Cincinnati Children's Hospital Medical Center is one of the few facilities offering bariatric surgery for teens. Our surgeons have performed surgery on 51 adolescents, with an average age of 17 and a mean BMI of 58 since the program was launched in 2001.

It's gratifying to see the kids after a successful surgery, but for every positive result, there are many more potential risks. Kids undergoing bariatric surgery are usually bigger than adults, and have more central fat in the abdomen. The bigger the patient, the bigger the surgical risk. We insist that adolescents meet five criteria before we consider them for bariatric surgery:

Five criteria
1. Lack of conventional success. Candidates need to have tried - and failed - at conventional weight loss attempts for at least six months. Bariatric surgery is a life-changing procedure, and should be considered as a last resort. To offer an alternative form of care, we instituted Health Works! - a behavioral and dietary program that runs parallel to the surgical treatment option. Patients attend the program on a weekly basis to work with a medical doctor, psychologist and dietician if they're considering surgery but don't have the required six-month attempt at conventional weight-loss measures.

2. Physiologic maturity. Cincinnati Children's requires boys to be 15 years old before undergoing bariatric surgery; girls need to be 13. Why the minimum age requirement? Patients must achieve skeletal maturity and be in at least the 50th percentile in linear growth for their age group, a figure determined by analyzing the growth plates in a simple wrist X-ray. Surgery will result in a dramatic reduction in caloric intake and we don't want that to affect an adolescent's growth.

3. Adequate BMI levels. Our patients need to have a BMI between 40 and 50 with serious co-morbidities (Type 2 diabetes, obstructive sleep apnea and pseudotumor cerebri) or a BMI of greater than 50 with less severe co-morbidities. The criteria are stricter than those in place for adults. You want to be conservative with teens because they're younger at the time of surgery and the long-term effects of the procedure aren't completely known.

4. A willingness to work. One of the most important criteria for surgery is also perhaps the hardest to judge. There isn't a great system to determine if a patient will follow nutritional guidelines after surgery. The far-from-exact science involves a litany of psychological tests, but even those aren't always predictive. Talk to the patient's parents, who are often also overweight, to ensure they're willing to be a positive post-op influence. Parents need to change their eating habits, too. They can't bring fast food into the house when their kids are eating cottage cheese.

5. Understanding informed consent. How do you define informed consent with respect to adolescents? You need to get approval of the kids and the parents. Review the risks and benefits of the surgery with the family unit, and think about alternative options if there are any signs of hesitation. The reasons for surgery also have to be valid. Wanting to sit at a regular desk in school is not reason enough to have life-altering surgery.

The popularity of bariatric surgery is a good conversation starter with teens. It's uncommon for one of our patients to not know someone who has undergone the surgery. How has that person done? Have they gained weight, or kept it off? Having seen the behavior changes that are required post-op, does the patient still want to go through with the procedure? Getting an adolescent's feedback about the experiences of someone they know who went through the surgery is a good way to determine informed consent.

Long journey ahead
A strength of our program is our comprehensive follow-up. We follow patients for two years after surgery and demand they adhere to a strict dietary program. Initially, the calorie intake may be only 500-600 cal/day (50-75 protein grams) but most patients transition to 1000-1200 cal/day (75-100 protein grams) after 10 months.

The large drop in calories a patient's body is used to means malnutrition is a huge post-op risk for adolescents and many run the risk of becoming B1 deficient, a problem that can have serious ramifications if not detected.

Adolescents should take a multi-vitamin, B-complex, vitamin B12 and a calcium supplement; females need an iron supplement as well. The problem is, many teens don't realize these are requirements and not recommendations. They live in the here and now, and don't see the long-term value in taking vitamins. So set the post-op expectations of teens higher than those for adults. Teens need to take ownership in their recovery, and must learn to diet and exercise on their own.