Bariatric Surgery in Adolescent Obesity: A Review of Current Evidence

Öz

Obesity is increasingly recognized as a significant health concern affecting not only adults but also younger populations, including children and adolescents. Type 2 diabetes, dyslipidemia, and hypertension, which are common in adults, are becoming increasingly prevalent in the pediatric population. The onset of these comorbidities at an early age will lead to a significantly reduced life expectancy. The widespread nature of obesity in the pediatric population has led to the initiation of various treatments, including surgical interventions at an early age. Certain risks and benefits must be considered when considering surgical treatment in adolescents. In the decision-making process for bariatric surgery in adolescents, not only the potential health benefits and risks but also the ethical, psychological, and social dimensions must be carefully considered. While perioperative and postoperative psychological status changes and patient selection differ significantly from those in adult patients, outcomes after bariatric surgery are similar to those in adult patients. Bariatric surgery in adolescence may be considered among treatment options after the implementation of other therapeutic approaches by a multidisciplinary team, taking into account the adolescent's and family's lifestyle as well as long-term health outcomes.

Anahtar Kelimeler

• Adolescent
• Bariatric Surgery
• Obesity
• Pediatric Obesity

Adölesan Obezitesinde Bariatrik Cerrahi: Güncel Kanıtların Değerlendirilmesi

Öz

Obezite sadece yetişkinler için değil, aynı zamanda çocuklar ve adölesanlar içinde önemli bir sağlık sorunu haline gelmiştir. Yetişkinlerde sıklıkla görülen Tip 2 diyabet, hipertansiyon, dislipidemi pediatrik popülasyonda da giderek daha yaygın hale gelmektedir. Bu eşlik eden hastalıkların erken yaşlarda ortaya çıkması önemli ölçüde azalmış bir yaşam beklentisine sebep olacaktır. Pediatrik popülasyonda obezitenin yaygınlığı erken yaşlarda cerrahi tedavilerde dahil olmak üzere çeşitli tedavilerin başlatılmasına yol açmıştır. Adölesanlarda cerrahi tedavi değerlendirilirken belirli riskler ve faydalar hesaba katılmalıdır. Ergenlerde bariyatrik cerrahi için karar verme sürecinde, yalnızca potansiyel sağlık yararları ve riskleri değil, aynı zamanda etik, psikolojik ve sosyal boyutlar da dikkatlice dikkate alınmalıdır. Perioperatif ve postoperatif psikolojik durum değişiklikleri ve hasta seçimi yetişkin hastalardan önemli ölçüde farklılık gösterirken, bariatrik cerrahi sonrası sonuçlar yetişkin hastalar ile benzerlik göstermektedir. Adölesan dönemde bariatrik cerrahinin multidisipliner bir ekiple diğer tedavi seçenekleri uygulandıktan sonra bireyin ve ailenin yaşam tarzı ile uzun vadedeki sağlık sonuçları göz önünde bulundurularak tedavi seçenekleri arasında yer alabileceği ön görülmektedir.

Anahtar Kelimeler

• Adölesan
• Bariatrik Cerrahi
• Obezite
• Pediatrik Obezite

Kaynakça

1. Alqahtani, A. R., Elahmedi, M., Abdurabu, H. Y., & Alqahtani, S. (2021). Ten-year outcomes of children and adolescents who underwent sleeve gastrectomy: weight loss, comorbidity resolution, adverse events, and growth velocity. Journal of the American College of Surgeons, 233(6), 657-664. https://doi.org/10.1016/j.jamcollsurg.2021.08.678
2. Antwi, F. A., Fazylova, N., Garcon, M.-C., Lopez, L., Rubiano, R., & Slyer, J. T. (2013). Effectiveness of webbased programs on the reduction of childhood obesity in school-aged children: a systematic review. JBI Evidence Synthesis, 11(6), 1-44. https://doi.org/10.11124/jbisrir-2013-459
3. Berdah, C. (2010). Obesity and psychiatric disorders. Paper presented at the Annales Medico- Psychologiques. https://doi.org/10.1016/j.amp.2009.03.010
4. Bjerregaard, L. G., Jensen, B. W., Ängquist, L., Osler, M., Sørensen, T. I., & Baker, J. L. (2018). Change in overweight from childhood to early adulthood and risk of type 2 diabetes. New England Journal of Medicine, 378(14), 1302-1312. https://doi.org/10.1056/nejmoa1713231
5. Bjornstad, P., Nehus, E., Jenkins, T., Mitsnefes, M., Moxey- Mims, M., Dixon, J. B., & Inge, T. H. (2020). Five-year kidney outcomes of bariatric surgery differ in severely obese adolescents and adults with and without type 2 diabetes. Kidney international, 97(5), 995–1005. https://doi.org/10.1016/j.kint.2020.01.016.
6. Bolt, I. L., & van Summeren, M. J. (2014). Competence assessment in minors, illustrated by the case of bariatric surgery for morbidly obese children. Best Practice & Research Clinical Gastroenterology, 28(2), 293-302. https://doi.org/10.1016/j.bpg.2014.02.006
7. Brenton, J. N., Koenig, S., & Goldman, M. D. (2014). Vitamin D status and age of onset of demyelinating disease. Multiple sclerosis and related disorders, 3(6), 684-688. https://doi.org/10.1016/j.msard.2014.07.004
8. Buchwald, H., & Williams, S. E. (2004). Bariatric surgery worldwide 2003. Obesity Surgery, 14(9), 1157-1164. https://doi.org/10.1381/0960892042387057

9. Cawley, J., & Spiess, C. K. (2008). Obesity and skill attainment in early childhood. Economics & Human Biology, 6(3), 388-397. https://doi.org/10.1016/j.ehb.2008.06.003
10. Centers for Disease Control and Prevention. BMI-for-age categories. Retrieved September 5, 2025, from https://www.cdc.gov/bmi/child-teen-calculator/bmicategories. html
11. Chalklin, C. G., Ryan Harper, E. G., & Beamish, A. J. (2021). Metabolic and bariatric surgery in adolescents. Current obesity reports, 10, 61-69. https://doi.org/10.1007/s13679-021-00423-3
12. Collaborators, G. O. (2017). Health effects of overweight and obesity in 195 countries over 25 years. New England Journal of Medicine, 377(1), 13-27. https://doi.org/10.1056/nejmoa1614362
13. Conceição, E. M., Utzinger, L. M., & Pisetsky, E. M. (2015). Eating disorders and problematic eating behaviours before and after bariatric surgery: characterization, assessment and association with treatment outcomes. European Eating Disorders Review, 23(6), 417-425. https://doi.org/10.1002/erv.2397
14. Desai, N. K., Wulkan, M. L., & Inge, T. H. (2016). Update on adolescent bariatric surgery. Endocrinology and Metabolism Clinics, 45(3), 667-676. https://doi.org/10.1016/j.ecl.2016.04.015
15. Dhindsa, S., Ghanim, H., Jenkins, T., Inge, T. H., Harmon, C. M., Ghoshal, A.,Dandona, P. (2022). High prevalence of subnormal testosterone in obese adolescent males: reversal with bariatric surgery. European Journal of Endocrinology, 186(3), 319-327. https://doi.org/10.1530/eje-21-0545
16. Eid, G. M., McCloskey, C., Titchner, R., Korytkowski, M., Gross, D., Grabowski, C., & Wilson, M. (2014). Changes in hormones and biomarkers in polycystic ovarian syndrome treated with gastric bypass. Surgery for obesity and related diseases, 10(5), 787-791. https://doi.org/10.1016/j.soard.2014.02.046
17. Eisenberg, D., Shikora, S. A., Aarts, E., Aminian, A., Angrisani, L., Cohen, R. V.,Haddad, A. (2023). 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. In: Springer. https://doi.org/10.1007/s11695-022-06332-1
18. Els, A. (2014). The preoperative use of restricted energy diets to reduce liver volume and liver fat content and improve postoperative outcome in obese patients scheduled for bariatric surgery: A systematic review and meta-analysis (Master's thesis, University of the Free State). University of the Free State. https://scholar.ufs.ac.za/bitstream/handle/11660/10 72/ElsA.pdf?sequence=1&isAllowed=y
19. English, W. J., DeMaria, E. J., Brethauer, S. A., Mattar, S. G., Rosenthal, R. J., & Morton, J. M. (2018). American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016. Surgery for obesity and related diseases, 14(3), 259-263. https://doi.org/10.1016/j.soard.2017.12.013
20. Freedman, D. S., Khan, L. K., Dietz, W. H., Srinivasan, S. R., & Berenson, G. S. (2001). Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics, 108(3), 712-718. https://doi.org/10.1542/peds.108.3.712
21. Freedman, D. S., Mei, Z., Srinivasan, S. R., Berenson, G. S., & Dietz, W. H. (2007). Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. The Journal of pediatrics, 150(1), 12-17. https://doi.org/10.1016/j.jpeds.2006.08.042
22. Fullmer, M. A., Abrams, S. H., Hrovat, K., Mooney, L., Scheimann, A. O., Hillman, J. B., & Suskind, D. L. (2012). Nutritional strategy for adolescents undergoing bariatric surgery: report of a working group of the Nutrition Committee of NASPGHAN/NACHRI. Journal of pediatric gastroenterology and nutrition, 54(1), 125- 135. https://doi.org/10.1097/MPG.0b013e318231db79
23. Goueslard, K., Jollant, F., Petit, J., & Quantin, C. (2022). Self-harm hospitalization following bariatric surgery in adolescents and young adults. Clinical Nutrition, 41(1), 238-245. https://doi.org/10.1016/j.clnu.2021.11.034
24. Grams, J., & Garvey, W. T. (2015). Weight loss and the prevention and treatment of type 2 diabetes using lifestyle therapy, pharmacotherapy, and bariatric surgery: mechanisms of action. Current obesity reports, 4, 287-302. https://doi.org/10.1007/s13679- 015-0155-x
25. Harris, K. M., Perreira, K. M., & Lee, D. (2009). Obesity in the transition to adulthood: predictions across race/ethnicity, immigrant generation, and sex. Archives of pediatrics & adolescent medicine, 163(11), 1022-1028. https://doi.org/10.1001/archpediatrics.2009.182
26. Hsia, D. S., Fallon, S. C., & Brandt, M. L. (2012). Adolescent bariatric surgery. Archives of pediatrics & adolescent medicine, 166(8), 757-766. https://doi.org/10.1001/archpediatrics.2012.1011
27. Inge, T. H., Courcoulas, A. P., Jenkins, T. M., Michalsky, M. P., Helmrath, M. A., Brandt, M. L.,Xanthakos, S. A. (2016). Weight loss and health status 3 years after bariatric surgery in adolescents. New England Journal of Medicine, 374(2), 113-123. https://doi.org/10.1056/nejmoa1506699
28. IPEG Guidelines for Surgical Treatment of Extremely Obese Adolescents. (2008). Journal of Laparoendoscopic & Advanced Surgical Techniques, 18(6). https://doi.org/10.1089/lap.2008.9987
29. Järvholm, K., Janson, A., Henfridsson, P., Neovius, M., Sjögren, L., & Olbers, T. (2024). Metabolic and bariatric surgery for adolescents with severe obesity: Benefits, risks, and specific considerations. Scandinavian Journal of Surgery. https://doi.org/10.1177/14574969241297517
30. Kahn, S. (2003). The relative contributions of insulin resistance and beta-cell dysfunction to the pathophysiology of Type 2 diabetes. Diabetologia, 46, 3-19. https://doi.org/10.1007/s00125-002-1009-0
31. Kapiotis, S., Holzer, G., Schaller, G., Haumer, M., Widhalm, H., Weghuber, D.,Widhalm, K. (2006). A proinflammatory state is detectable in obese children and is accompanied by functional and morphological vascular changes. Arteriosclerosis, thrombosis, and vascular biology, 26(11), 2541-2546.
32. https://doi.org/10.1161/01.atv.0000245795.08139.7 Kaulfers, A.-M. D., Bean, J. A., Inge, T. H., Dolan, L. M., & Kalkwarf, H. J. (2011). Bone loss in adolescents after bariatric surgery. Pediatrics, 127(4). https://doi.org/10.1542/peds.2010-0785
33. Kelly, A. S., Barlow, S. E., Rao, G., Inge, T. H., Hayman, L. L., Steinberger, J.,Daniels, S. R. (2013). Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association. Circulation, 128(15), 1689-1712. https://doi.org/10.1161/cir.0b013e3182a5cfb3
34. Kelly, A. S., Hebbel, R. P., Solovey, A. N., Schwarzenberg, S. J., Metzig, A. M., Moran, A., Steinberger, J. (2010). Circulating activated endothelial cells in pediatric obesity. The Journal of pediatrics, 157(4), 547-551. https://doi.org/10.1016/j.jpeds.2010.04.069
35. Khidir, N., El-Matbouly, M. A., Sargsyan, D., Al-Kuwari, M., Bashah, M., & Gagner, M. (2018). Five-year outcomes of laparoscopic sleeve gastrectomy: a comparison between adults and adolescents. Obesity Surgery, 28(7), 2040-2045. https://doi.org/10.1007/s11695- 018-3139-6
36. Kovacs, B. E., Gillison, F. B., & Barnett, J. C. (2018). Is children’s weight a public health or a private family issue? A qualitative analysis of online discussion about National Child Measurement Programme feedback in England. BMC Public Health, 18(1), 1295. https://doi.org/10.1186/s12889-018-6214-y
37. Kubik, J. F., Gill, R. S., Laffin, M., & Karmali, S. (2013). The impact of bariatric surgery on psychological health. Journal of obesity, 2013(1). https://doi.org/10.1155/2013/837989
38. Landau, Z., Karplus, G., Hanukoglu, A., Abiri, S., Levy, A., & Serour, F. (2011). Laparoscopic sleeve gastrectomy (LSG) in adolescents with morbid obesity. Harefuah, 150(10), 765-768, 816, 815. https://orcid.org/0000- 0003-1486-6641
39. Li JianFang, L. J., Lai DanDan, L. D., Ni Bin, N. B., & Sun KuanXue, S. K. (2013). Comparison of laparoscopic Roux-en-Y gastric bypass with laparoscopic sleeve gastrectomy for morbid obesity or type 2 diabetes mellitus: a meta-analysis of randomized controlled trials. https://doi.org/10.1503/cjs.026912
40. Li, Y., Dai, Q., Jackson, J. C., & Zhang, J. (2008). Overweight is associated with decreased cognitive functioning among school‐age children and adolescents. Obesity, 16(8), 1809-1815. https://doi.org/10.1038/oby.2008.296
41. Lim, R. B., Zhang, M. W., & Ho, R. C. (2018). Prevalence of all-cause mortality and suicide among bariatric surgery cohorts: a meta-analysis. International Journal of Environmental Research and Public Health, 15(7), 1519. https://doi.org/10.3390/ijerph15071519
42. Machytka, E., Gaur, S., Chuttani, R., Bojkova, M., Kupka, T., Buzga, M., Levy, S. (2017). Elipse, the first procedureless gastric balloon for weight loss: a prospective, observational, open-label, multicenter study. Endoscopy, 49(02), 154-160. https://doi.org/10.1007/s11695-015-1783-7
43. Marceau, P., Marceau, S., Biron, S., Hould, F.-S., Lebel, S., Lescelleur, O.,Kral, J. G. (2010). Long-term experience with duodenal switch in adolescents. Obesity Surgery, 20, 1609-1616. https://doi.org/10.1007/s11695-010- 0262-4
44. Mark, A. L. (2006). Dietary therapy for obesity is a failure and pharmacotherapy is the future: a point of view. Clinical and Experimental Pharmacology and Physiology, 33(9), 857-862. https://doi.org/10.1111/j.1440-1681.2006.04454.x
45. Martyn-Nemeth, P. A., & Penckofer, S. (2012). Psychological vulnerability among overweight/obese minority adolescents. The Journal of School Nursing, 28(4), 291-301. https://doi.org/10.1177/1059840511430508
46. Maffazioli, G. D., Stanford, F. C., Campoverde Reyes, K. J., Stanley, T. L., Singhal, V., Corey, K. E., ... & Misra, M. (2016). Comparing outcomes of two types of bariatric surgery in an adolescent obese population: Roux-en-Y gastric bypass vs. sleeve gastrectomy. Frontiers in Pediatrics, 4, 78. https://doi.org/10.3389/fped.2016.00078
47. Melissas, J., Stavroulakis, K., Tzikoulis, V., Peristeri, A., Papadakis, J. A., Pazouki, A.,Kabir, A. (2017). Sleeve Gastrectomy vs roux-en-Y gastric bypass. Data from IFSO-European chapter Center of Excellence Program. Obesity Surgery, 27, 847-855. https://doi.org/10.1007/s11695-016-2395-6
48. Michalsky, M. P., Inge, T. H., Jenkins, T. M., Xie, C., Courcoulas, A., Helmrath, M., Dixon, J. B. (2018). Cardiovascular risk factors after adolescent bariatric surgery. Pediatrics, 141(2). https://doi.org/10.1542/peds.2017-2485
49. Mitchell, D. M., Singhal, V., Animashaun, A., Bose, A., Carmine, B., Stanford, F. C., Bouxsein, M. L. (2023). Skeletal effects of sleeve gastrectomy in adolescents and young adults: a 2-year longitudinal study. The Journal of Clinical Endocrinology & Metabolism, 108(4), 847-857. https://doi.org/10.1210/clinem/dgac634
50. Morales-Medina, J. C., Dumont, Y., & Quirion, R. (2010). A possible role of neuropeptide Y in depression and stress. Brain research, 1314, 194-205. https://doi.org/10.1016/j.brainres.2009.09.077
51. Morrison, K. M., Shin, S., Tarnopolsky, M., & Taylor, V. H. (2015). Association of depression & health related quality of life with body composition in children and youth with obesity. Journal of affective disorders, 172, 18-23.https://doi.org/10.1016/j.jad.2014.09.014
52. Must, A., Jacques, P. F., Dallal, G. E., Bajema, C. J., & Dietz, W. H. (1992). Long-term morbidity and mortality of overweight adolescents: a follow-up of the Harvard Growth Study of 1922 to 1935. New England Journal of Medicine, 327(19), 1350-1355. https://doi.org/10.1056/nejm199211053271904
53. Nehus, E. J., Khoury, J. C., Inge, T. H., Xiao, N., Jenkins, T. M., Moxey-Mims, M. M., & Mitsnefes, M. M. (2017). Kidney outcomes three years after bariatric surgery in severely obese adolescents. Kidney international, 91(2), 451-458. https://doi.org/10.1016/j.kint.2016.09.031
54. Neovius, M., Bruze, G., Jacobson, P., Sjöholm, K., Johansson, K., Granath, F., Ottosson, J. (2018). Bariatric surgery & suicide: results from two controlled matched cohort studies. The lancet. Diabetes & endocrinology, 6(3), 197. https://doi.org/10.1016/s2213-8587(17)30437-0
55. Nguyen, N. T., & Varela, J. E. (2017). Bariatric surgery for obesity and metabolic disorders: state of the art. Nature reviews Gastroenterology & hepatology, 14(3), 160-169. https://doi.org/10.1038/nrgastro.2016.170
56. Onyike, C. U., Crum, R. M., Lee, H. B., Lyketsos, C. G., & Eaton, W. W. (2003). Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey. American journal of epidemiology, 158(12), 1139-1147. https://doi.org/10.1093/aje/kwg275
57. Olbers, T., Beamish, A. J., Gronowitz, E., Flodmark, C.-E., Dahlgren, J., Bruze, G., . . . Järvholm, K. (2017). Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): a prospective, 5-year, Swedish nationwide study. The lancet Diabetes & endocrinology, 5(3), 174-183. https://doi.org/10.1016/S2213-8587(16)30424-7
58. Owen, C. G., Whincup, P. H., Orfei, L., Chou, Q.-A., Rudnicka, A. R., Wathern, A. K., Cook, D. G. (2009). Is body mass index before middle age related to coronary heart disease risk in later life? Evidence from observational studies. International Journal of Obesity, 33(8), 866-877. https://doi.org/10.1038/ijo.2009.102
59. Oyola, C., Berry, M., Salazar, M. A. P., De Abreu, D., Formiga, A., Escalona, A., Ienca, R. (2024). Successful Weight Loss in Adolescents with Overweight or Obesity Using a Swallowable Intragastric Balloon and Nutritional Oversight. Obesity Surgery, 34(10), 3762- 3770. https://doi.org/10.1007/s11695-024-07458-0
60. Parrott, J., Frank, L., Rabena, R., Craggs-Dino, L., Isom, K. A., & Greiman, L. (2017). American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient 2016 update: micronutrients. Surgery for obesity and related diseases, 13(5), 727- 741. https://doi.org/10.1016/j.soard.2016.12.018
61. Papadia, F. S., Adami, G. F., Marinari, G. M., Camerini, G., & Scopinaro, N. (2007). Bariatric surgery in adolescents: a long-term follow-up study. Surgery for obesity and related diseases, 3(4), 465-468. https://doi.org/10.1016/j.soard.2006.12.010
62. Pratt, J. S., Browne, A., Browne, N. T., Bruzoni, M., Cohen, M., Desai, A., Michalsky, M. (2018). ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surgery for obesity and related diseases, 14(7), 882- 901. https://doi.org/10.1016/j.soard.2018.03.019
63. Pratt, J. S., Lenders, C. M., Dionne, E. A., Hoppin, A. G., Hsu, G. L., Inge, T. H., Rosenblum, J. L. (2009). Best practice updates for pediatric/adolescent weight loss surgery. Obesity, 17(5), 901-910. https://doi.org/10.1038/oby.2008.577
64. Reece, L. J., Sachdev, P., Copeland, R. J., Thomson, M., Wales, J. K., & Wright, N. P. (2017). Intra-gastric balloon as an adjunct to lifestyle support in severely obese adolescents; impact on weight, physical activity, cardiorespiratory fitness and psychosocial well-being. International Journal of Obesity, 41(4), 591–597. https://doi.org/10.1038/ijo.2016.192
65. Richards, G. E., Cavallo, A., Meyer III, W. J., Prince, M. J., Peters, E. J., Stuart, C. A., & Smith, E. R. (1985). Obesity, acanthosis nigricans, insulin resistance, and hyperandrogenemia: pediatric perspective and natural history. The Journal of pediatrics, 107(6), 893-897. https://doi.org/10.1016/s0022-3476(85)80182-7
66. Roberts, C. A. (2021). Physical and psychological effects of bariatric surgery on obese adolescents: A review. Frontiers in pediatrics, 8, 591598. https://doi.org/10.3389/fped.2020.591598
67. Roebroek, Y. G., Paulus, G. F., Talib, A., van Mil, E. G., Vreugdenhil, A. C., Winkens, B., Van Heurn, L. E. (2024). Weight Loss and Glycemic Control After Bariatric Surgery in Adolescents With Severe Obesity: A Randomized Controlled Trial. Journal of Adolescent Health, 74(3), 597-604 https://doi.org/10.1016/j.jadohealth.2023.10.024
68. Rogovik, A. L., Chanoine, J.-P., & Goldman, R. D. (2010). Pharmacotherapy and weight-loss supplements for treatment of paediatric obesity. Drugs, 70, 335- 346 https://doi.org/10.2165/11319210-000000000- 00000
69. Romanova, I. V., Ramos, E. J., Xu, Y., Quinn, R., Chen, C., George, Z. M.,Meguid, M. M. (2004). Neurobiologic changes in the hypothalamus associated with weight loss after gastric bypass. Journal of the American College of Surgeons, 199(6), 887-895. https://doi.org/10.1016/j.jamcollsurg.2004.07.013
70. Ruiz-Cota, P., Bacardí-Gascón, M., & Jiménez-Cruz, A. (2019). Long-term outcomes of metabolic and bariatric surgery in adolescents with severe obesity with a follow-up of at least 5 years: a systematic review. Surgery for obesity and related diseases, 15(1), 133- 144. https://doi.org/10.1016/j.soard.2018.10.016
71. Sachdev, P., Reece, L., Copeland, R., Thomson, M., Natarajan, A., Wales, J., & Wright, N. (2016). Biomedical outcomes of weight loss associated with intragastric balloon therapy supported by a life style programme in severe adolescent obesity. Paper presented at the Endocrine Abstracts. https://doi.org/10.1530/endoabs.45.oc8.5
72. Salmi, A., Greco, F., & Belleri, E. (2020). Ultrasound-guided insertion of the elipse® gastric balloon: technical details, learning curve, and perioperative outcome in 36 cases. Journal of Ultrasound, 23, 593-597. https://doi.org/10.1007/s40477-020-00499-y
73. Shehata, M., Abosena, W., Elhaddad, A., & El Attar, A. (2025). Seven years follow-up after sleeve gastrectomy in adolescents. Obesity Surgery, 35, 1–9. https://doi.org/10.1007/s11695-025-07966-7
74. Spieth, L. E., Harnish, J. D., Lenders, C. M., Raezer, L. B., Pereira, M. A., Hangen, S. J., & Ludwig, D. S. (2000). A low–glycemic index diet in the treatment of pediatric obesity. Archives of pediatrics & adolescent medicine, 154(9), 947-951. https://doi.org/10.1001/archpedi.154.9.947
75. Stevens, G. A., Beal, T., Mbuya, M. N., Luo, H., Neufeld, L. M., Addo, O. Y.,Brown, K. H. (2022). Micronutrient deficiencies among preschool-aged children and women of reproductive age worldwide: a pooled analysis of individual-level data from populationrepresentative surveys. The Lancet Global Health, 10(11), e1590-e1599. https://doi.org/10.1016/s2214- 109x(22)00367-9
76. Styne, D. M., Arslanian, S. A., Connor, E. L., Farooqi, I. S., Murad, M. H., Silverstein, J. H., & Yanovski, J. A. (2017). Pediatric obesity—assessment, treatment, and prevention: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(3), 709-757. https://doi.org/10.1210/jc.2016-2573
77. Thomson, M., Natarajan, A., Copeland, R., Wales, J., & Wright, N. (2017). Intragastric balloon as an adjunct to lifestyle programme in severely obese adolescents: Impact on biomedical outcomes, and skeletal health. https://doi.org/10.1038/ijo.2017.215
78. Treadwell, J. R., Sun, F., & Schoelles, K. (2008). Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Annals of surgery, 248(5), 763-776. https://doi.org/10.1097/sla.0b013e31818702f4
79. Turkish Society of Endocrinology and Metabolism. (2019). Bariatric surgery guideline. Ankara, Turkey. https://file.temd.org.tr/Uploads/publications/guides/ documents/201905271603252019tbl_kilavuza1dab03 7d3.pdf
80. Umer, A., Kelley, G. A., Cottrell, L. E., Giacobbi, P., Innes, K. E., & Lilly, C. L. (2017). Childhood obesity and adult cardiovascular disease risk factors: a systematic review with meta-analysis. BMC public health, 17, 1- 24. https://doi.org/10.1161/circ.135.suppl_1.p145
81. Wahba, I. M., & Mak, R. H. (2007). Obesity and obesityinitiated metabolic syndrome: mechanistic links to chronic kidney disease. Clinical journal of the American Society of Nephrology, 2(3), 550-562. https://doi.org/10.2215/cjn.04071206
82. Wang, Y., Chen, X., Song, Y., Caballero, B., & Cheskin, L. (2008). Association between obesity and kidney disease: a systematic review and meta-analysis. Kidney international,73(1),19 33. https://doi.org/10.1038/sj.ki.5002586
83. Wasserman, H., & Inge, T. H. (2014). Bariatric surgery in obese adolescents: opportunities and challenges. Pediatric annals, 43(9). https://doi.org/10.3928/00904481-20140825-10
84. Wilfley, D. E., Stein, R. I., Saelens, B. E., Mockus, D. S., Matt, G. E., Hayden-Wade, H. A., Epstein, L. H. (2007). Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial. Jama, 298(14), 1661-1673. https://doi.org/10.1001/jama.298.14.1661
85. World Health Organization. (2007) Growth Reference Data BMI-for-age (5-19 years). Retrieved September 5, 2025, from https://www.who.int/toolkits/growth-referencedata- for-5to19‑years/indicators/bmi‑for‑age
86. Xanthakos, S. A., Daniels, S. R., & Inge, T. H. (2006). Bariatric surgery in adolescents: an update. Adolesc Med Clin, 17(3), 589-612. https://doi.org/10.1016/b978-0-323-02842-4.50081-4
87. Xiao, N., Devarajan, P., Inge, T. H., Jenkins, T. M., Bennett, M., & Mitsnefes, M. M. (2015). Subclinical kidney injury before and 1 year after bariatric surgery among adolescents with severe obesity. Obesity (Silver Spring, Md.), 23(6), 1234–1238. https://doi.org/10.1002/oby.21070
88. Xiao, N., Jenkins, T. M., Nehus, E., Inge, T. H., Michalsky, M. P., Harmon, C. M.,Moxey‐Mims, M. (2014). Kidney function in severely obese adolescents undergoing bariatric surgery. Obesity, 22(11), 2319- 2325. https://doi.org/10.1002/oby.20870
89. Yuan, W., Yu, K.-H., Palmer, N., Stanford, F. C., & Kohane, I. (2019). Evaluation of the association of bariatric surgery with subsequent depression. International Journal of Obesity, 43(12), 2528-2535. https://doi.org/10.1038/s41366-019-0364-6
90. Zhang, X., Man, K.-W., Li, G. H.-Y., Tan, K. C., Kung, A. W.- C., & Cheung, C.-L. (2022). Osteoporosis is a novel risk factor of infections and sepsis: A cohort study. EClinicalMedicine. https://doi.org/10.1016/j.eclinm.2022.101488
91. Zhu, X., Zhou, G., Gu, X., Jiang, X., Huang, H., You, S., & Zhang, G. (2023). Comparing bariatric surgery and medical therapy for obese adolescents with type 2 diabetes. Asian journal of surgery, 46(10), 4337-4343. https://doi.org/10.1016/j.asjsur.2022.10.079