Ethical Issues and Dilemmas in Caring for Children and Adolescents

E D I T O R I A L

Invited Commentary: Childhood and Adolescent Obesity: Psychological and Behavioral Issues in Weight Loss Treatment

David B. Sarwer • Rebecca J. Dilks

Received: 5 May 2011 / Accepted: 11 May 2011 / Published online: 31 May 2011

� Springer Science+Business Media, LLC 2011

Abstract The prevalence of childhood and adolescent

obesity has tripled in the past three decades. This increase

has been accompanied by a dramatic rise in obesity-related

health complications among American youth. Thus, many

obese youth are now experiencing illnesses that will

threaten their life expectancy in the absence of significant

weight loss. Despite these concerns, a relatively modest

body of research has focused on the treatment of adolescent

obesity. Results from trials investigating the efficacy of

behavioral and pharmacological treatments, like studies of

these interventions with adults, suggest that individuals

typically lose 5–10% of their initial weight. Unfortunately,

weight regain is common. Given the increase in the number

of obese adolescents, coupled with the modest results from

more conservative treatment approaches, it is not surprising

that bariatric surgery for adolescents who suffer from

extreme obesity has grown in popularity. The weight losses

after surgery are impressive and many adolescents, like

adults, experience significant improvements in their phys-

ical and mental health postoperatively. However, only a

small fraction of adolescents and adults who are heavy

enough for bariatric surgery present for surgical treatment.

Among those who undergo surgery, a significant minority

appear to struggle with a number of behavioral and psy-

chosocial issues that threaten their lifelong success. With

all of this in mind, the current obesity problem in the

United States and other Westernized countries likely will

present a significant challenge to both current and future

medical and mental health professionals who work with

adolescents and young adults.

The Childhood and Adolescent Obesity Problem

Obesity is a growing problem among America’s youth. The

rate of obesity or overweight ([95th percentile for age and gender) has doubled among children and tripled among

adolescents over the last 20 years (Ogden et al. 2002). The

most recent data suggests that 31% of children in the United

States are currently overweight or obese (Ogden et al. 2010),

which translates into approximately 5 million children.

Furthermore, recent estimates suggest that 4% of American

children and adolescents are above the 99th percentile and,

thus, are extremely obese (Freedman et al. 2007). This

percentage is larger than the number of American youth

affected by cancer, cystic fibrosis, HIV and type I diabetes

mellitus combined (Freedman et al. 2007).

Instead of using the term ‘‘obesity’’ with children and

adolescents, several authorities recommend using the

Centers for Disease Control’s (CDC) BMI tables

(Kuczmarski et al. 2002). The CDC guidelines do not label

individuals as ‘‘obese’’. Instead, ‘‘at risk of overweight’’ is

used to describe youth between the 85th and 94th BMI

percentile and ‘‘overweight’’ is used for those above the

95th percentile (Dietz and Bellizzi 1999; Kuczmarski et al.

2002). By later adolescence, the 95th percentile approaches

the definition of adult obesity, &30 kg/m2 (Cole et al. 2000). Generally, the term ‘‘obesity’’ is only used for the

problem at the population level and for individual children

when adiposity has been confirmed by another measure in

addition to BMI (Speiser et al. 2005).

A particularly alarming trend suggests that the heaviest

youth are becoming heavier, thus placing more individuals

D. B. Sarwer (&) � R. J. Dilks Center for Weight and Eating Disorders,

University of Pennsylvania School of Medicine,

3535 Market St., Suite 3121, Philadelphia, PA 19104-3309, USA

e-mail: dsarwer@mail.med.upenn.edu

123

J Youth Adolescence (2012) 41:98–104

DOI 10.1007/s10964-011-9677-z

at greater risk for more immediate and serious weight-

related health problems. Overweight and obesity are

associated with insulin resistance, type II diabetes mellitus,

cardiovascular risk, menstrual irregularities, obstructive

sleep apnea, non-alcoholic fatty liver disease, and psy-

chosocial problems in children and adolescents (Daniels

et al. 2005; Zeller et al. 2006). Adolescent obesity is known

to increase the rate of atherosclerosis, type II diabetes

mellitus, coronary heart disease, hip fractures, and gout in

adulthood. An investigation from the Nurses’ Health Study

found that obese adolescents had an almost 3-fold increase

in premature deaths (van Dam et al. 2006). The social

impact of obesity, especially on females, is staggering. As

obese female adolescents age, they are likely to suffer

extreme social consequences from obesity, including

achieving less educational status, earning less money,

being more likely to live in poverty, and being less likely to

marry (Gortmaker et al. 1993).

These physical and psychological issues recently have

led researchers to begin to study the efficacy of neighbor-

hood and school-based obesity prevention programs (e.g.,

Foster et al. 2008). The goal of these programs is to

increase physical activity, decrease sedentary behavior and/

or reduce caloric intake. These approaches involve policies

to alter the social, regulatory or physical environments of

children and adolescents to promote the engagement of

healthy behaviors, even if the child is not aware that they

are adopting these behaviors (Robinson and Sirard 2005).

By starting early, the goal is to avoid excess weight gain as

the children go through adolescence and into adulthood

(Caballero 2004).

Although these programs may be shown to have some

impact, it is unlikely that these will stop, let alone reverse,

the obesity epidemic (Boutelle et al. 2011). Thus, most

researchers and clinicians remain focused on the issue of

treatment. Below, we will provide a review of the treatment

of childhood and adolescent obesity. We begin with an

overview of more conservative treatment approaches, such

as behavioral modification and pharmacotherapy. The

limited efficacy and durability of these approaches has led

to interest in the surgical treatment of obese adolescents.

Thus, the commentary concludes with a discussion of

recent and ongoing research on the use of bariatric surgery

for obese adolescents.

Behavioral Modification and Pharmacotherapy

for Adolescent Obesity

The treatment of childhood and adolescent obesity, as

compared to adult obesity, has been sadly neglected. Fewer

than a dozen controlled trials have been conducted with

adolescents. Most have examined lifestyle modification

programs that included dietary and exercise counseling,

behavioral modification strategies, and, in some studies,

parental participation. This approach is effective at pro-

ducing moderate weight losses of 2–4 kg, with many ado-

lescents remaining substantially obese (BMI C 35 kg/m 2 )

at the end of treatment (e.g. Robinson 1999; Johnson et al.

1997).

Within the past decade, investigators have tried a

number of strategies to maximize initial weight loss and

promote more successful long term maintenance (e.g.

Berkowitz et al. 2003, 2006, 2010; Oude Luttikhuis et al.

2009). These approaches have typically involved the

combination of behavioral treatment (BT) and either

pharmacotherapy or the use of meal-replacement products

designed to reduce portion sizes and control total caloric

intake. For example, Berkowitz et al. (2003) randomized

82 adolescents to BT with either placebo or sibutramine, a

medication designed to promote feelings of satiety. As is

often done in behavioral based treatment for weight loss,

adolescents in both conditions were instructed to consume

a self-selected diet of approximately 1300 kcal/d and were

encouraged to engage in C120 min per week of aerobic

exercise. At months 3 and 6, adolescents treated by BT?

sibutramine lost more than twice as much weight as those

treated by BT ? placebo (7.8 kg vs. 3.2 kg; p \ .001). The BT? sibutramine group had an 8.5 ± 6.8% reduction in

initial BMI compared to a 4.0 ± 5.4% loss in the BT?

placebo group (p \ .001), suggesting that the combination of BT and pharmacotherapy can be used to promote greater

weight loss.

Although these results were encouraging, the Food and

Drug Administration removed sibutramine from the United

States market in 2010 because of concerns about an asso-

ciation with heart disease. At present there is only one

medication, orlistat, approved for long-term usage in the

United States. However, as it is rarely covered by insur-

ance, its usage by pediatricians to treat adolescents is quite

infrequent.

Furthermore, there are a number of additional limita-

tions to both behavioral and pharmacologically based

treatments. First, while modest weight losses of 5–8% of

initial body weight may improve the health and psycho-

social status of those with moderate obesity, they may have

little effect on the health and well being of the extremely

obese. Second, the majority of obese adults treated with

behavioral and pharmacologic treatments typically regain

weight over time. Little is known about successful, long

term weight maintenance in obese adolescents.

For these and other reasons, investigators have turned

their attention to bariatric surgery as a treatment for ado-

lescents with extreme obesity who may have tried (and

failed) these more conservative treatments or for whom the

severity of their obesity is so great that the more modest

J Youth Adolescence (2012) 41:98–104 99

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weight losses of these treatments are likely to have little

impact on their physical health and psychosocial status.

While this may sound preposterous to some, there is

compelling evidence to suggest that obese children and

adolescents are likely to become obese adults and, as a

result, be at risk for premature death (Whitaker et al. 1997).

This observation, coupled with the medical and psycho-

social toll that obesity can take on an obese adolescent (as

noted above), provides further support for the need for

more aggressive interventions.

Surgical Treatment of Obesity

Bariatric surgery is the most effective weight control

option for obesity. Bariatric surgery is currently recom-

mended for individuals 18 years and older with a

BMI C 40 kg/m 2

(or a BMI [ 35 kg/m2 in the presence of significant co-morbidities) (Consensus Development Con-

ference Panel 1991). The most reliable statistics published

to date suggest that 103,000 individuals underwent bari-

atric surgery in the United States in 2003 (Santry et al.

2005); more recent estimates suggest that over 200,000

procedures are performed annually. Approximately 3,000

bariatric surgical procedures were performed on adoles-

cents between 1996–2003, with a 3-fold increase between

2000 and 2003 (Tsai et al. 2007). These numbers are pre-

dicted to increase in the future. However, relatively little is

known about the safety and efficacy of bariatric surgery in

adolescents.

The patient selection criteria for adults interested in

bariatric surgery are well established. An American

Academy of Pediatrics expert panel developed guidelines

for considering bariatric surgery in adolescents (Inge et al.

2004b). In brief, the panel recommended surgery for

adolescents with BMI C 50 kg/m 2

or BMI C 40 kg/m 2

in

the presence of serious, obesity-related comorbidities. The

adolescent must have attained or nearly attained physical

maturity and have a history of organized attempts at

weight management without success. Finally, the adoles-

cent must demonstrate reasonable decision making abili-

ties, be willing to commit to the comprehensive medical

and psychological assessment process prior to surgery,

and understand and be willing to adhere to the postop-

erative nutritional guidelines. Readiness and motivation to

make long-term dietary and lifestyle changes are major

factors when determining if a candidate is appropriate for

bariatric surgery. If the patient is struggling to commit to

dietary changes required of surgery, it is often recom-

mended that they enter a pre-surgical medical weight-

management program or seek individual treatment from a

Registered Dietitian to help them better prepare for

surgery.

The most common surgical procedures include laparo-

scopic adjustable gastric banding (LAGB) and the Roux-

en-Y gastric bypass (RYGB). In both procedures, food

intake is limited by the creation of a gastric pouch

(approximately 30 ml in size) at the base of the esophagus.

RYGB operations have a restrictive component, but also

are thought to induce weight loss through selective mal-

absorption and favorable effects on gut peptides. The

stomach and part of the intestine are bypassed by attaching

the small pouch to a limb of the intestine, thus, limiting the

absorptive surface. Both types of operations are routinely

performed laparoscopically.

As has been reviewed in detail elsewhere, adolescent

obesity is associated with a number of untoward psycho-

social characteristics, including increased symptoms of

depression and impaired self-esteem, body image, and

quality of life (e.g., Cooperberg and Faith 2004). Not

surprisingly, these issues may be even more profound in

adolescents with extreme obesity (e.g., Benoit Ratcliff

et al. 2011). For example, Kim et al. (2008) found that 22

of 25 (88%) adolescents received a psychiatric diagnosis

based on their psychological evaluation prior to bariatric

surgery (which is required by the vast majority of bariatric

programs and third party payers throughout the country).

Depression was the most common condition, diagnosed in

17 patients (65%). Four patients had anxiety disorders, one

of whom had concurrent depression. One patient had a

diagnosis of schizophrenia. Significant psychological

issues, such as uncontrolled depression, substance abuse,

thought disorders or significant family discord, typically

are considered contraindications to bariatric surgery.

Postoperative Outcomes

Two years postoperatively, adults typically lose 50–60% of

excess body weight with RYGB procedures and 40–50%

with the LAGB (Buchwald et al. 2004). There are a number

of small reports of comparable outcomes in adolescents

(e.g., Inge et al. 2004a; Sugerman et al. 2003). Weight loss

following bariatric surgery is associated with significant

improvements in obesity-related co-morbidities in adults

and adolescents. These impressive outcomes must be bal-

anced by the incidence of complications. Early postoper-

ative complications occur in 5–10% of patients, while late

complications have been reported in at least 25% of

patients (Buchwald et al. 2004). Approximately 25% of

patients fail to reach the typical postoperative weight loss

or begin to regain large amounts of weight within the first

few postoperative years (Sjostrom et al. 2004). Among

adolescents, 5 of 33 patients regained some or all of their

weight within the first decade after surgery (Sugerman

et al. 2003). These suboptimal results typically are

100 J Youth Adolescence (2012) 41:98–104

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attributed to poor adherence to the postoperative diet or a

return of maladaptive eating behaviors (Sarwer et al. 2005).

Patients must adhere to a rigorous diet following bari-

atric surgery. In 2008, the American Society of Metabolic

and Bariatric Surgery (ASMBS) published the Allied

Health Nutritional guidelines for the Surgical Weight Loss

Patient (ASMBS 2008). After surgery, patients typically

begin with a liquid diet and progress to pureed and soft

foods during the first several weeks. At approximately

2 months postoperatively, patients typically return to a diet

of regular foods. Common dietary recommendations also

include using meal replacement products to control portion

sizes, reducing fat and sugar intake, reducing alcohol

consumption, increasing consumption of fruits and vege-

tables, consuming meals consistently throughout the day,

and preparing meals at home instead of eating out. A

commitment to life-long dietary changes is required

of patients undergoing any of the bariatric surgical

procedures.

Despite the guidelines, a number of studies have sug-

gested that adherence to the postoperative diet is poor.

Caloric intake often increases significantly during the

postoperative period (Sarwer et al. 2008). These increases

in caloric intake likely contribute to weight regain, which

typically begins during the second postoperative year

(Sjostrom et al. 2004). While total caloric intake typically

increases during the postoperative period, a small subset of

bariatric surgery patients suffers from malnutrition. Most

cases of malnutrition among bariatric surgery patients

appear to be responsive to improved dietary adherence or

vitamin supplementation (Xanthakos and Inge 2006).

Nevertheless, these problems may be of greater relevance

for adolescent patients because of their developmental

status at the time of surgery, as well as their longer life

span.

Disordered Eating after Bariatric Surgery

Disordered eating, particularly binge eating, is thought to

be relatively common among candidates for bariatric sur-

gery. Binge eating disorder (BED) is characterized by the

consumption of an objectively large amount of food in a

brief period of time (i.e., 2 h) with the patient’s report of

subjective loss of control during the overeating episode

(Spitzer et al. 1992). Patients with BED do not engage in a

compensatory behavior, such as vomiting, laxative abuse,

or excessive exercise, following the binge episode, which

distinguishes BED from bulimia nervosa. Although initial

reports suggested that up to 50% of adult bariatric surgery

patients may suffer from the disorder, more recent studies

suggest that approximately 5–15% of patients have the

condition (e.g., Allison et al. 2006).

Estimates suggest that less than 3% of obese adolescents

meet criteria BED (Johnson et al. 2002). The prevalence of

sub-threshold binge eating among overweight adolescents

who present for weight loss treatment, however, is con-

siderably larger (20–30%) (e.g. Decaluwe et al. 2003;

Glasofer et al. 2007; Isnard et al. 2003). A few studies have

looked at binge eating behavior in adolescents who pre-

sented for bariatric surgery. Zeller et al. (2006) found that

13% of candidates for bariatric surgery reported symp-

tomatology consistent with a diagnosis of BED, a rate

comparable with a comparison group of extremely obese

teenagers not interested in surgery (15%).

Studies have found that, after bariatric surgery, a sig-

nificant minority of patients reported feelings of loss of

control consistent with BED. In other studies, it appears

that binge eating is related to smaller weight losses, or

weight regain within the first two postoperative years (e.g.,

Kalarchian et al. 2002) even though bariatric surgery

makes it impossible for them to eat excessively large

amounts of food. This may be caused by stretching of the

gastric pouch, allowing for increased food intake over time.

A recent study, however, suggested no differences in

weight loss at 1 year after surgery in persons with and

without BED (Wadden et al. 2011).

Psychosocial Outcomes after Bariatric Surgery

As reviewed in detail elsewhere, numerous studies have

found that the majority of adult bariatric patients experi-

ence psychological improvements postoperatively (e.g.,

Sarwer et al. 2005). Most psychosocial characteristics,

including self-esteem, depressive symptoms, health-related

quality of life, and body image improve dramatically in the

first year after surgery. These psychosocial benefits, how-

ever, may be limited to the first few postoperative years.

The impact of bariatric surgery on longer-term psycho-

logical functioning is largely unknown.

Despite the impressive psychological improvements

following surgery, there appears to be a small yet sig-

nificant minority of patients who experience behavioral

or psychological complications following bariatric sur-

gery. These complications include depression and suicide,

disordered eating, body image dissatisfaction, sexual

dysfunction and/or marital discord, and substance abuse

(Sarwer and Fabricatore 2010). There is a similar, if not

greater, concern for these and other psychological com-

plications in teenagers who undergo bariatric surgery.

This population has a high prevalence of psychological

dysfunction and disordered eating practices. Detection

and treatment of these psychological and behavioral

problems may be of particular importance during

adolescence.

J Youth Adolescence (2012) 41:98–104 101

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Conclusions and Future Directions

Our country’s obesity problem has gone essentially

unchecked for the past several decades. A majority of

Americans are currently overweight or obese. Many of

those individuals are suffering from significant weight-

related health problems which may threaten their life

expectancy. Furthermore, the health care costs associated

with treating these conditions, on both the individual and

societal level, are staggering and represent a significant

threat to our country’s economic well being over the next

several decades.

Although there is much greater awareness of these

issues than before, researchers, clinicians and policy

makers have made little progress to date. The past decade

has witnessed an increased emphasis on prevention, par-

ticularly among American youth. Unfortunately, studies of

the effectiveness of prevention efforts have not been

encouraging (e.g., Foster et al. 2010). On the individual

level, behavioral and dietary treatments typically lead to

modest weight losses and corresponding improvements in

health. Unfortunately, these benefits are rarely maintained

beyond the period of active treatment, leaving many

patients back where there they started with regard to their

weight and health, and discouraged about their ability to

reduce and maintain their weight in the future.

This cycle is particularly concerning when we consider

the growth of childhood and adolescent obesity. It is very

disconcerting to consider the potential psychological toll

that obesity can have on a child growing up in a culture that

overemphasizes and equates thinness with physical beauty.

Add to the mix frustration of repeated weight loss and

regain, as well as the societal and economic burden of

obesity noted above, and it is hard not to be discouraged

when thinking about childhood obesity.

For these as well as other reasons, bariatric surgery has

become an increasingly popular treatment option for adults

with extreme obesity. The postoperative weight losses are

sizable and typically lead to significant improvements in

obesity-related comorbidities and psychosocial status.

However, a significant minority of patients appears to

struggle with these issues, and, as a result, experience

suboptimal weight losses or premature and significant

weight regain. Thus, there is growing consensus that

improvements in dietary intake and eating behaviors are

critical to long term success following bariatric surgery.

There has been little study of these issues in adolescents

who undergo bariatric surgery. Dietary intake and eating

behaviors may be of even greater importance for adoles-

cents who undergo surgery because of their maturational

status and longer life expectancy. Over the past several

years, the National Institutes of Health has been funding

the Teen-Longitudinal Assessment of Bariatric Surgery

(Teen-LABS) consortium. The primary objective of the

consortium is to investigate the safety and efficacy of

bariatric surgery in adolescents (Inge et al. 2004c). Ado-

lescents (19 years old or younger) are being recruited from

five sites: Cincinnati Children’s Hospital Medical Center,

Texas Children’s Hospital, Children’s Hospital of Ala-

bama, Nationwide Children’s Hospital, and University of

Pittsburgh Medical Center.

The Teen-LABS consortium also is supporting a number

of ancillary studies specifically focused on psychological

and behavioral issues. One such study is investigating

changes in a variety of psychosocial domains, including

depressive symptoms, quality of life, body image, and

other issues related to socialization, including participation

in high-risk health behaviors that may put these adolescents

at increased risk for some of the poor psychosocial out-

comes detailed above. Another study is looking at changes

in eating behavior and dietary intake after surgery to see if

adolescents are able to successfully adhere to the rigorous

postoperative diet as they transition into early adulthood.

These as well as the other studies in the consortium will

provide both medical and mental health professionals with

vitally important information about the efficacy of bariatric

surgery for adolescents.

In summary, obesity represents one of the Western

world’s most significant health problems. Rates of obesity

among both adults and adolescents have risen dramatically

over the past several decades. The most popular weight loss

treatments—lifestyle modification and pharmacotherapy—

typically produce modest weight losses which may

improve some weight-related health problems. Unfortu-

nately, most individuals who use these treatments regain

their weight within a few years and, as a result, return to

being obese. This cycle of weight loss and regain is par-

ticularly concerning for adolescents, who may end up liv-

ing with obesity, and its associated medical and mental

health consequences, for decades. This scenario, whether

considered from the individual or societal level, is sober-

ing. At the present time, bariatric surgery holds the greatest

promise in promoting larger and sustained weight losses

which are associated with significant improvements in

weight-related comorbidities. Unfortunately, only one

percent of adults who are heavy enough for surgery cur-

rently receive it; the percentage is even smaller for ado-

lescents. This intersection of circumstances—a growing

public health problem, a lack of effectiveness of the most

common treatments, and an under-utilization of the most

efficacious treatment—will challenge professionals from

countless disciplines to work together in novel and creative

ways to combat the daunting obesity problem facing youth

around the world.

102 J Youth Adolescence (2012) 41:98–104

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Author Biographies

David B. Sarwer is Associate Professor of Psychology in Psychiatry and Surgery at the University of Pennsylvania School of Medicine as

well as Director of Clinical Services at the Center for Weight and

Eating Disorders. He received his doctorate in clinical psychology

from Loyola University Chicago. His major research interests include

the psychosocial and behavioral aspects of obesity.

Rebecca J. Dilks is a Research Coordinator at the Center for Weight and Eating Disorders. A Registered Dietitian and a Licensed

Dietitian-Nutritionist, Ms. Dilks received a B.S. from Immaculata

University. Her major research interests focus on the nutritional

management of obesity.

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