When to Consider Surgery for an Obese Teen

January 7, 2010

My daughter has been overweight her whole lifeand is always the largest kid in class. She’s juststarted high school and wants so badly to feelattractive, yet she cannot bear trying anotherweight loss program. At 5 ft 6 in, she weighs262 lb. Can you refer her to a surgeon so she canhave the operation that helps her lose weight?

A MOTHER ASKS:

My daughter has been overweight her whole life and is always the largest kid in class. She’s just started high school and wants so badly to feel attractive, yet she cannot bear trying another weight loss program. At 5 ft 6 in, she weighs 262 lb. Can you refer her to a surgeon so she can have the operation that helps her lose weight?

THE PARENT COACH ADVISES:

The decision to recommend weight reduction surgery is not an easy one. It is even more complicated in adolescents.

The need for more effective weight loss techniques. The increased risk of lifelong chronic illness in overweight adolescent patients is a major concern, and in patients who are morbidly obese, rates of obesity-related chronic conditions are even higher.1-3 Recent data have shown that the probability that a morbidly obese patient will achieve “durable weight loss” (weight loss that is maintained for at least 2 years) through dieting, exercise, and/or behavior modification is about 5%.2,3 This disappointing statistic, together with increasing awareness of the severity of the health impact of morbid obesity, has led to the development of various surgical weight reduction techniques and to more inquiries about these techniques from obese patients.

Little is known about long-term effects of weight loss surgery in teens. Despite the wealth of knowledge about weight reduction surgery in adults, relatively little is known about long-term health outcomes of bariatric surgery in adolescents. Unfortunately, the current literature on adolescent patients consists mostly of small retrospective series collected over long periods.4 In addition to the relatively anecdotal nature of these series, the various procedures involved have usually been performed by bariatric surgeons who operate primarily on adults rather than by pediatric surgeons.4,5 Thus, bariatric surgery is still not FDA-approved for patients younger than 18 years.

Currently, only a few centers in the United States offer weight loss surgery specifically for teens. These include Nationwide Children’s Hospital, Cincinnati Children’s Hospital Medical Center, Texas Children’s Hospital, Children’s Hospital of Alabama, and the University of Pittsburgh Medical Center. These institutions are all involved in an ongoing study to help clarify the medical and psychological health outcomes of bariatric surgery in teens-the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS), funded by the NIH.

Conditions under which bariatric surgery might be considered for a teen. Even though weight reduction surgery for adolescents is not FDA-approved, the answer to this parent’s question is not an absolute “no.” The reason that the surgery can at least be considered for her daughter is that she does not appear to fall into one of the categories in which such surgery is contraindicated. Bariatric surgery is contraindicated in the following groups of pediatric patients:

• Preadolescent children.
• Adolescents who are pregnant or breast-feeding.
• Adolescents who are planning to become pregnant within 2 years of surgery.
• Patients who have not mastered the principles of healthy dietary and activity habits.
• Patients who have an unresolved eating disorder, untreated psychiatric disorder, or Prader-Willi syndrome.4,5

The most important questions to ask when considering a bariatric procedure in an adolescent patient who is not in one of these excluded categories are:

• Is the patient’s health being compromised by severe obesity?
• Have more conservative options for achieving weight loss failed in this patient?
• Does the patient have decisional capacity?

The answers to all 3 questions should be “yes.” Note that decisional capacity is not determined strictly by chronological age; however, by age 13 years, adolescents who are developmentally normal may be able to make informed decisions.4,5

In addition, to qualify for weight reduction surgery, an adolescent patient typically must fulfill the following criteria4-7:

• Have a body mass index above the 99th percentile for age.
• Have made a documented attempt to lose weight by following a medically supervised diet (for at least 6 months).
• Have undergone a comprehensive medical and psychological evaluation in a center with a multidisciplinary weight management team. The evaluation should include a physical examination, a nutritional workup, and psychological tests and consultations to address comorbid conditions.
•Have had routine preoperative diagnostic tests (including a comprehensive serum analysis, echocardiography, an upper GI series, and a sleep study) to screen for common comorbid conditions (eg, insulin resistance, type 2 diabetes, obstructive sleep apnea, mitral valve prolapse, gastroesophageal reflux disease, hypertension, and hyperlipidemia).
•Have attained a majority of skeletal maturity (this generally occurs by age 13 years in girls and by age 15 years in boys).

Finally, the decision to pursue surgery should take into account the lifelong burden that postoperative care entails. Extensive follow-up is required to ensure that patients receive proper nutritional and vitamin supplementation during the period of rapid weight loss that follows surgery. In addition, it is strongly recommended that all patients who undergo bariatric surgery be monitored throughout their lives to ensure optimal postoperative weight loss, eventual weight maintenance, and overall health.4-7 This is particularly important for adolescents because the long-term effects of bariatric surgery in younger, reproductively active populations have not been well characterized. Thus, any teen for whom weight loss surgery would be an appropriate option should be willing to comply with the recommended ongoing monitoring.

The next step for patients who are candidates for bariatric surgery. This patient’s weight and height put her at the 99th percentile for her age. If she can document a previous unsuccessful, sustained attempt to lose weight, and if she has known weight-related health issues, she may be a candidate for weight loss surgery.

When the decision is made that an adolescent is a potential candidate for bariatric surgery, he or she should be referred to a center with a multidisciplinary weight management team that has expertise in meeting the unique needs of overweight teens. There, a comprehensive evaluation can be performed, which will determine definitively whether weight loss surgery is an appropriate treatment.

References:

REFERENCES:1. Freedman DS, Khan LK, Dietz WH, et al. Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics. 2001;108:712-718.

2. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA. 2002;288: 1728-1732.

3. Wang G, Dietz WH. Economic burden of obesity in youths aged 6 to 17 years: 1979-1999 [published correction appears in Pediatrics. 2002;109:1195]. Pediatrics.
2002;109:E81.

4. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004;114:217-223.

5. Freedman DS, Mei Z, Srinivasan SR, et al. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr. 2007;150:12-17.e2.

6. Garcia VF, Langford L, Inge TH. Application of laparoscopy for bariatric surgery in adolescents. Curr Opin Pediatr. 2003;15:248-255.

7. Strauss RS, Bradley LJ, Brolin RE. Gastric bypass surgery in adolescents with morbid obesity. J Pediatr. 2001;138:499-504.


FOR MORE INFORMATION:
• Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year follow-up of behavioral, family-based treatment for obese children. JAMA. 1990;264:2519-2523.

• Finkelstein EA, Fiebelkorn IC, Wang G. National medical spending attributable to overweight and obesity: how much, and who’s paying. Health Aff (Millwood). 2003; Jan-Jun(suppl Web exclusives):W3-219-226.

• Tsai WS, Inge TH, Burd RS. Bariatric surgery in adolescents: recent national trends in use and in-hospital outcome. Arch Pediatr Adolesc Med. 2007;161:
217-221.

• Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337:869-873.