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Although controversial, bariatric surgery might help weight loss

„Y d
{ Allan M Conway, Robert Jones
„Y × 
 { 06 agosto 2009
„Y J
{ 10.1136/sbmj.b3215
„Y Cite this as{ Student BMJ 2009;17{b3215

Obesity is a global pandemic. In 2005 the World Health Organization estimated that more than 400
million adults were obese.[1] In developed countries, such as the United Kingdom, the United
States, and Australia, rates of obesity have more than doubled in the past 25 years.[2]

Body mass index (BMI), commonly used to classify obesity, is calculated by dividing the patients¶
weight in kilograms by the square of their height in metres. The National Institute for Health and
Clinical Excellence, the agency that considers whether the National Health Service should provide
treatments, recommends that weight loss (bariatric) surgery should be considered for adults with a
BMI greater than 40 or greater than 35 if there is serious associated disease, such as type 2 diabetes.

A recent review in a
 controversially recommended that children with a BMI greater than 35
and short term morbidity, such as type 2 diabetes, as well as children with a BMI greater than 40
with longer term risks, should be candidates for surgery.[3] But should we be performing an
operation that will affect someone for the rest of their life based on their behaviour in their first 15
years?

About 4% of children in the US are extremely obese (above the 99th percentile of BMI for age),
and this number has tripled in the past 30 years. These patients almost always become obese
adults.[4] Obesity of this severity is associated with many health problems, including diabetes,
hypertension, sleep apnoea, atherosclerosis, and osteoarthritis. Obesity is associated with huge
social stigma, which can be devastating for young patients. Children who seek treatment for obesity
report a reduced quality of life, on a par with paediatric patients with cancer.[5]

Obesity is an expensive problem. In 1995 the global cost was estimated at $99.2bn (£58bn;¼69bn) a
year.[6] In the UK an estimated £480m of spending a year by the National Health Service is a direct
result of obesity. Indirect costs to UK society, through lost productivity and death, are more than
£2bn a year.[7] Treating obesity and its complications is far more costly than preventing obesity.[8]
Treating obesity at a young age, and preventing an extended lifespan with expensive health
problems, would seem to make financial sense.

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The most commonly performed bariatric operations are laparoscopic adjustable gastric banding, in
which a restrictive band is fitted around the patient¶s stomach to limit volume, or gastric bypass. In
children the surgery of choice is now laparoscopic roux-en-Y gastric bypass, in which intake is
restricted by the formation of a small gastric pouch, and absorption is limited by bypassing a section
of the small intestine.[9]
A recent large meta-analysis of adults undergoing surgery found that patients undergoing gastric
banding lost 47.5% of their excess weight; patients undergoing formal bypass lost 61.6%.
Comorbidities also improved. Type 2 diabetes resolved in 76.8% of patients, hypertension resolved
in 61.7%, and hyperlipidaemia improved in 70%. Obstructive sleep apnoea resolved in 85.7% of
patients. Patients¶ quality of life improved, with more employed and better social relations.[10]

Although sparse, more data to support paediatric bariatric surgery is becoming available. A recent
US meta-analysis showed that surgery in children can lead to sustained and significant weight loss,
with resolution of many comorbidities and acceptable morbidity and mortality.[11]

Bariatric surgery is not the only answer. Strong evidence shows that successful weight loss can be
achieved among young people who attend weight loss camps. In one observational study of a
programme that consisted of a diet of 1800 kcal (7500 kJ) a day, supervised physical activity,
nutrition classes, and support groups led by psychologists, participants experienced significant
average drops in BMI of 2.9 points and weight loss of 7.5 kg. Self esteem, body esteem, and
negative attitudes towards fat also improved.[12] Despite recent advances, however, no
recommended dietary programme or drugs result in long term weight loss of more than 10% for
most people who attempt these interventions.[13]

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Although the exact number of paediatric patients undergoing surgical intervention is not recorded,
about 2% of the members of the American Society for Bariatric Surgery have performed a bariatric
procedure on a patient under the age of 18. Bariatric surgery in children has complications.
Nutritional depletion is a recognised risk in adult patients. Some doctors fear that surgery in
children who have yet to reach musculoskeletal maturity may cause long term problems. US
recommendations suggest that in addition to fulfilling the BMI and comorbidity criteria, all
paediatric patients should have failed six months of intense medical management at a specialised
centre as well as having achieved most of their skeletal maturity (nominally 13 years for girls and
15 years for boys). The decisional capacity of the patient and their family and the amount of
psychosocial support available after operation should also be formally assessed.[14]

Bariatric surgery is a cost effective intervention to treat obesity and its hugely expensive
complications. Although drugs development continues apace, surgical intervention remains the best
treatment. Although once considered a peculiarly US problem, childhood obesity is increasing
worldwide. We argue that although children undertaking serious non-essential surgery may be
controversial, the long term health risks associated with morbid obesity require urgent intervention.
In selected groups, with appropriate psychosocial support, surgery is an effective and cost efficient
intervention that can be performed with minimal morbidity and mortality.