Adolescent bariatric surgery: a systematic review of recommendation documents

Author’s Accepted Manuscript Adolescent bariatric surgery: A systematic review of recommendation documents Janet E. Childerhose, Amal Alsamawi, Tanvi Mehta, Judith E. Smith, Susan Woolford, Beth A. Tarini www.elsevier.com/locate/buildenv

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To appear in: Surgery for Obesity and Related Diseases Cite this article as: Janet E. Childerhose, Amal Alsamawi, Tanvi Mehta, Judith E. Smith, Susan Woolford and Beth A. Tarini, Adolescent bariatric surgery: A systematic review of recommendation documents, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.08.008 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Adolescent Bariatric Surgery: A Systematic Review of Recommendation Documents Janet E. Childerhose, PhD,a Amal Alsamawi, MPH,b Tanvi Mehta, MHSA,c Judith E. Smith, MSLIS,d Susan Woolford, MD, MPH,e Beth A. Tarini, MD, MS.f a

Berman Institute of Bioethics, Johns Hopkins University; bDevelopmental Disabilities Institute, Wayne State University; cHealthcare Affairs, Association of American Medical Colleges; d Taubman Health Sciences Library, University of Michigan; e Division of General Pediatrics at the University of Michigan; fStead Family Department of Pediatrics, University of Iowa. Corresponding Author: Janet E. Childerhose, Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Avenue, Baltimore, MD 21205, 734.625.7877 (phone), 410.614.5360 (fax), [email protected] Short Title: Adolescent Bariatric Surgery: A Systematic Review Abbreviations: ASBS — American Society for Bariatric Surgery ASBSF — American Society for Bariatric Surgery Foundation BMI — body mass index CPG — clinical practice guideline CS — consensus statement NGC — National Guidelines Clearinghouse NIH — National Institutes of Health PRISMA — Preferred Reporting Items for Systematic Reviews and Meta-Analyses PS — position statement US — United States Funding Source: The Center for Bioethics and Social Sciences in Medicine at the University of Michigan provided support for this study. Financial Disclosure Statement: No authors have financial relationships to declare. Contributors’ Statement Janet E. Childerhose: Dr. Childerhose conceptualized and designed the study; coordinated and supervised data collection, extraction, and analysis; drafted the initial manuscript; critically reviewed and revised the manuscript; and approved the final manuscript as submitted. Amal Alsamawi and Tanvi Mehta: Ms. Alsamawi and Ms. Mehta assisted with data collection, extraction, and analysis; contributed to drafting the initial manuscript; reviewed and revised the manuscript; and approved the final manuscript as submitted. Judith E. Smith: Ms. Smith assisted with study design; designed and coordinated the search strategy; reviewed and revised the manuscript; and approved the final manuscript as submitted.

Susan Woolford: Dr. Woolford assisted with designing the search strategy and interpreting the data; critically reviewed and revised the manuscript; and approved the final manuscript as submitted. Beth A. Tarini: Dr. Tarini assisted with conceptualizing the study; assisted with data extraction and analysis; critically reviewed and revised the manuscript; and approved the final manuscript as submitted.

ABSTRACT Bariatric surgery has been performed on adolescents since the 1970s but little is known about the guidance offered to providers in recommendation documents published in the United States (US). A systematic review was conducted to generate a complete record of all US recommendation documents and describe variability across the documents. The study had 3 aims: to identify the developers, examine selection criteria, and document reasons why developers have recommended this intervention for adolescents. Four databases (Medline, National Guidelines Clearinghouse, Trip, and Embase) were searched, followed by a hand search. Documents were eligible for inclusion if they satisfied 5 criteria: English language; developed and published by a US organization; a clinical practice guideline, position statement, or consensus statement; minimum 1-sentence recommendation for bariatric surgery for the treatment of obesity or related co-morbidities; minimum 1-sentence recommendation on bariatric surgery for children, adolescents, or both. No date limits were applied. Sixteen recommendation documents published between 1991 and 2013 met our inclusion criteria: 10 clinical practice guidelines, 4 position statements, and 2 consensus statements. Nine were produced by medical organizations, 3 by surgical organizations, and 4 by public health / governmental bodies. One document recommended against bariatric surgery for minors, and 15 endorsed the intervention for this population. Body mass index (BMI, a measure of obesity calculated by dividing weight in kilograms by the square of height in meters) thresholds were the selection criteria most often provided. Minimum age varied widely. Of the 15 endorsing documents, 10 provided a reason for performing bariatric surgery on minors, most often to treat obesity related co-morbidities that threaten the health of the adolescent. We make 3 suggestions to improve the quality of future recommendation documents.

KEYWORDS Adolescent; Pediatric; Bariatric surgery; Clinical recommendations; Obesity; Ethics; History.

INTRODUCTION For carefully-screened adolescent candidates (mean age=18 years), bariatric surgery is more effective for treating severe obesity and related co-morbidities than lifestyle changes, medications, or supervised weight-loss programs (1, 2). Recent findings from the Teen-LABS longitudinal study of 242 adolescents undergoing bariatric surgery at 5 centers show a 3-year mean weight loss of 27% in the cohort, remission of type 2 diabetes in 95% of participants, high remission rates for other serious obesity co-morbidities, and low rates of short-term complications (3, 4). Yet surgical treatment of adolescents for severe obesity and related comorbidities is at an impasse (5). Despite evidence that bariatric surgery leads to excellent shortterm outcomes, the annual number of inpatient bariatric surgery admissions for adolescents ≤20 years remains low (1615 procedures in 2009) (6). Survey data suggest that United States (US) providers have been reluctant to refer obese adolescents to bariatric surgery (7, 8). Barriers to referral may include limited medical education about the physiology of obesity and its treatment (9), lack of awareness that adolescents are eligible for bariatric surgery (8), and obesity bias amongst providers (10). Clinical and ethical concerns about bariatric surgery for adolescents have also been described (11, 12). These include the limited decisional capacity and autonomy of adolescents (11, 13, 14), poor compliance with permanent lifestyle changes (11, 14, 15), delayed or arrested growth from malnutrition (11, 13, 14), disordered eating (13), inequities in access (11, 13, 14), and unknown long-term outcomes (15). Even amongst proponents of bariatric surgery for suitable adolescent candidates, there is a lack of consensus on the timing of surgery and selection criteria (13, 16). Recommendation documents could play an important role in educating providers and addressing concerns, but little is known about the evidence-based guidance that is offered to providers in these documents. Four reviews have analyzed recommendations for the treatment of pediatric obesity, including bariatric surgery (16-19), but none have reviewed recommendations about adolescent bariatric surgery for US providers. To address this knowledge gap, a systematic review was conducted to provide a complete record of all recommendation documents published by US developers. Our overarching goal was to describe the variability in guidance offered to providers across the documents, without making clinical recommendations. Our specific aims were to identify the developers, examine key selection criteria that developers provide, and document the reasons why developers recommend this intervention for use with adolescents.

METHODS Study design We employed a mixed-methods design. A quantitative data collection strategy generated 7,727 initial records. A quantitative descriptive methodology was used to inform our first two aims. A qualitative descriptive methodology was used to inform our third aim. Inclusion and exclusion criteria Following an earlier review (18), we selected 3 types of recommendation documents for inclusion: clinical practice guidelines (CPG), position statements (PS), and consensus statements (CS). CPG are developed by a guideline panel or task force that consists of multidisciplinary stakeholders who review and grade published evidence, and provide algorithms to optimize patient care (20). PS are developed by a single medical or scientific body that draws on peerreviewed studies but does not grade evidence to make its recommendations. CS are a recommendation model that was developed by the National Institutes of Health (NIH) when it organized consensus development conferences from 1977 to 2013 on controversial topics in medicine (21, 22). The purpose of including all 3 document types, despite their marked methodological differences, was to include a range of guidance sources for providers. Documents were eligible for inclusion if they met 5 criteria: 1) English language; 2) developed and published by a US organization; 3) a CPG, PS, or CS; 4) made a minimum 1sentence recommendation on bariatric surgery as an intervention for severe obesity or related comorbidities; and 5) made a minimum 1-sentence explicit recommendation about bariatric surgery for children, adolescents, or both. For the last criterion, we searched within each document using keywords (e.g. child, children, adolescent, teen, and pediatric). “Child,” “children,” and “pediatric” were used as keywords because recommendations for bariatric surgery have been made in documents that focus on the prevention and treatment of childhood obesity. To generate a complete record of all documents that have made a minimum 1-sentence recommendation on adolescent bariatric surgery, the team considered all published documents, including those that had been withdrawn, as long as they met inclusion criteria. We excluded commentaries, case series, and studies (such as clinical trials) that did not make recommendations (23). We also excluded documents published by international organizations or those that communicated an international consensus, even when recommendations were relevant to clinical practice in the US (24-27). We considered documents that made recommendations for a combined adult and pediatric population, but within this subset, we excluded documents that did not make recommendations clearly intended for adolescent treatment (28-30). We retained all CPG without a transparent grading system as long as they met other inclusion criteria (e.g. developed by a guideline panel or expert committee).

Search strategy A health sciences informationist (JS) created a robust search to capture all CPG, PS, and CS on bariatric surgery as an intervention for obesity in children and adolescents. Four databases were searched between March 6, 2014 and March 15, 2014: Medline (through OVID Platform), Embase, Trip (www.tripdatabase.com), and National Guidelines Clearinghouse (NGC) (www.guideline.gov). The informationist developed a base search strategy for Medline that included both medical subject headings (MeSH) and keywords in titles and abstracts, and adapted this search for use with other resources (Figure 1). Searches were limited to English language and to humans, but not to the adolescent population, to capture documents that targeted combined (adult and adolescent) populations. To identify documents not captured in the core database searches, an extensive hand search was conducted by 3 team members (JC, JS, TM) between March 15, 2015, and March 18, 2015. We searched websites of relevant societies and associations for recommendation documents, scanned reference lists of all retained documents, used Scopus to track citations of retained recommendation documents, examined the reference list of a leading bariatric surgery textbook (31), and consulted an expert (SW) to identify additional resources. Data extraction and analysis Three authors (JC, TM, and AA) independently screened the records in each database and the hand search results, then met to reconcile individual screening decisions for each of the 5 record sets. Disagreements were resolved through extensive discussions to reach consensus. In the case of 2 records for which the screening team could not reach a consensus, the senior author (BT) was asked to render the final decision by screening each citation with the inclusion criteria and justifying her decision. Each screening author made detailed notes of methodological and substantive questions that screening generated. These notes were discussed at meetings to guide analysis. Analysis of retained documents was conducted in 2 stages. First, we reviewed and compared all documents to identify variability across the documents and address the 3 aims. We then compared documents within each type (CPG, PS, and CS).

RESULTS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram displays the screening process (Figure 2) (32). From 7,727 records generated through a search of 4 databases and an extensive hand search, we excluded 7,040 documents based on title and abstract. This count included 10 missing records that could not be screened. That left 481 full-text records that we assessed for eligibility. After excluding duplicates and records that did

not meet inclusion criteria, we reviewed 32 documents in depth. We then reapplied our inclusion and exclusion criteria to these 32 documents and excluded an additional 16, leaving 16 recommendation documents that we retained for analysis (Table 1). General characteristics of the documents We retained 10 CPG, 4 PS, and 2 CS. We classified scientific statements published by the American Heart Association (33, 34) as PS. All documents endorsing adolescent bariatric surgery were published between 2005 and 2013. Eleven documents targeted children and/or adolescents exclusively, while 5 made recommendations for a combined adult and adolescent population (Figure 3). Six focused on surgical treatment of obesity: 3 specifically for minors, and 3 for a combined adult and adolescent population. The remaining 10 focused on obesity prevention and treatment, weight management, cardiovascular health, or nutrition, and made recommendations for bariatric surgery as a tertiary treatment. We identified 2 publications that were early reference documents for developers. One was a CS from a 1991 NIH consensus development conference on bariatric surgery (35). This CS was the only retained document that made a 1-sentence recommendation against bariatric surgery for children and adolescents under 18 years of age, due to lack of evidence to support the safety and benefits for this population. Although we retained this document because it met all inclusion criteria, we excluded it from our analysis. As the only retained document to recommend against bariatric surgery for minors, it has historical significance but no clinical relevance. The other reference document, published by Inge et al 2004 in Pediatrics (36), outlined the first comprehensive clinical recommendations for adolescent bariatric surgery. Although the document has clinical relevance and historical significance, we excluded it because it was not a CPG developed by a guideline panel. The authors outlined conservative selection and treatment criteria that distinguished adolescents from the adult population, including the need to establish a minimum 6-month treatment failure threshold, screening for adolescent decisional capacity and a supportive family environment, and lifelong monitoring. Developers of recommendation documents Nine of the retained documents were published by medical organizations, 3 by surgical organizations, and 4 by public health / governmental organizations (Table 2). When multiple organizations authored a document, we classified the document based on the lead authoring body or convener of the panel. Five organizations published more than 1 document: American Academy of Nutrition and Dietetics (formerly American Dietetic Association), American Heart Association, American Society for Metabolic and Bariatric Surgery (formerly American Society for Bariatric Surgery), Betsy Lehman Center for Patient Safety, and Institute for Clinical Systems Improvement.

Sociologists studying the production of evidence-based standards have observed that the expertise and professional interests of developers shape decisions about which evidence to include and discard (37). Yet composition of author groups for some retained documents was more multidisciplinary than might be expected for a small field (Table 1). For example, the authorship for the 2009 Betsy Lehman Center CPG on pediatric/adolescent weight loss surgery (38) consisted of a pediatric gastroenterologist, a pediatrician, an adolescent medicine internist, a psychiatrist specializing in eating disorders, a clinical psychologist, and a dietician/nutritionist, in addition to several surgeons. We also observed instances of multiple authorship by some individuals (Table 1). For example, bariatric surgeon Thomas Inge, who first-authored the 2004 Pediatrics practice guidelines, was an author of 3 retained documents (34, 38, 39). Other individuals authoring more than 1 document in our review include public health scientist and obesity researcher Shiriki Kumanyika (33, 35), pediatric cardiologist Stephen Daniels (33, 34, 40), surgeon Janey Pratt (38, 39, 41), pediatric gastroenterologist Sarah Barlow (34, 42), and physician and pediatric obesity researcher Goutham Rao (34, 42). Selection criteria To assess variability in selection criteria across the documents, we focused on 2 criteria that other reviews (13, 16) have flagged as variable: body mass index (BMI, a measure of obesity calculated by dividing weight in kilograms by the square of height in meters) thresholds, and minimum age. Of 15 documents endorsing adolescent bariatric surgery, 9 outlined recommendations for both BMI thresholds and minimum age (38, 40-47), 5 documents made recommendations for 1 of these criteria (33, 39, 48-50), and 1 document made recommendations for neither (34).

BMI thresholds Our review found that BMI thresholds were the selection criteria that developers most often provided, a finding that is consistent with a review of international guidelines for adolescent bariatric surgery (16). From 2005 to 2008, 5 documents (33, 41-43, 48) adopted the conservative BMI thresholds first outlined in the Inge et al 2004 guidelines. The one exception during this 4-year period was the 2005 CS published by the joint Consensus Conference Panel of the American Society for Bariatric Surgery and the American Society for Bariatric Surgery Foundation (ASBS/ASBSF) (49). The authors recommended the adoption of adult BMI thresholds for the adolescent population (BMI ≥ 35 kg/m2 with 1 serious comorbidity or BMI ≥ 40 kg/m2 with less serious comorbidities). Writing that “BMI guidelines for adolescents should be identical to those advocated for adults,” (Buchwald 2005:602) (49), they argued that treating severe obesity at an earlier stage by aligning adolescent BMI thresholds with adult thresholds would result in better surgical outcomes with fewer complications and improvement in co-morbid conditions, particularly type 2 diabetes. Because we applied no date limits to our review, we were able to observe that the recommended BMI threshold again dropped in 2008 (Table 1), when the Society of American

Gastrointestinal and Endoscopic Surgeons adopted the adult BMI threshold for the adolescent population in its CPG (45). This was a sustained downward shift: all documents published afterwards endorsed adult BMI thresholds for adolescents, although only 1 provided a reason (50).

Minimum age Minimum age was variable across the documents (Table 1). Physiological maturity was used most often to calculate minimum age. Six documents (38, 41-44, 46) adopted Tanner stage IV and/or 95% of adult height based on bone age, which corresponds to ≥13 years old for girls and ≥15 years old for boys. Two documents published 3 years apart (45, 47) recommended mutually exclusive age ranges: one identified young adolescence (≤18 years) as the appropriate window for surgery; the other, mature adolescence (≥ 18 years). One CPG for cardiovascular health risk reduction of children and adolescents (40) adopted a single age range (12-21 years) for all interventions, including bariatric surgery. Six documents did not specify a minimum age. Reasons to perform bariatric surgery on minors Ten of the 15 documents that endorsed adolescent bariatric surgery identified 1 or more reasons to perform the intervention (Table 1). We identified 4 overlapping reasons, which also summarize the benefits described in the documents: 1) surgery is effective in producing shortterm and long-term weight loss in the adolescent patient (43, 45); 2) surgery is appropriate when severe obesity in the adolescent patient does not respond to behavioral changes or medical interventions (34, 42, 44); 3) surgery is an appropriate treatment when serious co-morbidities threaten the health of the adolescent patient (34, 39, 47-49); and 4) surgery can prevent or improve long-term health and/or emotional problems in the adolescent patient (38, 39, 45, 49). Comparison within document types

Clinical practice guidelines CPG provided the most comprehensive guidance for adolescent bariatric surgery. Three of the 10 CPG focused exclusively on bariatric surgery (38, 41, 45), and 2 of these (published in 2005 and 2009) targeted children and adolescents. The remaining 7 CPG focused more broadly on the prevention and treatment of obesity and cardiovascular disease (40, 42-44, 46-48). While most of these broadly-focused CPG provided limited guidance on bariatric surgery, the 3 CPG published by the Institute for Clinical Systems Improvement include detailed discussion of indications for surgery, risks and benefits of procedures, and perioperative care. Six CPG identified a reason for performing bariatric surgery on minors (38, 42, 43, 45, 47, 48).

Position statements All 4 PS targeted the pediatric population, but only 2 PS provided reasons for performing

bariatric surgery on minors (34, 39). One provided a robust discussion of the effectiveness of bariatric surgery and compared procedures, even though it did not outline selection criteria (34). Only the 2012 PS from the American Society for Metabolic and Bariatric Surgery (39) focused exclusively on adolescent bariatric surgery with a detailed discussion of clinical indications, patient selection criteria, team qualifications, procedures, and risks and outcomes. The authors discussed the unique risks attached to performing surgery with this population, including psychosocial risks, pregnancy, nutritional deficiencies, adolescent cognitive development, and parental coercion.

Consensus statements One CS made recommendations on adolescent bariatric surgery (49), discussing selection criteria, timing of referral, and risks and benefits. It also identified a reason to perform bariatric surgery on minors.

DISCUSSION General observations Discussion of adolescent bariatric surgery in recommendation documents ranged from cursory to extensive. Most documents focused on obesity and related health conditions rather than surgical weight loss for adolescents. The range of developer types (medical, surgical, and public health/governmental), diverse methodologies for arriving at evidenced-based recommendations, and long period of coverage make comparison difficult. Because of this heterogeneity, providers seeking guidance on whether, when, and why adolescents should undergo bariatric surgery may need to consult several documents. Nine of the documents making recommendations on adolescent bariatric surgery were published over a five-year period (2005 to 2009). This clustering of documents followed an increase in the number of annual bariatric procedures performed with adolescents, from 328 to 987 procedures between 2000 and 2003 (51). After 2009, there was a short gap, before the publication of 6 documents over 3 years (2011 to 2013). Trends in the acceptance of new procedures are evident. Sleeve gastrectomy (SG) for adolescents was first mentioned in a 2008 document, just after the publication of data for adult (52) and pediatric patients (53). A cautious stance towards SG was apparent in the 2009 Betsy Lehman CPG. The authors wrote that “[l]aparoscopic sleeve gastrectomy is a new operation that produces significant initial weight loss with low operative risk in adults” but “should be considered investigational; existing data are not sufficient to recommend widespread and general use in adolescents” (Pratt et al 2009: 903) (38). By 2012, SG was no longer portrayed as

investigational. The authors of the ASMBS PS wrote: “Although long-term adolescent outcomes data are required, the preliminary results from ongoing studies of adolescents undergoing sleeve gastrectomy appear to demonstrate excellent weight reduction, reversal of associated co-morbid diseases, and morbidity outcomes similar to those of the adult population” (Michalsky et al 2012:5) (39). There was significant variability in whether developers discussed clinical and ethical concerns. Two documents published 6 years apart (41, 47) characterized adolescent bariatric surgery as controversial. Two others (38, 44) acknowledged the lack of consensus on selection criteria. Several identified short- and long-term risks for this population, including dumping syndrome (44), nutritional deficiencies and delayed growth (43, 44, 46, 50), difficulty adopting and maintaining new eating habits (42), psychological adjustment problems (46) such as eating disorders and body image distortion (43, 46), and the management of excess skin (43) with the possibility of postoperative body contouring surgery (46). A single document mentioned that bariatric surgery can fail (47). Gaps and opportunities for research Gaps in recommendation documents suggest opportunities to improve guidance to providers and strengthen the underlying evidence base. Discussion of the risks and benefits of bariatric surgery for adolescents was inconsistent across the documents, even taking into account changes to procedures. Secondly, while some authors pressed for a centralized database or longitudinal studies (34, 41), there has been no evident interest in understanding adolescent experiences of bariatric surgery or using these data to inform the development of recommendations (54). A third gap concerns the high proportion of females (75%) who comprise the adolescent surgical population. Given that most patients are adolescent girls, there may need to be greater emphasis in recommendation documents on pre- and post-operative counseling tailored to female reproductive and psychosocial development. Suggestions to improve recommendation documents Due to the increasing prevalence of severe obesity in adolescents (55), the increasing use of SG with adolescents (5), and the publication of longitudinal outcomes data (3, 4), there is a need for updated recommendations for adolescent bariatric surgery. We offer 3 suggestions to strengthen recommendation documents and support providers in their decision-making. Developers should outline well-supported reasons for performing bariatric surgery on adolescents, with a thorough discussion of risks and benefits for each procedure. A values and preferences section could provide more transparency in how developers arrive at their recommendations (48). There are clear benefits to performing surgery on minors at a lower BMI, which may require intervening earlier in adolescence (2, 56). However, potential benefits should be

assessed alongside the evolving decisional capacity of individual adolescent patients (57) and their ability to manage challenging lifestyle changes after surgery. Both of these were stressed in the Inge et al (2004) practice guidelines. We encourage developers to provide more detailed recommendations for the perioperative care of adolescent patients undergoing bariatric surgery. Selection criteria alone provide limited guidance for providers. All adolescents who have undergone bariatric surgery require ongoing care by pediatric providers in a pediatric weight management program until they reach adulthood. Even as surgeons become more experienced performing procedures such as SG on adolescents, the immaturity of adolescents and their capacity to manage the substantial lifestyle changes that support the success of bariatric surgery remain important considerations for providers considering referral. We also urge developers to acknowledge the ethical concerns that are inherent to performing a permanent surgical intervention with this population. Finally, we encourage developers to consider publishing stand-alone recommendations for adolescent bariatric surgery. Because adolescents are developmentally immature, they are uniquely vulnerable to the impacts of surgical interventions that permanently alter their anatomy and physiology. This fact should be highlighted in recommendation documents, not minimized. Bariatric surgery carries different risks and benefits for adolescents than it does for adults, and generates unknown long-term outcomes. While it may be cost-effective for developers to combine a discussion of bariatric surgery for adult and adolescents populations in the same document, this practice does not serve adolescent providers, unless a full discussion of selection criteria, risks and benefits, and perioperative care is tailored to the adolescent population. Study limitations Our overarching goal was to describe variability in guidance to providers across recommendation documents published by US developers. A quantitative assessment of the quality of evidence or risk of bias was therefore outside the scope of the study, as was making clinical recommendations. We excluded documents produced by international developers, while recognizing both that US providers may consult these documents and international studies form some of the evidence base for the recommendations we reviewed.

CONCLUSION In 1991, an NIH consensus conference on gastrointestinal surgery for adults made the first recommendation on bariatric surgery for adolescents, advising against the intervention for lack of evidence. Thirteen years later, in 2004, the first practice guidelines for adolescent bariatric surgery were published. These guidelines were an important reference for many of the evidencebased documents that followed. From 2005 to 2013, 15 evidence-based recommendation

documents that endorsed the surgical treatment of severe obesity in adolescents were published. During this eight-year period, the field of bariatric surgery evolved rapidly for adolescents as well as adults. Not surprisingly, our review of these 15 recommendation documents shows variability across multiple domains: target population (pediatric and combined), document focus (bariatric surgery, obesity, cardiovascular disease, and nutrition), specific recommendations, and comprehensiveness. With the ongoing publication of high-quality evidence to guide recommendation documents, we anticipate a further evolution of recommendations for adolescent bariatric surgery, along with changes in provider attitudes. Developers of future recommendation documents have a unique opportunity to educate providers about this intervention by providing comprehensive guidance that incorporates best practices from the documents reviewed here. By explaining why bariatric surgery is indicated for some adolescents, and addressing the ongoing clinical and ethical concerns inherent to performing a permanent procedure with this population, developers can better support providers to make sound decisions for the young patients and families that they treat.

CONFLICT OF INTEREST STATEMENT No authors have conflicts of interest to declare.

LEGEND FOR TABLE 1 Doc Type = Document Type CPG = Clinical Practice Guideline; PS = Position Statement; CS = Consensus Statement. Target Population: Adult +Ped = Adult and Pediatric; Ped = Pediatric only (children, adolescents, or children and adolescents). Surgery Rationale: Yes = Developer provides 1 or more rationales for performing bariatric surgery on minors; No = Developer does not provide a rationale for performing bariatric surgery on minors. Procedures Described: AGB = adjustable gastric banding; BPD = biliopancreatic diversion without duodenal switch; BPD/DS = biliopancreatic diversion with duodenal switch; BPD±DS = biliopancreatic diversion with or without duodenal switch; DS = duodenal switch; JB = jejunoileal bypass; LAGB = laparoscopic adjustable gastric banding; RYGB = Roux-en-Y gastric bypass; SG = sleeve gastrectomy; VBG = vertical banded gastroplasty BMI Thresholds = Body Mass Index Thresholds kg = weight in kilograms m2 = height in meters squared Min Age= Minimum Age PM = Physiological maturity as indicated by Tanner stage IV and 95% of adult height based on bone age. PM corresponds to ≥13 years for girls and ≥15 years for boys

N/A = Not applicable for this criterion, as bariatric surgery is not recommended for adolescents

LEGEND FOR FIGURE 2 NGC = National Guidelines Clearinghouse US = United States

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Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011;17 Suppl 2:1-53.

30.

31.

Orringer KA, Harrison RV, Nichani SS, et al. Obesity Prevention and Management. University of Michigan Health System; May 2014. Available at: http://www.med.umich.edu/1info/FHP/practiceguides/obesity/obesity.pdf Accessed March 18, 2015. Nguyen NT, Blackstone RP, Morton JM, et al. The ASMBS Textbook of Bariatric Surgery Volume 1: Bariatric Surgery. 2015; New York, NY: Springer.

32.

Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6(7).

33.

Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: Pathophysiology, consequences, prevention, and treatment. Circulation. 2005;111(15):1999-2012.

34.

Kelly AS, Barlow SE, Rao G, et al. Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: A scientific statement from the American Heart Association. Circulation. 2013;128(15):1689-1712.

35.

National Institutes of Health. Gastrointestinal surgery for severe obesity. Reprinted from NIH Consens Dev Conf Consens Statement; 1991. p. 1-20.

36.

Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004;114(1):217-223.

37.

Knaapen L. Being 'evidence-based' in the absence of evidence: The management of nonevidence in guideline development. Soc Stud Sci. 2013;43(5):681-706.

38.

Pratt JSA, Lenders CM, Dionne EA, et al. Best practice updates for pediatric/adolescent weight loss surgery. Obesity (Silver Spring). 2009;17(5):901-910.

39.

Michalsky M, Reichard K, Inge T, et al. ASMBS pediatric committee best practice guidelines. Surg. 2012;8(1):1-7.

40.

National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Full Report: U.S. Department of Health and Human Services, National Institutes of Health; 2012.

41.

Apovian CM, Baker C, Ludwig DS, et al. Best practice guidelines in pediatric/adolescent weight loss surgery. Obes Res. 2005;13(2):274-282.

42.

Barlow SE, The Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics. 2007;120 Suppl 4:S164-192.

43.

44.

45.

American Dietetic Association. Pediatric weight management evidence-based nutrition practice guideline. 2007. Available at: http://www.andeal.org/topic.cfm?format_tables=0&cat=2721. Accessed August 14, 2014. Fitch A, Fox C, Bauerly K, et al. Prevention and management of obesity for children and adolescents. Institute for Clinical Systems Improvement. July 2013. Available at: https://www.icsi.org/_asset/xlnkf7/obesitywebinar-claudiafox2013.pdf Accessed August 14, 2014. SAGES Guidelines Committee. SAGES guideline for clinical application of laparoscopic bariatric surgery. Surg Endosc. 2008;22(10):2281-2300.

46.

Institute for Clinical Systems Improvement. Prevention and Management of Obesity (Mature Adolescents and Adults). Fourth edition, January 2009.

47. 48.

Institute for Clinical Systems Improvement. Prevention and Management of Obesity (Mature Adolescents and Adults). Fifth edition, April 2011. August GP, Caprio S, Fennoy I, et al. Prevention and treatment of pediatric obesity: An Endocrine Society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab. 2008;93(12):4576-4599.

49.

Buchwald H, Consensus Conference Panel. Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. J Am Coll Surg. 2005;200(4):593-604.

50.

Hoelscher DM, Kirk S, Ritchie L, Cunningham-Sabo L, for the Academy Positions Committee. Position of the Academy of Nutrition and Dietetics: Interventions for the prevention and treatment of pediatric overweight and obesity. J Acad Nutr Diet. 2013;113(10):1375-1394.

51.

Kelleher DC, Merrill CT, Cottrell LT, Nadler EP, Burd RS. Recent national trends in the use of adolescent inpatient bariatric surgery: 2000 through 2009. JAMA Pediatr. 2013;167(2):126-132.

52.

Hamoui N, Anthone GJ, Kaufman HS, Crookes PF. Sleeve gastrectomy in the high-risk patient. Obes Surg. 2006;16(11):1445-1449.

53.

Till H, Blüher S, Hirsch W, Kiess W. Efficacy of laparoscopic sleeve gastrectomy (LSG) as a stand-alone technique for children with morbid obesity. Obes Surg. 2008;18(8):1047-1049.

54.

Childerhose JE, Tarini BA. Understanding outcomes in adolescent bariatric surgery. Pediatrics. 2015;136(2):e312-e314.

55.

Skinner AC, Perrin EM, Skelton JA. Prevalence of obesity and severe obesity in US children, 1999-2014. Obesity (Silver Spring). 2016;24(5):1116-1123.

56.

Inge TH, Xanthakos SA, Zeller MH. Bariatric surgery for pediatric extreme obesity: Now or later. Int J Obesity. 2007;31(1):1-14.

57.

Unguru Y. Making sense of adolescent decision-making: Challenge and reality. Adolesc Med State Art Rev. 2011;22(2):195-206, vii-viii.

TABLE 1. Characteristics of Recommendation Documents Year

Developer and Identified Authors / Experts

1991 National Institutes of Health (35) Consensus Development Panel: Scott M. Grundy (Conference and Panel Chairman), Jeremiah A. Barondess, N.J. Bellegie, Hans Fromm, Frank Greenway, Charles H. Halsted, Edward J. Huth, Shiriki K. Kumanyika, Efrain Reisin, Marie K. Robinson, June Stevens, Patrick L. Twomey.

Doc Target Surgery Procedures BMI MinAge Type Population Rationale Described Thresholds (kg/m2) CS

Adult + Ped

N/A

N/A

N/A

N/A

Year

Developer and Identified Authors / Experts

2005 Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety (41)

Doc Target Surgery Procedures BMI MinAge Type Population Rationale Described Thresholds (kg/m2) CPG Ped

Caroline M. Apovian, Christina Baker, David S. Ludwig, Alison G. Hoppin, George Hsu, Carine Lenders, Janey S.A. Pratt, R. Armour Forse, Adrienne O’Brien, Michael Tarnoff. 2005 American Society CS for Bariatric Surgery and the American Society for Bariatric Surgery Foundation (49) Consensus conference panel: Henry Buchwald (Chair), Charles J Billington, Katherine M Detre, Victor Garcia, Michael D Jensen, David E Kelley, Samuel Klein, J Patrick O’Leary, George F Sheldon, Thomas Wadden, Alan Wittgrove, Bruce M Wolfe.

Adult + Ped

No

RYGB, LAGB, BDP±DS, JB, VBG

≥ 40/50

PM

Yes

RYGB, LAGB, VBG, BPD±DS

≥ 35/40

-

Year

Developer and Identified Authors / Experts

2005 American Heart Association (33) Stephen R. Daniels, Donna K. Arnett, Robert H. Eckel, Samuel S. Gidding, Laura L. Hayman, Shiriki Kumanyika, Thomas N. Robinson, Barbara J. Scott, Sachiko St. Jeor, Christine L. Williams. 2007 American Dietetic Association (43) Pediatric Weight Management (Treatment) Work Group: Christina Biesemeier (Chair), Joyce Bittle, Nancy Copperman, Heather Holden Med, Shelly Kirk, Aida Miles, Lorrene Ritchie, Denise Sofka. Position paper authors: Lorrene D. Ritchie, Patricia B. Crawford, Deanna M. Hoelscher, Melinda S. Sothern.

Doc Target Surgery Procedures BMI MinAge Type Population Rationale Described Thresholds (kg/m2) PS

Ped

CPG Ped

No

RYGB

> 40/50

-

Yes

-

≥ 40/50

PM

Year

Developer and Identified Authors / Experts

2007 American Medical Association, Health Resources and Service Administration, Centers for Disease Control (42)

Lead Author: Sarah E. Barlow. Expert Committee Members: Heather Walter, Goutham Rao, Caroline R. Richardson, Reginald Washington, Jim Guillory, Steven Stovitz, Susan H. Laramee, Keith Oldham, James Sallis, Susan Sloan, Phyllis Speiser, Margaret Grey, Shirley Schantz, Flavia Mercado, Winston Price, Jeffrey B. Schwimmer. Treatment writing group members: Bonnie Spear, Sarah E. Barlow, Chris Ervin, David S. Ludwig, Brian E. Saelens, Karen E. Schetzina, Elsie M. Taveras.

Doc Target Surgery Procedures BMI MinAge Type Population Rationale Described Thresholds (kg/m2) CPG Ped

Yes

RYGB, LAGB

≥ 40/50

PM

Year

Developer and Identified Authors / Experts

2008 Endocrine Society

Doc Target Surgery Procedures BMI MinAge Type Population Rationale Described Thresholds (kg/m2) CPG Ped

Yes

RYGB, LAGB

> 40/50

-

CPG Adult + Ped

Yes

≥ 35/40

<18

CPG Adult + Ped

No

RYGB, VBG, LAGB, SG, BPD±DS VBG, LAGB, RYGB, BPD±DS, SG

≥ 35/40

PM

(48)

Gilbert P. August, Sonia Caprio, Ilene Fennoy, Michael Freemark, Francine R. Kaufman, Robert H. Lustig, Janet H. Silverstein, Phyllis W. Speiser, Dennis M. Styne, Victor M. Montori. 2008 Society of American Gastrointestinal and Endoscopic Surgeons (45) 2009 Institute for Clinical Systems Improvement (46) Work Group Leader: Angela Fitch. Work Group Members: Jennifer Goldberg, Tara Kaufman, Kathryn Nelson-Hund, Patrick O'Connor, Andrea Carruthers, Linda Haltner, Kathy Johnson, Claire Kestenbaun, Nancy Sherwood, Walt Medlin.

Year

Developer and Identified Authors / Experts

2009 Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety (38) Janey S.A. Pratt, Carine M. Lenders, Emily A. Dionne, Alison G. Hoppin, George L.K. Hsu, Thomas H. Inge, David F. Lawlor, Margaret F. Marino, Alan F. Meyers, Jennifer L. Rosenblum, Vivian M. Sanchez.

Doc Target Surgery Procedures BMI MinAge Type Population Rationale Described Thresholds (kg/m2) CPG Ped

Yes

RYGB, LAGB, SG, BPD, DS

≥ 35/40

PM

Year

Developer and Identified Authors / Experts

2011 Institute for Clinical Systems Improvement (47)

Doc Target Surgery Procedures BMI MinAge Type Population Rationale Described Thresholds (kg/m2) CPG Adult + Ped

Work Group Leader: Angela Fitch. Work Group Members: Roxana Merz, Jennifer Goldberg, Tara Kaufman, Mike Lano, Kathryn Nelson-Hund, Patrick O'Connor, Andrea Carruthers, Linda Haltner, Bridget Slusarek, Kathy Johnson, Claire Kestenbaun, Nancy Sherwood, Steven Stovitz, Sayeed Ikramuddin. 2012 American Society PS for Metabolic and Bariatric Surgery (39)

Marc Michalsky (Chair), Kirk Reichard, Thomas Inge, Janey Pratt, Carine Lenders.

Ped

Yes

RYGB, LAGB, SG, DS

≥ 35/40

18+

Yes

RYGB, AGB, SG, BPD, DS

≥ 35/40

-

Year

Developer and Identified Authors / Experts

2012 National Health, Lung, and Blood Institute (40)

Doc Target Surgery Procedures BMI MinAge Type Population Rationale Described Thresholds (kg/m2) CPG Ped

Stephen R. Daniels (Panel Chair), Irwin Benuck, Dimitri A. Christakis, Barbara A. Dennison, Samuel S. Gidding, Matthew W. Gillman, Mary Margaret Gottesman, Peter O. Kwiterovich, Patrick E. McBride, Brian W. McCrindle, Albert P. Rocchini, Elaine M. Urbina, Linda V. Van Horn, Reginald L. Washington. 2013 Academy of PS Nutrition and Dietetics (50) Deanna M. Hoelscher, Shelley Kirk, Lorrene Ritchie, Leslie CunninghamSabo.

Ped

No

-

≥ 35/40

12-21

No

RYGB, LAGB, SG

≥ 35/40

-

Year

Developer and Identified Authors / Experts

2013 Institute for Clinical Systems Improvement (44) Authors: Fitch A, Fox C, Bauerly K, Gross A, Heim C, Judge-Dietz J, Kaufman T, Krych E, Kumar S, Landin D, Larson J, Leslie D, Martens N, Monaghan-Beery N, Newell T, O’Connor P, Spaniol A, Thomas A, Webb B. Work Group Leaders: Angela Fitch and Claudia K. Fox. Work Group Members;, Nancy K. Monaghan-Beery, Jessica N. Larson, Tracy Newell, Patrick J. O'Connor, Andrew J. Thomas, Tara Kaufman, Esther Krych, Seema Kumar, Jo Anne Judge-Dietz, Amber Spaniol, Nicole Martens, Kathleen Bauerly, Amy C. Gross, Dan Leslie, Deborah F. Landin.

Doc Target Surgery Procedures BMI MinAge Type Population Rationale Described Thresholds (kg/m2) CPG Ped

Yes

RYGB, LAGB, SG

≥ 35/40

PM

Year

Developer and Identified Authors / Experts

2013 American Heart Association (34)

Doc Target Surgery Procedures BMI MinAge Type Population Rationale Described Thresholds (kg/m2) PS

Ped

Yes

RYGB, AGB, SG, BPD, DS

-

-

Aaron S. Kelly (Co-Chair), Sarah E. Barlow (CoChair), Goutham Rao, Thomas H. Inge, Laura L. Hayman, Julia Steinberger, Elaine M. Urbina, Linda J. Ewing, Stephen R. Daniels. Doc Type = Document Type CPG = Clinical Practice Guideline; PS = Position Statement; CS = Consensus Statement Target Population: Adult +Ped = Adult and Pediatric; Ped = Pediatric only (children, adolescents, or children and adolescents) Surgery Rationale: Yes = Developer provides 1 or more rationales for performing bariatric surgery on minors; No = Developer does not provide a rationale for performing bariatric surgery on minors Procedures Described: AGB = adjustable gastric banding; BPD = biliopancreatic diversion without duodenal switch; BPD/DS = biliopancreatic diversion with duodenal switch; BPD±DS = biliopancreatic diversion with or without duodenal switch; DS = duodenal switch; JB = jejunoileal bypass; LAGB = laparoscopic adjustable gastric banding; RYGB = Roux-en-Y gastric bypass; SG = sleeve gastrectomy; VBG = vertical banded gastroplasty BMI Thresholds = Body Mass Index Thresholds kg = weight in kilograms m2 = height in meters squared Min Age = Minimum Age PM = Physiological maturity as indicated by Tanner stage IV and 95% of adult height based on bone age. PM corresponds to ≥13 years for girls and ≥15 years for boys N/A = Not applicable for this criterion, as bariatric surgery is not recommended for adolescents

TABLE 2. Recommendation Documents by Category of Developer Category

Year

Developer

Medical (n = 9)

2005 2005 2007

American Dietetic Association American Heart Association American Medical Association, Health Resources and Service Administration, Centers for Disease Control Endocrine Society Institute for Clinical Systems Improvement Institute for Clinical Systems Improvement Academy of Nutrition and Dietetics American Heart Association Institute for Clinical Systems Improvement American Society for Bariatric Surgery and the American Society for Bariatric Surgery Foundation Society of American Gastrointestinal and Endoscopic Surgeons American Society for Metabolic and Bariatric Surgery National Institutes of Health Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety National Heart, Lung, and Blood Institute

Surgical (n = 3)

2008 2009 2011 2013 2013 2013 2005 2008

Public health / Governmental (n = 4)

2012 1991 2005 2009 2012

FIGURE 1. Medline Search Strategy 1. exp Bariatric Surgery/ 2. (bariatric and surg*).ab,ti. 3. exp Gastroenterostomy/ 4. Gastroenterostomy.ab,ti. 5. gastroenterostomies.ab,ti. 6. billroth I.ab,ti. 7. billroth II.ab,ti. 8. "metabolic surg*".ab,ti. 9. (stomach and stap*).ab,ti. 10. (metabolic and surg*).ab,ti. 11. wls.ab,ti. 12. gastric bypass.ab,ti. 13. Gastroplasty.ab,ti. 14. Lipectomy.ab,ti. 15. exp Anastomosis, Roux-en-Y/ 16. Roux-en-Y.ab,ti. 17. RYGB.ab,ti. 18. (sleeve and gastrectom*).ab,ti. 19. (gastric and band*).ab,ti. 20. LAGB.ab,ti. 21. LRYGB.ab,ti. 22. LSG.ab,ti. 23. JIB.ab,ti. 24. exp Gastric Bypass/ 25. (bariatric and (procedure* or operation*)).ab,ti. 26. "greenville gastric bypass".ab,ti. 27. gastroileal bypass.ab,ti. 28. "gastrojejunostom*".ab,ti. 29. "gastroplast*".ab,ti. 30. (Jejunoileal and Bypass*).ab,ti. 31. (jejuno-ileal and bypass*).ab,ti. 32. (ileojejunal and bypass*).ab,ti. 33. (intestinal and bypass*).ab,ti. 34. exp Lipectomy/ 35. "lipectom*".ab,ti. 36. "liposuction*".ab,ti. 37. "lipoplast*".ab,ti. 38. (stomach and band*).ab,ti. 39. (adjustable and silicone and band*).ab,ti. 40. exp Weight Reduction Programs/ 41. weight reduction programs.ab,ti. 42. ("weight loss surger*" or "weight-loss surger*").ab,ti.

43. "surg*".ab,ti. 44. (weight and management).ab,ti. 45. (weight and maintenance).ab,ti. 46. exp Biliopancreatic Diversion/ 47. Biliopancreatic Diversion.ab,ti. 48. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 49. exp Practice Guideline/ 50. Guidelines as Topic/ 51. exp Practice Guidelines as Topic/ 52. exp Guideline/ 53. "guideline*".ab,ti. 54. exp Health Planning Guidelines/ 55. "health planning guide*".ab,ti. 56. exp Clinical Protocols/ 57. "clinical protocol*".ab,ti. 58. "practice parameter*".ab,ti. 59. exp Consensus Development Conference/ 60. exp Consensus Development Conference, NIH/ 61. exp Consensus Development Conferences as Topic/ 62. consensus.ab,ti. 63. "recommendation*".ab,ti. 64. "best practice*".ab,ti. 65. exp Advisory Committees/ 66. "advisory committee*".ab,ti. 67. "expert committee*".ab,ti. 68. "expert panel*".ab,ti. 69. "scientific statement*".ab,ti. 70. "position paper* ".ab,ti. 71. 49 or 50 or 51 or 52 or 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 or 68 or 69 or 70 72. exp Obesity/ 73. "obes*".ab,ti. 74. exp Body Mass Index/ 75. bmi.ab,ti. 76. "body mass index".ab,ti. 77. exp Body Weight/ 78. "body weight".ab,ti. 79. body size.ab,ti. 80. exp Body Constitution/ 81. "body constitution".ab,ti. 82. body composition.ab,ti. 83. exp Overnutrition/

84. overnutrition.ab,ti. 85. overweight.ab,ti. 86. over-weight.ab,ti. 87. prader-willi syndrome.ab,ti. 88. "body surface area".ab,ti. 89. waist-hip ratio.ab,ti. 90. adiposity.ab,ti. 91. fat.ab,ti. 92. sagittal abdominal diameter.ab,ti. 93. waist circumference.ab,ti. 94. "quetelet* index".ab,ti. 95. "body weight changes".ab,ti. 96. weight gain.ab,ti. 97. weight loss.ab,ti. 98. 72 or 73 or 74 or 75 or 76 or 77 or 78 or 79 or 80 or 81 or 82 or 83 or 84 or 85 or 86 or 87 or 88 or 89 or 90 or 91 or 92 or 93 or 94 or 95 or 96 or 97 99. 48 and 71 and 98 100. limit 99 to (english language and humans)

FIGURE 2. PRISMA (Preferred Reporting Items for Systematic Reviews and Metaanalyses) Flowchart of Document Selection Process

Identification

Records identified (n = 7,727)  

Duplicate records removed (n = 206)

Records identified through database searching (NGC, Embase, Trip, and Medline)(n = 7,615) Additional records identified through hand search (n = 112)

Records excluded based on title, title + abstract (n = 7,030)

Screening

Full-text records remaining after duplicates removed (n = 7,521)     

NGC (n = 250) Embase (n = 3,147) Trip (n = 645) Medline (n = 3,411) Hand search (n = 68)

Full-text records assessed for eligibility (n = 481)

Missing records excluded (could not screen) (n = 10)

Full-text records excluded with reasons (n = 465)

Eligibility

    

Included

   Documents retained for analysis (n = 16)

NGC = National Guidelines Clearinghouse US = United States

Not English (n = 2) Not US developer (n = 41) Not a recommendation document (n = 167) No 1-sentence recommendation for bariatric surgery (n = 132) No 1-sentence recommendation for pediatric or adolescent bariatric surgery (n = 70) Duplicate of excluded (n = 26) Duplicate of retained (n = 11) Rescreened with inclusion criteria (n = 16)

FIGURE 3. Target Population and Treatment Focus of Recommendation Documents, by Year and Developer

Pediatric population (n = 11)

Surgical treatment of obesity (n = 6)

Obesity prevention and treatment, weight management, cardiovascular disease, or nutrition (n = 10)



  

 

Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety (2005) Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety (2009) American Society for Metabolic and Bariatric Surgery (2012)

   

Combined population (n = 5)

  

National Institutes of Health (1991) American Society for Bariatric Surgery and the American Society for Bariatric Surgery Foundation (2005) Society of American Gastrointestinal and Endoscopic Surgeons (2008)

  

American Heart Association (2005) American Dietetic Association (2007) American Medical Association, Health Resources and Service Administration, Centers for Disease Control (2007) Endocrine Society (2008) National Health, Lung, and Blood Institute (2012) Academy of Nutrition and Dietetics (2013) Institute for Clinical Systems Improvement (2013) American Heart Association (2013) Institute for Clinical Systems Improvement (2009) Institute for Clinical Systems Improvement (2011)