Tuesday, January 10, 2012

Helping Fat People

This is not funny
When I was a rookie fellow in adolescent medicine in the Bronx in the 1980's, I was assigned a new patient, a "morbidly obese" fifteen year old who weighed over 200 pounds at about 5'2".  He moved with difficulty and he smelled even from across the room.   My assignment was to engage him in a program of weight management through diet and exercise.  He lived close to the hospital so we had weekly appointments.   After a few months of watching his weight increase, I decided to alter my therapeutic goals for him.  The purpose for our visits became simply managing his hygiene.  He and I bonded and he started to groom himself in a more age appropriate way.  I did nothing for his weight.

So now, I wonder if he is still alive, almost 30 years later.  I wonder if he suffered a heart attack or stroke, if he has diabetes, if he can walk at all or if he smells bad again.   If he's alive I  wonder if he was ever offered surgery to help manage his weight.

Nowadays, this young man would be evaluated for many problems beyond the not insignificant social ostracism he was experiencing.   With a BMI exceeding 35 he would be worked up for metabolic syndrome.  Experts disagree on what the components are, but they are some combination of large abdominal girth, elevated triglycerides, blood pressure, and fasting blood sugar.  He would also be evaluated for sleep apnea, gallbladder disease, Type II diabetes, thyroid disease and substance abuse. 

Current insurance companies might require my patient to undergo six months of medically supervised diet and weight managment.  Nowadays, if he continued to gain weight he might be a candidate for weight loss surgery. A recent article in the New York Times profiled a young woman with marginal success after laparoscopic adjustable gastric banding, the simplest and possibly safest of the procedures available to obese teens.  Her story underscores the continued efforts required by a multi-disciplinary team to promote the life-long lifestyle changes required to be successful at keeping the weight off. 

Many US childrens' hospitals are currently participating in a multi-center study of the efficacy and safety of "lap-band" surgery in adolescents.  Here is a quote from the website of the New York-Presbyterian Children's Hospital:

Our investigations evaluate the safety and success rates of laparoscopic adjustable gastric banding surgery in treating adolescents who are obese. There is substantial evidence worldwide that attests to the safety and efficacy of laparoscopic gastric banding, and we are now documenting its role in the adolescent population.

In addition to evaluating the general body changes that occur in the months and years following adjustable gastric banding, we also study the metabolic effects of banding in growing teens. It is our hypothesis that gradual, steady weight loss will not result in nutritional deficiencies, but rather will result in long-term and sustainable weight reduction.
In spite of this progress and the mounting number of success stories, most primary care providers, pediatricians and family medicine doctors, are reluctant to refer patients.  Susan Woolford and her colleagues at the University of Michigan studied hundreds of such primary care providers and concluded that "some severely obese adolescents may desire and potentially benefit from bariatric surgery, but referral for the procedure may depend heavily on the attitudes of their primary care physicians."

With one in three US gradeschool  children overweight, and epidemic numbers of adults with complications of obesity looming, it behooves all of us to look at all the many ways available to tackle this problem.  For some who are beyond a certain BMI, surgery is a life-saving option that deserves exploration.
image from creativeminorityreport.com via Googleimages

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