Metabolic and bariatric surgery for adolescents: Progress and persistent challenges

Pediatric obesity, the most common chronic childhood disease in the United States is associated with significant comorbidities that persist into adulthood and increase the risk of early mortality. Metabolic and bariatric surgery (MBS) is the most effective intervention for severe obesity with durable reductions in BMI and obesity-related comorbidities as compared with medical therapy. MBS utilization remains strikingly low. Nearly three million children currently meet eligibility criteria for MBS, yet only about 2500 procedures are performed annually. There are many barriers to accessing MBS, including subspecialty surgeon availability, cost and geographic concentration of multidisciplinary programs, and the substantial burden of perioperative outpatient visits. Primary care physicians remain hesitant to refer adolescents for MBS due to outdated concerns about surgical risks, growth disruption, and adherence to the ineffective strategy of "watchful waiting." Insurance denials likewise remain a persistent challenge with approval of only 40 % of initial requests for pediatric MBS, leading to delays, program attrition, and widening disparities. These barriers are compounded by persistent socioeconomic and racial inequities. Minority and socioeconomically disadvantaged youth are disproportionately affected by obesity, yet less likely to receive early referral or access to specialized obesity care. At the time of surgery, these patients have higher BMI and more advanced comorbidities, reflecting systemic failures. Despite these challenges, MBS offers transformative, and often lifesaving, benefits. Addressing persistent disparities in access to care by improving physician education, expanding program access and capacity, and reforming insurance policies are essential steps toward equitable access to effective obesity treatment for all children.