Recent data highlighting current trends in rates of obesity among various age ranges within the US population from the National Health and Nutrition Examination Survey study, an ongoing nationally representative interview- and examination-based survey, show that previously reported increases in the relative rates of obesity, including childhood obesity, appear to be on an unremitting rise. ^{Reference Emmerich, Fryar, Stierman, Gu, Afful and Ogden1} The most recently published survey results indicate that the rate of childhood obesity, defined as body mass index ≥ 95^th percentile for age and sex, among the adolescent population (i.e. 12 to 19 years of age) is now 22.9%, representing a 0.3% increase compared to the most recent National Health and Nutrition Examination Survey reporting cycle. Even more noteworthy, concurrent analysis of adolescents with severe forms of obesity, defined as body mass index ≥ 120% of the 95^th percentile; or equivalent to a body mass index ≥ 35 kg/m², is approaching an alarming 9%. ^{Reference Emmerich, Fryar, Stierman, Gu, Afful and Ogden1} In the United States of America alone, this figure represents several million adolescents who are affected by severe obesity, with millions more no doubt impacted across the globe.

A mounting body of data have undeniably shown that the consequence of untreated obesity, and in particular severe forms of obesity, leads to numerous related conditions resulting in impaired cardiometabolic health and diminished quality of life among the paediatric population. ^{Reference Hampl, Hassink and Skinner2} As illustrated in a previously published large-scale longitudinal observational study of late adolescents (mean age 17.3 years) designed to evaluate the impact of body mass index on subsequent risk of cardiovascular-related mortality, investigators have identified a clear link between elevated body mass index and the risk of death related to coronary heart disease, stroke, and sudden death. The result of such data, along with numerous other studies, serves to highlight the imperative to employ effective treatment strategies, including metabolic and bariatric surgery, to mitigate such risk. ^{Reference Twig, Yaniv and Levine3,Reference Michalsky, Inge and Jenkins4}

In the current report, entitled Cardiac Geometry Alterations Following Bariatric Surgery in Severely Obese Adolescents: A One-Year Follow-Up Study of a Randomized Controlled Trial, the investigators are to be congratulated for presenting the results of a prospective randomised trial designed to compare potential changes in cardiac function and anatomy as a result of two treatment arms consisting of participation in multidisciplinary lifestyle intervention alone or in combination with the insertion of a laparoscopic adjustable gastric band. In addition to expanding a line of investigation designed to directly address potential changes in cardiac function and related anatomy, the result of the current study also represents the first attempt to conduct a prospective analysis of this nature, offering the opportunity to address the relative paucity of cardiac functional and geometric data focused on comparative interventions within the paediatric population affected by severe obesity. In addition to showing improved Left Ventricular structure, suggesting partial reversal of obesity-related cardiac remodelling among affected adolescents undergoing surgically induced weight loss in combination with lifestyle therapy, the investigators have raised a number of important questions, which should serve to identify opportunities to inform future, larger, and more robust long-term analyses.

While the current study was designed to compare the cardiac-related consequences of lifestyle intervention, with and without the use of a bariatric surgical procedure, the investigators should strongly consider designing future studies utilising the most contemporary and clinically significant forms of such surgical interventions in order to fully leverage the opportunity to investigate comparative effectiveness. While laparoscopic adjustable gastric band surgery in both the adult and paediatric populations has been associated with significant reduction in body mass index during the early post-operative time frame, longer-term studies have reported significant weight regain and higher-than-expected rates of adverse events, including the need for band removal and in some instances, conversion to more effective forms of bariatric surgery, including Roux-en-Y gastric bypass or vertical sleeve gastrectomy. ^{Reference Fleming, Jenkins and Inge5} The results of such concerns have led to a significant reduction in the procedural prevalence of adjustable gastric band in the United States of America and elsewhere, including within the paediatric population, in favour of vertical sleeve gastrectomy and gastric bypass. ^{Reference Inge, Coley and Bazzano6} Within the context of the current study, one might easily predict that the favourable results observed at 12 months within the intervention arm (i.e. gastric band recipients) might be undetectable in follow-up analysis several years later as a consequence of predictable weight regain. Alternatively, one also may hypothesise that the anticipated improvements in cardiac geometry observed in the short term may also be shown to have a durable effect years later, as suggested when considering recent evidence showing long-term and sustained reduction in body mass index (up to 10 years) following both gastric bypass and vertical sleeve gastrectomy in adolescents. ^{Reference Ryder, Jenkins and Xie7} Additional opportunities for future investigation should also include enrolment of a broader age range than was presented herein, in order to potentially determine differential effects of obesity on cardiac geometry and function during all phases of adolescence. Such future studies would help to expand preliminary observations citing the relatively lower cardiometabolic risk burden observed among younger teens undergoing metabolic and bariatric surgery compared to their older peers; namely with respect to improved levels of low-grade inflammation, elevated blood pressure, and composite dyslipidemia. ^{Reference Michalsky, Inge and Jenkins4} Lastly, considerations for future studies, which are vitally important in order to further define the nature and optimal timing of high-intensity treatment paradigms, should include the development of comparative effectiveness models that include the application of newer classes of highly effective pharmacotherapeutic agents, including glucagon-like peptide-1 receptor agonists.