BACKGROUND AND OBJECTIVES:

Youth with cognitive impairment or developmental disability (CI/DD) face higher rates of obesity and secondary medical issues. Bariatric surgery may be a helpful tool for health improvement because it has been shown efficacious for adolescents. We aim to contribute to literature regarding bariatric surgery for adolescents with CI/DD and explore the association between cognitive functioning and weight loss outcomes.

METHODS:

Adolescents (N = 64) received a preoperative psychological evaluation, including cognitive assessment, and bariatric surgery at 1 weight loss program between 2010 and 2017. For these adolescents with measured cognitive performance, CI/DD was defined by an IQ <80 or previous diagnosis. In analyses, we compared adolescents with and without CI/DD. Structural equation modeling was used to assess the impact of cognitive functioning on weight loss 3 to 24 months postsurgery.

RESULTS:

There were no significant differences between adolescents with or without CI/DD in terms of preoperative BMI, age, and sex. Having CI/DD did not significantly impact weight loss or weight loss trajectory in the 2 years after surgery, although modeling revealed a trend toward individuals with CI/DD losing more weight over time. Similarly, intelligence scores did not predict weight loss after surgery.

CONCLUSIONS:

Bariatric surgery may be a helpful tool for adolescents with severe obesity and CI/DD. They could benefit from the surgery as much as those with typical development, and having CI/DD should not be used as a criterion to deny surgery. Continuing research with this population can be used to determine long-term outcomes in addition to defining best practices.

What’s Known on This Subject:

Adolescents with cognitive impairment or developmental delays are more likely to acquire severe obesity. Little is known about effective interventions for addressing obesity in this population, including bariatric surgery. Limited data, primarily from case reports, present a mixed picture.

What This Study Adds:

In the current study, we examine weight loss outcomes for adolescents with cognitive impairment and developmental disabilities and severe obesity after laparoscopic sleeve gastrectomy. This special population (and the relationship of cognitive functioning to surgery outcomes) is understudied.

Recent reports reveal that 1 in 5 adolescents in the United States has obesity, and nearly 1 in 10 has severe obesity (BMI >120% of the 95th percentile).1,2 Furthermore, obesity and severe obesity are more prevalent among certain subsets of the population such as youth with cognitive impairment or developmental disability (CI/DD).3,5 For instance, adolescents with Down syndrome or autism spectrum disorder are 2 to 4 times more likely to be affected by obesity.6,8 More generally, low IQ has been associated with greater obesity in childhood, and this has been shown to be a unidirectional relationship (ie, obesity does not lead to significantly lower IQ).9,10 Risk for developing obesity increases with age for children with developmental delays.11 These youth also experience higher rates of obesity-related conditions, including high blood pressure, blood cholesterol, diabetes, depression, fatigue, liver or gallbladder problems, low self-esteem, preoccupation with weight, early maturation, and pressure sores.6 Because adolescents with CI/DD face a host of serious, obesity-related medical comorbidities, weight management is imperative for improved health.

Although the negative impacts of severe obesity are numerous for youth with CI/DD, treatment modalities are understudied for this group, including bariatric surgery. Well-established treatments are available for youth, although these often fail to result in meaningful or sustained weight loss.12,13 Similarly, lifestyle modification interventions adapted for youth with CI/DD have revealed small or nonsignificant decreases in BMI.13,17 These findings suggest a need for other approaches to improving weight and well-being of adolescents with cognitive impairments.

Bariatric surgery is increasingly used as an effective and cost-effective tool for reducing weight and improving comorbid medical concerns among typically developing youth with severe obesity.18,21 Results suggest that adolescents experience significant and sustained weight loss, improvement in life-threatening medical conditions caused by obesity, and improvement in quality of life as a result of surgery.19,20 However, there are few studies in which bariatric surgery for individuals with CI/DD is examined and even fewer for adolescents with CI/DD. Adults with CI/DD and severe obesity may receive bariatric surgery with few surgical complications and a mean excess weight loss of 31.1%, according to 1 review.22 This percentage of excess weight loss was noted to be lower than average for adults without cognitive impairment receiving bariatric surgery. A recent review of 16 studies included 5 case studies or case series reports of surgery in youth with CI/DD and reported 50.5% to 79% excess weight loss for these individuals.23 Authors of a single matched-controlled study have examined the bariatric surgery outcomes of youth with Prader-Willi syndrome, which is a syndrome characterized by cognitive impairment, hypotonia, and hyperphagia that often results in childhood obesity. This unique report revealed no significant difference in BMI change between youth with Prader-Willi syndrome and matched controls receiving bariatric surgery. During the 5-year follow-up period, there were also no differences between groups in terms of growth, and both groups experienced 95% comorbidity resolution or improvement.24 Research on this special population is limited, but available data present bariatric surgery as a promising intervention for youth with severe obesity and CI/DD.

In the current study, we endeavor to evaluate weight loss outcomes for adolescents with CI/DD receiving laparoscopic sleeve gastrectomy (LSG), compared with those without CI/DD having the same operation, and to examine the relationship of IQ scores and postsurgical weight loss. Individuals receiving LSG surgery were categorized as having a cognitive impairment if measured IQ was <80 or an existing diagnosis of developmental disability was reported. We first aimed to learn whether adolescents with CI/DD would experience proportionate weight loss after LSG compared with typically developing youth after LSG. Secondly, we set out to determine if IQ scores might predict weight loss from 3 to 24 months after receiving LSG. On the basis of the existing literature, which reveals a mixed- but positive-leaning picture for adults and youth with CI/DD after surgery, we hypothesized that there would be no significant differences in weight loss outcomes for adolescents with and without CI/DD at any of the follow-up time points.22,24 In reference to the second aim, we hypothesized that the IQ score would not be significantly related to weight loss after the LSG procedure.

Participants and their guardians completed signed informed assent and consent, respectively, for the first 2 years of data collection. Afterward, signed informed consent was waived, and an information sheet was provided to families in which their ability to opt out of any research involvement was detailed. This was done with the permission of the institutional review board because the signed consent was the only document linking participant name to the database, ultimately increasing the risk for a confidentiality breach. No patients during the time period of data collection opted out of the research. Four families were not included in the research because the parents did not- speak English, and no translator was available at time of consent. The applicable institutional review board approved this research.

Adolescents were self-referred or referred for bariatric surgery by medical providers if they met medical criteria (a BMI ≥35 with a medical comorbidity or a BMI ≥40). Approximately 1 to 4 months before a potential surgery, the youth and their caregivers participated in a psychological evaluation. Clinicians referred to recommended guidelines in evaluating whether adolescents were well positioned to move forward with the surgery.25,27 This evaluation was conducted by a licensed clinical psychologist. Assessment of cognitive functioning via standardized intelligence testing was performed on a subset of patients between 2013 and 2016. From 2013 to 2015 the intelligence testing was performed for almost all patients attending preoperative visits and thereafter only for adolescents for whom there was a concern regarding cognitive ability or ability to assent or consent for surgery.

Standardized cognitive assessment was administered to 56 adolescents in the course of preoperative psychological evaluation between 2013 and 2016 out of a larger sample of 226 adolescents receiving bariatric surgery at 1 weight loss program from January 2010 to December 2017. Additionally, 8 patients were identified as having a previous diagnosis of intellectual or developmental disability and were included in this subset; these patients received surgery between 2010 and 2017. The adolescents included in the following analyses (N = 63) were primarily girls (65%) and African American (57%; 24% non-Hispanic white, 18% Hispanic, and 1% other race or biracial). The average age of participants was 17.7 years (SD = 2.0; range = 13–24 years). The pediatric patients in this study were affected by severe obesity, with an average BMI of 51.2 (SD = 8.6; range = 36–74). Approximately half of the participants were on Medicaid; no other indicators of socioeconomic status were recorded.

The data presented were gathered in the course of the preoperative psychological evaluation or during follow-up visits with the surgeon at 3, 6, 12, and 24 months postsurgery. Anthropomorphic data were gathered during these follow-up visits.

Demographic Variables

Age, race and/or ethnicity, and sex were extracted from the medical record. Participants reported these variables at their first medical visit.

CI/DD

Adolescents were identified as having CI/DD by 2 methods: Beginning in 2013 and through 2016, the Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II) was added to the preoperative evaluation procedure to assess domains of cognitive functioning. This is a well-established measure of cognitive performance. It has been validated for use with individuals 6 to 90 years of age.28 Adolescents with a full-scale IQ (FSIQ-4) <80 (n = 9), falling within the borderline to extremely low range, were included in the CI/DD group (see Table 1). Other adolescents had been identified in the medical record and by parent report in the preoperative psychological evaluation as having a diagnosed intellectual impairment or developmental disability (n = 8). Three of the participants presented with Down syndrome, and 5 presented with a previous mild-to-severe intellectual disability diagnosis of unknown etiology. For the current study, both the presence and absence of CI/DD and the FSIQ-4 score were used as predictors.

TABLE 1

Demographic and Preoperative Patient Descriptors and Weight Loss Outcomes, by Group

VariableCI/DD (n = 17)Non-CI/DD (n = 46)
   
Female sex, No. (%) 11 (64.7) 30 (65.2) 
Race, No. (%)   
 African American 11 (64.7) 27 (58.7) 
 White 4 (23.5) 12 (26.1) 
 Hispanic 1 (5.9) 7 (15.2) 
 Other or biracial 1 (5.9) 0 (0) 
Age at surgery, y, mean (SD) 17.7 (2.7) 17.6 (1.7) 
Preoperative baseline BMI, mean (SD) 51.5 (10.5) 51.1 (7.9) 
FSIQ-4 score, mean (SD) 71.4 (8.3)a 93.8 (10.7)a 
BMI at 3 mo (n/N = 59/63),b mean (SD) 42.1 (9.7) 43.0 (7.8) 
BMI at 6 mo (n/N = 40/62), mean (SD) 41.5 (10.2) 38.8 (8.1) 
BMI at 12 mo (n/N = 35/61), mean (SD) 37.5 (9.5) 36.1 (9.4) 
BMI at 24 mo (n/N = 14/48), mean (SD) 45.2 (4.5) 38.1 (9.7) 
%EBMIL at 3 mo (n/N = 59/63), mean (SD) 39 (17) 34 (14) 
%EBMIL at 6 mo (n/N = 40/62), mean (SD) 48 (14) 50 (19) 
%EBMIL at 12 mo (n/N = 35/61), mean (SD) 58 (19) 59 (25) 
%EBMIL at 24 mo (n/N = 14/48). mean (SD) 39 (12) 55 (23) 
BMI change at 3 mo (n/N = 59/63), mean (SD) 9.4 (3.3) 8.4 (2.5) 
BMI change at 6 mo (n/N = 40/62), mean (SD) 12.6 (2.5) 11.6 (3.1) 
BMI change at 12 mo (n/N = 35/61), mean (SD) 14.4 (4.0) 12.9 (4.3) 
BMI change at 24 mo (n/N = 14/48), mean (SD) 13.8 (6.3) 13.9 (5.5) 
%TWL at 3 mo (n/N = 59/63), mean (SD) 18 (7) 17 (5) 
%TWL at 6 mo (n/N = 40/62), mean (SD) 24 (5) 24 (7) 
%TWL at 12 mo (n/N = 35/61), mean (SD) 29 (9) 27 (9) 
%TWL at 24 mo (n/N = 14/48), mean (SD) 43 (42) 27 (10) 
VariableCI/DD (n = 17)Non-CI/DD (n = 46)
   
Female sex, No. (%) 11 (64.7) 30 (65.2) 
Race, No. (%)   
 African American 11 (64.7) 27 (58.7) 
 White 4 (23.5) 12 (26.1) 
 Hispanic 1 (5.9) 7 (15.2) 
 Other or biracial 1 (5.9) 0 (0) 
Age at surgery, y, mean (SD) 17.7 (2.7) 17.6 (1.7) 
Preoperative baseline BMI, mean (SD) 51.5 (10.5) 51.1 (7.9) 
FSIQ-4 score, mean (SD) 71.4 (8.3)a 93.8 (10.7)a 
BMI at 3 mo (n/N = 59/63),b mean (SD) 42.1 (9.7) 43.0 (7.8) 
BMI at 6 mo (n/N = 40/62), mean (SD) 41.5 (10.2) 38.8 (8.1) 
BMI at 12 mo (n/N = 35/61), mean (SD) 37.5 (9.5) 36.1 (9.4) 
BMI at 24 mo (n/N = 14/48), mean (SD) 45.2 (4.5) 38.1 (9.7) 
%EBMIL at 3 mo (n/N = 59/63), mean (SD) 39 (17) 34 (14) 
%EBMIL at 6 mo (n/N = 40/62), mean (SD) 48 (14) 50 (19) 
%EBMIL at 12 mo (n/N = 35/61), mean (SD) 58 (19) 59 (25) 
%EBMIL at 24 mo (n/N = 14/48). mean (SD) 39 (12) 55 (23) 
BMI change at 3 mo (n/N = 59/63), mean (SD) 9.4 (3.3) 8.4 (2.5) 
BMI change at 6 mo (n/N = 40/62), mean (SD) 12.6 (2.5) 11.6 (3.1) 
BMI change at 12 mo (n/N = 35/61), mean (SD) 14.4 (4.0) 12.9 (4.3) 
BMI change at 24 mo (n/N = 14/48), mean (SD) 13.8 (6.3) 13.9 (5.5) 
%TWL at 3 mo (n/N = 59/63), mean (SD) 18 (7) 17 (5) 
%TWL at 6 mo (n/N = 40/62), mean (SD) 24 (5) 24 (7) 
%TWL at 12 mo (n/N = 35/61), mean (SD) 29 (9) 27 (9) 
%TWL at 24 mo (n/N = 14/48), mean (SD) 43 (42) 27 (10) 
a

Independent samples t test; P < .01.

b

n/N value reveals the ratio of patients presenting to a clinic compared with patients eligible for clinic follow-up at each time point.

Weight Loss

The percentage of excess BMI lost (%EBMIL) was calculated to indicate the degree of weight loss after surgery. This is a standard measure of weight loss after surgery and is calculated by assuming an ideal BMI of 25, subtracting this from preoperative BMI, and reaching the excess BMI.29 At follow-up visits, the measured BMI is compared with the excess BMI to calculate the %EBMIL. We also examined weight loss using other metrics, including BMI postsurgery, change in BMI pre- and postsurgery, and percentage of total weight loss (%TWL). Because of loss to follow-up and the fact that some patients were not yet due for the 2 year follow-up, 94% of participants had weight loss data at 3 months postsurgery (n = 59), 63% at 6 months postsurgery (n = 40), 56% at 12 months postsurgery (n = 35), and 22% at 24 months postsurgery (n = 14). Table 1 provides a ratio of patients for whom data were collected compared with patients who were eligible for a clinic visit at each time point.

Data Analytic Plan

Descriptive statistics were calculated to characterize the sample, and t tests were conducted to evaluate between-group differences in baseline characteristics as well as differences in BMI, %EBMIL, change in BMI, and %TWL at each follow-up time point. Next, the growth trajectory of change in weight was examined by using nonlinear latent growth models (LGMs).30,33 In the LGM, outcome measures are %EBMIL, change in BMI, and %TWL measured at 3, 6, 12, and 24 months postsurgery. There are 2 latent growth factors in the model (ie, latent intercept growth factor [Eta0] and latent slope growth factor [Eta1]); for instance, the former represents the average level of %EBMIL at 3 months postsurgery, and the latter is used together with time scores to represent the rate of change in the %EBMIL between each time point. Whereas the time score was fixed to 0 and 1 at 3 and 6 months postsurgery for the purpose of model identification, the time scores at 12 and 24 months postsurvey were estimated. First, the unconditional LGM was estimated to explore the growth trajectory of %EBMIL (and, secondarily, to ensure that findings were consistent when models were estimated by using the other measures of weight outcome) between 3 and 24 months postsurgery. Two conditional LGMs were estimated, in which a dichotomous IQ measure (1: presence of intellectual disability, 0: absence intellectual disability) and the FSIQ-4 score, measured on a continuous scale, were used to predict the growth trajectory of %EBMIL (or other measure of weight outcome), respectively, controlling for covariates (eg, age, sex, ethnicity, and preoperative BMI).

The Bayesian approach was applied for model estimation because it has superior performance in small samples without reliance on asymptotic and data normality assumptions and is also more robust for handling missing data.34,36 The Bayesian approach is a full-information estimator in which all of the available data under a missing-at-random (MAR) assumption are used. Such a full-information approach is superior to the traditional approaches and similar response pattern imputation, especially in the context of longitudinal studies.37,39 Different from the missing completely at random assumption in the traditional statistical methods, MAR allows missingness to be related to observed covariates and/or outcome measures.34,36,40 That is, any association between missing data and the observed covariates or observed outcomes does not violate the MAR assumption. The LGM was estimated by using Mplus 8.0.41 

The goodness of fit of the model was assessed by the posterior predictive checking (PPC) method.42 If the model fits the data well, the 95% confidence interval (CI) of the difference between the observed and replicated χ2 values should center around 0, and the posterior predictive P value (PPP) should be >.05.35,42 Statistical inferences were made by examining the range of parameter estimates that captures 95% of the posterior probability distribution (ie, 95% Bayesian credibility interval). If the 95% CI of a parameter estimate does not cover 0, then the parameter estimate is statistically significant at the α = .05 level.36,42 

Participants did not differ in covariate or outcome variables on the basis of their classification of having an intellectual disability or not (see Table 1). For all the LGMs, Bayesian estimation reached convergence after 2000 iterations, and all models fit the data well (PPC 95% CI covers 0, and PPP is close to .50). Selected results of the unconditional model are shown in Table 2. The means of the latent intercept and slope growth factors estimated from the model are Eta0 = 0.368 (95% CI: 0.326 to 0.410) and Eta1 = 0.104 (95% CI: 0.073 to 0.138), respectively, which means an average %EBMIL of 37% at 3 months postsurgery and increases of another 10% in 3 months to reach a mean change of 47% at 6 months. However, the change in %EBMIL slowed down at 6 months postsurgery such that the mean %EBMIL increased only 10% in 6 months and was 57% at 12 months. In the following year, there was almost no change in %EBMIL and the mean %EBMIL was 58% at 24 months postsurgery (see Fig 1).

TABLE 2

Selected Results of the Unconditional LGM

Unconditional LGM(95% Bayesian Credibility Interval)
Time score   
 T3 — 
 T6 — 
 T12 1.952a (1.522 to 2.493) 
 T24 2.038a (1.024 to 3.195) 
Latent growth factor   
 Eta0 0.368a (0.326 to 0.410) 
 Eta1 0.104a (0.073 to 0.138) 
 Cov (Eta0, Eta1) −0.002 (−0.008 to 0.003) 
Model fit   
 Bayesian PPC 95% CI −14.330 to 17.294 — 
 PPP 0.429 — 
Unconditional LGM(95% Bayesian Credibility Interval)
Time score   
 T3 — 
 T6 — 
 T12 1.952a (1.522 to 2.493) 
 T24 2.038a (1.024 to 3.195) 
Latent growth factor   
 Eta0 0.368a (0.326 to 0.410) 
 Eta1 0.104a (0.073 to 0.138) 
 Cov (Eta0, Eta1) −0.002 (−0.008 to 0.003) 
Model fit   
 Bayesian PPC 95% CI −14.330 to 17.294 — 
 PPP 0.429 — 

Cov (Eta0, Eta1), covariance between the latent intercept and slope growth factors; T3, 3 month follow-up; T6, 6 month follow-up; T12, 12 month follow-up; T24, 24 month follow-up; —, not applicable.

a

95% Bayesian credibility interval does not cover 0 (ie, statistically significant at the .05 level).

FIGURE 1

%EBMIL 2 years after surgery for entire sample (N = 63).

FIGURE 1

%EBMIL 2 years after surgery for entire sample (N = 63).

Close modal

The selected results of the 2 conditional LGMs are shown in Table 3. Presence of CI/DD did not have a significant effect on either the %EBMIL at 3 months postsurgery (β = .019; 95% Bayesian credibility interval: 0.059 to 0.095) or the rate of change in %EBMIL (β = .019; 95% Bayesian credibility interval: −0.046 to 0.082), controlling for covariates. There was a trend for a higher rate of change in %EBMIL for those individuals with CI/DD, suggesting that they may experience greater rates of weight loss over time than their typically developing peers. The preoperative BMI predicted the level of %EBMIL at 3 months postsurgery (β = −.01; 95% Bayesian credibility interval: −0.014 to −0.006) such that a lower baseline BMI predicted a greater %EBMIL over time. The second LGM, in which the FSIQ-4 score was used to predict the trajectory of %EBMIL, produced the same findings (see the right panel of Table 3). In other words, cognitive impairment, whether noted by the presence of CI/DD or measured with a standardized IQ measure at baseline, did not predict the %EBMIL after sleeve gastrectomy in adolescents. Latent growth modeling, as described above, was repeated by using BMI at each time point, change in BMI, and %TWL as outcome variables. Findings were consistent regardless of weight-outcome measure used.

TABLE 3

Selected Results of the Conditional LGMs

VariableConditional LGM Presence or Absence of CI/DDaConditional LGM FSIQ-4 Score
Eta0 (95% Bayesian Credibility Interval)Eta1 (95% Bayesian Credibility Interval)Eta0 (95% Bayesian Credibility Interval)Eta1 (95% Bayesian Credibility Interval)
Age 0.004 (−0.011 to 0.020) −0.003 (−0.016 to 0.010) 0.09 (−0.010 to 0.029) −0.008 (−0.024 to 0.008) 
Sexb 0.015 (−0.058 to 0.090) −0.029 (−0.091 to 0.032) 0.000 (−0.078 to 0.080) −0.023 (−0.089 to 0.047) 
Race and/or ethnicityc 0.069 (−0.015 to 0.153) 0.004 (−0.070 to 0.079) 0.073 (−0.017 to 0166) 0.002 (−0.081 to 0.001) 
PreBMI −0.010 (−0.014 to −0.006)d −0.003 (−0.006 to 0.000) −0.012 (−0.016 to 0.007)d −0.002 (−0.006 to 0.001) 
FSIQ-4 0.019 (−0.059 to −0.095) 0.019 (−0.046 to 0.082) 0.002 (−0.001 to 0.005) −0.001 (−0.0030 to 0.002) 
Model fit     
 PPC 95% CI (−23.050 to 27.993) (−25.280 to 27.105) 
 PPP 0.418 0.448 
VariableConditional LGM Presence or Absence of CI/DDaConditional LGM FSIQ-4 Score
Eta0 (95% Bayesian Credibility Interval)Eta1 (95% Bayesian Credibility Interval)Eta0 (95% Bayesian Credibility Interval)Eta1 (95% Bayesian Credibility Interval)
Age 0.004 (−0.011 to 0.020) −0.003 (−0.016 to 0.010) 0.09 (−0.010 to 0.029) −0.008 (−0.024 to 0.008) 
Sexb 0.015 (−0.058 to 0.090) −0.029 (−0.091 to 0.032) 0.000 (−0.078 to 0.080) −0.023 (−0.089 to 0.047) 
Race and/or ethnicityc 0.069 (−0.015 to 0.153) 0.004 (−0.070 to 0.079) 0.073 (−0.017 to 0166) 0.002 (−0.081 to 0.001) 
PreBMI −0.010 (−0.014 to −0.006)d −0.003 (−0.006 to 0.000) −0.012 (−0.016 to 0.007)d −0.002 (−0.006 to 0.001) 
FSIQ-4 0.019 (−0.059 to −0.095) 0.019 (−0.046 to 0.082) 0.002 (−0.001 to 0.005) −0.001 (−0.0030 to 0.002) 
Model fit     
 PPC 95% CI (−23.050 to 27.993) (−25.280 to 27.105) 
 PPP 0.418 0.448 

PreBMI, Preoperative BMI; —, not applicable.

a

Presence (low IQ = 1) or absence (low IQ = 0) of CI/DD is used to predict the growth trajectory of %EBMIL over time.

b

0 for female sex and 1 for male sex.

c

0 for minority and 1 for white.

d

95% Bayesian credibility interval does not cover 0 (ie, statistically significant at the .05 level).

In the current study, we examined the impact of developmental disability and impaired cognitive functioning on weight loss outcomes after LSG. Although individuals with CI/DD may more commonly experience obesity and associated comorbidities, our data suggest that borderline to extremely low IQ or previous diagnosis of developmental disability do not negatively impact weight loss after bariatric surgery in the short-term. In fact, the findings suggest no significant differences in overall weight loss (as defined by %EBMIL, BMI, change in BMI, or %TWL) or rate of weight loss and reveal a trend toward a better rate of weight loss in adolescents with CI/DD compared with their typically developing peers. Moreover, regarding general cognitive functioning, given that the FSIQ-4 score did not predict weight loss outcomes as anticipated, there seems to be no benefit to adolescents who are higher functioning regarding weight loss after surgery.

On the basis of these new data, LSG appears to be a viable and successful short-term weight management tool for adolescents with CI/DD, who are established as particularly vulnerable to obesity and secondary health concerns.3,6 In fact, there may be advantages to undergoing surgery during adolescence rather than waiting until adulthood for this population. During adolescence, individuals with CI/DD are likely to have greater supports in place to assist them with tasks of daily living and may still be in the process of developing greater independence. It guarantees that the adolescent is not “going it alone.” This could translate to better cooperation with parental guidance regarding surgery requirements, including diet and exercise recommendations. Generally, there is also evidence that younger children respond better to behavioral interventions than adolescents do, suggesting that older youth may require a different treatment approach.43 Bariatric surgery performed earlier in the trajectory of large weight gain has also been shown to lead to greater resolution of obesity, suggesting that waiting for adulthood can be detrimental.19 

Concerns with offering bariatric surgery to individuals with CI/DD include the limited information available about the risks and benefits for these adolescents and questions about capacity to provide informed assent and/or consent. For the patients in the current study, we used the preoperative psychological evaluation to assess ability to provide assent and to ensure that a legal guardian was able to provide informed consent, and we discussed the ability to adhere to pre- and postoperative requirements, assessing the need for additional support (eg, additional education or pre- or postoperative inpatient stay). The multidisciplinary team considered this information and weighed it alongside other variables (eg, the success of previous weight loss efforts, patient BMI, medical comorbidities, etc) in offering guidance to families. Although recommendations regarding patient selection for bariatric surgery list cognitive disability as a potential reason to preclude surgery, it has been suggested that adolescents with CI/DD be considered on a case-by-case basis.25,27 Given the paucity of published research in which outcomes of LSG in youth with CI/DD are documented, the current study adds valuable data to the discourse regarding this topic and reveals that the presence of a CI/DD alone should not be used to exclude patients from possibly having surgery.

One clear limitation of the current study is the small sample of adolescents with CI/DD who received surgery as well as fewer participants who provided data for later follow-up time points. Additionally, follow-up data only extended to 24 months postsurgery in the current study. It will be important in future research to evaluate progress across a longer time period after surgery. Although this provides less power for detecting longer-term impacts of surgery on the %EBMIL, the results immediately after surgery, and particularly the LSG procedure, are promising.

The current study reveals the importance of considering LSG as a treatment of severe obesity for all adolescents, regardless of intellectual ability. The preoperative assessment should consider risks and benefits of the surgery, ability to provide assent (and for a guardian, consent, if assent is unable to be obtained), and specific supports necessary for ensuring safety and the highest likelihood of success after surgery.

Drs Hornack, Mackey, and Nadler conceptualized and designed the study, collected the data, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Wang conducted the data analyses, contributed to the writing of the manuscript, and reviewed and revised the manuscript; Ms Hansen collected the data and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/doi/10.1542/peds.2018-4112.

     
  • CI

    confidence interval

  •  
  • CI/DD

    cognitive impairment or developmental disability

  •  
  • Eta0

    latent intercept growth factor

  •  
  • Eta1

    latent slope growth factor

  •  
  • FSIQ-4

    full-scale IQ

  •  
  • LGM

    latent growth model

  •  
  • LSG

    laparoscopic sleeve gastrectomy

  •  
  • MAR

    missing-at-random

  •  
  • PPC

    posterior predictive checking

  •  
  • PPP

    posterior predictive P value

  •  
  • %EBMIL

    percentage of excess BMI lost

  •  
  • %TWL

    percentage of total weight loss

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.