From the Journals

Bariatric surgery viable for teens with cognitive disabilities

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Thoughtful approach to informed consent essential

Despite increasing evidence to support the safety and effectiveness of bariatric surgery in confronting the challenge of increasing obesity rates among adolescents, access to care remains limited for many such teens.

Prominent examples include a significant disparity in insurance authorization for bariatric surgical care when comparing pediatric patients to their adult counterparts, low rates of referral from primary caregivers, and general uncertainty regarding potential exclusionary criteria.

The researchers should be commended for exploring bariatric surgery outcomes in an understudied population. However, both the likely importance of social supports to the participants’ success and, especially, the need to approach the issue of informed thoughtfully, perhaps with additional institutional guidance are crucial to success.

Although literature addressing ethical concerns specifically associated with bariatric surgery for children with intellectual or developmental disability is limited, previous attempts to offer a logical clinical framework highlight the importance of using a case-by-case approach predicated on the need to establish a well-defined risk/benefit ratio.

As an important part of efforts to tackle such challenges, bariatric surgical care providers should strongly consider the routine use of available resources (i.e., institutional ethics committees) to assist in complex medical decision making.”

These comments are adapted from an accompanying editorial by Marc P. Michalsky, MD, of the Ohio State University and Nationwide Children’s Hospital, both in Columbus (Pediatrics. 15 April 2019; doi: 10.1542/peds.2018-4112). He reported having no disclosures.



Adolescents with severe obesity and cognitive impairment or developmental delay (CI/DD) lost as much weight, and at a similar rate, as their typically developing peers following laparoscopic sleeve gastrectomy (LSG), according in an observational study.

“On the basis of these new data, LSG appears to be a viable and successful short-term weight-management tool for adolescents with CI/DD, who are established as particularly vulnerable to obesity and secondary health concerns,” wrote Sarah E. Hornack, PhD, a psychologist with Children’s National Health System and George Washington University, both in Washington, and her associates.

“In fact, there may be advantages to undergoing surgery during adolescence rather than waiting until adulthood for this population,” they wrote in the journal Pediatrics. With more supports likely in place for teens undergoing this surgery, they won’t be “going it alone,” the authors noted, which “could translate to better cooperation with parental guidance regarding surgery requirements, including diet and exercise recommendations.”

Despite higher rates of obesity and related medical issues among youth with CI/DD, little research explores effective interventions in this population, the authors wrote.

They therefore compared outcomes among a group of 63 teens with obesity who underwent bariatric surgery during 2010-2017. The adolescents, who had a body mass index (BMI) of at least 40 kg/m2 or one of at least 35 kg/m2 with a medical comorbidity, first underwent preoperative psychological evaluations involving a cognitive assessment. The 17 adolescents with an IQ less than 80 were classified as having CI/DD, leaving 46 without CI/DD. Three teens had Down syndrome.

Age, sex, and BMI before surgery were similar in those with CI/DD versus those without. The majority of participants overall were female (65%) and black (57%) with an average age of 17 years and an average BMI of 51.2. Whites comprised 24% of participants while 17% were Hispanic and 1% another race/ethnicity.

The findings revealed that IQ did not predict weight loss. The percentage of excess BMI lost (%EBMIL) and rate of excess weight loss remained similar between those with and without CI/DD, though “a trend for a higher rate of change in %EBMIL for those individuals with CI/DD” suggested “they may experience greater rates of weight loss over time than their typically developing peers,” the authors reported. However, the proportion of participants assessed decreased with each follow-up, from 59 at 3 months to 14 at 24 months.

In addition to the small population, short-term follow-up and loss to follow-up, another study limitation is the lack of a control group of CI/DD patients who did not undergo bariatric surgery and instead received a behavioral intervention or other therapy.

But the authors noted existing evidence that “younger children respond better to behavioral interventions than adolescents do, suggesting that older youth may require a different treatment approach.” In addition, “bariatric surgery performed earlier in the trajectory of large weight gain has also been shown to lead to greater resolution of obesity, suggesting that waiting for adulthood can be detrimental,” they wrote.

SOURCE: Hornack SE et al. Pediatrics. 2019 Apr 15. doi: 10.1542/peds.2018-2908.

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