This Clinician’s View opinion piece is written by Aleksander Bernshteyn, MD, pediatric surgeon at AdventHealth for Children.
Childhood obesity remains a serious medical concern in the U.S., negatively impacting the health of 14.7 million children and adolescents -- 19.7% of this population.. Left untreated, it increases the risk of developing numerous co-morbidities, including diabetes, hypertension, heart disease, liver disease and mental health conditions. Early, multidisciplinary intervention is critical to achieving the best possible outcomes. Although underutilized, adolescent bariatric surgery can be a safe and effective option for certain pediatric patients with severe obesity (BMI ≥ 120% of the 95th percentile for age and sex) who have not achieved success with other weight loss methods.
At AdventHealth for Children in Orlando, we established our multidisciplinary Pediatric Weight Management Program in 2010, and in January 2022, we became the first program in Central Florida to earn accreditation from the American College of Surgeons’ Metabolic Bariatric Surgery Accreditation and Quality Improvement Program for surgical treatment of severe obesity and its related conditions. To achieve this designation, we had to meet stringent criteria for staffing, training and facility infrastructure, and protocols for care. We performed our first adolescent bariatric surgery case in July 2022 and have since completed an additional 4 cases.
Effectiveness of Adolescent Metabolic and Bariatric Surgery
In January 2023, the American Academy of Pediatrics released the Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents with Obesity, a revision from the original guidelines established in 2007. These evidence-based guidelines included the following recommendation:
“Pediatricians and other primary health care providers should offer referral for adolescents 13 y and older with severe obesity (BMI ≥ 120% of the 95th percentile for age and sex) for evaluation for metabolic and bariatric surgery to local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery centers.”
This comes after the 2018 update to the American Academy of Pediatric Endocrinology’s Pediatric Metabolic and Bariatric Surgery Guidelines first released in 2012 that state the following:
“Metabolic and bariatric surgery (MBS) is a proven, effective treatment for severe obesity disease in adolescents and should be considered standard of care. Pediatricians and primary care providers should recognize that children with severe obesity require tertiary care and refer early to a MBS center with advanced treatments and support.”
Both recommendations stem from numerous research studies on the safety and effectiveness of bariatric surgery in severely obese adolescents. While exact results vary from patient to patient, demonstrated outcomes three years after bariatric surgery include the following:
- Blood pressure remission of 74%
- Remission of abnormal kidney function by 86%
- Up to 66% reduction of dyslipidemia (lipid imbalance)
- Up to a 95% resolution of Type 2 diabetes
Studies on the long-term outcomes of adolescent metabolic and bariatric surgery continue, and our program hopes to contribute to this body of knowledge in the future. A published review of 5-year outcomes found the following remission rates of co-morbidities:
- Dyslipidemia — 75%
- Musculoskeletal Problems — 78%
- Hypertension — 85%
- Type 2 Diabetes — 85%
In addition to the physical health benefits, there are also psychological and social benefits, including improved self-confidence, greater activity levels and better lifestyle choices.
Safety of Sleeve Gastrectomy and Gastric Bypass
Medical researchers have also carefully examined the safety of adolescent bariatric surgical procedures, including the more commonly used sleeve gastrectomy (SG) as well as Roux-en-Y gastric bypass (RYGB). One of the most recent studies published last year in the Journal of Pediatric Surgery examined all patients ages 10 to 19 years old in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who underwent laparoscopic RYGB or SG from 2015 through 2018. It found adolescent metabolic and bariatric surgery to be low risk, and 30-day readmission, re-operation and complication rates to be rare.
Surgical Selection Criteria
To qualify for adolescent bariatric surgery at AdventHealth for Children in Orlando, patients must be recommended by our adolescent bariatric surgery care team after undergoing a thorough evaluation process:
- The patient is entered into a 6-month medically-supervised weight management program if they have not already completed one.
- They must complete the workup for bariatric surgery, including virtual, monthly psychoeducational support group sessions.
- As part of the research efforts of our program, all patients approved for surgery need to sign a consent form for data collection.
- Patients must be over their ideal body weight (BMI greater than 40 kg/M2 or BMI greater than 35 kg/M2 with medical problems).
- We also use percentile of BMI; obesity of >99 percentile of BMI for age or severe obesity of >120 percentile of BMI for age.
Determining the right bariatric surgery procedure for a specific patient — SG vs. RYGB — depends on many factors, including the patient’s goals, co-morbidities and unique healthy history.
The Importance of a Multidisciplinary Approach to Pediatric Obesity Care
Childhood obesity is a complex condition, and when caring for adolescent patients with severe obesity, surgery is not the first option. Our team begins with more conservative approaches that are customized to meet both the physical and psychological needs of each individual patient and their family. This can include any combination of exercise, nutrition, endocrinology evaluation, psychological support and medication. If bariatric surgery becomes part of the treatment plan, it is always paired with lifestyle modifications, multidisciplinary support and weight loss medications (when appropriate) to achieve the best possible results.
At AdventHealth for Children in Orlando, our experienced and highly specialized pediatric obesity care team includes the following professionals who meet every day to review cases and make recommendations on next steps for each child under our care:
- Indira Abraham-Pratt, PhD, Pediatric Clinical Health Psychologist
- Angela Fals, MD, FAAP, DABOM, CCMS, Obesity Medicine Physician
- Konda Reddy, MD, Pediatric Endocrinologist
- Leslie Berry, Pediatric Dietitian
- Olivia De Fanti, MS, CSCS, EP-C, Exercise Physiologist
- Kara Hubbard, RN, Nurse Care Coordinator
Building Healthier Futures for Children with Severe Obesity
One of our first adolescent bariatric surgery patients, India Foster, had been with our medical weight loss program for many years. At age 6, she was diagnosed with craniopharyngioma and had a craniotomy to remove the tumor which left her with panhypopopituitary and hypothalmus dysfunction. The latter led to hypothalamic obesity, causing her to struggle with weight gain at a rapid pace. While we attempted to control the weight gain medically, she struggled with numerous comorbidities and developed diabetes. In addition, India shared that the medications left her with a lack of energy and a feeling of hopelessness.
On September 6, 2022, we performed a gastric sleeve procedure on India. At that time, she was 17 years old, and her BMI was 44. She could hardly walk half a mile without exhaustion. At India’s most recent visit, her BMI was down to 36, and she proudly shared that she is wearing a size XL, down from a 3X before her surgery. Now 18, she reported that her weight lost has not only given her more energy, but more confidence and a new look on life. She enjoys working out at the gym and can comfortably walk 5 miles now. With plans to become a nurse, she is looking forward to starting her studies at Valencia College in the fall.
It is stories like India’s, combined with the growing body of medical evidence on safety and successful outcomes, that affirm my belief that adolescent bariatric surgery is an important and effective treatment option in our ongoing battle against severe childhood obesity.