Pediatrician group recommends more surgical treatments for severe obesity

Recognizing that severe obesity is a serious and worsening public health crisis in children and adolescents, the American Academy of Pediatrics (AAP) is calling for greater access to metabolic and bariatric surgery, one of the few strategies that has been shown to be effective in treating the most severe forms of the chronic disease.

In a new policy statement, “Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices,” published Sunday, Oct. 27, the AAP describes severe obesity among children and adolescents as an “epidemic within an epidemic,” one that portends a dramatically shortened life expectancy for today’s generation compared to their parents.

Few strategies have proven effective in helping people who have the most severe forms of obesity to lose weight. In children and adolescents with less severe forms of obesity, lifestyle modifications have shown moderate success. But these strategies have not worked as well for young people with severe obesity, which is defined as having a body mass index (BMI) of at least 120% of the 95th percentile for age and sex, which roughly equals 35kg/m2 or greater. Recent evidence shows that surgical treatment is safe and effective, but it is widely underutilized.

“Children with severe obesity develop health problems earlier than those with lesser degrees of obesity, including diabetes, high blood pressure, fatty liver disease, and sleep apnea. While lifestyle changes remain the mainstay of treatment, medical care is unlikely to significantly change the trajectory for most children with severe obesity,” said pediatrician Sarah Armstrong, MD, FAAP, lead author of the policy statement and a member of the Executive Committee of the AAP Section on Obesity. “The last decade of evidence has shown surgery is safe and effective when performed in high-quality centers, with the primary care pediatrician and family in a shared decision-making process. Unfortunately, we see significant disparities in which patients have access to bariatric surgery. Surgery needs to be an option for all qualifying patients, regardless of race, ethnicity or income.”

The policy statement and an accompanying technical report will be presented during a session on bariatric surgery from 8 a.m. to noon Sunday, Oct. 27, at the AAP National Conference & Exhibition at the Ernest N. Morial Convention Center in New Orleans. Christopher Bolling, MD, FAAP, Chair of the AAP Section on Obesity, will speak at a news conference at noon in the Press Office.

Studies of adolescents and young people who have undergone bariatric surgery have found significant long-term reductions in weight and comorbid chronic diseases. In one study that followed adolescents up to 12 years post-surgery, it found an average 29% reduction in BMI for patients undergoing one type of surgery, and significant reductions in diabetes and high blood pressure. By contract, adolescents enrolled in a lifestyle modification program saw their BMIs increase.

Recent data from the National Health and Nutrition Examination Survey report the prevalence of severe obesity in youth at 7.9%. Among 12- to 15-year-olds, 9.7% have severe obesity, and among 16- to 19-year olds, it’s 14%. This is roughly double the prevalence in 1999.

The AAP recommends pediatricians refer patients to high-quality multidisciplinary centers that have extensive pediatric surgical experience and where pediatric specialists can evaluate and care for patients before and after surgery. Insurance should cover the procedure and follow-up care, according to the AAP. The AAP also recommends avoiding setting arbitrary age limits; rather the procedure should be considered for any patient with severe obesity who meets the criteria for surgery.

“The decision to have metabolic and bariatric surgery should be based on the health and needs of the individual patient,” said pediatric surgeon Marc Michalsky, MD, FACS, FAAP, FASMBS, one of the authors of the policy statement. “This should be a thoughtful, collaborative decision made between the patient, their parents and their medical and surgical team, based on their body mass index, other health conditions and quality of life.”

Currently, access to bariatric surgery is often limited by lack of insurance coverage, as well as a scarcity of qualified centers. Patients from lower socioeconomic groups and racial and ethnic minorities suffer the highest burden of severe obesity, yet are least likely to have metabolic and bariatric surgery.

AAP recommends pediatricians, government, medical centers and insurers work on strategies to reduce barriers and improve access to surgery, so that more children and adolescents can receive the health care they need.

Information for parents on bariatric surgery will be available on HealthyChildren.org, on Oct. 27.

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