In obese adolescents, gastric banding associated with greater weight loss than lifestyle modification, trial data suggest

Among obese adolescents, laparoscopic adjustable gastric banding leads to greater weight loss and improvement in related health outcomes as compared with a lifestyle intervention promoting diet and exercise, according to data from a randomized controlled trial conducted in Melbourne, Australia. During the trial, 50 adolescents (aged 14-18 years) with a body mass index (BMI) of >35 kg/m2 were randomized to participate in a lifestyle intervention, which focused on reduced energy intake and...

Among obese adolescents, laparoscopic adjustable gastric banding leads to greater weight loss and improvement in related health outcomes as compared with a lifestyle intervention promoting diet and exercise, according to data from a randomized controlled trial conducted in Melbourne, Australia.

During the trial, 50 adolescents (aged 14-18 years) with a body mass index (BMI) of >35 kg/m2 were randomized to participate in a lifestyle intervention, which focused on reduced energy intake and increased physical activity, or to undergo gastric banding. The primary endpoint was the proportion of patients who lost >50% of excess body weight, defined as weight leading to a BMI exceeding the 85th percentile for age and sex, after 24 months of follow-up.

At 2 years, 21 of the 25 patients (84%) in the gastric-banding group lost >50% of their excess body weight, compared with 3 of the 25 patients (12%) in the lifestyle-intervention group who did so (P<.001).

The mean weight loss in the surgery group was 34.6 kg, which represented a decrease in total body weight of 28.3%, a decrease in excess body weight of 78.8%, a loss of 12.7 BMI units, and a BMI z score change from 2.39 to 1.32. The mean weight loss in the lifestyle group was 3.0 kg, representing a decrease in total body weight of 3.1%, a decrease in excess body weight of 13.2%, a loss of 1.3 BMI units, and a BMI z score change from 2.41 to 2.26 (P<.001 for all between-group differences).

In addition, from baseline to 2 years, the proportion of patients with the metabolic syndrome decreased from 36% to 0% in the gastric-banding group (P=.008) and from 40% to 22% in the lifestyle-intervention group (P=.13; P=.025 for the between-group comparison).

Additional analysis of secondary endpoints showed that gastric banding was associated with significant improvements in waist circumference, insulin sensitivity, triglycerides, and HDL cholesterol compared with baseline values, and significantly greater improvements in waist circumference and insulin sensitivity as compared with the lifestyle intervention. Both interventions were associated with improvements in blood pressure, plasma insulin levels, and beta-cell function, with no statistically significant between-group differences.

Quality of life was assessed with the Child Health Questionnaire. Gastric banding was associated with significant improvements in the physical functioning, self-esteem, family activities, and change in health domains, and both interventions were associated with significant improvements in general health.

Although there were no perioperative complications in the gastric-banding group, adverse events in this group included 8 operations in 7 patients for revisional procedures (to treat proximal pouch dilatation or needlestick injuries to tubing).

Twenty-four of the 25 patients in the gastric-banding group and 18 of the 25 patients in the lifestyle-intervention group completed the study.

The study authors acknowledged that lifestyle interventions can lead to weight loss and better health and should remain the first option for obese adolescents, but they concluded that these data support the use of gastric banding in select patients when such measures fail. (O'Brien PE, et al. JAMA 2010;303:519-526.)

In an accompanying editorial, Dr. Edward Livingston with the University of Texas Southwestern Medical Center at Dallas noted that this research provides "difficult-to-come-by level 1 evidence in support of bariatric surgery" and "demonstrates that randomized controlled trials can and should be conducted to evaluate surgical technologies."

However, he noted, the trial also "demonstrates that the decision to offer laparoscopic banding procedures to adolescents is not straightforward."

Specifically, he explained, the procedure was associated with greater improvements in weight and other health outcomes relative to a lifestyle intervention, but these benefits are potentially offset by the presence of postoperative complications. Dr. Livingston added that--given the study group's level of expertise with this procedure--complications associated with surgery are likely to be even more frequent in typical community practice. (JAMA 2010;303:559-560.)

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