Long-term Outcomes Following Adolescent Metabolic and Bariatric Surgery

Motivators and Barriers to Seeking Metabolic and Bariatric Surgery Among Adolescents: A Qualitative Study

Background

The prevalence of severe obesity among adolescents has increased the use of metabolic and bariatric surgery (MBS) as a therapeutic option. Understanding factors influencing adolescent MBS choice and the support needed to undergo MBS is crucial for improving health outcomes. This study examines the motivations and support needs of a diverse sample of adolescents seeking MBS via the patient voice.

Methods

Adolescents (n = 14) at a weight loss surgery clinic in a large academic healthcare system participated in qualitative interviews. Of the participants, 10 were female, 6 were non-Hispanic Black, 3 were non-Hispanic White, and 5 were Hispanic. Interviews were recorded, transcribed, and thematically analyzed.

Results

Three themes emerged: Intrinsic motivators, extrinsic motivators, and barriers. Intrinsic motivators include personal physical and mental health goals. Extrinsic motivators involved family and medical team support, which provided encouragement, validation, and perceived confidence for lifestyle changes. Additionally, observing family members who previously completed MBS was a significant extrinsic motivator. Concerns included fear of dying/complications from MBS, and possible weight regain post-MBS.

Conclusion

Adolescent MBS programs should enhance intrinsic motivation for behavior changes. Findings highlight opportunities for bolstering support pre- and post-MBS and addressing MBS-related anxieties related to long-term weight management.

Bone Composition Changes and Calcium Metabolism in Obese Adolescents and Young Adults Undergoing Sleeve Gastrectomy: A Systematic Review

Background/Objectives: Sleeve gastrectomy (SG) is increasingly used to treat severe obesity in adolescents, but its effects on bone health during this critical period of bone accrual are not fully understood. This systematic review aims to evaluate the impact of SG on the bone mineral density (BMD), bone microarchitecture, marrow adipose tissue (MAT), and bone turnover markers in adolescents. Methods: A comprehensive literature search was conducted to identify studies assessing bone health outcomes in adolescents undergoing SG. Nine studies met the inclusion criteria, comprising prospective cohorts, observational cohorts, and one randomized controlled trial, with sample sizes ranging from 10 to 197 participants aged 13 to 25 years, and a total sample size of 597 individuals. Data were extracted and synthesized into tables summarizing changes in BMD, bone microarchitecture, MAT, and bone turnover markers. Results: SG in adolescents is associated with significant reductions in areal BMD at critical skeletal sites, particularly the femoral neck and total hip, with decreases ranging from -4.7% to -8.9%. Studies utilizing high-resolution peripheral quantitative computed tomography (HRpQCT) reported deteriorations in bone microarchitecture, including a decreased trabecular number, increased trabecular separation, and reduced cortical thickness. Two studies observed significant increases in MAT at the lumbar spine post-SG. Elevated bone turnover markers, particularly C-terminal cross-linking telopeptide (CTX), indicate increased bone resorption following SG. Conclusions: SG leads to negative effects on bone health in adolescents, including reductions in BMD, deterioration of the bone microarchitecture, increases in MAT, and elevated bone resorption markers. These findings highlight the need for careful monitoring of bone health and the development of strategies to mitigate bone loss in adolescents undergoing SG.

Compared to dual-energy X-ray absorptiometry, bioelectrical impedance effectively monitors longitudinal changes in body composition in children and adolescents with obesity during a lifestyle intervention

Accurate and efficient body composition assessment is essential for diagnosing and monitoring childhood obesity in clinical and research settings. This study evaluated the agreement between bioelectrical impedance analysis (BIA) and dual-energy X-ray absorptiometry (DXA) in assessing body composition and its changes during a long-term lifestyle intervention in children and adolescents with obesity. We hypothesized that BIA is comparable to DXA in tracking longitudinal changes in body composition in this population. The study included 92 children and adolescents 5 to 17 years of age (mean 10.5 ± 2.9 years) classified as obese at the time of measurement (body mass index-standard deviation score ≥ 2 SD). From January 1, 2014, to December 31, 2017, they participated in a lifestyle intervention at Randers Regional Hospital. Body composition was assessed using BIA and DXA at baseline and follow-up (mean 20.5 ± 9.3 months). Bland-Altman plots, correlation- and concordance analyses were used to evaluate the agreement between methods. Bland-Altman plots demonstrated wide limits of agreement without significant bias for longitudinal changes in fat mass (FM), FM%, fat-free mass (FFM), and FFM% (0.39 kg (CI -0.14, 0.93), -0.39% (CI -1.06, 0.26), -0.21 kg (CI -0.73, 0.31), and 0.39% (CI -0.27, 1.05), respectively). Correlations between methods for changes in FM, FM%, FFM, and FFM% were 0.93, 0.83, 0.88, and 0.83, respectively. In cross-sectional assessments, BIA underestimated FM and FM% and overestimated FFM and FFM% compared to DXA. Conclusively, BIA effectively monitors longitudinal changes in body composition at a group level in a pediatric population with obesity. However, caution is needed for individual assessments.

Psychosocial outcomes after adolescent metabolic and bariatric surgery: a narrative review of the literature

The prevalence of severe obesity among adolescents continues to be a significant global concern. Metabolic and bariatric surgery (MBS) has increasingly shown to produce safe, efficacious, and durable effects on weight loss and related physical health complications, and evidence of psychosocial outcomes are beginning to mature. The revised American Society for Metabolic and Bariatric Surgery pediatric guidelines published in 2018 reported emergent data regarding key psychosocial outcomes, including mental health, disordered eating, and quality of life, although data were limited by small, short-term studies and often without comparison groups. The purpose of this narrative review was to expand the relevant findings regarding youth with severe obesity who receive MBS to further clarify the impact of surgery on psychosocial outcomes.

14. Children and Adolescents: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Successful Weight Loss in Adolescents with Overweight or Obesity Using a Swallowable Intragastric Balloon and Nutritional Oversight

PURPOSE

Medical devices benefit patients living with overweight or obesity, but studies in the adolescent population are lacking. The goal of this study was to collect information on the performance and safety of a swallowable intragastric balloon program (SGBP) in adolescent patients.

MATERIALS AND METHODS

Data were collected retrospectively on patients aged 15 to 17 years with body mass index (BMI) ≥ 27 kg/m2 who received the swallowable intragastric balloon (SGB) and associated lifestyle and nutritional change program. Patients had not responded to previous dietary and behavioral modification weight loss treatments and elected to undergo SGBP. The SGB was swallowed and filled with 550 mL of distilled water in an outpatient setting, and a multidisciplinary team delivered a lifestyle/nutritional change program. Mean % total body weight loss (%TBWL) was calculated for each patient compared with baseline.

RESULTS

A total of 91 patients, 69 (75.8%) female and 22 (24.2%) male, underwent SGBP and completed follow-up through SGB passage at 4 months. Baseline mean ± SD age, weight, and BMI were 16.4 ± 0.77, 99.70 ± 21.33 kg, and 35.60 ± 5.59 kg/m2, respectively. After 4 months, mean weight and BMI were 86.37 ± 18.83 kg and 30.86 ± 5.16 kg/m2 respectively; %TBWL was 13.05 ± 7.64 (1-sided t-test, p < 0.0001). Most (80, 87.9%) reported no adverse events; 11/91 (12.1%) experienced an adverse event. Of these, 9/91 (9.9%) experienced nausea and/or vomiting; 1/91 (1.1%) reported abdominal pain only; 1/91 (1.1%) reported flatulence only. There were no serious adverse events or premature device removals.

CONCLUSION

The SGBP provides safe and effective short-term weight loss in adolescents living with overweight and obesity.

Intermittent Energy Restriction for Adolescents With Obesity: The Fast Track to Health Randomized Clinical Trial

Importance

Adolescent obesity requires effective and accessible treatment. Intensive dietary interventions have the potential to be used as adjunctive therapy for behavioral weight management.

Objective

To examine the effectiveness of 2 diet therapies, delivered as part of an intensive behavioral weight management intervention, in adolescents with metabolic complications associated with obesity.

Design, Setting, and Participants

This multisite, 52-week randomized clinical trial was conducted from January 31, 2018, to March 31, 2023, at 2 tertiary pediatric centers in Australia. Adolescents (aged 13-17 years) with obesity and 1 or more associated complications were included.

Interventions

Intensive behavioral interventions, delivered by a multidisciplinary team, comparing intermittent energy restriction (IER) or continuous energy restriction (CER), with 3 phases: very low-energy diet (weeks 0-4), intensive intervention (weeks 5-16), and continued intervention and/or maintenance (weeks 17-52).

Main Outcomes and Measures

The primary outcome was body mass index (BMI) z score at 52 weeks in the IER vs CER group. Anthropometry, body composition, and cardiometabolic health were assessed at baseline and 52 weeks. The BMI z score and percentiles were determined using Centers for Disease Control and Prevention growth charts. Insulin resistance, dyslipidemia, and elevated hepatic function were assessed.

Results

A total of 141 adolescents (median [IQR] age, 14.8 [12.9-17.9] years; 71 male [50.4%]) were enrolled, 71 in the IER group and 70 in the CER group, and 97 (68.8%) completed the intervention, 43 in the IER group and 54 in the CER group. At week 52, both groups had reduced BMI z scores (estimated marginal mean change, -0.28 [95% CI, -0.37 to -0.20] for IER and -0.28 [95% CI, -0.36 to -0.20] for CER) and reduced BMI expressed as a percentage of the 95th percentile (estimated marginal mean change, -9.56 [95% CI, -12.36 to -6.83] for IER and -9.23 [95% CI, -11.82 to -6.64] for CER). No differences were found in body composition or cardiometabolic outcomes between the groups. Both groups had a reduction in the occurrence of insulin resistance (from 52 of 68 [76.5%] to 32 of 56 [57.1%] in the IER group and from 59 of 68 [86.8%] to 31 of 60 [57.1%] in the CER group) at week 16; however, at week 52, this effect was observed in the CER group only (from 59 of 68 [86.7%] to 30 of 49 [61.2%]). The occurrence of dyslipidemia was unchanged between baseline and week 52 (60 of 137 [42.6%] and 37 of 87 [42.5%], respectively), with a small improvement in occurrence of impaired hepatic function tests (37 of 139 [27.0%] and 15 of 87 [17.2%], respectively). No differences were found in dyslipidemia or hepatic function between groups.

Conclusions and Relevance

These findings suggest that for adolescents with obesity-associated complications, IER can be incorporated into a behavioral weight management program, providing an option in addition to CER and offering participants more choice.

Trial Registration

http://anzctr.org.au Identifier: ACTRN12617001630303.

Weight Nadir and Long-Term Weight Outcomes After Laparoscopic Sleeve Gastrectomy in a Diverse Cohort of Adolescents and Young Adults

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is currently the most common bariatric procedure performed in adolescents and young adults in the United States (USA), but there are limited data available on long-term postoperative weight outcomes in these patients. This single-institution US study follows longitudinal weight data in a diverse group of patients undergoing LSG at age 25 years or younger.

METHODS

We retrospectively reviewed records of all patients 25 years or younger who underwent LSG at our institution between 2013 and 2020. All weight data documented in the medical record through January 2023 was included. We calculated weight change postoperatively as percent total weight loss (%TWL) relative to preoperative weight.

RESULTS

One hundred forty-one patients underwent LSG, at a mean age of 23.1 years. Within this cohort, 56.1% identified as non-Hispanic Black or Hispanic, and 39.7% had private health insurance. The mean %TWL at weight nadir was 28.5% at a mean of 1.35 years postoperatively. The mean long-term %TWL (in patients with ≥ 4 years of follow-up) was 11.8% at a mean of 5.6 years postoperatively, with 43 of the 84 patients with long-term weight data (51%) within 10% of their preoperative weight at most recent follow-up.

CONCLUSION

Adolescents and young adults undergoing LSG at our institution had weight nadir comparable to published results during the first 1 to 2 years postoperatively, but the majority developed significant weight recurrence over the ensuing years. Our findings highlight the need for adjuvant weight loss strategies to improve the durability of weight outcomes after LSG in this population.

A commentary review on endoscopic sleeve gastroplasty: Indications, outcomes and future implications

Metabolic and bariatric surgeries have been shown to be the most effective strategy to induce and maintain significant weight loss for people living with severe obesity. However, ongoing concerns regarding operative risks, irreversibility and excess costs limit their broader clinical use. Endoscopic bariatric therapies are pragmatic alternatives for patients who are not suitable for metabolic and bariatric surgeries or who are concerned regarding their long-term safety. Endoscopic sleeve gastroplasty has emerged as a novel technique of endoscopic bariatric therapies, which have garnered significant interest and evidence in the past few years. Its safety, efficacy and cost-effectiveness have been shown in various studies, while comparisons with sleeve gastrectomy have been widely made. This review brings together current evidence pertaining to the technicality of the procedure itself, current indications, safety and efficacy, cost-effectiveness, as well as its future role and development.

Kidney function evaluation in children and adolescents with obesity: a not-negligible need

The role of obesity as risk factor for chronic kidney disease (CKD) has been well-recognized. As previously demonstrated in adults, emerging data highlighted the relevant impact of obesity on renal function since childhood. As a matter of fact, obesity also affects renal health through a complex pathogenic mechanism in which insulin resistance (IR) plays a pivotal role. Worthy of note, the vicious interplay among obesity, IR, and renal hemodynamics clinically translates into a plethora of kidney function impairments potentially leading to CKD development. Therefore, renal injury needs to be added to the well-known spectrum of cardiometabolic obesity comorbidities (e.g., type 2 diabetes, IR, metabolic syndrome, cardiovascular disease).

CONCLUSION

Taking this into account, a careful and timely monitoring of kidney function should not be neglected in the global assessment of children with obesity. We aimed to provide a comprehensive overview on the relevance of kidney evaluation in children with obesity by shedding lights on the intriguing relationship of obesity with renal health in this at-risk population.

WHAT IS KNOWN

• Obesity has been found to be a risk factor for chronic kidney disease. • Unlike adults, pediatric data supporting the association between obesity and renal function are still limited.

WHAT IS NEW

• As observed in adults, obesity might affect renal function since childhood. • Kidney function should be carefully evaluated in children with obesity.

Bone mineral density in young adults 5 to 11 years after adolescent metabolic and bariatric surgery for severe obesity compared to peers

OBJECTIVE

Metabolic and bariatric surgery (MBS) is associated with decreased bone mineral density (BMD) in adults. The long-term impact of MBS during adolescence on BMD is unknown. We report bone health status 5 to 11 years after Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) from the Teen-LABS study cohort.

METHODS

Between 2016 and 2022, BMD was measured by dual energy x-ray absorptiometry (DXA) in 106 young adults who had undergone MBS as adolescents. Volumetric BMD by peripheral quantitative computed tomography was measured on a subset. Ninety-one controls who had not undergone MBS were recruited for comparison.

RESULTS

In cases (RYGB: mean age 26.8 ± 1.9 years, mean BMI 42.1 ± 9.9 kg/m2, VSG: mean age 25.1 ± 2.1 years, mean BMI 37.1 ± 8.4 kg/m2), compared to controls (mean age 26.5 ± 2.7 years, mean BMI 40.2 ± 8.7 kg/m2) (age p < 0.001, BMI p = 0.02), adjusted mean DXA-BMD (g/cm2) of the RYGB (n = 58) and VSG (n = 48) groups were lower at the hip (-10.0% and -6.3%), femoral neck (-9.6% and -5.7%) and ultra-distal radius (-7.9% and -7.0%; all p < 0.001), respectively. DXA-BMD did not differ between RYGB and VSG groups. Trabecular volumetric BMD at the radius and tibia were lower in the RYGB (-30% and -26%) and VSG (-15% and -14%) groups compared to the control group (p < 0.001). Greater time since MBS was associated with lower BMD Z-scores at the hip (p = 0.05) and femoral neck (p = 0.045). Percent change in body mass index (BMI) from baseline or in the first year after MBS were not associated with bone measures at a median of 9.3 years post MBS.

CONCLUSION

BMD, especially of the hip and femoral neck, was lower in young adults who underwent MBS during adolescence compared to matched peers who had not undergone MBS. BMD Z-scores of the femoral neck were inversely associated with time since MBS but were not associated with BMI change.

Bone health following paediatric and adolescent bariatric surgery: a systematic review and meta-analysis

Background

Childhood obesity is a pressing health crisis of epidemic proportions. Bariatric surgery (BS) is an effective weight loss solution however its role in the paediatric population is contentious owing to the paucity of weight specific and generalised health outcomes. This systematic review and meta-analysis aimed to assess the impact of paediatric BS on bone health.

Methods

This prospectively registered systematic review (PROSPERO ID: CRD42023432035) was performed in accordance with PRISMA guidelines. We searched MEDLINE (1946-1928 September 2023), EMBASE (1947-1928 September 2023) via the Ovid platform, and the Cochrane Review Library to identify scientific publications reporting bone outcome measures in patients under the age of 18 years who underwent BS. Meta-analysis was undertaken on post-operative weight and bone parameters in paediatric patients following BS. Outcomes were reported as weighted or standardized mean difference with 95 percent confidence intervals. Subgroup analysis by intervention, quality scoring and risk of bias were assessed.

Findings

Twelve studies with 681 patients across 5 countries (mean age 17 ± 0.57 years) were included. The quality of included studies was rated as high and there was substantial between-study heterogeneity for most factors included in the meta-analysis (I2 from 0% to 99.1%). Patients underwent Roux-en-Y gastric bypass (RYGB, n = 216), sleeve gastrectomy (SG, n = 257), gastric band (n = 184) or intragastric balloon placement (n = 24). BS was associated with significant weight reduction, body mass index (BMI) -12.7 kg/m2 (95% CI -14.5 to -10.9, p < 0.001), with RYGB being most effective, BMI -16.58 kg/m2 (95% CI -19.6 to -13.6, p < 0.001). Patients who underwent SG or RYGB had significantly lower lumbar bone mineral density, -0.96 g/cm2 (95% CI -0.1 to -0.03, p < 0.001), Z score, -1.132 (95% CI -1.8 to -0.45, p < 0.001) and subtotal body bone mineral density, -0.7 g/cm2 (95% CI -1.2 to -0.2, p < 0.001) following surgery. This was accompanied with higher markers of bone resorption, C-terminal telopeptide of type 1 collagen 0.22 ng/ml (95% CI 0.12-0.32, p < 0.001) and osteocalcin, 10.83 ng/ml (95% CI 6.01-15.67, p < 0.001). There was a significant reduction in calcium levels following BS, -3.78 mg/dl (95% CI -6.1 to -1.5, p < 0.001) but no difference in 25-hydroxyvitamin D, phosphate, bone alkaline phosphatase, procollagen type 1 N propeptide or parathyroid hormone.

Interpretation

BS effectively reduces weight in paediatric patients, but RYGB and SG may have adverse effects on bone health in the medium term. It is crucial to monitor and support bone health through appropriate nutritional supplementation and judicious follow-up. Long-term data is needed to fully understand the clinical implications of these findings on bone outcomes.

Funding

Medical Research Council (MRC), United Kingdom.

Changes in adipose tissue distribution and relation to cardiometabolic risk factors after Roux-en-Y gastric bypass in adolescents

BACKGROUND

Roux-en-Y gastric bypass (RYGB) among adolescents with obesity results in significant weight loss; however, depot-specific changes have been understudied.

OBJECTIVE

We hypothesized that visceral adipose tissue (VAT) reduction in adolescents undergoing RYGB would be greater than other depots and associated with improvement in cardiometabolic risk factors.

SETTING

Three specialized treatment centers in Sweden.

METHODS

Fifty-nine adolescents underwent dual x-ray absorptiometry before surgery and at 1, 2, and 5 years after RYGB. Changes in body composition in multiple depots (total fat, lean body, gynoid fat, android fat, subcutaneous adipose tissue, and VAT) and cardiometabolic risk factors were assessed using multiple linear regression analysis and generalized estimating equations adjusting for age, sex, and baseline risk factor levels. Data are presented as percent change (95% CI) with regression models showing slopes and estimated P values.

RESULTS

At 1 year post-RYGB, a significant reduction was observed across all body composition measures (P < .001) with the greatest reduction observed in VAT (-65.1% [-68.7, -61.8]). From year 1 to 5 years post-RYGB, a regain was observed in all depots except lean body mass (1.2% [.3, 2.7], P = .105). A sex-specific difference in overall trajectories was only observed in lean body mass with males consistently having higher mean levels. Change in VAT at 1 year correlated with change in triglycerides (slope: .21 mg/dL/kg, P = .034) and fasting plasma insulin (slope: 44 pmol/L/kg, P = .027).

CONCLUSIONS

Adiposity measures all decreased after RYGB but poorly predicted change in cardiometabolic risk. Despite significant reductions at 1 year, a steady regain was observed out to 5 years, with values still well below baseline. Further research should consider control group comparison and extended follow-up.

Bariatric and metabolic surgery in patients with low body mass index: an online survey of 543 bariatric and metabolic surgeons

BACKGROUND

Metabolic and bariatric surgery (MBS) in patients with low body mass index patients is a topic of debate. This study aimed to address all aspects of controversies in these patients by using a worldwide survey.

METHODS

An online 35-item questionnaire survey based on existing controversies surrounding MBS in class 1 obesity was created by 17 bariatric surgeons from 10 different countries. Responses were collected and analysed by authors.

RESULTS

A total of 543 bariatric surgeons from 65 countries participated in this survey. 52.29% of participants agreed with the statement that MBS should be offered to class-1 obese patients without any obesity related comorbidities. Most of the respondents (68.43%) believed that MBS surgery should not be offered to patients under the age of 18 with class I obesity. 81.01% of respondents agreed with the statement that surgical interventions should be considered after failure of non-surgical treatments.

CONCLUSION

This survey demonstrated worldwide variations in metabolic/bariatric surgery in patients with class 1 obesity. Precise analysis of these results is useful for identifying different aspects for future research and consensus building.