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Severe adolescent obesity (body mass index (BMI) > 99.6th centile) is a significant public health challenge. Current non-invasive treatments, including community-based lifestyle interventions, are often of limited effectiveness in this population, with NICE guidelines suggesting the use of bariatric surgery as the last line of treatment. Health professionals are understandably reluctant to commission bariatric surgery and as an alternative, the use of an intra-gastric balloon as an adjunct to a lifestyle programme might offer a reversible, potentially safer and less invasive option.Explore the use of an intra-gastric balloon as an adjunct to a lifestyle support programme, to promote weight loss in severely obese adolescents. Outcomes included weight loss, waist and hip measurements, psychosocial outcomes including health-related quality of life (HRQoL) and physical self perceptions, physical activity and cardiorespiratory fitness.Non-randomised pilot study.Twelve severely obese adolescents (5 males, 7 females; mean age 15 years; BMI > 3.5 s.d.; puberty stage 4 or more) and their families were recruited. Mean weight loss at 12 months (n = 9) was 3.05 kg ± 14.69; d = 0.002, P = 0.550, and a BMI Z-score (n = 12) change of 0.2 s.d.; d = 0.7, P = 0.002 was observed at 6 months with a large effect, but was not sustained at 12 months (mean change 0.1 s.d.; d = 0.3, P = 0.146). At 24 months (n = 10), there was a weight gain from baseline of +9.9 kg ± 1.21 (d = 0.4; P = 0.433). Adolescent and parent HRQoL scores exceeded the minimal clinical important difference between baseline and 12 months for all domains but showed some decline at 24 months.An intra-gastric balloon as an adjunct to a lifestyle support programme represents a safe and well-tolerated treatment approach in severely obese adolescents, with short-term effects on weight change. Improvements in psychosocial health, physical activity and cardiorespiratory fitness were maintained at 12 months, with varying results at 24 months.