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Turning Around My Thoughts on Bariatric Surgery

Christopher F. Boling, MD, FAAP
November 18, 2019

Life in a pediatric office is all about chaos management. Responding to emergencies, working on that ‘Oh-By-The-Way’ problem, recognizing and dealing with social determinants of health in each and every visit, keeping your business financially healthy and countless other indispensable tasks can make life for pediatricians stressful. The chaos can be overwhelming, but for me, it is also invigorating. I never go home wondering what I accomplished that day.  

Complexity is also what attracts me to the obesity work I have been doing more seriously over the last 15 years. Improving obesity care in primary care settings feels like my professional mission these days. Still, little did I expect that I, a primary care pediatrician through and through, would wind up being on an American Academy of Pediatrics (AAP) writing group advocating for my patients with severe obesity to have increased access to bariatric surgery.

Like many people currently believe, I thought bariatric surgery was too extreme, was too irreversible, was too expensive and somehow just missed the boat on what these patients really needed.  And the thought of doing the procedure on patients who were minors just seemed beyond the pale.

With mounting evidence about the long-term results of bariatric surgery in young patients with severe obesity, Dr. Christopher Bolling @FitKYKids let go of his value judgments about the procedure. #AAPvoices

It became pretty obvious to me that I needed to get over the value judgments I was making about bariatric surgery, about severe obesity and about my individual patients. These patients, and the kids especially, have the deck stacked against them. People think they aren’t as smart as “normal weight” kids. They get accused of not being motivated.  They get bullied about being overweight, and then they get food pushed on them because “they obviously like it.” And most tragically, they get very sick because of their weight and get blamed personally for their illness. It’s actually one of the more shameful aspects of American society that bias against people with severe obesity is a permissible form of discrimination.

Severe obesity, currently defined as having a BMI over 30 or having a weight greater than 120% of the weight that puts you at the 95th percentile BMI, is affecting more and more of our children. While one can debate whether or not childhood obesity rates are stabilizing, it is irrefutable that rates for severe obesity in the pediatric population continue to climb. As the science progresses, the genetic nature of severe obesity and its resistance to treatment with behavior modification are becoming increasingly evident.

“Our fight is not a zero-sum game. We need good prevention and effective in-office treatment. And, we also need options for our sickest patients."

And you know what? We have an effective treatment for this disease. Recent studies have demonstrated that bariatric surgery, when done for pediatric patients who have co-morbidities, is curative. It is a little-known fact that patients who have Type II diabetes usually resolve their diabetes after bariatric surgery before they lose significant weight. Younger patients tend to have at least comparable outcomes to adults who get the surgery. In addition, since patients tend to lose about 30% of their body weight following surgery regardless of their starting weight, delaying the discussion and not making patients aware of viable options until they are much heavier results in less optimal outcomes. In my experience, patients undergoing this treatment receive intensive psychological support and help with lifestyle modification to promote enduring healthy eating and activity instead of cyclic dieting.

Sadly, too few centers around the country are equipped to do these procedures for younger patients. Patients from lower socio-economic groups tend to have higher rates of severe obesity and less access to bariatric surgery than others. Centers that do exist are routinely required to submit multiple appeals to get patients approved for surgery. And often, insurers will simply refuse to pay for the procedure. Insurers will mandate multiple diet trials and demand other non-evidence-based requirements to exclude patients from getting surgery. Our guidelines also address the need for improved access.  

Obesity, like primary care, is confusing and multi-factorial in cause and in treatment. This illness is single-handedly bringing down the national life expectancy, and there is not going to be a quick fix. Our fight is not a zero-sum game. We need good prevention and effective in-office treatment. And, we also need options for our sickest patients. While throwing in a surgical option for treatment appears to make things more complicated and may stretch your perceptions about severe obesity, we should be thankful that the option exists for our sickest patients.

The researchers behind the Teen-LABS study, the AMOS study and the FABS-5+ study that looked at long-term results of bariatric surgery in young patients have done us and the families we care for a great service.  So, I ask you to make yourself aware of this potentially life-saving therapy and understand its indications. Please join me in helping a wonderful group of kids who desperately need our assistance.

* The views expressed in this article are those of the author, and not necessarily those of the American Academy of Pediatrics.

About the Author

Christopher F. Bolling, MD, FAAP, recently completed his term as Chair of the AAP Section on Obesity Executive Committee and is a co-author of the AAP policy statement, “Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices,” and technical report, “Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity.” A founder of Pediatric Associates in Crestview Hills, KY, Dr. Bolling is a primary care pediatrician, Volunteer Professor of Pediatrics at the University of Cincinnati College of Medicine and a Community Partner in the Center for Better Health and Nutrition at Cincinnati Children’s Hospital Medical Center.