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Should obese adolescents have the same opportunity as adults for a new lease on life or are they just too young?

After failing weight-loss methods, including intensive weight-management programs, weight-loss camp, and even padlocking the refrigerator and cabinets, 15-year-old Ashley Hardy turned to weight-loss surgery to transform her 385-pound frame. Five months later, Ashley had lost 130 pounds but had endured complications, readmissions, new procedures, pain, and nausea.

Stories of teenagers battling obesity through bariatric surgery have surfaced in newspapers, magazines, and television specials. In some areas of the United States, the prevalence of pediatric overweight is approximately 40% and pediatric obesity approximately 22%. Even severe obesity (body mass index [BMI] > 50) is becoming more common among children.1

It Comes With the Territory
Problems for the obese child are plentiful. For starters, as many as 83% of obese children will become obese adults. Obesity can lead to many comorbidities. Cardiac risk factors include hypertension, hyperlipidemia, hyperinsulinemia, and sleep apnea. Eighty percent of overweight adolescents have one risk factor for cardiac disease and 20% have two. Glucose metabolism is altered in as many as 25% of obese children, corresponding with a rise in type 2 diabetes among children. Conditions associated with childhood obesity include tibia vara, slipped capital femoral epiphysis, steatohepatitis, polycystic ovarian syndrome, pseudotumor cerebri, biliary disease, depression, and lack of self-esteem, which can result in underperformance in school and society.1 Quality-of-life scores for obese children are significantly lower than those of normal-weight children.2

Bariatric Surgery as an Option
For severely overweight adolescents, for whom conventional methods of weight loss have failed and who are faced with life-threatening conditions, bariatric surgery can offer a light at the end of the tunnel. Behavior modification, diet, and exercise are the cornerstones of weight management, but only one in five children succeeds.1

“Bariatric surgery is a good tool to get them into the start of weight loss. It is the first step to get out of a vicious cycle,” says Susanne Trout, RD, LD, bariatric pediatric dietitian at Texas Children’s Hospital. She reports that her hospital has performed 12 bariatric surgeries on pediatric patients but screened roughly 50. Brittany Caesar weighed 404 pounds (BMI of 59.4) at the age of 15. After bariatric surgery at Texas Children’s Hospital, she has made it to a BMI of 24. “Brittany is a beautiful, almost 16 year old. She is 5’11” and now has a normal BMI. She is very attractive,” says Trout.

“There is a resounding opinion these days that we’ve got to do something about this disease,” says Thomas Inge, MD, PhD, FACS, FAAP, assistant professor of surgery and pediatrics surgical director at the Comprehensive Weight Management Center at Cincinnati Children’s Hospital Medical Center. Inge reports that his hospital has performed approximately 65 bariatric surgeries on adolescents over the past five years. “I have seen diabetes, fatty liver disease, and even liver fibrosis, obstructive sleep apnea, cardiac hypertrophy, and orthopedic deformities due to weight that can cause permanent functional impairment and poor quality of life. And so many come in with previously undiagnosed or silent health problems,” says Inge.

Controversy in Choice of Obesity Treatment
Ernesto Cavazos, a bariatric surgery patient from Texas Children’s Hospital, tells Trout, “The surgery has given me a new lease on life. It has made a dramatic change in my life now and it has provided me with a future. It has extended my life and I am so grateful. I am just so grateful.”

Aside from the publicized success stories, some in the medical community view bariatric surgery in pediatrics to be controversial at best. “I think that many teens and their families always look for the magic bullet. When some adolescents come to us and they are overweight, they are looking for some sort of treatment to stop them from being overweight that is not involved with lifestyle change,” says Nancy Copperman, MS, RD, CDN, of the division of adolescent medicine at Schneider Children’s Hospital in New Hyde Park, N.Y. Copperman also serves as chair of the Committee on Prevention and Treatment of Childhood and Adolescent Overweight and Obesity for the Prevention and Treatment of Childhood and Adolescent Overweight for the American Dietetic Association (ADA) Pediatric Nutrition Practice Group. Copperman points out that comorbidities can be resolved in obese children through traditional lifestyle interventions. She published data in a 2003 issue of the Journal of Pediatrics on weight loss and the reduction of cardiovascular risk factors for adolescents using a low-carbohydrate diet.

“The guidelines for bariatric surgery in pediatrics list diet intervention failure as one of the prerequisites for surgical candidacy, but the guidelines do not specify exactly what the nutritional/behavioral intervention should include,” comments Copperman, who would like to see dietitians intervene with overweight children before the problem becomes an emergency. “I have kids who walk into my office that are 300 pounds plus, diabetic, and this is their first contact with a dietitian. We need to get to these kids before it’s a salvage job.”

Trout says, “Some people think that bariatric surgery is too drastic. They are reluctant because they think it is an easy way out.” She points out that some patients are so heavy that they can barely breathe or walk up the stairs. “A huge amount of dietitians have a bias about bariatric surgery,” says Leslie Jaroch, MS, RD, LD, CNSD, total parenteral nutrition dietitian at Akron General Medical Center. Jaroch has been providing nutritional care for bariatric surgery patients (including approximately 20 adolescents) at her hospital since 1992. She believes there is a growing awareness about bariatric surgery in the ADA and American Society for Parenteral and Enteral Nutrition (ASPEN).

“Bariatric surgery is performed only for severely obese adolescents who have not had long-term success with any other means of weight-loss methods and are suffering from severe complications related to their weight. The procedure is not a quick fix to obesity, but it is a catalyst in helping severely obese adolescents to get to a healthier weight at an earlier age in order to prevent the worsening of their obesity-related complications,” says Ning Wan, MS, RD, clinical dietitian at Lucile Packard Children’s Hospital at Stanford.

Caroline Apovian, MD, FACN, director of the Nutrition & Weight Management Center at Boston Medical Center, agrees that the healthcare community should be concerned about accepting bariatric surgery as a treatment option for childhood obesity, adding, “Bariatric surgery for adolescent obesity is being done in selected centers of excellence and only as a last resort.”

A Fit for Pediatric Bariatric Surgery
A National Institutes of Health (NIH) consensus panel established indications for bariatric surgery in 1991, but adolescents were not included as potential candidates.1 According to the National Institute of Diabetes & Digestive & Kidney Diseases’ Weight Control Information Network, the rate of weight issues among youths is on the rise and bariatric surgery may be considered as a treatment option for adolescents who are severely overweight. However, they note concerns about the long-term effects of this sort of operation on adolescents’ developing bodies and minds.

To limit the risk of negative medical and psychosocial outcomes of bariatric surgery, many factors must be considered involving the patient, family, and barriers to adherence. Experts recommend that surgical treatment only be considered when adolescents have tried unsuccessfully for at least six months to lose weight. Candidates should be severely overweight (BMI of 40 or more), have reached their adult height (usually at age 13 or older for girls, 15 or older for boys), and have serious weight-related health problems such as type 2 diabetes or heart disease. In addition, potential patients and their parents should be evaluated to ensure they are emotionally prepared for the surgery lifestyle changes they will need to make.1

“We don’t do surgery on every obese pediatric patient. Special criteria must be met. A board of people, including the dietitian, has to meet every candidate,” says Trout, who reports that the criteria for surgery is a BMI > 40 with one major comorbidity and a BMI > 50 with minor but life-altering comorbidities. “I had a patient with a BMI of 54 that is now down to a BMI of 24,” says Trout, who reports that this patient is now actively engaged in a marching band.

One major ethical concern is establishing the patients’ decisional capacity, which may not be determined strictly by chronologic age. At the age of 13 or older, adolescent patients who are developmentally normal may be able to make informed decisions, but the responsibility falls on the healthcare team to make the argument for or against this capacity. Patients with decisional capacity should be included in self-determining decisions.2

In a study of children and adolescent weight-loss surgery cases published between 1980 and 2004, researchers noted that physiological status, comprehensive screening of patients and their families, and required education and counseling were identified as key factors in assessing eligibility for surgery.3

Pediatric Bariatric Surgery Up Close
According to the American Society for Bariatric Surgery (ASBS), the number of bariatric surgery procedures has increased from approximately 16,000 in the early 1990s to 103,000 in 2003. Experts stress that adolescent bariatric surgery should take place in centers with multidisciplinary weight management teams experienced in meeting the distinct physical and psychological needs of adolescents. The teams may benefit from undergoing subspecialty training by the American College of Surgeons and the ASBS, and their approach should include a review process similar to that of transplant programs.2 The American Pediatric Surgical Association suggests that a multidisciplinary program for pediatric bariatric surgery should include individuals with special expertise, including pediatric endocrinologists, nephrologists, psychiatrists, psychologists, dietitians, and exercise therapists.4

“It has to be done in a way that is sensitive to all of the needs in children in a center with experts that deal with all aspects of care using a multidisciplinary team,” says Inge. “This process must be different than the ‘surgery center’ adult bariatric model that is seen in some areas. There is a much more detailed evaluation process for teenagers.”

The two most common bariatric surgical procedures are the Roux-en-Y gastric bypass and the adjustable gastric band, which can both be done laparoscopically and have been effective in treating the medical consequences of severe obesity in adolescents.1,2 The adjustable gastric band is restrictive in nature, as it forms a small proximal gastric pouch that creates early satiety and decreased oral intake. The gastric band is connected to a subcutaneous reservoir that can be accessed through the skin. Increasing or decreasing the amount of saline in the band system adjusts the pouch size. The adjustable gastric band is not yet approved by the FDA for use in patients younger than 18. With an average of 21% to 38% weight loss of the patient’s excess weight, it has not been as successful as the gastric bypass. Mortality after gastric band surgery is less than 1%.1

The Roux-en-Y gastric bypass is both restrictive and malabsorptive. A small gastric pouch is created, but the distal stomach is separated from the pouch and the jejunum is brought up and attached to the pouch. The stomach, duodenum, and a small portion of the proximal jejunum are then attached to the jejunum downstream from the pouch. Digestion is less efficient and some malabsorption results. Gastric bypass is considered by many to be the best surgical treatment for morbid obesity. After Roux-en-Y gastric bypass surgery, 84% to 90% of adults lose more than 50% of their excess weight and have a significant improvement of comorbidities. Weight loss reaches a plateau after 12 to 18 months in most adults, and as many as 30% regain much, if not all, of the weight lost after surgery. Surgical mortality is 0.5% to 1%.1

A long-term, integrated, multidisciplinary education program targeted at both the patient and family is important and should include nutritional guidelines, daily physical activity, behavioral strategies, and support group meetings before and after surgery. Specialists recommend meticulous, lifelong medical supervision of adolescent patients who undergo bariatric surgery.2

“I have great continuum of care with these patients. I see them pre-op, post-op, in between, and in support groups. They have to commit to us for 10 years,” says Trout, who meets with each patient before surgery and does an entire work-up, reviewing support groups and behavior therapy. Wan reports, “I provide pre-op nutrition education on the dietary guidelines and discuss special needs that may arise after surgery. I monitor post-op nutritional status and act as the nutrition consultant for the bariatric team, which includes the surgeons, physicians, nurse practitioners, and other hospital staff.”

“I follow these patients forever. I see them when they come back into the hospital as patients or when they volunteer at the hospital,” adds Jaroch, who provides ongoing nutrition education for her bariatric surgery patients by providing them with the basics, such as how to eat out, shop at the grocery store, and cook. “It is important to keep the family in the loop. The mother usually does the cooking. And these children need to understand about how to eat after the surgery and how not to get sick.”

Fine-Tuning the Diet
“The bariatric surgery nutrition protocol for adolescents is exactly the same as for adults,” says Jaroch, who has been very involved with developing and promoting nutritional management protocols for bariatric surgery patients and has presented at ASBS, ADA, and ASPEN conferences over the past decade. She believes one of the biggest challenges in this field is the variation of diets recommended by bariatric surgeons.

According to a recent article in the Journal of the American Dietetic Association, there are no standardized nutritional guidelines for bariatric surgery. The specific dietary guidelines vary from surgeon to surgeon and facility to facility.5 After gastric bypass, a very low-calorie, low-carbohydrate diet is enforced by the surgery itself. It is important to maintain protein intake adequate to maintain lean body mass. Vitamin and mineral supplementation is required. Calcium citrate supplements (1,200 to 1,500 milligrams per day), B complex vitamin, and iron supplementation is recommended.1 The postoperative diet begins with frequent, small (1-ounce) servings of water and/or ice chips for the first few days. The diet progression to solid foods can be as fast as one week, moving from liquids and pureed foods to soft textured foods. Patients return to solid foods gradually. General dietary guidelines may include chewing small volumes of food well, taking liquids before or after meals, and eating protein before fats and carbohydrates.5

Bariatric Surgery Outcome
Bariatric surgery has been proven effective in decreasing morbidity and mortality in obese adults.1 It has shown to be effective in the long-term maintenance of significant weight loss.6 “We know that obesity surgery works,” says Jaroch, who reports that often the medical community is hesitant to refer obese children for bariatric surgery until they become extremely obese, at which point they have medical issues that make weight loss the secondary concern. Apovian reports weight loss of more than 60% of excess body weight and improvement and resolution of diabetes and high blood pressure after gastric bypass surgery. Inge reports, “We are seeing reversal in terms of disease, it just disappears. Hypertriglyceridemia, diabetes and insulinemia, and obstructive sleep apnea resolves.”

The outcome data of bariatric surgery in adolescents has been similar to that reported in adults. Based on the long-term follow-up for five to 10 years of 33 obese teenagers aged 12.4 to 17.9 who underwent bariatric surgery, it was concluded that the procedure can be performed safely in adolescents and that it results in significant weight loss (with a mean of 63% loss of excess body weight), correction of obesity-related comorbidity, and improvement in self-image and socialization. But five of the 33 patients regained all or most of the weight lost at five to 10 years after surgery, largely because of snacking on high-fat foods.6

Facing the Fears
The long-term metabolic, nutritional, and psychological effects in adolescents undergoing bariatric surgery are simply unknown.2 There are many concerns, including the effect of significant weight loss on linear growth, ethical considerations regarding obtaining assent from adolescents, the potential effect on reproductive ability and pregnancy outcome, and the nutritional impact of the decreased absorption of essential nutrients such as calcium, iron, zinc, and specific vitamins.1 Copperman is concerned about numerous issues ranging from pregnancy and the potential for developing eating disorders to social issues such as body image and sexuality after dramatic weight loss.

“I am concerned with linear growth. Are we costing nutrients in the long run? Our goal is not to hurt these patients long-term,” says Trout, whose primary team is collecting data on their pediatric bariatric surgery patients.

Although it is possible to have successful pregnancy after bariatric surgery, there is a potential risk to the fetus during the rapid weight-loss phase in the first year after surgery.1 “Pregnancy adds a new dimension to the post-op bariatric diet,” says Jaroch, regarding reproductive concerns with adolescent surgery patients later in life. Nevertheless, Jaroch has observed successful pregnancies following bariatric surgery.

Early complications among adolescent bariatric surgery patients have been similar to those observed among adults, including pulmonary embolism, wound infections, stomal stenoses, dehydration, and marginal ulcers. Late complications have included small-bowel obstruction, incisional hernias, and late weight regain in up to 15% of cases. Suboptimal vitamin intake and micronutrient deficiencies have also occurred among adolescents after gastric bypass.2 Studies have raised concerns about how adolescents may fare in adhering to a highly structured, long-term dietary regimen, daily vitamin and mineral supplements, healthy eating habits, and physical activity to maintain weight loss. The comorbidities associated with adolescent obesity respond well to bariatric surgery and ultimately it may yield a long-term increase in quality and length of life.1 Long-term data is essential to determining the risk in relation to benefits in pediatrics.

“One of the first things that we had to come to grips with was that there weren’t any criteria. We convened a group of specialists from all over the county, as well as organizations like CDC [Centers for Disease Control and Prevention] and NIH, to meet in Chicago to determine the best practices for the surgery,” says Inge. The group published their recommendations in Pediatrics in July 2004. They concluded that surgical management may be warranted for severely obese adolescents who have serious, obesity-related, comorbid conditions and who have failed organized attempts at sustained weight loss. The group also noted that the suggested criteria for surgical treatment should not be rigidly applied to every patient and should be tailored to the individual’s needs. They stressed the importance of establishing a multidisciplinary team to handle the challenges of the obesity treatment, suggesting that surgery should be performed only at facilities capable of treating adolescents with complications of severe obesity where clinical data collection can occur, emphasizing that patients and families must realize that obesity surgery is not a cure.2

The American Pediatric Surgical Association stresses that a system for collecting clinical data and long-term follow up is very important as practitioners move into the arena of pediatric obesity surgery. Such little experience with these procedures in this population offers an opportunity for clinical research and outcome analysis.4

“Pediatric obesity surgery should be a treatment option for severely overweight adolescents and will probably become more popular in the future. However, more research needs to be done in evaluating the long-term effects of the surgery on adolescents,” says Wan. Trout adds, “People think bariatric surgery is a cure for obesity. It’s just a tool. Weight loss plateaus around 18 to 24 months post surgery and all patients are at risk for regaining weight if they do not make changes toward a healthier lifestyle.” Copperman stresses, “We need to focus on prevention. The treatment rates for obesity are dismal. We need to get the whole family involved in lifestyle change.”

Patients like Maida Mayfield, who had bariatric surgery eight months ago at Texas Children’s Hospital, praise surgery as a life-altering catalyst for change. Mayfield tells Trout, “I am able to sleep better and wake up feeling rested. I am able to do the things that I always wanted to do but could not because I was too heavy. Now I have a real personality. It has allowed Maida to be Maida.”

— Sharon Palmer, RD, is a freelance food and nutrition writer living in Southern California.

Guidelines for Patient Selection for Bariatric Surgery in Adolescents
• Failure to lose weight after at least six months of organized attempts

• Near mature physiologic status of Tanner stage III or above

• Body mass index = 40 with major life-threatening comorbidities or = 50 with minor, but life-altering, comorbidities

• Commitment to medical and psychological evaluation before and after surgery

• Commitment to avoid pregnancy for at least one year after surgery

• Ability and intent to adhere to postoperative nutritional guidelines

• Supportive family environment

• Ability to provide informed assent (patient) and consent (family)

— Source: American Pediatric Surgical Association Clinical Task Force on Bariatric Surgery

Pediatric Bariatric Surgery Resource Guide
American Dietetic Association
www.eatright.org

American Society for Bariatric Surgery
www.asbs.org

American Society for Parenteral and Enteral Nutrition
www.nutritioncare.org

Bariatric Nutrition Dietitian’s Discussion Group
http://health.groups.yahoo.com/group/BariatricNutritionDietitians

2. Inge T, Krebs N, Garcia V, et al. Bariatric surgery for severely overweight adolescents: Concerns and recommendations. Pediatrics. 2004;114:217-233.

3. Apovian C, Baker C, Ludwig D, et al. Best practice guidelines in pediatric/adolescent weight loss surgery. Obes Res. 2005;13(2):274-282.

4. Rodgers B. Bariatric surgery for adolescents: A view from the American Pediatric Surgical Association. Pediatrics. 2004;114:255-256.

5. Marcason W. What are the dietary guidelines following bariatric surgery? J Am Diet Assoc. 2004;104:487-488.

6. Kirk S, Scott B, Daniels S. Pediatric obesity epidemic: Treatment options. J Am Diet Assoc. 2005;105:44-51.