Bariatric (weight control) surgery for adolescents: is there any place for it?
It’s well known that an increasing number of Americans are overweight, and many more of those are frankly obese. The reasons are several. We have a more sedentary lifestyle and fewer and fewer of us get regular exercise. Our caloric intake, on average, has been steadily rising for decades, and many of us now eat the same number of calories as a person who a century ago did hard manual labor for 12 hours each day. Evolutionary biologists tell us that, in effect, our metabolism is programmed for how we lived 10,000 years ago, when our ancestors had infrequent, large meals and needed to store energy between them because the interval might be days. Now we have frequent large meals every day. As a result, our caloric balance is slanted toward accumulation, and we get fat.
The statistics for adolescent obesity are discouraging. The Centers for Disease Control says that 17% of our children are now obese, defined as a body mass index (BMI) of greater than 30. Because of the dismal results of traditional behavioral methods of weight contol in adolescents, more than a few experts are urging us to consider the role of weight-control surgery for so-called morbid obesity in children. It seems a bit extreme at first blush, but think about it: what we have to offer medically to these children virtually always fails, and we know that continued morbid obesity is a true threat to their lifes — not just in the long-term, but even in the medium-term. Why not do bariatric surgery on them?
The issue, of course, is what data do we have that this sort of surgery has any better long-term outcome than medical therapy. That is, does it work? Thinking of the risk-benefit ratio, is the short-term risk of surgery (which is not trivial) worth the chances of long-term success? A recent editorial in the New England Journal of Medicine asks that question. The answer is that we don’t know, but we should find out. We should offer the procedure to carefully selected cases, and keep track of how well it works out for them. From the editorial:
Will bariatric surgery in the young prove more effective over time than other less-invasive approaches? Given the health effects of massive obesity, many practitioners believe that weight-loss surgery is a better alternative than watching a morbidly obese youngster develop myriad complications. All adolescents must navigate the journey into adult life, and those who have undergone bariatric surgery will need to adhere to a stringent diet and medication and exercise regimens for the rest of their lives. There may be as-yet-unknown adverse effects of the surgery — for example, effects on bone density over decades. We also have much to learn about why bariatric surgery leads to a recalibration of the weight set point. It appears that bariatric surgery for adolescents has caught on, whether “right” or “wrong.” But the current strict requirements for having a bariatric procedure should not be relaxed until we know more.