Obesity is a complex, multifactorial condition influenced by individual genetic characteristics and non-genetic factors. In children and adolescents, obesity typically results from a positive energy balance due to a lack of physical activity and unhealthy eating habits that lead to excessive energy intake or a combination of both. While rare single-gene defects can cause obesity, they are uncommon and are considered rare causes of early-onset pediatric obesity. Examples include genetic mutations in the leptin signaling pathway and defects in the melanocortin-4 receptor. Early childhood obesity may also result from certain genetic syndromes such as Prader-Willi syndrome, Bardet-Biedl syndrome, Alström syndrome, and WAGR syndrome. Endocrinological disorders like hypothyroidism, growth hormone deficiency, and excess cortisol can also contribute to obesity.

The prevalence of obesity is rising globally. Over the past thirty years, the number of obese individuals has doubled among adults in developed countries and tripled among children and adolescents. The increasing frequency of childhood obesity has led to the early onset of obesity-related diseases. Childhood obesity can negatively impact nearly every system in the body and is often associated with serious outcomes, such as hypertension, insulin resistance, diabetes, obstructive sleep apnea, dyslipidemia, fatty liver disease, and psychosocial complications. Historically considered an adult disease, type 2 diabetes has become increasingly prevalent in children, with cases reported even among six-year-olds in parallel with rising obesity rates. Childhood and adolescent obesity remain inadequately addressed and are pressing issues.

Childhood obesity often persists into adulthood. Obese children and adolescents face an increased risk of early onset of obesity-related diseases. Early intervention is crucial to promote weight loss and prevent or treat obesity-related conditions, leading to a growing trend toward early treatment of obesity.

Currently, pharmacotherapy options for childhood obesity are limited. The first step in treating obesity in children and adolescents involves lifestyle changes, including behavioral and dietary modifications. These interventions require a multidisciplinary approach involving physicians, dietitians, psychologists, and physiotherapists. While these treatments may be effective in the short term, their long-term success rates are low. Bariatric and metabolic surgery (BMS) currently appears to be the most successful method for achieving permanent weight control and treating obesity-related diseases. According to the American Society for Metabolic and Bariatric Surgery (ASMBS), BMS is indicated for adolescents with moderate to severe obesity, especially when accompanied by comorbidities.

Eligibility Criteria:

• BMI ≥ 35 kg/m² with associated obesity-related diseases or BMI greater than 120% of the age- and height-based 95th percentile value.
• BMI ≥ 40 kg/m² (even without accompanying diseases) or BMI greater than 140% of the age- and height-based 95th percentile value.

Contraindications:

• Obesity that can be treated medically.
• Untreated substance/alcohol addiction.
• Pregnancy planned within 12-18 months post-surgery.
• Active eating disorders.
• Cognitive and psychosocial conditions preventing adherence to postoperative recommendations and lifestyle changes.

In adults, BMS has been shown to reduce BMI, improve obesity-related conditions, and decrease mortality rates. Correspondingly, these surgeries have been applied to adolescents with severe obesity, and their frequency has increased over recent decades. Concerns regarding the unknown long-term outcomes, potential effects on growth and development, and the irreversibility of surgeries (except for LAGB) remain. Nevertheless, studies have demonstrated that bariatric surgery is safe and effective for adolescents with severe obesity.

Laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), and laparoscopic sleeve gastrectomy (LSG) are bariatric procedures performed in children and adolescents. Currently, LSG is the most commonly performed surgery in adolescents, yielding significantly better outcomes compared to lifestyle changes alone.

The estimated BMI reductions are approximately:

• 11.6 kg/m² with LAGB
• 16.6 kg/m² with RYGB
• 14.1 kg/m² with LSG

These figures represent much higher and more successful rates compared to non-surgical treatment methods. All three surgical techniques have resulted in significant weight loss and improvement in obesity-related diseases in the short to medium term, with 65-95% of operated patients showing improvements in type 2 diabetes, insulin resistance, hypertension, dyslipidemia, and abnormal kidney functions.

References:

1. Pratt JSA, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surgery for Obesity and Related Diseases. 2018;14(7):882–901.
2. Inge TH, et al. Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-LABS study. JAMA Pediatr. 2014;168(1):47-53.
3. Givan F. Paulus, et al. Bariatric Surgery in Morbidly Obese Adolescents: a Systematic Review and Meta-analysis. Obes Surg. 2015; 25(5): 860–878.