The present data are from the first prospective longitudinal study to document psychosocial outcomes of RYGBP surgery in adolescents with extreme levels of obesity. Our data demonstrate that RYGBP is an effective weight loss intervention for adolescents, which also results in significant improvement in overall and weight-related HRQOL, and depressive symptomatology across the first postoperative year. Prior to RYGBP, adolescents with extreme obesity present with the most significant and global impairments in HRQOL relative to other pediatric chronic illness populations (35
). Similarly, the number of adolescents presenting for RYGBP with depressive symptoms in the clinical range is at a rate 3–4 times higher than national base rates for adolescent males (7.4%) and females (13.9%) (36
At 1 year post-RYGBP, teens reported generic HRQOL within 1 s.d. of healthy adolescent normative comparisons (24
). These findings of more normative adolescent psychosocial status at 1 year post-RYGBP are similar to those reported by Dymek and colleagues (16
) in their cross-sectional study comparing adults pre-/postbariatric surgery. These marked psychosocial improvements for adolescents following RYGBP are quite notable given that the vast majority of adolescents remain obese or even extremely obese at 1 year following their procedure. These data suggest that from the psychosocial standpoint, the change
in weight may be more important than the final BMI achieved following surgery.
At 6 and 12 months after RYGBP, adolescents reported a significant improvement in their day-to-day weight-related physical comfort (e.g., “Because of my weight it is hard to… bend over”, “move around”, “fit in public seats”), their general physical capabilities (e.g., “It is hard for me to…walk more than a block”, “run”), and their weight-related body esteem (e.g., “Because of my weight I am…ashamed of my body”). Furthermore, teens reported significant improvements in their overall psychosocial health and weight-related social relations (e.g., “Because of my weight people…tease me”, “avoid spending time with me”), as well as “minimal” depressive symptoms. Interestingly, a post hoc chart abstraction revealed a decrease in the use of antidepressant or mood stabilizing medications over time. Specifically, 6 of the 31 (19.4%) adolescents were taking an antidepressant or mood stabilizing medication at baseline with only two remaining on medication at the 12-month follow-up. Thus, despite a decrease in use of pharmacological treatment for depression, patients reported clinical improvements in depressive symptomatology over time.
Our statistical approach (LMM analyses) allowed for examination of the rate of change over time in BMI and psychosocial status from baseline through the first postoperative year. Consistent with reports on adult RYGBP outcomes in Sweden (37
), our analyses detected a deceleration of BMI change from 6 to 12 months postoperatively. As hypothesized and in parallel with initial weight loss phases, the rates of improvement in the majority of psychosocial domains substantially slowed down beginning at 6 months postoperatively. Furthermore, for scales in which established MCID scores exist (e.g., general physical capabilities and general psychosocial health), the statistical findings and clinically meaningful improvements mirrored each other. In other words, as the rate of improvement in PedsQL scores began to decelerate during the 6- to 12-month postoperative period, patients also did not perceive meaningful improvements during this time. Interestingly, adolescents’ social relations with peers in the context of their weight (e.g., stigmatization, friendships) demonstrated no slowing in the rate of improvement across the first postoperative year.
Although these initial findings of marked improvements in psychosocial functioning for adolescents who have undergone RYGBP are quite promising, the adult literature would suggest caution. Longitudinal trends for adults suggests HRQOL changes parallel patterns of weight loss, weight regain, and weight stability (17
). Furthermore, initial improvements in depressive symptoms may dissipate for some individuals 18–24 months after bariatric surgery (17
) and new onset of depressive symptoms may occur despite good weight loss outcome (39
). Weight regain trends after adolescent gastric bypass are not yet adequately characterized, although may be as high as 10–20% (40
). If longer-term adolescent bariatric outcomes are found to be similar to those described in adults, it is crucial to identify and provide intervention to adolescents who may experience weight regain after undergoing RYGBP to prevent relapse in behavioral and psychosocial functioning.
Finally, what role medical comorbidities and their resolution play in an adolescent’s psychosocial improvements following RYGBP remains an important area of future research. For example, there is sound evidence that adolescent RYGBP leads to resolution of medical comorbidities (40
). Given the developing pediatric literature which has suggested obese youth with medical comorbidities may experience poorer HRQOL relative to those whose health status is less impaired (44
), future work with larger samples should explore whether changes in comorbid conditions might be mediating the changes in HRQOL.
Longer-term adolescent studies are critically needed to document adolescent RYGBP weight, health, and psychosocial trajectories, and their interrelations. Furthermore, clinical practice and postoperative adolescent treatment models will benefit from understanding which, if any, psychosocial components drive BMI change dynamically. Specifically, are there psychosocial factors which, if monitored and addressed, would improve (or help sustain) adolescent postoperative weight loss outcomes. Unfortunately, this type of dynamic modeling (i.e., multilevel mixed longitudinal modeling with dynamic or time-varying predictors (30
)) was not possible in the present study given there were only three time points. These types of questions will be addressed through our adolescent bariatric research consortium (Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS)) (45
) with a considerably larger multi-site sample. Designed as a prospective, longitudinal cohort observational study, the main objectives of Teen-LABS are to document the safety of bariatric surgery in adolescence and postoperative health and psychosocial outcomes at 6-, 12- and annually in comparison to adult outcomes (46
Finally, it is noteworthy that adolescent bariatric surgery occurs at an important time in psychosocial development—a period of rapid change in emotional, interpersonal, social, and career/vocational domains in which good adaptation bodes well for continued positive adaptation in the transition to emerging adulthood (aged 18–20) (47
). We argue that bariatric surgery has the potential to positively alter the psychosocial and resultant developmental trajectory of this unique adolescent subpopulation. To fully understand the impact of adolescent bariatric surgery on psychosocial and developmental outcomes, we must examine their interactions within these age-salient contexts (e.g., peers, family, romantic relationships, co-workers, school, work). Thus, a more comprehensive assessment of psychosocial factors, contexts, and outcomes particularly salient to youth as they transition from adolescence to young adulthood is needed. Only long-term, prospective and controlled studies utilizing a nonoperative extremely obese adolescent comparison group will provide such evidence.