Bariatric Surgery and Other AAP Recommendations for Children With Obesity

Kenny Lin, MD, MPH
Posted on November 13, 2023

A recent article in The New York Times Magazine profiled a 16-year-old girl with severe obesity who underwent bariatric surgery at a children’s hospital in Texas. In January 2023, the American Academy of Pediatrics (AAP) published a clinical practice guideline that suggested referring all children 13 years and older with a body mass index (BMI) greater than or equal to 120% of the 95th percentile for age and sex for bariatric surgery evaluations. Although only a tiny fraction of eligible U.S. adolescents undergo surgery, the number of procedures increased from fewer than 800 in 2016 to 1,349 in 2021. (In comparison, more than 200,000 adults had bariatric surgery in 2021.)

In an editorial in the October issue of AFP, Dr. Kathryn McKenna and I analyzed the quality and quantity of evidence supporting the AAP guideline recommendations. Notably, few studies have evaluated short-term outcomes of the most commonly performed metabolic surgery procedures in adolescents, and long-term outcomes are unknown. Similarly, although semaglutide (Wegovy) was approved by the U.S. Food and Drug Administration in December 2022 for treating obesity in adolescents, we pointed out that “only 5 out of 27 randomized controlled trials [of pharmacotherapy] included results beyond six months.”

The desire of family physicians and pediatricians to make an impact on the obesity epidemic, which affects 22% of adolescents, is understandable. To date, the results of nonpharmacologic, nonsurgical weight interventions recommended by the U.S. Preventive Services Task Force have been mostly disappointing. A 2017 Cochrane review of 70 randomized controlled trials concluded that diet, physical activity, and behavioral interventions in elementary school–aged children (6 to 11 years of age) have modest short-term effects on weight and BMI compared with no treatment or usual care. A more recent Cochrane review confirmed this finding but also found low-quality evidence that these interventions did not change BMI in children 13 years and older.

Could intensive weight management of children with obesity cause unintended harms, such as increasing rates of disordered eating? This possibility hasn’t been well studied, but anecdotes suggest it is a real concern. A STAT News story about the AAP guideline interviewed an eating disorder specialist at Boston Children’s Hospital who “has seen weight fluctuations evolve into serious and possibly life-threatening eating disorders,” and the New York Times Magazine article related the story of another patient who developed life-threatening anorexia after she was referred to a weight management program by her pediatrician. Although the AAP guideline authors discussed several expert-recommended approaches to mitigate this risk (use nonstigmatizing language, eliminate blame, and focus on improving health status rather than weight or BMI), these approaches are implemented inconsistently in primary care practice, where adults with obesity often experience weight stigma and bias.