Background & Aims Little is known about the prevalence of nonalcoholic fatty liver disease (NAFLD) among severely obese adolescents or factors that determine its development. We investigated the prevalence of NAFLD in a multicenter cohort of adolescents undergoing bariatric surgery and factors associated with it. Methods We enrolled 242 adolescents undergoing bariatric surgery between March 2007 and February 2012 at 5 tertiary care centers into a multicenter, prospective observational cohort study. Intra-operative core liver biopsies were collected from 165 subjects; 17 were excluded because of insufficient liver tissue or use of hepatotoxic medications, so 148 remained in the study (mean age 16.8±1.6 y old; median body mass index [BMI], 52 kg/m2). Liver tissues were analyzed by histology using validated criteria. Hepatic gene expression was analyzed in 67 samples. Results NAFLD was present in 59% of this predominantly female (72%), white (68%), non-Hispanic (91%) cohort. Of subjects with NAFLD, 24% had borderline and 10% had definite nonalcoholic steatohepatitis (NASH). Mild fibrosis (≤ stage 2) was observed in 18% of liver biopsies and stage 3 in 0.7%, but cirrhosis was not detected. Dyslipidemia was present in 78% of subjects, hypertension in 44%, and diabetes in 14%. More severe NAFLD was associated with increasing levels of alanine aminotransferase (ALT), fasting glucose level, hypertension (each P<.01) and white blood cell count (P=.04). Only diabetes was associated with detection of fibrosis (odds ratio, 3.56; 95% confidence interval, 1.93–6.56). Microarray analysis associated presence of NASH with altered expression of genes that regulate macrophage chemotaxis, cholesterol absorption, and fatty acid binding. Conclusions More than half of adolescents undergoing bariatric surgery in this cohort had NAFLD, yet the prevalence of severe or fibrotic NASH was low. Increasing severity of NAFLD was associated with level of ALT and cardio-metabolic risk factors, but not BMI. Based on gene expression analysis, borderline and definite NASH were associated with abnormal immune function, intestinal cholesterol absorption, and lipid metabolism.

Objective: Adolescents seeking weight loss surgery (WLS) frequently encounter obstacles obtaining treatment authorization from insurance carriers. This study identified factors influencing authorization for adolescents with clinical indications for WLS. Methods: A retrospective review was conducted for adolescents with clinical indications for WLS at five adolescent centers. This cohort represented a consecutive series of adolescents with insurance benefits for WLS for whom insurance authorization was sought between 2009 and 2011. Outcomes included number and timing of insurance authorizations for surgery, denials, and appeals. Results: Records from 57 adolescents (74% female; mean age 16 (range: 12-17) years; mean BMI 51.3 kg/m 2 ) were reviewed. Of these, only 47% were approved with the original request. Eighty percent of those denied were approved on appeal, while 11% never obtained authorization for surgery. Age less than 18 years and proposed procedure were the most common reasons for denial.Conclusions: Less than half of adolescents with clinical indications for surgery received approval for the procedure on the first request. The appeal process typically resulted in overturning of denials, so that surgical care could be delivered.

NCT03326713; clinicaltrials.gov.