Introduction

Obesity is not exclusive to adults. Each day, more and more children are finding themselves at risk for overweight and obesity. Childhood obesity often accompanies many of the obesity-related conditions adults affected by obesity often experience, such as type 2 diabetes, hypertension, sleep apnea and more. Recent data shows that up to 80 percent of children affected by obesity will continue to be affected by obesity into adulthood.

Childhood Obesity at a Glance

Obesity impacts children in a variety of ways. First and foremost, a child’s health is impacted as they have now opened themselves up to a wide variety of health issues – issues that most of us didn’t experience until middle-age. In addition to health implications, there’s also one other area that children face which can be very serious – weight bias and bullying. Kids impacted by obesity often find themselves the target of bullying. This bullying can take place in the classroom, in your neighborhood and even in your own home. It is very important to recognize this type of behavior and address it quickly. The Obesity Action Coalition (OAC), a nonprofit dedicated to educating and advocating for those affected by obesity, provides valuable resources on weight bullying. To view them, click here

How Do We Treat Childhood Obesity?

You may be thinking to yourself, “I know my child is affected by obesity, but I don’t know what to do.” This is not uncommon. Treating childhood obesity is similar to treating obesity in adults; however, it is important to keep very open lines of communication with your children during treatment choice and when it starts as children will often not share their feelings as they fear disappointing you as their parent. There are various treatments available for childhood obesity, such as behavioral and lifestyle modification, pharmacotherapy and bariatric (weight-loss) surgery. We are going to focus on bariatric surgery in this section.

Why Bariatric Surgery?

When a child is first examined by his or her pediatrician or primary care doctor, you can expect a thorough evaluation detailing the child’s food intake, physical activity level, blood work and more. Once you, your child and their healthcare professional have gathered this information, you can then begin to discuss treatment options. While treatments such as behavioral and lifestyle modifications may work for the majority of children affected by obesity and help them increase their health, there are children affected by severe obesity that require more aggressive treatment such as bariatric surgery. Bariatric surgery, which is commonly performed on adults affected by severe obesity, has been shown to produce long-lasting weight-loss and improvement in many obesity-related conditions such as type 2 diabetes, high blood pressure, sleep apnea and more. Currently, the most common operations being performed in children affected by severe obesity are the Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB) and vertical sleeve gastrectomy. The goal of bariatric surgery is to provide the most benefit possible with the lowest risk. With this in mind, many research studies have been done to evaluate outcomes following bariatric surgery in adolescents, and many more are ongoing. The information and recommendations contained here are based on a recent review of the available medical literature and extensive discussion by a panel of experts on childhood obesity and bariatric surgery.

Co-Morbidities (obesity-related health problems)

Type 2 diabetes mellitus (T2DM)

Compared with Type 1 (or juvenile) diabetes, T2DM usually develops later in life, and is associated with overweight and obesity. Some children and adolescents affected by obesity develop T2DM early. This is a long-standing disease that tends to worsen throughout time, and diabetic children are at increased risk of developing high blood pressure, high cholesterol and liver disease. Recent data suggests that adolescents who undergo bariatric surgery can have significant improvement or complete remission of their T2DM.

Obstructive sleep apnea

Up to 22 percent of children and adolescents affected by obesity have obstructive sleep apnea, which is characterized by shallow breathing or abnormal pauses in breathing during sleep. Sleep apnea can cause fatigue, moodiness and difficulties with paying attention and completing tasks. In many patients, obstructive sleep apnea has been shown to improve or go away after bariatric surgery.

Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis

Approximately 38 percent of children and adolescents affected by obesity have fatty deposition in their livers, compared with 5 percent of normal-weight individuals, and about 9 percent have associated inflammation (called steatohepatitis), compared with 1 percent of lean children. Studies have shown that such fatty deposition and inflammation may lead to fibrosis, or scarring in the liver. This has been shown to improve in adolescents who have undergone bariatric surgery.

Pseudotumor cerebri

Pseudotumor cerebri is a condition caused by increased pressure inside the skull, and symptoms can include headache, visual changes, ringing in the ears, nausea and vomiting.  There is often no obvious cause for this condition, but it has been associated with obesity and symptoms frequently improve several months after bariatric surgery.

Cardiovascular disease

Although we are still learning about risk factors for heart disease in children affected by obesity, research suggests that childhood obesity may lead to increased risk of heart and vascular diseases in adulthood. Weight-loss from bariatric surgery has been shown to improve several such risk factors in adults; however, for children and adolescents these effects would take many years to measure, and studies are still ongoing.

Quality of life

Many children and adolescents affected by obesity feel that their obesity and health issues have a negative impact on their quality of life and emotional health, and several studies have shown significant improvement after weight-loss.

Depression

Adolescents affected by obesity often find themselves affected by depression as well. Adolescents who undergo weight-loss surgery often see improvement in their emotional wellbeing. Conversely, weight-loss studies suggest that adult patients seem to be at slightly increased risk for suicide after bariatric surgery. We recommend that adolescents with depression before surgery be watched closely for signs of depression after surgery.

Eating disorders

Binge eating and purging (sometimes called bulimia) has been seen in some adolescents with obesity who desire bariatric surgery. Eating disturbances are quite serious, and outcomes following bariatric surgery in teens with eating disorders have not been studied. Because of this, bariatric surgery in these adolescents is generally discouraged unless the eating disturbance has been appropriately treated and is well-controlled.

Who Should Be Considered for Bariatric Surgery?

In general, the more severe obesity is, the higher the risk for co-morbidities. The BMI (body mass index) is an index of weight for height that is commonly used in the medical profession to classify underweight, overweight, obesity and severe obesity in adults. BMI is typically used a little differently for children, but most surgeons use BMI thresholds while trying to determine if an adolescent is a candidate for weight-loss surgery. In addition to BMI, physicians consider co-morbidities and the potential long-term health risks associated with untreated obesity when determining a patient’s appropriateness for bariatric surgery. Recommended selection criteria for adolescents being considered for a bariatric procedure include:

1. BMI 35 kg/m2 or higher with major co-morbidities (such as type 2 diabetes, moderate or severe sleep apnea, pseudotumor cerebri, or severe fatty liver disease)
2. BMI 40 kg/m2 or higher with other less severe co-morbidities (such as high blood pressure, high cholesterol, mild or moderate sleep apnea)

Despite the above minimum BMI criteria, many insurance companies will not cover bariatric surgical procedures for adolescents under the age of 18 years, or they may have different criteria or only cover a certain specific procedure or procedures. If you are considering bariatric surgery for your child, it would be helpful to contact your insurance company to see if these procedures are covered under your plan.

Team Member Qualifications

Adolescents qualified for bariatric surgery should be evaluated and cared for by a team of expert individuals. The makeup of this team may vary among institutions, but may typically include the following members:

1. Bariatric Surgeon – experienced in performing bariatric procedures.
2. Pediatric specialist – a pediatrician with special training in endocrinology, gastroenterology, nutrition and/or adolescence, or an internist or family practitioner with special experience caring for adolescents.
3. Registered dietitian – should be experienced in treating obesity and working with children and families, and is helpful if also experienced in caring for patients undergoing bariatric surgery
4. Mental health specialist – psychiatrist, psychologist, or other qualified and independently licensed mental health specialist with specialty training in pediatric, adolescent and family treatment. The specialist should also be trained in the treatment of eating disorders and obesity, with special experience evaluating patients and families for bariatric surgery.
5. Coordinator – typically a registered nurse, social worker, or another team member who coordinates the evaluation and follow-up care for each child.
6. Exercise specialist – exercise physiologist, physical therapist or other individual trained to provide safe physical activity prescriptions to adolescents affected by severe obesity.

Risks and Outcomes

When considering bariatric surgery as a treatment for your child’s weight, it is important to recognize that bariatric surgery is a serious procedure. All surgical procedures have an associated risk of complications. Patients with a higher BMI and more serious medical illness are at increased risk of complications after bariatric surgery, some of which can be life-threatening.  Having surgery earlier rather than later in life (before obesity-associated health problems can worsen) may decrease the risks of complications after surgery and of long-term complications from obesity. The risks specifically associated with the surgical procedure should be discussed at length with your surgical team. A few particular risks of concern in the adolescent population include:

Psychosocial risks

Short term data suggest that weight-loss following bariatric surgery improves depression, eating disturbances and quality of life. However, potential negative psychosocial risks have not been well studied.

Nutritional risks

Depending on the type of bariatric surgery chosen, certain vitamin and other nutritional deficiencies have been reported in adolescents after bariatric surgery. In particular, low levels of iron, vitamin B12, vitamin D and calcium are common problems after RYGB.  Calcium and vitamin D are crucial for bone development during adolescence. In order to prevent these nutritional deficiencies, all patients need to follow special dietary recommendations and take vitamin supplements after bariatric surgery.  Because this is so important, adolescents preparing to undergo bariatric surgery are carefully assessed for their ability to follow the recommended regimens and come to scheduled appointments.

Informed Consent

Individuals under the age of 18 years cannot legally provide consent for bariatric surgery; formal consent must be provided by an adolescent’s parent or guardian. However, informed consent for bariatric surgery is a complex process that involves much more than the simple signing of a consent form for the surgical procedure. It is important for the health care team to discuss in detail with the adolescent and his or her parent(s) or guardian(s) the anticipated benefits and specific risks of bariatric surgery, especially those that are most relevant for adolescents.   An understanding of the many complex issues involved should be formally assessed as part of the consent process. Frequently, the adolescent and parent have differing ideas about the effect that obesity has on their lives, and may disagree about bariatric surgery. While a child cannot consent to surgery, it is important that they are in agreement (called assent) without inappropriate influences, even if those influences are subtle. Assessing an adolescent’s capacity to make an informed decision about bariatric surgery can be challenging; the clinical team must consider the adolescent’s cognitive, social and emotional development and support his or her independent role in the decision-making process.

Types of Bariatric Surgery

Current data shows that bariatric surgery in adolescents is as safe and effective as bariatric surgery in adults. A number of different weight-loss procedures are performed in adults, and many of these have also been performed in adolescents. The decision regarding which procedure is appropriate for an individual patient is a complex one that is made by the surgical team, in conjunction with the adolescent and his or her family.

Gastric bypass

In the United States, gastric bypass surgery (RYGB) for weight-loss was first performed in adults in the 1960s and in adolescents in the 1970s. Recent data shows that this procedure provides lasting weight-loss in adolescents, with complication rates similar to those seen in adults. Severe complications, although rare, have been reported. It is very important that adolescents undergoing this or any bariatric procedure attend all follow-up visits with their bariatric health care team, and that this follow-up should be long-term (at least several years).

Laparoscopic Adjustable Gastric Banding

Placement of an adjustable gastric band is not yet approved by the Food and Drug Administration in children under the age of 18 years, but some institutions perform this procedure through what is known as “off-label” use of the banding device. Adjustable gastric banding (LAGB) involves the placement of an adjustable band around the upper portion of the stomach so that an individual will feel full sooner and eat less. A balloon on the inner surface of the band is connected to a port that sits under the skin on the abdomen. Injecting saline into the port will fill the balloon and tighten the band around the stomach. These band adjustments are done periodically during special visits to the surgeon, and close follow-up with the surgical team after LAGB is necessary for the best outcomes. Studies of adolescents who have undergone LAGB demonstrate it to be an effective and safe procedure, and associated with fewer nutritional complications than RYGB. Weight-loss and improvement in obesity-related co-morbidities appear similar to those seen in adults, though long-term data has not yet been published. Most complications are device-related and not life threatening. In two studies, 8-25 percent of adolescents needed another operation to fix a mechanical problem related to the band. LAGB has been shown to be more effective than behavioral interventions alone in producing significant weight-loss and reduction in obesity-related co-morbidities, but long-term data is still lacking.

Vertical Sleeve Gastrectomy

The vertical sleeve gastrectomy (VSG) involves cutting the stomach to make it into a smaller tube shape. No intestinal bypass is performed, and no devices are left in place. This procedure has been performed less often in adolescents than the RYGB or the LAGB, but has been performed in increasing numbers throughout the past few years.  Long term data is not yet available, but preliminary results from on-going studies of adolescents undergoing VSG demonstrate excellent weight reduction, reversal of co-morbidities, and complication rates similar to those of the adult population.

Other procedures

Other bariatric procedures, such as the biliopancreatic diversion and duodenal switch (both of which involve intestinal bypass) have been performed in adolescents, but outcome data is scarce. These procedures are less commonly performed in the pediatric population than the others, largely due to concerns for vitamin deficiencies and protein malnutrition.

Selected References:

1. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724 –37.
2. Silberhumer GR, Miller K, Kriwanek S, Widhalm K, Pump A, Prager G. Laparoscopic adjustable gastric banding in adolescents: the Austrian experience. Obes Surg 2006;16:1062–7.
3. Lawson ML, Kirk S, Mitchell T, et al. One-year outcomes of Rouxen-Y gastric bypass for morbidly obese adolescents: a multicenter study from the Pediatric Bariatric Study Group. J Pediatr Surg 2006; 41:137– 43.
4. Sugerman HJ, Sugerman EL, DeMaria EJ, et al. Bariatric surgery for severely obese adolescents. J Gastrointest Surg 2003;7:102– 8.
5. Barnett SJ, Stanley C, Hanlon M, et al. Long-term follow-up and the role of surgery in adolescents with morbid obesity. Surg Obes Relat Dis 2005;1:394–8.