Trianna is sending out signals of distress. At each of her past appointments with dietitian Erika Zeff, the 13-year-old girl has been cheerful, voluble, and enthusiastic. But at tonight’s meeting in an examining room at the University of Virginia’s “fitness clinic,” she sits silently beside her mother, her big dark eyes focused on the floor. When Zeff asks Trianna a question, the teenager often looks at her mom, waiting for her to answer first. Then, more often than not, she takes issue with the answer.

The fitness clinic was established at the University of Virginia Medical Center to teach overweight Charlottesville youngsters and their families how to make changes in diet, activity, and lifestyle. Thanks to a research grant, treatment is free. Zeff is a registered dietitian, but during her monthly appointments with Trianna she also plays the roles of psychologist, nurse, cheerleader, and personal trainer, drawing on her people skills and her intuition about what makes families tick. The clinic’s medical treatment plan is designed and super-

vised by Milagros Huerta, a pediatrician trained in endocrinology and obesity treatment; a psychologist provides training and backup for staff in behavior modification techniques. Zeff is the person who sees the majority of the clinic’s young patients at their monthly visits. It’s her first real job after completing her internship as a clinical dietitian, and she looks almost as young as some of the teenagers she is treating. Warm, energetic, and confident, she seems well suited to coaching kids in the difficult task of changing their eating habits.

Trianna has been coming to the clinic for several months. Dressed in a bright red polo shirt and shorts, the young African American girl looks fairly fit but carries some extra weight around her middle. Since enrolling in the program she had been losing weight steadily, but tonight, for the first time, her weight is up slightly. Zeff suspects she’s getting tired of following the regimen. She runs through the list of goals Trianna set for herself at their last meeting. Is she eating breakfast every day? Yes, Trianna says. But her breakfast—a juice drink and a package of peanut butter crackers—usually is consumed during a midmorning break in classes, more than three hours after she boards the school bus each morning.

Is she measuring her serving sizes?

“No, not really,” Trianna admits. “But I don’t eat chips anymore.”

How has she been doing on her activity goals?

Her pedometer count is up to about 5,000 steps a day, Trianna reports. She has been practicing with a dance team five days a week and goes to a “steps” exercise workout on Saturdays. She plays basketball for an hour one or two afternoons each week at a local youth club. Zeff is impressed by the amount of physical activity she is doing.

“When are you hungriest?” Zeff asks.

When she comes home from school, Trianna replies. Her mother is still at work then, she adds, and “I can’t find anything to eat.”

“So what do you actually eat?”

“Oodles of Noodles,” admits Trianna. “Half a container.”

“That’s OK,” Zeff tells her. “It’s not the healthiest, but at least you’re only eating half.”

Trianna’s mother says she is worried that the fat on Trianna’s abdomen is not coming off fast enough. She’s afraid her daughter will

become the target of teasing. “She is going to high school in September,” she says. “High school kids, they’re mean.”

Zeff reminds her that changing unhealthy habits is more important than losing pounds rapidly. She turns to Trianna. “Are you maybe getting a little tired of all this?” she asks. “Is it hard for you?” Trianna says no. This time her mother is the one who jumps in to contest the answer.

“You were telling me it was hard,” she reminds her daughter. “We were in the kitchen and I was fixing something, sweet potato pie.” Trianna’s sister—the “skinny one” in the family—was expected home from college. “You said, ‘That’s not fair that I can’t have it!’ You always say it’s hard. I think I did give you just a little slice.”

Zeff smiles sympathetically. She asks Trianna whether she has been getting regular nonfood rewards for sticking with her eating and activity guidelines. She turns to the sheet of paper where she has been listing Trianna’s goals for the coming month. She helps Trianna and her mother negotiate an agreement about an activity they can do together: Trianna’s mother likes to go for walks in a large cemetery near their house, but Trianna would rather have her mom take bike rides with her. “I’ll put down that if you do five days of your goals, nutrition, and exercise, you get something special,” Zeff says. “Maybe a privilege.”

Trianna grins. “Stay out late!” she crows.

For the parents of an overweight child, locating high-quality treatment—and figuring out how to pay for it—can be challenging. Although just about everyone agrees that the steeply rising rates of obesity in American children and adults constitute an epidemic, obesity itself is not yet fully recognized as a disease. In most cases, weight-loss treatment for an overweight child or adult is not covered by health insurance unless and until the excess body fat produces a complication that is universally recognized as a disease. The commonest such complications in overweight kids include diabetes or high insulin levels, high blood pressure, and high blood levels of cholesterol or triglycerides. However, obese children are also at risk for developing a variety of other medical problems.

Fortunately, rising national concern about the health impact of the obesity epidemic is gradually beginning to prompt changes in the position of health insurers. In 2004 policymakers at the U.S. Department of Health and Human Services declared that obesity would no longer be automatically excluded from the list of conditions whose treatments were eligible for coverage by the federal government’s vast Medicare program. They instructed Medicare officials to begin collecting data to determine which types of weight-loss treatment were effective and should be paid for. Although Medicare primarily covers the elderly, its policy decisions influence those of other insurers. Specialists in pediatric obesity treatment note that a few other health insurance programs have covered such treatment for children in selected cases; more will likely begin to do so in the future.

Helping overweight children achieve a healthier weight as early as possible—before they develop medical complications from the excess weight—is clearly the best way to improve their long-term health outlook. Yet the incentives currently built into the medical insurance system seem designed to discourage prevention and prompt, early treatment not just for obesity but for many other diseases. This has created a situation in which surgery for severe obesity—most commonly a major abdominal operation that is highly effective at producing weight loss but has the potential for life-threatening complications—is covered by insurance and is being performed on very obese teenagers with weight-related medical conditions at some U.S. hospitals. Meanwhile, nutritional counseling and behavioral treatment for less severely overweight children and their families aimed at improving eating and activity habits—although safe and in many cases effective—is usually not covered by insurance and as a result is difficult for many families to obtain.

In the past doctors sometimes advised parents of an overweight child not to worry about the excess weight, reassuring them that their child would probably “grow out of” being fat during the growth spurt that occurs before puberty in girls and during early adolescence in boys. That advice may still hold true for some moderately overweight kids, but in general today’s pediatricians are being urged to be more proactive in trying to change the eating and activity habits of overweight

children and their families. In part, this is because American kids are heavier now than ever before, making it unlikely that many of today’s overweight boys and girls will “grow into” their weight as they mature. Current American Academy of Pediatrics guidelines recommend that all children whose BMIs are at or above the 95th percentile for their age—as well as children with BMIs between the 85th and 95th percentiles who have any medical condition associated with obesity—should be evaluated and considered for treatment.

What we know about the biology of children’s bodies favors early treatment. Evidence suggests that treating overweight kids before they go through puberty may be more likely to produce substantial and sustained weight loss than waiting until a fat child has become a fat adolescent. Some of the hormonal and physiological changes associated with puberty, particularly in girls, tend to facilitate weight gain and to make weight loss more difficult. Puberty in both sexes may also be associated with changes in brain centers that regulate appetite and body weight, tending to “lock in” a particular level of fat stores as the body’s set point. Adolescents, especially girls, are less physically active on average than younger kids.

For girls, being overweight can make puberty begin earlier and can lead to specific hormonal changes related to the reproductive system, fertility, and possibly future breast cancer risk. High body weight is associated with an earlier age of first menstruation, apparently because hormonal signals from body fat stores influence the age at which a girl enters puberty. In turn, girls who start menstruating at a young age have a higher lifetime risk of breast cancer than those who start later. Obesity in adolescent girls is also a risk factor for a disorder of the ovaries that can cause menstrual irregularities and infertility. “Puberty is a risk factor [for excess weight gain] for girls more than it is for boys,” notes Leonard Epstein, a nationally known expert in treating overweight children. Women’s bodies have evolved to prepare for childbearing: with the onset of puberty, the female sex hormones estrogen and progesterone tend to promote the deposition of fat as an energy depot that the body can use to sustain a future pregnancy. In addition, perhaps as a behavioral response to hormonal factors, girls entering puberty tend to reduce their level of physical activity.

As children approach the teenage years, their increasing desire for independence may also make them more reluctant to cooperate with family-based treatment aimed at changing their eating and activity habits. Parents usually have more influence on the behavior of their kids during the preschool and elementary school years than they do once their offspring are adolescents. The dietary habits of kids during elementary school are also less firmly established and easier for parents to change than are the eating habits of older children, and the food environment and opportunities for physical activity are usually better in elementary schools than in middle schools and high schools.

Perhaps as a result of a combination of biological, social, and environmental factors, preadolescent kids aged 6 or older who are obese have about a 50-50 chance of still being obese when they grow up, while obese teenagers have about a 75 percent chance of becoming obese adults. (In children younger than 3 years old, being fat has been found not to predict future obesity risk.)

The best-documented and most lasting success in treating obese children has been achieved by specialized multidisciplinary teams of professionals who work with the entire family to change eating and physical activity habits. Epstein’s program, which he started in Pittsburgh and has continued in Buffalo, has the longest track record with this approach. In 1994 Epstein reported the results of 10 years of follow-up among 158 children he had treated for obesity. All of the kids had been between the ages of 8 and 12 when they and their families participated in his program, whose primary strategy was reducing children’s calorie intake and promoting healthier eating habits by a combination of a diet, modifying the home environment, and teaching parents to use behavior modification techniques to reward positive changes. Ten years after being treated, 30 percent of the children were not obese. In a subset of children whose treatment had combined diet with “lifestyle exercise” (allowing the kids to choose the kinds and amount of physical activity they did and rewarding them for doing it), the success rate was higher: a decade after treatment, 50 percent were not obese. These figures compare favorably with the results achieved by most weight-loss treatment programs for obese adults. Many studies have found that within five years after losing weight by following

treatment programs, 90 to 95 percent of overweight adults have regained the pounds they had lost.

A number of behavioral treatment programs, including the University of Virginia’s fitness clinic in Charlottesville, have been based wholly or partly on Leonard Epstein’s model. Many use an eating plan based on his Stoplight Diet, which I describe in more detail later in this chapter. Some other experts note that the families in Epstein’s program were very highly motivated and say that the success rate in achieving long-term weight loss among children who went through his intensive program has been difficult to match in other communities. “Successful behavioral programs are labor intensive, are not yet translated into versions that can easily be applied on the primary care level, and require intensive parental involvement which, for many families, is simply not realistic,” write NIH obesity researchers Jack and Susan Yanovski in a recent assessment of the current state of treatment for overweight children.

Epstein acknowledges that achieving comparable long-term success rates with his obesity treatment program today may be more difficult than it was when he started in the 1980s. The children entering his program today are twice as obese, on average, as the those he treated 20 years ago. That shift reflects the fact that, in addition to the recent increase in the number of overweight kids in the United States, the proportion who are severely obese has grown. He and his team have found that once children have become very obese—weighing twice as much, or more, than they should weigh for their height—it becomes more difficult for them to lose weight.

Assembling a multidisciplinary team to treat obese children is expensive for a hospital or clinic. Typically, it includes a pediatrician (often an endocrinologist, a specialist in hormone disorders), a clinical dietitian, one or more nurses or nurse practitioners, a psychologist trained in behavioral treatment, and sometimes a social worker and an exercise physiologist skilled in developing and monitoring physical activity programs for kids. Since insurance in most cases will not pay for such services, few medical centers have been able to make the investment, even though treatment for overweight kids is urgently needed all over the United States. Even in those cities that do have state-of-the-

art behavioral treatment programs for obese children and their families, such programs are often supported almost entirely by government research grants; children sometimes must be enrolled in clinical research studies in order to be treated.

Parents can find federally funded research programs on childhood obesity by searching a Web site maintained by the National Institutes of Health. (See page 271 in Resources.) NIH officials caution that the research institutes cannot recommend individual treatment programs since they have no way to assess or monitor the quality of clinical care provided.

“I would say that of all the difficulties parents will face” in finding treatment for an overweight child, “the biggest are, first of all, trying to find people who know how to do it, and also trying to find affordable care,” says Robert Berkowitz, a psychiatrist who treats obese adolescents as part of a research program at the University of Pennsylvania in Philadelphia. “It’s a paradox: here we are in an epidemic, and yet we have very few programs.”

Epstein’s findings and those of other pediatric researchers treating obesity have established some general principles about the most effective strategies for getting kids to change their eating habits, reduce their daily calorie intake, and become more active. An important point to remember is that children differ from adults both physically and psychologically. Parents should not unilaterally decide to put their child on a diet or sign a teenager up for the commercial weight-loss program that worked for them. Consulting a child’s primary care doctor should always be the first step for parents worried about whether their child needs to lose weight. In making decisions about treatment, the pediatrician or family physician will consider whether the parents are also overweight and whether there is a family history of obesity or of related diseases, such as diabetes, high blood pressure, or heart disease, as well as review the child’s overall health and growth records. The physician will also want to talk with the child alone, to find out how the child feels about his or her body and to ask questions that assess mood, eating patterns, and overall mental health.

In addition to outlining the kinds of treatment approaches for overweight kids likely to be available in many communities, I will

briefly discuss treatments that are considered experimental or controversial in children or teenagers. The latter include prescription weight-loss drugs and bariatric surgery (operations that induce weight loss by reducing stomach capacity and/or changing the anatomy of the digestive tract to decrease absorption of food).

Sometimes it’s a mother or father who first becomes worried that a child is becoming overweight; sometimes it’s the pediatrician or family doctor. And sometimes it’s the child who comes home from school and reports that classmates have begun to tease him or her about being fat. In any case, the first step is for child and parents (or at least one parent) to sit down with the child’s doctor to review the growth and health records and to talk about the family’s medical history and habits. It’s important to discuss whether the child is taking any prescription or over-the-counter medicines or supplements. Certain drugs, including steroids, some antiseizure medicines, and some medications used to treat depression or psychiatric illnesses, can cause considerable weight gain.

By asking questions and performing a physical examination, your doctor can usually determine whether there is any reason to suspect an identifiable medical cause for the excessive weight gain, such as a hormone disorder or one of the extremely rare genetic mutations that produce obesity (discussed in Chapter 2). Hormone and genetic disorders cause far fewer than 10 percent of cases of childhood obesity and are usually easy for doctors to distinguish from “idiopathic obesity”—obesity of unknown cause—which accounts for the vast majority of cases. Children who are fat because of hormonal or genetic disorders are usually short for their age and have symptoms or physical characteristics that provide clues to their diagnosis. Also, their bone growth and development are typically delayed for their age, a feature that can easily be evaluated on an X-ray. In contrast, most children with idiopathic obesity are taller than average for their age and have no unusual physical characteristics or delayed bone growth. They often enter puberty earlier than their peers. Most overweight children do not need to undergo a battery of expensive laboratory tests to seek a medical explanation for their weight problem.

On the other hand, certain medical tests are recommended for kids whose BMI is at the 85th percentile or higher for their age. These tests are done to screen for common medical problems that can be caused by being overweight, such as high cholesterol or triglycerides in the blood, high blood pressure, and diabetes or a prediabetic condition in which the body’s response to glucose is abnormal and insulin levels are high.

Special attention is often required when examining overweight children. They frequently need a specially sized blood pressure cuff to measure pressure accurately. The doctor should also question the child about headaches, hip or knee pain, snoring, and daytime sleepiness and should carefully check eyes and leg joints. (Snoring and sleepiness can be symptoms of sleep apnea, an obesity-related disorder in which breathing becomes obstructed during sleep. The other parts of the examination help screen for potentially serious neurologic and orthopedic complications of being overweight.)

Checking for obesity-associated medical problems helps the doctor and family plan the next steps in treatment. For example, an abnormally high fasting blood glucose level in a child whose BMI is at the 85th percentile would signal the need to test more extensively for a prediabetic condition and would increase the urgency of addressing the child’s weight. Identifying any medical condition associated with obesity would also mean that the family’s health insurance would be more likely to cover the obesity treatment.

Nancy McLaren, clinical associate professor of pediatrics and medical director of the Teen Health Center at the University of Virginia in Charlottesville, explains that her first priority in talking with parents of an overweight child is to get them to recognize their child’s weight as a health problem. Many families are not aware of the potential medical consequences of a child’s obesity and may not have been concerned about it. “We talk initially about what the family history is of diabetes or heart problems,” she said. “I start from the perspective of trying to make them see that their child is moving into that. You’re used to Grandma having [such diseases] at 65 or 70. We even have some patients in their teens now that have these problems.”

McLaren assesses her patients’ mental health and asks about eating

disorders such as binge eating disorder or bulimia nervosa, in which loss of control of eating is followed by vomiting or other purging behaviors. She finds that children’s attitudes about their bodies are strongly influenced by standards of beauty within their culture or ethnic group: for example, white girls often want to weigh less, but some African American girls want to weigh more. “I always ask them how they feel about themselves and their bodies,” she says. “That’s where I get ‘I’m too fat’ or ‘I don’t weigh enough.’” Parents and doctors need to find out about such perceptions before they focus on changing a child’s eating habits. “You want to be careful with kids, because kids can become obsessed,” McLaren cautions. Sometimes, when trying to reduce their food intake, “what you can see is, these kids lose weight and then go to the other extreme.” Such a response to treatment is rare, however. Parents should not allow fears about inducing an eating disorder to preclude sensible and healthful attempts to address a child’s weight problem.

McLaren next questions the child and parent in detail about eating and activity patterns. “It takes a long time,” she says. “I try to look at where most of the calories are coming from. I try to talk about what initial small changes they can make” within that framework. She focuses especially on her young patients’ intake of sodas, sugary drinks, and juice; their snacking habits; and their calcium intake. Her goal is to look for obvious ways to help the child or teenager cut back on sugar and fat intake and boost intake of whole grains and of calcium, whether from nonfat dairy products or other sources. A high calcium intake—from dairy foods, other sources rich in this element, or supplements—is recommended for children and teenagers to aid in bone development. Preliminary evidence also suggests that a high calcium intake, particularly from nonfat or low-fat dairy sources, may reduce fat storage by the body and facilitate weight loss. Some nutrition experts are skeptical of these findings, pointing out that some of the research that yielded these results was paid for by the dairy industry. Additional larger and longer-running studies are needed in order to confirm them.

Based on the information she gathers, McLaren usually works with each overweight patient to come up with a simple plan, one containing

just a few steps the child and family can take to cut back on high-calorie foods or drinks. For example, “We might talk about cutting back to one soda a day from four,” she states. “I tell them, if they are going to drink fruit juice, to use 100 percent juice and to have one 8-ounce glass a day. Then the rest of the time, try to drink only water.”

Another effective strategy is to ask patients what “white foods” they are eating. The list might include white bread, white pasta, white potatoes, and white rice. She routinely suggests that they cut back on such foods, switching when possible to darker-colored, whole grain alternatives (or perhaps, in the case of potatoes, choosing sweet potatoes or squash). Whole grains contain more fiber and more vitamins and are also digested more slowly than processed grains, a factor that may help reduce hunger between meals. The 2005 edition of the federal government’s dietary guidelines, being prepared as this book goes to press, is expected to urge Americans to try to choose whole grain products such as whole wheat bread or brown rice instead of refined products like white bread or white rice.

McLaren advises her patients to cut back on pasta and other starches, opting sometimes to have a small portion of meat, chicken, or fish and ample portions of vegetables instead of including a starch in every main meal. She talks to them about reading food labels and measuring portion sizes. She sometimes suggests that her teenage patients use an inexpensive food handbook published for users of the South Beach Diet as a pocket-size resource to help them choose foods relatively low in sugar, fat, and refined carbohydrates. (She does not, however, recommend that her teenagers follow the South Beach Diet’s “induction” phase, which she considers overly restrictive.)

The Stoplight Diet, an eating plan developed by Leonard Epstein in the 1980s, is another approach to changing children’s eating habits that has been widely and successfully used by pediatricians and dietitians. Calling it a diet is something of a misnomer: like David Ludwig’s OWL plan (discussed in Chapter 4), the Stoplight approach teaches kids healthy lifelong eating patterns. Rather than forbidding any specific food, it groups foods into “green,” “yellow,” and “red” categories based on their calorie content by weight (energy density). Most vegetables, except starchy ones like potatoes and beans, have low energy

density and are green foods. Candy, cookies, sweet desserts, butter, oils, pizza, and high-fat snacks or fast food items are energy dense and are therefore red foods. The majority of foods, such as fruits, bread and cereal, starchy vegetables, fish, eggs, and meat, fall into the yellow category. They are intermediate in energy density and low or moderate in fat and provide vitamins, minerals, fiber, and complex carbohydrates or protein. Yellow foods are the mainstay of the eating plan but are to be eaten cautiously, with careful attention to portion size. Children are encouraged to eat as much of the green foods as they want. Red foods are to be eaten only occasionally and in small amounts, and parents are urged to banish them from the home if possible.

The principle behind the Stoplight Diet is that low-energy-density foods like vegetables can help satisfy hunger without contributing too many calories to a child’s daily intake. By following it, kids learn to eat a low-fat, nutritionally balanced diet that emphasizes lots of vegetables and fruits and to avoid foods high in simple sugars or fat. “If you eat a bigger volume of low-calorie food, you will feel full,” Epstein says. He also recommends about 2 servings a day of nonfat dairy products. And kids should be allowed to have their favorite snacks or treats on occasion, even if those items are red foods. In working to change children’s and teenagers’ eating behavior, McLaren notes, a cardinal rule is not to make strict prohibitions. “Never do an absolute thing,” she says. “Never say, ‘Don’t do this anymore.’”

Incorporating more physical activity into the daily routine should be part of any strategy for helping a child attain a healthier weight. Overweight children have poorer endurance than lean kids and are often reluctant to exercise. Treatment guidelines suggest that overweight kids should initially be physically active for at least 30 minutes a day, the minimum recommended for all children in a report by the U.S. Surgeon General. But more recent recommendations for all children urge a minimum of 60 minutes of moderate to vigorous exercise daily, a goal that overweight kids should work toward achieving. Physical activity will make it easier for kids to stabilize their weight, will help make them fitter, and will increase their chances of keeping off any pounds they lose.

McLaren’s approach to physical activity is similar to that for food

intake: she starts by questioning her patients about their daily routines, how much TV they watch, and their opportunities for building in exercise. She urges them to cut back on the time they spend watching television or playing computer games. “We talk about walking. Where can you walk to rather than ride to? Are there exercises you can do at home—can you put on music and dance? Could you park farther away at the mall—or walk around more while you’re there?” Many of her young patients cannot safely ride bicycles in their neighborhoods, but they may have access to playgrounds or community recreation centers. McLaren urges them to play basketball, go bowling or rollerblading, dance, or play with hula hoops. “The kids who are really obese, I don’t want them going out and running,” she says.

Leonard Epstein’s best results for achieving sustained weight loss have come from combining dietary changes with “lifestyle exercise,” in which kids earned points by doing any of a variety of physical activities. Letting the child choose the activity is a key feature of the program’s success. “Children could get exercise points as long as they did at least 10 minutes of something,” he says. “They could walk back and forth to school. They could play on the playground. It didn’t have to be aerobic exercise.” Aerobic exercise is better for fitness—it conditions the heart, lungs, and muscles to work more efficiently—but frequent periods of lower-intensity exercise can be very effective in helping people achieve and maintain weight loss. “Weight loss depends on energy expenditure, not the intensity,” Epstein states.

Obesity experts emphasize that overweight kids and their families should try to make just a few small permanent changes at a time. Once they have succeeded in incorporating those changes, they can build on them by going on to the next step. Too much information at once or too drastic a revision of a child’s and family’s lifestyle are likely to be overwhelming and frustrating for everybody. Epstein urges parents to keep in mind that in helping an overweight child the goal is not to instantly transform habits or to drop pounds overnight. That’s one of the ways a good treatment plan for children differs from commercial weight-loss programs for adults. “Adult weight control programs get evaluated by how much you lose and how fast you lose,” Epstein says. “With kids the speed at which they develop healthy habits is not nearly as important as how permanent they are.”

For many children, parents can achieve a lot simply by changing the food environment at home to get rid of calorie-dense snacks, drinks, and sweets, by reducing TV time, and by improving their own eating and exercise habits. It’s important for the whole family to make a commitment to a healthier lifestyle. “I bet you lots of kids would benefit tremendously by the parents really moderating the eating and exercise environment and adopting healthier behavior—and not even talking to the kids about changing,” Epstein says. “They would just change automatically.”

Current guidelines for doctors treating overweight kids advise that in setting up a treatment plan the first step in weight control for all overweight children over 2 years old should be trying to maintain the current weight. Since children are growing in height, a child’s BMI will automatically decrease as he or she grows if body weight remains stable. For many children, modest changes in diet and activity will be enough to keep the weight steady. If a child and family can achieve this, they are already succeeding. For some kids, especially those whose BMI is between the 85th and 95th percentiles for age and who do not have medical complications, continuing to maintain a steady weight under a pediatrician’s supervision can provide a safe, gradual way to get to a healthier BMI as the child continues to grow.

Children whose BMI is above the 95th percentile, as well as kids who have already achieved most of their growth and those who have medical complications caused by being overweight, are likely to need to make additional changes in diet and activity once their weight has stabilized in order to lose some of the excess fat. They should be monitored regularly by a doctor and, if possible, by a dietitian. Current treatment guidelines suggest that the goal in most cases should be to lose weight at a rate of about 1 to 4 pounds per month. The child and family should work with the doctor to set realistic goals. Although many overweight kids (like many overweight adults) dream of looking like the actors, pop stars, or athletes they see on television, those body types are not possible for everyone. Developing permanent, healthy habits and choosing an achievable BMI goal should be the priorities. “These are habit-changing programs. These are lifelong programs,” advises psychiatrist Robert Berkowitz. A pitfall of many adult weight-control programs is that people think of them as a short-term fix, after

which they will be able to revert to their old habits. “That model doesn’t work,” he says. “Right from the beginning, we say to people that this is a lifelong issue.”

Severe restrictions on caloric intake in children can interfere with growth, and unsupervised efforts to achieve rapid weight loss can lead to vitamin deficiencies, eating disorders, and other medical problems. Any child who has a serious or life-threatening medical illness requiring rapid weight loss should be treated by a specialist in pediatric obesity. The best way for parents to find such physicians, or to locate high-quality programs specializing in obesity treatment in children, is to call the office of the department of pediatrics at local medical schools or the nearest children’s hospital.

What factors have been found to contribute to a positive outcome? Much research on behavior change, including studies of obesity treatments, has shown that long-term success depends on the participants’ ability to monitor their own behavior. That doesn’t necessarily require counting calories, but a child’s treatment plan should include some way of keeping track of the kinds of food and drink, the portion sizes, and the number of servings the child has each day. Similarly, it should include a system for recording the type and duration of exercise, as well as “screen” time: hours spent watching TV, playing video games, or sitting at the computer. Keeping track of daily diet and activity patterns will help motivate the child and family and will make it easier to identify specific factors that might be interfering with success—such as problem foods or situations that trigger impulsive snacking. The parents, the doctor, and the child undergoing treatment should discuss how often the child will be weighed and who will be responsible for weighing and recording weights. Among overweight teenagers treated at the University of Pennsylvania’s treatment program, “those kids who actively monitor their food intake and exercise and have pretty good estimates of their calorie consumption—those are the kids who actually do pretty well,” says Berkowitz.

Another element common to successful programs is a requirement that the entire family should be on board, as well as caregivers who spent significant amounts of time with the child. Treatment plans tend to fail when they focus only on the overweight child, imposing differ-

ent rules for that child than for the rest of the family. Programs in which least one parent goes along to each treatment session are also more likely to work, although parents and children often meet in separate groups during the sessions, especially if the program is treating adolescents. In Leonard Epstein’s program, parents do more than simply learn the rules: they are given the same diet as their child and are also asked to follow their own exercise program. “I would guess probably two-thirds of the parents are clinically obese, and … almost all probably could either improve the quality of their diet or improve their physical activity—so there’s plenty to target,” he says. “They have to model healthier behaviors. They also see what the kid’s going through.”

The psychological component of Epstein’s program and others like it is probably the most difficult part for parents to learn and the most difficult and costly feature to replicate in community treatment settings, yet the techniques families learn from psychologists and counselors are critical to long-term treatment success. A key technique is contingency contracting, in which parent and child sign a weekly or monthly contract in which the child earns rewards if he or she succeeds in reaching mutually agreed upon short-term goals, such as cutting TV time by an hour a day or switching from drinking soda to drinking water. Rather than food or expensive prizes, rewards should be an activity that the parent and child can do together, like going to a movie or hosting a pajama party. Children and adults can also sign contracts in which a child promises to reward a parent. (For example: “I promise to let you sleep late on Saturday morning if you will play Frisbee with me after dinner two nights this week.”)

Other important behavior change techniques for parents include learning to praise children on a daily basis, especially for performing a desired new behavior such as keeping track of portion sizes or recording TV time in a diary; avoiding being critical or making negative comments; acting consistently; restructuring the home environment to contain fewer temptations and more healthy options; and helping the child figure out strategies in advance for dealing with difficult situations such as parties or visits to restaurants.

At a Stanford University treatment program for overweight children between 8 and 12 years old, parents and kids start each weekly

session together by weighing in and talking about how the week has gone. They review not just their dietary intake, but how well they did at remembering to praise each other. They examine how many points the kids earned for following the eating plan, reducing TV time, and exercising. Then adults and children meet in separate groups with program staff to discuss their progress during the preceding week in greater detail, to ask questions, and to plan new goals. Parents and children sign new contracts, agreeing on goals and rewards to be earned during the week to come. The program uses an eating plan based on the Stoplight approach. “We don’t put kids on diets. We help them eat more healthfully,” says Stanford researcher Tom Robinson. “If they are losing more than 1 pound a week, we look to see if they are skipping meals.”

Research data collected at Stanford, as well as data from Epstein’s studies and other programs, suggest that such an approach helps kids lose weight without promoting obsessive or disordered eating patterns. “We do focus on weight loss—that’s what they come to us for,” Robinson says. “We know that overweight girls, to start with, are at higher risk of bulimia and, probably, anorexia nervosa…. We measure weight concerns in girls. To date, we haven’t seen anything get worse—mostly, we see it get better. We believe that by promoting healthful behavior changes, we can reduce the risk for eating disorders.”

Some families will find that several visits with a pediatrician and dietitian, combined with a concerted effort to change their eating and exercise routines, help their overweight child achieve a healthier BMI. However, a severely obese child or one who has suffered a medical complication of obesity needs specialized treatment at the outset. Parents should ask their pediatrician for help in finding the best treatment program in their region. Many other children could probably benefit from something in between.

What about commercial weight-loss programs? Pediatric treatment guidelines do not recommend commercial programs designed for adults, such as Weight Watchers or Jenny Craig, for children because no studies exist of their effectiveness in kids. In a recent assess-

ment of the current state of treatment for overweight kids, NIH researchers Jack and Susan Yanovski cautioned that doctors should not automatically assume that adult weight-loss programs (or other options, such as drugs) will work and be safe in young children.

Still, commercial programs may be a reasonable option for some motivated adolescents who have obtained their doctor’s and parents’ permission. Parents should thoroughly familiarize themselves with the program’s approach, and parents and doctor should carefully consider the boy’s or girl’s overall health, eating habits, and personality makeup in deciding whether to permit enrollment.

A spokeswoman for Jenny Craig said the program accepts adolescents 13 and older who have no preexisting health conditions as long as a parent provides permission for them to participate. Weight Watchers International revised its policy in 2003 to more strictly limit access to its programs by children and adolescents. Kids between the ages of 10 and 16 may participate only if they have both a parent’s signature and a doctor’s referral that includes an individualized weight goal or range.

A few commercial programs have been developed specifically for children, but little scientific research has been done to evaluate their long-term effectiveness. The Shapedown Pediatric Obesity Program, developed in the 1980s by researchers at the University of California, San Francisco, is a commercially licensed program for children, teenagers, and their parents. An older program, it is offered in many U.S. cities and has probably been used by thousands of families. The only published scientific trial of its effectiveness was done in adolescents between the ages of 12 and 18. The 1987 study compared 37 overweight kids who were randomly assigned to receive the 14-session program combining dietary change, exercise, and behavioral counseling, with 29 kids receiving no treatment. Children in the treatment group lost weight (an average of about 7 pounds) during the three-month program, while those in the control group did not. The study suggested that Shapedown participants derived some benefit for at least a year. No studies providing longer follow-up or more recent results for Shapedown participants have been published.

Committed to Kids is a treatment program for obese adolescents

developed at Louisiana State University’s Pennington Biomedical Research Center in Baton Rouge. The program is promoted in the book Trim Kids by LSU exercise physiologist Melinda S. Sothern and two colleagues. The Committed to Kids curriculum, patient materials, and training manuals are marketed to health professionals on a Web site, so some families may find the program in their area. It combines a reduced-calorie diet, behavior modification techniques, and an exercise program and is usually presented in weekly sessions for adolescents and their parents. A program using a similar approach, without the physical activity component, was studied in two randomized controlled trials published in the 1990s; it was found to be safe and produced significant weight loss over a six-month period. Sothern says the program has since been updated and a physical activity component added. The current version has not been tested in a randomized clinical trial. Of a group of 93 adolescents enrolled in the current program for a year, 56 agreed to be evaluated for a recent study. In that subset, participants had reduced their BMIs from an average of 32.3 at the program’s start to an average of 28.2 at one year. (However, the results in the 37 adolescents who declined to be evaluated may have been quite different.) Longer-term follow-up data on Committed to Kids participants are not available.

In addition to programs that require regular attendance for a prescribed period, dozens of summer camps offer short-term treatment for overweight kids. However, few scientific studies have examined whether such camps work. Leonard Epstein points out that it’s also difficult for families to evaluate commercial weight-loss programs or camps for children, since there are no laws requiring that such programs be scientifically evaluated for safety or effectiveness before they are marketed to the public. “Anybody can just say they have a program and start it,” he says. He suggests that parents considering such a program should ask a series of questions: “I’d want to know how many families they have treated, the length of the program, and what kind of a BMI change or percent overweight change they usually get.” He advises parents to ask about the staff’s credentials, the program’s dropout rate, and whether officials can provide any data on how well participants maintain their weight loss after the program ends. Parents may

also find it helpful to talk with others whose children have attended. “I’d want a program that also took care of the parents,” he adds. “I think family-based programs are always going to be better than programs that just target the child.”

Prescription medicines to promote weight loss have had a checkered history, with dangerous side effects forcing some drugs to be taken off the market or to be prohibited for use as weight-loss aids. Amphetamines, considered safe for certain other uses, were once widely prescribed as diet pills but produced heart palpitations, high blood pressure, psychiatric symptoms, addiction, and other serious complications in some people who used them to induce weight loss; they are no longer approved for that purpose. Fenfluramine, prescribed during the 1990s as part of a popular two-drug weight-loss treatment nicknamed “fen-phen,” was removed from the U.S. market after the combination was associated with heart valve damage in some users.

Nevertheless, the search continues for safer and more effective medicines to help people lose weight. Inspired by recent advances in scientific understanding of how the body regulates appetite and weight, researchers are currently pursuing a host of new drugs for treating obesity. Perhaps one or more of these candidates will turn out to be well-tailored medicines that can safely and specifically produce weight loss or help people avoid regaining lost pounds without undesirable side effects. At the moment, however, the drugs approved for treating obesity in adults are only modestly effective: used in combination with diet and exercise, they can help people lose a bit more weight than they would otherwise. Individual patients often benefit most during the early weeks of treatment, with the drugs becoming somewhat less effective over time. These medicines have side effects that make them inadvisable for some people to take. Only one is approved for use in children. Current treatment guidelines recommend that kids or teenagers should be prescribed weight-loss drugs only as an adjunct to better-established treatment strategies such as dietary modification, increased activity, and family therapy.

Two drugs—orlistat (Xenical) and sibutramine (Meridia)—are

approved for use in adults to aid in weight loss. Orlistat has recently been approved for obese children 12 years old or older. It does not suppress appetite, but it partially blocks the absorption of fat from the digestive tract, so that people on the drug do not fully digest and store all the fat calories they eat. In two studies on obese adolescents aged 12 to 16, children taking the drug reduced their BMI while those taking a placebo did not. In adult studies the drug improved weight loss in people on a weight-reducing diet and helped them maintain weight loss for up to two years. The drug’s most common troublesome side effects are oily bowel movements and oily spotting on underwear caused by unabsorbed fat that ends up in the feces. Because it can interfere with the absorption of the soluble vitamins, people taking the drug must also take a daily supplement.

Sibutramine is an appetite suppressant that affects the functioning of nerve cells in the many brain pathways that use the chemical signals norepinephrine and serotonin. It can raise blood pressure and pulse rate and is hazardous for people with high blood pressure, various types of heart disease, or a history of stroke. In adult patients it produces moderate weight loss when combined with a calorie-restricted diet. In one large European study in adults, almost half of people who took the drug were able to maintain most of their weight loss for two years, compared with only 16 percent of people who took a placebo. However, a large number of participants dropped out of both groups, which limits the conclusions that can be drawn.

Robert Berkowitz conducted a trial of sibutramine in overweight teenagers. In his study kids who were given the drug in addition to standard obesity treatment lost about twice as much weight as those given a placebo, and most were able to keep the weight off for up to 12 months. They reported that sibutramine reduced hunger and made it easier for them to stick with their eating plan. Almost half of the teenagers taking the drug, however, experienced increases in blood pressure or pulse severe enough to require lowering the dose or in some cases stopping the medication. Experts caution that longer and larger studies are needed before the drug is approved for use in teenagers.

Overweight adolescents at risk of developing diabetes may benefit from a different drug, metformin (Glucophage). Approved as a treat-

ment for type 2 diabetes in adults and in children 10 and older, metformin is not a weight-loss treatment, but in overweight adults with prediabetes it has been found to reduce the risk of developing diabetes or to delay the disease’s onset. Some experts are also using it in overweight teenagers whose blood tests show a prediabetic pattern of abnormalities, such as high fasting insulin levels.

The best evidence supporting metformin’s value in delaying diabetes comes from the Diabetes Prevention Program, a large government-funded clinical trial whose results have important health implications for millions of overweight Americans. Participants in the study—all of whom were at least 25 years old—were obese (average BMI: 34) and had impaired glucose tolerance, as shown by a high fasting blood glucose or an abnormal response to an oral glucose tolerance test. One group was assigned to intensive lifestyle changes to reduce weight and increase exercise, a second group was assigned to take metformin, and a third group was given a placebo and standard medical care. In the placebo group, 29 percent developed diabetes during the follow-up period, which averaged three years. In contrast, 14 percent of the lifestyle change group developed the disease (representing a 58 percent reduction in risk), and 22 percent of the metformin group developed diabetes (a 31 percent reduction in risk).

Metformin improves the body’s control of glucose by increasing the liver’s sensitivity to insulin and by reducing the liver’s production of glucose. Unlike most other diabetes drugs, metformin does not promote weight gain. Its major risk is its potential for causing lactic acidosis, a rare but serious metabolic disorder that happens most often in people with kidney disease, liver disease, or heart failure—problems uncommon in children and teenagers.

Some doctors feel the Diabetes Prevention Program findings, combined with data from studies in adolescents, justify prescribing metformin for overweight teenagers who have impaired glucose tolerance, or prediabetes, although the drug is not currently approved for this purpose. Duke University researchers conducted a trial of metformin in obese children aged 12 to 19 who had high fasting insulin levels and found that the drug improved their insulin sensitivity and lowered both insulin levels and BMI. “Through its ability to re-

duce fasting blood glucose and insulin concentrations and to moderate weight gain, metformin might complement the effects of dietary and exercise counseling and reduce the risk of type 2 diabetes” in some patients, they write. Type 2 diabetes rates are rising dramatically as American kids become more overweight. The proven benefits of metformin for delaying diabetes in adults should make additional studies of its potential value for children with prediabetes an urgent priority.

What about nonprescription weight-loss aids? Consumers in general should steer clear of dietary supplements and over-the-counter (OTC) medicines that are promoted for weight loss. In particular, such products should not be used by children or adolescents. Unlike the prescription drugs described previously, a wide variety of herbal products and dietary supplements are aggressively marketed as weight-loss treatments with no requirement for approval by the Food and Drug Administration (FDA) and, therefore, no legal standards demanding scientific proof of their safety and efficacy. Ingredients of dietary supplements marketed for weight loss include chitosan, chromium picolinate, conjugated linoleic acid, and garcinia cambogia. Scientists reviewing the medical literature have found that there is insufficient data to show that any of these agents are safe or effective. “Because of the unpredictable amounts of active ingredients and the potential for harmful effects, the National Institutes of Health guidelines state that herbal preparations are not recommended as part of a weight-loss program,” concludes a recent review by NIH scientists.

Some OTC medicines are also promoted to help people lose weight. Although the FDA regulates OTC drugs more stringently than it does dietary supplements, there is little evidence of their long-term effectiveness. Phenylpropanolamine, until recently a major ingredient in many OTC drugs sold as weight-loss remedies and nasal decongestants, was taken off the U.S. market after it was shown to increase the risk of strokes caused by bleeding in the brain. Ephedra and chemically related substances (known as ephedrine alkaloids, including the dietary supplement ma huang) have long been major ingredients in dietary supplements promoted for weight loss. They too have been linked with serious complications, including heart attacks, abnormal

heart rhythms, strokes, seizures, and sudden deaths and were ordered off the market by the FDA in 2004. Ephedrine remains an approved ingredient in some OTC decongestants and asthma drugs.

On a soft spring day, Brian came home to Washington, D.C., from Cumberland Hospital, in southeastern Virginia, 104 pounds lighter than when he had been admitted as a patient eight months earlier. At 271 pounds Brian was still a heavyset young African American man, but he was no longer the nearly 400-pound teenager whose doctor had hospitalized him to lose weight because at 17 he had developed the kind of diabetes more often seen in overweight adults.

Cumberland is an isolated pediatric rehabilitation hospital set in marshy woodland, a place that specializes in slimming down children and teenagers whose obesity threatens their lives. The hospital once treated a 14-year-old who weighed 650 pounds; another patient was 12 years old, 5 feet tall, and weighed 500 pounds. Because specialized in-hospital treatment for obese kids is so difficult to find, patients have come from as far away as Alaska and Saudi Arabia. To the round-faced, homesick teenager from the District of Columbia, it felt like a prison. “I ain’t going to lie,” he says. “I thought I was in hell.” Brian’s obesity had been fueled by a voracious appetite. “My son could eat a whole pizza,” recalled his mother, Cassandra. “He’d eat a box and a half of cereal in one day. A gallon of milk, he’d go through like nothing. Cookies, candy—he loved to eat.”

In the hospital every aspect of Brian’s life was transformed. For the early weeks of his stay he was placed on a regimen of medically monitored semistarvation called a protein-sparing modified fast. He was given a small amount of protein plus vitamin and mineral supplements and ample fluids each day so that his body was forced to break down fat rapidly to keep him alive. He lost about a pound a day. Staff members watched him constantly to make sure he didn’t sneak food. Brian saw a psychotherapist several times a week and attended group sessions with other teenage patients to discuss the feelings and situations that could trigger his compulsive eating. He was taught how to read food labels and went on a field trip to learn what to order at

McDonald’s. As he continued to lose weight, his doctors gradually liberalized his diet to allow him more calories and more choice about what he ate.

This type of inpatient treatment is only for children who are considered morbidly obese. They must be suffering medical complications serious enough to urgently threaten their health, and their doctors must determine that appropriate treatment in the community is either unavailable or unlikely to produce sufficiently rapid weight loss. Hospital director Daniel Davidow said the residential program at Cumberland, which also includes a daily exercise regimen, physical and occupational therapy, and a school program, costs between $800 and $1,000 per day. One boy who was at the hospital with Brian needed a heart transplant but was too heavy to undergo the operation. Others suffered from dangerous sleep apnea: their throats would close up as they slept and they would stop breathing. Some had legs so bowed from carrying excess pounds that they could scarcely walk. A few teenagers treated at Cumberland were being considered for gastric bypass surgery, an operation now being used to treat extreme obesity in adults, yet had been ordered by their surgeons to lose some weight before they could safely undergo the procedure.

Before he was judged ready to leave the hospital, Brian needed to reduce his BMI—which was initially above 55—to below 40. (Davidow explained that a BMI of 40 is considered the boundary between “severe clinical obesity” and “morbid obesity,” according to guidelines for adults.) In addition, the Cumberland staff had to feel reasonably confident that Brian had acquired the skills and motivation to stick to the diet he would have to follow at home to maintain his weight loss. He was told that his future health depended on reaching those goals: if he regained the lost pounds, his diabetes would inevitably worsen, putting him at high risk of future heart disease, kidney failure, blindness, and other complications. A planned six-month stay stretched to eight. Brian celebrated his eighteenth birthday in the hospital. At last the day arrived for him to go home.

Brian and his mother were proud of what he achieved during his hospital stay, but for Brian the far bigger challenge was to keep the pounds off once he was back in his world—a world where fast food

was plentiful, getting regular exercise was difficult, and everyday life was filled with the stresses of living with his single mother, struggling to finish high school, and trying to fit in among the other young men and women in his neighborhood. Within a month or two of his return to Washington, Brian had regained about 30 pounds of the weight he had lost, according to his former doctor at Washington’s Children’s National Medical Center. Now legally an adult, he told his mother he did not want to go back to his doctor—in fact, he didn’t want to go to doctors at all anymore.

Dozens of studies have shown that maintaining weight loss is much harder than losing it, because the human body has evolved highly effective mechanisms to defend itself against starvation. Weight loss activates those defenses, even prompting the body to lower its resting metabolic rate and to make muscles work more efficiently so they burn less energy during physical activity.

Brian and the other children and teenagers who undergo weight-loss treatment at Cumberland Hospital are at the extreme end of the obesity curve—so heavy that their BMIs are literally off the growth charts and their bodies are being ravaged by the medical consequences of carrying so much fat. Such super-obese children are becoming more numerous in our society, and their treatment is a subject of intense debate. In many cases multiple biological and social factors combine to produce this degree of obesity. These children often come from families where virtually everyone is fat, families that have lost numerous loved ones to diseases caused by excess weight. There are super-obese kids who also have a history of overeating compulsively, sometimes for reasons in addition to hunger: to protect themselves from physical or sexual abuse, to assuage depression or anxiety. Some live in neighborhoods without supermarkets or recreational facilities, neighborhoods where high crime rates and gang activity make it dangerous for them to venture outside.

Hospital-based treatment programs like the one at Cumberland are rare. Despite their high cost, there is no evidence that they are any more effective than community-based outpatient programs for achieving long-term weight loss, says Thomas Wadden, a psychologist at the University of Pennsylvania who has reviewed research findings on

treating obesity in children and teenagers. Very-low-calorie diets like the one Brian received during the initial weeks of his stay do produce rapid weight loss, often a pound or more per day, which is sometimes necessary for treating life-threatening complications of obesity. However, Wadden says, studies show that children or teenagers who lose weight on these diets usually regain at least half the weight lost within a year of stopping treatment.

Because of the high failure rate of medical treatments for severe obesity—especially among adolescents—small but growing numbers of very obese teenagers are undergoing the same kind of weight-loss surgery whose popularity has surged in recent years for obese adults. In the United States, the operation done most frequently to induce weight loss is called gastric bypass, but several other procedures are also being performed by surgeons in this country and abroad. An estimated 120,000 such operations were performed in the United States during 2003, and the number is expected to continue to grow.

Such operations, collectively known as bariatric surgery, are by far the most effective way doctors have discovered to produce long-lasting weight loss. Considered major surgery, in most cases they permanently alter the anatomy of the digestive tract. They carry a small risk of death at the time of operation (about 1 percent if the surgeon and hospital team are experienced in the procedure, but significantly higher if the surgeon and staff are not trained in bariatric surgery or have handled few such cases). They can cause short- and long-term complications. They are also expensive, typically $25,000 to $30,000. Insurance carriers have become so alarmed by the rapidly expanding cost of bariatric surgery that some have refused to pay for certain types of procedures and others have established criteria to strictly limit coverage even for severely obese adults with obesity-related medical problems.

In part, these operations are designed to force obese people to drastically reduce their intake of calories: one surgeon refers to them as “behavioral surgery.” In addition to restricting stomach capacity, the procedures seem to reduce appetite, probably by altering the levels of various chemical messengers produced in the stomach and intestinal tract that influence perceptions of hunger and satiety. Because gastric bypass and some of the other bypass procedures also reduce the diges-

tive tract’s ability to absorb nutrients, including some vitamins and minerals, people become vulnerable to nutritional deficiencies for the rest of their lives. They must be willing to follow dietary instructions, take multiple pills daily, and see their doctors regularly. If they fail to take their daily supplements, they can develop anemia, bone disease, and many other problems.

Although some data currently exist on adults who have been living healthy lives following such surgery for 15 years, 20 years, or longer, they come chiefly from the “case series” of individual surgeons, not from randomized controlled trials that compared long-term outcomes in obese patients treated surgically with those who received standard nonsurgical treatment for their obesity and its complications. There are no studies yet on the surgery’s long-term effects on teenagers, whose bodies are still developing and who can be expected to live for many decades after undergoing such operations. Medical experts are understandably nervous about the uncontrolled use of bariatric surgery in adolescents, yet surgeons who have studied the treatment’s effects for years in their adult patients point out that the weight loss resulting from bariatric surgery usually cures or dramatically improves diabetes, high blood pressure, high cholesterol, sleep apnea, orthopedic problems, and numerous other complications of obesity. If serious medical problems are threatening an obese teenager’s life they argue, why should such a patient be denied access to this surgery simply because he or she is not yet 18 years old?

During the past 25 years surgeons have devised several operations for producing weight loss. Because surgical procedures are not legally regulated the way drugs or medical devices are, different operations have proliferated without first being subjected to the kinds of studies required of medicines and without being scientifically compared with one another. In the United States the most frequent and most thoroughly studied bariatric operation is the Roux-en-Y gastric bypass, in which most of the stomach is closed off and a small stomach pouch is connected to the jejunum, the middle portion of the small intestine. The result is that food “bypasses” most of the stomach and the entire duodenum, the first part of the small intestine. This operation both restricts stomach capacity so that patients cannot eat much food at a

time and reduces absorption of nutrients by the digestive tract. Gastric bypass operations can be done either as open surgery—through a large incision—or laparoscopically, which requires only a small incision.

In Israel, Australia, and much of Europe a more common operation is adjustable gastric banding, in which a surgeon, operating through a viewing device called a laparoscope, positions an inflatable belt or band around the upper portion of the stomach. A tube leads from the band to an external injection port on the abdominal wall. At any time after the operation doctors can inject saline solution through the tube to inflate the band, gradually restricting the diameter of the stomach so the patient will be able to eat only small amounts at a time. They can also remove saline to deflate the band if the diameter becomes too small, causing discomfort or nausea. Unlike gastric bypass surgery, adjustable gastric banding is easily reversible and doesn’t involve cutting through the digestive tract or permanently altering its anatomy, and it’s less likely to cause malabsorption of nutrients and lead to nutritional deficiencies. It is thus a lower-risk procedure. These advantages have led some experts to argue that it might be a more appropriate operation for severely obese adolescents, but in the United States the procedure is relatively new, and the band is currently approved for use only in patients 18 and older. Some U.S. trials of the device have reported significant complications with the adjustable band as well as lesser degrees of weight loss than with gastric bypass. Even in countries where the gastric band is widely used, long-term data on its success are not yet available; recipients have generally been monitored for less than a decade.

In studies of gastric bypass surgery during the past 10 years, about 10 percent of patients have suffered serious postoperative complications, including blood clots, bleeding, infections, problems with wound healing, bowel obstruction, and hernias. Both the risk of dying and the risk of complications are highly dependent on the surgeon’s expertise and the number of such procedures routinely performed at the hospital. The chances of long-term complications from the operation are much more uncertain. Common problems include gallstones (which can be associated with rapid weight loss) and nutritional deficiencies

such as iron-deficiency anemia, osteoporosis and fractures caused by calcium deficiency, and other diseases arising from vitamin deficiencies. One of the major questions about the operation’s use in adolescents is whether its effect on absorption of calcium and other minerals will cause eventual weakening of bones. Moreover, the procedure is not uniformly successful. Most patients lose weight steadily for a year or two but then reach a plateau, and some regain the lost weight. In studies of more than 600 patients by surgeon Walter J. Pories, patients had lost, on average, almost 70 percent of their excess weight at one year after surgery. By 14 years after surgery they had kept off an average of about 50 percent of the original excess weight, but there was considerable individual variation.

Despite the operation’s risks, there is some evidence that in severely obese adults it can improve health and may prolong life. Surgeon Kenneth G. MacDonald and colleagues compared outcomes in 154 obese adults with diabetes who had the surgery and 78 similar patients who did not undergo the procedure, either out of personal choice or because medical insurance would not pay for it. The annual chance of dying was 4.5 percent in patients who had not had the surgery, but only 1 percent in the surgical group. Pories found that in 83 percent of his obese patients with type 2 diabetes and in 99 percent of those with abnormal glucose tolerance, the operation cured the disorder, normalizing patients’ blood levels of insulin and glucose. The weight loss produced by gastric bypass surgery also improves and sometimes normalizes high blood pressure, high cholesterol and triglycerides, heart function, and obesity-related liver disease. It commonly cures sleep apnea and pseudotumor cerebri, a potentially life-threatening obesity-related condition caused by elevated pressure of the fluid surrounding the brain. It improves weight-related respiratory and bladder problems. In women it often restores menstrual regularity and improves fertility and pregnancy outcomes. Losing large amounts of weight dramatically increases the ability of very obese people to move around, work, exercise, and perform routine daily tasks that most other people take for granted. At support group meetings for adults who have undergone the surgery, recipients often say that their operation marked the start of a new life.

In 1991 a panel of experts convened at a consensus development conference sponsored by the National Institutes of Health concluded that bariatric surgery could be considered an appropriate treatment for certain very obese adults, but that there were too few data to recommend the surgery for people under 18. The guidance expressed in the 1991 consensus statement is widely followed by the medical community and the insurance industry; nevertheless, in recent years it is likely (based on anecdotal evidence from bariatric surgeons) that more than 100 severely obese teenagers have undergone such operations.

Harvey J. Sugerman of Virginia Commonwealth University, a pioneer in the field of bariatric surgery, recently reviewed the results of gastric bypass surgery done at his hospital in 33 adolescents aged 12 to 18. Complication rates were similar to those seen in adults; there were no operative deaths. Two patients died suddenly two years and six years, respectively, after the procedure—probably of causes unrelated to the surgery, but the deaths are worrisome. Most patients lost weight successfully and kept off significant amounts, but five (about 15 percent) regained most or all the weight they had lost. Two additional “late deaths” in adolescents who had undergone weight-loss surgery were reported by pediatric surgeon C. W. Breaux of Birmingham, Alabama. These deaths occurred 15 months and 3 ¹/₂ years, respectively, after the procedure.

When might bariatric surgery be medically and ethically justified in a teenager? Surgeons and obesity experts at Cincinnati Children’s Hospital Medical Center have proposed a set of guidelines addressing this controversial question. Because the long-term balance of risks and benefits of this kind of surgery is so uncertain in adolescents, they urge that whenever such operations are contemplated for people under 18, the patients should be evaluated and treated at medical centers that offer comprehensive childhood obesity treatment and by a skilled surgical team that is committed to collecting detailed data and performing careful follow-up on all patients. (In the United States that is not the case at present: many bariatric surgeons around the country operate occasionally on adolescents without systematically collecting information on outcomes.)

Victor F. Garcia, the pediatric surgeon who founded the Cincin-

nati program, believes strongly that surgery should not be denied to adolescents whose obesity is causing them serious medical problems and who have been unable to lose weight by other means. He argues, however, that bariatric surgery in children under 18 should be regionalized and performed only at centers that can offer patients a surgeon experienced in such procedures, a multidisciplinary support team, and a commitment to providing long-term follow-up care and collecting data on outcomes. He points to cancer treatment in children as a specialty that has been successfully regionalized and could provide a model for bariatric surgery in obese adolescents. “I fear that unless it is regionalized … we are going to have children unnecessarily undergoing surgery, suffering complications and even dying,” Garcia says.

The Cincinnati physicians propose in their guidelines that BMI criteria for considering surgery in people under 18 should be more stringent than in adults. The 1991 consensus document indicates that adults with a BMI above 40 may be considered potential candidates for bariatric surgery, as well as certain patients with BMIs between 35 and 40 who are suffering severe medical complications of their obesity. However, they suggest that in adolescents the surgery should be considered only for patients with a BMI of 40 or higher who have serious medical complications of obesity, such as diabetes, sleep apnea, or pseudotumor cerebri. It could also be considered in those with a BMI of 50 or higher who have less serious complications, including severe psychosocial difficulties related to obesity, if weight loss is likely to correct such problems. They emphasize that decisions about surgery should be made on an individual basis, primarily by considering the impact of obesity on health rather than relying on absolute BMI cut-offs. They recommend that adolescents should not be considered for surgery unless they have failed to lose weight during at least six months of organized attempts at weight management, as determined by their primary doctors. Surgery also should not be considered unless an adolescent has attained at least 95 percent of his or her predicted adult height, which usually occurs by about age 13 in girls and about age 15 in boys. An X-ray of the hand and wrist can indicate whether a child’s bones still have significant growth to complete.

The Cincinnati guidelines also recommend that obese youngsters

being considered for surgical treatment undergo a comprehensive psychological and medical evaluation. Factors precluding surgery would include a medically correctable cause of obesity; a history of recent substance abuse; pregnancy, breastfeeding, or plans for pregnancy in the near future; a medical, mental, or psychiatric condition that impairs the patient’s ability to make an informed decision, to consent to surgery, or to follow doctors’ instructions afterward; and an unwillingness or inability (on the part of the patient or family) to participate in regular checkups after the operation. Young people who have exhibited self-destructive behavior or who have been unable to stick with a medical regimen in the past are not considered good candidates for surgery.

Thomas H. Inge, surgical director of the Comprehensive Weight Management Center at Cincinnati Children’s Hospital Medical Center and a coauthor of the guidelines, estimates that a quarter-million adolescents in the United States have a BMI of 40 or higher. Most of them have some medical or psychological consequences of their weight, including risk factors for diabetes or heart disease, but not all have developed obesity-related diseases. At the same time, as Inge and his coauthors acknowledge in the article describing their guidelines, the long-term metabolic, nutritional, and psychological effects of bariatric surgery in teenagers are unknown, and “the durability of surgically induced weight loss among adolescents remains to be clearly defined.” He says, “It’s easier for me to envision the risk/benefit ratio being in favor of the operation if the BMI is over 50.” If a teenager’s BMI were between 40 and 50 but the patient had no overt illness caused by being overweight, “I would hesitate,” he adds. “They are adolescents, and we really need to be treating disease, not risk factors.”

The Cincinnati surgeons are part of a multispecialty program devoted to treating obesity in children. Before proceeding with surgery, team members meet on several occasions with the patient and family to teach them what to expect. They require their adolescent patients to take a written test to evaluate how much they understand.

Each young candidate for surgery is then assessed by a panel that includes the surgeon, another physician who specializes in medical treatment of obesity, a child psychologist, and a dietitian. Panel mem-

bers consider the medical issues, the child’s ability to make decisions and cooperate with treatment, and the family environment. Between 2001 and the spring of 2004, 32 adolescents underwent gastric bypass surgery at Cincinnati Children’s Hospital. The average age was 17 for girls and 16 for boys; the youngest patient was a 14-year-old girl with diabetes. The patients had an average BMI of 56, and all had obesity-related illnesses. Doctors are still studying the long-term outcome of the treatment in these young people.

Inge says that medical insurance has paid for surgery in some obese teenagers treated in the Cincinnati program. But with 23 million U.S. adults and a quarter-million U.S. adolescents who are overweight enough to be considered possible candidates, the potential demand for such surgery is great enough to overwhelm the nation’s pool of trained surgeons and qualified hospitals. Bariatric surgeons in many cities have long waiting lists of obese adult patients. Most surgical residency programs have not yet developed the capacity to thoroughly impart the skills needed for bariatric surgery, especially for the newer laparoscopic techniques, and surgeons entering the field should attend training courses at qualified institutions before they embark on bariatric procedures. Anyone considering whether to have a gastric bypass or other weight-loss operation should be sure to obtain detailed information about the operating surgeon’s experience and outcomes, as well as the volume of such cases performed at the hospital involved. “No matter how renowned the children’s hospital is, make sure they have a surgeon who is experienced and well trained in doing the procedure,” says pediatrician Victor Garcia. “If the surgeon doing this surgery has done only one, you are, I think, inviting disaster.”

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