The debate over adolescent bariatric operations

by Tripp Underwood on April 15, 2011

Operations to treat obesity are proven to help in many cases but remain controversial

“What happened to young people being active? Don’t parents make young kids and teens go out and play anymore?”

“Why the heck aren’t these kids tossed in a gym and given reasonable, healthy food to lose weight? Americans are too desperate for a quick fix that they don’t have to put any effort into!”

These are just a few comments people made in reaction to a news story about teenage bariatric surgery. Though the commenters’ concerns aren’t entirely off base, the “Pick yourselves up by the bootstraps” mentality represents a lot of misconceptions about childhood obesity and its treatments. No one’s denying the importance of exercise and parental influence in the battle against childhood obesity, but citing it as the epidemic’s only contributing factors is a gross oversimplification.

For starters, maintaining a healthy weight involves a lot of elements, some of which are outside the control of parents and kids. Access to reasonably priced fresh fruits and vegetables and clean, safe parks for kids to play in (not to mention enough parental free time to cook and play with kids) are important for fighting obesity. Without them many families are at a distinct disadvantage for helping their children maintain a healthy weight. And while science doesn’t fully understand all the factors that lead to patients becoming morbidly obese, it’s believed the cause is a combination of genetic predisposition and environmental factors, much like many other medical conditions. It’s an issue of national concern, and in the most severe obesity cases, bariatric surgery may be the most medically sound option.

Brad Linden, MD

“The medical community has long debated the ethics of bariatric surgery for young patients, but that debate is coming to an end because we now have data to indicate that, in select cases, the health benefits of bariatric surgery outweigh the risks in adolescent patients,” said surgeon Bradley Linden, MD, director of the new Adolescent Bariatric Surgery Program at Children’s Hospital Boston. “When left untreated, severe obesity can lead to serious medical conditions like type 2 diabetes, high blood pressure and cholesterol and fatty liver disease. But there’s a window of time where the long-term effects of morbid obesity are more reversible, which leads us to believe that earlier intervention is important. It has gotten to a point where we worry that if we don’t offer bariatric surgery to these patients, we may be withholding life-saving therapy.”

The Children’s program will focus primarily on three different laparoscopic weight loss operations, but based on the program’s strict guidelines, only a small number of patients will be eligible. In general, the candidate must have a body mass index (BMI) of 35 or greater, suffer from obesity-related health conditions, been unable to lose weight through other medically supervised dietary and exercise programs and show a strong willingness to alter their diet and lifestyle permanently.

“Bariatric surgery is a commitment to healthy lifestyle, not just a few hours in the operating room and a week or two of recuperation,” says Linden. “The right diet and exercise figure prominently into treatment because without a commitment to change, patients can end up not achieving what they need for their health after enduring the risks associated with having an operation.”

A permanent commitment to a healthy lifestyle is a required for bariatric operations to be successful.

As with any operation, bariatric operations have risks. Studies show short and long-term complications may include infection, hernias and, if patients do not follow-up closely with their program, vitamin and nutritional deficiencies. These are serious concerns, but for a Children’s patient to be approved for weight loss surgery, Linden says much effort will have already been taken to ensure that the benefits will be far greater than the risks.

“Complications like pneumonia, infection and post-operative hernias are rare for these operations, but they are always on our radar,” he says. “Our pediatric surgical team is well equipped to manage risks before, during and after surgery.”

As long as the obesity epidemic continues to adversely affect the long-term health of children and strain America’s healthcare system, conversations about adolescent bariatric surgery will continue. But by better informing people about the science and facts behind obesity and its treatment it’s possible that we can shift the tone of the discussion. By looking at obesity and obesity treatment in a more individualized way, instead of as a blanket issue, may be we can initiate conversations that are more focused on personal solutions than assigning blame.

2 comments

  • Cheryl Obrien

    Given the status of obesity in children; we at Children’s Hospital should help promote better food choices. We should be setting an example for these families and children. For instance, in the cafeteria we should NOT offer sugery beverages, high caloric fried foods or caffeinated sodas. If the Boston School System is implemented such changes, perhaps we should as well. We no longer have a smoking area at Childrens, why should we have a high fat and calorie area !!

    Juli-Anne Evangelista and Cheryl O’Brien, Cardiology Department

  • Elizabeth Niederer

    Thanks to Chandra for linking this post. I hope more people from the obesityhelp.com site will chime in here.

    I am frankly puzzled at the nearly schizophrenic attitude of the vast majority of people in the medical profession regarding morbid obesity. There is a significant body of evidence in the literature showing that the “go on a diet and exercise more” advice that every single provider gives obese patients does NOT work. If health care providers prescribed treatments with such a poor success rate for any other condition as detrimental to health as morbid obesity, the lawsuits would bankrupt entire institutions.

    Assume, for example, that a teenager came to your institution with cancer and the entire treatment team insisted that the answer to the problem was a treatment protocol that had a less than ten percent remission rate for just one year. I daresay Children’s oncology program would no longer exist.

    This is exactly what almost the entire medical world does for morbidly obese people. It should be considered malpractice in my opinion.

    All the evidence shows that there is currently only one way to obtain any significant degree of lasting weight loss and remission of associated comorbidities, and that is bariatric surgery. Among the procedures currently performed, the adjustable gastric bands have the poorest rates of maintained excess weight loss and the highest rates of reoperation. The gastric reduction with duodenal switch has the best records in both of these areas. The Roux-en-Y gastric bypass and the vertical sleeve gastrectomy fall somewhere in the middle, although as more data become available via longterm followup of RNY patients, concerns are rising about late complications and weight regain. I am optimistic that the vertical sleeve gastrectomy will emerge as a superior option to gastric banding for patients desiring a procedure that provides restriction of food intake without malabsorption of calories or micronutrients.

    Nonetheless, even the gastric bands have an inordinately better success rate than traditional diet and exercise programs. Why, then, are so few providers educating themselves and their patients about these options? I repeat, this should be considered malpractice.

    Childhood and adolescent obesity is killing a generation of Americans. The causes are indeed very complicated and need to be researched and better understood, so that future generations can be helped. In the meantime, we have a generation of young people who are doomed to a shortened lifespan and horrible health problems along the way unless the medical field becomes more open minded and aggressive in educating itself and patients about the most effective treatment options and in making those options as widely available as possible.

    To that end, I applaud Children’s for venturing into the world of bariatric surgery. Please add the duodenal switch to your list of surgical options for appropriate patients, namely those with the severest metabolic problems, intractible type II diabetes and related issues. There are adolescents for whom the benefits of this cutting edge procedure far outweigh both the real and the imaginary risks.

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