Childhood Obesity and Bariatric Surgery

Childhood obesity and adolescent obesity is linked with many serious health issues in adulthood.  Unfortunately, there is little evidence that preventive measures such as lifestyle interventions and pharmacological treatments are effective.  There are several surgical procedures for children and adolescents but the long term effects remain uncertain.

Researchers from University College of Gjovik and the University of Oslo, Norway in a paper “Bariatric surgery for obese children and adolescents:  A review of the moral challenges” concluded that surgery on children’s healthy organs to discipline their eating behavior in order to help them to be socially acceptable or to compensate for poor parenting is ill advised.  There needs to be more evidence on outcomes and risk factors.  There also needs to be a valid consent or assent.

In making a decision on bariatric surgery for children and adolescents, parents need to look at the moral implications with regard to values, viewpoints and arguments before they make the decision to go forward.

bariatric surgery child obesity

Long Term Outcomes and Benefits of Bariatric Surgery for Children

There is little evidence on the benefits of bariatric surgery on youngsters.  The overwhelming research has been on adults and those results don’t necessarily generalize to a children and adolescents.  If, after 100 – 150 procedures there are few complications then it might be permissible to perform this procedure, but only in specialized, high volume centers where the doctors have plenty of experience.

Much consideration needs to be given to how this procedure might affect psychological and social development.  Few studies address these issues.  The other moral consideration is informed consent.  Should a parent make the decision for a child, or is a child or adolescent mature enough to have a say?  Surgery should not replace self discipline.

Studies show that one third of obese adults were sexually abused as children.  So as part of the assessment process for children and adolescents, this should be addressed.

Preconceptions on Bariatric Surgery for Youth

Overweight children and adolescents are often the target of discrimination and prejudice.  And medical practitioners are known to also discriminate against the obese, by assuming they are ill prepared to take care of themselves.  So, few referrals are made for surgery among this population.  But should this social problem be addressed with surgery anyway?

Bariatric surgery poses particular questions for minors because it uses medical interventions to alter everyday behavior when there are other solutions available such as dieting, exercising, and cognitive behavioral therapy that pose no risk to healthy organs in the body.  Also this surgery does not address the many unknown causes of obesity.

In conclusion these researchers posed the following questions that need to be addressed when making a decision such as bariatric surgery for a child or adolescent:

  • Who to operate on
  • When to do it
  • Who is to decide
  • How to decide
  • Who is to operate
  • How best to prepare
  • How to follow-up

 

And the most important question would be how to generate more high quality evidence in a morally acceptable manner.

I would love to know your option on this topic of Childhood Obesity and Bariatric Surgery. Please Comment!

 

 

How the Brain Responds to Food After Gastric Bypass Surgery

Gastric Bypass Surgery patients lose more weight over the long them than those who have undergone gastric band operations.

A recent study found that obese patients who’ve had gastric bypass surgery experience changes in their brain which affect how the brain itself responds to food.  The Medical Research Council (MRC) found that this procedure reduces not only hunger, but the drive to eat for pleasure.

This was not found to be true of patients who have undergone gastric banding operations.  Therefore over the long run, gastric bypass patients lose more Gastric Bypass eat lessweight.  The research was published in the journal Gut and the theory is that physical changes made to the gut during surgery somehow have an effect on the drive to eat for pleasure.

Dr. Tony Goldstone from the MRC Clinical Sciences Centre at Imperial College London and consultant endocrinologist at Imperial College Healthcare NHS Trust said that  “Both procedures reduce appetite and have health benefits including long-term weight loss and improvement or even complete resolution of type 2 diabetes. However, gastric bypass surgery appears to be more effective for weight loss and has a more profound effect on the way in which the brain responds to food.”

Magnetic Resonance Imaging (MRI) was used to measure brain activity by scientists from Imperial College London, UK.  They studied 61 men and women who had lost weight using either one of these surgical methods.  21 people had gastric bypass and 20 people had gastric band surgery.  They used a control group of 20 people who had no surgery.

Patients who had gastric bypass surgery had less activity in brain’s reward centers when shown pictures of food, compared with those who had gastric banding surgery.  Gastric bypass patients also rated high-calorie foods as less appealing and as a result ate less fat in their diet than patients having gastric banding surgery or people in the control group.

However compared to the un-operated control group, both groups that had surgery had similarly reduced hunger and seemed unrelated to their psychological traits.

Researchers could not determine what caused these changes in brain activity, but did see differences in the patients’ metabolism which might be a factor.  The gut hormones that make us feel full after a meal were higher in the gastric bypass patients.  Levels of bile, which pay a role in digestion were also higher.

Another factor that was observed was that patients with gastric bypass surgery were physically uncomfortable, even nauseous after eating foods high in sugar and fat.  So this of course influenced their eating habits.

Dr. Goldstone concluded that “These findings emphasize that different bariatric procedures work in different ways to influence eating behavior,” added Goldstone. “This may have important implications for the way we treat patients with obesity and could help pave the way for a more personalized approach when deciding on the choice of bariatric procedure by taking the impact on food preferences and cravings into account.”

 

 

 

 

 

Medicaid and Medicare Drops Requirement for Bariatric Center of Excellence

On September 25th 2013, the Centers for Medicare and Medicaid Services (CMS) has dropped the requirement that bariatric surgery facilities be certified as a Bariatric Center of Excellence.

CMS released this statement on September 24, 2013 giving their reasons:

            “We believe the available evidence is sufficient to determine that the requirement for facility certification/COE designation for coverage of approved bariatric surgery procedures does not provide improved outcomes for Medicare beneficiaries.”

 

Why remove the Center of Excellence requirement?Bariatric Center of Excellence Medicaid

They concluded that certifying these facilities did not improve results.  There was also a downside and this was that fewer people could get the services they needed.  These included mostly the disadvantaged.

 

The Change in Policy

The policy in place since 2006 requiring these facilities be accredited to be covered on Medicare has been reversed.

This National Coverage Determination (NCD) on Bariatric Surgery for the Treatment of Morbid Obesity spelled out certain criteria for patients, procedures that would be covered and specific requirements that bariatric facilities must have in order to have coverage.

At the time every facility performing these services and procedures had to be certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center or approved by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE).

In 2005 the thought was that these certifications were beneficial but since then this has not been proven out.

 

Reconsideration Request

 A formal request to have this 2006 policy lifted was submitted by representatives of the Michigan Bariatric Surgery Collaborative.  The members requesting that CMS consider removing the certification policy were John Birkmeyer, MD, Nancy Birkmeyer, PhD and Justin Dimick, MD.

These doctors spelled out the results of several current studies that showed no real difference in mortality or complications between the centers of excellence and the facilities that were not.

So the CMS opened a National Coverage Analysis (NCA) in January 2013, in order to review the evidence.

They analyzed nine current research articles on the topic, they got input from the public at large and they reviewed professional society position statements.

 

The following groups opposed the new CMS policy removing accreditation:

  • The American Society for Metabolic and Bariatric Surgery (ASMBS)
  • American College of Surgeons (ACS)
  • The Obesity Society
  • Academy of Nutrition and Dietetics
  • American Society of Bariatric Physicians (ASBP)
  • American Association of Clinical Endocrinologists (AACE)
  • Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

 

The issues raised by those commenting had to do with:

  • Access to Care
  • Quality and Outcomes
  • Commitment to Multi-disciplinary Team Approach and Structure
  • Consistency of CMS Policy
  • Medicare Population at Risk
  • Communication with Certifying Organizations
  • Review of the Evidence

 

The major issue was access to care.  One of the studies concluded that “the Center of Excellence requirements have increased the travel distance for Medicare patients”, making it more difficult to access.

 

Bariatric Surgery Accreditation

The American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS) are responsible for carrying out the accreditation.  Last year they joined forces forming the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

This program establishes a national standard for accreditation so that patients have better care before, during and after their procedures.  Across the country there are currently about 750 inpatient and outpatient center accredited by either the ASMBS or ACS.

CMS is the only major insurer to have dropped the certification requirement.  Others still may require accreditation in order to cover bariatric surgery:

 

Before the decision was made by CMS to drop the accreditation Justin Dimick, MD, who was in favor of this decision said:

“There are definitely two points of view on the issue.  There is the professional association point of view, representing the people who perform accreditation, and obviously they support keeping the requirement, which is certainly understandable.  Doctors Birkmeyer and I represent the scientific perspective, which is about what the evidence shows, and we think the evidence does not support the need for mandatory accreditation.”

“We are not against certification,” said Dimick.  “We just don’t think it should be mandatory.”

 

 

Primary Source:  Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity – Facility Certification Requirement (CAG-001250R3), accessed at www.cms.gov.

 

 

Type II Diabetes Cure: Bariatric Surgery

Looking for a Type II Diabetes Cure? Many health conferences are starting to talk about the ability of bariatric surgery to improve the symptoms of and cure type II diabetes. For years, it has been known that people who undergo bariatric surgery often seen an improvement in their diabetes long before they start seeing weight loss results. If you have type II diabetes you may want to consider bariatric surgery as a way to improve and cure your diabetes.

Consider some more information about the procedure before you decide to talk with your doctor about undergoing the procedure since all surgical procedures should be carefully considered.

Is Bariatric Surgery Really the Answer for Type II Diabetes Cure?

Much talk can be found online about bariatric surgery as a cure for type II diabetes. In fact, some medical studies have bariatric surgery for type II diabeteseven shown the benefit of bariatric surgery in treating or at the least reducing the symptoms of type II diabetes. Perhaps the best news comes from two new studies published in the New England Journal of Medicine. These new tests were done from a random group of people that compared people with bariatric surgery versus those who received conventional or intense medical treatment for their type II diabetes. Before this, there was no definitive test about the effects of bariatric surgery and type II diabetes.

These two new studies were done in Italy and had the goal of dropping a type II diabetes patient A1C to under 7 after 2 years of treatment. Those who didn’t undergo bariatric surgery underwent lifestyle changes such as a low-fat diet and increased exercise based on the American Diabetes Association guidelines. Both of these studies showed that those who underwent bariatric surgery had lower BMIs, lower A1C’s and other health benefits such as lower blood pressure and lipid levels than those who didn’t undergo the surgery.

In addition, these benefits came from the surgery itself and not from any medication help. This is what many doctors and the press are talking about when it comes to bariatric surgeries ability to be the type II diabetes cure.

While these studies show good results from people with type II diabetes that undergo bariatric surgery. It is important to also keep in mind that people who don’t undergo surgery also see improvements in their type II diabetes with rigorous medical treatments. So it is important to carefully look into bariatric surgery and see if it is right for you. Often if you aren’t obese, a doctor won’t recommend this type of surgery just to help with type II diabetes. However, if you are both obese and suffering from type II diabetes it may be reasonable to talk with your doctor about the benefits of undergoing bariatric surgery.

After undergoing the procedure you need to be prepared to deal with a lifetime of nutritional and dietary changes that must be rigorously followed in order to avoid complications. You will need to be vigilant about taking additional supplements to avoid malnutrition. Tracking your nutritional status is important.

Bariatric surgery is certainly an option for people who are looking for a long term type II diabetes cure. You should carefully consider the information above and talk with your doctor to make sure bariatric surgery is right for you. You may want to schedule a free information session that most bariatric practices offer, so the surgeon can help answer any questions you may have about the procedure.