Guidelines Backlash, the Biggies — Surgery, Part 3

Today’s post serves a dual purpose, being also the Sixth Bariatric Surgery Roundup. Obviously, it’s not as if weight-loss surgery for kids had never been discussed prior to the publication of new guidelines from the American Academy of Pediatrics at the beginning of this year.

“Conscience and Consent”
In an era when court cases about sexual reassignment surgery are being argued, bariatric surgery might seem rather tame. Still, both kinds change the body irreversibly and bring lifelong consequences.

“Does It Have to Be Surgery?”
Despite what may seem like a too-hearty endorsement of bariatric surgery, the AAP has always held that it would be preferable for childhood obesity to be corrected in some other way. The organization would like to emphasize this point: Surgery or no surgery, the obese patient who is serious about change will, either way, have to adhere to a limited diet forever.

“Bariatric Surgery and Race”
Even though minority children and teens are statistically more likely to be overweight or obese, the majority of weight-loss surgeries are performed on white patients. It seems that figuring out the reasons for this disparity might be rather important.

“Evaluation for Metabolic and Bariatric Surgery”
This post explains the green light, yellow light, and red light system of evaluating a surgical candidate.

“Bariatric Surgery’s Progress”
A major drawback is the lack of long-term followup studies. In the short term, the failure rate seems to hover around 20%. Children and teens do not even have fully-formed personalities in the first place, and they tend to emerge from major surgery with the same emotional problems that led to obesity in the first place.

“Bariatric Surgery in a Less than Ideal World”
A discussion of the studies that have been completed about the medical and psychosocial effects on people who had undergone bariatric surgery as children and teens. The definition of “complications” includes the need for subsequent surgeries of the same kind. Sometimes, the problem is traceable to insufficient nutrition, particularly a shortage of calcium, iron, and various vitamins. Additionally, at the two-year mark after the completion of such surgeries, it was found that almost one in five of the young patients showed signs of clinical depression. Obviously, both nutritionists and psychologists are very important members of the clinical team.

“Can Best Be Improved On?”
In the great majority of cases, Type 2 diabetes ceases to be a problem after bariatric surgery. The opportunity to end all that misery should thrill the fiscal conservative, because if uncorrected, all those co-morbidities will cost even more than the operations.

“The Aspirations of Bariatric Surgery”
Another post includes more about the multidisciplinary team concept, and includes words from Dr. Pretlow:

I’m not an advocate of bariatric surgery, particularly in the pediatric population, except for life-threatening cases. I feel strongly that overeating/obesity is an addictive process and should be treated with addiction medicine methods. Our research results support this position.

“Contemplating Bariatric Surgery”
This one is basically a review of a horrifying and hilarious article whose author suggests that “death on the operating table can start to sound like the best-case scenario.”

Your responses and feedback are welcome!

Image by Yeison Varón Velásquez

Guidelines Backlash, the Biggies — Surgery, Part 2

For all practical purposes, today’s post is also known as the Fifth Bariatric Surgery Roundup. In other words, Childhood Obesity News has looked into this subject diligently, because it is so impactful. Those who are in favor of recommending bariatric surgery at a younger age say that the longer obesity is allowed to flourish in a child, the more difficult it will be to reverse that trend and get back to a healthy weight — and that is a valid point.

Another, and even more valid point, is that non-surgical methods should be tried earlier and more earnestly. The American Academy of Pediatrics is doing the best it knows how with new recommendations for more weight-loss drugs and earlier surgery. Meanwhile, Dr. Pretlow is working toward a world where both pharmaceuticals and bariatric surgery become exceedingly rare.

“Bariatric Surgery and Very Young Children”
Obesity was officially defined as a disease only about 10 years ago. To leap so quickly from that, to blithely recommending life-altering surgery for kids, seems rather precipitous. Let’s quote Dr. Pretlow on this one:

If non-surgical methods were effective, then bariatric surgery would be unwarranted. Therefore, we need to figure out exactly why non-surgical methods are ineffective, and create non-surgical methods that ARE effective, like addiction-based and displacement-based methods.

“Bariatric Surgery for Children”
Back in 2019 when this post was published, many professionals believed that “marketing weight loss surgery to children is wrong because it is invasive and dangerous, and can irreversibly transform the metabolic system.” And many still agree. For instance, Dr. David L. Katz opined,

Epidemic childhood obesity is a cultural crisis. Turning to the literal cutting edge of biomedical advance to address it is not a solution, but an abdication.

“Bariatric Surgery for Children — A Desperate Case”
This post relates a disturbing story of a sleeve gastrectomy performed on a child less than a year old, and what made it particularly horrific is that it did not work, possibly because her parents continued to supply “chips, biscuits, chocolates, and ice cream.” The youngster’s stomach expanded, leading to a second sleeve gastrectomy when she was seven.

“Weight-Loss Surgery and Non-Adults”
Some of the difficulty with assessing the usefulness of these procedures for children lies in the disparity between different methods of defining success — for instance, measuring loss in terms of excess body weight, versus loss relative to baseline weight. Despite the uproar over the AAP’s recent endorsement of surgery for kids, it has already been employed in extreme cases for very young children for years, even in the USA.

“Who Is Ready for Bariatric Surgery?”
In this post, we noted how enthusiastically Saudi Arabia has embraced surgical solutions for obesity, and how the government willingly pays for it under the citizens’ standard insurance policy.

“Why Operating on Children and Teens Is Okay”
This post reviewed some of the history of the trend toward acceptance of bariatric surgery for children and young people. Even before the recent headline-grabbing new AAP guidelines, that organization had stated that there is “no evidence to support the application of age-based eligibility limits.”

Your responses and feedback are welcome!

Image by Nutritional Doublethink/CC BY-SA 2.0

Guidelines Backlash, the Biggies — Surgery, Part 1

As we have seen, plenty of experts have a lot to say about the concept that kids as young as 12 (and in extreme cases, even younger) should be prescribed weight-loss drugs. It turns out to be a pretty controversial topic. But that debate almost fades into the background when compared to the real shocker. For patients as young as 13, bariatric surgery also is now on the table.

Before approaching this subject in light of the new American Academy of Pediatrics guidelines, let’s look back on some previous Childhood Obesity News discussions. So far, there have been three related “roundups.” The first was titled “Many Aspects of Bariatric Surgery for Teens.” The second was “Another Teen Surgery Compendium,” and the most recent was “The Third Bariatric Surgery Roundup.” A multitude of angles have already been covered but there is, astonishingly, still much more to consider. So today’s post wears two hats. It is also, officially, the Fourth Bariatric Surgery Roundup. Here goes:

“Bariatric Surgery, Qualifications, and Conscience”
“MBS” stands for metabolic and bariatric surgery, and for an adult, five major decision criteria must be taken into consideration. When the candidate is a minor child, issues become much more complicated.

“Bariatric Surgery and Consent”
Even a highly motivated mature adult, who is willing to practice total compliance, can find some aspects of post-operative care barely manageable. What happens when the patient is not even old enough to drive or vote?

“Bariatric Surgery and the Mind”
Adherence to post-op dietary and medication regimens is vital to success. What happens when the patient is cognitively impaired, psychiatrically unstable, or developmentally disabled? What happens when that already troubled patient is a minor child?

“More on Bariatric Surgery and the Mind”
When the patient is young and the procedure involves far-reaching lifestyle changes, forever can be a long, long time. What happens if a complication like substance abuse later enters the picture?

“Still More on the Mind and Bariatric Surgery”
One expert says, “Co-morbid psychosocial and emotional problems of obesity generally act as causal or maintaining factors of obesity and thus significantly affect the treatment outcome.” Weight-loss surgery alone does not straighten out any mental or emotional kinks the patient may have possessed in their pre-surgical life.

“Body, Mind, and Bariatric Surgery”
Just a couple of years before the controversial decision to endorse surgery for young obese patients, the American Academy of Pediatrics issued a couple of significant reports on the subject.

“The Evolution of Thought about Pediatric Bariatric Surgery”
Bariatric surgery is not only about reducing appetite. It is an investment in the future. Some experts feel that the only real justification for inflicting this kind of surgery on a child is that it will prevent a severity of obesity that ushers in one or more complications, known as co-morbidities.

Your responses and feedback are welcome!

Image by Nutritional Doublethink/CC BY-SA 2.0

Guidelines, Quibbles and Quirks — Part 4

This continues the description of some uncommon but dangerous eating disorders, brought to public attention by the National Eating Disorders Association during National Eating Disorders Awareness Week. Today’s post describes two more of the lesser-known eating disorders which are not yet officially deemed to be such.

Diabulimia

Diabulimia is something that afflicts only Type 1 diabetes patients, especially adolescents, who fear that the insulin that keeps them alive also makes them overweight. They will limit or skip their required insulin injections, which leads to nothing good.

Pregorexia

Pregorexia is also limited to certain patients, in this case, the pregnant ones. The expectant mother wants to control the amount of weight she gains during pregnancy. This behavior can turn into an eating disorder like anorexia or bulimia. The possible consequences affect not only herself but the unborn child. The infant may suffer restricted growth, fetal development irregularities, or low birth weight, as well as outright miscarriage, or the risks incurred by prolonged labor. For the mother, the possibilities also include bone loss, abnormal fatigue, dizziness, electrolyte abnormalities, and dehydration.

Along with calorie counting and food intake restriction, the prospective mother might insist obsessively on a demanding exercise routine. Several other warning signs should be watched for:

— Self-induced vomiting
— Laxative use
— Feeling shame or guilt about weight gain
— Weighing yourself several times a day or doing other things to measure the size of your body
— Fear or intense distress about gaining weight
— Avoid going to doctor’s appointments
— Feel disconnected from the baby growing inside them
— Avoid social situations with friends or family

Why have these unusual disorders been brought up here? Because one of the major objections to the new American Academy of Pediatrics guidelines for childhood obesity treatment is that the beliefs and intentions expressed therein are in danger of inspiring a new wave of eating disorders, especially among the young.

National Public Radio’s “All Things Considered” interviewed eating disorder specialist Nooshin Kiankhooy, who points out that there have been no long-term studies of how a child may be impacted by either weight-loss drugs or bariatric surgery.

There is also the psychological angle. When many adults barely grasp how these treatments could affect them, how are children supposed to understand what they are letting themselves in for? Kiankhooy says,

The fact that we are placing such an emphasis on the size of a child’s body, to me, is a huge concern — and how that not only is going to impact a child’s body from a physical standpoint but how it’s really going to impact them from a mental standpoint in — this is what your body is, and we must now change it…

Also for NPR, journalist Kaitlyn Radde wrote,

[W]hen adult patients stop taking the class of weight loss drugs recommended in the guidelines, they often gain the weight back, which means kids might be on the medication for the rest of their lives. But supporters say the updated guidance will help destigmatize obesity precisely because it treats it as a disease — like cancer or COVID — that requires medical intervention and isn’t the patient’s fault.

Your responses and feedback are welcome!

Source: “NEDA National Eating Disorder Awareness Week 2023,” EatingDisorderHope.com, undated
Source: “This eating disorder expert is worried by new guidelines to treat childhood obesity,” WVIA.org, 02/17/23
Source: “New childhood obesity guidance raises worries over the risk of eating disorders,” NPR.org, 02/15/23
Image by Enzymlogic/CC BY-SA 2.0

Guidelines, Quibbles and Quirks — Part 3

Today, February 27, is the first day of National Eating Disorder Awareness Week, sponsored by the National Eating Disorders Association (NEDA). One of the problems with the new American Academy of Pediatrics guidelines for treating childhood obesity is a fear that making a big deal out of weight only leads to a rising incidence of eating disorders.

The Education and Awareness section of NEDA’s website includes articles on Anorexia, Bulimia, Binge Eating, Weight & Body Image, Body Dysmorphia, Orthorexia, Compulsive Eating, Addictions, Diabulimia, Night Eating Syndrome, Pregorexia, Atypical Anorexia, and more. Childhood Obesity News has already covered several of these, so let’s take a look at a few of the less frequently discussed conditions. Of these four, none holds the title of official mental health diagnosis as defined by the institutions in charge of definitions. Yet they have been observed, and present themselves distinctively enough to earn their own categories.

Orthorexia

Whether it is regarded as a disease or a lifestyle, it affects a person by causing malnutrition, fatigue, emotional instability, social isolation, diminished quality of life, and stigmatization. In 2016, three defining characteristics of Orthorexia were named by Stevenn Bratman:

— An obsessive focus on “healthy” eating and avoidance of “unhealthy” foods,
— Mental preoccupation regarding dietary practices, and
— Very rigid dietary rules with violations causing exaggerated emotional distress (fear of disease, anxiety, shame, and negative physical sensations)

Night Eating Syndrome

In 2008, the First International Night Eating Symposium was held to figure out exactly what goes on with a phenomenon that, even though not officially named or claimed, was and is observed by many healthcare professionals. A person who takes in 25% or more of their daily calories after dinner or during the night may have Night Eating Syndrome. That is, if the disordered pattern “is not secondary to substance abuse or dependence, medical disorder, medication, or another psychiatric disorder” and has been going on for at least three months.

Other tentative diagnostic criteria are at least two episodes of nocturnal eating per week, along with awareness and recall of the event. Night Eating Syndrome is also considered to be present if three out of the following six items can be checked off:

— Lack of desire to eat in the morning and/or breakfast is omitted on four or more mornings per week.
— Presence of a strong urge to eat between dinner and sleep onset and/or during the night.
— Sleep onset and/or sleep maintenance insomnia is present four or more nights per week.
— Presence of a belief that one must eat in order to initiate or return to sleep.
— Mood is frequently depressed and/or mood worsens in the evening.
— The disorder is associated with significant distress or impairment in functioning.

(To be continued…)

Your responses and feedback are welcome!

Source: “NEDA National Eating Disorder Awareness Week 2023,” EatingDisorderHope.com, undated
Image by Karen/CC BY 2.0

Guidelines Backlash, the Biggies — Drugs, Part 4

In Part 1 of this series we mentioned orlistat, the generic name of one of the six kinds of drugs that the Food and Drug Administration has approved specifically for weight loss. As all pharmaceuticals of this type must warn, it is “Only effective as an adjunct to caloric restriction, increased physical activity, and behavioral modification.”

According to the manufacturer’s description,

Orlistat is a gastrointestinal lipase inhibitor that works by blocking the absorption of 25% of the fat in a meal and is used for weight loss in overweight adults, 18 years and older…

But that statement is misleading because it’s outdated. True, the substance’s safety and efficacy have not been established for children under 12 years old, and apparently it is not authorized for them. Which means, it is able to be prescribed for young persons over 12, to be taken by mouth every eight hours. And guess what? A half-strength version of the drug is available over the counter!

Another source says that for that age group,

A 6-12 month trial of orlistat… may be appropriate after specialist assessment, particularly in morbid obesity… or when co-morbidities exist, although evidence for long-term effectiveness in this age group is lacking.

A common side effect of its use is oily leakage that stains the undergarments, which results from another side effect, flatulence (gas) with discharge. The child might defecate more frequently, and the stools produced might be fatty, oily, painful, loose, liquid, clay-colored, or uncontrollable. A child who was previously picked on for being fat might have the chance to experience something new and different, the mortification of being picked on because they pooped their pants.

Then there is the possible onset of nausea, stomach pain, vomiting, weakness, itching, skin rash, dark urine, loss of appetite, jaundice, headache, and/or back pain. There might be problems with the teeth and gums, liver failure, or the whole spectrum of cold/flu symptoms, including chills and fever. The child might come down with a fancy ailment like oxalate nephropathy or leukocytoclastic vasculitis.

Orlistat has been known to interact mildly with at least 21 other drugs, and to interact moderately with at least 65 different drugs. To top it all off, the manufacturer cautions, “This information does not contain all possible interactions or adverse effects.” Orlistat is classified as a Gastrointestinal Agent and also, as Other. Maybe Other is code for “Let’s hope this is never authorized for younger kids.”

Your responses and feedback are welcome!

Source: “Orlistat,” RxList.com, 08/27/21″
Source: “Preventing Childhood Obesity: Evidence Policy and Practice,” Wiley.com, 2010
Image by Michael Saechang/CC BY-SA 2.0

Guidelines, Quibbles and Quirks — Part 2

The association between the new American Academy of Pediatrics guidelines and Body Mass Index (BMI) has been mentioned. A lot of healthcare providers take issue with the standard of measurement, and this is nothing new. The author here is a psychiatrist and eating disorder specialist Kimberly Dennis, who says there are many more accurate obesity markers, “such as blood pressure, cholesterol levels, blood glucose, mental health, and level of engagement with exercise.”

In the mental health area, she and others see the preoccupation with weight as a species of fat-shaming, and are of course worried that this leads to dangerous territory:

There is robust research showing that a history of dieting is the number-one risk factor for developing an eating disorder, with weight stigma and “the thin ideal” following close behind.

Whether one agrees with that point or not, it is certainly worthwhile for institutions and individual researchers to take the trouble to establish more appropriate measurement standards. Part of what bothers a lot of professionals is the ranking-system nature of using BMI percentages. It’s like a criminal court, where stealing a certain amount is larceny, and anything over that amount is grand theft. This dependence on numerical classification is a trait of bureaucracy, and an essential one in some cases, but perhaps not necessary in assessing medical conditions.

Race

Recently The New York Times hosted an opinion page about the latest developments in the childhood obesity field. Registered dietitian and board-certified eating disorder specialist Cristina Rivera wrote in to say that she and many colleagues reject the new guidelines. The guidelines seem to suggest or imply that losing weight will solve everything, and factors like poverty, an unsafe environment and a lack of access to things like fresh food and healthcare, will no longer be obstacles in children’s lives.

Exactly the reverse is true. Being economically disadvantaged in a chaotic environment is likely to cause unhealthy eating behaviors. Rivera said,

Additionally, as a person of color, I take much offense to these guidelines as they will without a doubt disproportionally affect and further stigmatize Black and brown folks… Rather than using this as an opportunity to state the need for meaningful policy change, the best they can do is encourage practitioners to prescribe weight loss medication to kids? I encourage all health care professionals to take a moment to reflect on the principle of “do no harm.”

Pharmaceuticals

Kate Bauer, an associate professor of nutritional sciences, states that she has seen adults make complicated and significant decisions about entering into a relationship with weight-loss drugs, “with the support of intensively trained health care providers.” Her fear is that children will be carelessly led into such impactful decisions without receiving this level of care. Her stand on the subject is,

General practice pediatricians should not be responsible for providing children pharmacotherapy for higher weight. There are serious medical and emotional implications of starting children on medication to alter their weight. Most pediatricians do not have the proper training to approach this topic with families or to adequately make clinical decisions and monitor.

Your responses and feedback are welcome!

Source: “A Critical Look at New Guidelines for Kids With Higher BMIs,” PsychologyToday.com, 02/11/23
Source: “Childhood Obesity: What to Do?,” NYTimes.com, 02/11/23
Source: “New Childhood Obesity Guidelines May Do More Harm Than Good,” Futurity.org, 02/13/23
Image by Medici con l’Africa Cuamm/CC BY-SA 2.0

Guidelines, Quibbles and Quirks — Part 1

Much has been said about the newest batch of guidelines from the American Association of Pediatrics. Before moving on to what is regarded as the most egregious ruling, the acceptability of bariatric surgery for very young humans, let’s catch up on some of the details, footnotes, and side issues that have been pulled into this conversation.

We have mentioned the burdensome cost of the new generation of weight-loss drugs, whether taken by adults or young people. The traditional choices, appetite suppressants like phentermine and topiramate, are available in generic versions that may cost as little as $30 a month, or a dollar per day. But the newer injectable GLP-1 agonists can run as much as $1,200 per month, or a daily tab of $40.

Insurers don’t want to pay that much, and who can blame them? Not when common sense and years of indoctrination have taught that the problem could be solved by saying no to the Big Mac and yes to running around the track a few times. It has so far proven difficult to convince insurance companies to foot the bill. They ask, quite reasonably, whether there is a medical necessity and whether that urgency could be met in some other way.

A great if unachievable goal

To quell childhood obesity, the AAP would prefer that the first resort be Intensive Health Behavior Lifestyle Treatment, or IHBLT. This means that parents and child(ren) all must be available to travel, sometimes a long way, to attend at least 26 hours of in-person therapy sessions together within three to 12 months. If each session is one hour, that means every other week. And even if weight-loss medication is prescribed for the child, the meetings are meant to continue.

At the Yale New Haven Children’s Hospital, a team headed by the associate director for pediatric obesity Maria Savoye developed the Bright Bodies Program. The AAP greatly admires the program, and this is where the ideal quota of 26 hours per year originated. Family therapy is not simply a finite program completed during a single year; not just a one-and-done proposition. It is recommended to continue indefinitely, which is a fine idea in theory, but how are people supposed to actually comply?

Psychiatrist and eating disorder specialist Kimberly Dennis says,

Because the therapy normally lasts from 3 to 12 months, dropout rates are high. Accessibility is a major problem, especially in socioeconomically disadvantaged communities.

Other views are held by others, like Nancy Ellen Abrams who wrote for the opinion page of The New York Times that overeating can be symptomatic of self-loathing and reminded her fellow grownups, “For children, food is the only numbing drug available.” She wrote,

What children need is a bigger picture that reveals the subtle cruelty of impossible physical expectations. They need a path to self-love, a simple practice of three meals a day and a peer group to discuss how hard — yet possible — it is to find peace with food. The peer group is essential; no one heals from a largely socially caused disease alone.

Your responses and feedback are welcome!

Source: “What you need to know about the new childhood obesity guidelines,” WashingtonPost.com, 01/20/23
Source: “A Critical Look at New Guidelines for Kids With Higher BMIs,” PsychologyToday.com, 02/11/23
Source: “Childhood Obesity: What to Do?, NYTimes.com, 02/11/23
Image by Cajsa Lilliehook/CC BY-SA 2.0

Guidelines Backlash, the Biggies — Drugs, Part 2

“Side effect” is a tricky term. For instance, a drawback of traditional appetite suppressants is that they probably exacerbate high blood pressure, or at the very least, do nothing to lower it. This is a negative side effect. On the other hand, a drug can have a side effect that is considered positive.

Side effects lead to what is called “off-label” use, until the point when the establishment does enough research to deem a drug officially suitable to be prescribed for whatever secondary use it is good for. As we have seen, the class of drugs known as GLP-1 agonists, used mainly to treat diabetes and other endocrine disorders, provide not only insulin sensitivity but appetite control. They imitate a peptide produced in the human gut that helps to regulate glucose in the system, and also contributes to a feeling of fullness. This in turn facilitates weight loss for some people.

Side effects, plural

Now that some drugs of this type have been approved to treat obesity, weight loss is no longer a side effect, but their primary purpose. Unfortunately, they still have other side effects, some of which are merely annoying, and may diminish with continued use as the body acclimates to the drug. Other side effects are more serious and even debilitating. In deciding whether or not to get involved with this type of pharmaceutical, several factors must be considered.

For instance, one of the recently approved drugs of this kind, whose generic name is semaglutide, is said to enable adolescents to reduce their BMI, or body mass index, by about 16%, which is a lot. But under any circumstances, rapid weight loss alone can stir up metabolic issues, hormone imbalance, and a malfunctioning gall bladder. In addition, experts have warned that the newer drugs can cause kidney problems, vision changes, and increased risk for rare forms of thyroid tumors.

As of February 2023, another such drug is on the way, having been set on the approval fast track by the Food and Drug Administration. Tirzepatide is another generic semaglutide whose brand name (if approval is granted) has not yet been chosen. Like its brothers, it works by slowing the passage of food through the digestive track, which allows the patient to feel sufficiently fed on a smaller amount of food.

The previous record of a semaglutide, causing an average weight loss of 16%, has been deemed impressive, but the newest contender beats that. A phase 3 trial chalked up weight loss as high as 20% of the person’s starting body weight, which in some cases translated into the loss of as much as 80 pounds.

There had already been concern over a version of semaglutide often prescribed to diabetes patients under the brand name Ozempic. Then, along came a jacked-up version of this injectable, approved by the FDA for long-term weight loss. When prescribed for that purpose it is branded Wegovy, about which we will have more to say.

Your responses and feedback are welcome!

Source: “The upsides and downsides of blockbuster weight loss drugs,” Web.musc.edu, 02/01/23
Source: “’Ozempic face?’ Dr. Siegel warns of popular diabetes drug’s bizarre side effect,” FoxNews.com, 01/29/23
Image by Jernej Furman/CC BY 2.0