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Outcomes of in Older Versus Younger Adolescents Sarah B. Ogle, DO, MS,a Lindel C. Dewberry, MD,a Todd M. Jenkins, PhD, MPH,b Thomas H. Inge, MD, PhD,a Megan Kelsey, MD,a Matias Bruzoni, MD,c Janey S.A. Pratt, MDc

OBJECTIVES: In this report, we compare , comorbidity resolution, nutritional abstract abnormalities, and quality of life between younger and older adolescents after metabolic and bariatric surgery. METHODS: From March 2007 to December 2011, 242 adolescents (#19 years of age) who underwent bariatric surgery at 5 clinical centers in the were enrolled in the prospective, multicenter, long-term outcome study Teen–Longitudinal Assessment of Bariatric Surgery. Outcome data from younger (13–15 years; n = 66) and older (16–19 years; n = 162) study participants were compared. Outcomes included percent BMI change, comorbidity outcomes (, dyslipidemia, and type 2 mellitus), nutritional abnormalities, and quality of life over 5 years post surgery. RESULTS: Baseline characteristics, except for age, between the 2 cohorts were similar. No significant differences in frequency of remission of hypertension (P = .84) or dyslipidemia (P = .74) were observed between age groups. Remission of mellitus was high in both groups, although statistically higher in older adolescents (relative risk 0.86; P = .046). Weight loss and quality of life were similar in the 2 age groups. Younger adolescents were less likely to develop elevated transferrin (prevalence ratio 0.52; P = .048) and low vitamin D levels (prevalence ratio 0.8; P = .034). CONCLUSIONS: The differences in outcome of metabolic and bariatric surgery between younger and older adolescents were few. These data suggest that younger adolescents with severe should not be denied consideration for surgical therapy on the basis of age alone and that providers should consider adolescents of all ages for surgical therapy for obesity when clinically indicated.

’ aChildren’s Hospital Colorado and School of , University of Colorado, Aurora, Colorado; bCincinnati WHAT S KNOWN ON THIS SUBJECT: Bariatric surgery is Children’s Hospital Medical Center, Cincinnati, Ohio; and cLucile Packard Children’s Hospital Stanford, Palo Alto, an effective, durable treatment of severe obesity in California adolescents, with results generally similar to or surpassing those for adults. However, little is known Dr Ogle conceptualized and designed the study, contributed to data interpretation, drafted the initial about the relative merits and risks of these procedures in manuscript, and critically reviewed the manuscript for important intellectual content; Dr Dewberry younger teenagers compared with older adolescents. conceptualized and designed the study and reviewed and revised the manuscript; Dr Jenkins designed the data collection instruments, collected data, conducted the analyses, contributed to WHAT THIS STUDY ADDS: We found that younger and data interpretation, and reviewed and revised the manuscript; Dr Inge conceptualized and designed older adolescents had similar weight loss, resolution of the study, contributed to data interpretation, obtained funding for the study, and critically reviewed hypertension and dyslipidemia, nutritional deficiencies, the manuscript for important intellectual content; Dr Kelsey contributed to data interpretation and and improvement in quality of life after surgery. Age alone critically reviewed the manuscript for important intellectual content; Dr Bruzoni conceptualized and should not dissuade providers and patients from designed the study, contributed to data interpretation, and reviewed and revised the manuscript; Dr pursuing surgery when medically indicated. Pratt conceptualized and designed the study, contributed to data interpretation, and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. To cite: Ogle SB, Dewberry LC, Jenkins TM, et al. Outcomes of Bariatric Surgery in Older Versus Younger Adolescents. . 2021;147(3):e2020024182

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 147, number 3, March 2021:e2020024182 ARTICLE Over recent decades, the global health postoperative instructions is a critical micronutrient status31 (ferritin, folate, and economic burden of obesity has barrier to treatment of severe obesity, vitamin B12, vitamin D, vitamin A, and continued to rise rapidly in both resulting in less than half of primary parathyroid ), and quality- developing and developed nations.1,2 care physicians considering referral of-life metrics (Impact of Weight on In the United States, obesity affects for pediatric patients.23,24 Data on Quality of Life [IWQOL] total score 13.7 million children, of whom 6% long-term outcomes after MBS in and 36-Item Short Form Health meet the definition of having severe younger adolescent or preadolescent Survey (SF-36) physical and mental obesity.3,4 Obesity has been linked to patients are limited, and outcomes in component scores) were evaluated. numerous complications involving the youngest children have only been Because of the small number of every body system.5,6 The rise of reported in case reports from outside participants who underwent – has brought an the United States.21,25 28 Comparative laparoscopic adjustable gastric emergence of chronic diseases once studies of adult and adolescent banding (n = 14), only those who only present in adulthood (eg, outcomes after MBS reveal similar underwent Roux-en-Y gastric bypass hypertension, dyslipidemia, and type weight loss and superior comorbidity (RYGB) (n = 161) or vertical sleeve 2 diabetes mellitus) and associated resolution in the adolescent gastrectomy (n = 67) were analyzed. with a decreased life expectancy of 5 population. To explore potential age- The clinical care of participants was to 20 years.7,8 Intensive medical and related differences in MBS outcomes at the discretion of the clinicians lifestyle interventions for the between older and younger at the centers where enrollment treatment of obesity have adolescents, we divided the occurred and was not dictated by demonstrated an average of 5% to Teen–Longitudinal Assessment of research protocol. Clinical care 15% weight loss, with variable results Bariatric Surgery (Teen-LABS) study – generally followed national guideline in sustainability.9 11 Alternatively, cohort into a younger and older group recommendations. Informed, written metabolic and bariatric surgery and compare weight loss, comorbidity consent was obtained from caregivers (MBS) has been shown to be an change, nutritional deficiencies, and and/or participants as appropriate effective and durable treatment for quality of life over 5 years.13,29 on the basis of age at the time of obesity and complications of obesity enrollment. Reconsenting was done in adolescents, with weight loss and METHODS when each participant reached the health improvements far surpassing age of 18. Study protocols, consents, those achieved with nonsurgical Teen-LABS is a multicenter – and data and safety monitoring were treatments.12 17 The most recent prospective observational study in approved by all institutional sites update of the pediatric American which 242 adolescents (#19 years of (Nationwide Children’s Hospital in Society for Metabolic and Bariatric age) were enrolled between 2007 and Columbus, OH; Cincinnati Children’s Surgery guidelines removed the 2011. Participants underwent MBS Hospital Medical Center in Cincinnati, recommendation of achieving adult between 2007 and 2012. Study OH; Texas Children’s Hospital in height or pubertal maturity before details, research methods, diagnostic Houston, TX; University of Pittsburgh pursuing MBS, thereby eliminating criteria, and data collection have Medical Center in Pittsburgh, PA; and younger age restrictions.12 previously been described and are Children’s of Alabama in Birmingham, available at ClinicalTrials.gov AL) and an independent data and In a recent policy statement, the (identifier NCT00474318).17,30 safety monitoring board before study American Academy of Pediatrics Baseline data were collected within initiation. Ongoing review of study advocates for increased use of and 30 days of MBS. Participants were performance and safety has been access to MBS for pediatric patients then evaluated at 6 months, 12 done by the data and safety and acknowledges insufficient months, and then annually, and monitoring board from 2007 to evidence to support age-based outcomes were evaluated up to present day. limitations for eligibility.18,19 5 years after surgery. During this time Evidence of the safety and frame, 230 of the 242 (95%) For this analysis, the Teen-LABS effectiveness of MBS in young participants remained as active study cohort was arbitrarily divided into adolescents and children is participants, completing 86% (1254 2 age groups: age 13 to 15 years increasing, but it is estimated that of 1452) of all postoperative research and age 16 to 19 years at the time ,1% of eligible pediatric patients visits. Baseline demographic, of surgery. Age group–specific undergo MBS for the treatment of anthropometric, and comorbidity categorical measures were presented – severe obesity.14,16 22 Hesitancy to data were obtained by trained study as frequencies and percentages refer due to concerns of safety, impact staff. Specifically, changes in 3 major and were compared by using x2 on growth, ethical concerns with comorbidities (hypertension, tests. Continuous variables were patient assent, and compliance with dyslipidemia, and type 2 diabetes), summarized by using means and SDs,

Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 OGLE et al and t tests were used to compare by RESULTS Fig 1), remained stable between years age group. Baseline BMI was 1 and 2 (P = .16), and then similarly, calculated as kilograms divided by Baseline Description of Participants but significantly, increased in both height (meters) squared. Linear The overall cohort was groups thereafter (P , .01). Five mixed models were used to compare predominantly female (75%) and years after surgery, the percentage the following outcomes by age group: white (72%) and had a mean baseline BMI change from baseline was similar percentage weight change from BMI of 52.6. Most participants between younger (222.2%; 95% CI: baseline, IWQOL total score, SF-36 underwent RYGB, as shown in 226.2% to 218.2%) and older physical composite score, and SF-36 Table 1. The younger cohort (n = 66) (224.6%; 95% CI: 227.7% to mental composite score. Poisson was 13 to 15 years of age at the time 222.5%) adolescents (P = .59). mixed modeling with robust error of surgery and had an average age of variance was used to compare 15.1 6 0.81 years and an average BMI Hypertension comorbidity (type 2 diabetes, of 53.1 6 11. The older cohort (n = Baseline prevalence of hypertension hypertension, and dyslipidemia) 162) was 16 to 19 years of age at the was 27% (n = 18) in younger remission and prevalence of time of surgery and had an average adolescents and 37% (n = 59) in micronutrient abnormalities by study age of 17.7 6 1 years and an average older adolescents (P = .16). At cohort. For all models, the following BMI of 52.4 6 9. In Table 1, we 5 years, remission of hypertension variables were considered for present baseline demographic and was achieved by 77% (95% CI: 57.1% inclusion in the final model: age clinical characteristics by age to 100.0%) of younger adolescents group, study visit, age group by visit grouping. and 67% (95% CI: 54.5% to 81.5%) interaction, sex, race, and baseline of older adolescents (Fig 1). After caregiver education. Percentage BMI Percentage Weight Loss Over 5 Years adjustment, postoperative change, quality-of-life metrics, and After Surgery hypertension remission was similar comorbidity prevalence were BMI significantly declined from by age group (P = .84). Five years adjusted for BMI. Remission of baseline until 1 year post surgery after surgery, the incidence of hypertension was adjusted for (group by time interaction, P = .60; hypertension in the younger group percentage BMI change, baseline hypertension medications, and TABLE 1 Baseline Characteristics by Age at Surgery baseline blood pressure. Remission Ages 13–15 y Ages 16–19 y P of dyslipidemia was adjusted for (n = 66) (n = 162) percentage BMI change, baseline lipid Age at surgery, mean (SD), y 15.1 (0.81) 17.7 (1.04) ,.001 medications, and baseline lipid levels. Female sex, % (n) 72.7 (48) 75.9 (123) .61 Remission of type 2 diabetes was White, % (n) 72.7 (48) 71.6 (116) .86 adjusted for percentage BMI change, Non-Hispanic, % (n) 97.0 (64) 91.4 (148) .16 baseline diabetes medications, Surgical procedure, % (n) .14 — baseline hemoglobin A1c levels, RYGB 63.6 (42) 73.5 (119) VSG 36.4 (24) 26.5 (43) — and duration of disease. For each income, % (n) .31 outcome, modeled estimates and ,$25 000 34.4 (22) 39.6 (61) — 95% confidence intervals (CIs) were $25 000–$74 999 34.4 (22) 39.0 (60) — calculated by age group and study $75 0001 31.3 (20) 21.4 (33) — visit. These models addressed Caregiver education attained .98 Less than high school 10.8% (7) 10.3% (16) — missing values by maximum High school graduate 30.8% (20) 30.8% (48) — likelihood estimation under the Some college 41.5% (27) 39.7% (62) — data missing at random assumption. College graduate or higher 16.9% (11) 19.2% (30) — Weight values from peripartum Wt, mean (SD), kg 148.6 (31.88) 148.9 (31.05) .95 female participants were omitted BMI, mean (SD) 53.1 (10.75) 52.4 (8.79) .66 Systolic BP, mean (SD), mm Hg 121.5 (12.53) 126.8 (13.31) .007 from analyses if obtained between the Diastolic BP, mean (SD), mm Hg 71.2 (8.96) 75.4 (10.27) .004 second trimester and 6 months post Type 2 diabetes, % (n) 10.6 (7) 13.6 (22) .54 partum. All statistical analyses were Hypertension, % (n) 27.3 (18) 37.1 (59) .16 conducted by using SAS version 9.4 Dyslipidemia, % (n) 73.4 (47) 77.0 (124) .57 (SAS Institute, Inc, Cary, NC); all IWQOL total score, mean (SD) 64.1 (17.75) 61.7 (18.16) .37 P SF-36 physical composite score, mean (SD) 44.8 (9.47) 43.9 (8.12) .49 reported values were 2 sided and SF-36 mental composite score, mean (SD) 50.0 (10.33) 49.2 (10.34) .59 considered statistically significant , Baseline demographics, anthropometrics, comorbidity status, and quality-of-life metrics for both age groups were similar, when .05. No adjustments were with the exception of age and BP, which were significantly different at P , .05. BP, blood pressure; VSG, vertical sleeve made for multiple comparisons. gastrectomy; —, not applicable.

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 147, number 3, March 2021 3 FIGURE 1 Percentage BMI change and comorbidity resolution over 5 years after MBS. A, Percentage BMI change from baseline. B, Remission of hypertension. C, Remission of dyslipidemia. D, Remission of type 2 diabetes mellitus. Younger adolescents were less likely to achieve remission of diabetes (P = .046). Error bars indicate 95% CIs. was 8% (n = 5), compared with 2% adolescents and 4% (n = 6) of older type 2 diabetes was rare and present (n = 4) in the older group. adolescents. in 4.5% (n = 1) of older adolescents and 0% (n = 0) of younger Dyslipidemia Type 2 Diabetes Mellitus adolescents. Baseline prevalence of dyslipidemia Baseline prevalence of type 2 was 73% (n = 47) in younger diabetes was 11% (n = 7) in younger Nutritional Abnormalities adolescents and 77% (n = 124) in adolescents and 14% (n = 22) in Compared with baseline, prevalence older adolescents (P = .57). Five-year older adolescents (P = .54). Remission of abnormal ferritin, transferrin, dyslipidemia remission was 61% of type 2 diabetes was achieved by vitamin B12, and vitamin A levels (95% CI: 46.3% to 81.1%) among 83% (n = 6) of young adolescents and significantly increased by 5 years post younger adolescents and 58% (95% 87% (n = 15) of older adolescents by surgery. However, over 5 years post CI: 48.0% to 68.9%) among older 5 years. Adjusted analyses revealed surgery, only prevalence of elevated adolescents (Fig 1). Over the 5-year that over the 5-year postoperative transferrin levels and vitamin D postoperative period, there was no period, younger adolescents were less deficiency was significantly different significant difference in remission likely to achieve remission compared by age group (Fig 2). Specifically, between age groups (P = .74). with older adolescents (relative risk younger adolescents were less likely Incidence of dyslipidemia at 5 years 0.86 [95% CI: 0.74 to 0.99]; P = .046). to have elevated transferrin levels occurred in 2% (n = 1) of younger Five years after surgery, incidence (prevalence ratio [PR] 0.52 [95% CI

Downloaded from www.aappublications.org/news by guest on September 28, 2021 4 OGLE et al 0.27 to 0.99]; P = .048) and low the timing of surgery and extended weight loss or stabilization in vitamin D levels (PR 0.80 [95% CI long-term durability.32 Alqahtani with severe obesity.35 Increased 0.65 to 0.98]; P = .034) compared et al21 retrospectively reviewed MBS duration of obesity is linked to with older adolescents. outcomes at a single center in increased mortality, cardiovascular patients aged .14 and #14 years risk, and risk of type 2 diabetes; Quality of Life and noted that although the older therefore, the BMI requirements for Quality-of-life measures evaluated in cohort had superior weight loss at pediatric patients with complications this study included the IWQOL total 1 year after surgery, there were no of obesity have been reduced to score by visit, the SF-36 physical significant differences at years 2 to 120% of the 95th percentile for composite score by visit, and the SF- 5 after surgery, and the groups age, allowing for earlier intervention 36 mental composite score by visit had similar rates of comorbidity before surgery alone may become – (Supplemental Figs 3–5). For each resolution, complications, and ineffective.36 39 measure, values significantly mortality. Therefore, this analysis improved by 6 months (each P , .05) confirms similar findings, in a Using MBS for the purpose of and remained similar thereafter. The slightly older age range, to those by resolving or improving complications trajectory of change for each measure Alqahtani et al21 within a multicenter of obesity carries significant positive did not differ by age group, nor were prospective observational data set. health benefits. This study revealed there any group differences observed. remission rates for hypertension and In this study, differences in dyslipidemia in younger and older percentage BMI loss were not adolescents similar to those found by DISCUSSION identified between the older and Alqahtani et al.21 Michalsky et al40 In this analysis, we identified similar younger groups. The average BMI in previously explored cardiovascular improvement to percentage BMI loss, each cohort was 53, indicating late risk prevalence and reduction after resolution of hypertension and referral in both age groups. Alqahtani MBS in the Teen-LABS cohort. dyslipidemia, and quality of life over et al21 also had similar percentage Comparative studies between adults 5 years after MBS between younger BMI loss; however participants had and adolescent patients reveal higher and older adolescents. We found a lower baseline BMI. Ability to rates of comorbidity resolution after a lower likelihood of nutritional achieve a normal BMI after MBS is surgery in adolescents, likely due deficiencies in younger adolescents. related to baseline BMI; therefore, to shorter duration of disease.13,41–43 Diabetes remission was slightly what may be more important for Resolution of cardiac risk factors with higher, although statistically postoperative success is intervening MBS is compelling because authors of significant, in older youth. These at a lower BMI rather than a specific previous studies have warned that results appear promising for the age.33,34 Surgical intervention at childhood hypertension generally treatment of severe obesity in young a lower BMI is particularly important persists in adulthood and leads to patients; however, further controlled because current medical treatments a significant increase in studies are needed to fully evaluate have limited success in resulting in .36,44,45

FIGURE 2 Micronutrient status over 5 years after MBS and age group associations with micronutrient abnormalities. Micronutrient status was similar over 5 years after surgery. Younger adolescents were less likely to have elevated transferrin (P = .048) or low vitamin D (P = .034) levels compared with older adolescents. Bars represent 95% CIs. Box symbols represent PRs.

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 147, number 3, March 2021 5 Extended long-term studies are hesitation to pursue MBS in understand the risks, benefits, and needed to evaluate the full potential adolescents for the treatment of type lifelong lifestyle changes that come benefit of early cardiovascular risk 2 diabetes. with MBS. However, the alternative of reduction with MBS in pediatric delaying MBS and managing severe In addition to the medical patients; however, in adult studies, obesity with less effective therapies, complications of obesity, obesity also researchers estimate a near 50% risk exposing pediatric patients to has detrimental effects on quality of reduction of myocardial infarction, insufficiently studied medications life. In the current study, we identified 33% to 50% risk reduction of stroke, for obesity and to comorbidities, a significant improvement in quality and .50% risk reduction of and increasing the exposure risk – of life in both age groups after MBS. after a cardiovascular event.46 48 of obesity to the ’s health may Long-term potential learning, provide an even greater ethical earnings, and opportunity can be The difference in remission of type challenge.64,67 The morbidity and impacted by obesity bias, obesity- 2 diabetes in younger and older mortality of MBS has improved with related cognitive or mental health adolescents was small, and with time and is now comparable to that impairments, and absenteeism a sample size of only 7 individuals of a laparoscopic cholecystectomy.11 secondary to chronic obesity-related in the younger adolescent group, it – Early comparisons between adult and health problems.56 63 Although no would not be appropriate to provide adolescent patients initially revealed extended long-term studies decades any recommendation on the basis of a potentially higher complication rate after MBS in the pediatric populations these preliminary data. Patients with in adolescents that may have been exist to evaluate the impact of type 2 diabetes in the Teen-LABS attributed to surgeon experience, increased quality of life on school study had an overall remission rate case volume, or increased use of performance, occupational of 86% (95% CI: 85 to 100), RYGB rather than patient age.13,43 opportunity, earnings, and overall comparable to similar MBS studies in However, more recent adolescent 17,20,21,42,49 psychosocial health, it could be adolescents. In a similar- studies reveal lower rates of 21 theorized that early intervention may sized group, Alqahtani et al found complications in comparison with limit the exposure risk of obesity and a higher baseline prevalence but adults and comparable complication provide early referral to trained similar rates of remission of type rates in both younger and older pediatric psychologists integrated 2 diabetes in older adolescents pediatric patients.21,25,41,42 Family into pediatric MBS programs and compared with younger adolescents. involvement is more common and access to long-term mental health The average age at type 2 diabetes necessary in the youngest patients follow-up.64 diagnosis is 13.6 years in pediatric to ensure compliance with patients, presenting a significant long- As MBS has become recognized as the supplements and access to healthy term health burden and risk of early safest and most effective treatment of foods. Older adolescents are at risk 50,51 mortality. Despite more rapidly severe obesity in adults, it initially for noncompliance as they transition progressive b- failure in youth was recommended that surgery be to adulthood and self-independence, with type 2 diabetes, youth with type delayed until patients could reach emphasizing the need for long- 2 diabetes have higher remission physical maturity, were of an age term follow-up for this unique rates after MBS than adult patients to consent to lifelong altering population.31,68 It is possible that undergoing bariatric surgery or procedures, and to avoid the risk of earlier initiation of postoperative those receiving maximum medical a surgery or potential nutritional habits and increased supervision 13,15,38,41,43,52,53 therapy. Improvement deficiencies. Here we demonstrate in the younger cohort lead to the in glycemic control and lower rates of the 2 most common pattern of nutritional deficiencies sensitivity after MBS leads to the nutritional deficiencies (vitamin D seen in this study and may support reversal or stabilization of many and iron) in younger adolescents and a role for earlier intervention. diabetes complications.53 Patients no differences in other nutritional with obesity and deficiencies between groups. Thus, Limitations of this study include the also benefit from MBS by reducing the risk of nutritional deficiency is observational nature of the study, insulin requirements and improving not a reason to delay surgery in lack of randomization, and potentially complications of diabetes; however, young adolescents. More recent subtle differences in care or glycemic control remains challenging studies have refuted common technique across the 5 participating in these individuals. Furthermore, concerns regarding the safety of institutions, although center effect MBS appears to prevent incident type MBS in pediatric patients and have was accounted for in the statistical 2 diabetes.54,55 As such, the authors revealed increased linear growth models. However, Teen-LABS data do not feel that the minor statistical after MBS.11,12,21,29,65,66 Arguably, the were collected prospectively by using differences in this analysis warrant youngest patients are unable to fully rigorous data collection methods.

Downloaded from www.aappublications.org/news by guest on September 28, 2021 6 OGLE et al Some analyses were based on small quality of life.5–8,46,69 MBS currently dedication and expertise. We also sample sizes (eg, type 2 diabetes), represents the most effective and thank the study participants for and results should be interpreted durable, yet underused, treatment of their long-term contributions, which with caution. Additionally, many severe obesity and complications of have made this research project studies of MBS, including this one, obesity in thoughtfully selected successful. have a greater percentage of white children.12,22,65,70 The findings in this and female patients, which limits the study support the use of early generalizability. Furthermore, lack of intervention based on clinical ABBREVIATIONS extended longitudinal studies indication rather than age alone, CI: confidence interval decades after MBS in this population thereby providing the patient with IWQOL: Impact of Weight on limits our current ability for fully the best opportunity to reach Quality of Life assess the long-term risk/ a normal BMI after surgery, MBS: metabolic and bariatric benefit ratio. promoting resolution of surgery complications of obesity, and PR: prevalence ratio reducing the number of obese years CONCLUSIONS RYGB: Roux-en-Y gastric bypass in a child’s lifetime. Obesity and duration of obesity are SF-36: 36-Item Short Form Health significant risk factors for early Survey mortality, type 2 diabetes, ACKNOWLEDGMENTS Teen-LABS: Teen–Longitudinal cardiovascular events, multiple We thank the Teen-LABS study Assessment of Bariat- , end-stage renal disease, end- coordinators and data coordinating ric Surgery stage disease, and decreased center staff for their ongoing

Deidentified individual participant data (including data dictionaries) are available via the National Institute of Diabetes and Digestive and Kidney Diseases Central Repository (https://repository.niddk.nih.gov/home). This trial has been registered at www.clinicaltrials.gov (identifier NCT00474318). DOI: https://doi.org/10.1542/peds.2020-024182 Accepted for publication Dec 4, 2020 Address correspondence to Janey S.A. Pratt, MD, Division of Pediatric Surgery, Department of Surgery, Stanford University Medical Center, 300 Pasteur Dr, Alway Building, Room M116, MC 5733, Stanford, CA 94305. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2021 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Funded by National Institute of Diabetes and Digestive and Kidney Diseases grants UM1DK072493 (University of Colorado) and UM1DK095710 (Universityof Cincinnati). The study was also supported by grants UL1TR000077-04 (Cincinnati Children’s Hospital Medical Center), UL1RR025755 (Nationwide Children’s Hospital), M01-RR00188 (Texas Children’s Hospital and Baylor College of Medicine), UL1RR024153 and UL1TR000005 (University of Pittsburgh), and UL1TR000165 (University of Alabama at Birmingham). The sponsors did not participate in the work presented. Funded by the National Institutes of Health (NIH). POTENTIAL CONFLICT OF INTEREST: Dr Inge has served as a consultant for Zafgen Corporation, Biomedical Insights, and L&E Research and has received honoraria from Standard , UpToDate, and Independent Medical Expert Consulting Services, all unrelated to this project; the other authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 28, 2021 10 OGLE et al Outcomes of Bariatric Surgery in Older Versus Younger Adolescents Sarah B. Ogle, Lindel C. Dewberry, Todd M. Jenkins, Thomas H. Inge, Megan Kelsey, Matias Bruzoni and Janey S.A. Pratt Pediatrics originally published online February 1, 2021;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2021/01/28/peds.2 020-024182 References This article cites 66 articles, 10 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2021/01/28/peds.2 020-024182#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Adolescent Health/Medicine http://www.aappublications.org/cgi/collection/adolescent_health:me dicine_sub Surgery http://www.aappublications.org/cgi/collection/surgery_sub Obesity http://www.aappublications.org/cgi/collection/obesity_new_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 28, 2021 Outcomes of Bariatric Surgery in Older Versus Younger Adolescents Sarah B. Ogle, Lindel C. Dewberry, Todd M. Jenkins, Thomas H. Inge, Megan Kelsey, Matias Bruzoni and Janey S.A. Pratt Pediatrics originally published online February 1, 2021;

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