Should Surgery Be Used to Treat the Childhood Obesity Epidemic?

Approach to Bariatric Surgery in Adolescents

The benefits of bariatric surgery must be carefully weighed against the risks. For morbidly obese adolescents with comorbidities of obesity, who have been unable to achieve clinically significant weight loss with conventional treatments, bariatric surgery is an option that can be considered. Several studies have demonstrated significant reductions in BMI in obese adolescents who have undergone gastric bypass surgery.^[15–18] One study demonstrated an average of a 36% reduction in BMI by 5 years postoperatively with those results maintained for up to 10 years postsurgery.^[18] These results are comparable to those reported in adults. All of the studies investigating the long-term effects of bariatric surgery in adolescents have included small numbers of patients with up to 10-years follow-up postoperatively, but inadequate numbers of patients followed out further than 10 years.^[18] Therefore, considerable uncertainty remains regarding the incidence of weight regain and other side effects of the surgery, such as vitamin and mineral deficiencies, as these individuals enter their third decade of life.

Current recommendations suggest that adolescents who should be considered for bariatric surgery include those who:

Have failed greater than 6 months of organized attempts at weight management with the assistance of a multidisciplinary weight-loss program;
Have attained physiologic maturity;
Have morbid obesity with comorbidities;
Demonstrate commitment to psychological and medical evaluations before and after surgery;
Agree to avoid pregnancy for at least 1 year postoperatively;
Be capable and willing to adhere to nutritional guidelines postoperatively;
Demonstrate decisional capacity;
Provide informed assent;
Have a supportive family environment.^[19,101,102]

Those who should not be considered for possible surgery include those who:

Have a medically correctable cause of obesity;
Have a substance abuse problem within the preceding year;
Have a psychiatric, medical or cognitive condition that would impair their ability to follow nutritional recommendations;
Current or planned pregnancy;
Whose parents or patient have the inability to comprehend the consequences of this surgical procedure and the need for lifelong medical surveillance.^[19,101,102]

Preoperative education of the patient and family is essential for the success of bariatric surgery. Since obese children often have obese parents, parental recognition of the lifelong dietary recommendations and requirements must be ascertained before proceeding forward with surgery. The adolescent whose home is stocked with high calorie, high sugar foods, will not be successful postoperatively and this must be clearly communicated to the parents before a referral to surgery is made. The family must all be ready to accept the necessary dietary changes that will occur postoperatively and be willing to change their lifestyle to accommodate this.

It is not known how bariatric surgeries performed before completion of puberty and epiphyseal fusion will affect neuroendocrine, skeletal and psychosocial maturation. While the majority of puberty and skeletal maturity occurs before the age of 14 years in girls and the age of 15 years in boys, the assessment of pubertal stage and bone age must be done before surgery is considered.^[20] If the bone age radiograph indicates that the individual has achieved greater than or equal to 95% of their adult stature, then there is little concern that a bariatric procedure would adversely affect the adult height.^[20]

Although most childhood obesity is the result of environmental effects on a susceptible population, some individuals with obesity in childhood have a genetic or neuroendocrine cause of their weight excess.^[21] These individuals have either defective feedback from the gut to the brain regarding hunger and satiety signals or a monogenic defect resulting in dysfunction of the hormones and neurotransmitters involved in brain recognition of satiety.^[21] These conditions must be evaluated for and ruled out before bariatric surgery can be considered ( Table 1 ). These causes of childhood obesity are not amenable to bariatric surgery and would have a tremendously increased risk of postoperative morbidity and mortality.

Cite this: Bariatric Surgery for Obese Adolescents: Should Surgery Be Used to Treat the Childhood Obesity Epidemic? - Medscape - Feb 01, 2009.

Known Genetic and Neuroendocrine Causes of Obesity Not Amenable to Bariatric Surgery
	Prader–Willi syndrome	Leptin deficiency	Leptin-receptor mutation	Melanocortin-4 receptor mutation	Proopiomelanocortin	Pseudohypo-parathyroidism
Phenotype	Hyperphagia, food-seeking behavior, short stature and small hands/feet	EMO, hyperphagia and decreased T-cell function	EMO, hyperphagia and aggressive food-seeking behavior	EMO, tall stature and increased lean muscle mass. Phenotype improves with time (adults report less intense hunger and have decreased insulin resistance)	EMO, hyperphagia and red hair	EMO, hyperphagia and can have tall stature
Laboratory abnormalities	Growth-hormone deficiency, hypogonadotropic hypogonadism. Central hypothyroidism and central adrenal insufficiency possible	Hypogonadotropic hypogonadism, hyperinsulinemia and hypothyroidism	Central hypothyroidism, low growth hormone and IGF-1 and absence of puberty	Hyperinsulinemia	Hypocortisolism and hypoglycemia	Primary hypothyroidism

EMO = Early-onset morbid obesity.

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