In the Journals

Research supports bariatric surgery for teens with extreme obesity

Photo of Ahmed Khattab
Ahmed Khattab

Bariatric surgical procedures are an underused, viable and cost-effective intervention for teenagers with persistent extreme obesity, according to a literature review published in The Journal of Pediatrics.

“Objective evidence of BMI reduction and improvement or resolution in associated comorbid conditions, especially [type 2 diabetes], suggest that primary care providers should consider referral of obese adolescents to bariatric surgical procedures in recognized centers of excellence,” Ahmed Khattab, MD, from Rutgers’ Robert Wood Johnson Medical School, and colleagues wrote. “Complications, such as standard surgical risk, the need for lifelong supplementation to prevent or treat dietary deficiencies, implications on bone health, and the possibility of resurgery are reasonable concerns, however, the benefit of bariatric surgical procedures in youth appears to outweigh the risks for the carefully selected patient in the appropriate medical center.”

One of the pressing issues facing this population of adolescents is the growing prevalence of type 2 diabetes (T2DM), particularly among minority populations in whom rates nearly doubled between 2002 and 2012, according to the study. The effects on youth from T2DM differ from those experienced by adults. Teens experience a 20% to 35% per year decline in beta-cell function vs. a 7% to 11% decline in adults, Khattab and colleagues wrote. Further, complications associated with T2DM develop more quickly in children, with albuminuria occurring in approximately 6% of adolescents in this population within 5 years of diagnosis, they wrote. About 2.3% experience end-stage renal failure by 10 years after diagnosis, according to the study.

T2DM in adolescents with persistent extreme obesity, as well as hypertension, dyslipidemia, cardiovascular disease, disturbances of reproduction, sleep apnea and nonalcoholic steatohepatitis “has been termed the plague of the 21st century and is increasing throughout the world in both adults and children,” the researchers wrote.

Teen receiving couseling 
Source: Adobe

Khattab and colleagues noted that consensus has been developed for adults regarding bariatric surgery, with the American Diabetes Association recommending it for adults with BMI of 30 kg/m2 and poorly controlled diabetes (BMI 27.5 kg/m2 in Asian Americans) as the most effective and durable treatment for obesity. However, consensus around this treatment option for adolescents is ”relatively sparse,” as “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,” they wrote.

The researchers’ conclusion adds to a growing body of research supporting bariatric surgeries for adolescents with severe obesity. In a recent study, Thomas Inge, MD, PhD, associate surgeon-in-chief for research, professor and director of pediatric surgery and founder of the adolescent bariatric surgery center at Children’s Hospital Colorado in Aurora, and colleagues found promising results for a form of the surgery, Roux-en-Y gastric bypass. Adolescents with severe obesity were 27% more likely than adults with obesity to experience type 2 diabetes remission 5 years after the surgery and were 51% more likely to experience hypertension remissions than adults, Inge and colleagues found.

Currently, the Endocrine Society recommends against bariatric surgery in any patient who has not “mastered the principles of healthy dietary and activity habits,” as outlined in its clinical practice guideline.

Khattab and colleagues said the cost-effectiveness of bariatric surgery in teens should be considered, pointing to a 2017 study by Klebanoff and colleagues published in JAMA Surgery.

“A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used to assess cost effectiveness,” Khattab and colleagues wrote. “Although bariatric surgery incurs substantial initial costs and morbidity, if assessed over a time period of 5 years, bariatric surgery in severely obese adolescents would be cost-effective.”

However, they emphasized that further long-term studies are needed to confirm these results. – by Joe Gramigna

References :

Inge TH, et al. N Engl J Med. 2019;doi:10.1056/NEJMoa1813909.

Khattab A, et al. J Pediatr. 2019;doi:10.1016/j.jpeds.2018.11.058.

Klebanoff, MJ, et al. JAMA Surg. 2017;doi:10.1001/jamasurg.2016.3640.

Styne DM, et al. J Clin Endocrinol Metab. 2017;doi:10.1210/jc.2016-2573.

Disclosures: The authors report no relevant financial disclosures.

Photo of Ahmed Khattab
Ahmed Khattab

Bariatric surgical procedures are an underused, viable and cost-effective intervention for teenagers with persistent extreme obesity, according to a literature review published in The Journal of Pediatrics.

“Objective evidence of BMI reduction and improvement or resolution in associated comorbid conditions, especially [type 2 diabetes], suggest that primary care providers should consider referral of obese adolescents to bariatric surgical procedures in recognized centers of excellence,” Ahmed Khattab, MD, from Rutgers’ Robert Wood Johnson Medical School, and colleagues wrote. “Complications, such as standard surgical risk, the need for lifelong supplementation to prevent or treat dietary deficiencies, implications on bone health, and the possibility of resurgery are reasonable concerns, however, the benefit of bariatric surgical procedures in youth appears to outweigh the risks for the carefully selected patient in the appropriate medical center.”

One of the pressing issues facing this population of adolescents is the growing prevalence of type 2 diabetes (T2DM), particularly among minority populations in whom rates nearly doubled between 2002 and 2012, according to the study. The effects on youth from T2DM differ from those experienced by adults. Teens experience a 20% to 35% per year decline in beta-cell function vs. a 7% to 11% decline in adults, Khattab and colleagues wrote. Further, complications associated with T2DM develop more quickly in children, with albuminuria occurring in approximately 6% of adolescents in this population within 5 years of diagnosis, they wrote. About 2.3% experience end-stage renal failure by 10 years after diagnosis, according to the study.

T2DM in adolescents with persistent extreme obesity, as well as hypertension, dyslipidemia, cardiovascular disease, disturbances of reproduction, sleep apnea and nonalcoholic steatohepatitis “has been termed the plague of the 21st century and is increasing throughout the world in both adults and children,” the researchers wrote.

Teen receiving couseling 
Source: Adobe

Khattab and colleagues noted that consensus has been developed for adults regarding bariatric surgery, with the American Diabetes Association recommending it for adults with BMI of 30 kg/m2 and poorly controlled diabetes (BMI 27.5 kg/m2 in Asian Americans) as the most effective and durable treatment for obesity. However, consensus around this treatment option for adolescents is ”relatively sparse,” as “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,” they wrote.

The researchers’ conclusion adds to a growing body of research supporting bariatric surgeries for adolescents with severe obesity. In a recent study, Thomas Inge, MD, PhD, associate surgeon-in-chief for research, professor and director of pediatric surgery and founder of the adolescent bariatric surgery center at Children’s Hospital Colorado in Aurora, and colleagues found promising results for a form of the surgery, Roux-en-Y gastric bypass. Adolescents with severe obesity were 27% more likely than adults with obesity to experience type 2 diabetes remission 5 years after the surgery and were 51% more likely to experience hypertension remissions than adults, Inge and colleagues found.

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Currently, the Endocrine Society recommends against bariatric surgery in any patient who has not “mastered the principles of healthy dietary and activity habits,” as outlined in its clinical practice guideline.

Khattab and colleagues said the cost-effectiveness of bariatric surgery in teens should be considered, pointing to a 2017 study by Klebanoff and colleagues published in JAMA Surgery.

“A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used to assess cost effectiveness,” Khattab and colleagues wrote. “Although bariatric surgery incurs substantial initial costs and morbidity, if assessed over a time period of 5 years, bariatric surgery in severely obese adolescents would be cost-effective.”

However, they emphasized that further long-term studies are needed to confirm these results. – by Joe Gramigna

References :

Inge TH, et al. N Engl J Med. 2019;doi:10.1056/NEJMoa1813909.

Khattab A, et al. J Pediatr. 2019;doi:10.1016/j.jpeds.2018.11.058.

Klebanoff, MJ, et al. JAMA Surg. 2017;doi:10.1001/jamasurg.2016.3640.

Styne DM, et al. J Clin Endocrinol Metab. 2017;doi:10.1210/jc.2016-2573.

Disclosures: The authors report no relevant financial disclosures.