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Should children get gastric bands?
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Nick Finer is probably confronted with more human flesh in a day than most of us see in a year. As a result, the consultant endocrinologist at University College London Hospital, and an obesity specialist, is depressingly familiar with the litany of life-threatening diseases that afflict grossly obese adults: heart disease, stroke, type 2 diabetes, as well as related horrors such as liver failure and blindness.
Then there is the psychological impact of belonging to what he believes is the most reviled group in society: social isolation, self-loathing, bullying. "When someone wants to insult you, they're quite happy to call you a fat bastard," Professor Finer says. "And it's the 'fat' that's the insult." This week it was reported that children's popularity is directly proportional to their size, with overweight children as young as 5 shunned and vilified by classmates. A study of more than 400 children aged between 5 and 10 suggested that the social cost of childhood obesity may be as high as the health costs; fat children struggle with rejection, loneliness and low self-esteem.
That is one of the reasons why,earlier this year, at a meeting of the Royal Society of Medicine in London, Finer stood up to announce that severely obese children should be allowed to have gastric bands, and undergo other forms of bariatric surgery (which reduce stomach size and/or reduce food absorption through bypassing the gut). Yes, it may mean putting children to the blade, with all the attendant risks of surgery, but the treatment is known to work in adults.
Surgery would save overweight children the hassle and heartache of embarking on diet-and-exercise programmes that are almost certain to fail (Finer calls them "lousy"), the surgery would add years to their lives and spare them the psychological burden that comes with being very obese. Given that excess fat starts to affect blood vessels in children as young as 6 or 7, and that there are almost no effective drugs for obese children, qualms about surgery on children must, he says, be weighed against the cost of doing nothing.
I met the outspoken professor a few days before his talk, over coffee in a London hotel opposite University College Hospital, where he runs a clinic. He told me that he was prepared for a hostile reception. Two weeks ago, a tabloid newspaper revealed that two 14-year-olds in Sheffield, thought to weigh more than 18st each, had had NHS surgery to fit gastric bands, which tie off most of the stomach leaving a pouch the size of a golf ball. At the time, Tam Fry, of the National Obesity Forum, said he thought "it was not a good idea to cut children up".
In fact, Fry largely backs the idea of under-18s undergoing surgery, provided the obesity is life-threatening and the child has gone through puberty. He believes that more primary care trusts should be treating adults and children in this way: "About 700,000 people would qualify for bariatric surgery under National Institute for Clinical Excellence (Nice) guidelines, and it costs between PCTs say they can't afford it, so they keep raising the bar. Some have even said that patients need to have a BMI of 50 to get the operation, so we have this unbelievably crazy situation of people eating themselves to death so they can qualify." Nice guidelines specify a BMI of 40 to qualify; 35 in the presence of severe health problems, and only in extreme circumstances for under-18s.
According to Finer, a former chair of the UK Association for the Study of Obesity, the life-shortening medical problems that beset the morbidly obese mean that these guidelines are too conservative. Bariatric surgery may be the most humane, rational and ethical course of action in even pre-teen kids.
"I know I'm raising my head above the parapet. But if we don't consider bariatric surgery we may be missing an opportunity to help these children and their families. I remember a time, years ago, when complicated toxic chemotherapy became available to treat leukaemia. People said it was unethical to treat children with these horrible drugs because it would make their lives a misery and only extend their lives by a year. We found that one year went to five years to ten years, and now 70 per cent of cases of childhood leukaemia are cured. I'm not saying that obesity is the same as leukaemia, but there are parallels. We have a treatment that cures adults of diabetes and liver disease. I think it's unethical not to see whether it could be successful and acceptable in children."
There might be a time, he says, when operating on ten-year-olds becomes acceptable. Bariatric surgery is already on the parental radar in other countries: Dr Mary Brandt, a paediatric surgeon in Texas who has contributed to a study of gastric bands in adolescents, told The New York Times recently that one mother had asked for a band for her eight-year-old daughter. There is even a case report in the medical literature of a six-year old undergoing bariatric surgery to save her life.
Finer called for a national research programme, in specialised centres, to start operating on older teenagers. "We could start with older teenagers with a BMI of 40 and above, and then start pushing back the age, first back to 14, then to 11 and 12. Then in a few years time, perhaps we can look at the case for intervening earlier."
He envisages a dedicated service with specialist surgeons, organised along the lines of renal transplants. Without this approach, we are left with "the worst scenario, which is that up and down the country, adult surgeons are persuaded to do the odd case of a 17-year-old, then a 16-year-old, then a 14-year-old."
Finer has tapped into the clinical zeitgeist. Cases of adolescents having surgery are beginning to crop up in the UK; one manufacturer of gastric bands in the States has applied for regulatory approval for the paediatric market (making the surgery an eligible expense under insurance) and two studies have recently shown that teenagers given bands appear to fare better than those given non-surgical treatments.
But the operation is not without complications. Finer makes the point that a gastric band, or any form of surgery, is not a quick fix; a patient's diet must change for ever, because fewer calories are required and they must come from healthy foods. Pre-surgery counselling would also be essential to identify those committed to change.
But, difficult as surgery might be to contemplate for children, lifestyle programmes aren't terribly effective. Tackling child obesity often means involving parents who cannot manage to lose weight themselves. "These families often have significant psychosocial issues (disordered eating is frequently linked to childhood sexual abuse) so some parents have psychological baggage. There are high rates of illiteracy, so handing out a diet sheet is pointless. The concepts of calories and energy may be difficult. These are often families who are not in control of their lives, who might be on benefits. You can tell them to go and buy apples and pears and they'll tell you that it's cheaper to buy chips." The point about surgery is that the amount of food that a child is able to digest is controlled by the band.
Some health trusts will pay for teenagers to attend "fat camps" but the difficulty is keeping the weight off. Children flit in and out of the health system, perhaps heading back to the GP at 10 or 11, by which time a BMI of 30 might have climbed to 35. There will be a few more years of trying - and usually failing - to adopt lifestyle changes. By the age of 18, Finer says, when surgery becomes an option, a child will think of themselves as a fat person and might find change harder to contemplate.
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