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COMMENTARY |
Division of Gastroenterology and Hepatology,
St Louis University School of Medicine,
St Louis, MO 63104-1095
More and more children are obese, and more and more of them are severely obese.1 As a result, children now experience severe consequences of obesity that until recently were considered diseases of adulthood, such as type 2 diabetes. Given the serious physical morbidity of obesity as well as the profound impairment of quality of life and function, we inevitably must consider the role of bariatric surgery, an aggressive and potentially risky treatment that until recently was reserved for adults. In this issue of Pediatrics, Inge et al, a panel of experienced pediatricians and surgeons, present recommendations to guide patient selection, surgical management, and long-term follow-up.2
The panel emphasizes the risks of surgery and the paucity of data, both short-term and long-term, among adolescents. The report recommends caution in patient selection. It proposes conservative physiologic criteria based on body mass index levels, medical comorbidities, and physiologic maturity, and it endorses psychological health and family support before and after surgery. The panel recommends surgery only after the child has attempted other treatment. In fact, first on the panel’s list of prerequisites for surgery is that the adolescent should "have failed 
6 months of organized attempts at weight management, as determined by their primary care provider."
Although everyone would agree that a trial of "organized weight management" should precede surgery, this broad recommendation leaves the primary provider with many unanswered questions. What constitutes an appropriate weight-management program for children? Where are these programs? Who pays for them? How does one define success or failure?
Epstein et al3,4 have demonstrated that 6 to 8 months of family-centered, multidisciplinary, behavior-based weight-management programs can result in normal weight among 30% of participants at 10-year follow-up. Although they studied younger children with less severe obesity, their principles are sound and at this point are the gold standard for behavior-based weight management. Unfortunately, programs that follow this approach are rare.
These programs require a long-term commitment of time and energy by the youth and their families, and as a result, they are expensive. Unless supported by research funding, such programs must be paid for by families themselves or health care payers. Insurance companies have reimbursed poorly or not at all for pediatric weight-management programs.5 Group programs such as Shapedown, although more affordable, may still be too costly for lower-income families. In addition, these programs may lack the medical oversight that severely obese adolescents require. Adult commercial programs are also expensive and lack established outcomes in adolescents. Because cost is a barrier, appropriate programs do not exist in many geographic areas. When no programs are available, the primary care provider is left to address severe obesity during office visits.
Primary care providers can use the recommendations from an expert committee on childhood obesity for evaluation and treatment.6 However, despite their high level of concern about obesity, pediatricians, pediatric nurse practitioners, and dietitians have reported frequent barriers including lack of patient motivation, lack of time, and lack of reimbursement.7 In the absence of enough time and reimbursement, pediatric providers cannot evaluate, educate, motivate, and then monitor behavior and weight change adequately in a severely obese child for 6 months. If no alternative programs are available, these adolescents have no real opportunity to attempt behavior-based weight management. To say the patients have failed is to place blame unfairly.
Another challenge for the primary health care provider is defining failure. In adults, weight loss of 5% or 10% may substantially improve medical conditions. The provider must decide whether this outcome is a success if the child remains very overweight and with related psychosocial issues. In contrast, an adolescent who has continued rapid weight gain during organized attempts at weight management has obviously not succeeded, but this failure may reflect an eating or emotional disorder that requires psychological treatment, not surgery. This panel recommends a comprehensive psychological examination of patient and parents; the primary care provider must have these mental health resources available.
I applaud the work of Inge et al,2 and especially their emphasis on the need for careful long-term monitoring and collection of clinical outcomes data. These data will be essential to learn the risks and benefits of these procedures in adolescents of various ages, degrees of obesity, medical conditions, and psychosocial states. However, these adolescents deserve the best chance possible to avoid surgery by initial participation in high-quality weight-control programs. Such programs should include medical evaluation and treatment of existing comorbidities; education in good nutrition with practical meal planning; education about physical activity appropriate for their condition; behavior modification taught by experienced professionals through frequent visits; and counselors available to address psychosocial issues and family interactions.
Programs such as these will cost money, but bariatric surgery, which insurance may cover, costs $25 000 on average8; that amount of money would go far in supporting high-quality, behavior-based weight-control programs. Many severely obese adolescents ultimately will benefit from bariatric surgery despite participation in these programs, but the programs will reduce the need for surgery. In addition, such programs will teach even the patients who "fail" the programs important skills that will help them achieve and maintain a healthier weight after surgery.
If families, physicians, payers, and society now recognize that the crisis of childhood obesity means that life-altering surgery is an appropriate intervention, surely now is the time is to insist on the availability of the best possible nonsurgical weight-management programs.
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FOOTNOTES |
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Address correspondence to Sarah E. Barlow, MD, MPH, Division of Gastroenterology and Hepatology, SSM Cardinal Glennon Children’s Hospital, 1465 S Grand Blvd, St Louis, MO 63104-1095. E-mail: barlowse{at}0040slu.edu
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REFERENCES |
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 TOP REFERENCES |
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This article has been cited by other articles:
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  Journal Watch Arch. Dis. Child., February 1, 2005; 90(2): 216 - 217. [Full Text] [PDF]
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 When All Else Fails: Bariatric Surgery for Severely Obese Adolescents Journal Watch Pediatrics and Adolescent Medicine, October 12, 2004; 2004(1012): 5 - 5. [Full Text]
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