Faith was not your average 15-year-old. She had severe obesity for as long as she could remember and waded through soul-crushing jeers in school every day. She was certain that weight loss surgery was the right choice for her. Both her parents had gone through gastric bypass surgery, and she saw how hard they worked to make healthy choices. No one had to tell Faith that surgery is not a quick fix.
In 2014 at age 16, Faith underwent the same procedure her parents had done. She now is about to graduate from college and recently won a national award for developing a teen advocacy group to battle weight stigma. She hopes to help other teens navigate the wilderness of living with severe obesity and emerge stronger.
Not every child with severe obesity has the access to care that Faith had, but they should, according to new guidance from the Academy on adolescent weight loss surgery or “bariatric surgery.”
The guidance is based on a comprehensive review of the literature and consultation with experts in surgical and medical pediatric weight management. It includes a policy statement titled Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices to help pediatricians select appropriate patients, guide teens and families through the decision-making process, locate high-quality surgical programs and advocate for payment. An accompanying technical report titled Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity details the evidence on procedure types, complications and outcomes.
The policy and technical report from the Section on Obesity and Section on Surgery are available at https://pediatrics.aappublications.org/content/early/2019/10/24/peds.2019-3223 and https://pediatrics.aappublications.org/content/early/2019/10/24/peds.2019-3224. They will be published in the December issue of Pediatrics.
Reports highlight urgency
The most important call to action is that severe obesity is an “epidemic within an epidemic” — defined as having a body mass index (BMI) that is 120% above the 95th percentile for age and sex. Severe obesity affects 4.5 million U.S. children and adolescents, and these children are unlikely to get better by adulthood even with the best medical care available.
Over the past decade, evidence has emerged that bariatric surgery is a safe and effective treatment option for youths with obesity. While randomization poses practical and ethical challenges, well-designed and longitudinal case studies consistently have found low complication rates (15% minor, 8% major) and no attributable deaths related to the two most common procedures, Roux-en-Y gastric bypass and vertical sleeve gastrectomy, when performed by a comprehensive care team.
Contrary to prior reports, the evidence does not clearly identify a lower age limit; research shows that complications were lowest and outcomes the best when individual and family-level factors drove the decision-making process.
There is no evidence to suggest that watchful waiting is effective; in fact, outcomes are improved and complication rates are lower when the surgery is done sooner — in one study, before the BMI is greater 55kg/m2. The American College of Surgeons’ Metabolic and Bariatric Surgery Association Quality Improvement Program lists programs that provide comprehensive care and report long-term outcomes to assist pediatricians and families in finding high-quality options (see resources).
Underutilization of surgery
Despite this surge of supporting evidence and centers equipped to provide care, the rates of adolescent weight loss surgery remain low. The evidence reveals a striking trend of underutilization, particularly for low-income teens.
One reason for this likely is related to insurance coverage; plans that include bariatric surgery for patients under 18 are uncommon. Less than half (47%) of qualifying teens who enter surgical programs have their procedure approved on the first request, and 11% never have them approved. Teens from low-income backgrounds have a much lower rate of insurance approval for surgery, despite bearing a higher burden of obesity and related comorbid disease.
A second reason for underutilization is low referral rates from primary care. Until now, little guidance has been available for pediatricians to identify appropriate patients, to educate families on the risks and benefits of surgery, to provide pre- and post-operative care for patients, and to identify high-quality surgical programs near them. This report provides such guidance for pediatricians.
Ideally, U.S. children and adolescents would have the best opportunity for a healthy future by growing up in an environment that supports healthy eating and an active lifestyle. Pediatricians and others should continue to advocate for this. However, for most children with severe obesity, lifestyle modification will not be enough to prevent disease. There is substantial evidence that for many youths with severe obesity, surgery is the most effective treatment option.
To promote equitable access to bariatric surgery for all qualifying patients, the AAP recommends the following:
- Recognize that severe obesity is a high-risk condition and unlikely to resolve with medical or lifestyle treatment alone.
- Consider surgery for a youth with severe obesity and comorbid medical conditions (see table 1 in the policy at https://doi.org/10.1542/peds.2019-3223).
- Engage with patients, the family and the surgical team in a shared decision-making process that accounts for patient autonomy, values, family support, emotional and physical maturity, and an understanding of the short- and long-term implications.
- Ensure that surgery is performed only in high-quality centers that can provide pediatric and family-specific care.
- Educate patients and families on surgical procedures and support them prior to and after weight loss surgery.
- Enable health care coverage for surgery for all children who meet the criteria regardless of income, race, ethnicity or other factors that could lead to disparities in care.
Dr. Armstrong is a lead author of the policy statement and technical report. She is a member of the AAP Section on Obesity Executive Committee.
