Jan. 15, 2021
Severe obesity is affecting increasing numbers of youth, leading to the emergence of conditions previously considered adult diseases, such as type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, fatty liver disease, and bone and joint dysfunction during adolescence. Despite plateauing in the rates of childhood obesity overall, the prevalence of severe obesity is on the rise: Nearly 10% of 12-to-15-year-olds and 14% of 16-to-19-year-olds have severe obesity. Unfortunately, it is highly likely that obese children and adolescents will carry their obesity into adulthood.
As noted in research by Armstrong and others in Pediatrics in 2019, lifestyle modifications remain a cornerstone for weight reduction in all children with obesity. However, lifestyle modifications have only modest success, particularly in youth with severe obesity. The role of medications in achieving weight loss in adolescents with severe obesity still needs to be defined due to scarcity of data on short- and long-term efficacy of weight-loss medications in children.
In adults with obesity, bariatric surgery has been shown to be the most effective option to achieve weight loss and remission of several comorbid conditions. Recent studies in adolescents also demonstrate good efficacy of bariatric procedures (laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass) in achieving weight loss in adolescents with severe obesity.
Seema Kumar, M.D., chair of Pediatric Endocrinology and Metabolism at Mayo Clinic in Rochester, Minnesota, says, "Bariatric surgery in adolescents has been associated with remission or improvement of several obesity-related comorbidities, including type 2 diabetes, hypertension and dyslipidemia. In fact, bariatric surgery in adolescents leads to higher rates of resolution of type 2 diabetes and hypertension in comparison with this surgery in adults."
In view of the available data on weight loss and resolution of cardiovascular risk factors among adolescents, the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American Academy of Pediatrics have developed more-recent guidelines that recommend bariatric surgery to be considered for youth with body mass indexes (BMIs) of 35 kg/m2 or more with concurrent severe comorbid disease, or for those with BMIs of 40 kg/m2 or more, even in the absence of any comorbid diseases. The guidelines, published in Surgery for Obesity and Related Diseases in 2018, no longer recommend using linear growth and Tanner staging to determine eligibility for surgery. The guidelines also suggest consideration of surgery in special cases such as in children with syndromic obesity, those with hypothalamic obesity and patients with limited decision-making capacity.
Todd A. Kellogg, M.D., Breast, Endocrine, Metabolic, and Gastrointestinal Surgery at Mayo Clinic in Rochester, Minnesota, elaborates: "Helping children and adolescents to manage their severe obesity through surgery should be viewed no differently than the treatment of other medical conditions with an operation. It's as safe as gallbladder surgery. It helps to level the playing field toward achieving the necessary weight loss and staving off chronic and debilitating weight-associated medical diseases, which then lead to a healthier lifestyle and improved quality of life."
Dr. Kumar continues: "It has been gratifying and extremely rewarding to see some of these adolescents come out of their shells after undergoing surgery."
Bridget K. Biggs, Ph.D., L.P., co-chair of Child and Adolescent Psychiatry and Psychology at Mayo Clinic in Rochester, Minnesota, notes: "I love seeing the young people in our program blossom in self-confidence with gradual successes in building a healthy lifestyle before and after surgery and witnessing the marked improvements in quality of life they experience, particularly after surgery."
The adolescent bariatric surgery program at Mayo Clinic in Rochester, Minnesota, is accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and staffed by a multidisciplinary team comprising Drs. Biggs, Kellogg, and Kumar and Rose J. Prissel, M.S., RDN, LD. Through this program, patients receive education and support to facilitate lifestyle modifications before surgery and receive close follow-up after surgery.
Weight regain remains a challenge in adolescents as in adults, and therefore close follow-up is necessary to achieve long-term efficacy. The team has used telemedicine widely to maintain contact with adolescents in the program both before and after surgery, particularly during the COVID-19 pandemic.
For more information
Armstrong SC, et al. Pediatric metabolic and bariatric surgery: Evidence, barriers, and best practices. Pediatrics. 2019;144:e20193223.
Pratt JSA, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surgery for Obesity and Related Diseases. 2018;14:882.