Issue 1 / 21 January 2013

BARIATRIC surgery is in the TV and newspaper headlines on a regular basis, often in a sensationalist and critical way.

However, bariatric surgery is a well recognised form of therapy for adults with severe obesity, and can lead to substantial, long-lasting weight loss, improvements in a range of comorbidities, and an increase in longevity.

But what about its role in adolescents? Certainly there is evidence of its effectiveness in severe obesity, with many reported case series and one randomised controlled trial of laparoscopic adjustable gastric banding versus medical therapy, conducted in Melbourne, which found a number of benefits for the banding group.

And, as of 2010, we now have Australian and New Zealand guidelines for bariatric surgery in adolescents. These were developed by a working group comprised of members from the Australia and NZ Association of Paediatric Surgeons, the Obesity Surgery Society of Australia and NZ and the Paediatrics and Child Health Division of the Royal Australasian College of Physicians.

The recommendations state that bariatric surgery should be considered in severely obese adolescents (generally with body mass index [BMI] > 40 kg/m2, or BMI > 35 kg/m2 with severe comorbidities) aged 15 years and older who have attained physical maturity. Factors such as the adolescent’s decision-making capacity and the presence of a supportive family environment should be taken into account.

The recommendations also emphasise the need for coordinated management in centres with multidisciplinary weight management teams, for the surgery to be performed in tertiary institutions experienced in bariatric surgery, and for long-term follow-up of patients.

Australia and NZ were the first countries to have consensus recommendations for bariatric surgery in adolescents. Unfortunately, there have been major challenges with their implementation in Australia.

One longstanding problem is that there are very few multidisciplinary programs for the medical/behavioural management of adolescent obesity in any of the Australian states or territories. Indeed, several jurisdictions have no tertiary level weight management service for children or adolescents. There are generally poor referral pathways across primary, secondary and tertiary level care services, and many health professionals perceive that they are poorly trained in the assessment and management of child/adolescent obesity.

Added to this is the fact that the vast majority of bariatric surgery procedures within Australia are performed in the private sector and hence are largely unavailable to non-insured patients. Few procedures are provided to adolescents.

Thus, at a time when obesity is one of the most common chronic conditions in young people, we have a health system that is unable to provide adequate treatment services for those who are affected.

So what might be a way forward?

Health systems in all states and territories need to invest in quality data on how obesity across the age spectrum influences health service use and costs. The few available data suggest that obese adolescents present more frequently to health services at all levels, and have higher costs of hospitalisation. With the rollout of Activity Based Funding it means, even more so, that the true costs of health care to hospital inpatients and outpatients who are obese need to be known.

There needs to be further development and provision of health professional training in the assessment and management of people who are obese, at both undergraduate and postgraduate level, and across a range of health professions. For most this will need to be provided in short, modular and accessible forms of training that could be delivered in a range of resource-effective ways.

All state and territory health departments should develop a coordinated approach to the delivery of obesity treatment across primary, secondary and tertiary levels of care, and for all age groups. This must include bariatric surgery, as well as e-communication and e-health approaches, and systems designs to reconfigure the existing chronic disease care workforce.

Importantly, such approaches must be resourced and made available in the public sector. For adolescents affected by severe obesity, there will need to be access to one or two major bariatric surgery centres in each state that are linked to adolescent multidisciplinary medical services.

Gulp! Providing effective treatment for obese young people in a resource-constrained environment is challenging. It will require planning, real resources and some hard decisions about resource reallocation.

What will it take for bariatric medical and surgical services to be provided to young people?

Professor Louise Baur is professor in the discipline of paediatrics and child health at the University of Sydney; and head of Weight Management Services at The Children’s Hospital, Westmead, Sydney.

Click here to read comment from Dr Michael Gliksman, who says the treatment of obese patients should be based on evidence.

 

Posted 21 January 2013

2 thoughts on “Louise Baur: Bariatric neglect

  1. Tom Ruut says:

    We need to dispel the notion of “puppy fat”.Early intervention with teenagers is the way forward!

  2. Tim Leahy says:

    Based on case series and one RCT of N=50 with 2 year follow up? 33% of those operated required re operation. Wouldn’t we want a bit more evidence and longer follow up? to quote from Uptodate: “It is not clear to what degree weight loss will be sustained in adolescents and whether comorbid conditions will recur if significant weight is regained in long-term follow-up. Two studies with 4 to 10 years of follow-up suggest that 10 to 15 percent of patients regain significant weight after gastric bypass procedures [36,49]. A substantial number of patients also regain some or all of their lost weight after adjustable gastric banding. In one retrospective series of 24 adolescents, maximal EWL (52 percent) occurred at one year after adjustable gastric banding with a regression to 42 percent EWL at two and three years [40]. Specific predictors of weight regain after surgical weight loss procedures are unknown for adults and adolescents. There is still insufficient information to directly compare the long-term weight loss outcomes of roux-en-Y gastric bypass to those for adjustable gastric banding or sleeve gastrectomy in adolescents”.
    Surely we should also be exploring other treatment modalities too, such as combined very low calorie diets and high intensity interval training and CBT face to face and by phone, in combination? Even if bariatric surgery is the most effective treatment can we afford it in the volume required?

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