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Moving Gastric Bypass for Severely Obese Adolescents into the Mainstream :

October 28, 2019

In a recently released issue of Pediatrics, readers will find both the Technical Report (10.1542/peds.2019-3224) and the current Policy Statement (10.1542/peds.2019-3223) on Pediatric Metabolic and Bariatric Surgery from the American Academy of Pediatrics.

In a recently released issue of Pediatrics, readers will find both the Technical Report (10.1542/peds.2019-3224) and the current Policy Statement (10.1542/peds.2019-3223) on Pediatric Metabolic and Bariatric Surgery from the American Academy of Pediatrics. These seminal documents contain key information for pediatric providers. The definition of severe obesity for children and adolescents ages differs from that for adults, and is clarified as a BMI ≥35 kg/m2 or a BMI that is ≥120% of the 95th percentile BMI for age and sex, whichever is lower. Severe obesity is not only increasing worldwide and among teens, but is associated with racial, gender and socioeconomic disparities: Black, Hispanic and Native American youth, females and youth living in poverty bear the burden of the rising prevalence of severe obesity. National data show that 7.9% of US (United States) youth are severely obese.1 This is not a problem any of us can ignore or wish away. Unfortunately, published literature2,3 demonstrates that behavioral, diet and lifestyle change interventions are not broadly effective, and hence this Technical Report and Policy Statement about gastric bypass are timely and relevant.

Both reports emphasize the key roles of patient and family preparation, including consultation and collaboration with a multi-disciplinary center with specific expertise in bariatric surgery. Patient selection (and insurance coverage) depend on documented pre-operative efforts to lose weight, psychological and medical assessment of the individual, and evaluation of family and social supports for post-operative lifestyle changes. There is a meaningful body of literature demonstrating the effectiveness of bariatric surgery for adolescents, and even some possible evidence of a “ceiling effect” (i.e. regardless of initial BMI the percentage of body weight lost is similar) suggesting that earlier referral (versus waiting for the BMI to climb further) may be optimal. Primary care pediatricians have a key clinical role in follow up through proactively monitoring for progress and complications, ranging from nutritional deficiencies to mental health concerns.

My own challenge has been in convincing severely obese teens and their parents to seriously consider bariatric surgery, including just to accept a referral for consultation. I now wonder if I previously presented enough parent and patient-friendly information in a sufficiently even-handed, realistic and positive way. These two articles have given me more knowledge to serve as a good resource, and have empowered me to say confidently to the family that I am not “handing off” the teen to another team, but rather will continue my involvement in preparatory care and post-operative follow up. Please share your thoughts about this topic, and any tips you may have about how to effectively make a bariatric surgery referral!

References

1. Skinner AC, Ravanbakht SN, Skelton JA, Perrin EM, Armstrong SC. Prevalence of 386 Obesity and Severe Obesity in US Children, 1999-2016. Pediatrics. Feb 26 2018.

2. Moore SM, Borawski EA, Love TE, Jones S, Casey T, McAleer S, Thomas C, Adegbite-Adeniyi C, Uli NK, Hardin HK, Trapl ES, Plow M, Stevens J, Truesdale KP, Pratt CA, Long M, Nevar A.Two Family Interventions to Reduce BMI in Low-Income Urban Youth: A Randomized Trial. Pediatrics. 2019;143(6). pii: e20182185. doi: 10.1542/peds.2018-2185.

3. Pratt K, Cotto J, Xu J, Watowicz R, Walston M, Eneli I. Adolescents' and Parents' Perspectives of a Revised Protein-Sparing Modified Fast (rPSMF) for Severe Obesity. Int J Environ Res Public Health. 2019;16(18):3385. Published 2019 Sep 12. doi:10.3390/ijerph16183385

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