With the number of adolescents and even younger children developing obesity rising over the past years, the question of the best way to address it has been examined recently. The “Teen Longitudinal Assessment of Bariatric Surgery” study concluded this year and results have been published (Micalsky, et al., 2015).
This study focused on cardiovascular risk factors in adolescents who were severely obese, along with safety and health effects of weight-loss surgery procedures for that population. The study, an undertaking involving several medical centers across the country, was funded by the National Institutes of Health.
It found the vast majority of the 242 subjects in the study to have much higher risk for cardiovascular disease that previous thought. Ninety-five percent of the subjects had at least one risk factor for CVD, seventy-five percent had high blood pressure, fifty percent had cholesterol levels higher than normal, and nearly seventy-five percent were insulin resistant. Overall, the risk among teenaged boys for higher than normal triglyceride levels was greater than for girls.
The study highlighted the need for medical intervention into the risk factors for CVD among severely obese adolescents.
Prevalence of Adolescent Obesity and Bariatric Procedures
The dramatic increase in adolescent obesity has been labeled an epidemic, a surge, and a crisis (Hofman, 2013). Regardless of the label, healthcare professionals are beginning to recognize obesity among teens as an emergency. The very serious health issues that come with obesity are well recognized. Among these are high blood pressure, elevated cholesterol levels, diabetes and pre-diabetes, fatty liver disease, obstructive sleep apnea, and many psychosocial difficulties.
Over the 30 years ending in 2004, the prevalence of adolescents and children with significant weight problems nearly tripled (Inge, et al., 2004). The likelihood of these overweight adolescents and children continuing to be significantly overweight into adulthood was placed at 50-77% in this same study. Moreover, the risk of this happening increases to 80% in cases where only one parent was also obese.
Ten years later, the U.S. Surgeon General’s report suggested that more than 12.5 million young people age 2 to 19 are overweight (Cleveland Clinic, 2014). A year earlier, another study showed overweight/obesity rates to be nearly 33% in the United States (Zwintscher, et al., 2013). Another study conducted that year (Stefater, et al., 2013) reported only 5% of children between the ages of 2 and 19 to be obese in 1976-1980. But 16.9% if children in that same age range were overweight in 2009-2010. This same study reported the chance of a normal weight child developing into an obese adult to be only 7%, but the chance of an obese child becoming an obese adult was 77%.
Although the rate of adolescent obesity is dramatically increasing, the use of surgery for weight loss among adolescents is still not common (Mann, 2014). Between 2000 and 2003, bariatric surgery for weight loss in adolescents increased more than threefold, but still was seen rarely in that population. A report from the Archives of Pediatrics & Adolescent Medicine in March of 2007 showed teens to be less than 1% of the total weight loss surgery patients (Tsai, et al., 2007).
A study published in 2010 (Zundel, et al., 2010) reported a five-fold increase in bariatric surgery procedures compared to 2002. At that time, long-term implications of such surgical procedures was not well known. Most surgeries for weight loss in the adolescent population took place in major academic centers with high numbers of bariatric surgeries.
Another study published that year (Woolford, et al., 2010) reported 50% of primary care physicians would not recommend bariatric surgery for patients under the age of 18. The difficulty among these physicians had to do with whether risks outweighed benefits of this kind of surgery. Increasing popularity of weight loss surgery makes it more likely that primary care physicians will have to discuss this option with families of obese teens.
Weight loss surgery should be a last resort according to a panel of pediatric experts (Nobili, et al., 2015). With the dramatic increase in adolescent obesity has come a dramatic increase in significant physical illnesses related to obesity.Nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes among them. This panel of experts suggested rather strict guidelines for the use of bariatric procedures with adolescents. One group of adolescent patients for which this panel said bariatric surgery should be limited are those with body mass indexes of 35 or higher who also have severe NAFLD or other related illnesses. Another group would be those adolescents with a body mass index of 40 or higher and mild medical conditions.
Psychological Impact of Obesity on Adolescents
The psychological impact of obesity on adolescents has not been well studied. Its impact can be relatively easy to assume, however. Adolescence is a time of very significant psychological development. Social contexts have a great impact, as well.
The great emphasis placed on physical appearance among teens comes into play here. At a time when young men are valued for their athletic prowess and popularity is based on physical appearance, the obese teen is often socially isolated. During this time, young women are valued for their slender, but well-developed bodies. The obese female adolescent may find herself the butt of degrading jokes.
Obesity makes these adolescents a significantly vulnerable group at a time when it is important to be accepted and valued by peers. It comes as no surprise that adolescents seeking weight loss surgery are more depressed than peers (Zeller, et al., 2009). This study reported 38.7% of their subjects reported symptoms of depression in the clinical range. Their health-related quality of life was significantly impaired over all domains.
Adolescent obesity has a psychological impact greater than obesity in children (Wardle & Cooke, 2005). A body mass index greater than 40 is known to be a risk factor for poor psychological health (Onyike, et al., 2003). And most weight loss surgeries for adolescents requires a body mass index of 40, according to the latest guidelines. Thus, this adolescent population is more at risk for major psychological difficulties.
A study conducted in the three largest childhood obesity centers in Sweden found significant levels of depression, anxiety, anger and lower self-concept among their subjects (Jarvholm, et al., 2012). These subjects had an average body mass index of 46.5 at the beginning of the study. Once again, there appears to be significantly more psychological distress among adolescents who are obese.
Obese teens often perceive others as making more negative than positive remarks about them than do their normal weight peers. They also find it harder to involve themselves in their peer group and they tend to abuse alcohol more frequently (Fonseca, et al., 2009).
Effects of Bariatric Procedures
Weight loss surgery for adults has been shown to be effective for many obese individuals. The process of losing weight even with bariatric surgery is difficult. Just having the procedure done is not an absolute guarantee of losing weight or of keeping weight off if the procedure is successful. A great deal of family and social support in addition to following rather strict dietary changes are required. These dietary changes also bring with them lifestyle changes for which the formerly overweight individual must be prepared. At times, these changes become too much for the individual and perhaps as many as 20% regain weight following bariatric procedures.
For adolescents, there are still many unknowns regarding weight loss surgery. There are no long-term studies examining the effects of weight loss surgery on adolescents’ future development. And there is no guarantee that bariatric surgery will enable a teen to lose all of his/her excess weight or keep it off over the long term.
A majority of primary care physicians recommend participation in some kind of monitored weight loss program prior to suggesting weight loss surgery (Woolford, et al., 2010). The duration of this type of intervention before surgery ranged from three months to over 5 years. The idea is to give adolescents plenty of time to consider weight loss surgery and possibly to develop healthy eating habits that will preclude undergoing surgery.
One unfortunate fact regarding adolescents and these kinds of monitored, behaviorally based weight loss efforts is that the success rate is very low and the incidence of regaining of whatever weight might be lost is very high (Stefater, et al., 2013). Requiring participation of this kind may also lead to further weight gain in adolescents.
The American Academy of Pediatrics in 2004 released guidelines for adolescent bariatric surgery (Cleveland Clinic, 2014). These guidelines included the teen having failed six months or more of some organized weight loss effort. Also, the teen must have attained or nearly attained physiologic maturity. This requirement would take effect typically at age 13 for girls or 15 for boys. And, be severely obese as determined by a body mass index of 40 or greater.
These recommendations are similar to those proposed by a panel of pediatric experts in 2015 (Nobili, et al., 2015).
Adolescent bariatric surgery has been shown to be safe for this age range, shown by low complication rates (Zwintscher, et al., 2013 & Michalsky, et al., 2014). Safe does not necessarily suggest effective, however, regarding loss of weight and the probability of keeping it off. With the social pressure to conform to peers, which would include eating habits, the likelihood of adolescents reverting to this pressure seems high. Once again, the long-term research into this aspect of effectiveness of adolescent bariatric procedures is lacking.
There are studies that suggest there are positive psychological effects of bariatric surgery with adolescents. Zeller and her associates (2009) studied changes in health-related quality of life and depression in a group of obese teens. They found continued improvement in health-related quality of life and depression over the first year following bariatric surgery. These results are more impressive when considered in light of the large majority of teens were still obese one year following the procedure. The fact that there was change in weight may be the important factor in the positive changes in quality of life and depression. Seeing that weight loss is possible may have engendered a sense of competency and success in these individuals.
For adults, a similar decrease in depression symptoms has been seen following weight loss surgery. Unfortunately, this decrease may change and depressive symptoms return after 18-24 months (Karlsson, et al., 2007). At present, it is unknown whether the same or similar results will be seen in adolescents. If these results prove to occur in adolescents, it then is imperative that interventions designed to prevent relapse be provided.
Other researchers (Jarvholm, et al., 2012) also noted significant positive changes in adolescents in psychological and psychosocial areas following weight loss surgery. Four months post-surgery these researchers found significant improvement in anxiety, depression, and self-concept among these teens. These positive changes tended to continue for several years following surgery, but started to level off after the first year. Feelings of competency and control appeared to be the major factors that brought these changes.
Even though bariatric surgery has increased in the U.S. over the past several years, and even though adolescent bariatric surgery is becoming more frequent, this type of surgery is still infrequent. Recent studies that suggest the effectiveness and safety of these procedures for adolescents may relieve some of the hesitancy among primary care physicians to recommend the procedures.
However, long-term studies regarding the effectiveness of the procedures and their effect on future development are not evident. More research of this nature is needed before these procedures will be strongly recommended for adolescents. This research is needed because of the short- and long-term health effects of obesity on teens.
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