Medical ProgressA Critical Appraisal of Evidence Supporting a Bariatric Surgical Approach to Weight Management for Adolescents
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Definitions and Epidemiologic Trends
Measures of body mass index (BMI) (weight in kg/height in m2) provide a reasonably accurate, reproducible screening tool for obesity in both adults and children. BMI-based definitions of varying degrees of obesity (Table I) that are in common use for adults may also be useful for adolescents who have completed their linear growth. The health risks that have been linked to higher classes of obesity have not yet been defined for adolescents, however.
Over the past decade and a half, BMI trends in
Adverse Effects of Obesity
For adults (nonsmokers) with no history of disease, the relative risk of death from any cause increases abruptly above a BMI of 30 kg/m2, whereas increased risk of death due to cardiovascular disease begins at a BMI of 25 kg/m2.8 A number of longitudinal studies have also shed light on the serious consequences of obesity in adolescence.9, 10, 11, 12, 13 Follow-up of more than 200,000 children over a 30-year period showed that those with a BMI above the 95th percentile (mean, 31 kg/m2) were
Weight Loss Procedures
All contemporary bariatric surgical procedures (Figure) dramatically restrict dietary intake and result in a period of negative energy balance, which is achieved by either hypocaloric intake or malabsorption. This usually results in a loss of 25% to 35% of body weight,41, 42, 43, 44, 45 preferentially lost as fat mass in both adults46 and adolescents.47 Subsequently, equilibrium of energy balance occurs, favoring weight stabilization at the reduced weight.48
Rationale for Surgical Intervention
One oft-raised question is whether extreme obesity in the teenage years justifies consideration of bariatric surgery rather than delaying surgery until adulthood when the individual may be more capable of making an informed decision. Although some health risks of extreme obesity in adolescence will not manifest as disease states for years, many weighing 100% or more over ideal weight manifest obesity-related diseases as teenagers that will predictably worsen over time. Bariatric treatment
Caveats
Despite the reported health- and cost-related benefits, bariatric surgery is a high-risk endeavor. Clinical evidence demonstrates that complications are directly related to the experience of the surgical team caring for patients. Population-based data from Washington suggest a mortality rate of up to 6% during a surgeon's first 20 bariatric procedures, with this rate decreasing significantly, to < 0.4%, beyond 100 operations performed.74 Others have noted that the operative time100 and rates of
Mechanism of Weight Loss After Bariatric Surgery
In patients who have undergone gastric bypass, early satiety is experienced after ingestion of very small (1 to 2 cups) portions, because of a ∼95% reduction in gastric reservoir size. It is generally agreed that macronutrient malabsorption does not occur to any significant degree after gastric bypass.105 If surgical weight reduction occurred by dietary restriction alone, then homeostatic systems that oppose weight loss should attempt to restore a patient to his or her preoperative BMI by
Nutritional Considerations
Because dietary vitamin and mineral intake is restricted after bariatric surgery, maintaining adequate levels of micronutrients necessitates daily supplementation.111 Deficiencies of vitamins B1, B6, B12, and E and iron have been described after bariatric surgery in adults.111, 112, 113 Beriberi has also been reported in adolescents after gastric bypass.114 It is recognized that vitamin and mineral intake after bariatric surgery in adolescents is suboptimal, with 73% reporting regular
Which Operation is Best for Adolescents?
Given the nutritional and gastrointestinal consequences of malabsorptive procedures, it is unlikely that such operations as biliopancreatic diversion or duodenal switch will be ideal for most adolescents. The limited available evidence indicates that both gastric bypass and adjustable gastric banding may be acceptable surgical treatments for highly selected adolescents.55, 57, 58, 123, 124, 125, 126, 127, 128 Both procedures are considered relatively safe, and there is little evidence of the
Research Considerations and Future Directions
Adolescents are now being considered for bariatric surgery with very little scientific data available on which to base decisions. Although bariatric procedures offer the greatest likelihood of major weight loss, the long-term outcomes remain uncertain, and the need for further research is crucial. Research efforts aimed at elucidating the physiological mechanisms by which weight loss procedures effect alterations in appetite, feeding behavior, and energy balance may ultimately lead to
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Preliminary data funded by a grant awarded to the second author from the Cincinnati Children's Hospital Medical Center, General Clinical Research Center, supported in part by the U.S. Public Health Service (M01 RR 08084) from the General Clinical Research Centers Program, National Center for Research Resources/National Institutes of Health.