In the first randomized controlled trial to pit bariatric surgery against lifestyle changes for the management of obesity in teenagers, laparoscopic adjustable gastric banding resulted in significantly better outcomes than diet and exercise (JAMA 2010;303:519-526).

Paul O’Brien, MD, director of the Centre for Obesity Research and Education, Monash University Medical School, The Alfred Hospital, in Melbourne, Australia, and colleagues randomized 50 individuals aged 14 to 18 years to receive either a gastric band or supervised lifestyle intervention with 24 months of follow-up.

Of 24 gastric band patients and 18 lifestyle intervention patients who completed the study, 21 (84%) and three (12%) patients, respectively, lost more than 50% of their excess weight. The mean weight loss in the gastric band group was 76.3 lb (78% of excess weight) and 6.6 lb (13% of excess weight) in the lifestyle group. Patients with metabolic syndrome who underwent gastric banding also experienced a reversal of that comorbidity.

“What you should always do in medicine is consider the simplest and safest approach, and if that doesn’t work, move on to the next one. This study compared what we regarded as the best possible lifestyle program versus the safest and simplest surgical option,” said Dr. O’Brien, who is also the national medical director for the American Institute of Gastric Banding, in Dallas.

Although some bariatric programs will operate on children younger than 14 years old, Dr. O’Brien’s general program for adolescent obesity—with or without surgery—does not accept younger patients. “They have to be essentially fully grown, and they have to have a level of mental maturity that we feel they understand what they’re getting themselves in for,” he said.

The teenagers need to show that they have tried diligently for at least two years to reduce their weight by other means, and they need to be willing to form a partnership with their weight loss team. “Gastric banding is a very different procedure from other procedures because it’s really the person who has the band working with us to get the best results,” Dr. O’Brien said. “That requires them to follow rules, it requires us to follow rules, and that partnership is critical.”

The Center for Adolescent Bariatric Surgery at NewYork-Presbyterian Morgan Stanley Children’s Hospital, in New York City, directed by Jeffrey L. Zitsman, MD, recently performed its 100th laparoscopic adjustable gastric banding procedure on an adolescent. Similar to Dr. O’Brien’s program and most others, patients must be at least 14 years old, and must have a body mass index (BMI) of at least 40 kg/m² or 35 kg/m² with comorbidities—the same parameters used for obese adults.

“They also have to have been in a screening program for a minimum of six months and have an absence of any serious psychological or behavioral problems,” said Dr. Zitsman.

The rigorous screening for Dr. Zitsman’s program begins with a phone interview to determine if the adolescent meets the basic criteria for BMI and associated medical problems. If so, he or she then meets with Dr. Zitsman and his nurse practitioner. Patients under 18 must sign a protocol to enroll in the program, and are then scheduled to meet with the medical director, the psychiatric team and a nutritionist.

“They’ll be followed for a period of not less than three months—usually six months—by the nutritionist and nurse practitioner looking for attempts to make dietary changes and increase exercise, overall compliance and a willingness to make the changes necessary to have a good outcome in laparoscopic banding,” Dr. Zitsman said.

The greatest concern that Dr. O’Brien’s program faces in operating on teenagers is establishing whether or not a young person is truly mature enough to make an autonomous choice about surgery. “We talk with them separately from their parents; we really want to get the feeling that they know what it’s about,” Dr. O’Brien said. “But can they make a major health care decision at that age? That’s a worry, and I don’t think there’s any way of resolving that,” he said. The advantage of gastric banding over other bariatric procedures is that it is reversible, he noted.

Compliance can be a problem in a population struggling to fit in with peers and also feeling a bit immortal, as young people often do. A handful of the teenagers who received bands in Dr. O’Brien’s trial needed revisional procedures to address enlargement of the stomach above the band.

“The critical thing with the band is to eat slowly and small amounts of food. We didn’t really perceive this until the trial was going, but kids think they’re risk-free. They want to go out with their mates and have a pizza or something, and this creates stress on the system,” Dr. O’Brien said. The problems were addressed successfully, however, and the ones who underwent revisions actually lost slightly more weight than the rest of the gastric band group.

In addition to concerns about maturity and compliance, follow-up can be challenging in teenagers who are more likely to relocate—for school and other reasons—than adults. “We don’t necessarily have as continuous contact as might be helpful for that person to get the best outcome,” Dr. Zitsman said.

His team follows program participants monthly for the first six to nine months, making adjustments to the band as needed in the second month. “If they’re stable and losing weight at a healthy and reasonable rate, the visits become less frequent,” Dr. Zitsman said. Their protocol calls for five years of follow-up. If the patient moves, Dr. Zitsman’s team will attempt to find a geographically accessible program and help the patient transition into it.

In addition to their struggle with weight, obese teenagers often have comorbidities, and at a rate higher than experts expect. “We are surprised to find how common these problems are in adolescents. We think they’ll be at risk for diabetes and sleep apnea but that [it] will come later,” Dr. O’Brien said. “But we found that about 40% of the kids in the study had metabolic syndrome.”

Teenagers, like adults, tend to experience a rapid reversal or improvement in comorbidities after surgery. Metabolic syndrome resolved rapidly in Dr. O’Brien’s gastric band group. “It doesn’t take a lot of weight loss to make a difference, but they need a substantial amount of weight loss to protect them long-term,” he said.

Along with improvements in physical health, teenagers who succeed with bariatric surgery experience big improvements in their self-esteem. “A lot of these kids have really felt quite isolated and socially outside of peer groups. Losing a bit of weight allows them to dress like their friends and be more comfortable in crowds,” Dr. Zitsman said. “It’s pretty dramatic.”

Despite the likelihood that obese teenagers will become obese adults, with the associated potential personal and social costs, bariatric surgery for adolescents has a way to go before it is widely accepted as a legitimate treatment, even by members of the medical community. A recent survey of primary care physicians revealed that 48% would never refer an obese teenager for bariatric surgery, and 46% considered 18 as the minimum age for referral (Obes Surg 2010; April 18 [Epub ahead of print]).

Before bariatric surgery gains greater acceptance, society, physicians and payers will need to recognize the true severity and cost of obesity, Dr. O’Brien said. “Obesity really is a malicious disease because it causes so many other diseases, and it costs the health care system a lot of money.

“Clearly, the best solution is simply prevention, but we don’t know how to do that yet,” he said. “If you have 80 million people in the United States with obesity, and it’s costing you money, you have to say, ‘what’s the best, most effective, cheapest way of getting a good result?’ We know we can’t do it with lifestyle. We know we can’t do it with drug therapy at this point. So you go to the next step, which is gastric banding.”

Further trials reproducing the results that Dr. O’Brien’s team achieved will probably help. “I think there needs to be a body of literature, which many of us are trying to produce, to demonstrate that bariatric surgery in many forms is safe and effective,” Dr. Zitsman said. “Over the long term, it saves health care dollars and produces people who are more effective in society. I think the insurance companies and health care plans will probably get in line to support surgery for carefully screened individuals for whom it is deemed medically appropriate.”