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AAP guidance

AAP calls for better access to bariatric surgery for adolescents

Less than half (47%) of qualifying teens who enter surgical programs have their procedure approved on the first request and 11% never have them approved
A second reason for underutilisation is low referral rates from primary care

The American Academy of Pediatrics (APP) has called for greater access for adolescent metabolic and bariatric surgery in a new policy statement, ‘Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices’. The Academy 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. Severe obesity affects 4.5 million US children and adolescents, and these children are unlikely to get better by adulthood even with the best medical care available.

The guidance is based on a comprehensive review of the literature and consultation with experts in surgical and medical paediatric weight management, and seeks to help paediatricians select appropriate patients, guide teens and families through the decision-making process, locate high-quality surgical programmes and advocate for payment. An accompanying technical report, ‘Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity details the evidence on procedure types, complications and outcomes’.

Sarah Armstrong

"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 apnoea. While lifestyle changes remain the mainstay of treatment, medical care is unlikely to significantly change the trajectory for most children with severe obesity," said paediatrician, Dr Sarah Armstrong, 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 centres, with the primary care paediatrician 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."

Over the past decade, evidence has emerged that bariatric surgery is a safe and effective treatment option for youth with obesity. While randomisation poses practical and ethical challenges, well-designed and longitudinal case studies consistently have found low complication rates (15% minor, 8% major) and no attributable deaths related to the two most common procedures, Roux-en-Y gastric bypass and vertical sleeve gastrectomy, when performed by a comprehensive care team.

Contrary to prior reports, the evidence does not clearly identify a lower age limit; research shows that complications were lowest and outcomes the best when individual and family-level factors drove the decision-making process.

There is no evidence to suggest that watchful waiting is effective; in fact, outcomes are improved and complication rates are lower when the surgery is done sooner - in one study, before the BMI> 55. The American College of Surgeons’ Metabolic and Bariatric Surgery Association Quality Improvement Program lists programmes that provide comprehensive care and report long-term outcomes to assist paediatricians and families in finding high-quality options.

Despite this surge of supporting evidence and centres equipped to provide care, the rates of adolescent weight loss surgery remain low. The evidence reveals a striking trend of underutilisation, particularly for low-income teens.

One reason for this likely is related to insurance coverage; plans that include bariatric surgery for patients under 18 are uncommon. Less than half (47%) of qualifying teens who enter surgical programs have their procedure approved on the first request, and 11% never have them approved. Teens from low-income backgrounds have a much lower rate of insurance approval for surgery, despite bearing a higher burden of obesity and related comorbid disease.

A second reason for underutilisation is low referral rates from primary care. Until now, little guidance has been available for paediatricians to identify appropriate patients, to educate families on the risks and benefits of surgery, to provide pre- and post-operative care for patients, and to identify high-quality surgical programs near them. This report provides such guidance for paediatricians.

For most children with severe obesity, lifestyle modification will not be enough to prevent disease. There is substantial evidence that for many youths with severe obesity, surgery is the most effective treatment option.

To promote equitable access to bariatric surgery for all qualifying patients, the AAP recommends:

  • Recognise that severe obesity is a high-risk condition and unlikely to resolve with medical or lifestyle treatment alone
  • Consider surgery for a youth with severe obesity and comorbid medical conditions
  • Engage with patients, the family and the surgical team in a shared decision-making process that accounts for patient autonomy, values, family support, emotional and physical maturity, and an understanding of the short- and long-term implications.
  • Ensure that surgery is performed only in high-quality centres that can provide paediatric and family-specific care.
  • Educate patients and families on surgical procedures and support them prior to and after weight loss surgery.
  • Monitor patients postoperatively for micronutrient deficiencies and consider providing iron, folate, and vitamin B12 supplementation as needed
  • Monitor patients postoperatively for risk-taking behaviour and mental health problems
  • Advocate for increased access for paediatric patients of all racial, ethnic, and socioeconomic backgrounds to multidisciplinary programs that provide high-quality paediatric metabolic and bariatric surgery

The AAP recommends that public and private insurers do the following:

  • Provide payment for multi-disciplinary pre-operative care to ensure appropriate selection of surgical candidates and for multidisciplinary postoperative care and required medications and supplements to improve surgical outcomes
  • Provide payment for bariatric surgery from evaluation through follow-up and ongoing care for paediatric patients who meet standard criteria as set forth here
  • Reduce barriers to paediatric metabolic and bariatric surgery (including inadequate payment, limited access, unsubstantiated exclusion criteria, and bureaucratic delays in approval requiring unnecessary and often numerous appeals) for patients who meet careful selection criteria.

"The decision to have metabolic and bariatric surgery should be based on the health and needs of the individual patient," said Dr Marc Michalsky, 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."

The policy report from the Section on Obesity and Section on Surgery are available here and the technical report here 

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