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Diabetes, hypertension remission more prevalent in adolescents than adults after gastric bypass

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For now, bariatric surgery for teens should remain case by case

For obese adolescents, making a decision with lifelong consequences, as is the case with bariatric surgery, should still be handled on a case-by-case basis, according to Ted D. Adams, PhD, of the University of Utah, Salt Lake City.

In general, treatment approaches for children and adults differ because of their physiological and psychological differences, but that does not apply in the case of obesity, wrote Dr. Adams, who noted the similarities in obesity across age groups. In addition, he said, most adolescents who are obese remain obese into adulthood, and obese adults who were obese when they were younger face worse outcomes than do those who become obese in adulthood.

As such, this study from Dr. Inge and his colleagues is clinically important given the prevalence of obesity in the United States and a step in the right direction. However, Dr. Adams acknowledged concerns over certain elements, including the higher rate of abdominal reoperations in adolescents during the 5-year postsurgery period.

For now, a case-by-case basis remains his recommendation. “More complete data will be required to fully inform clinicians, parents, and adolescents whether to embark on surgical intervention or to postpone it,” he wrote, adding that “the 5-year data look promising but ... the lifetime outcome is unknown.”

These comments are adapted from an editorial (N Engl J Med. 2019 May 16. doi: 10.1056/NEJMe1905778 ). Dr. Adams reported receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases as well as the Intermountain Research Foundation and Ethicon Endo-Surgery, a subsidiary of Johnson & Johnson.



Adolescents and adults had similar weight loss after bariatric surgery, but diabetes and hypertension reoccurred more often in the older cohort, according to two related studies of 5-year outcomes after Roux-en-Y gastric bypass.

However, despite adolescents’ better outcomes for diabetes and hypertension, their rate of abdominal reoperations was significantly higher during the 5-year follow-up period, and at 2 years post surgery, they were found to have low ferritin levels. The rates of death were similar in the two groups at 5 years.

“We have documented similar and durable weight loss after gastric bypass in adolescents and adults, but important differences between these cohorts were observed in specific health outcomes,” wrote Thomas H. Inge, MD, PhD, of the University of Colorado at Denver, Aurora, and his coauthors. The study was published in the New England Journal of Medicine.

To evaluate and compare outcomes after bariatric surgery, the researchers undertook the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study and the LABS study. The two were related but independent observational studies of postsurgery patient cohorts. The Teen-LABS study included 161 adolescents with severe obesity, and the LABS study included 396 adults who reported becoming obese during adolescence.

At 5-year follow-up, there was no significant difference in mean percentage weight change between adolescents (−26%; 95% confidence interval, −29 to −23) and adults (−29%; 95% CI, −31 to −27; P = .08). Adolescents were more likely than were adults to have remission of type 2 diabetes (86% vs. 53%, respectively; risk ratio, 1.27; 95% CI, 1.03 to 1.57; P = .03) as well as hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88; P less than .001).

In addition, 20% of adolescents and 16% of adults underwent intra-abdominal procedures within 5 years of surgery, with cholecystectomy being the most common, followed by surgery for bowel obstruction or hernia repair, and gastrostomy. At 2 years, ferritin levels were lower in adolescents than in adults (48% of patients vs. 29%, respectively). Five-year ferritin levels were not assessed.

In all, three adolescents (1.9%) and seven adults (1.8%) died over the 5-year period. Among the adolescents, one patient with type 1 diabetes died 3 years after surgery from complications after a hypoglycemic episode, and the other two deaths, both 4 years after surgery, were consistent with overdose. Among the adults, three of the deaths occurred within 3 weeks of surgery and were related to gastric bypass, two were of indeterminate cause (at 11 months and 5 years after surgery), one was by suicide at 3 years, and one was from colon cancer at 4 years.

The authors acknowledged the limitations of their study, including its observational design, low counts for some of the outcomes, and a lack of nonsurgical controls. They also noted potential unmeasured biases in the adult cohort, including the effects of weight cycling and inaccuracies in recalling adolescent weight issues.

The study and several of its authors were supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases. Several authors reported receiving grants, honoraria, and consulting fees from medical technology and pharmaceutical companies.

SOURCE: Inge TH et al. N Engl J Med. 2019 May 16. doi: 10.1056/NEJMoa1813909.

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