Moving Gastric Bypass for Severely Obese Adolescents into theMainstreamby Lydia Furman MD, Associate Editor, 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 fromthe 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 asa BMI 35 kg/m2 or a BMI that is 120% of the 95th percentile BMI for age and sex, whichever is lower. Severeobesity is not only increasing worldwide and among teens, but is associated with racial, gender andsocioeconomic disparities: Black, Hispanic and Native American youth, females and youth living in poverty bearthe burden of the rising prevalence of severe obesity. National data show that 7.9% of US (United States) youthare severely obese.1 This is not a problem any of us can ignore or wish away. Unfortunately, publishedliterature2,3 demonstrates that behavioral, diet and lifestyle change interventions are not broadly effective, andhence 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 collaborationwith a multi-disciplinary center with specific expertise in bariatric surgery. Patient selection (and insurancecoverage) depend on documented pre-operative efforts to lose weight, psychological and medical assessmentof the individual, and evaluation of family and social supports for post-operative lifestyle changes. There is ameaningful body of literature demonstrating the effectiveness of bariatric surgery for adolescents, and evensome possible evidence of a "ceiling effect" (i.e. regardless of initial BMI the percentage of body weight lost issimilar) suggesting that earlier referral (versus waiting for the BMI to climb further) may be optimal. Primary carepediatricians 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 bariatricsurgery, including just to accept a referral for consultation. I now wonder if I previously presented enough parentand patient-friendly information in a sufficiently even-handed, realistic and positive way. These two articles havegiven me more knowledge to serve as a good resource, and have empowered me to say confidently to thefamily that I am not "handing off" the teen to another team, but rather will continue my involvement inpreparatory care and post-operative follow up. Please share your thoughts about this topic, and any tips youmay 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

Copyright © 2019 American Academy of Pediatrics

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 toReduce 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 RevisedProtein-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

Intellectual Disability and Adolescent Bariatric Surgery: Support of Special Eligibility Criteria●

Cardiovascular Risk Factors After Adolescent Bariatric Surgery●

Adolescent Loss-of-Control Eating and Weight Loss Maintenance After Bariatric Surgery●

Facebook●

Instagram●

Copyright © 2019 American Academy of Pediatrics