Recent evidence highlighting the ongoing rise in the rate of childhood obesity across all pediatric age groups in the United States, in combination with a prevalence of severe obesity (BMI ≥120% of the 95th percentile or BMI ≥40) among adolescents approaching 10%,1,2 serves to support the increased use of metabolic and bariatric surgery among teenagers.3 Furthermore, an expanding body of literature reporting long-term prospective and multiinstitutional outcomes after weight-loss surgery highlight both the significant prevalence of baseline obesity-related comorbid diseases (eg, hypertension, fatty liver disease, obstructive sleep apnea, and chronic renal disease) as well as strong evidence demonstrating comorbidity reduction in the postoperative time period, including improvements in a number of defined cardiometabolic disease risk factors.4,–7 In addition, a recent comparative analysis of surgical weight reduction versus medical therapy for adolescents with severe obesity and type 2 diabetes revealed significant improvements in weight, glycemic control, and related comorbidity remission among the group undergoing a bariatric procedure.8
Despite such compelling evidence related to the safety and efficacy of bariatric surgery in the pediatric population, a number of challenges continue to limit overall access to care. Prominent examples include a significant disparity in insurance authorization for bariatric surgical care when comparing pediatric patients (<18 years of age) to their adult counterparts,9 low rates of referral from primary caregivers,10 and general uncertainty regarding potential exclusionary criteria.11
In the current study in Pediatrics entitled “Sleeve Gastrectomy for Youth With Cognitive Impairment or Developmental Delay,”12 the authors present the results of a comparative analysis of a single institutional cohort of adolescents with severe obesity with and without a concurrent diagnosis of intellectual or developmental disabilities (IDDs). In doing so, the investigators should be commended for designing an analysis that directly addresses the current paucity of data related to surgical weight management in this important and vulnerable subgroup, and they should also be recognized for the overall impact of this line of investigation within the larger context of health care disparities and the need to further define clinical parameters related to evidence-based treatment eligibility.
At first glance, the results of the current study serve to dispel any preconceived concerns that individuals with IDD may not do as well as their developmentally typical counterparts, at least in the short-term. This is evidenced by the observations that the individuals with IDD not only experienced a similar degree of postoperative weight loss, including characteristics of associated weight-loss trajectory, but that preoperative intelligence scores did not correlate with postoperative outcomes. Furthermore, the investigators highlight results suggesting that the cohort with IDD may even experience a greater rate of weight loss after bariatric surgical intervention compared with controls. Although the current report is admittedly limited by several variables, including the short-term nature of the analysis and relatively small sample size, the results serve to highlight several related issues that deserve further consideration and focused study as part of future investigations.
Although the determination of causal relationships responsible for the favorable outcomes among the group with IDD are not feasible in the current analysis, the investigators draw attention to the support mechanisms available to children and adolescents with significant IDD, including supports for routine daily tasks, which may translate into improved compliance with recommended postoperative guidelines designed to optimize long-term outcomes (ie, diet, exercise, medication compliance, and routine medical follow-up).
Although only briefly addressed, the authors also point to the important matter of surgical assent, informed consent, and by extension, consideration of the ethical implications associated with surgical treatment of this markedly vulnerable patient population. Although literature addressing ethical concerns specifically associated with bariatric surgery for children with IDD is limited, previous attempts to offer a logical clinical framework highlight the importance of using a case-by-case approach predicated on the need to establish a well-defined risk/benefit ratio.11,13,14 As an important part of efforts to tackle such challenges, bariatric surgical care providers should strongly consider the routine use of available resources (ie, institutional ethics committees) to assist in complex medical decision-making.
Future related investigations that feature populations with unique considerations, such as those highlighted in the current report, should be highly encouraged and will no doubt serve to further inform patient and/or families as well as the medical community and potentially lead to improved clinical outcomes and expanded access to safe and effective treatment options.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-2908.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.