Why Is Treating the Kids So Difficult?

When I was first asked to write this Introduction for the pediatric obesity edition of Bariatric Nursing and Surgical Patient Care, I began to think about what makes bariatric surgery in adolescents so unique. It's far easier to start with the similarities to bariatric surgery in adult patients. Basically, there is only one: the technical operation. The pediatric surgeon who performs weight-loss operations and the bariatric surgeon who operates on patients under 18 years of age are both experts in minimally invasive surgery. Both can reconfigure the intestinal anatomy, resect nearly 90% of the stomach, or place a silicone band around the gastro-esophageal junction with very little difference in operative approach, complication rates, and overall length of hospital stay. After that, everything else is completely different. There are parents involved, the social pressures of being a teenager, and the fact that adolescents by their very nature are tempted to rebel against authority and test things out on their own. It is these differences that make adolescent bariatric surgery a specialty in itself, and one that is fraught with hurdles, naysayers, and a nation that is unwilling to accept or embrace the only known treatment for morbid obesity that results in significant and sustained weight loss.

It all starts at the top, the very top, meaning the White House. Kudos to Michelle Obama and the Lets Move! campaign for bringing childhood obesity to the forefront of American minds. Obesity awareness seems to be at an all-time high. Her goal, as stated on her website, is to “Raise a Healthier Generation of Kids.” On the website are the standard suggestions for eating healthy, getting more physically active, and a general call to action to get the country to think more critically about how we treat food and exercise. What's missing on the website is guidance for the care of the child with obesity, where to go for help with treatment, what questions to ask the pediatrician if your child is obese, or any other mention of the one third of America's youth who are already overweight or obese. The Institute of Medicine (IOM) also avoids the critical topic of treatment in its latest report. The IOM, with sponsorship from the Robert Wood Johnson Foundation and the Dell Foundation, brought together a comprehensive group of leading thinkers in the field of obesity to gain consensus regarding what to do about the obesity epidemic. It's title? “Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.” Is obesity treatment not part of how we should solve the weight issues in this country? The numbers documented in their report are staggering: $190.2 billion of care being delivered yearly due to obesity-related illness; one third of all kids and two thirds of all adults are overweight or obese. The report brief of four pages and the eight pages of recommendations only mention treatment once. “Difficulties in treating obesity” is one of the reasons they list why accelerating progress in prevention is so crucial. How about spending more time, money, and effort in addressing the difficulties in treatment? Wouldn't that also be a useful focus for our national strategy? Working with HBO, “The Weight of the Nation” will publicize the IOM's findings, an unprecedented awareness campaign to urge Americans again to change the way we think about our weight. Unfortunately, none of the campaign will be dedicated to the care of those already affected by obesity and obesity-related comorbidities. “Treatment” can't even make it into the conversation! Surgical treatment is particularly poorly received by many. While there are some advocacy groups that have taken on the care of the patient with obesity as their main focus, only 1% of adults who qualify for weight-loss surgery actually come to an operation. And the kids? Only about 1,000 cases per year are performed based on the administrative data that are available, and that number has hit a plateau since 2006. The biggest reason why care of the adolescent with obesity is so difficult is that no one wants to talk about it or address it head on.

So my gratitude goes out to the contributors in this issue who clearly have a passion for changing the direction America has taken in turning a blind eye to treatment and to focus only on obesity prevention. Can you imagine the Livestrong website only mentioning cancer prevention and not dealing at all with treatment? Absurd, right? Yet, that is where we are today in the discussion regarding our children, ignoring the entire generation who is already suffering from obesity and its related illnesses.

So what does it take to care for children with obesity? The foregoing articles will detail some of the nuances of caring for adolescents who are undergoing bariatric surgery. Clearly, it takes a village, and that village needs to include pediatricians, bariatricians, psychologists, dieticians, physical therapists, and when all else has failed, surgeons. But most of all it takes nurses. Nurses have always been the patient advocates when no one else would stand up for their patients' rights. I can think of no group of patients who need more advocacy than adolescents with morbid obesity. There are no medications that work for weight loss, behavioral modification programs have yielded modest results, pediatricians don't know how to care for the adolescent with obesity and won't refer the patient for surgical care, insurance companies don't want to pay for surgery, and our nation's leaders both political and medical don't even want to discuss the possibility that obesity is a disease that requires treatment in addition to prevention. We as a group need to get out there and educate our colleagues and the patients about their treatment options. Nurses are on the front line and should be the leaders of this effort to get appropriate care to those in need.