Efficacy of Bariatric Surgery Among Adolescent Patients with Super-Obesity

Abstract

Background:

We sought to determine if adolescent patients with super-obesity (body mass index, BMI >50 kg/m²) have different outcomes in weight loss and obesity-related co-morbidity (ORC) resolution when compared to patients with a BMI <49.9kg/m².

Methods:

We identified patients aged 15–21 years who underwent bariatric surgery from 2011 to 2016. Patients were stratified according to the preoperative BMI into BMI greater than 50 kg/m² (group A) compared to those with BMIs between 30 and 49.9 kg/m² (group B). Mean change in percent weight loss and rate of ORC resolution were measured.

Results:

One hundred twenty patients were included, with 21 patients in group A and 99 patients in group B. Patients in group A had a BMI of 56.09 kg/m², while group B had a BMI of 42.61 kg/m². Group A's percent weight loss of 30% (45.5 kg) and 41% (62.3 kg), at 1- and 2-year follow-up, respectively. Group B's percent weight loss was 28% (34.7 kg) and 32% (38.8 kg), at 1- and 2-year follow-up, respectively (p < 0.05). There was no difference in ORC resolution rates.

Conclusions:

We found that group A had greater percent weight loss at 1 and 2 years compared to patients in group B. No significant differences were found in ORC resolution.

Introduction

The global incidence of obesity has reached epidemic proportions. Unfortunately, even the youngest members of society have fallen victim to this disturbing trend. Pediatric and adolescent obesity rates continue to increase despite efforts to prevent obesity and raise awareness of the negative health impacts associated with obesity.^1–3 In pediatric and adolescent patients up to age 19, obesity is defined as having a body mass index (BMI) (weight in kilograms divided by the square of the height in meters) at or greater than the 95th percentile in weight.⁴ The prevalence of obesity among the youth (2–19 years), in the United States, is currently 18.5%, and from 1999 to 2016, there was a significant upward trend in prevalence in both the pediatric and adolescent patients.³

The prevalence of more severe forms of obesity has also increased. Class I obesity is defined as a BMI greater than the 95th percentile, Class II obesity is >120% of the 95th percentile—or a BMI greater than 35 kg/m², and Class III obesity is >140% of the 95th percentile—or a BMI greater than 40 kg/m².^2,5 Over the past 15 years, obesity rates in these populations has increased from 14.6% to 17.4%, 4.0% to 6.3%, and 0.9% to 2.4% in Class I, Class II, and Class III, respectively.² According to the American Society for Metabolic and Bariatric Surgery guidelines, adolescents with Class II obesity and a designated comorbidity or with Class III obesity should be considered for metabolic-bariatric surgery.^6,7

Obesity related co-morbidities (ORCs) are adverse health problems linked to obesity. These include type 2 diabetes mellitus, obstructive sleep apnea, dyslipidemia (i.e., hypercholesterolemia and/or hypertriglyceridemia), hypertension, nonalcoholic fatty liver disease, and gastroesophageal reflux disease (GERD)—all of which are associated with deleterious long-term health effects.^8,9 Earlier surgical intervention could combat persistent obesity and the risk of end organ damage related to obesity-related conditions.^6,8

Bariatric surgery remains the most effective way of treating morbid obesity and has been proved to be safe and effective in the pediatric and adolescent populations.⁶ In addition, bariatric surgery has been shown to reduce cardiovascular risk factors such as hypertension, elevated C-reactive protein, and hyperinsulinemia. Increases in self-esteem, physical activity, social well-being, and quality of life are also seen following bariatric surgery.^6–9,12 There is a paucity of data regarding outcomes among adolescent patients with super-obesity undergoing bariatric surgery. Adult patients suffering from severe obesity have been shown to benefit from these procedures. A study from our institution demonstrated that weight loss and comorbid resolution are similar in adults with a BMI above 50 kg/m².¹⁹ The purpose of this study is to determine if pediatric and adolescent patients with a BMI above 50 kg/m² have similar outcomes with regard to weight loss, and comorbidity resolution when compared to patients with classified obesity (i.e., BMI less than 49.9 kg/m²).

Materials and Methods

Data were obtained from a single institution's prospectively maintained database. Institutional Review Board approval was obtained. A total of 120 pediatric and adolescent patients who underwent bariatric surgery aged 15–21 years between 2011 and 2016 were included in this investigation. Patients were followed for 2 years after surgery. All patients underwent evaluation for bariatric surgery, which included consultation with a bariatric surgeon, a psychological, nutritional, and medical evaluation. Patients either underwent a laparoscopic sleeve gastrectomy (LSG), or a laparoscopic Roux-en-Y gastric bypass (LRYGB). The type of bariatric surgery was determined by discussing the options with the patient and their guardian with consideration of the patients associated with comorbidities. We preferred Roux-en-Y gastric bypass in patients with diabetes or GERD.

Demographic information included age, race/ethnicity, and gender. Racial and ethnic groups included non-Hispanic white, Hispanic, black, and “other.” The “other” group included Asians, native-Hawaiians, or Pacific Islanders, and unknown/not reported. The primary outcomes of interest were weight loss, measured by change in BMI, and the change in percent of excess weight loss (EWL)—and resolution of comorbidities present before undergoing the bariatric procedure. Comorbidities included hypertension, defined as a measured blood pressure greater than or equal to 140/90 mmHg, and/or taking one or more antihypertensive medications. Hypertension was considered resolved once medications were no longer needed to keep blood pressure in normal range. Sleep apnea, defined as the need for consistent use of a CPAP mask. Sleep apnea was considered resolved if mask use was no longer needed. Dyslipidemia, defined as measurable hypercholesterolemia or hypertriglyceridemia during the pre and postoperative period. Finally type 2 diabetes mellitus, defined as having a HbA1C greater than 6.5%, with subsequent resolution being less than 5.8%.

The data were stratified according to the preoperative BMI's. Patients considered “super-obese,” with a BMI greater than 50 kg/m² were compared to those with a BMI between 30 and 49.9 kg/m² (Classes I–III obesity). Mean changes in BMI, in percent weight loss, and % EWL, and rate of comorbidity resolution between the two groups were measured. These mean differences were evaluated and statistically analyzed using t-tests to evaluate for the presence of statistical significance, defined as a having a p-value of <0.05.

Results

Of the total 120 pediatric patients aged between 15 and 21 years old (mean–19.48), there were 54 (45%) males and 66 females (55%). Twenty one (17.5%) patients were in the super-obese group (group A), while 99 (82.5%) had a BMI <49.9kg/m² (group B). Sixty-three patients were followed up at 1 year, 14 (22.2%) in group A and 49 (77.8%) in group B. Twenty-three patients were followed up at 2 years, 7 (30.4%) in group A and 16 (69.6%) in group B. One hundred eleven (92.5%) patients underwent a sleeve gastrectomy; eight (6.6%) patients underwent Roux-en-y gastric bypass. The mean preoperative BMI of the entire sample was 45.01 ± 7.13 kg/m² (Table 1).

Table 1.

Patient Demographics

Mean ± STD	Super-obese (BMI >50 kg/m²)	Class I–III obesity (BMI <49.9 kg/m²)	Total
(n)	21	99	120
Age (years)	19.9 ± 1.5	19.4 ± 1.5	19.5 ± 1.5
Sex
Female	14 (66%)	52 (53%)	66 (55%)
Male	7 (33%)	47 (45%)	54 (45%)
Ethnicity
White	10	63	73
Hispanic	6	26	32
African American	5	3	8
Not reported	0	6	6
Asian	0	1	1
Preoperative BMI	54.9 ± 5.1	43.6 ± 3.5	45.0 ± 7.1
Preoperative weight (kg)	153.6 ± 22.7	123.4 ± 14.8	128.7 ± 20.0
Ideal body weight (kg)	59.3 ± 10.4	64.7 ± 10.7	63.8 ± 10.8
Comorbidities
Type 2 DM	1	2	3
Sleep apnea	3	9	12
Dyslipidemia	1	1	2
Surgery type
LSG	20	91	111
LRYGB	1	7	8

STD, standard deviation; n, sample size; DM, diabetes mellitus; LSG, laparoscopic sleeve gastrectomy; LRYGB, laparoscopic Roux-en-y gastric bypass.

The mean postoperative BMI measured among all those who were followed up at 1 year was 33.07 ± 6.12 kg/m², and at 2 years, it was 31.05 ± 6.02 kg/m². Postsurgical mean hospital stay was 1.66 ± 0.85. There was one readmission and one reoperation. There were no mortalities in our patient sample.

Weight loss

Among the 14 patients in group A who were followed up at 1 year, the mean pre- and postoperative BMIs were 54.96 ± 5.05 kg/m² and 38.69 ± 7.99 kg/m², respectively. The mean reduction in BMI was 16.26 kg/m² at 1 year follow-up. Among the 49 patients in group B, who were followed up at 1 year, the mean pre- and postoperative BMIs were 43.55 ± 3.48 kg/m² and 31.46 ± 4.38 kg/m², respectively. The mean BMI reduction was 12.09 kg/m² at 1-year follow-up. Seven group A patients who were followed up at 2 years, the mean pre- and postoperative BMIs were 54.44 ± 3.91 kg/m² and 35.91 ± 7.57 kg/m², respectively. The mean BMI reduction was 18.53 kg/m² at 2-year follow-up. Among the 16 patients in group B, who were followed up at 2 years, the mean pre- and postoperative BMIs were 42.99 ± 3.36 kg/m² and 28.91 ± 3.79 kg/m², respectively. The mean BMI reduction was 14.08 kg/m². The decreases in BMI were found to be statistically significant (<0.05) with group A having greater reduction in BMI at both 1 and 2 years.

Patients in group A had a mean baseline weight of 153.59 kg—mean percent weight loss was 30% (45.57 kg) and 41% (62.30 kg), at 1- and 2-year follow-up, respectively. Patients in group B had a mean baseline weight of 123.36 kg—mean percent weight loss was 28% (34.77 kg) and 32% (38.87 kg), at 1- and 2-year follow-up, respectively. The patients in group A had significantly greater percent weight loss at both 1 and 2 years (p < 0.05). Patients in group A had a mean percent EWL of 47.9% and 62.5% at 1- and 2-year follow-up, respectively. Patients in group B had a mean percent EWL of 57.5% and 69.8% at 1- and 2-year follow-up, respectively (Fig. 1). The comparative mean percent EWL at 1-year was found to be statistically significant (p-value <0.05), but not at 2 years (Tables 2 and 3).

FIG. 1.

Comparison of %EWL after 1 and 2 years of follow-up between patients with a BMI of 30 to 49.9 kg/m² versus BMI ≥50 kg/m². BMI, body mass index; %EWL, percentage of excess weight loss; F/U, follow-up.

Table 2.

Outcomes at 1 Year

Mean ± STD	Super-obese (BMI >50 kg/m²)	Class I–III obesity (BMI <49.9 kg/m²)	Total
(n)	14	49	63
BMI	38.7 ± 7.9	31.5 ± 4.4	33.1 ± 6.1
Mean decrease in BMI	16.3^*	12.1	11.9
Weight (kg)	108.0 ± 28.0	88.6 ± 15.3	92.9 ± 19.9
% EWL	47.9%	57.5%^*	55.3%
Mean weight loss (kg)	40.3	35.0	36.2
% TBWL	16.9%	13.0%	14.5%

denotes statistical significance (p < 0.05).

% EWL, percent excess weight loss.

Table 3.

Outcomes at 2 Years

Mean ± STD	Super-obese (BMI >50 kg/m²)	Class I–III obesity (BMI <49.9 kg/m²)	Total
(n)	7	16	23
BMI	35.9 ± 7.6	28.9 ± 3.8	31.1 ± 6.0
Mean decrease in BMI	18.5^*	14.1	13.9
Weight (kg)	91.3 ± 22.2	84.5 ± 13.4	86.1 ± 15.6
% EWL	62.5%	69.8%	68%
Mean weight loss (kg)	56.2	41.8	70.6
% TBWL	38.4%	33.0%	33.8%

denotes statistical significance (p < 0.05).

Co-morbidity resolution

No adolescent patients in either group had hypertension. There was one (6.25%) patient in group A and one (1.85%) adolescent patient in group B who had dyslipidemia. No patients had dyslipidemia at 1- or 2-year follow-up, resulting in a 100% resolution of dyslipidemia for the both groups. There were three (18.75%) patients in group A and nine (16.67%) adolescent patients in group B who reported having sleep apnea. At 2-year follow-up, there was one (6.25%) patient in group A and two (3.70%) in group B who reported persistent sleep apnea. This showed a 66.7% and 77.8% resolution rate of sleep apnea for group A patients and the group B, respectively. There was no significant difference in sleep apnea resolution rates. Finally, one (6.25%) patient in group A had type 2 DM with remission at 2-year follow-up. There were two (3.70%) patients from group B who had a type 2 DM with remission of the DM in one patient at 2 years follow-up.

Discussion

Pediatric and adolescent obesity is a growing problem in the United States, now accounting for the greatest threat to the health of our youth.⁸ Patients who develop obesity in their adolescent years are more than five times more likely to be obese adults compared with nonobese adolescents.^1,13 With increased prevalence of obesity in the adolescent population, we are seeing a significantly younger onset of ORCs, including metabolic syndrome. Persistent obesity and ORCs, when untreated, can lead to irreversible end organ damage. ORCs are not limited to metabolic and cardiovascular disorders, and they can take a toll on the musculoskeletal system and can increase the risk of cancer.^{6–8,10–12} Bariatric surgery has been shown to be a safe and effective means for achieving weight loss and resolution of comorbid conditions in the obese adolescent population. Studies have shown that earlier intervention, with metabolic-bariatric surgery, can go so far as reduce the risk of persistent obesity and the risk of complication related to metabolic syndrome.^6,8 Despite this, bariatric surgery remains underutilized in this population. Results from a multicenter analysis found that only 3% of eligible adolescent patients receive bariatric surgery, with significant variation between academic centers. Obesity is a disease that requires the management by a multidisciplinary team.^6–8

Several meta-analyses have been performed to assess outcomes following bariatric surgery in the adolescent population. These have demonstrated a significant mean reduction in BMI following surgery.^14–16 These analyses include data following laparoscopic adjustable gastric banding (LAGB), LSG, as well as LRYGB. LSG and LRYGB have shown greater weight loss at 1-year compared to the adjustable gastric banding. These results are echoed by Inge et al. who in 2018 reported the outcomes of 544 adolescent patients undergoing bariatric surgery; among patients with LAGB, the mean percent reduction in BMI was −10% compared to −28% and −31% among patients with LSG and LRYGB after 1 year.¹⁷ Surgeons have largely avoided placing adjustable gastric bands in adolescent patients, and their use has decreased considerably in recent years.¹⁸ The types of bariatric surgeries done at our institution reflect this trend.

Less is known about the outcomes in severely obese adolescents. Severely obese adults appear to have similar outcomes to less obese patients with regard to weight loss and comorbidity resolution following bariatric surgery.¹⁹ Our study revealed a significantly improved mean percent weight loss and mean decrease in BMI among adolescents with super-obesity when compared to adolescents with Class I–III obesity. On the contrary, patients with BMIs less than 49 kg/m² had a significantly greater % EWL at 1 year but not at 2 years. We hypothesized that having a significantly higher mean preoperative weight and BMI results in relatively greater weight loss, but less EWL given the greater discrepancy in actual and ideal body weight. Even though the super-obese patients experienced a greater degree of reduction in BMI and percent weight loss, the mean BMI remained above 35 at 2-year follow-up.

We report no clinical or statistically significant difference in comorbidity resolution when comparing the patients with super-obesity versus those with Class I-III obesity. Our cohort did not have many patients with ORC's at baseline, and we found no associated statistical significant difference in comorbid resolution.

Our study also highlights important aspects that are unique to adolescent patients undergoing bariatric surgery. We lost 57 (47.5%) and 97 (80%) patients at 1- and 2-year follow-up, respectively. Bariatric procedures are only successful in achieving their long-term outcomes when the patient has a full understanding of the changes his or her body will go through after surgery and the importance of life-style modification, nutritional supplementation, and early recognition of complications.²⁰ Depending on the age that the surgery is performed, their understanding of the impact that surgery will have on their life will take time to be fully complete and adequate. Adolescents also have busy lifestyles and go through complex developmental stages that are associated with a tendency to resist authority, which further complicates their compliance to essential postoperative instructions and follow-up appointments.²¹ In addition, patients in this age group often relocate to pursue higher education, potentially increasing the risk of being lost to follow-up. This means that these patients require a close follow-up within a multidisciplinary team to recognize complications and deficiencies in postoperative management and reinforce the importance of adherence to the necessary life-style modifications; as surgery is tool for weight loss but not the absolute solution. This team should include their pediatrician and primary care provider as they transition to adult life.²⁰ Simple strategies that have been shown to be effective in reducing the attrition rate include flexible scheduling, reminder letters, phone interviews to obtain recent weight information, access to informative webpages, and frequently updating their contact information.²²

This study is a single institution study at a large academic medical center in a densely populated urban setting. We report data with a follow-up period of 2 years. We did not control for the type of procedure performed on these patients. We could not account for certain variables that may have influenced weight loss outcomes; for example compliance with recommended diet, exercise plans, and/or ethnicity. In our cohort, there was one readmission for patient who had developed PO intolerance and persistent vomiting, although they did not require reoperation. The single reoperation was for obstruction at the level of the gastroesophageal junction. The adolescent patients in this study only underwent LSG or LRYGB. This is reflective of the trend in bariatric surgery to avoid placing adjustable gastric bands in this population.

Conclusion

The rise in the prevalence of adolescents with obesity, over the past two decades suggests that preventative strategies have been unsuccessful. Pharmacological and behavioral treatment strategies have also had limited success with patients with severe obesity and ORCs. Bariatric surgery has emerged as a superior treatment option, with respect to weight loss and resolution of comorbidities. We found that patients with a BMI greater than 50 kg/m² had significantly greater mean decrease in BMI and mean percent weight loss at 2 years compared with patients with a BMI less than 49.9 kg/m². No significant differences were found in comorbidity resolution between these two groups. Several other studies have also revealed improvement in psychosocial well-being in this patient population. Adolescent patients are prone to noncompliance and high attrition rates, and specific strategies and multidisciplinary care teams should be implemented to attenuate these challenges. Early intervention in adolescents with severe obesity and super-obesity could provide benefits from weight loss and comorbidity resolution as is also seen in the adult population.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was used in the preparation of this article.

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