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Recommendations Summary

Pediatric Weight Management (PWM) Adjunct Therapies: Weight Loss Surgery and Adolescent Obesity

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    PWM: Weight Loss Surgery

    Dietitians should collaborate with other members of the health-care team regarding the appropriateness of weight-loss surgery for severely obese adolescents who have not achieved weight-loss goals with less-invasive weight-loss methods and who meet specified criteria (see Conditions of Application below). Research indicates that for a subset of adolescents who meet the recommended criteria, weight-loss surgery may be effective in bringing about significant short-term and long-term weight loss. Obese children (under 13 years of age) are generally not considered to be appropriate candidates for weight-loss surgery.

    Rating: Consensus
    Imperative

    • Risks/Harms of Implementing This Recommendation

      • Surgical complications,
      • Micro-nutrient deficiencies (e.g., vitamin D for African-Americans, vitamin K).

    • Conditions of Application

      The Expert Committee Recommendations include the following criteria for adolescents being considered for weight-loss surgery:

      • Experienced failure of at least six months of organized weight-loss attempts, as determined by their primary care provider
      • Have met certain anthropometric and medical criteria:
        • Be severely obese (BMI 40 or greater) with serious obesity-related medical complications or have a BMI of 50 or more with less-severe co-morbidities
        • Have co-morbidities related to obesity that might be resolved with durable weight loss
        • Have attained a majority of skeletal maturity (generally at least 13 years of age for girls and at least 15 years of age for boys).
      • Demonstrate commitment to comprehensive medical and psychological evaluations both before and after weight-loss surgery
      • Be capable and willing to adhere to nutritional guidelines post-operatively
      • Possesses decisional capacity and participates in the decision process to undergo weight-loss surgery. In other words, the adolescent must want the intervention and understand what is involved.
      • Have a supportive family environment
      • Is being evaluated by a multi-disciplinary team that is involved in the patient selection, preparation and surgery as well as immediate and long-term post-operative follow-up care. 

      Potential candidates for bariatric surgery should be referred to centers with multi-disciplinary weight-management teams that have expertise in meeting the unique needs of obese adolescents. Surgery should be performed in institutions that are equipped to meet the tertiary needs of severely obese patients and to collect long-term data on the clinical outcomes of these patients.

    • Potential Costs Associated with Application

      • If organizational and program costs are passed on to participants, this could limit program access. Additionally, parent commitment to program participation is required.
      • The absence of health insurance coverage for weight management could limit program access.

    • Recommendation Narrative

      What Are the Effects of Weight-Loss Surgery in Children and Adolescents?

      • A small number of case studies report sustained weight loss in severely obese adolescents with serious co-morbidities following weight-loss surgery. Associated surgical complications and short- and long-term macro- and micro-nutrient deficiencies are reported.
      • However, the research on children and adolescents is still very limited and the ADA evidence-analysis work group for pediatric weight management recommends more research in the following areas.
        • Surgical technique and design of the pre- and post-operative nutritional intervention
          • Effects of different surgical procedures on children and adolescents
          • Impact of pre-operative weight loss on surgical complications and adherence to post-operative nutritional care plan
          • Optimal post-operative dietary progression, regarding the type, amount, consistency and texture of foods and the frequency of feedings
          • Role of the dietitian in pre- and post-operative care.
        • Physiologic effects
          • Short- and long-term changes in body composition (muscle mass and body fat)
          • Growth risks
          • Bone health
          • Management of excess skin following significant weight loss.
        • Behavioral or psychological aspects
          • Risk-taking behaviors (e.g., cigarette-smoking, substance abuse, sexually intimate relationships)
          • Impact on establishing a healthier lifestyle (e.g., making healthier food choices, becoming more physically active) and improving quality of life
          • Risk of developing an eating disorder
          • Body image distortion.

    • Recommendation Strength Rationale

      A review paper of only six case studies involving a small number of patients (range, 11 to 41 patients) reports sustained weight loss in severely obese children and adolescents with serious co-morbidities following weight-loss surgery. Associated surgical complications and short- and long-term macro- and micro-nutrient deficiencies are reported.

    • Minority Opinions

      None.