This document discusses bariatric surgery for morbidly obese adolescents. It outlines the risks of childhood obesity and increasing rates of bariatric surgery in adolescents. The document presents a case study of an 18-year-old female considering bariatric surgery and undergoing evaluation and counseling. While she meets criteria for surgery, concerns about her ability to adhere to dietary demands post-operation require ongoing monitoring and focus on nutrition and activity first. More research is still needed on long-term impacts of bariatric surgery in adolescents.

1. Morbid Obesity and the Implications of
Bariatric Surgery in the Adolescent Population
Children’s National Medical Center Case Study
Amy Bortnick
1/22/2013
S

2. Presentation Outline
S Childhood Obesity and the indication for Bariatric Surgery
S Bariatric Surgery in adolescents
S Case Study of nutrition counseling for an 18 year old female
in the IDEAL Outpatient Clinic considering Bariatric
Surgery
S Clinic Analysis of the patient and her appropriateness for
Bariatric Surgery
S Conclusion and questions

3. Childhood Obesity
S The Percent overweight children in the United States has almost
tripled in the past 30 years.
S 15.5% of children estimated to be obese.
S 50-77% of obese children grow up to be obese adults.
S Obesity in both adolescents and adults greatly increases the risk of
developing chronic life threatening diseases and can lead to
premature death.
S Overweight children have a reduced quality of life compared with
non-overweight children (1).

4. Bariatric Surgery in
Adolescence
S For severely overweight children and adolescents who have
tried and failed to lose weight for longer than 6 months
through conventional weight loss methods, bariatric surgery
may provide a practical alternative for achieving a healthy
weight (1).
S From 1996-2003, according to recent national trends, the
US has seen a great increase in bariatric surgeries performed
in adolescents.
S There is very little data documenting long term effects of
bariatric surgery in adolescents.

5. Bariatric Surgery in
Adolescence
S Inclusion Criteria
S >14 years of age
S Tanner development stage 4 or greater
S BMI >40 w/ obesity related comorbidity or BMI> 50.
S Documented history of obesity for 3 years
S Consent
S Confirmation by psychologist or psychiatrist

6. Choice of Bariatric Surgery
Procedure
S Laparoscopic Roux-en-Y Gastric Bypass (LGB)
S Laparoscopic Adjustable gastric band (LAGB)
S Laparoscopic Sleeve Gastrectomy (LSG)
.

7. Source:http://www.nationalbariatriclink.org/imgs/surgery_types.jpg

8. Critical Labs for Bariatric
Candidates
S fasting glucose
S hemoglobin A1c
S liver function
S lipid profile
S complete blood counts
S thyroid function
S Pregnancy
S micronutrient deficiencies.
S Polysomograpy ( patients with sleep apnea)
S Bone age assessment (younger patients)

9. Potential Complications
S Early Complications: pulmonary embolism, wound
infections, stomal stenosis, dehydration and marginal ulcers
S Late Complications: small bowl obstruction, incisional
hernias, and late weight regain, sub optimal vitamin intake and
micronutrient deficiencies.
S Gastric Bypass: intestinal leakage, thromboembolic disease, small
bowl obstruction, incisional hernia, protein calorie
malnutrition, micronutrient deficiencies.
S Adjustable Gastric Band: port mal absorption or mal
function, tubing leaks, band slippage, infection, band erosion into
stomach or esophagus

10. Pre-Operative Bariatric Diet
S Suggested full liquid diet of protein rich supplements for
two weeks
S Been show to result in greater weight loss after surgery
S Shrinks the liver decreasing surgery time
S Displays ability to adhere to diet and lifestyle changes

11. Post Operative Bariatric Diet
S First 2-3 weeks: of a liquid diet.
S Mainly supplements high in protein and low in fat and
carbohydrates
S After: 4-6 weeks Pureed diet
S After 6 weeks: Soft regular foods
S Vitamin and Mineral Supplements: 2 multivitamin’s
daily, calcium, vitamin B12, and additional
vitamins/minerals as needed

12. Case study
S

13. Subjective
S XX is an 18 year old female presenting to the IDEAL Clinic for
with morbid obesity her second follow up visit accompanied by
her mother. She is currently considering bariatric surgery for
weight loss. XX was pleasant and interactive during her last visit.
She appears morbidly obese with a buffalo hump, acnathosis
nigricans, and abnormal hirstuism on present the face.

14. Diet Prior to Admission
S XX admits to trying several diets in the past. Prior to
admission she was following a diet that involved having 8
very small-portioned meals a day. Additionally, on 7/4/12
patient became a vegetarian. XX has never seen a dietitian
in the past.

15. PES Statements
S Overweight/obesity (N.C-3.3) related to excessive energy
intake, and food and knowledge related deficit as evidenced by
BMI > 95%, inability to apply some nutrition related
recommendations.
S Physical Inactivity (NB-2.1) related to lack of value for
behavior change or competing values, as evidenced by obesity
>97th percentile, infrequent/ low duration exercise, large
amounts of sedentary activities e.g. T.V.
watching, computer, and phone use and reports of getting tired
easily.
S Not Ready for Diet/ Lifestyle Change (NB-1.3) related to
lack of self efficacy for making change or demoralization from
previous failures at change as evidenced by lack of eye
contact, lack of focus, and lack of efficacy to make change or
to overcome barriers to change

16. Anthropometrics
Anthropometrics Growth Evaluation
S Height: 5’5” S Weight trends: 11/27: 158.8
kg, 12/18: 156.5 kg, 1/22: 156.6
S Weight: 345 lbs.
S BMI trends: 11/27 56.93
S BMI: 99.5% (>97%), 12/18: 55.38
(>97%), 1/22: 56.28 (>97%).
S BMI percentile: >97th
S Height trends:
11/27:167cm, 12/18: 168.1
cm, 1/22: 166.8 cm

17. Notable Labs
S 12/44
S HgA1c: 5.8
S Low HDL: 26
S HOMA-IR: 17.9 –elevated, insulin resistant, on
metformin
S Low Vitamin D: 9.5 (deficient) – on vitamin D
supplements
S ALT 37
Labs are significant for: impaired fasting
glucose, hypertriglyceridemia, low HDL, mild elevation of
ALT, and elevated HOMA-IR

18. Assessment
S Estimated Energy Needs
S Kcals/kg: 31-43/kg ADBW/day: 2223-2438 kcal
S Grams protein/ kg: 0.8/kcal/kg = 125.8 g protein
S mL/day to meet maintenance fluid needs: 20/kg/day 3132 ml

19. Plan/ Goals
S Physical Activity Goals
S Move at least 10 minutes 3/day a week
(Tuesday, Wednesday, Saturday).
S Nutrition Goals
S Pre-op diet for one week (bariatric guide, RD email address
provided)
S Use meal replacement instead of skipping breakfast

20. XX and Bariatric Surgery
S BMI of 56.28 meets criteria
S 18 YO meets maturation and bone growth
S IDEAL clinic provides multi-disciplinary support (patient is seeing a
physician, psychiatrist and RD)
S Patient is currently trying to lose weight through nutrition and
physical activity without significant success
S Mother displays evidence of a supportive family member, respecting
the patient’s decision.
S However patient shows concern for adherence to dietary demands of
bariatric surgery
S Patient and mother have been receiving on going education on
bariatric surgery

21. Case Conclusion
S It is too early to tell if XX will be appropriate for weight loss
surgery. Her personal desire for the surgery as well her
efficacy and ability to understand and adhere to dietary
restrictions will be critical. However, her current BMI status
places her a substantial risk for chronic life threatening
conditions, she has documented her weight has interfered
with her quality of life. For now the focus is physical activity
a healthful diet and the ability to follow a pre-operative diet.

22. Discussion
S More research on bariatric surgery in adolescence is needed to
determine long term impacts on overall health and well being.
S Israel Study: Comparing inpatient intervention with bariatric
surgery
S Netherlands Study: Interventional study comparing laparoscopic
adjustable band surgery and behavioral therapy
S Results of such studies won’t be forth coming for several years

23. Questions?
Source: http://adiaryofamom.files.wordpress.com/2011/01/ist2_5853965-question-mark.jpg

24. References
1. Inge T et al. Bariatric Surgery for Severely Overweight Adolescents:
Concerns and Recommendations. Pediatrics Vol 114 No. 1 July 2004
217-223.
2. Ingelfinger, Julie. Bariatric Surgery in Adolescents. N Engl Med
365;15
3. Wilson S. Tsai, MD; Thomas H. Inge, MD, PhD; Randall S.
Burd, MD, PhD. “Baratric Surgery in Adolescents- Recent National
Trends in Use and In-Hospital outcome”. American College of
Medicine.
4. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting
obesity in young adulthood from childhood and parental obesity. N
Engl J Med. 1997;25:869-873. Reousce:
http://www.nejm.org/doi/full/10.1056/NEJM199709253371301#t=arti
cleTop
5. University of Michigan Health System: Adult Bariatric Surgery
Program.
http://www.med.umich.edu/bariatricsurgery/about/bypass/postop.shtm
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