Weight loss surgery has traditionally been viewed as a procedure for adults with severe obesity who haven’t been able to lose weight or keep it off. Now, pediatricians are calling for it to be more accessible for children and teens with severe obesity too.
The American Academy of Pediatrics now recommends that metabolic and bariatric surgery should be considered a safe treatment option for children and teens with severe obesity – and should be covered by insurance for young people. The AAP made the recommendation in its first-ever policy statement on surgical treatments for children and teens with severe obesity, published in the medical journal Pediatrics on Sunday.
“This policy statement focuses more upon acceptance of – and access to – appropriate care than anything else,” said Dr. Kirk Reichard, surgical director of the Bariatric Surgery Program at Nemours/Alfred I. duPont Hospital for Children in Delaware, who was a co-author of the policy statement.
“Right now there’s a lot of variability in what’s paid for. There are certain plans that simply consider bariatric surgery under the age of 18 as experimental, which means they’re not going to be covered,” he said. “This policy statement specifically says that there’s no specific age guideline. Furthermore, we recognize that severe obesity in children disproportionally affects racial and ethnic minorities, and the economically disadvantaged, especially for girls.”
Becoming the person she wanted to be
Avery Feinstein, who underwent a gastrectomy last year when she was 18 to treat her severe obesity, called the new AAP recommendations “awesome” and said she hopes that more awareness is raised around adolescent bariatric surgery. Gastrectomy is a surgical procedure to remove part or all of the stomach.
“It changed my life and it’s cool that they’re going to try to help other people change their lives too at a young age,” Feinstein said.
“It’s helped me so much with who I am now,” she said. “If I did that in older age, I would miss my college years, living like how I am now and having the best time of my life.”
As a 19-year-old college sophomore at the University of Missouri, Feinstein now says she’s thriving. She joined a sorority, maintained her studies to become a psychiatrist, and continued to eat a healthy diet and stay active. Her favorite pastime is riding her horse, Rudy, whom she houses in a barn just 15 minutes away from campus.
Yet the journey to this point in Feinstein’s life wasn’t easy.
Feinstein struggled with her weight throughout childhood. She went to a weight-loss camp in middle school and tried strict diets, but neither helped her manage a healthy weight. During that time, Feinstein felt self-conscious and concerned about her health.
“I was trapped in how big I was,” she said.
At age 17, Feinstein and her mother visited a nutritionist at Ann & Robert H. Lurie Children’s Hospital of Chicago, and the nutritionist recommended Feinstein to the hospital’s adolescent bariatric surgery program.
Immediately, Feinstein knew that – with support from her mother and the help of the hospital staff – she wanted to undergo surgery to improve her health, especially before starting college in the fall.
“I had no clue that this could have been an option,” Feinstein said about the surgery.
“I knew that I was going to go off to college and this was the perfect time to turn my life around,” she said. “This was something that was going to help me become the person that I wanted to be, and not the person that I was.”
Obesity, which now affects 1 in 5 children and adolescents in the United States, can raise the risk for many health problems, including diabetes, heart disease, stroke, arthritis, breathing problems and certain cancers.
Body mass index, or BMI, is a person’s weight in kilograms divided by the square of their height in meters – and is used to screen for obesity. Obesity is defined as a BMI at or above the 95th percentile for children and teens of the same age and sex.
BMI is assessed when deciding whether surgery could be the best treatment approach for a person with severe obesity, said Dr. Ann O’Connor, a pediatric surgeon and director of the adolescent bariatric surgery program at Ann & Robert H. Lurie Children’s Hospital of Chicago. She performed Feinstein’s procedure.
“People who have a BMI over 40 – they normally would be people you would consider candidates for surgery,” O’Connor said. “If the BMI is 35 and higher, and they have other health problems like diabetes or hypertension or sleep apnea, then they might be candidates as well.”
The program’s protocol also requires that “teens must be 13 years or older and mature enough to understand the implications of surgery.”
‘This surgery is not just ‘here’s a fix’ ‘
The adolescent bariatric surgery program required Feinstein to complete a six-month diet and exercise plan before surgery, to encourage lifestyle changes that could continue after surgery – changes such as having salads for lunch instead of sandwiches. Feinstein was also required to stabilize her weight during that six-month period.
“If you’re going to choose to do this surgery, you have to change your lifestyle. This surgery is not just ‘here’s a fix.’ You have to do most of the work, and the surgery is just a little bit of help,” Feinstein said. “You have to be mentally ready for it.”
During that six-month period, however, Feinstein and her family were unsure whether their insurance would cover the surgery, which can be expensive.
One cost estimate for adolescent bariatric surgery from 2010 to 2013 found the average total intervention cost to be $25,854. But studies suggest the procedure is a cost-effective treatment in the long-term.
Feinstein’s mother, who raised Feinstein and her two siblings as a single parent, had “pretty good insurance through her work,” Feinstein said, but the family still had to undergo an extensive process to get the procedure approved.
“Every day, I would be like, ‘Mom, did they call? Do we know if insurance approved it?’ And so that was definitely a huge factor for me and my family,” she said. “It was nerve-racking.”
About one month before the surgery, Feinstein’s insurance approved the procedure and agreed to pay a portion of the costs, she said.
Feinstein underwent a sleeve gastrectomy, which was performed robotically. The procedure involved removing about 80% of the stomach, which limits the amount of food eaten and helps improve metabolism, O’Connor said. The addition of the robot technology helped with visualization and improved postoperative pain.
In the months following her surgery, Feinstein lost about 70% of her excess body weight.
“She started off in the morbidly obese category and is now at a normal body weight,” O’Connor said. “She’s done great: zero complications and resolved all of her health issues.”
‘The real power of these operations is the ability to alter physiology’
Bariatric surgery as a treatment strategy was developed around the the early 1960s, according to Dr. Marc Michalsky, surgical director for the Center for Healthy Weight and Nutrition at Nationwide Children’s Hospital in Columbus, Ohio, and an author of the AAP policy statement.
Then in 1991, the National Institutes of Health formalized clinical guidelines describing weight loss surgery as a treatment option for severe obesity, but those guidelines were just for adults.
Focused efforts to “analyze the application of bariatric surgery in the pediatric population” didn’t come until much later, Michalsky said.
“There are a lot of misconceptions about the appropriateness of bariatric surgery in the pediatric world,” he said. “At the end of the day, what this policy statement is saying is that bariatric surgery as a treatment strategy for severely obese pediatric patients is safe and effective and should be considered early in patients.”
The AAP policy statement noted that in an ongoing study of adolescents undergoing bariatric surgery, called the Teen-Longitudinal Assessment of Bariatric Surgery or Teen-LABS, young patients who underwent gastric bypass or a sleeve gastrectomy experienced an average weight reduction of 27% and resolved their obesity-related health issues within three years – including type 2 diabetes among 95% of the patients and high blood pressure among 74% of the patients. Those findings were based on 242 patients ages 12 to 28.
The “real power” of these operations is the ability to eliminate these long-term and cumulative impacts of significant excess body weight, said Michalsky, an author of Teen-LABS.
“The data that we are seeing now is very encouraging and has shown a significant reduction and in some cases complete reversal of some of these disorders,” he said.
This data also could lead to more young people with severe obesity having access to surgery as a treatment option under insurance coverage.
According to the Teen-LABS study, less than half – 47% – of young patients who met the criteria to be candidates for surgery received insurance coverage. Being younger than 18 years old was cited as the most common reason for coverage denial among those patients.
In contrast, 85% of adults who meet surgical criteria obtain initial insurance coverage authorization, according to the AAP policy statement.
“The hope would be, now that there’s an endorsement from the AAP, that a couple of things will happen. First, pediatricians who may be a little hesitant or unsure can now look at their organization and say, ‘OK this is endorsed by our national organization and therefore it’s a strategy that I should be using for my patients,’” said O’Connor, who was not involved in the policy statement.
“Then, even maybe more importantly, would be that we can hopefully use this as leverage for insurance companies to actually approve and pay for these procedures,” she said.
In the policy statement, the AAP called for public and private insurers to provide payment for bariatric surgery in young patients who meet standard criteria:
- Having a BMI of at least 35 or 120% of the 95th percentile for your age and sex, plus a clinically significant disease associated with your obesity, such as sleep apnea or hypertension;
- Or having a BMI of at least 40 or 140% of the 95th percentile for your age and sex; and no associated health condition is required but is commonly present.
‘This is something that we should be offering early’
To develop its policy statement, the AAP felt that there has been a “strong enough body of literature” to now evaluate the risks and benefits of bariatric surgery for young patients, said Reichard, one of the authors.
Metabolic and bariatric surgeries come with several risks – including the danger of blood clots or infection – but based on the literature, evidence has suggested that weight loss outcomes are similar or better in children than in adults after surgery.
Specifically, studies have found that conditions often associated with obesity – such as diabetes, high blood pressure or sleep apnea – resolve at higher rates in children who undergo surgery than they do in adults, “which was an interesting finding,” Reichard said.
“It makes sense. If the condition has been present for less time, it’s easier to cure,” he said. “That really gave us the foundation to say this is something that we should be offering early, rather than waiting until they’re in their adulthood and they’ve had more longstanding disease.”
A research abstract that was presented at the AAP national conference in New Orleans on Sunday found that sleeve gastrectomy is “quickly becoming the operation of choice” for the bariatric surgical treatment of children with obesity, and performing the surgical intervention at earlier ages was not associated with increased risk of complications.
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“Originally we hypothesized that age may play a factor in complication rates, but we found that young patients did just as well as older teenagers,” said Dr. Robert Swendiman, a sixth-year general surgery resident at Penn Medicine in Philadelphia and senior author of the research.
That research involved analyzing data on 3,705 patients ages 19 and younger with a BMI of at least 30 who underwent either gastric bypass or sleeve gastrectomy between 2015 and 2017. The data, which came from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, showed that there were complications in 1.4% of those cases, readmissions in 3.5% and no patients died.
“As the rate of childhood obesity continues to increase, it’s critical for us to identify whether weight loss procedures that are frequently performed on adults are also safe and effective options for adolescents,” Swendiman said. “For certain patients, surgical therapy may be the best option for long-term treatment.”