just asking questions

Should a 13-Year-Old Have Bariatric Surgery?

Dr. Sandra Hassink on what the new child obesity guidelines she co-authored do and don’t say.

Photo: PhotoAlto/Ale Ventura/Getty Images
Photo: PhotoAlto/Ale Ventura/Getty Images

According to the CDC, 19.7 percent of American children are considered obese, a number that has crept higher and higher for decades. So it wasn’t altogether surprising that the first revised guidelines issued by the American Academy of Pediatrics on childhood obesity in 15 years took an urgent tone. The kind of lifestyle changes the guidelines stress aren’t new, but the AAP’s updated guidance on using weight-loss drugs and bariatric surgery to treat more severe child obesity cases has attracted a lot of attention. For more perspective on the guidelines and the reaction they’ve prompted, I spoke with Sandra Hassink, one of the doctors who helped write them. Hassink, who has previously served as the AAP’s president, is a pioneer in this area: She founded the Nemours/Alfred I. duPont Weight Management Clinic in 1988, directed the AAP Institute for Healthy Childhood Weight (she has also served as the organization’s president), and authored multiple books on childhood obesity.

The new childhood obesity guidelines, which you co-wrote along with 20 other experts, are considerably more aggressive than the old ones. Since they came out last month, they’ve prompted quite a bit of conversation, debate, and criticism. I’m wondering what you’ve made of the reaction so far.
The purpose of the guidelines was to look at the evidence we had for obesity treatment, which means how we can treat children who already have obesity. And the basis of that treatment is intense health and lifestyle behavioral treatment.

The focus in many cases has been on the drugs and the surgery. But I think it’s important to realize that there is no evidence that drugs alone are effective in treating obesity. And the guidelines clearly state that children have to be participating in intense health and behavioral lifestyle treatment, and the drugs are an adjunct to that treatment. The same goes for metabolic and bariatric surgery: The children participate in intense health and lifestyle behavioral treatment before surgery and after surgery. So I think if you look at the broad context of the guidelines, it’s to provide pediatric health-care providers and families the evidence that there is treatment available, that it’s effective, and what that treatment is.

Virginia Sole-Smith recently wrote in a New York Times op-ed that “we cannot solve anti-fat bias by making fat kids thin. Our current approach only teaches them that trusted adults believe the bullies are right, that a fat body is just a problem to solve.” What’s your response to that kind of criticism?
I think we have to realize that we now understand that obesity is a complex chronic disease. Obesity itself causes metabolic and inflammatory changes in the body that can result in what we call the comorbidities of obesity, which are the associated diseases of type 2 diabetes, liver disease, lipid problems, hypertension. But this disease, which affects 14 million children in the United States, lives within an environment of incredible weight stigma and bias. What we want is for children and adolescents with obesity to have access to effective treatment and have the environment be non-stigmatizing and non-biased. We’re not blaming kids for having asthma, and we’re not blaming kids for having other chronic diseases. And so society has this incredible problem, and the problem is the pervasive late stigma and bias that’s been applied to this complex chronic disease.

One of the fundamental issues here is the extent to which obesity causes serious health problems down the line. Lots of people argue that just because someone’s BMI is at a certain level, it doesn’t mean they’re necessarily at high risk for the problems you describe. But it seems like these guidelines are saying the correlation is so strong between severe obesity and diseases like diabetes and others that intervention is warranted. How strong do you feel like the evidence is on that score?
I think the evidence is that the health risk rises with the degree of BMI. This treatment has to be individualized. So if you have an elevated BMI, it doesn’t automatically mean you get some kind of non-individualized treatment. The step that a lot of people are skipping is the evaluation component. We measure BMI because that tells us that this particular child or adolescent is at increased risk for these health problems, is at increased risk for weight bias and stigma and behavioral problems. And then we evaluate the child.

The guidelines talk about an extensive physical laboratory evaluation, evaluation for eating disorders, evaluation for mental health problems. And based upon that evaluation, then we have an individualized treatment plan for that individual. So I think that it’s important to recognize that there’s a huge component of evaluation going on here, and we’re interacting with the family and parents and the kid and evaluating the whole situation to figure out how best to help the kid. And the guidelines provide information about, Okay, so what’s the best treatment tools in our toolbox that we have to help that child? But I think it’s important not to sort of skip over that evaluation stuff.

BMI is a very inexact way of measuring someone’s overall health. Why do the guidelines still depend on it so much?
Once again, BMI is the starting place of the evaluation. So we know that there are kids who have high muscle mass that won’t have elevated obesity. But nevertheless, the correlation between obesity and a high BMI is significant. And again, you don’t just stop there. You investigate the physical condition of the child and all the things we talked about in the thorough evaluation. So I think BMI needs to be thought of more like measuring blood pressure. I’ll measure your blood pressure when you come in, and if it’s high, I’m not going to stop there or put you on just an automatic treatment until I figure out: “Why is your blood pressure high?”

How do you think these guidelines will trickle down, not only to the medical Establishment but to people’s primary-care physicians and local doctors? Will this be like gospel to them or more like some friendly advice?
I think the discussions that are occurring now because of the guidelines are really important because it’s raising the issue up and initiating discussions. But we knew from the beginning that we would have a lot of implementation to do, a lot of education to do. We have continuing medical-education programs. We have quality-improvement programs. We are lecturing at meetings. Articles and journals. We know we have a lot of education to do. And so this is a frame shift for many people. But I think it’s important to know that these discussions we’re having now are helping to change the conversation and to change the approach.

The stigma of obesity isn’t limited to the general population. It also happens among medical professionals and doctors themselves. And there’ve been studies showing that sometimes doctors miss serious health problems that aren’t just obesity because they’re so focused on weight loss.
Yeah. And we actually say in the guidelines that this implicit bias about obesity is in the medical profession and provide resources for doctors to assess their own implicit bias and be aware of it. So we know that that’s a problem. And the point of backing up the guidelines with a lot of education is to help doctors and move the needle on this.

It seems like obesity is being viewed more and more as a traditional medical condition, as you said, and one that’s caused largely by genetics. One thing I don’t understand is why has the obesity rate in this country skyrocketed in the last few decades? Doesn’t that point to some sort of environmental factor as well, whether it’s diet or whatever?
Yeah, absolutely. What you have is a gene-environment interaction. You have genetic predisposition to one degree or another and then you have an environment that’s gotten increasingly obesogenic or worse. So the more predisposed you are to developing obesity, maybe it only takes a few things in the environment to change, but if more and more things in the environment change, you don’t have to have as much genetic predisposition to get triggered.

In the guidelines, we list all the factors that have changed over these last three decades that are fueling this epidemic. So we have a big responsibility in society to say: We’re living in this environment that’s making it increasingly likely that people will develop obesity and making it increasingly difficult for them to get healthy.

Are you hopeful that this problem could actually get a lot better in the next few years or decades?
I am always hopeful. It’s been tough to move the dial on this, but I think the problem is now in the action arena. We’ve talked about it, and the guidelines are out there. There are a lot of factors we know are fueling obesity at the population level and it’s now, I think, time to really recognize that we have to take action on every front.

This interview has been edited for length and clarity.

Should a 13-Year-Old Have Bariatric Surgery?