Free isn't always a benefit: free bariatric surgery for kids

We now have an idea of what the “or else” might be for fat children in the UK who fail to lose weight. Under a new proposal for the clinical management of fat children under NICE (National Institute for Health and Clinical Excellence) guidelines, bariatric surgery would be provided for free in Norfolk...to children.

According to the evening news:

Children at N&N to get stomachs stapled

Children in Norfolk who are overweight or obese could for the first time be offered surgery under radical plans to stem the growing problem. More than a quarter of children living in the county are classed as overweight or obese, but if they want to lose weight through surgery they cannot do so for free in Norfolk.... the Norfolk and Norwich University Hospital is to submit a plan to county health chiefs to carry out surgery on the most severe cases, although only involving children. A spokeswoman for the N&N said: “The Jenny Lind Children's Department at the N&N is in the process of preparing a business case to provide obesity surgery for children only. “We are putting the case forward because of a rise in childhood obesity and illnesses associated with it....

Dr Michael Rhodes, a Norfolk surgeon who currently carries out operations on a private basis and would be one of the surgeons who operate on the youngsters next year, said: “I am very pleased that youngsters will soon be offered gastric banding. Of course this will only be in extreme cases when everything has been tried and the child just cannot lose weight....

A staggering 15,700 children up to the age of 15 are overweight in Norfolk and 5,700 obese. Last month health experts warned that despite prolonged efforts to promote healthy eating and exercise in schools the number of overweight children is not falling....

Nothing better exemplifies the importance of sound, science-based information and government programs accurately defining a ‘problem’, its causes and interventions, for which actual health benefits have been proven to outweigh the risks.

The clinical practice guidelines issued by NICE** last December to be followed by British doctors under the National Health Services (NHS), included “Obesity: prevention, identification, assessment and management of overweight and obesity in adults and children.” Under these “evidence-based” guidelines, prevention and management are directed towards getting everyone to a “healthy weight,” as defined as a “BMI of 18.5 to 24.9,” primarily through diet and exercise interventions and healthy lifestyle changes. The NICE guidelines also include sweeping recommendations outlining actions that should be taken by local authorities, employers, town planners, communities, childcare providers and schools to stop the epidemic of obesity.

The current NICE obesity guidelines for children have been reviewed here previously, but briefly include:

· assessment of children’s BMIs, family lifestyles and environmental/social factors affecting diet and exercise;

· children and families are to be instructed on the health dangers of being overweight, treatment options and behavioral modification techniques;

· families are to be counseled and expected to eat regular meals together without television, including breakfast, encourage active play and discourage sedentary activities in children;

· results of the discussions should be documented and a copy of the agreed goals and actions are to be kept in the child’s medical records;

· referral of overweight children to weight loss specialists and weight loss programs that focus on behavioral changes to reduce calories and increase physical activity;

· overweight children may need to do more than an hour of exercise a day and encouraged into structured activities;

· extensive work-ups for overweight children to identify “comorbidities” (cholesterol, blood pressure, insulin and glucose, liver and endocrine function, etc.);

· for those who fail to meet their weight loss target weight, orlistat or sibutramine is recommended for children 12 years and older with comorbidities, and may be used indefinitely to maintain weight loss; and....

· “Bariatric surgery is recommended as an option for adults and children after all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months.” However, “surgical intervention is not generally recommended in children or young people [section 1.2.6.12]. Bariatric surgery may be considered for young people only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity [section 1.2.6.13].” These restrictions would be removed under this new proposal.

As researchers continue to point out, simply calling guidelines evidence-based does not make them so. British researchers, for example, who conducted a careful and extensive review of the clinical evidence on the government’s initiatives for childhood obesity, found no evidence for the effectiveness of monitoring or screening children to prevent or reduce obesity. Disturbingly lacking were studies that credibly examined the potential harm of such programs. Worse, no study identified an effective weight reduction or preventive intervention. Not surprisingly given what is known about childhood obesity, every childhood obesity initiative, even with the most intensive focus on healthy lifestyles and balancing "calories in-calories out", has proven ineffective long-term.

There’s even less evidence for long-term health benefits of bariatric surgeries or that they outweigh risks for children. And there is absolutely no evidence that bariatric surgery is an emergency procedure and that without it fat children will die before they reach the age of consenting adults. What is the “or else” for parents who don’t want their eligible children to undergo surgery or who feel the risks and long-term nutrition-related consequences are not in their children’s best interests? Will their children be removed from the home and forced into state care if they don’t lose weight, too?

** The NICE obesity guidelines were created by a long list of public health officials working with about 250 stakeholder organizations, which included all of the major pharmaceutical companies, Atkins Nutritional, Inc., obesity and bariatric trade associations, the International Obesity Taskforce of the International Association for the Study of Obesity, Slim-Fast Foods Ltd, Weight Watchers UK, etc.