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Background: Up to 50% of adolescents who undergo metabolic and bariatric surgery (MBS) have obesity 3 years post-MBS, placing them at continued risk for the consequences of obesity., Objectives: We conducted an open-label, 16-week pilot study of liraglutide in adolescents with obesity after sleeve gastrectomy (SG) to investigate liraglutide effects on weight and body mass index (BMI) post-SG., Methods: Adolescents aged 12-20.99 years with obesity and a history of SG ≥1 year prior were enrolled. Liraglutide was initiated at 0.6 mg/day, escalated weekly to a maximum of 3 mg/day, with treatment duration 16 weeks. Fasting laboratory assessments and an oral glucose tolerance test were performed at baseline and end-treatment., Results: A total of 43 participants were screened, 34 initiated liraglutide (baseline BMI 41.2 ± 7.7 kg/m 2 ), and 31 (91%) attended the end-treatment visit. BMI decreased by 4.3% (p < 0.001) with liraglutide. Adolescents who had poor initial response to SG (<20% BMI reduction at BMI nadir) had less weight loss with liraglutide. Fasting glucose and haemoglobin A1C concentrations significantly decreased. There were no serious treatment-emergent adverse events reported., Conclusions: Liraglutide treatment was feasible and associated with a BMI reduction of 4.3% in adolescents who had previously undergone SG, quantitatively similar to results obtained in adolescents with obesity who have not undergone MBS., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA.)

Objective: The American Academy of Pediatrics (AAP) recently released clinical guidelines for the treatment of childhood obesity, including surgery being appropriate for children 13 years of age and older. The use of this age cut-off was due to a lack of data for children younger than 13. To address this knowledge gap, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried to compare outcomes in preteens to teens after bariatric surgery hypothesizing that there would be no difference in outcomes between the two groups., Methods: Patients from the MSAQIP database (2016-2021) were identified and divided into groups <13 years and 13-18 years and were matched using propensity scores based on race, sex, and preoperative BMI. Outcomes were compared including change in BMI, complication rates, 30-day readmission or reoperation, and mortality. Additionally, the centers responsible for the bulk of the preteen patient entries queried their center-specific databases to evaluate weight loss over time., Results: A total of 4755 patients were identified, 47 of whom were <13 years of age. Preteens had similar sex distribution (66% vs. 75% female), were more likely to be Black (27.7% vs. 18.3%) or Hispanic (21.3% vs. 7.6%) race, and weighed less (274 ± 58 vs. 293 ± 85 lb, p = 0.01), but they had similar BMI (46.9 ± 7 vs. 47 ± 13 kg/m 2 ) as their teen counterparts. Preteens were more likely to suffer from sleep apnea (34% vs. 19%, p < 0.01) and insulin-dependent type 2 diabetes (10.6% vs. 1.8%, p < 0.01). There were no complications in the preteens compared to teens (0% vs. 0.5%), and they did not undergo any unplanned readmissions (0% vs. 2.9%) or reoperations (0% vs. 0.8%) within 30 days of surgery. There were also no mortalities reported in preteens (0% vs. 0.1%). The risk-adjusted decrease in BMI between preteens and teens was also comparable at 30 days (4.2 [95% CI: 3.0-5.4] vs. 4.6 [95% CI: 4.4-4.7], p = 0.6). Decrease in BMI in preteens was 7 ± 3 kg/m 2 at 3 months and 9 ± 4 kg/m 2 at 12 months after surgery, which represented a percentage BMI change of 16 ± 7 and 20 ± 8, respectively., Conclusions: This study demonstrates that bariatric surgery in preteens is safe and efficacious when performed at specialized centers, and that age criteria may not be required. The AAP and others are encouraged to include age cut-offs in their guidelines for children with obesity and bariatric surgery only when data are available to support their inclusion., (© 2023 The Obesity Society.)

Obesity affects 42.4% of adults and 19.3% of children in the United States. Childhood obesity drives many comorbidities including hypertension, fatty liver disease, and type 2 diabetes mellitus. Prior research suggests that aberrant compositional development of the gut microbiome, with low-grade inflammation, precedes being overweight. Therefore, childhood may provide opportunities for interventions that shape the microbiome to mitigate obesity-related diseases. Children with obesity have gut microbiota compositional and functional differences, including increased proinflammatory bacterial taxa, compared to lean controls. Restoration of the gut microbiota to a healthy state may ameliorate conditions associated with obesity and help maintain a healthy weight. Pediatric bariatric (weight-loss) surgery is an effective treatment for childhood obesity; however, there is limited research into the role of the gut microbiome after weight-loss surgery in children. This review will discuss the magnitude of childhood obesity, the importance of the developing microbiome in establishing metabolic pathways, interventions such as bariatric surgery that may modulate the gut microbiome, and future directions for the potential development of microbiome-based therapeutics to treat obesity.

Background: Adolescent obesity is multifactorial, but parental history is the most significant risk factor. Laparoscopic sleeve gastrectomy (LSG) is part of the multidisciplinary approach to adolescent weight loss., Objective: We aimed to evaluate the effects of parental history of bariatric surgery, as well as age at time of operation, on adolescents who underwent LSG at our institution., Methods: We performed a retrospective review of patients, aged 10 to 19 years, who underwent LSG from January 2010 to December 2019. The adolescent bariatric surgical dataset maintained by our group was used to obtain patient demographics, weight, body mass index (BMI), and parental history of bariatric surgery., Results: Among 328 patients, 76 (23.2%) had parents who had previously undergone bariatric surgery. These patients were significantly heavier by weight (p = 0.012) at the time of operation but had no difference in postoperative weight loss. When all patients were compared by age at operation (&lt; 16 years, n = 102, ≥ 16 years, n = 226), there were few differences in outcomes., Conclusions: LSG is an effective approach to surgical weight loss in adolescents. Patient age should not be a barrier to weight loss surgery, especially among patients with a parental history of obesity. By intervening at a younger age, the metabolic sequelae of obesity may be reduced., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose of Review: Approximately 20% of children and adolescents in the USA suffer from obesity with significant long-term effects well into adulthood. Metabolic and bariatric surgery, although well adopted in the adult population, has been underutilized in children., Recent Findings: There are four categories of weight loss devices regulated by the Food and Drug Administration for use in adults - gastric bands, gastric balloon systems, electrical stimulation systems, and gastric emptying systems. In this commentary we discuss the role these devices may play in increasing the adoption of procedural intervention for severe obesity in children and adolescents., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Neurocognitive differences in pediatric obesity may be underpinned by cortical structural alterations. Differences in cortical thickness associated with severe obesity were examined, and preliminary evidence was sought for changes following vertical sleeve gastrectomy (VSG)., Methods: A total of 18 adolescents with severe obesity (OB) and 17 without obesity (nOB), aged 14 to 21, underwent T1-weighted structural magnetic resonance imaging. A subset was scanned twice 5 months apart to compare cortical thickness following VSG (n = 6) with two control groups: wait-listed (n = 9) and nOB (n = 12)., Results: At baseline, OB had a thinner cortex than nOB in motor and superior parietal cortices. At follow-up, VSG adolescents lost weight, the wait-listed group gained weight, and nOB did not change. Group × Time interactions indicated that VSG had cortical thinning in orbitofrontal, primary sensorimotor, superior, and middle temporal cortices and thickening in lingual, fusiform, and lateral occipital cortices. Wait-listed and nOB groups largely did not change., Conclusions: Severe obesity is associated with a thinner cortex in motor and attentional function-associated regions. VSG resulted in cortical thinning in reward valuation, sensory, and perceptual regions and thickening in visual regions. Surgery-related changes in regions distinct from those associated with obesity suggest compensation, rather than normalization. These results provide preliminary evidence supporting structural neural alterations following sleeve gastrectomy., (© 2021 The Obesity Society.)

Introduction: Severe obesity predisposes youth to a higher risk of venous thromboembolism (VTE). This study evaluates a BMI-stratified prophylactic dosing regimen of enoxaparin in adolescents with severe obesity undergoing surgery., Methods: Adolescents aged 12-20 years received prophylactic enoxaparin at 40 mg SC (for a BMI < 50 kg/m 2 ) and 60 mg SC (for a BMI ≥ 50 kg/m 2 ) every 12 h until discharge. Blood samples were drawn at pre-dose, 1, 2, 4, 6, and 12 h. Plasma Anti-Factor Xa (Anti-FXa) activity was used as a surrogate marker for enoxaparin pharmacokinetics., Results: Ten female and two male obese adolescents (age range 14-19 years) had a mean BMI of 49.9 kg/m 2 (38.4-58 kg/m 2 ). Four patients had a BMI of less than 50 kg/m 2 and received 40 mg enoxaparin, resulting in a mean dosage of 0.352 ± 0.070 mg/kg body weight. Eight patients were dosed with 60 mg enoxaparin every 12 h, resulting in a mean dosage of 0.395 ± 0.028 mg/kg. Peak plasma anti-FXa activity (C max ) ranged from 0.14 to 0.30 IU/mL, median C max was 0.205 IU/mL. Median T max was 5.67 h (range 3.78-7.52 h). Median AUC i was 1.00 h IU/mL (range 0.42-1.67 h IU/mL). Ten out of 12 patients (83%) reached the primary endpoint with anti-FXa activity in the range for VTE prevention (0.1-0.3 IU/mL)., Conclusions: Our dosing scheme of 40 mg vs. 60 mg enoxaparin stratified according to BMI proved to be effective in reaching prophylactic anti-FXa activity in 83% of adolescent patients.

Background: Macrophage cholesterol efflux capacity has been identified as a predictor for cardiovascular disease. We assessed the relationship between adipocyte-derived extracellular vesicle microRNAs and macrophage cholesterol efflux capacity., Methods: We assessed an adolescent cohort (n = 93, Age, median (IQR) = 17 (3) year, Female = 71, Male = 22) throughout the BMI continuum (BMI = 45.2 (13.2) kg/m 2 ) for: (1) cholesterol efflux capacity and lipoprotein profiles; (2) adipocyte-derived extracellular vesicle microRNAs in serum; (3) the role of visceral adipose tissue extracellular vesicle in regulation of cholesterol efflux and cholesterol efflux gene expression in THP-1 macrophages in vitro., Results: Efflux capacity was significantly associated with HDL (r = 0.30, p = 0.01) and LDL (r = 0.33, p = 0.005) particle size. Multivariate-analysis identified six microRNAs associated (p < 0.05) with cholesterol efflux capacity: miR-3129-5p (Beta = 0.695), miR-20b (0.430), miR9-5p (0.111), miR-320d (- 0.190), miR301a-5p (0.042), miR-155-5p (0.004). In response to increasing concentrations (1 μg/mL vs. 3 μg/mL) of VAT extracellular vesicle, cholesterol efflux (66% ± 10% vs. 49% ± 2%; p < 0.01) and expression of ABCA1 (FC = 1.9 ± 0.8 vs 0.5 ± 0.2; p < 0.001), CD36 (0.7 ± 0.4 vs. 2.1 ± 0.8, p = 0.02), CYP27A1 (1.4 ± 0.4 vs. 0.9 ± 0.5; p < 0.05), and LXRA (1.8 ± 1.1 vs. 0.5 ± 0.2; p < 0.05) was altered in THP-1 cells in vitro., Conclusion: Adipocyte-derived extracellular vesicle microRNAs may, in part, be involved macrophage cholesterol efflux regulation.

Background: Preoperative exercise is associated with weight loss following bariatric surgery in adults, but this relationship in adolescents and young adults (AYA) is not well studied., Objectives: The present study examined AYA-reported preoperative exercise and demographic factors and their prediction of percent excess body mass index (BMI) loss at 6 and 12 months following sleeve gastrectomy., Setting: The setting for recruitment and surgeries was in a children's hospital in the United States., Methods: Participants were 173 AYA aged 12-21 years (mean age, 16.5 [SD, 2.0] yr; mean preoperative BMI, 50 [SD, 8.5] kg/m 2 ). Demographic characteristics including age, sex, ethnicity, and preoperative BMI were extracted from the medical record. Preoperatively, adolescents self-reported on exercise using 5 items from the Center for Disease Control's Youth Risk Behavior Surveillance Survey. The study evaluated the association of self-reported preoperative exercise in total and obtained a threshold of higher exercise to weight loss at 6 and 12 months after surgery., Results: More preoperative exercise was associated with greater weight loss at 12 months. Grouping participants by those who reported exercising at high levels (≥5 hr/wk) compared with those who reported <5 hr/wk, high levels of exercise predicted greater weight loss at 6 and marginally at 12 months postoperatively. Lower preoperative BMI was a significant predictor of weight loss in all analyses., Conclusions: Preoperative exercise may predict and contribute to weight loss in AYA and could be a target for pre- and postoperative intervention to improve outcomes. The importance of lower preoperative BMI for maximizing postoperative weight loss was also supported., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: The purpose of this review is to discuss the current state of surgical intervention for obesity in children and adolescents. Specifically, this review will discuss the different types of metabolic and bariatric surgery (MBS) procedures, guidelines for patient selection, and recent findings regarding surgical outcomes and complications., Recent Findings: MBS is safe in adolescents and has also demonstrated sustainable long term weight loss and improvement in obesity-associated comorbidities. A recent prospective multi-institutional trial demonstrated BMI reductions of 3.8 kg/m 2 (8%) to 15.1 kg/m 2 (28%) after 3 years among adolescents undergoing the three most common MBS procedures. Moreover, MBS is associated with remission of type 2 diabetes, prediabetes, hypertension, dyslipidemia, and abnormal kidney function in 65-95% of patients in the study. Childhood and adolescent obesity is a continuing problem that has not been adequately addressed by the medical community. MBS is currently the most successful strategy for significant and sustained weight loss and improvement of associated comorbidities. This review focuses on the different types of MBS, the selection and preparation of patients for surgery, and the expected outcomes and common complications.

Objectives: Quality of life (QoL) is an important outcome to evaluate in adolescents with severe obesity, yet intrapersonal predictors of QoL are understudied. The current study assessed whether difficulty with impulse control when experiencing a negative mood (negative urgency) is associated with poorer QoL, mediated by more emotional eating and food addiction., Method: Participants consisted of 69 primarily female (71%), minority (76%) adolescents aged 13-21 (M age = 16.5, SD = 1.5) with severe obesity presenting for prebariatric surgery psychological evaluations. Structural Equation Modeling was used to appraise a model of the association of adolescent report of negative urgency with more emotional eating (Emotional Eating Scale for Children) and food addiction (Yale Food Addiction Scale) and poorer weight-related QoL (Impact of Weight on Quality of Life-Kids)., Results: Greater difficulty controlling behavior when experiencing a negative mood was significantly associated with poorer weight-related QoL, and this relationship was mediated by an association with emotional eating and food addiction such that adolescents with severe obesity who reported more difficulties with impulse control in negative mood states were more likely to report more emotional eating and food addiction, which was in turn associated with lower QoL., Conclusions: Intrapersonal factors, including impulse control in negative mood states, are associated with lower QoL in adolescents with severe obesity. Interventions aimed at reducing frequency of negative affect, reducing impulsivity in negative mood states, and improving coping skills that are not eating based may contribute to improved QoL and merit further study.

Objective: Executive and motivational dysfunction have been associated with pediatric obesity. Poor sleep quality and psychopathology, often comorbid with obesity, are also associated with executive and motivational dysfunction. We examined the contribution of these comorbid factors to the association between obesity and executive function and reward-related decision-making., Methods: Seven- to 18-year-old children with and without obesity performed a working memory task with low and high loads, a response inhibition task, and a probabilistic reward-related decision-making task. Parents filled out standardized measures of executive function in everyday behavior, sleep health, and psychiatric symptoms. Analyses controlled for age, gender, IQ, and parental education., Results: Children with obesity showed worse working memory performance under higher load (p = 0.007), and worse parent-reported behavioral regulation (p = 0.05) and metacognition (p = 0.04) in everyday behavior and their reward-related decision-making was less consistent with learned probabilistic conditions (p = 0.04). Response inhibition did not differ between groups. Children with obesity had worse parent-reported sleep health (p < 0.01) and 4.27 greater odds of clinically relevant internalizing symptomology (p = 0.03), both of which mediated the effect of obesity on behavioral regulation (p's < 0.01) and metacognition (p's < 0.01). Performance-based assessments were not associated with sleep health or psychopathology., Conclusions: Sleep quality and internalizing psychopathology were worse in children with obesity and contributed to parent-reported executive dysfunction in their everyday behavior. Performance-based measures of working memory and decision-making were not associated with those comorbidities of obesity.

Objectives: Bariatric surgery is an effective treatment for youth with severe obesity. However, outcomes are variable and there remains sparse understanding of predictors of weight loss following surgery. The current study examines the role of adolescent-reported pre-operative social support around exercise, binge eating, and exercise to predict excess body mass index (EBMI) loss from 3 to 12 months post-surgery., Method: Participants were 101 adolescents ages 12-21 (M age = 16.6, SD = 1.8). Pre-operative body mass index (BMI) ranged from 35 to 87 (M = 50.3, SD = 8.6). Structural equation modeling (SEM) was used to evaluate a model of the association of adolescent report of perceived social support for exercise with less binge eating (items from the Eating Disorder Diagnostic Scale) and more self-reported exercise (items from the Youth Risk Behavior Surveillance System). The model was used to predict EBMI loss at 3, 6, 9, and 12 months post-surgery., Results: Social support significantly predicted exercise and demonstrated a trend for predicting binge eating, such that more social support was associated with more exercise and a trend for less binge eating. Binge eating was associated with less EBMI loss. However, there was no association of exercise with EBMI loss., Conclusions: Pre-operative binge eating should be a target for identification and treatment prior to sleeve gastrectomy in adolescents. Although not directly or indirectly associated with EBMI loss, perceived social support around exercise was associated with increased exercise, which may make it a consideration for a target for intervention as well.

Objective: Neurocognitive deficits in pediatric obesity relate to poor developmental outcomes. We sought preliminary evidence for changes in brain and cognitive functioning relevant to obesogenic behavior following vertical sleeve gastrectomy (VSG) in adolescents relative to wait-listed (WL) and healthy controls (HC)., Methods: Thirty-six adolescents underwent fMRI twice 4 months apart, during executive, reward, and episodic memory encoding, in addition to behavioral testing for reward-related decision making., Results: VSG adolescents lost weight, while WL gained weight and HC did not change between time points. Gains in executive and reward-related performance were larger in VSG than control groups. Group × Time interaction (P < 0.05 corrected) in left prefrontal cortex during N-back showed greater presurgical activation and postsurgical reduction comparable to HC levels but increased in WL between time points. Similarly, left striatal parametric response to reward value reduced after surgery to HC levels; WL did not change. Memory-related medial temporal activation did not change in any group., Conclusions: Results provide pilot evidence for functional brain changes induced by VSG in adolescents with severe obesity. Weight loss and gain were paralleled by reduced and increased prefrontal activation, respectively, suggesting neural plasticity related to metabolic change., (© 2017 The Obesity Society.)

Background: Obese patients have a higher risk of venous thromboembolism when immobilized due to surgery. The objective of this study was to assess anti-factor Xa activity in adolescent bariatric surgical patients receiving prophylactic enoxaparin., Methods: Four morbidly obese adolescents undergoing laparoscopic sleeve gastrectomy were enrolled. Enoxaparin was administered (40 mg subcutaneous (SC) if BMI ≤50 kg/m(2) or 60 mg SC if BMI >50 kg/m(2)) for prevention of venous thromboembolism every 12 h starting after induction of anesthesia until discharge. Plasma anti-factor Xa activity was assessed over 12 h after the first dose and used as a surrogate marker for enoxaparin levels. Non-compartmental analysis of anti-factor Xa activity levels was performed and compared with previously published studies., Results: Patients recruited were 16 to 18 years of age with a mean BMI of 52.6 ± 5.8 kg/m(2) (>99th BMI percentile). Peak anti-factor Xa activity ranged from 0.20 to 0.23 IU/mL in our study population, compared to 0.38 to 0.53 IU/mL in the cited lean comparator groups., Conclusions: Our current dosing practice of 40 mg SC for individuals with a BMI ≤50 kg/m(2) and 60 mg for individuals with a BMI ≥50 kg/m(2) resulted in anti-factor Xa activity that was sufficient for adequate thromboprophylaxis in adolescent bariatric surgical patients. Our data also demonstrates lower drug exposures in the obese when compared to lean patients. Therefore, randomized controlled efficacy and safety studies are urgently needed to guide the use of low-molecular-weight heparins in the pediatric and adolescent obese population.

Obesity is a worldwide epidemic, and surgical weight loss operations have been performed for over 20 years. Laparoscopic sleeve gastrectomy was first performed as part of the biliopancreatic diversion over 30 years ago. Recently, laparoscopic sleeve gastrectomy has led to excellent excess weight loss with limited morbidity, especially compared to Roux-en-Y gastric bypass. In adolescents, laparoscopic sleeve gastrectomy is an excellent option to provide excess weight loss and remission of comorbid conditions without long-term malabsorptive risks., (© 2013 Published by Elsevier Inc.)

Background: As the obesity epidemic takes its toll on patients stricken with the disease and our health care system, debate continues regarding the use of weight loss surgery and its long-term consequences, especially for adolescents. One subset of patients regarding whom there is increased controversy is adolescents with extreme obesity (BMI > 60 kg/m(2)) because the risk of complications in this weight category is higher than for others undergoing bariatric surgery. Several strategies have been suggested for this patient group, including staged operations, combined operations, intragastric balloon use, and endoluminal sleeve placement. However, the device options are often not available to adolescents, and there are no data regarding staged or combined procedures in this age group., Methods: All adolescents with BMI >60 kg/m(2) referred to our program were evaluated for inpatient medical weight loss prior to laparoscopic sleeve gastrectomy. The program utilizes a multidisciplinary approach with a protein-sparing modified fast diet, exercise, and behavioral modification., Results: Three patients completed the program, and each achieved significant preoperative weight loss through the inpatient program and successfully underwent bariatric surgery., Conclusions: Presurgical weight loss via an inpatient program for adolescents with a BMI >60 kg/m(2) results in total weight loss comparable to a primary surgical procedure alone, with the benefit of decreasing the perioperative risk.