Type 2 diabetes

ADA 2020: Surgery should be an option for obese teens with T2D

Bariatric surgery has a role to play in the management of obese adolescents with youth-onset type 2 diabetes, paedatric endocrinologists say.

Speaking at the American Diabetes Association’s (ADA) 80th Scientific Sessions, Associate Professor Megan Kelsey said the benefits outweighed the risks.

The American Society for Metabolic and Bariatric Surgery (ASMBS) and American Academy of Pediatrics (AAP) recommend consideration of bariatric surgery in adolescents with a BMI 35-39 and comorbidities such as type 2 diabetes or a BMI ≥40 with no contraindications.

A/Professor Kelsey, medical director of adolescent bariatric surgery at the Children’s Hospital Colorado, told the virtual Scientific Sessions that bariatric surgery in adolescents was more effective than medications and intensive lifestyle modification.

Adolescents who underwent bariatric surgery had better glycaemic control, improved BMI and better resolution of comorbidities.

For example, a comparison of the Teen-LABS and TODAY studies showed bariatric surgery in obese youth with type 2 diabetes was associated with a reduced risk of diabetic kidney disease than medical treatment.

However there was a risk of complications including readmissions and reoperations for bowel obstruction, leak and cholecystectomy and ongoing issues of nutritional deficiencies after bariatric surgery.

She said the guidelines no longer recommended that bariatric surgery be delayed until adolescents had completed their linear growth.

Associate Professor Kelsey said a 5-year comparison of gastric bypass in adolescents and adults had shown the mean weight loss was similar in both groups (-25% v -29%).

“Despite the fact that beta-cell failure usually occurs very quickly in youth compared to adults, diabetes remission rates seem to be higher for adolescents than adults after bariatric surgery, as do remission rates for hypertension,” she said.

She added that in adolescents, weight loss was similar in those who had the more popular sleeve gastrectomy and those who had Roux-en-Y gastric bypass.

However the reality in Australia is the lack of access to bariatric surgery as a treatment option for teenagers with obesity and type 2 diabetes.

Paediatric endocrinologist Dr Alexia Pena, from the University of Adelaide, told the limbic that bariatric surgery for adolescents was not available in the public sector and there were many barriers to the situation changing quickly.

In particular there was a lack of multidisciplinary teams with expertise in paediatric bariatric surgery, she said.

“The limitations are that you need to have a surgeon whose expertise is not only in paediatrics but in transitions to adult care – because these people are at risk of being lost in the system. As with adolescent transition for any other chronic illnesses, this will be a challenge.”

Dr Pena said there were also issues with consent and family support that were unique to adolescents, along with the challenges of puberty, adolescent behaviour and development.

“Without a doubt the data is coming out that it should be an option to improve diabetes control and we are about to publish Australasian guidelines on type 2 diabetes in children and adolescents where we did mention the option of bariatric surgery,” she said.

“We acknowledge it will be a potential benefit in adolescents with type 2 diabetes, but at the same time we need to have all the logistics and the follow-up.”

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