Adolescent bariatric surgery--thoughts and perspectives from the UK

Adolescent bariatric surgery-a survey of referring practitioners

BACKGROUND

Recent guidelines, supported by large, well-designed studies, suggest that bariatric surgery is a safe and effective treatment for adolescents living with severe obesity to improve health and psychosocial functioning. The aim of this study was to assess the opinions and referral practices of general practitioners (GPs) and paediatricians in Ireland.

METHODS

A cross-sectional survey was circulated online to practising paediatricians and GPs. The survey consisted of a short introduction about childhood obesity and 12 questions on adolescent bariatric surgery and obesity medications.

RESULTS

There were 45 unique responses to the survey from 22 GPs (48%), 8 paediatricians (17%), and 15 others. Most GPs (72%) would not consider referring an adolescent for bariatric surgery. Paediatricians were significantly more likely to refer (72% vs. 28%, p = 0.034). A minimum BMI of 40 kg/m2 was the most common response, which GPs (45%) and paediatricians (37.5%) suggested should be a pre-requisite for surgery. There was strong support for family psychological assessment and a reported deficit in the community support needed to manage obesity. GPs were more likely than paediatricians to respond that anti-obesity medications should be made available to adolescents, specifically liraglutide (45% vs. 25%), semaglutide (45% vs. 37.5%), and orlistat (22% vs. 0%).

DISCUSSION

There is a reluctance among GPs to refer adolescents with severe obesity for consideration of bariatric surgery. Concerns regarding the different obesity treatments held by medical professionals should be addressed through education and engagement and should be fundamental to the development of child and adolescent obesity services.

Referral and utilization of paediatric bariatric surgery in an academic freestanding children's hospital with dedicated paediatric bariatric programme

OBJECTIVE

This report estimates the percent of medically eligible adolescents who are referred for metabolic and bariatric surgery (MBS) evaluation or factors associated with referral.

METHODS

This cross-sectional retrospective review evaluated patients aged 13 to 18 years seen between 2017 and 2019 for demographics, insurance status, body mass index (BMI), obesity-related comorbidities, and compared these data to patients whom had been referred and received MBS.

RESULTS

Half of the patients (86 411/163137, 53%) between ages of 13 and 18 years identified had BMI documented, of which, 1974 (2.3%) were medically eligible for MBS, 238 (12%) were referred for MBS and 52 (22%) underwent MBS. Females had similar odds of being eligible for MBS [odds ratio (OR) = 1.01, 95% confidence interval (CI) 0.92-1.11, P = .9], but greater odds of referral (OR = 1.58, 95% CI 1.13-2.23, P = .009). Independently, miniorities and patients with public insurance had higher odds of being eligible for MBS, but similar odds of being referred as non-Hispanic white patients. Black patients with public insurance had greater odds of being referred for MBS (OR = 12.22, 95% CI 2.08-235.15, P = .022). Patients' multiple comorbidities had greater odds of being referred for MBS (OR = 2.16, 95% CI 1.29-3.68, P = .004).

CONCLUSIONS

Referral is barrier for patients medically eligible for MBS; however, this barrier is not uniformly faced by all patients.

Treatment of type 2 diabetes in children: what are the specific considerations?

Introduction: The number of individuals under 18 years of age with type 2 diabetes is increasing at an alarming rate worldwide. These patients are often characterized by obesity and they often experience a more rapid disease progression than adults with type 2 diabetes. Thus, focus on prevention and management of complications and comorbidities is imperative. With emphasis on weight loss and optimal glycemic control, treatment includes lifestyle changes and pharmacotherapy, which in this patient group is limited to metformin, liraglutide and insulin. In selected cases, bariatric surgery is indicated.Areas covered: This perspective article provides an overview of the literature covering pathophysiology, diagnosis, characteristics and treatment of pediatric type 2 diabetes, and outlines the gaps in our knowledge where further research is needed. The paper draws on both mechanistic studies, large scale intervention trials, epidemiological studies and international consensus statements.Expert opinion: Type 2 diabetes in pediatric patients is an increasing health care problem, and the current treatment strategies do not successfully meet the many challenges and obstacles in this patient group. Treatments must be early, intensive, multifaceted and durable. Also, prevention of obesity and type 2 diabetes in at-risk children should be addressed and prioritized on all levels.

Bariatric Surgery in Youth: the Perspective of Dutch Pediatricians, Parents, and Adolescents

BACKGROUND

Recent studies have indicated that bariatric surgery is effective for the treatment of youth with severe obesity. The attitudes of pediatricians, parents, and adolescents regarding this topic remain unclear. Therefore, the aim of this study was to assess the current thoughts and beliefs of Dutch pediatricians, parents, and adolescents regarding bariatric surgery in youth.

METHODS

An online survey containing twenty questions on bariatric surgery in youth was distributed to pediatricians of the Dutch Society of Pediatrics. Parents and adolescents who participated in an interdisciplinary care program for overweight, obesity, and severe obesity filled out an online survey of twelve questions.

RESULTS

One hundred and twenty-one pediatricians, 49 parents, and 19 adolescents completed the surveys. Seventy-two pediatricians (59.5%) considered bariatric surgery to be an effective treatment for youth with severe obesity when conventional treatment fails, and intend to refer patients for bariatric surgery. The most frequently suggested conditions for bariatric surgery were a minimum age of 16 years (n = 59, 48.7%), a BMI threshold of 40 kg/m² (n = 51, 42.2%), and a minimum Tanner stage of IV (n = 59, 48.8%). Thirty parents (61.2%) and fourteen adolescents (73.7%) responded that bariatric surgery should become available for youth with severe obesity.

CONCLUSION

Dutch pediatricians, parents, and adolescents increasingly accept bariatric surgery as a treatment modality in youth with severe obesity who do not respond successfully to lifestyle intervention. Whether pediatricians will actually refer youth for bariatric surgery remains to be seen when this treatment option will be implemented in the Netherlands.

Bariatric surgery in the treatment of adolescent obesity: current perspectives in the United States

Introduction: Rates of severe obesity in adolescents have increased at an alarming rate. Unfortunately, there are limited successful treatments for severe obesity in adolescents. Metabolic and bariatric surgery (MBS) is the most effective treatment available for adolescents with Class 2 and above severe obesity and has demonstrated variable degrees of sustained long-term weight loss which leads to resolution of multiple associated conditions and an improved quality of life.Areas covered: We discuss the current landscape of MBS in adolescents and evidence to support its long-term safety and efficacy. A literature search through PubMed, ResearchGate and HOLLIS Harvard Library Online Catalog was performed from the date of inception until 3/15/2021. A combination of the following keywords was used: Pediatric metabolic/bariatric surgery; long term outcomes of Pediatric metabolic/bariatric surgery, perioperative assessment, pediatric metabolic/bariatric surgery barriers; attitudes toward metabolic/bariatric surgery.Expert opinion: MBS is emerging as a safe and effective treatment strategy for adolescents with severe obesity, with recent studies demonstrating durable and sustainable weight loss. There remains an urgent need for longitudinal studies to assess durability of weight loss. Obesity stigma and bias, limited access to tertiary care centers, and skepticism around the treatment of obesity poses a major challenge.

Short- and long-term safety and efficacy of bariatric surgery for severely obese adolescents: a narrative review

The selection criteria, safety, and efficacy of bariatric surgery are well established in adults but are less well defined for severely obese adolescents. The number of severely obese adolescents who could benefit from weight loss surgery is increasing, although referral rates have plateaued. Surgical options for these adolescents are controversial and raise several questions. Recent studies, including the prospective Teen-Longitudinal Assessment of Bariatric Surgery Study and the Adolescent Morbid Obesity Surgery Study, help answer these questions. Early bariatric surgical intervention improves body mass index but, more importantly, improves cardiovascular and metabolic co-morbidities of severe obesity. A review of the medical, psychosocial, and economic risks and benefits of bariatric surgery in severely obese adolescents is a step toward improving the management of a challenging and increasing population. We describe the current knowledge of eligibility criteria, preoperative evaluation, surgical options, outcomes, and referral barriers of adolescents for bariatric surgery.

Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices

Severe obesity among youth is an "epidemic within an epidemic" and portends a shortened life expectancy for today's children compared with those of their parents' generation. Severe obesity has outpaced less severe forms of childhood obesity in prevalence, and it disproportionately affects adolescents. Emerging evidence has linked severe obesity to the development and progression of multiple comorbid states, including increased cardiometabolic risk resulting in end-organ damage in adulthood. Lifestyle modification treatment has achieved moderate short-term success among young children and those with less severe forms of obesity, but no studies to date demonstrate significant and durable weight loss among youth with severe obesity. Metabolic and bariatric surgery has emerged as an important treatment for adults with severe obesity and, more recently, has been shown to be a safe and effective strategy for groups of youth with severe obesity. However, current data suggest that youth with severe obesity may not have adequate access to metabolic and bariatric surgery, especially among underserved populations. This report outlines the current evidence regarding adolescent bariatric surgery, provides recommendations for practitioners and policy makers, and serves as a companion to an accompanying technical report, "Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity," which provides details and supporting evidence.

Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity

Severe obesity affects the health and well-being of millions of children and adolescents in the United States and is widely considered to be an "epidemic within an epidemic" that poses a major public health crisis. Currently, few effective treatments for severe obesity exist. Metabolic and bariatric surgery are existing but underuse treatment options for pediatric patients with severe obesity. Roux-en-Y gastric bypass and vertical sleeve gastrectomy are the most commonly performed metabolic and bariatric procedures in the United States and have been shown to result in sustained short-, mid-, and long-term weight loss, with associated resolution of multiple obesity-related comorbid diseases. Substantial evidence supports the safety and effectiveness of surgical weight loss for children and adolescents, and robust best practice guidelines for these procedures exist.

Hurdles to Take for Adequate Treatment of Morbidly Obese Children and Adolescents: Attitudes of General Practitioners Towards Conservative and Surgical Treatment of Paediatric Morbid Obesity

BACKGROUND

Bariatric surgery is regarded as the most effective treatment of morbid obesity in adults. Referral patterns for bariatric surgery in adults differ among general practitioners (GPs), partially due to restricted knowledge of the available treatment options. Reluctance in referral might be present even stronger in the treatment of morbidly obese children.

OBJECTIVES

The aim of this study was to investigate the current practice of GPs regarding treatment of paediatric morbid obesity and their attitudes towards the emergent phenomenon of paediatric weight loss surgery.

METHODS

All GPs enlisted in the local registries of two medical centres were invited for a 15-question anonymous online survey.

RESULTS

Among 534 invited GPs, 184 (34.5%) completed the survey. Only 102 (55.4%) reported providing or referring morbidly obese children for combined lifestyle interventions. A majority (n = 175, 95.1%) estimated that conservative treatment is effective in a maximum of 50% of children. Although 123 (66.8%) expect that bariatric surgery may be effective in therapy-resistant morbid obesity, only 76 (41.3%) would consider referral for surgery. Important reasons for reluctance were uncertainty about long-term efficacy and safety. The opinion that surgery is only treatment of symptoms and therefore not appropriate was significantly more prevalent amongst GPs who would not refer (58.3% vs. 27.6%, p < 0.001).

CONCLUSION

There is a potential for undertreatment of morbidly obese adolescents, due to suboptimal knowledge regarding guidelines and bariatric surgery, as well as negative attitudes towards surgery. This should be addressed by improving communication between surgeons and GPs and providing educational resources on bariatric surgery.

Weight loss after bariatric surgery in obese adolescents: a systematic review and meta-analysis

Of adolescents in the United States, 20% have obesity and current treatment options prioritize intensive lifestyle interventions that are largely ineffective. Bariatric surgery is increasingly being offered to obese adolescent patients; however, large-scale effectiveness data is lacking. We used MEDLINE, Embase, and Cochrane databases, and a manual search of references to conduct a systematic review and meta-analysis on overall weight loss after gastric band, gastric sleeve, and gastric bypass in obese adolescent patients (age ≤19) and young adults (age ≤21) in separate analyses. We provided estimates of absolute change in body mass index (BMI, kg/m²) and percent excess weight loss across 4 postoperative time points (6, 12, 24, and 36 mo) for each surgical subgroup. Study quality was assessed using a 10 category scoring system. Data were extracted from 24 studies with 4 having multiple surgical subgroups (1 with 3, and 3 with 2 subgroups), totaling 29 surgical subgroup populations (gastric band: 16, gastric sleeve: 5, gastric bypass: 8), and 1928 patients (gastric band: 1010, gastric sleeve: 139, gastric bypass: 779). Mean preoperative BMI (kg/m²) was 45.5 (95% confidence interval [CI]: 44.7, 46.3) in gastric band, 48.8 (95%CI: 44.9, 52.8) in gastric sleeve, and 53.3 (95%CI: 50.2, 56.4) in gastric bypass patients. The short-term weight loss, measured as mean (95%CI) absolute change in BMI (kg/m²) at 6 months, was -5.4 (-3.0, -7.8) after gastric band, -11.5 (-8.8, -14.2) after gastric sleeve, and -18.8 (-10.9, -26.6) after gastric bypass. Weight loss at 36 months, measured as mean (95%CI) absolute change in BMI (kg/m²) was -10.3 (-7.0, -13.7) after gastric band, -13.0 (-11.0, -15.0) after gastric sleeve, and -15.0 (-13.5, -16.5) after gastric bypass. Bariatric surgery in obese adolescent patients is effective in achieving short-term and sustained weight loss at 36 months; however, long-term data remains necessary to better understand its long-term efficacy.