surgery) study.”
He goes on to say that “this type of evidence supports the hypothesis that the degree of comorbid disease resolution may actually be more robust in children.”5
Taken together with numerous reports that demonstrate significant long-term negative health implications related to untreated severe obesity, these data help to make a powerful counter-argument against the commonly held suggestion that pediatric healthcare professionals should take a “wait and see” approach with children and adolescents affected from the most severe forms of obesity.
“In other words, these studies show that watchful waiting is not appropriate,” Dr. Michalsky said. “If you have an 11-year-old or a 12-year-old defined as having severe obesity, there is no evidence to suggest that waiting to see what happens is a sound medical paradigm.”
“More than 90% of the patients we spoke with were happy with their outcomes and would do bariatric surgery again. Even a patient who had regained much of their weight told me that the weight loss during that period was instrumental in their development into a well-functioning adult.”
AAP Clinical Practice Guidelines
As obesity rates continue to rise and treatment options including metabolic and bariatric surgery continue to be researched, a leading pediatric health authority has taken a significant step to formalize clinical guidance for obesity in younger demographics.
In January 2023, the American Academy of Pediatrics (AAP) released its first “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity,” which promotes a comprehensive, whole-child approach to obesity.6
The guideline outlines the importance of supportive communication and provides recommendations for various treatment options, starting with intensive health behavior and lifestyle treatment—as well as medication and bariatric surgery, if indicated.
This evidence-based guideline is the result of an extensive literature review, combined with previously released guidance.
“We got to a point where there was critical mass in the literature regarding the management of obesity,” according to Christopher F. Bolling, MD, FAAP, a recently retired general pediatrician and a contributor to the AAP guideline.
An option for managing obesity in adolescents, as the science has continued to indicate, is bariatric surgery. In 2019, the AAP released a policy statement focused on evidence, barriers, and best practices for pediatric bariatric surgery, which serves as a key repository of evidence featured in the 2023 guideline.7
However, despite the strength of the evidence, the AAP’s clinical practice guideline has received pushback—mostly from laypersons and the media, but also from some healthcare practitioners. Because obesity can be an emotional issue, particularly in relation to adolescents, Dr. Bolling suggests that there may be some misinterpretation of the guideline.
“We see some statements suggesting that because the guideline asserts that every patient should be given the option to start medications, people are interpreting that as every patient above the 95th percentile for weight should be given a prescription for medication and/or a referral to a bariatric surgery program,” he said.
The controversy, such as it is, did not go unanticipated by the contributors to the clinical practice guideline.
“A degree of skepticism is naturally anticipated and, in some ways, understandable—because the pediatric population is, by definition, vulnerable and the continued formation of more concrete and evidence-based recommendations regarding care for the pediatric population takes time to be incorporated into generally accepted practice,” said Dr. Michalsky, who contributed to both the 2019 and the 2023 AAP releases.
“It would have been surprising and unrealistic to assume that all of the responses would be positive, and that there would be no avenue for disagreement,” he said, noting that disagreement on a topic of such clinical and health significance can be important, as it allows individuals on both sides of the issue a chance to better understand one another.
At the very least, “it’s safe to assume that even where there is discourse, everyone’s heart is in the right place and everybody wants to see safe, effective, and thoughtful care administered to children,” he said, which presents an opportunity to persuade skeptics.
Bridging Divides
One of the ways that the guideline is intended to work through modern sensitivities regarding the issue of weight, by both the lay public and medical professionals, is by furthering the understanding that obesity is a medical issue that can have, among other options, a medical solution.
“That’s one of the things we’re trying to impart—that obesity is a chronic disease,” Dr. Bolling said. He added that a comparison to a less emotionally charged chronic condition like asthma might be able to help guide a conversation.
“There are some people with asthma who can manage it with avoidance of allergens and cigarettes, or good cardiovascular conditioning,” he said. “But there are other people who require medications, and other people who require medications with side effects, or people who require tonsillectomy or adenoidectomy to assist with airway issues. There are all sorts of corollaries with other chronic disease.”
According to Dr. De la Cruz-Muñoz, who was not involved with the AAP clinical practice guideline but supports its collective message, it is important to communicate to potential detractors that bariatric surgery is not the first and only solution. But for the patient in whom alternative, less-invasive approaches—behavior modification, dietary changes, therapy, and so on—have not achieved results, “think about surgery as an option when nothing else has worked.”
“We’re not telling you not to try less invasive approaches,” Dr. De la Cruz-Muñoz said. “But if other methods do not work with some patients, do not give up on them when there’s an efficacious treatment that you can offer.”
All evidence suggests that severely obese adolescents are predisposed to becoming severely obese adults, and that incidence of heart disease, major cardiac events, and other comorbidities is higher than people with lower weight. As noted, there may be danger in doing nothing.
“Try all you can first. But if you aren’t seeing results, don’t give up—refer them out,” Dr. De la Cruz-Muñoz said.
Communication strategies for adolescent bariatric surgery patients need to be collaborative, acknowledge the autonomy of this patient group, and recognize that their motivation to take this leap must reside within them, and not come from an outside source like parents.
Addressing Adolescents’ Social, Communication Needs
Underlying the modest rate of research into metabolic and bariatric surgery and the charged response to the AAP clinical practice guideline is a recognition that adolescents are, as previously identified, a vulnerable population in their development and their social environment.
Recent research suggests that the media often stigmatize and sensationalize obesity in adolescents, as well as patients who elect to pursue bariatric surgery,8 which exacerbates the skeptical response to clinical guidance and may worsen patient sensitivities to discussing their weight.
In this sometimes unfriendly climate, pediatric clinicians, bariatric surgeons, and weight management professionals are working to provide patient-centered environments and communication styles.
“Within their social universe, there are distinct differences when comparing pediatric and adolescent patients with adults,” Dr. Michalsky said. “As an example, a certain proportion of our patients are home schooled. The decision to participate in home schooling is a very individualized matter and may be the result of patients feeling stigmatized within their own social peer group. Centers that offer metabolic and bariatric surgery to the pediatric population attempt to create a safe space that fosters therapeutic relationships between the clinical team, patients, and their families, which are founded on mutual respect.”
Because there is not a guarantee of an environment conducive to open and effective communication for adolescents in a standard adult treatment institution, it is important for patients and families to seek out pediatric-focused centers.
“With adults, the common thinking is you should have your bariatric surgery done in a center of excellence that does so many surgeries, but that doesn’t necessarily work as well with adolescent bariatric surgery,” Dr. Bolling said.
“I don’t think it’s the volume of procedures that you do that makes it a better procedure, in this case—I think it’s having the procedure done in a pediatric facility with pediatric psychology support, pediatric nutritional services, and so on,” he said, adding that bariatric surgery and its preoperative and postoperative support is something that needs to be done at a place that is entirely designed around catering to adolescents’ needs.
Communication strategies for adolescent bariatric surgery patients need to be collaborative, acknowledge the autonomy of this patient group, and recognize that their motivation to take this leap must reside within them, and not come from an outside source like parents, Dr. Bolling suggested—although it is critical that the patient have a support structure that can help them accomplish their long-term goals.
The teenage patient must be able to reflect on their wants and needs, and what they hope to achieve through surgery, with their care team and surgeon. This requires a direct, one-on-one conversation, according to Dr. De la Cruz-Muñoz.
“I start my conversation with all the adolescents directly, ignoring the parent for a while, because I want to make sure that they’re mature enough to be able to carry on a conversation with me. If they’re not, then it’s a non-starter,” he said. “We don’t move on from there because they need to be able to explain themselves and their issues and be mature enough to follow a treatment plan. So, we start with just that conversation.”
Just as they have been in the vanguard of building technique and outcomes data and contributing to key clinical practice guidelines for evaluating and managing obesity, surgeons play a vital role in presenting bariatric surgery as a viable, safe, and effective treatment that will pay lifelong dividends. But their work cannot be done alone.
“The surgical profession by itself is limited in terms of providing access to patients that would benefit from bariatric surgical care,” Dr. Michalsky said. “Trying to build bridges to our nonsurgical colleagues has really been an important tool to raise professional awareness about what these operations do, the level of safety that they provide, and, ultimately, their long-term benefits.”
Matthew Fox is the Digital Managing Editor in the ACS Division of Integrated Communications in Chicago, IL.
References
Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. NCHS Data Brief No. 360. February 27, 2020. Available at: https://www.cdc.gov/nchs/products/databriefs/db360.htm. Accessed April 15, 2023.
Overweight and obesity statistics. National Institute of Diabetes and Digestive and Kidney Diseases. Available at: https://bit.ly/3GYN7kW. September 2021. Accessed April 13, 2023.
De la Cruz-Muñoz N, Xie L, Quiroz HJ, et al. Long-term outcomes after adolescent bariatric surgery. J Am Coll Surg. 2022;235(4):592-602.
Inge TH, Courcoulas AP, Jenkins TM, et al. Five-year outcomes of gastric bypass in adolescents as compared with adults. N Engl J Med. 2019;380(22):2136-2145.
Hampl SE, Hassink SG, Skinner AC, et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics. 2023;151(2):e2022060640.
Armstrong SC, Bolling CF, Michalsky MP, et al. Pediatric metabolic and bariatric surgery: Evidence, barriers, and best practices. Pediatrics. 2019;144(6):e20193223.
Lefere S, Vergote K, De Bruyne R, Provoost V, Satalkar PP. ‘A radical operation’—A thematic analysis of newspaper framing of bariatric surgery in adolescents. BMC Public Health. 2023;23(1):447.
