This chapter will address the following American College of Graduate Medical Education competencies: patient care, medical knowledge, and interpersonal and communication skills.

Patient Care: Understanding the development of severe obesity is critical to helping families implement appropriate and effective obesity treatment plans.

Medical Knowledge: Understanding and being able to accurately assess obesity and obesity-related comorbidities in an adolescent with severe obesity is critical to individualizing treatment, including bariatric surgery.

Interpersonal and Communication Skills: Excellent interpersonal and communication skills are critical in partnering with the adolescent with severe obesity through treatment while at the same time fostering family support and patient autonomy.

Approximately 2% to 3% of the US adolescent population has a body mass index (BMI) over 40 kg/m², with an estimate of 45,000 adolescents with a BMI greater than 50 kg/m².¹ A BMI of 40 kg/m² translates into being about 100 lb over ideal body weight, and a BMI of 50 kg/m² is equivalent to being about 200% of ideal body weight. Most children who reach a BMI over 40 kg/m² have experienced years of pathological weight gain. A normal-weight 4-year-old child who gains 10 extra pounds per year will have a BMI of 40 kg/m² at the age of 14 years. In a genetically susceptible person, this may equate to having a positive caloric imbalance of 100 calories per day. Children may experience even more pathological weight gain of up to 40 to 60 extra pounds per year during puberty or during times of individual and family psychosocial stress. The vicious cycle of abnormal weight gain can often result in an adolescent who feels hopeless about his or her ability to manage obesity and leaves the adolescent with an extraordinary amount of weight to lose. Despite this hopelessness and frustration, it is very important for the patient and their medical provider to understand the factors that have contributed to a patient’s pathological weight gain.

Factors contributing to pathological weight gain can be divided in 3 major categories. The first are genetic and medical factors contributing to weight gain. Adolescents with severe obesity who present with short stature, developmental/cognitive delay, or abnormal pubertal development may have an underlying genetic syndrome contributing to their severe obesity which may have not been previously diagnosed. In addition to obesity syndromes, severe obesity often runs in families. A history of obesity and obesity comorbidity in first- and second-degree relatives will give the pediatric health care provider some insight into the potential genetic influences of a patient’s weight and comorbidity status. It is helpful to get an immediate family history of people who have severe obesity (eg, ask if there is anyone who weighs over 300 lb) and those who have had bariatric surgery. Weight outcomes and significant side effects experienced by immediate relatives following bariatric surgery are starting points to generate discussion about potential bariatric surgical outcomes. Medical problems that, either primarily or through their treatment, affect hunger, satiety, or physical mobility can contribute to abnormal weight gain in children. Common examples may include pulmonary conditions such as asthma and sleep disordered breathing; psychiatric conditions such as depression, anxiety, or bipolar disease; neurological conditions such as spina bifida, myasthenia gravis, reflex sympathetic dystrophy, or seizure disorders; and orthopedic conditions such as slipped capital femoral epiphysis (SCFE) or Blount disease.

Unhealthy environments can predispose patients to behaviors that can result in pathological weight gain. Often times because of socioeconomic, medical, and psychological burden, parents are challenged to modify home environments to enable healthy weight gain in their children. Outside the home, adolescents interact with their community and school environments. Those environments that support healthy eating and activity behaviors make it easier for adolescents to manage their obesity. Unfortunately, many adolescents with morbid obesity have experienced negative environmental influences that affect both motivation and ability to lose weight. Understanding the important interactions between environment and behavior may decrease the blame and guilt that families and patients experience in managing severe obesity.

Last, adolescent lifestyle behaviors can directly impact their weight. The independence of adolescents allows them to be somewhat responsible for their behaviors. Healthy eating, decreasing sedentary behaviors while increasing physical activity, good sleep hygiene, and positive coping strategies are all behaviors that increase the chances of an adolescent effectively managing their weight. Morbid obesity may make controlling hunger and satiety, and participating in physical activity more challenging. When present, unhealthy habits are often longstanding and challenging to rehabilitate.

Asking patients about the factors that have contributed to their severe obesity will help pediatric health care providers understand the history of their past and current weight gain. In addition, the management of any modifiable factors needs to be undertaken, both prior to a patient having bariatric surgery and postoperatively. A skilled multidisciplinary bariatric team should have the resources necessary to manage the many factors that can contribute to a successful bariatric surgical outcome.

Assessment and evaluation

The degree of current medical morbidity should be the primary factor when considering bariatric surgical treatment for an adolescent with severe obesity. Medical morbidity can be identified by a detailed history, physical examination, screening blood work, and focused procedures. A history that details the patient’s weight gain history, previous attempts at weight loss, previous weight-related diagnoses and medication use, a focused obesity review of symptoms, family weight status, family history of bariatric procedures, family weight–related comorbidity, and a detailed psychosocial history focusing on past and current psychological morbidity, family functioning, social functioning, and school performance will help define the patient’s medical burden.

Adolescents may have a history of using medications that promote weight gain. Steroids, anticonvulsants, and psychotropic medications have the potential to have weight gain as a side effect.^2,3

Exploring the potential for alternative treatments for ongoing medical diseases or issues that minimize weight gain is important prior to having bariatric surgery. Consultation with a pharmacist to understand the impact of a bariatric procedure on a patient’s current medication regimen should also be considered. Sometimes formulations must be changed, dosages adjusted, or alternative therapy considered because of the changes in gastrointestinal absorption patterns expected with bariatric surgery.

Physical examination should include anthropometric measurements such as weight, height, BMI, neck, and waist circumference. An appropriately sized cuff is crucial to obtaining a valid blood pressure measurement. The presence of somnolence or tachypnea on general examination should raise concern for acute cardiorespiratory compromise in the adolescent with severe obesity. A pulse oximetry and an exhaled carbon dioxide level will document the degree of hypoxia and hypoventilation. Limited abduction of the eye (sixth nerve palsy), decreased peripheral vision, and papilledema raise concern for the presence of intracranial hypertension. Findings of acanthosis nigricans or keratosis pilaris suggest underlying insulin resistance and possible type 2 diabetes mellitus. A thorough musculoskeletal examination will identify bone and joint issues of the lower back, hip, knee, ankle, and foot. Orthopedic pathology is often under-recognized in patients with severe obesity. A focused mental status examination should identify concerns around cognition and mood, such as limited cognition, depression, anxiety, social phobia, and body image issues.

Adolescents with BMI over 40 kg/m² often have both cardiometabolic risk factors and medical conditions associated with excessive adiposity. The number of cardiometabolic risk factors has been shown to be correlated to the BMI percentile of the adolescent, with heavier adolescents having higher prevalence of individual risk factors, such as dyslipidemia, hypertension, and prediabetes.⁴

Studies have documented that the number of risk factors is associated with pathological changes in the cardiovascular system in adolescents.⁵

Initial laboratory assessment for patients considering bariatric surgery should include lipids (total cholesterol, low density lipoprotein [LDL], cholesterol, high density lipoprotein [HDL] cholesterol, fasting triglycerides), liver function (alanine transaminase [ALT], aspartate aminotransferase [AST], gamma-glutamyl transferase [GGT]), diabetes screening (fasting glucose, insulin, and hemoglobin A1c), thyroid screening (free T4 and thyroid-stimulating hormone [TSH]), and baseline vitamin levels (including folic acid, thiamine, cobalamin, and vitamin D). Additional laboratory testing should be performed as clinically indicated. Any patient with signs or symptoms of cardiorespiratory compromise should receive an echocardiogram, pulmonary function tests, and a polysomnography. Stratifying the results of the laboratory tests and procedures into normal, at risk, and abnormal will help define treatment options. Any morbidity identified prior to surgery should be treated prior to surgery. The adolescent’s ability to adhere to treatment recommendations for the medical comorbidity should be a criterion used to determine appropriateness for a bariatric procedure. Failure to take medicine or to keep follow-up medical visits is a red flag to patients’ ability to adhere to postoperative medical recommendations, which may compromise clinical outcomes and increase patient safety risk.

The adolescent patient should be able to assent to the bariatric surgical procedure. The patient must be able to understand and express their understanding of the potential risks and benefits of bariatric surgery. Ideally, the ability to do this is reconfirmed at several presurgical bariatric visits. Patients with cognitive deficits or severe emotional lability warrant significant preoperative evaluation, education, and psychological treatment prior to being considered appropriate for bariatric surgery. Evidence in the literature is lacking regarding the effectiveness of bariatric surgery in special populations, such as children with Down syndrome, Prader-Willi syndrome, Smith-Magenis syndrome, and hypothalamic obesity. The health care provider should be aware of the potential for parental coercion and adolescent magical thinking when assenting adolescents for surgery. Any concerns regarding the adolescent’s ability to assent should result in a consultation with a psychologist who specializes in adolescent medicine.

All bariatric patients should participate in some form of family-based behavioral weight management prior to bariatric surgery. The adult literature is mixed regarding whether presurgical weight loss is predictive of postsurgical weight loss.⁶

There is no evidence in the adolescent literature to guide presurgical weight loss recommendations. Despite this, it would seem prudent to demonstrate an adolescent’s ability to understand and implement healthy lifestyle changes prior to surgery. Depending on the intensity of the preoperative intervention, 6 months would allow the patient to become educated on healthy lifestyles and demonstrate the ability to change their lifestyle behaviors.

Having the patient work with a licensed registered dietitian will give the patient the best chance at receiving proper education and effective dietary counseling. The dietitian’s task prior to surgery involves working with a patient to change lifestyle habits and also educating them on the postoperative diet. Before surgery, dietary changes must include eliminating sugared beverages, establishing a structure around eating, and increasing consumption of highly nutritious and low-calorie food choices. Binge eating, which may express itself in unexplained significant weight gain, parental concerns about missing food or hidden food, or an adolescent’s self-report of lack of control and guilt following consumption of a large amount of food, must be identified by either the dietitian or psychologist prior to surgery. Failure to do so puts the adolescent at increased postoperative risk of complications and long-term risk of failed weight loss.

Decreasing sedentary behaviors and increasing moderate-to-vigorous physical activity are challenges for the adolescent with severe obesity. Barriers include low self-efficacy, shortness of breath with physical activity, easy overheating, and chronic foot, knee, hip, or lower back pain. Adolescents with morbid obesity often feel very uncomfortable from both a physical and emotional standpoint when exercising. Having a professional trained in either physical therapy or exercise science benefits patients who have a lot of barriers to implementing an exercise prescription. Performance on a submaximal or maximal exercise test can be tracked and be a potential motivation to change habits around physical activity.

Many adolescents with morbid obesity have some history of psychopathology that may be impacting their current weight or their future ability to change their behaviors to maximize postsurgical outcomes. Psychopathology can include attention deficit disorder, depression, anxiety, binge eating, substance abuse, poor family communication, and learning disorder. Major psychopathology should be under control prior to having bariatric surgery. Targeted interventions that improve self-efficacy and family communication will decrease conflict and improve mood in most adolescents with severe obesity. The development of coping mechanisms that enable an adolescent to better respond to stress, hunger, sadness, or anger may be helpful to implement healthier lifestyle behaviors. Strategies to improve adherence to lifestyle or medical interventions will also be applicable to most adolescents. Patients will benefit from working with a psychologist to maximize outcomes in areas of individual and family psychosocial functioning.

Significant family and parental involvement is crucial in obtaining good outcomes in pediatric weight management programs. Parents are responsible for the critical components of making the home environment healthy and role modeling positive healthy lifestyle behaviors. They are often responsible for the transportation and financial resources necessary to attend clinic and implement the medical and lifestyle treatment necessary to achieve weight loss. Many families carry significant psychosocial burdens that impact the health of their children. Burdens can be due to poverty, lack of education, physical or mental illness in child or parent, substance abuse, unhealthy relationships, and lack of healthy social support. Providers skilled in assessing the psychosocial burden of the family unit and understanding the resources available often make the difference between a patient able to adhere to treatment recommendations or dropping out of care. Because obesity is a chronic disease, keeping adolescents and families engaged in care is important to achieve both short- and long-term outcomes following adolescent bariatric surgery.

Many adolescents with severe obesity and their families are very desperate for a treatment option to help them lose weight. They often pressure the treatment team to speed up the presurgical process in order to obtain a sooner surgical date. Failure of the adolescent and family to engage in family-based weight management lifestyle treatment potentially compromises both short- and long-term efficacy following bariatric surgery. Ideally, the treatment team, the family, and the adolescent are all equally confident that their preoperative preparation will support significant weight loss following surgery. Although short-term bariatric weight loss in adolescents looks promising,⁷ long-term data and studies on the importance of lifestyle behaviors in contributing to good outcomes are lacking. It seems prudent to not ignore the importance of family-based behavioral weight management in the care of the adolescent bariatric patient.

Background

The surgical approach to treating morbid obesity is not new. The specialty of bariatric surgery has developed in parallel to the rising incidence of morbid obesity in adults over the past generation. In 1991, the first National Institutes of Health (NIH)-sponsored consensus panel on gastrointestinal surgery for severe obesity was convened. The panel set initial criteria for bariatric surgery in adults with morbid obesity who had failed nonsurgical options, citing improved safety and efficacy of these surgical procedures.⁸ No recommendations were made for adolescents due to lack of data. A follow-up panel in 2004 determined that bariatric surgery is the most effective treatment for morbid obesity, and can lead to improvement and even complete resolution of severe comorbid conditions.⁹ (More recent studies have demonstrated improvement in long-term survival in adults after bariatric surgery.¹⁰)

This panel also acknowledged that bariatric surgery could be considered in select adolescents with morbid obesity treated at an experienced center.² There have been several reports demonstrating safety and efficacy of surgery in this age group.¹¹ More recently, criteria for bariatric surgery in adolescent patients with morbid obesity have been proposed and refined.^12,13 Despite the recent trends, many primary care providers are reluctant to refer children and adolescents with morbid obesity for bariatric surgery. Many point to the lack of end-stage disease, the risk to growth and development, and the risk of long-term weight regain. It is becoming clear, however, that the efficacy of a bariatric procedure is dependent upon starting BMI,¹⁴ and that childhood-onset obesity leads to greater morbidity in adulthood.¹⁵ Moreover, there is mounting evidence for resolution of many of the comorbidities seen in adolescents with severe obesity after bariatric surgery.^16,17

Indications for bariatric surgery

The indications for bariatric surgery in adolescents have evolved.⁶ Current consensus supports using adult guidelines for adolescents who have achieved full maturity. A BMI of 35 kg/m² corresponds to the 99th percentile or greater in this group, and correlates with increased cardiovascular risk in adolescents. Patients with a BMI at 35 kg/m² or greater, who have a severe comorbid condition (type 2 diabetes, moderate-to-severe sleep apnea, benign intracranial hypertension, severe nonalcoholic steatohepatitis), should be considered as candidates for bariatric surgery. In addition, for patients with less severe conditions (insulin resistance, hypertension, dyslipidemia, impaired quality of life, etc), a BMI at 40 kg/m² or greater cutoff may also be appropriate. Patients must have reached skeletal (95% adult stature) and sexual maturity (tanner Stage IV). They should have achieved sufficient emotional maturity to make critical health and lifestyle decisions, demonstrate the ability to make necessary lifestyle changes, be willing and able to participate in long-term follow-up, and have a stable and supportive psychosocial environment. In addition, the adolescent must be able to assent for the proposed procedure, and have the capacity to understand the risks, benefits, and alternatives, as explained at their level of intellectual development. Reversible medical causes of obesity should be excluded, and the patient must have actively participated in at least 6 months of structured medical weight management without significant weight loss. Females should be carefully counseled to avoid pregnancy for at least 18 months, because one study has shown higher than expected pregnancy rates in adolescents who have undergone bariatric surgery.^17a It is best to depend upon a multidisciplinary team to fully evaluate the risks and benefits and recommend bariatric surgery in each specific situation (Tables 14-1 and 14-2).