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Background Pediatric surgeons are often asked to treat clinical problems for which little high-quality data exist. For adults with adhesive small bowel obstruction (ASBO), water soluble contrast-based protocols are used to guide management. Little is known about their utility in children. We aimed to better understand key factors in clinical decision-making processes and integration of adult based data in pediatric surgeon's approach to ASBO. Methods We administered a web-based survey to practicing pediatric surgeons at institutions comprising the Western Pediatric Surgery Research Consortium. Results The response rate was 69% (78/113). Over half of respondents reported using contrast protocols to guide ASBO management either routinely or occasionally (n = 47, 60%). Common themes regarding the incorporation of adult-based data into clinical practice included the need to adapt protocols for pediatric patients, the dearth of pediatric specific data, and the quality of the published adult evidence. Conclusions Our findings demonstrate that pediatric surgeons use contrast-based protocols for the management of ASBO despite the paucity of pediatric specific data. Furthermore, our survey data help us understand how pediatric surgeons incorporate adult based evidence into their practice.

Purpose Adoption of telemedicine (TME) in surgical specialties, prior to the COVID-19 pandemic, has previously been slow. The purpose of this prospective, observational, single institution study is to evaluate surgeon and caregiver perspectives of TMEs during the pandemic. Methods Surveys were distributed to surgical faculty regarding perceptions of TME early during the pandemic and 2 months later. Caregivers (or patients > 18 years old) were asked after each TME to complete a survey regarding perceptions of TMEs. Results Surveys were distributed to 73 surgeons. Response rates were 71% initially and 63% at follow-up. Sixty-eight percent reported no prior TME experience. No significant differences were noted in the overall satisfaction. An inverse relationship between surgeon age and satisfaction at the follow-up survey was identified (p = 0.007). Additional surveys were distributed to 616 caregivers or patients (response rate 13%). Seventy-two percent reported no prior experience with TME and 79% described TME as similar to an in-person visit. Audiovisual satisfaction of the TME was higher in greater income households (p = 0.02). Conclusions Pre-pandemic experience with TME was low in both groups; however, experiences were perceived as satisfactory. Positive experiences with TME may encourage increased utilization in the future, although demographic variations may impact satisfaction with TME. Trial registration Unique identifier NCT04376710 at Clinicaltrials.gov (5/6/2020).

BACKGROUND: Little is known regarding obstructive sleep apnea’s (OSA’s) prevalence or the factors related to OSA remission post–metabolic bariatric surgery (MBS) in adolescents. OBJECTIVES: To identify the baseline OSA prevalence in adolescents with severe obesity and examine factors associated with post-MBS OSA remission. SETTING: Tertiary-care children’s hospital. METHODS: We conducted a retrospective chart review of 81 patients pre-MBS with OSA assessments done between June 2017 to September 2020 to collect demographic characteristics; co-morbidities; polysomnography (PSG) results, if indicated; and weight data. Chi-square or Mann-Whitney tests compared baseline characteristics and surgical outcomes by pre-MBS OSA status. McNemar’s test or t tests assessed differences in baseline characteristics, stratified by remission versus no remission of OSA. RESULTS: The patients were 71% female, had an average age of 16.9 ± 2.0 years, and had a mean body mass index (BMI) of 47.9 ± 7.3 kg/m(2). Half (50%) of the patients were Hispanic and 20% had type 2 diabetes. The OSA prevalence, defined as an Obstructive Apnea Hypopnea Index (OAHI) score ≥5, was 54% pre-MBS (n = 44), with 43% having severe OSA (OAHI > 30). Those with OSA were older (17.3 versus 16.4 yr, respectively; P = .05), more likely to be male (79% versus 42%, respectively; P = .022), and had higher baseline weights (142.0 versus 126.4 kg, respectively; P = .001) than those without OSA. Of the 23 patients with a post-MBS PSG result (average 5 mo post MBS), 15 (66%) had remission of OSA. Patients with OSA remission had a lower average pre-MBS BMI (46.0 versus 57.7 kg/m(2), respectively; P < .001) and weight (132.9 versus 172.6 kg, respectively; P = .002) but no significant differences in percentage weight loss through 12 months post MBS versus those with continued OSA. CONCLUSION: The OSA prevalence in an adolescent MBS population was higher than that in the general adolescent population with severe obesity. Remission of OSA was correlated with lower pre-MBS BMI and weight, but not weight loss within the first year post-MBS. (Surg Obes Relat Dis 2021;17:711–717.)

The surgical morbidity and mortality (MM) conferences at a regional children's hospital achieved the goals of case by case peer review and education for trainees but provided limited data for trending and analysis. In 2019, an institution-wide effort was initiated to create an electronic case review system with the goals of improving event capture and real-time practice performance feedback. Surgical MM was migrated to this structured case review format to provide a platform for surgical performance improvement.An online secure database was created with a 3-step classification system based on Clavien-Dindo severity score, peer review, and causality fishbone analysis. The data entered were available in an interactive dashboard. Retrospective tabulation of the 2018 MM data was performed using the archived paper system used prior to 2019.For the calendar year of 2019, the division of pediatric surgery captured and categorized 193 complications in the case review system. The capture rate was 50 per 1000 surgical procedures. For a similar time frame in 2018, the capture rate was 35 per 1000 surgical procedures. The dashboard provided run charts of the incidence and types of complications by procedure and by surgeon. Similar trend data were not available in 2018. The dashboard output has made possible the creation of (non- risk adjusted) individual surgeon performance reports. The output has been used to direct process improvement projects and educational content.Creation of an online database with interactive dashboard has allowed surgical MM to evolve into a systematic case review that greatly facilitates quality improvement efforts. This system increased the event capture rate and provided novel practice performance feedback, resulting in process improvement projects and educational objectives predicated on the trending data. These electronic reporting tools are now available to all surgical divisions and represent a transformative approach to surgical case review.Retrospective Historical control; Quality improvement.Level III.

PURPOSE The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia. METHODS A multi-institutional, retrospective cohort study was performed at nine tertiary-level children's hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance. RESULTS Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (± 24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3 months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97-0.99). CONCLUSION Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.

BACKGROUND: Bariatric surgery results in significant and durable weight loss and improved health in severely obese adolescents. An important adverse consequence of the massive weight loss after bariatric surgery is excess skin and soft tissue. The prevalence and clinical characteristics of excess-skin related symptoms have been described in adults undergoing bariatric surgery but not in adolescents. While the higher skin elasticity of adolescents may result in fewer excess skin problems compared to adults, this hypothesis remains untested. The purpose of the present study was to describe the natural history of excess skin and its associated complications among severely obese adolescents undergoing bariatric surgery. METHODS: We evaluated data from the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) cohort, a prospective, multi-institutional study of adolescents (13-19 years) undergoing bariatric surgery. Abdominal pannus severity (graded 0-5) and excess skin symptoms were evaluated pre-operatively and for the first five years after bariatric surgery. RESULTS: Among the 217 study participants, 198 (90%) had an abdominal pannus and 16 (7%) reported pannus related symptoms at the time of bariatric surgery. Preoperative symptoms included intertriginous infections (n=12, 75%), recurrent cellulitis (n=5, 31%), and superficial cutaneous ulcerations (n=1, 6%). Participants with a higher pannus grade pre-operatively experienced both a greater reduction in pannus severity (p

Background/Objectives: We hypothesized that physical activity (PA) improves insulin sensitivity in adolescents with severe obesity beyond that attributable to metabolic bariatric surgery (MBS). Subjects/Methods: StepWatch™ monitors objectively measured PA in 88 participants in the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study. Primary outcomes included absolute change in fasting insulin, HOMA-IR, and fasting glucose from pre-surgery (baseline) to 6, 12, 24, and 36 months post-MBS. SAS PROC TRAJ generated activity trajectories based on probability and individual participant step count trajectories. Linear regression models were used, adjusted for baseline value, visit, surgical procedure, sex, and percent change in BMI. Additional models adjusted for percent change in iliac waist circumference (IWC) or percent body fat (BF), measured by bio-impedance. Results: Two activity trajectories were identified: more active (MA, n=13) and less active (LA, n=75). MA baseline mean daily step count was >6 000, increasing to > 9 000 at 2 years. LA mean daily step count remained at approximately 4 000. Few participants recorded moderate step activity (cadence >80 steps/minute). Still, fasting insulin and HOMA-IR differed in association with activity trajectory. MA was associated with a greater absolute decrease in fasting insulin (−7.8μU/ml [95% CI: (−11.8, −3.7)], p =

Bariatric surgery improves markers of kidney health in severe obesity, yet it is unclear if kidney disease outcomes differ according to age at surgery. Therefore, we examined health effects of Roux-en-Y gastric bypass between 161 adolescents and 396 adults participating in two related but distinct studies. Primary outcomes were elevated urine albumin-to-creatinine ratio (UACR) of 30mg/g or more and hyperfiltration (an estimated glomerular filtration rate of 135 ml/min/1.73m(2) or more). Analyses were stratified by the presence of pre-operative type 2 diabetes. Adolescents with pre-operative type 2 diabetes had a significantly increased prevalence of elevated UACR prior to surgery compared to adults (22.5 vs. 9.0%). Resolution of elevated UACR following surgery differed between adolescents and adults with type 2 diabetes, with adolescents experiencing a significantly earlier improvement following surgery. Adolescents without pre-operative type 2 diabetes demonstrated a significantly increased prevalence of UACR prior to surgery compared to adults (9.4 vs. 4.5%), with no improvement occurring in either group post-operatively. Adolescents with pre-operative type 2 diabetes had a significantly increased prevalence of hyperfiltration that remained throughout the study period, whereas hyperfiltration prevalence was similar among those without type 2 diabetes. Thus, adolescents with pre-operative type 2 diabetes experienced earlier attenuation of elevated UACR compared to adults with pre-operative type 2 diabetes in response to gastric bypass. TRIAL REGISTRATION: (ClinicalTrials.gov NCT00465829 and NCT00474318

Background Few studies have addressed the effect of bariatric surgery on factors related to energy balance, including resting energy expenditure (REE) and thermic effect of food (TEF). To our knowledge, very few studies have examined changes in REE and none have investigated modifications in TEF after sleeve gastrectomy (SG) performed in adolescents. Objective To assess energy expenditure in females who underwent SG as adolescents and matched-control participants as preliminary data about the potential of SG to confer differences in postprandial energy expenditure. Setting Children’s Hospital Medical Center, Cincinnati, Ohio, United States. Methods In this observational study, REE and respiratory quotient (RQ) were measured via indirect calorimetry, followed by a standardized meal and assessment of TEF and postprandial RQ. Plasma drawn before and every 15 minutes after the meal was assayed for insulin, glucose, and C-peptide. Usual dietary intake was estimated using 24-hour recall interviews. Results Fasting REE and RQ were similar between surgical and control groups. Postmeal TEF also did not differ between groups. The surgical group had higher RQ early in the postprandial period, whereas the control group RQ was higher after 125 minutes post meal. Compared with the control group, the surgical group had lower postprandial glucose, higher insulin and C-peptide, and consumed less daily energy during usual intake. Conclusions Postprandial RQ was consistent with the rapid gastric emptying typical of SG, yet we observed no group differences in REE or TEF. These findings may have been due to limited statistical power. More comprehensive studies of EE after SG are warranted.

BACKGROUND: Adolescent obesity is associated with significant comorbidities including decreased quality of life (QOL). QOL improves after metabolic and bariatric surgery (MBS), but recent studies have demonstrated that certain gastrointestinal symptoms (GIS) worsen after surgery, including reflux symptoms, nausea, bloating and diarrhea. OBJECTIVE: The aim of this study was to evaluate QOL and the effect of these symptoms on QOL after bariatric surgery. SETTING: Five academic centers performing adolescent MBS in the United States. METHODS: We prospectively studied 228 adolescents undergoing MBS using the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) cohort. Gastrointestinal symptoms and QOL scores were assessed before surgery, at 6-months and yearly to 5 years after surgery. Analysis involved linear models examining QOL and the association between GIS and QOL adjusting for a priori determined covariates. RESULTS: Adjusting for body mass index (BMI) change over time, the physical component score (PCS) of the Short Form-36 (SF-36) increased after surgery from 44.2 at baseline to 54.4 at 5 years (p

BACKGROUND: Extant literature warns of elevated suicide risks in adults post-bariatric surgery, making understanding risks for adolescent patients imperative. OBJECTIVES: To examine prevalence and predictors/correlates of suicidal thoughts and behaviors (STBs) in adolescents with severe obesity who did/did not undergo bariatric surgery from presurgery/baseline to 4 years postsurgery. SETTING: Five academic medical centers METHOD: Utilizing a prospective observational design, surgical adolescents (n=153; 79% female, 65% White, M(age)=17, M(BMI)=52) and nonsurgical comparators (n=70; 80% female, 54% White, M(age)=16, M(BMI)=47) completed psychometrically sound assessments at presurgery/baseline and postsurgery Years 2 and 4 (Year 4: n=117 surgical [M(BMI)=38], n=56 nonsurgical [M(BMI)=48]). RESULTS: For the surgical group, rates of STBs were low (Year 2 [1.3–4.6%]; Year 4 [2.6–7.9%], similar to national base rates. Groups did not differ on a Year 4 postsurgical STBs composite (PostSTBs: ideation/plan/attempt; n=18 surgical [16%], n=10 nonsurgical [18%]; OR=0.95,p=0.90). For the surgical group, predictors/correlates identified within the broader suicide literature (e.g., psychopathology [ps

OBJECTIVE To compare diabetic kidney disease (DKD) rates over 5 years of follow-up in two cohorts of severely obese adolescents with type 2 diabetes (T2D) undergoing medical or surgical treatment for T2D. RESEARCH DESIGN AND METHODS A secondary analysis was performed of data collected from obese participants of similar age and racial distribution enrolled in the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and the Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY) studies. Teen-LABS participants underwent metabolic bariatric surgery (MBS). TODAY participants were randomized to metformin alone or in combination with rosiglitazone or intensive lifestyle intervention, with insulin therapy given for glycemic progression. Glycemic control, BMI, estimated glomerular filtration rate (eGFR), urinary albumin excretion (UAE), and prevalence of hyperfiltration (eGFR ≥135 mL/min/1.73 m2) and elevated UAE (≥30 mg/g) were assessed annually. RESULTS Participants with T2D from Teen-LABS (n = 30, mean ± SD age, 16.9 ± 1.3 years; 70% female; 60% white; BMI 54.4 ± 9.5 kg/m2) and TODAY (n = 63, age 15.3 ± 1.3 years; 56% female; 71% white; BMI 40.5 ± 4.9 kg/m2) were compared. During 5 years of follow-up, hyperfiltration decreased from 21% to 18% in Teen-LABS and increased from 7% to 48% in TODAY. Elevated UAE decreased from 27% to 5% in Teen-LABS and increased from 21% to 43% in TODAY. Adjusting for baseline age, sex, BMI, and HbA1c, TODAY participants had a greater odds of hyperfiltration (odds ratio 15.7 [95% CI 2.6, 94.3]) and elevated UAE (27.3 [4.9, 149.9]) at 5 years of follow-up. CONCLUSIONS Compared with MBS, medical treatment of obese youth with T2D was associated with a higher odds of DKD over 5 years.

BACKGROUND AND AIM: Perfluoroalkyl substances (PFAS), the “forever chemicals”, accumulate mainly in the liver and have various adverse health effects. Little is known about the mechanistic pathways...

IntroductionThe pathophysiology of type 2 diabetes (T2D) in youth differs from adults and conventional medical treatment approaches with lifestyle change, metformin, thiazolidinediones or insulin are inadequate. Metabolic bariatric surgery (MBS) improves multiple health outcomes in adults with T2D. Initial small, uncontrolled studies of Roux-en-Y gastric bypass have also suggested beneficial effects in adolescents. Definitive studies in youth with T2D are lacking, especially with the now more common form of MBS, vertical sleeve gastrectomy (VSG). The surgical or medical treatment for paediatric type 2 diabetes (ST2OMP) clinical trial was designed to test the hypothesis that VSG will more effectively reduce hyperglycaemic and diabetes comorbidities than the best currently available medical treatment incorporating state of the art pharmacotherapies. ST2OMP is also designed to better understand the pancreatic and enterohepatic mechanisms by which MBS improves diabetes and its associated comorbidities.Methods and analysisST2OMP is a prospective, open-label, controlled clinical trial that will recruit 90 postpubertal participants, age range 13–19.9 years, with body mass index ≥35 kg/m2or >120% of 95th percentile and youth-onset T2D. The primary outcome is the per cent of youth achieving haemoglobin A1c Ethics and disseminationThe ST2OMP protocol was approved by the Cincinnati Children’s Hospital Medical Center and the University of Colorado Institutional Review Boards. Written informed consent is obtained prior to study enrolment. Study findings will be widely disseminated through peer-reviewed publications and conference presentations.Trial registration numberClinical Trials.GovNCT04128995.

Metabolic syndrome (MetS) affects ∼10% of adolescents and is associated with cardiometabolic disease risk. The most prevalent MetS component is abdominal obesity. Healthy diet and physical activity (PA) are inversely associated with abdominal obesity and may reduce MetS risk in youth. Our aim was to examine associations of diet, activity, and abdominal obesity with MetS z-score (MetS-z).An analysis of National Health and Nutrition Examination Survey (NHANES) 2011-2016 data in adolescents was performed. Healthy Eating Index (HEI)- 2015 scores were calculated for diet quality, PA habits were used to determine alignment with national guidelines, and abdominal obesity was assessed by sagittal abdominal diameter (SAD). MetS-z represented severity or potential risk for MetS. Multivariable regression evaluated the relationships of HEI, SAD and PA with MetS-z. Among 1214 black and white adolescents, SAD was significantly associated with MetS-z [β (95% CI) = 0.17 (0.16, 0.19); P0.0001] while HEI-2015 components showed associations with MetS-z overall (HEI total, dairy, and sodium scores), and by sex (total, refined grains, dairy for males; added sugar, protein, whole grains for females). Mean HEI-2015 score was 47.4/100 (51.6 using the population-ratio method), and the proportion of adolescents meeting national PA guidelines was 37.6%, yet PA was not a significant predictor of MetS-z.US adolescents have poor diet quality and fewer than half meet PA guidelines. Strategies for preventing MetS and related conditions in adolescence should focus on weight management - specifically, abdominal fat reduction - with individualized diet counseling.

Objective This report estimates the percent of medically eligible adolescents who are referred for metabolic and bariatric surgery (MBS) evaluation or factors associated with referral. Methods This cross-sectional retrospective review evaluated patients aged 13 to 18 years seen between 2017 and 2019 for demographics, insurance status, body mass index (BMI), obesity-related comorbidities, and compared these data to patients whom had been referred and received MBS. Results Half of the patients (86 411/163137, 53%) between ages of 13 and 18 years identified had BMI documented, of which, 1974 (2.3%) were medically eligible for MBS, 238 (12%) were referred for MBS and 52 (22%) underwent MBS. Females had similar odds of being eligible for MBS [odds ratio (OR) = 1.01, 95% confidence interval (CI) 0.92-1.11, P = .9], but greater odds of referral (OR = 1.58, 95% CI 1.13-2.23, P = .009). Independently, miniorities and patients with public insurance had higher odds of being eligible for MBS, but similar odds of being referred as non-Hispanic white patients. Black patients with public insurance had greater odds of being referred for MBS (OR = 12.22, 95% CI 2.08-235.15, P = .022). Patients' multiple comorbidities had greater odds of being referred for MBS (OR = 2.16, 95% CI 1.29-3.68, P = .004). Conclusions Referral is barrier for patients medically eligible for MBS; however, this barrier is not uniformly faced by all patients.

Background Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) are effective for weight loss in adolescents with severe obesity. However, little is known about adverse gastrointestinal symptoms (GIS) following these operations in adolescents. The objective was to examine GIS over 5 years after surgery and differences by surgery type. Methods We prospectively studied 228 adolescents (161 RYGB, 67 VSG) undergoing bariatric surgery. Gastrointestinal symptoms were assessed before surgery, at 6-months, and yearly to 5 years after surgery. Symptom severity was dichotomized for analysis. Analysis of post-surgery symptoms involved linear models adjusting for baseline symptoms, BMI, early post-operative complication, sex, and race. Results Participants at surgery were 17 ± 1.6 years with preoperative BMI 53 ± 9.4 kg/m2. From 6 months to 5 years, gastroesophageal reflux symptoms (GERS), nausea, bloating, and diarrhea increased. Crude prevalence rates of GERS increased from 4% (1% RYGB, 11% VSG) at 6-months post-surgery to 14% (10% RYGB, 26% VSG) at 5-years. In adjusted analyses, the VSG group experienced 4-fold (4.85 95% CI 2.63, 8.91, p Conclusions Adolescents who underwent VSG experienced greater risk of GERS compared to those undergoing RYGB. Adolescents undergoing VSG should be counseled preoperatively about GERS and objectively monitored postoperatively for gastroesophageal reflux when indicated. Clinical trial registration ClinicalTrials.gov , Identifier: NCT00474318 , https://clinicaltrials.gov/ct2/show/NCT00474318?term=Teen-LABS&rank=1 . Type of Study Treatment Study. Level of Evidence Level II.

Current surgical options for the management of adolescent obesity include Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG), with recent trends favoring VSG. While both operations result in similar weight reduction, baseline micronutrient status may influence the choice of the procedure in youth. We describe an adolescent with severe obesity, iron deficiency, poor iron absorption, and their impact on decision-making for surgical treatment of her severe obesity. We present a case of a 15-year-old female with a BMI of 50 kg/m2 who was referred for bariatric surgery requesting a RYGB. During her preoperative evaluation, mild iron deficiency anemia was identified after noting a low hemoglobin concentration and mean corpuscular volume. Endoscopic biopsy revealed mild chronic gastritis. Iron supplementation over a 9-month period did not improve her anemia preoperatively and an oral iron challenge demonstrated inadequate absorption. A VSG was recommended to reduce further nutritional risk. Four months following surgery, her anemia resolved, and iron indices normalized while on supplemental micronutrients. Weight loss and hematologic status remained stable over the ensuing eight years of follow-up. Given the risks of micronutrient deficiency following bariatric surgery, particularly RYGB, preoperative evaluation of iron status among patients with microcytic anemia and anticipated nutritional risks of available surgical procedures should influence decision-making during surgical management. Keywords: Bariatric surgery, Obesity, Laparoscopic sleeve gastrectomy, Vertical sleeve gastrectomy, Iron deficiency anemia, Adolescent

Objective Treating pediatric severe obesity is challenging because of the complex biological, behavioral, and environmental factors that underpin the disease. The multifactorial etiology of obesity combined with the physiologic complexity of the energy regulatory system contributes to treatment variability. The goal of this secondary analysis of pooled data was to describe the degree of individual variation in response to various interventions among adolescents with severe obesity. Methods Data from three centers across the United States conducting either lifestyle (n = 53), pharmacotherapy (n = 40), or metabolic and bariatric surgery (n = 78) interventions were pooled. Inclusion criteria were severe obesity at baseline and at least one follow-up visit > 30 days after treatment start. Results Change in BMI following intervention ranged from -50.2% to +12.9%, with each intervention (lifestyle [range: -25.4% to 5.0%], pharmacotherapy [range: -10.8% to 12.9%], and metabolic and bariatric surgery [range: -50.2% to -13.3%]) exhibiting wide individual variation in response. Changes in cardiometabolic risk factors demonstrated similarly high variability. Conclusions Adolescents with severe obesity demonstrated a high degree of heterogeneity in terms of BMI reduction and cardiometabolic risk factor response across treatment modalities. Reporting individual response data in trials and identifying factors driving variability in response will be vital for advancing precision medicine approaches to address obesity.

OBJECTIVE The study objective was to empirically identify subgroups of patients with obesity and investigate their association with postoperative weight change. METHODS A longitudinal analysis of 2,458 adults in the Longitudinal Assessment of Bariatric Surgery (LABS) study was used. Baseline data were used to identify subgroups. The outcome was 3-year weight change after bariatric surgery. RESULTS We identified four classes (subtypes) of obesity, which could be characterized as diabetes with low rates of high-density lipoprotein (Class 1), disordered eating (Class 2), mixed (Class 3), and extreme obesity with early onset (Class 4). Approximately 98% of participants in Class 1 had diabetes compared with < 40% in the other classes. There were high rates of binge eating in Class 2, and more than 92% of those in this class reported eating when not hungry. Class 4 was characterized by a higher BMI at baseline. Adults in Class 4 lost an average of 25.0% (males) and 30.3% (females) of their baseline weight over 3 years. In contrast with participants in Class 1, those in Classes 2 and 3 had significantly larger 3-year weight losses than their peers in Class 4. CONCLUSIONS Obesity is a heterogeneous disease. Bariatric surgery may be most beneficial for adults with disordered eating.

Objectives The aim of this study was to assess associations between loss of control (LOC) eating and health outcomes among adolescents undergoing metabolic and bariatric surgery. Methods A total of 234 adolescents were studied before and up to 6 years after surgery in a prospective, observational cohort design. Adolescents provided self-reports of LOC eating, pain severity, sleep quality, polycystic ovary syndrome, gastroesophageal reflux disease, and medication usage and objective measures of fasting glucose, serum insulin, glycohemoglobin A1c , cholesterol, triglycerides, and blood pressure. χ2 tests, Wilcoxon rank sums, and generalized linear mixed models were used to assess concurrent and prospective associations between LOC eating and health indicators. Results LOC eating presented in 32.5% of adolescents before surgery and was positively associated with sleep disturbances and psychiatric medication usage. After surgery, LOC eating presented in 7.9% to 14.6% of participants and was correlated with improved low- and high-density lipoprotein cholesterol levels and greater back pain. LOC eating was inversely associated with low-density lipoprotein cholesterol at the next consecutive time point. Conclusions LOC eating was unexpectedly associated with improved low- and high-density lipoprotein cholesterol in adolescents undergoing metabolic and bariatric surgery. Deleterious effects of LOC eating on obesity-related health conditions, aside from back pain, were not detected. Metabolic and other weight-independent health benefits of surgery may persist postoperatively despite LOC eating and associated weight regain.

OBJECTIVES: In this report, we compare weight loss, comorbidity resolution, nutritional abnormalities, and quality of life between younger and older adolescents after metabolic and bariatric surgery. METHODS: From March 2007 to December 2011, 242 adolescents (≤19 years of age) who underwent bariatric surgery at 5 clinical centers in the United States were enrolled in the prospective, multicenter, long-term outcome study Teen–Longitudinal Assessment of Bariatric Surgery. Outcome data from younger (13–15 years; n = 66) and older (16–19 years; n = 162) study participants were compared. Outcomes included percent BMI change, comorbidity outcomes (hypertension, dyslipidemia, and type 2 diabetes mellitus), nutritional abnormalities, and quality of life over 5 years post surgery. RESULTS: Baseline characteristics, except for age, between the 2 cohorts were similar. No significant differences in frequency of remission of hypertension (P = .84) or dyslipidemia (P = .74) were observed between age groups. Remission of type 2 diabetes mellitus was high in both groups, although statistically higher in older adolescents (relative risk 0.86; P = .046). Weight loss and quality of life were similar in the 2 age groups. Younger adolescents were less likely to develop elevated transferrin (prevalence ratio 0.52; P = .048) and low vitamin D levels (prevalence ratio 0.8; P = .034). CONCLUSIONS: The differences in outcome of metabolic and bariatric surgery between younger and older adolescents were few. These data suggest that younger adolescents with severe obesity should not be denied consideration for surgical therapy on the basis of age alone and that providers should consider adolescents of all ages for surgical therapy for obesity when clinically indicated.

OBJECTIVE This study aimed to track conventional cigarette smoking behaviors and associated correlates in adolescents with severe obesity who did or did not undergo metabolic and bariatric surgery to 4 years after surgery/baseline. METHODS Utilizing a prospective controlled design, surgical (n = 153; mean BMI = 52) and nonsurgical (n = 70; mean BMI = 47) groups that completed assessments before surgery/at baseline and at Years 2 and 4 post surgery (Year 4: n = 117 surgical [mean BMI = 38]; n = 56 nonsurgical [mean BMI = 48]) were compared. Separate logistic regression models tested correlates of Year 4 current smoking. RESULTS More than half of participants (surgical: 55%; nonsurgical: 60%) had ever smoked a cigarette, with current smoking increasing with time. Groups did not differ in Year 4 current smoking (surgical: 23%; nonsurgical: 33%), with ≈ 50% meeting criteria for "heavy" smoking (≥ half pack/day) and ≈ 40% smoking their first cigarette before ninth grade. Factors associated with higher odds of Year 4 current smoking included dysregulation (P

Context Few studies have examined the clinical characteristics that predict durable, long-term diabetes remission after bariatric surgery. Objective To compare diabetes prevalence and remission rates during 7-year follow-up after Roux-en-Y gastric bypass (RYGB) and laparoscopic gastric banding (LAGB). Design An observational cohort of adults with severe obesity recruited between 2006 and 2009 who completed annual research assessments for up to 7 years after RYGB or LAGB. Setting Ten US hospitals. Participants A total sample of 2256 participants, 827 with known diabetes status at both baseline and at least 1 follow-up visit. Interventions Roux-en-Y gastric bypass or LAGB. Main Outcome Measures Diabetes rates and associations of patient characteristics with remission status. Results Diabetes remission occurred in 57% (46% complete, 11% partial) after RYGB and 22.5% (16.9% complete, 5.6% partial) after LAGB. Following both procedures, remission was greater in younger participants and those with shorter diabetes duration, higher C-peptide levels, higher homeostatic model assessment of β-cell function (HOMA %B), and lower insulin usage at baseline, and with greater postsurgical weight loss. After LAGB, reduced HOMA insulin resistance (IR) was associated with a greater likelihood of diabetes remission, whereas increased HOMA-%B predicted remission after RYGB. Controlling for weight lost, diabetes remission remained nearly 4-fold higher compared with LAGB. Conclusions Durable, long-term diabetes remission following bariatric surgery is more likely when performed soon after diagnosis when diabetes medication burden is low and beta-cell function is preserved. A greater weight-independent likelihood of diabetes remission after RYGB than LAGB suggests mechanisms beyond weight loss contribute to improved beta-cell function after RYGB. Trial Registration clinicaltrials.gov Identifier: NCT00465829.

Background Cardiovascular disease (CVD) remains the leading cause of mortality in type 2 diabetes (T2D). Better interventions are needed to mitigate the high lifetime risk for CVD in youth T2D. Objective To compare 30-year risk for CVD events in 2 cohorts of adolescents with T2D and severe obesity undergoing medical or surgical treatment of T2D. Setting Longitudinal multicenter studies at University hospitals. Methods A secondary analysis of data collected from the participants with T2D enrolled in the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS, n = 30) and participants of similar age and racial distribution from the Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY, n = 63) studies was performed. Teen-LABS participants underwent metabolic bariatric surgery (MBS). TODAY participants were randomized to metformin alone or in combination with rosiglitazone or intensive lifestyle intervention, with insulin therapy given for glycemic progression. A 30-year CVD event score developed by the Framingham Heart Study was the primary outcome, assessed at baseline (preoperatively for Teen-LABS), 1 year, and 5 years of follow-up. Results Participants with T2D from Teen-LABS (n = 30; mean ± SD age = 16.9 ± 1.3 yr; 70% female; 60% white; body mass index (BMI) = 54.4 ± 9.5 kg/m2) and TODAY (n = 63; 15.3 ± 1.3 yr; 56% female; 71% white; BMI 40.5 ± 4.9 kg/m2) were compared. The likelihood of CVD events was higher in Teen-LABS versus TODAY at baseline (17.66 [1.59] versus 12.11 [.79]%, adjusted P = .002). One year after MBS, event risk was significantly lower in Teen-LABS versus TODAY (6.79 [1.33] versus 13.64 [0.96]%, adjusted P Conclusion Despite higher pretreatment risk for CVD events, treatment with MBS resulted in a reduction in estimated CVD event risks, whereas medical therapy associated with an increase in risk among adolescents with T2D and severe obesity.

Background As severe obesity continues to rise among youth, metabolic and bariatric surgery (MBS) will increasingly be used as a treatment of choice for durable weight loss and improvement of obesity-related complications. MBS for youth with intellectual and developmental disabilities (IDD) and for preadolescents has raised ethical questions. Objectives The purpose of this article is to present the creation and application of an ethical framework that supports why MBS should be considered in pediatrics based on the principle of justice without automatic exclusions. This framework also provides a guide for how to conduct a robust, ethically grounded evaluation of pediatric patients presenting for MBS in general, and among subpopulations including youth with IDD and preadolescents. Setting Academic medical center, United States. Methods An ethical framework was developed and applied through a collaboration between an MBS center at a children’s hospital and the institution’s ethics consult service. Results Application of the ethical framework to address 4 core ethical questions is illustrated using 2 hypothetical cases: 1 that highlights an adolescent with IDD and 1 that highlights a preadolescent. Conclusions We have demonstrated the application of a novel, overarching framework to conduct the ethical evaluation of youth presenting for MBS. This framework resulted from a collaboration between MBS and ethics consult teams and has the potential to be used as a prototype for other youth-focused MBS programs. Next steps include prospective data collection to test the framework and determine its validity in the target population.

This prospective cohort analysis describes changes in weight, cardiometabolic health, and weight-related quality of life (WRQOL) following adolescent LAGB. Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) collected demographic, anthropometric, micronutrient, cardiometabolic risk, and WRQOL data for 242 adolescents. Data through 5 years were analyzed for 14 participants who underwent LAGB with 2 patients lost to follow-up. Participants (mean age 18.2 ± 0.4 years) were mostly female (86%) and white (71%) with a median body mass index (BMI) of 48.7 kg/m2 (45.5–54.1). Preoperatively, 100%(13/13), 62%(8/13), 57%(8/14), and 7%(1/14) had elevated high sensitivity C-reactive protein (hs-CRP), dyslipidemia, elevated blood pressure (EBP), and type 2 diabetes (T2D), respectively. At 5 years, mean BMI decreased by 3.3% (51.0 vs. 49.3 kg/m2, p = 0.6), 43%(6/14) had BMI values exceeding baseline and 21% (3/14) underwent band removal. Postoperative prevalence of hs-CRP, dyslipidemia, EBP, and T2D was 45% (4/11), 36% (5/11), 33% (4/12), and 0% (0/11), respectively. Adolescents undergoing LAGB experienced modest initial weight loss and improvements in cardiovascular risk factors with later weight regain and frequent need for band removal. Despite the small sample size, this prospective study highlights long-term outcomes with high rates of participant retention over time. Clinical Trial Registration: NCT00465829

OBJECTIVE Following metabolic and bariatric surgery (MBS), most adolescents experience weight loss and improvement of many obesity-associated complications (OACs). The relationship between weight loss and remission of OACs after MBS in adolescents has not been well described. METHODS The Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) is a multi-institutional prospective observational study of adolescents who underwent MBS between 2007 and 2012. Lower-weight-loss responders (LWLRs) were defined as having

Background: Sleeve gastrectomy is the most commonly performed weight loss surgery in adolescents with moderate-to-severe obesity. While studies in adults have reported on the deleterious effects of gastric bypass surgery on bone structure and strength estimates, data are lacking for the impact of sleeve gastrectomy on these measures in adolescents. Objective: To evaluate the impact of sleeve gastrectomy on bone outcomes in adolescents and young adults over 12 months using dual energy x-ray absorptiometry (DXA) and high resolution peripheral quantitative computed tomography (HRpQCT). Participants and Methods: We enrolled 33 youth 14-22 years old with moderate to severe obesity; 17 underwent sleeve gastrectomy and 16 were followed without surgery. DXA was used to assess areal bone mineral density (aBMD). HRpQCT was used to assess bone geometry, microarchitecture and volumetric BMD (vBMD) and finite element analysis to assess strength estimates (stiffness and failure load) at the distal tibia and distal radius at baseline and 12 months. 25(OH) vitamin D (25OHD) levels were obtained at baseline and follow-up. Results: The surgical group lost 28.2% of total body weight compared to 1.4% in the non-surgical group. The groups did not differ for changes in 25OHD levels (P=0.181). After controlling for age and sex, compared to the non-surgical group, the surgical group had reductions in aBMD Z-scores at the femoral neck and total hip (p≤ 0.0005). At the distal tibia, there were reductions in cortical thickness and trabecular number, and increases in trabecular separation and cortical vBMD, without changes in strength estimates in the surgical group vs. controls (p≤0.043). Changes were less marked at the distal radius. While sleeve gastrectomy resulted in deleterious effects on most bone parameters, there was an increase in cortical vBMD at both sites, possibly from a decrease in cortical porosity. Most differences were attenuated after adjusting for changes in BMI over 12 months. Conclusions: Over 12 months, weight loss associated with sleeve gastrectomy in adolescents had deleterious effects on areal BMD, bone geometry and trabecular microarchitecture at weight-bearing sites. However, strength estimates did not decrease, possibly because of a simultaneous increase in cortical volumetric BMD. Additional research is necessary to determine the relative contribution(s) of weight loss and the metabolic effects of surgery, and whether the observed effects on bone stabilize or progress over time.

Youth-onset type 2 diabetes (T2D) is a formidable threat to the health of obese adolescents because of its potential for early-onset and aggressive co-morbidities and complications. The physiology of youth-onset T2D differs from T2D in adults and is associated with a greater degree of insulin resistance, a more rapid decline in pancreatic β-cell function, and a poorer response to medications. Medical management in youth is focused on combining lifestyle intervention and pharmacological treatment, but these therapies have yet to demonstrate improvements in disease progression. Metabolic bariatric surgery (MBS) is now recommended for the treatment of T2D in adults largely because of the beneficial effects on weight, ability to improve glycemic control, and, in a large proportion of people, induce diabetes remission. MBS is now being performed in adolescents with severe obesity and T2D, with initial results also showing high rates of T2D remission. Here, we review the state of medical management of youth-onset T2D and the outcomes of MBS studies in youth with T2D published to date.

Objective: To examine sleep behaviors and their associations with health characteristics in a cohort of adolescents with severe obesity undergoing bariatric surgery at Children’s Hospital Colorado. Methods: A retrospective chart review of electronic medical records was performed. All patients receiving care at the Children’s Hospital Colorado (CHCO) Bariatric Surgery Center between 06/17-08/19 were included. Demographic, medical and family history, self-reported sleep behaviors, and laboratory measures were abstracted, including medical problem list (e.g., type 2 diabetes (T2D), hypertension) and body mass index (BMI). A sleep behavior risk score (SBRS) was developed using five criteria (short sleep defined as Results: Data from 78 patients, aged 16.82.1, were reviewed. The majority of patients were female (71%), Hispanic (52%) and in 10-12 th grade in school (64%). Prior to surgery, 24% of the patients were diagnosed with hypertension and 20% with type 2 diabetes. The majority of patients (60%) had a high SBRS at baseline. High SBRS was significantly associated with higher baseline BMI (49.2 vs 45.0; p=0.03). SBRS score was not significantly associated with diagnosis of hypertension, type 2 diabetes, hyperlipidemia, or obstructive sleep apnea. Conclusions: In a population of adolescents seen in the Bariatric Surgery Center at CHCO, a majority of patients met criteria for high risk sleep behaviors, and worse sleep behaviors preoperatively were related to higher baseline BMI. A high SBRS may adversely impact adolescents’ overall health prior to surgery, which may have implications for weight loss success post-surgery. The evaluation for sleep health should be more rigorously evaluated and standardized as part of efforts to improve health outcomes in patients undergoing bariatric surgery.

Background Vertical sleeve gastrectomy (VSG) has been associated with gastroesophageal reflux symptoms and, in adults, with a development of Barrett’s esophagus. Adults with Barrett’s esophagus identified at baseline before bariatric operation are generally advised against VSG operations. The role of preoperative esophagogastroduodenoscopy (EGD) in adolescents preparing for bariatric surgery is not clearly defined. Objective The goal of this study was to report the frequency of abnormalities identified on EGD performed at baseline in adolescents undergoing VSG for severe obesity. Setting Free-standing academic children's hospital. United States. Methods A retrospective chart review was conducted to describe findings of EGD performed just before VSG in a cohort of 40 adolescents and young adults (age range 14–25 yr) immediately before VSG. Review of findings from gross and histopathological evaluation of the esophagus, resected stomach, and duodenum was performed. Results Five individuals reported preoperative symptoms of gastroesophageal reflux. Anatomic findings at EGD were normal in 98% of individuals. Histopathology of the esophagus, stomach, and duodenum was normal in 88%, 70%, and 95%, respectively. Abnormal findings of gastritis (18%), esophagitis (13%), and/or Helicobacter pylori (10%) infection were most common. Those with evidence of H. pylori in gastric resection specimens were treated appropriately with eradication therapy postoperatively. With the exception of 2 patients with incidentally detected esophageal mucosal eosinophilia, EGD findings did not lead to additional changes in medical or surgical management. There were no complications of the EGD procedure. Conclusions Routine EGD at the time of VSG was safe but resulted in low yield of abnormal findings requiring a change in clinical management.

BACKGROUND: It is unknown whether previously noted racial disparities in the use of metabolic and bariatric surgery (MBS) for the management of pediatric obesity could be mitigated by accounting for primary insurance. OBJECTIVES: To examine utilization of pediatric MBS across race and insurance in the U.S. SETTING: Retrospective cross-sectional study. METHODS: The National Inpatient Sample was used to identify patients 12–19 years old undergoing MBS from 2015–2016, and these data were combined with national estimates of pediatric obesity obtained from the 2015–2016 National Health and Nutrition Examination Survey. Severe obesity was defined as class III obesity, or class II obesity plus hypertension, dyslipidemia, or diabetes mellitus. RESULTS: 1,659,507 (5.0%) adolescents with severe obesity were identified, consisting of 35.0% female, 38.0% white, and 45.0% privately insured adolescents. Over the same time period, 2,535 MBS procedures were performed. Most surgical patients were female (77.5%), white (52.8%), and privately insured (57.5%). Black and Hispanic adolescents were less likely to undergo MBS than whites (OR 0.50, 0.46 respectively; p

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.

The prevalence of obesity, measured by body mass index, has risen to unacceptable levels in both men and women in the United States and worldwide with resultant hazardous health implications. Genetic, environmental, and behavioral factors influence the development of obesity, and both the general public and health professionals stigmatize those who suffer from the disease. Obesity is associated with and contributes to a shortened life span, type 2 diabetes mellitus, cardiovascular disease, some cancers, kidney disease, obstructive sleep apnea, gout, osteoarthritis, and hepatobiliary disease, among others. Weight loss reduces all of these diseases in a dose-related manner—the more weight lost, the better the outcome. The phenotype of “medically healthy obesity” appears to be a transient state that progresses over time to an unhealthy phenotype, especially in children and adolescents. Weight loss is best achieved by reducing energy intake and increasing energy expenditure. Programs that are effective for weight loss include peer-reviewed and approved lifestyle modification programs, diets, commercial weight-loss programs, exercise programs, medications, and surgery. Over-the-counter herbal preparations that some patients use to treat obesity have limited, if any, data documenting their efficacy or safety, and there are few regulatory requirements. Weight regain is expected in all patients, especially when treatment is discontinued. When making treatment decisions, clinicians should consider body fat distribution and individual health risks in addition to body mass index.

Background Obesity has been associated with daytime urinary incontinence (UI), likely due to increased intra-abdominal pressure. Objectives To assess incontinence symptoms in severely obese adolescents before and 3 years after bariatric surgery. Setting Tertiary care pediatric hospitals in the United States. Methods The Teen-Longitudinal Assessment of Bariatric Surgery is a prospective, multicenter study designed to evaluate efficacy and safety of bariatric surgery in adolescents. Patients Results A total of 242 patients (76% female) were evaluated at baseline. The mean age was 17.1 years at baseline, and 72% were of white race. The preoperative median body mass index was 50.5 kg/m2. At baseline, 18% of females and 7% of males reported UI. Prediction analysis at baseline indicated that females, white race, and increasing body mass index had greater odds for UI. UI prevalence in females and males decreased to 7% and 0%, respectively, at 6 months after surgery (P Conclusions In adolescents undergoing bariatric surgery, UI was more common in females than in males. Incontinence status significantly improved by 6 months and was durable to 3 years after surgery, suggesting that bariatric surgery favorably affects anatomic or physiologic mechanisms of bladder control in both males and females.

Severe obesity in adolescents is increasing and few effective treatments exist. Bariatric surgery is one option, but the extent to which surgery influences cardiovascular risk factors over time in youth is not clear. We hypothesized that Roux-en Y gastric bypass (RYGB) would be associated with sustained improvements in lipids over time (5 years).Youth who underwent RYGB from 2001 to 2007 were recruited for the Follow-up of Adolescent Bariatric Surgery-5+ (FABS-5+) in 2011-2014. Baseline body mass index (BMI) and lipids were abstracted from medical records. Follow-up data were obtained at a research visit. Analyses included paired t-tests to assess changes in BMI and lipids over time. General linear models were used to evaluate predictors of high-density lipoprotein (HDL) and non-HDL-cholesterol at follow-up. A non-operative group was recruited for comparison.Surgical participants (n=58) were a mean±s.d. age of 17±2 years at baseline and 25±2 years at long-term follow-up. Eighty-six percent were Caucasian and 64% were female. At long-term follow-up BMI decreased by 29% and all lipids (except total cholesterol) significantly improved (P0.01). Female sex was a significant predictor of non-HDL-cholesterol level at 1 year, while change in BMI from 1 year to long-term follow-up was a significant predictor of non-HDL-cholesterol and HDL-cholesterol during the same interval (P0.05). In the non-operative group, BMI increased by 8% and lipid parameters were unchanged.This is the longest and most complete follow-up of youth following RYGB. Weight loss maintenance over time was significantly associated with improvements in lipid profile over 5 years.

Summary Background Little is known about the long-term outcomes of bariatric surgery for severe adolescent obesity, raising questions about the durability of early responses to surgery. We aimed to analyse long-term (>5 years) outcomes of Roux-en-Y gastric bypass in a cohort of young adults who had undergone the operation during adolescence, in the Follow-up of Adolescent Bariatric Surgery at 5 Plus Years (FABS-5+) extension study. Methods A cohort of young people aged 13–21 years underwent Roux-en-Y gastric bypass for clinically severe obesity at a paediatric academic medical centre in the USA. We did a prospective follow-up analysis of these patients' outcomes 5–12 years after surgery. Outcomes assessed included BMI, comorbidities, micronutrient status, safety, and other risks. The FABS study is registered with ClinicalTrials.gov, number NCT00776776. Findings Between May, 2001, and February, 2007, 74 young people underwent Roux-en-Y gastric bypass in the FABS study. Of these, 58 individuals were eligible for the FABS-5+ study, could be located, and agreed to follow-up assessment. At baseline, the mean age of the cohort was 17·1 years (SD 1·7) and mean BMI was 58·5 kg/m 2 (10·5). At mean follow-up of 8·0 years (SD 1·6; range 5·4–12·5), the mean age of the cohort was 25·1 years (2·4) and mean BMI was 41·7 kg/m 2 (12·0; mean change in BMI −29·2% [13·7]). From baseline to long-term follow-up, significant declines were recorded in the prevalence of elevated blood pressure (27/57 [47%] vs 9/55 [16%]; p=0·001), dyslipidaemia (48/56 [86%] vs 21/55 [38%]; p vs 1/55 [2%]; p=0·03). At follow-up, 25 (46%) of 58 patients had mild anaemia (ie, not requiring intervention), 22 (45%) had hyperparathyroidism, and eight (16%) had low amounts of vitamin B12 (ie, below the normal cutpoint). Interpretation Roux-en-Y gastric bypass surgery resulted in substantial and durable bodyweight reduction and cardiometabolic benefits for young adults. Long-term health maintenance after Roux-en-Y gastric bypass should focus on adherence to dietary supplements and screening and management of micronutrient deficiencies. Funding Ethicon Endosurgery, National Center for Advancing Translational Sciences (US National Institutes of Health).

This study evaluates accuracy of self-reported weight in adolescent bariatric surgery patients. During follow-up visits, participants self-reported weight and had weight measured. The differences between self-reported and measured weights were analyzed from 60 participants. Participants were 70% (n = 42) female, 72% (n = 43) white, mean age of 20.8 years and a median body mass index of 36.6 kg/m2. At an average of 3.5 years following surgery, females underestimated weight (0.5 kg, range: −18.7 to 5.6 kg), while males overestimated (1.1 kg, range: −7.8 to 15.2 kg). Most (80%, n = 48) reported within 5 kg of measured weight. The majority of adolescents who previously underwent bariatric surgery reported reasonably accurate weights, but direction of misreporting varied by gender. Self-reported weights could be utilized when measured values are unavailable without markedly biasing the interpretation of outcomes.

The high prevalence of severe obesity and data demonstrating childhood obesity tracks into adulthood suggest that these adolescents are at high risk to develop obesity-related comorbidities—such as insulin resistance, type 2 diabetes, obstructive sleep apnea, polycystic ovarian syndrome, fatty liver disease, and cardiovascular disease—by young adulthood. Diet, exercise, and behavior modification have limited success in providing significant and durable weight loss, while pharmacological therapy is currently limited in the pediatric population. Metabolic/bariatric surgery (MBS) in the adolescent population is emerging as an effective long-term option, as it results in sustained weight loss and improves obesity-related comorbidities. This chapter will review common MBS procedures, the indications for use, and the effects of surgery on obesity, associated comorbidities, and insulin resistance in adolescents.

OBJECTIVES: To evaluate the longitudinal effects of metabolic and bariatric surgery (MBS) on the prevalence of musculoskeletal and lower extremity (LE) pain, physical function, and health-related quality of life. METHODS: The Teen Longitudinal Assessment of Bariatric Surgery study (NCT00474318) prospectively collected data on 242 adolescents undergoing MBS at 5 centers over a 3-year follow-up. Joint pain and physical function outcomes were assessed by using the Health Assessment Questionnaire Disability Index, Impact of Weight on Quality of Life – Kids, and the Short Form 36 Health Survey. Adolescents with Blount disease (n = 9) were excluded. RESULTS: Prevalent musculoskeletal and LE pain were reduced by 40% within 12 months and persisted over 3 years. Adjusted models revealed a 6% lower odds of having musculoskeletal pain (odds ratio = 0.94, 95% confidence interval: 0.92–0.99) and a 10% lower odds of having LE pain (odds ratio = 0.90, 95% confidence interval: 0.86–0.95) per 10% reduction of BMI. The prevalence of poor physical function (Health Assessment Questionnaire Disability Index score >0) declined from 49% to CONCLUSIONS: Joint pain, impaired physical function, and impaired health-related quality of life significantly improve after MBS. These benefits in patient-reported outcomes support the use of MBS in adolescents with severe obesity and musculoskeletal pain and suggest that MBS in adolescence may reverse and reduce multiple risk factors for future joint disease.

OBJECTIVE Quantifying risk for cardiovascular disease (CVD) events among adolescents is difficult owing to the long latent period between risk factor development and disease outcomes. This study examined the 30-year CVD event risk among adolescents with severe obesity treated with and without metabolic and bariatric surgery (MBS), compared with youths with moderate obesity, overweight, or normal weight. METHODS Cross-sectional and longitudinal comparisons of five frequency-matched (age and diabetes status) groups were performed: normal weight (n = 247), overweight (n = 54), obesity (n = 131), severe obesity without MBS (n = 302), and severe obesity undergoing MBS (n = 215). A 30-year CVD event score developed by the Framingham Heart Study was the primary outcome. Data are mean (SD) with differences between time points for MBS examined using linear mixed models. RESULTS Preoperatively, the likelihood of CVD events was higher among adolescents undergoing MBS (7.9% [6.7%]) compared with adolescents with severe obesity not referred for MBS (5.5% [4.0%]), obesity (3.9% [3.0%]), overweight (3.1% [2.4%]), and normal weight (1.8% [0.8%]; all P

Background Prolonged sitting time has been associated with numerous deleterious effects on humans. The degree to which sitting time influences weight loss outcomes of obesity treatments is poorly understood. Objectives The objective was to characterize and describe the amount of time spent sitting in an adolescent bariatric surgical and nonoperative cohort and evaluate its relationship with long-term change in body mass index (BMI). Setting Tertiary care hospital, United States. Methods From 2011 to 2014, a 1-time study visit was conducted to collect long-term outcomes of Roux-en-Y gastric bypass (RYGB; n=58) and nonoperative (n = 30) management of adolescents with severe obesity. The International Physical Activity Questionnaire was used to assess sitting time. Linear regression was used to evaluate the association between sitting time and percent BMI change from baseline. Results A total of 88 patients participated in the long-term follow-up visit at an average of 8 years from baseline. Percent BMI loss for participants who underwent RYGB (mean age at follow-up 25 yr) and for nonoperative (mean age at follow-up 23 yr) participants was −29% and +8%, respectively. The surgical group reported a median sitting time of 5.1 hr/d, while the nonoperative group reported a median sitting time of 7.0 hr/d (P = .11). Increasing sitting time was significantly associated with decreased percent BMI loss (P Conclusions RYGB was associated with long-term weight loss. Those participants with and without prior RYGB self-reported similar amounts of time spent sitting each day. Irrespective of whether participants had previously undergone surgery, lower levels of sitting time were found to be associated with greater BMI loss many years later.

Background/objectives Weight-related quality of life (WRQOL) and generic health-related quality of life (HRQOL) have been identified as important patient-reported outcomes for obesity treatment and outcome research. This study evaluated patterns of WRQOL and HRQOL outcomes for adolescents at 24-months post-bariatric surgery relative to a nonsurgical comparator sample of youth with severe obesity, and examined potential weight-based (e.g., BMI, weight dissatisfaction) and psychosocial predictors and correlates of these outcomes. Subjects/methods Multi-site data from 139 adolescents undergoing bariatric surgery (Mage = 16.9; 79.9% female, 66.2% White; MBody Mass Index [BMI] = 51.5 kg/m2) and 83 comparators (Mage = 16.1; 81.9 % female, 54.2% White; MBMI = 46.9 kg/m2) were collected at pre-surgery/baseline, 6-, 12-, and 24-months post-surgery/baseline with high participation rates across time points (>85%). Self-reports with standardized measures of WRQOL/HRQOL as well as predictors/covariates (e.g., weight dissatisfaction, social support, peer victimization, family dysfunction, loss of control eating, self-worth, and internalizing symptoms) were obtained. Growth curve models using structural equation modeling examined WRQOL/HRQOL over time and linear regressions examined predictors and correlates of WRQOL/HRQOL outcomes. Results Significant improvement in WRQOL and Physical HRQOL, particularly in the first postoperative year with a leveling off subsequently, was found for the surgical group relative to comparators, but with no significant Mental HRQOL change. At 24 months, the surgical group had significantly greater WRQOL/HRQOL across most subscales. Within the surgical group at 24 months, weight-based variables were significantly associated with WRQOL and Physical HRQOL, but not Mental HRQOL. Mental HRQOL was associated with greater internalizing symptoms and loss of control eating. Conclusions For adolescents undergoing bariatric surgery, most clinically meaningful changes in WRQOL and Physical HRQOL occurred early postoperatively, with weight-based variables as the primary drivers of 24-month levels. In contrast, expectations for Mental HRQOL improvement following surgery should be tempered, with 24-month levels significantly associated with psychosocial rather than weight-based correlates.

To compare DKD rates over 5-years of follow-up in two cohorts of severely obese adolescents with T2D undergoing medical vs. surgical interventions. A secondary analysis of data collected by the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and Treatment Options of type 2 diabetes in Adolescents and Youth (TODAY) studies was performed. Teen-LABS participants underwent bariatric surgery; TODAY participants were randomized to metformin alone or in combination with rosiglitazone or intensive lifestyle intervention, and insulin therapy was given when there was loss of glycemic control. TODAY participants (irrespective of treatment group assignment) were frequency matched to the 30 Teen-LABS participants with T2D by baseline age (13-18 years), ethnicity, sex, and baseline BMI (>35 kg/m2). Urinary albumin excretion (UAE), estimated glomerular filtration rate (eGFR) by creatinine and cystatin C equation, and prevalence of elevated UAE (≥ 30mg/g) and hyperfiltration (eGFR ≥ 135ml/min/1.73m2) were assessed. Thirty Teen-LABS participants with T2D (mean±SD age, 16.9±1.3 years; 70% female; 66% white; BMI 54.4 kg/m2) and 63 TODAY participants (15.3±1.3 years; 44% female; 71% white; BMI 40.5 kg/m2) were compared. During 5-years of follow-up, hyperfiltration decreased from 20% to 13% in Teen-LABS and increased from 5% to 37% in TODAY. Elevated UAE decreased from 27% to 5% in Teen-LABS and increased from 21% to 43% in TODAY. Adjusting for baseline age, sex, BMI and HbA1c, Teen-LABS participants had 15-fold lower odds of hyperfiltration (OR: 0.06, 95% CI 0.01-0.38) and 27-fold lower odds of elevated UAE (OR: 0.04, 95% 0.01-0.20) at 5-years of follow-up. Decreases in HbA1c and BMI showed the strongest associations with attenuation of hyperfiltration and elevated UAE, respectively. Compared with medical treatment, bariatric surgery of severely obese youth with T2D was associated with significantly lower odds of DKD over 5-years of follow-up. Disclosure P. Bjornstad: Advisory Panel; Self; Horizon, XORTX. Consultant; Self; Bayer US, Boehringer Ingelheim International GmbH, Bristol-Myers Squibb Company. K.S. Hughan: None. M.M. Kelsey: None. A. Shah: None. J.L. Lynch: Board Member; Self; American Academy of Pediatrics. Consultant; Self; Novo Nordisk Inc. Research Support; Self; Daiichi Sankyo Company, Limited, National Institutes of Health, Novo Nordisk Inc., Pediatric Diabetes Consortium. E. Nehus: Other Relationship; Self; Certara. M. Mitsnefes: None. T.M. Jenkins: None. P. Xu: None. C. Xie: None. T.H. Inge: Other Relationship; Self; Independent Medical Expert Consulting Services, Standard Bariatrics, UpToDate. K.J. Nadeau: None. Funding National Institutes of Health; National Institute of Diabetes and Digestive and Kidney Diseases

Bariatric surgery results in weight loss and health improvements in adults and adolescents. However, whether outcomes differ according to the age of the patient at the time of surgery is unclear.We evaluated the health effects of Roux-en-Y gastric bypass in a cohort of adolescents (161 patients enrolled from 2006 through 2012) and a cohort of adults (396 patients enrolled from 2006 through 2009). The two cohorts were participants in two related but independent studies. Linear mixed and Poisson mixed models were used to compare outcomes with regard to weight and coexisting conditions between the cohorts 5 years after surgery. The rates of death and subsequent abdominal operations and selected micronutrient levels (up to 2 years after surgery) were also compared between the cohorts.There was no significant difference in percent weight change between adolescents (-26%; 95% confidence interval [CI], -29 to -23) and adults (-29%; 95% CI, -31 to -27) 5 years after surgery (P = 0.08). After surgery, adolescents were significantly more likely than adults to have remission of type 2 diabetes (86% vs. 53%; risk ratio, 1.27; 95% CI, 1.03 to 1.57) and of hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88). Three adolescents (1.9%) and seven adults (1.8%) died in the 5 years after surgery. The rate of abdominal reoperations was significantly higher among adolescents than among adults (19 vs. 10 reoperations per 500 person-years, P = 0.003). More adolescents than adults had low ferritin levels (72 of 132 patients [48%] vs. 54 of 179 patients [29%], P = 0.004).Adolescents and adults who underwent gastric bypass had marked weight loss that was similar in magnitude 5 years after surgery. Adolescents had remission of diabetes and hypertension more often than adults. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; ClinicalTrials.gov number, NCT00474318.).

Introduction: Severe obesity is increasing in adolescents and is strongly associated with CVD risk. Weight loss surgery (WLS) effectively treats severe obesity and improves CVD-related lipid measures. Independent of weight loss (WL), physical activity (PA) also improves lipid-related CVD measures and is key to WL maintenance. Longitudinal PA behaviors post-WLS and the impact on CVD-related lipid measures in adolescents is unclear, in part because PA data are largely self-reported. Hypothesis: We assessed the hypothesis that PA improves plasma lipids beyond that associated with active WL in adolescents, post-WLS. Methods: We used objective StepWatch TM PA data from 108 participants of the Teen-LABS bariatric surgery study from baseline to 3 years post-WLS. Inclusion criteria included 1) at least 3 days (1 weekend day and 2 weekdays) of recorded StepWatch TM data, including 6 hours or more of continuously recorded data per day, 2) at least 10 steps per hour, 3) data at baseline and one or more postoperative time points (6 months, 1 year, 2 years and/or 3 years), and 4) matched laboratory and anthropometric data. Participants on lipid lowering therapy were excluded. The primary outcome of interest was absolute change in plasma lipids (TC, TG, HDL-C, LDL-C, and non-HDL-C), holding sex, race, time, % change in iliac waist circumference and procedure constant in a linear regression model with generalized estimating equations assuming an exchangeable working correlation structure. PROC TRAJ in SAS was used to determine the optimal number of group activity trajectories based on step counts at all visits. Results: Two activity groups were identified from PROC TRAJ : less and more active. When considering all mean daily step count data, the overall mean was 4241 (95% CI: 3970, 4513), the more active trajectory mean was 8494 (95% CI: 7596, 9392), and the less active trajectory mean was 3722 (95% CI: 3530, 3915), all well below the recommended 12,000 steps for age. Yet statistically and clinically significant differences by activity trajectory emerged. Greater absolute decreases in LDL-C and non-HDL-C (-15 mg/dL [95% CI: (-28, -2)], p =0.026 and -15 mg/ld. [95% CI: (-28, -1)], p = 0.035), respectively, were associated with activity, holding stated co-variables constant. Activity was also associated with greater percentages of TG, LDL-C and non-HDL-C values being within acceptable ranges, by 2011 NIHLB Integrated Criteria, at 2 years, (TG, 83% vs 70%; LDL-C, 100% vs 83%; non-HDL-C, 83% vs 70%). Conclusion: In conclusion, greater improvement in CVD-related lipid measures was associated with more activity 2 years post-WLS in adolescents, one year post-active WL. Of great interest, the predominant lipid measure influencing CVD risk post-WLS was not HDL-C, as reported in adults. Importantly, the PA-associated reductions of LDL-C, and non-HDL-C are more strongly associated with improved CVD risk than HDL-C increase.

Background Adolescent obesity is a significant factor in caring for patients with developmental delay (DD). Sleeve gastrectomy provides durable weight loss for teens with obesity but requires behavioral change that may not occur in patients with DD. Objectives To determine whether patients with DD had similar weight loss and adverse outcomes to patients without a diagnosis of DD after sleeve gastrectomy. Setting Academic children's hospital, United States. Methods Patients with DD undergoing sleeve gastrectomy were matched to adolescents without DD. Chart review was performed to determine etiology and severity of DD, weight, and body mass index (BMI) change in each group at 3, 6, 9, and 12 months postoperatively. One-year emergency department visits, readmissions, and reoperations were reviewed. Results Ten patients with DD and 44 patients without DD underwent sleeve gastrectomy between 2008 and 2017. Six patients with DD (60%) had mild cognitive impairment, 3 patients (30%) had moderate cognitive impairment, and 1 patient (10%) had severe cognitive impairment. Patients were 81.5% female, had a mean age of 17.3 years, and had a preoperative BMI of 48.6 kg/m2. Preoperative BMI was similar in the 2 groups, and percent BMI reduction at 1 year was −29% (95% confidence interval: −35 to −23) and −26% (95% confidence interval: −29 to −23) in groups with and without DD respectively (group by time interaction, P = .27). Conclusion Adolescents with DD experience similar 1-year weight loss and adverse events following sleeve gastrectomy to adolescents without DD. Understanding the long-term outcomes for this population is crucial to ensure appropriate implementation of surgical weight loss programs.

Objective: To test the hypothesis that Physical Activity (PA) improves cardiovascular disease (CVD)-related lipids beyond that associated with weight loss in adolescents with severe obesity, post-metabolic bariatric surgery (MBS). Methods: We used objective StepWatch™ PA data from 108 participants of the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study from baseline to 3 years post-MBS. Primary outcomes included absolute change in low density lipoprotein (LDL-C) and non-high density lipoprotein (non-HDL-C) from baseline. We adjusted for baseline measurement, visit, surgical procedure, and percent change in iliac waist circumference (IWC) or body mass index (BMI) from baseline in linear regression models using generalized estimating equations. PROC TRAJ in SAS generated optimal activity trajectories based on individual step count. Results: Despite low step counts and slow cadence, differences by activity trajectory were found. Greater absolute decreases in LDL-C and non-HDL-C (−15 mg/dL [95% CI: (−28, −2)], p =0.026 and −15 mg/dL [95% CI: (−28, −1)], p = 0.035), respectively, were associated with more activity (MA). MA was associated with greater resolution of triglycerides, LDL-C and non-HDL-C dyslipidemia and with greater weight loss 3 years post-MBS. Conclusion: More activity in adolescents was associated with improvements in CVD-related lipid measures and weight loss, post-MBS.