Disparity Between United States Adolescent Class II and III Obesity Trends and Bariatric Surgery Utilization, 2015–2018

Sarah E. Messiah, PhD; Luyu Xie, PharmD; Folefac Atem, PhD; Matthew S. Mathew, MS; Faisal G. Qureshi, MD; Benjamin E. Schneider, MD; Nestor de la Cruz-Muñoz, MD


Annals of Surgery. 2022;276(2):324-333. 

In This Article

Abstract and Introduction


Objectives: Class II (120% > body mass index [BMI] < 140% of the 95th percentile for age and sex) and Class III (BMI >140% of the 95th percentile for age and sex) obesity are the fastest growing subcategories of obesity in the United States pediatric population. Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for with class II/III obesity. The primary objectives of this analysis were to determine the (1) current US MBS utilization rates in those with class II/III obesity and (2) utilization rates and 30-day postoperative outcomes.

Background: The 2015 to 2018 National Health and Nutrition Examination Survey cross-sectional data (N = 19,225) generated US with class II/III obesity prevalence estimates. The 2015 to 2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) longitudinal (30 days) cohort data were used to compare adolescent and adult (N = 748,622) postoperative outcomes and to calculate utilization rates.

Methods: The 2015 to 2018 youth and adult MBS utilization rates were calculated using MBSAQIP data (numerator) and National Health and Nutrition Examination Survey data (denominator). Two-sample tests of proportions were performed to compare the MBS utilization rates by age, ethnicity, and sex and expressed per 1000.

Results: Mean age of the analytical MBSAQIP sample was 17.9 (1.15) years in youth (n = 3846) and 45.1 (11.5) in adults (N = 744,776), majority female (77.4%, 80.7%, respectively) and non-Hispanic White (68.5%, 59.4%, respectively). The overall 2015 to 2018 MBS utilization rate for youth was 1.81 per 1000 and 5.56 per 1000 for adults (P < 0.001). Adult patients had slightly higher percentage (4.2%) of hospital readmissions compared to youth (3.4%, P = 0.01) but there were no other post-MBS complication differences. From 2015 to 2018 the US prevalence of youth with class II/III obesity increased in Hispanics and non-Hispanic Blacks (P trend < 0.001), but among youth who did complete MBS non-Hispanic Whites had higher rates of utilization (45.8%) compared to Hispanics (22.7%) and non-Hispanic blacks 14.2% (P = 0.006).

Conclusions: MBS is an underutilized obesity treatment tool for both youth and adults, and among ethnic minority groups in particular.


Class II obesity (defined as 120% ≥body mass index or BMI ≤ 140% of the 95th percentile for age and sex) and class III obesity (defined as BMI ≥ 140% of the 95th percentile for age and sex) are the fastest growing subcategories of obesity in the US pediatric population.[1] As of 2016, approximately 9% of 12–to 19–year-olds had class II/III obesity, triple the prevalence from 1988 to 1994.[1] Even more concerning, almost 12% of non-Hispanic Black and 9% of Hispanic adolescents ages 12 to 19 have class II/III obesity compared to 7% of their non-Hispanic White counterparts.[2] Class II/III obesity during the pediatric years has become such a prevalent issue that it has been labeled "an epidemic within an epidemic."[3] Obesity in youth is associated with many cardiometabolic comor-bidities, liver and kidney disease, lower sleep quality, and mental health comorbidities resulting in lower quality of life scores.[2–5] Moreover, class II/III obesity during adolescence tracks strongly into adulthood and is associated with adult asthma, arthritis, and poorer cardiometabolic and psychological risk profiles.[6–10]

Metabolic and bariatric surgery (MBS) is safe and efficacious in treating adolescents with class II/III obesity.[11–13] As such, in late 2019, the American Academy of Pediatrics called for better access to MBS for adolescents and teenagers with class II/III obesity when medically indicated.[14] In addition, weight loss behavioral, lifestyle, and pharmacotherapy treatment programs in inpatient and ambulatory settings have reported mixed findings, especially in terms of similar, and sustained weight loss trajectories.[15–21]

MBS continues to remain a popular adult elective procedure in the United States with about a quarter of a million patients undergoing the procedure annually.[22] Over the past several years the overall number of surgeries has increased from 158,000 in 2011 to 228,000 in 2017.[22] We report here the latest available (through 2018) national prevalence estimates for class II/III obesity in US youth and calculate MBS utilization rates during the same time period. We also compared youth and adult MBS utilization rates and 30-day complication rates. It was hypothesized that MBS utilization would be lower among US youth compared to adults, despite similar post-MBS complication rates.