Addressing Disparities and Underutilization of Adolescent Metabolic and Bariatric Surgery

In response to the unremitting rise of childhood obesity in the United States,1,2 a growing body of literature supports the utilization of metabolic and bariatric surgery (MBS) for the treatment of severe obesity (body mass index [BMI] ≥120% of the 95th percentile or BMI ≥35 kg/m2) in the pediatric population.3–5 In addition to offering important insight regarding the physiologic and psychosocial phenotypes observed among individuals presenting for MBS, numerous studies to date have shown improvement and/or complete resolution of most comorbid conditions with significant improvements in quality of life. Despite favorable results and a recent rise in procedural prevalence, ongoing controversy, including professional bias related to the treatment of childhood obesity and misinformation among the general public, access to care remains limited compared with the corresponding adult population.6–10 In a series of recently published policy statements and clinical practice guidelines, the American Academy of Pediatrics (AAP) and the American Society of Metabolic and Bariatric Surgery have recommended approaches to address disparities in the use of MBS in the pediatric population and have unambiguously stated that pediatric health care providers should refer eligible patients to comprehensive multidisciplinary pediatric MBS centers.2–4In this issue of Pediatrics, Shapiro et al describe the proportion of adolescents receiving care in a large multicenter health care system in Southern California that met clinical criteria to receive MBS.11 Among the 603 041 adolescents included in the analysis, 9.3% (n = 56 082) were classified as having class 2 obesity or higher (5.4% class 2 and 3.9% class 3), thus satisfying anthropomorphic qualifications for bariatric surgical eligibility. Interestingly, the initial exclusion of 10 individuals from the analysis cohort because of a history of having had a bariatric procedure, representing a procedural prevalence of only 0.002%, stands out as a striking reminder of the relative infrequency of MBS in the pediatric population. Additionally, the low frequency of MBS highlights the disparity of access to care compared with the procedural prevalence (1%) often cited in the adult population.12,13Although the current study offers important insights into patient eligibility and associated availability of MBS, it also highlights important limitations associated with retrospective analysis of large administrative data sets that should prompt the need for additional prospective and uniform multi-institutional studies. For example, although the reported prevalence of obesity with the study cohort (22.2%) appears to align with previous reports, including 10% being considered class 2 obesity or higher, the associated prevalence of related comorbid diseases across the entirety of the cohort may be a gross underestimation in that the authors found only 3.2% had gastroesophageal reflux, 0.5% nonalcoholic fatty liver disease, 0.4% Blount disease, and 0.4% type 2 diabetes. Although it is acknowledged that direct comparison of the reported disease prevalence with prospective interventional studies related to adolescent MBS is difficult, these low percentages differ from comorbid illnesses observed among the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABORATORIES) study cohort, the largest prospective observation study of adolescents undergoing MBS. For example, Teen-LABS reported significantly higher rates of obesity-related illnesses, including obstructive sleep apnea (57%), hypertension (45%), nonalcoholic fatty liver disease (37%), type 2 diabetes (14%), and Blount disease (4%), to name a few.14Reading between the lines, the current report not only shows the underuse of MBS to treat severe childhood obesity but serves to highlight the potential lack of evaluation for underlying comorbidities within the affected pediatric population. Furthermore, the highly heterogeneous composition of the study cohort (ie, >65% ethnic minorities) serves to support recent data demonstrating disparities in care related to race, ethnicity, and socioeconomic status of youth undergoing MBS.15,16Although the root causes responsible for a failure to recognize and treat severe obesity are multifactorial, including systemic biases pertaining to the nature and treatment of obesity as a disease and the inadequate access to pediatric obesity–directed multidisciplinary care; the outcome is leaving the current generation of children extremely vulnerable to the cumulative impact of untreated disease. As clearly demonstrated in recent large longitudinal studies, untreated childhood obesity will undoubtedly lead to higher rates of cardiometabolic disease risk and related rates of early mortality.17,18In addition to continued efforts to expand our overarching knowledge related to health outcomes after MBS in the pediatric population, robust efforts must be undertaken to address the systemic shortcomings resulting in significant disparities of care on an individual, organizational, and governmental level as outlined by the AAP. Pediatricians need to heed the AAP recommendations for screening and treatment of comorbidities and obesity simultaneously. Open discussion of MBS and its benefits should start at the primary care level. More centers using advanced therapies for pediatric obesity must be funded by insurance and Centers for Medicare & Medicaid Services. Systemic bias with regard to pediatric obesity and its treatment must be counteracted with better education about the genetic nature, the aggressive progression, and the effective treatments for pediatric obesity. In most pediatric patients meeting BMI eligibility criteria for MBS, surgery will be delayed by limited access to MBS programs, insurance denials, or simply never being referred. The opportunity for a health system like that studied here is immense: as an integrated care system, the institution of standard screening for comorbidities based on BMI and standard referrals to advanced therapies such as MBS could become a reality.