When Vicky Counsell was 16, her doctor told her that if she didn’t have surgery to reduce her weight, there was a good chance it would kill her. She was 140kg (22st), her weight gain accelerated by the steroids she was taking for a lung condition, and she had tried everything to lose it. “It was an easy choice,” she says. “It was life or death.” At 17, she had gastric band surgery, in which a band around the stomach creates a small pouch, meaning only a small amount of food can be consumed. Ten years on, she has lost more than 44kg (7st). “Before the surgery, I couldn’t even walk on the flat for 200m,” she says. “Now I walk for miles.” She works as a support worker for older people, a physical job she couldn’t have done before.
Although it has “definitely been worth it”, she wasn’t prepared for how difficult living with a gastric band would be. “I remember the doctors telling me I wouldn’t be able to eat a lot of food, but I don’t think I realised how tough it would be,” she says. “At the very beginning I couldn’t even keep water or juice down. Now I can’t eat bread, pizza or anything high-carb.” It can be difficult going to restaurants with friends and explaining to waiters what she can and can’t eat, and she says her portion sizes are about what you would give a child. It is a lifelong commitment, which as a teenager she says she didn’t really grasp.
Last week, the new president of the Royal College of Paediatrics and Child Health, Prof Russell Viner, said that the NHS could be doing up to 100 times more obesity surgery, or bariatric surgery, on the most obese children and teenagers. In England, on the NHS last year, there were 18 cases of bariatric surgery performed on patients aged 17 and under (12 of those were for gastric bypasses, in which the stomach is sectioned off into a smaller part which is joined to the small intestine). The number has been fairly stable for the last few years – the year before, it was 11; five years ago, there were 16 procedures. But, according to Viner, the number of children who could be considered eligible is around 90,000.
“Most of those will not want it and I’m absolutely not suggesting that they all get it, but what we have is an exceptional mismatch between those who are [operated on and those who are] theoretically eligible,” he says. “It’s unclear how many we should be doing. It’s important that this is seen within a broader response to obesity. The first response is prevention, absolutely. The second is to say we have a significant number of children who are already obese and, for the very obese, no amount of prevention is going to make an impact on their lives right now. We need to get away from this idea that surgery is somehow ‘giving in’ to people. It all arises from the idea that obesity is people’s fault and they shouldn’t get surgery for it, they should just work harder.”
Surgery is a last resort, following months or years of attempted weight management, but he adds: “We shouldn’t shy away from last resorts. Bariatric surgery is incredibly effective. Once you are very, very obese, the chances of you losing a significant amount of weight without bariatric surgery are very low. We’re talking about super-obese teenagers.” In adults, Nice guidelines suggest that bariatric surgery is an option for those with a BMI of 40 or above, or 35 and above if they have comorbidities (eg, type 2 diabetes or other associated serious health problems). The guidelines for children state that, “Bariatric surgery may be considered for young people only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity.”
“If it’s done very carefully, within the NHS with an experienced team, including psychologists and social workers and others, it can be life-changing,” says Viner. It is, for many obese teenagers, “the only way. Once you become super-obese, your body fights weight loss. There are potentially new drugs that may become available over the next few years, but at the moment it’s the only proven way we know to do it.”
We shouldn’t shy away from last resorts. Bariatric surgery is incredibly effective
So why is the surgery so rarely performed on young people? “There are a range of barriers,” says Viner. “Number one, there are barriers to all bariatric surgery. We know we should be doing more adult bariatric surgery.” This is probably down to cost, he says, though surgery is cost effective to the health service in the long term. “Second, there are particular barriers to teenagers; people get fearful about doing what they perceive is a very big operation on teenagers. Then there are concerns about people’s ability to consent. There are a whole range of reasons why people are much more careful, and we should be, but I think we need to think as well about the benefits of surgery.”
We know we are in an obesity epidemic, with the UK doing worse than most. A recent report by the Organisation for Economic Co-operation and Development found that we are the most obese nation in western Europe, with 26.9% of adults classed as obese. In England, 32.4% of girls and 36.1% of boys leaving primary school are overweight or obese, with children in deprived areas more than twice as likely to be affected than those in affluent areas. The causes are numerous and complex, involving everything from genetics to environment to education to poverty, and especially the power of the food corporations. Viner has called for a ban on adverts for junk food before the watershed and for Ofsted to include a school’s PE provision and healthy meals in inspections. Of course, the vast majority of overweight or obese children won’t end up having bariatric surgery, but some will.
Viner emphasises that performing bariatric surgery on someone under 14 is only to be done in extreme cases. Examples of when it might be considered include if someone has uncontrolled diabetes, obstructive sleep apnoea (where breathing stops during sleep) or liver disease. “Where it has been done in this country, it has been for life-threatening complications,” he says. “They are exceptional cases.”
“We need to be waking up to obesity as a disease, and it is taking hold in epidemic proportions,” says Shaw Somers, consultant bariatric surgeon at Portsmouth hospitals NHS trust, and president of the British Obesity and Metabolic Surgery Society. “We are ignoring it at the moment and we’re doing a pitiful number of interventions – medical treatments as well as surgical treatments. We need to wake up and start dealing with it properly, both prevention for children and adolescents as well as adults.”
Somers has operated on several teenagers, “and to this day I worry about them”. The youngest was 15. “I would probably balk at much younger than that.” You are, he says, “drastically changing their digestive system”. To do this on a child or younger teenager could put them at risk of malnutrition and not developing properly. “That all adds an extra layer of complexity. If you can spend three or four years getting a 13-year-old patient prepared for surgery as well as you can, and then make the final decision at that stage, at 16 or 17, I think you do them a better service than just operating on them at 13.”
The surgery itself is relatively safe – though still a significant operation – but it is also too new for there to be data on the long-term safety of undergoing it, particularly as a teenager. “The risks of surgery are negligible compared with the benefits of weight loss,” says Somers. But, for some people, there can be complications such as the gut leaking or becoming blocked, and even in cases where the procedure has gone well, there is still lifelong monitoring afterwards. Nutrition still needs to be carefully watched, especially throughout pregnancy in women who had one of the procedures. Some treatments, such as a gastric band or bypass, can technically be reversed, but with varying difficulty and further possible complications.
“If you perform this surgery on a young person, you hope they’re going to live a long time, and they will need monitoring for a long time,” says Somers. Does he think a 14-year-old can give informed consent to have surgery which comes with long-term aftercare? “No, I don’t. I don’t believe they can make properly judged consent over a long-term issue. It requires a multidisciplinary approach [including psychological assessment, and support from the family], so while the individual adolescent might wish for the surgery we’ve got to be very careful. If we are going to do surgery we ought to do the reversible types.” With patients he has operated on at the younger end of the age range, “I judged them to have capacity and the family were in agreement, and their psychologist was. Generally speaking, they are happy with the result and it has turned their life around.”
But, like Viner, he stresses that bariatric surgery on very young people is a last resort and that these super-obese adolescents are already suffering from serious problems caused by their weight. “You can’t just wait until they become adults before you start to look into how to help them.”