Adolescent Obesity and Weight Loss Surgery: Special Report
Childhood and adolescent obesity is an epidemic in the United States. The latest statistics from the U.S Surgeon General are sobering. They show that more than 12.5 million children and adolescents aged 2 to 19 are overweight. And these numbers are on the rise. As a result, growing numbers of children and teens are at increased risk for diseases traditionally seen only in adults, including heart disease and type 2 diabetes.
Despite the soaring rates of adolescent obesity, weight loss surgery in adolescents remains uncommon. The number of adolescents undergoing weight loss surgery more than tripled between 2000 and 2003, but these surgeries are still relatively rare in adolescents. In fact, teens represent less than 1 percent of weight loss surgery patients, according to a report in the March 2007 issue of Archives of Pediatrics & Adolescent Medicine.
Some doctors will recommend this surgery if a child's weight poses a greater health threat than the potential risks of the surgery. Risks of adolescent obesity include diabetes, high blood pressure, joint problems, liver problems, lung and breathing issues and increasing pressure in the brain that can cause vision impairment or blindness.
When Is Weight Loss Surgery the Answer to Adolescent Obesity?
Weight loss surgery is not a panacea for obesity in teens. There are many unknowns. No studies document the long-term effects of weight loss surgery on a child's future growth and development. What's more, weight loss surgery does not guarantee that an adolescent will lose all of his or her excess weight and/or keep it off long-term. Weight loss surgery also doesn't replace the long-term need for a healthy diet and regular physical activity.
If weight loss surgery is deemed an option for an adolescent, he or she should be referred to centers with multidisciplinary weight management teams. These teams should include specialists in adolescent obesity evaluation and management, such as psychologists, nutritionists, physical activity instructors and weight loss surgeons. Additional expertise in adolescent medicine, endocrinology, pulmonology, gastroenterology, cardiology and orthopedics may be helpful, too.
Exactly when an adolescent should undergo weight loss surgery is controversial. It depends on the severity of obesity-related health problems faced by the individual patients. This individualized decision should be made on a case-by-case basis with the medical team.
According to guidelines set forth by the American Academy of Pediatrics in 2004, adolescents under consideration for weight loss surgery should:
- Have failed six or more months of organized attempts at weight management. This should be determined with the assistance of a doctor.
- Have attained or nearly attained physiologic or skeletal maturity. This generally occurs at age 13 or older for girls and at age 15 or older for boys.
- Be severely obese, with a body mass index (BMI) of greater than 40, with serious obesity-related problems; or have a BMI of greater than 50 with less severe obesity-related problems. (Other organizations, including the American Society for Metabolic and Bariatric Surgery, have less stringent weight criteria for teens, due to the severity of medical problems that obese adolescents now face.)
BMI takes height and weight into account to measure body fatness. For children and teens, BMI is age- and sex-specific and is often referred to as BMI-for-age. After BMI is calculated for children and teens, the BMI number is plotted on the federal Centers for Disease Control and Prevention (CDC) BMI-for-age growth charts (for either girls or boys) to obtain a percentile ranking. [For more information on body mass index and to try an adult BMI calculator, please read our article on obesity and weight loss surgery. To use the CDC's BMI calculator for children and teens, please click here.]
- Be committed to comprehensive medical and psychological evaluations that should occur before and after surgery
- Agree to avoid pregnancy for at least one year after surgery. Pregnancies are safe after weight loss surgery, but reliable contraception should be used for at least the first year after the operation due to increased risk to the developing fetus posed by the rapid weight loss. After the period of rapid weight loss is over, pregnancies should be carefully planned and monitored.
- Be capable of and willing to adhere to a strict bariatric surgery nutrition program following your operation. For example, after gastric bypass surgery, patients must consume a very low-calorie, low-carbohydrate diet with more than 0.5 grams of protein per kilogram of body weight per day. Daily multivitamins, as well as supplements of key nutrients such as calcium, vitamin B12, folate, thiamine and iron (for menstruating females), may also be needed.
- Provide informed consent to surgical treatment.
- Demonstrate the ability to make sound decisions. Age is not necessarily the limiting factor here.
- Have a supportive family environment.
Weight loss surgery is not an option in certain adolescents, including those with:
- A medically correctable cause of obesity.
- A substance abuse problem within the preceding year.
- An inability or unwillingness of either the adolescent or the parents to fully comprehend the surgical procedure and its consequences.
- Current pregnancy or plans to become pregnant within two years after surgery. Also, adolescents who are currently lactating following a recent pregnancy must wait.
Teens who had gastric bypass surgery showed dramatic, often immediate, remission of their type 2 diabetes following surgery, according to a study reported in the January 2009 issue of Pediatrics. In fact, many teens checked out of the hospital without any diabetes-related medications.
Previous studies have shown that weight loss surgery can induce remission of type 2 diabetes in adults, but this is the first study to show that the treatment may do the same in adolescents.
The new study included 78 adolescents with type 2 diabetes. Eleven teens had gastric bypass surgery at one of five participating medical centers, while the remaining 67 teens were part of a comparison group who received routine medical management for their diabetes, but did not have any surgery.
Extremely obese teens who underwent bariatric surgery had an average 34 percent reduction in weight one year after surgery, with all but one seeing their type 2 diabetes disappear. In comparison, obese teens who were medically managed saw their weight remain essentially the same, and all were still taking medication for their diabetes. The teens that had gastric bypass showed other improvements too, such as lower blood pressure and cholesterol levels.
Teens suffering with metabolic syndrome which greatly increases their risk of heart attack, stroke and diabetes who undergo Lap-band surgery may be cured as a result. The findings were presented at The Endocrine Society's 91st Annual Meeting in Washington, D.C.
In the new study, 24 morbidly obese teens who had Lap-Band surgery showed significant decreases in their BMI, their waistline and blood levels of an inflammatory marker called C-reactive protein, six months after the weight loss surgery. These improvements in metabolic syndrome symptoms lasted for at least one year.
In fact, five of the teens who were followed for one year had been diagnosed with metabolic syndrome before the surgery. Of these, just two still had metabolic syndrome one year later, the study showed.
Tests for Weight Loss Surgery Eligibility
Along with a complete physical exam and counseling, your doctor will run several tests that can help determine whether the weight poses a greater health threat than the potential risks of weight loss surgery. They include:
- Fasting glucose and hemoglobin A1C measurement to look for blood sugar anomalies that suggest type 2 diabetes
- Liver function tests
- Lipid profile tests to see if blood cholesterol levels are elevated
- Complete blood counts
- Thyroid function tests
- Pregnancy tests for female patients
- Screening for nutrient deficiencies
- Sleep study (polysomnography) for adolescents with sleep apnea (one or more pauses in breathing or shallow breaths while you sleep)
- Bone age assessment to document the degree of skeletal maturity
Choosing a Weight Loss Surgery Procedure
Exactly which weight loss surgery is best for teens is not yet known. Both the Roux-en-Y gastric bypass and adjustable gastric banding have been effective in treating adolescent obesity.
During gastric banding, an adjustable band is placed around the stomach to restrict food intake. In contrast, the Roux-en-Y-gastric bypass creates a small stomach pouch to curb food intake by stapling a portion of the stomach. Then a Y-shaped part of the small intestine is attached to the stomach pouch so that food can bypass the duodenum (the first part of the small intestine, located between the stomach and the middle part of the small intestine, or jejunum).
Unlike gastric bypass, which involves cutting or stapling the stomach to permanently decrease its size, the Lap-Band is adjustable and, if necessary, removable.
The rate and amount of weight loss also differs. The weight loss from gastric bypass is very rapid, occurring in the first nine to 12 months. It tends to plateau after 18 months. Weight loss with gastric banding, however, is more gradual. Adolescents who undergo gastric banding lose about five to 10 pounds a month. Teenagers do lose weight faster with gastric banding compared with adults who undergo this weight loss surgery, possibly because they are more motivated and receive more positive social feedback.
Risks of Weight Loss Surgery for Obese Adolescents
Weight loss surgery is risky business. Although these procedures can result in substantial weight loss, the long-term effects among teens are unknown. A recent study offers up some good news. It shows that the risks are no greater in teens than they are in adults. In fact, adolescents who undergo weight loss surgery have fewer complications and a faster rate of recovery than older patients, according to research published in the March 2007 issue of Archives of Pediatrics & Adolescent Medicine.
Risks vary based on choice of procedure.
Risks of gastric bypass include:
- Infection at the point of incision
- Blood flow blockage in the lung
- A leak from the stomach into another area of the body
- Loosened staples
- Narrowing of the link between the stomach and intestines
- "Dumping" syndrome (a group of symptoms that may include nausea, bloating, vomiting, cramps, diarrhea and/or other symptoms), which occurs if food moves too fast through the body
Other risks may include:
- General weakness
- Hiccupping and bloating if the stomach becomes enlarged
- Nutritional deficiencies (iron, calcium, other vitamins and minerals), which can lead to iron-poor blood (anemia) or the brittle bone disease osteoporosis if left untreated
- Death, which is always possible with surgery
Certain risks can be reduced. For example, the doctor can provide a vitamin supplement regimen to help prevent nutritional deficiencies. Specifically, menstruating girls who undergo this weight loss surgery should take extra iron and vitamin B-12, as mentioned above, to prevent anemia.
Risks of the Lap-Band procedure include:
- Slippage of the band, which can occur with persistent vomiting if behavioral changes regarding moderate food intake do not take place
- Erosion of the band into the inside of the stomach
- Spontaneously deflation of the band due to leakage
- Enlargement of the stomach pouch
- Blockage of the stoma (stomach outlet)
Scheduling Weight Loss Surgery for a Teen
Oftentimes, adolescents undergo weight loss surgery during school breaks. The down-time for gastric banding is much shorter than for gastric bypass surgery: people who undergo gastric banding are fully recovered within a week, so gastric banding can be done over Christmas or spring break. The more invasive gastric bypass surgery might be reserved for the longer summer vacation.
Along with the physical recovery from surgery, adolescents must also use this time to get used to eating solid foods. During the recovery period, they have to slowly reintroduce solid foods, starting with a liquid diet, then on to pureed food and finally, solids. This process takes longer for gastric bypass surgery than for gastric banding. Within four to six weeks, all patients are eating solid food regardless of which surgery they choose. Some physical restrictions also exist during the recovery period, such as avoiding heavy lifting and gym class for about a month.
Most adolescents who undergo weight loss surgery look forward to returning to school after surgery. They may look and feel different. Once they return to school, they find that they are not teased anymore. Surgeons and parents report that the vast majority of adolescents who undergo weight loss surgery are so happy, that their personality changes for the better.
Adolescent Life After Weight Loss Surgery
The journey is not over after weight loss surgery. Far from it. Some teens may need body contouring surgeries to get rid of the excess skin and flab that remain after massive weight loss. Unlike their peers, teens who have undergone weight loss surgery must be hypervigilant about what they eat, when they eat and how they eat it. Teens often want to fit in, and such regimented eating may make them stand out.
Long-term medical and psychological follow-up is also necessary after weight loss surgery. It is no quick fix. Weight loss surgery involves a deep commitment and intensive follow-through. In the right adolescent, however, weight loss surgery can improve overall quality of life and self-esteem.
Many of the questions regarding weight loss surgery in adolescents may be answered when the Teen Longitudinal Assessment of Bariatric Surgery (LABS) study, begun in 2006, is completed. This five-year, multi-center study of 200 adolescents aims to determine if weight loss surgery is an appropriate treatment option for extremely overweight teens. Stay tuned.
U.S. Department of Health and Human Services website. The Surgeon General's Call To Action To Prevent and Decrease Overweight and Obesity.
CDC website. About BMI for Children and Teens.
Inge TH, Krebs KF, Barcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004; 11: 217-223
Tsai WS, Inge TH, Burd RS. Bariatric Surgery in Adolescents: Recent national trends in use and in-hospital outcome. Arch Pediatr Adolesc Med. 2007l161:217-221
Shawn M. Garber, MD, FACS, FASMBS
Spencer A. Holover, MD, FACS, FASMBS
John D. Angstadt, MD, FACS, FASMBS
Eric A. Sommer, MD
Nikhilesh Sekhar, MD, FACS, FASMBS
The New York Bariatric Group
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NYU Medical Center
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