Metabolic and Bariatric Surgery Recommended for Adolescents With Severe Obesity

Metabolic and bariatric surgery has been established in adults for more than 50 years. Studies now indicate the procedures are safe and appear to be the only therapy that enables severely obese adolescents to keep weight off while reducing their risk factors for cardiovascular and metabolic diseases and osteoarthritis.

Compared with adults who had been obese since age 18 or younger but had undergone bariatric surgery as adults, teens who underwent bariatric surgery had higher remission rates for type 2 diabetes and hypertension. This suggests benefits may be greater if surgery is done earlier rather than decades later. In fact, studies suggest that even among teens, the younger they are when they have weight loss surgery, the greater potential for benefit.

Supported by these studies, the American Academy of Pediatrics (AAP) has released its first policy statement for the multidisciplinary care of metabolic and bariatric surgery for pediatric patients with severe obesity. The policy statement, published in Pediatrics with an accompanying technical paper, offers a series of recommendations for treatment and advocacy.

The policy comes against this backdrop: severe obesity among youth has nearly doubled since 1999, affecting 4.5 million children in the United States and shortening their life expectancy compared to their parents’ generation.

“Individuals in their teen years suffering from being severely obese — class 2 obesity or higher — have about an 80% chance of carrying that consistent level of weight forward into their adult years,” says Marc Michalsky, MD, FACS, FAAP, FASMBS, surgical director of the Center for Healthy Weight and Nutrition at Nationwide Children’s Hospital and co-author of the policy statement and a number of the studies. “Evidence shows they’re not likely to lose and keep off a significant amount of weight through diet, exercise and behavior modifications alone .”

“Pediatricians and family practitioners need to understand these are very safe operations that should to be considered in the context of ‘what are the consequences of doing nothing?’” adds Dr. Michalsky, who is also a professor of clinical surgery and pediatrics at The Ohio State University College of Medicine. “The consequences are quite grave if nothing is done to reduce significant excess body weight. A large volume of data shows that the associated diseases are progressive, ongoing and ultimately lead to hard physiologic endpoints that can result in a shortened life.

Atherosclerotic heart disease, heart failure, stroke, diabetes and cancer are all highly associated with obesity, particularly severe obesity, research shows.

According to the policy statement, AAP recommends pediatricians:

• Recognize that severe obesity places children and adolescents at higher risk for liver disease, type 2 diabetes, dyslipidemias, sleep apnea, orthopedic complications and mental health conditions
• Seek out high-quality multidisciplinary centers experienced in assessing risks and benefits of various treatments for pediatric patients with severe obesity
• Identify patients who meet criteria for surgery and provide timely referrals
• Understand the efficacy, risks, benefits and long-term health implications of the procedures so as to help guide families considering treatments
• Advocate for more centers and equal access for all patients who meet treatment criteria

AAP recommends government, health and academic medical centers:

• Use best-practice guidelines to support safe and effective multidisciplinary pediatric-focused metabolic and bariatric surgery programs
• Consider best practice guidelines in context with potential health care benefits and individualized patient-centered care; avoid unsubstantiated lower age limits
• Increase the number of the multidisciplinary centers and ensure equal access to all patients who meet treatment criteria

AAP recommends public and private insurers:

• Provide payment for multidisciplinary preoperative care to ensure appropriate selection of surgical candidates
• Provide payment for bariatric surgery from evaluation through follow-up and ongoing care
• Reduce barriers to procedures, including limited access, inadequate payment, unsubstantiated exclusion criteria and approval delays

Shortly after publication of the policy statement online, Dr. Michalsky and fellow researchers published a study in Pediatrics providing further validation. During a three-year follow-up, adolescent gastric bypass surgery patients reported joint pain, impaired physical function and impaired health-related quality of life significantly improved following surgery.

“We know that childhood obesity in particular is associated with the future potential to develop osteoarthritis, which can be enormously debilitating in the adult population,” Dr. Michalsky says. “This study adds to the expanding body of evidence showing that adolescence may be an interesting window of opportunity to not only mitigate current obesity-related problems but also to potentially mitigate the risk of developing future problems.”

References:

1. Armstrong SC, Bolling CF, Michalsky MP, Reichard, KW, Section on Obesity, Section on Surgery. Pediatric metabolic and bariatric surgery: evidence, barriers, and best practices. Pediatrics. 2019 Dec;144(6). pii: e20193223
2. Bolling CF, Armstrong SC, Reichard KW, Michalsky MP, Section on Obesity, Section on Surgery. Metabolic and bariatric surgery for pediatric patients with severe obesity. Pediatrics 2019 Dec;144(6). pii: e20193224.
3. Bout-Tabaku S, Gupta R, Jenkins TM, Ryder JR, Baughcum AE, Jackson RD, Inge TH, Dixon JB, Helmrath MA, Courcoulas AP, Mitchell JE, Harmon CM, Xie C, Michalsky MP, Teen-LABS Consortium. Musculoskeletal pain, physical function, and quality of life after bariatric surgery. Pediatrics. 2019 Dec;144(6). pii: e20191399
4. Inge TH, Courcolas AP, Jenkins TM, Michalsky MP, Brandt ML, Xanthakos SA, Dixon JB, Harmon CN, Chen MK, Xie C, Evans ME, Helmrath MA, Teen-LABS Consortium. Five-year outcomes of gastric bypass in adolescents as compared with adults. New England Journal of Medicine. 2019 May 30;380(22):2136-2145
5. Michalsky MP, Inge TH, Jenkins TM, Xie C, Courcoulas A, Helmrath M, Brandt ML, Harmon CM, Chen M, Dixon JB, Urbina EM, Teen-LABS Consortium. Cardiovascular risk factors after adolescent bariatric surgery. Pediatrics. 2018 Feb;141(2). pii: e20172485.