Bariatric Surgery: Why Youth Are Not Getting This Treatment For Obesity

"Whatever it takes." That's what the superheros said they would do when faced with a major crisis in the movie Avengers: Endgame. Is our health care system then doing "whatever it takes" to address childhood obesity, which certainly qualifies as a major crisis, a major, major epidemic?

Not even close. Captain America would say, "what the bleep," if he were to look at our health care system. For example, consider the new policy statement from the American Academy of Pediatrics (AAP) entitled "Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices." The policy statement, authored by Sarah C. Armstrong, MD, FAAP, Christopher F. Bolling, MD, FAAP, Marc P. Michalsky, MD, FACS, FAAP, FASMBS, and Kirk W. Reichard, MD, MBA, FAAP, in effect says that our health care system is not doing "whatever it takes" when it comes to youth with severe obesity.

In this case, the "whatever" is metabolic and bariatric surgery. The "it" is severe obesity that is afflicting a growing number of America's adolescents. The policy statement called severe obesity among youth an "epidemic within an epidemic" and metabolic and bariatric surgery "an important treatment for adults with severe obesity." The statement continued by saying that metabolic and bariatric surgery "has been shown to be a safe and effective strategy for groups of youth with severe obesity." Safe and effective sounds good. Certainly way better than "dangerous and a waste of time." For example, a study published in The Lancet Diabetes and Endocrinology found that adolescents who underwent Roux-en-Y gastric bypass tended to have significant decreases in their body mass indices (BMI) that were maintained into adulthood and reduced risks of high blood pressure, type 2 diabetes, and cholesterol and lipid problems. A study published in the New England Journal of Medicine revealed that adolescents experienced "significant improvements in weight, cardiometabolic health, and weight-related quality of life" three years after going through Roux-en-Y gastric bypass or sleeve gastrectomy. Over half (57%) did experience iron deficiency, and 13% had to have further surgical procedures.

Ah, but take a gander at the next sentence in the AAP policy statement: "however, current data suggest that youth with severe obesity may not have adequate access to metabolic and bariatric surgery, especially among underserved populations." Wait, isn't that like being in a battle with Thanos and saying, "let's keep Thor's hammer in the tool shed and try some plastic forks instead?"

Of course, metabolic and bariatric surgery is not just one thing like Thor's hammer, Captain America's shield, or Tony Stark's sarcasm. Instead, it encompasses various procedures that "cause weight loss by restricting the amount of food the stomach can hold, causing malabsorption of nutrients, or by a combination of both gastric restriction and malabsorption," according to the American Society for Metabolic and Bariatric Surgery (ASMBS). If you surgically reduce the size of your stomach, your stomach may not be able to hold or absorb as much food. This helps you feel full sooner and more food to just pass through your gastrointestinal tract in the end or rather through the end. Such surgery may also help re-wire a person's metabolism.

Of course, bariatric surgery is not for everyone and is not the sole solution for the ongoing childhood obesity epidemic. Instead, it is part of range of possible policies and interventions. Indeed, the AAP statement supported the ASBMS recommendations that "bariatric surgery be considered for youth with BMI ≥35 with concurrent severe comorbid disease or for those with BMI ≥40 kg/m2 (where comorbid disease is commonly encountered but not mandatory)." Your BMI is your weight in kilograms divided by your height in meters squared and is just one potential measure of obesity. A comorbid disease is an obesity-related major condition such as type 2 diabetes, cardiovascular disease, liver disease, or sleep apnea.

Note that "be considered" doesn't mean "be done" or "be performed" or "go, go, go." The AAP statement recognized that there are a number of reasons why a child or adolescent should not get bariatric surgery, such as "a medically correctable cause of obesity, untreated or poorly controlled substance abuse, concurrent or planned pregnancy, current eating disorder, or inability to adhere to postoperative recommendations and mandatory lifestyle changes." In this sense, bariatric surgery is not like Thor's hammer. You shouldn't ever lead with it when trying to combat severe obesity. It should be an option only after other measures and treatments have failed and only if the patient is dedicated to following through with the rigorous diet and physical activity requirements that will accompany the surgery.

Yet, evidence suggests that bariatric surgery isn't even being considered for many youth who could benefit from the procedures. Does this make any sense? Well, since when did our health care system make total sense?

Part of the problem is the continuing ways that obesity is being portrayed and viewed in our society and health care system. There is still the "obesity is a choice" notion that is floating around like poop on water, including assertions that obesity is simply the result of laziness and bad lifestyle decisions. People continue to push certain diets or exercise regimens and claim that everyone can lose weight if they just choose to do so. Heck, you even have people advocating for more fat-shaming, which is analogous to wanting yet even more racism or sexism, as if these are not already in abundance in our society.

Then there are the misconceptions about bariatric surgery. Not everyone really understands what bariatric surgery is and what it involves. There may be the belief that bariatric surgery is an easy way out, a way to avoid making adjustments to your diet and physical activity. There may be the thought that bariatric surgery is an adults-only procedure. There may be the perception that severe childhood obesity is not a serious medical condition.

To all of this, consider the quote from the movie 10 Things I Hate About You, "not even close, not even a little bit, not even at all." Childhood obesity is an epidemic that is the result of broken systems and not simply personal choice. Obesity is medical condition that can have serious consequences such as diabetes, heart disease, stroke, and cancer. Also, as this OWN story by Lisa Ling showed, obesity can have substantial mental and emotional consequences for adolescents:

And if you think that bariatric surgery is an easy way out, get to know some people who have actually gone through bariatric surgery and its accompanying regimens. It's not exactly a walk in the park and requires motivation and dedication. As shown by this Nemours/Alfred I. duPont Hospital for Children video, which includes Dr. Reichard, one of the AAP statement authors, bariatric surgery is a complex effort that requires an experienced multi-disciplinary team:

Bariatric surgery may be effective for many but it certainly ain't easy.

Another barrier is money, because when is money not a barrier when it comes to health care? Many insurance companies may not adequately reimburse for bariatric surgery for adults let alone youth. According to a study published in the journal Obesity, less than half of adolescents who qualified for bariatric surgery from a medical standpoint received insurance authorization to move forward with the procedure. Even if an insurance company has a stated policy that it covers bariatric surgery, they may act like a person who is reluctant to go on a date after agreeing to do so. There can be hemming and hawing, delays, obstacles, and a whole lot of extra paperwork. (Note: if someone asks you to fill out paperwork to go on a date, reconsider the date.) Clinics and hospitals then can behave the same way because they may follow the money, prioritizing the approaches and treatments that bring higher and easier reimbursement. Plus, it's not just the surgical procedure that needs to be covered. It is all the follow up, counseling, and care that occurs afterwards too.

Our health care system needs to seriously reconsider how it is treating the obesity epidemic, including the childhood obesity epidemic. After all, what is the endgame here? If the obesity epidemic is not properly addressed and all of the available tool used now, our health care system and society will have to deal with the overwhelming resulting costs and burden very soon and into the future. When it comes to the obesity epidemic, where's the urgency, where is the willingness to do "whatever it takes"?