Fat chance

25th May 2012 at 01:00
Why drastic surgery is now seen as necessary to combat Scotland's teen obesity

At least one Scottish child has undergone surgery in order to lose weight, TESS has learnt.

An investigation by the magazine into childhood obesity has revealed that while Scottish figures show that no youngster under the age of 15 has undergone bariatric surgery, at least one teenager has been sent to England for the procedure.

Dr Peter Fowlie, paediatrician and Scottish officer for the Royal College of Paediatrics and Child Health, says: "We would never have seen or considered this 10 years ago - a child being referred for surgery because they are overweight. Today it's exceptionally rare, but it does happen."

Meanwhile, the surgeon behind the first specialist surgical centre for paediatric obesity in the UK has called for teen weight loss surgery to be made available in Scotland.

The two most common types of weight loss surgery are gastric band, in which a device is used to reduce the size of the stomach, and gastric bypass, in which the digestive system is rerouted past most of the stomach so that it takes less food to feel full.

There is a need for a surgical option when youngsters are morbidly obese and all else has failed, says Ashish Desai, a paediatric surgeon at King's College Hospital in London. It is in the patient's best interests if this can be delivered locally, he says.

The childhood obesity statistics are worse in Scotland than in England, says Mr Desai. And research has shown that by the time an obese youngster hits 14 or 15, health starts to suffer.

According to the Scottish Health Survey in 2010, 29.9 per cent of Scottish children were overweight or obese; of the two- to 15-year-olds, 7.4 per cent were obese and 6.9 per cent were morbidly obese.

Academics, however, are calling for fuller statistics on childhood obesity to be recorded in Scotland.

At present, a child's weight in P1 is the country's only universally recorded statistic. They want to see children's weight recorded at more regular intervals with the caveat that it should be done "appropriately" and "sensitively", not en masse in school, where the results become a topic of discussion.

The best source of information on childhood obesity in Scotland is the Scottish Health Survey, says Dr Joanna Inchley, assistant director of the Child and Adolescent Health Research Unit (CAHRU) at the University of St Andrews. But the survey involves just 600 boys and 600 girls. "It's not a huge sample," she adds.

Another source of obesity statistics is the Health Behaviour in School- Aged Children (HBSC) survey run by CAHRU. But the fact that only half of Scottish youngsters taking part answer the questions about height and weight is one of the survey's weak points, Dr Inchley admits. And if anything, the results are likely to be an underestimation.

"We don't have really good data on obesity in Scotland," she concludes.

Anecdotal evidence abounds, however.

We are in the midst of an obesity crisis, concede the health professionals and academics contacted by TESS.

One expert predicts Scotland is up to a decade into a public health problem likely to be as intractable as smoking and to last 50 or 60 years. Another says things will get worse before they get better.

They all agree that education has a significant role to play in tackling overweight and obesity and that prevention is better than cure. Early intervention is critical, they stress. Obesity in early life is the best determinant of obesity later in life, Dr Inchley points out.

Messages need to be spread, they say, about portion size; the negative effects of sedentary behaviour and obesity on health; and how to prepare healthy meals. They also call for schools to hit the target of two hours' PE a week.

Positive moves have been made, they acknowledge. Health and well-being is central to the new Scottish curriculum and the food and drink served in Scottish schools must now meet strict nutritional guidelines, in accordance with the Schools (Health Promotion and Nutrition) (Scotland) Act 2007.

However, they challenge the Scottish government to take its healthy eating message beyond the school gates and to get retailers and food outlets on board. Half of secondary pupils do not eat in school and value for money does not usually equate to healthy eating, they argue.

One calls for the Scottish government to make school meals compulsory, although the Scottish government rejects this idea, arguing that parents have a role to play. It is, however, working with the food industry on other issues, says a spokesman.

"The Preventing Obesity Route Map (2010) includes commitments on product reformulation, portion sizes, stocking policies, pricing and promotions, labelling and packaging, marketing and advertising, all across manufacture, retail and catering," he continues.

A partnership with industry, the Food Implementation Group (FIG), is charged with taking forward these commitments, he explains. Reducing the calorie and salt content of products is a priority.

Meanwhile, work with retailers is ongoing under the banner of the Scottish Grocers' Federation's Healthy Living Programme, which aims to increase healthy options in stores, particularly in low income areas, he says.

It is too simplistic to blame parents for children being overweight, the experts all agree. Behind the problem is our "obesogenic environment", which makes it easier to gain weight than to lose it.

Last year, medical journal The Lancet ran a series of articles on obesity. In one, "increasing fatness" was described as "the result of a normal response, by normal people, to an abnormal situation".

Mr Desai became interested in offering a surgical option to overweight children after noticing the increasing size of his young patients.

When he had operated on a girl for five hours and her parents' main concern was whether the procedure would help her lose weight, the impact of obesity on youngsters' quality of life struck home.

"The operation was unrelated to her weight, but the parents' first concern was their daughter's obesity," he says.

Mr Desai's research into the problem led to the first unit in the UK specialising in weight-loss surgery for adolescents being set up eight months ago.

According to Dr Fowlie, who works at Ninewells Hospital in Dundee, until five or 10 years ago he virtually never received a referral because a child was overweight; now he receives up to 10 a year.

The referrals come from GPs looking to rule out a medical explanation for weight gain. In the vast majority of cases, the diagnosis is "simple obesity", he says.

Dr Fowlie adds: "Simple obesity is probably not the best term because this is not a simple issue, but we use simple obesity because there is no underlying medical cause."

Scotland is roughly a decade into a 50- or 60-year battle with obesity, he says.

Dr Laura Stewart, a dietician who heads up the Paediatric Overweight Service Tayside (POST), believes the problem will get worse before it gets better. Prevention and early intervention are key, she argues.

"We are finding we are having our best outcomes with the younger age group - two- to eight-year-olds. Their behaviour is not so ingrained," she says.

Apart from school PE, many children take no exercise, and that is why it is crucial that schools hit the Scottish government's physical activity targets, she says. And while people are aware of public health messages like eating five pieces of fruit and vegetables a day, knowledge is lacking on many fronts - and portion size is a major problem, she adds.

People are also unaware of how many calories they take in across various products.

"Packets of crisps and sweets have actually got bigger and cheaper," she says. "People are not realising how many empty calories they are taking in these foods."

And parents often don't recognise that their child has a weight problem. "Weight has increased in the population as a whole, therefore I think it's just harder for people to recognise when someone is overweight," says Dr Stewart.

The latest findings from the Growing Up in Scotland survey, which is following thousands of Scottish children from infancy through to their teens, appears to support that view. Researchers found that less than a third of mothers (30 per cent) who have an obese child recognise that their child's weight is not normal, while only 3 per cent of mothers of overweight children realise their offspring are overweight.

When working with families in which youngsters are already overweight, POST targets three lifestyle areas. It aims to decrease the child's total energy intake, increase physical activity to at least an hour every day and decrease screen time to no more than two hours a day.

"The average child that comes to our service is probably using about five to six hours of screen time on school days," says Dr Stewart. "Probably the highest we have seen was a young person who spent 10 hours in front of a screen on weekdays, with more at the weekend."

Scottish 15-year-olds are among the keenest TV viewers in the developed world, ranked ninth out of 39 countries by the HBSC international report for watching two hours or more a day, says Dr Inchley. Evidence of the impact of sedentary behaviour on health is beginning to emerge.

Dr Inchley adds: "There are three strands to it: time spent sitting is time not spent active; during time spent watching TV, there is a higher intake of snacks; and there is evidence that if you spend a lot of time sitting idle, your body becomes inefficient."

Dr Sue Robertson, a GP and kidney specialist from Dumfries, hit the headlines recently by calling on the UK government to promote the culture of children playing outside and to instruct local authorities to stop selling off outdoor play spaces for development. Free play stimulates the imagination and requires no sports ability, skills or equipment, she says.

"We should not be selling off parks for development even if the developers are going to build sports facilities, because then the poorest in the population will miss out, and they may be most in need," Dr Robertson says.

Like Dr Stewart, she emphasises the vital role of PE. But schools need to examine the content of lessons to ensure they contain enough exercise - and double periods should be the norm to allow time for an activity after changing, Dr Robertson argues.

She adds: "There should be facility at schools, both primary and secondary, to allow exercise at lunchtimes and balls should be encouraged - not banned."

US president Barack Obama's adviser on child nutrition, Janey Thornton, has argued in TESS that Scotland should keep pupils in school for lunch to improve health (TESS, 5 April); Dr Stewart agrees and calls for the Scottish government to make school meals compulsory.

But Dr Inchley feels there are benefits to leaving school at lunchtime, not least the exercise that pupils get as they leave the school grounds. She calls on the Scottish government to take more action to make it easier for them to make healthy choices.

"No one is taking responsibility for what happens in food outlets and stores outwith school," she says.

However, she warns against the risk of becoming obesity-obsessed. "There has to be a balance between encouraging youngsters to maintain a healthy weight and not becoming so obsessed that there is a negative impact on mental health and well-being."

Last month, the medical profession launched a campaign to combat child and adult obesity. It is seeking the views of teachers. Its first report will be published later this year; evidence must be submitted by 6 June.



The Scottish Education Awards single out schools that excel at keeping their pupils in good physical and mental health through health and well- being and active nation awards.

St Margaret's Academy in Livingston won the health and well-being award for having persuaded 80 per cent of pupils to eat a healthy school dinner. Even those who opted out were encouraged to eat on campus, keeping them away from burger vans and supermarkets.

The School Nutrition Action Group ensured that pupils' opinions about school dinners were heard, and the school created a pleasant environment for pupils to dine in.

St Kenneth's Primary in Greenock has also won the award - teachers encouraged pupils to refine their palates by letting those who cleared their plates dine in the school's restaurant, rather than the more modest canteen. Pupils who ate their school dinners also got to skip the lunch queue.

The school went from throwing out about 6kg of wasted food to 0.5kg.

It also encouraged pupils to get active in a weekly running programme which led to every child from P2 to P7 being able to run 2km without stopping.

At South Lanarkshire's Lanark Primary, all pupils get far more than two hours' physical activity a week. As a result, it scooped the active nation award. One of the most popular activities was hula hooping.

Perth Grammar won the same award by increasing participation in PE and expanding activities during and after school. All pupils from S1 to S6 took part in at least two hours' PE a week and the number taking certificated courses in the subject increased dramatically. By introducing cheerleading, the school managed to get girls to become more active.


The UK's first specialist surgical centre for paediatric obesity opened in London last year.

To be considered for weight loss surgery, teenagers have to be morbidly obese with a BMI of 40 or more, says Ashish Desai, the paediatric surgeon behind it.

One patient weighed 23 stone at the time of the operation - just before her 17th birthday.

It is highly unlikely that these youngsters will lose weight in the conventional way, says Mr Desai.

"Once a person is rather seriously obese, only 3 to 5 per cent manage to lose weight," he explains.

Since the unit was established eight months ago, Mr Desai has carried out four weight loss operations on teenagers. The youngest was 13-and-a-half but had "significant medical issues".

"He was wheelchair-bound and had significant quality-of-life issues. It took two or three people to move him from his wheelchair and into his bed."

As many patients have been rejected for surgery as have gone through it, he says.

"If we are unsure of their commitment or if we are not sure whether they comprehend the consequences of surgery, we will not go ahead."

In addition to Mr Desai, the team, which is based at King's College Hospital, London, consists of psychologists, dieticians and paeditricians. Before youngsters are referred to the unit, they will have spent years trying to lose weight, but surgery is not contemplated for at least six months.

First, the youngsters are seen by the paediatrician and dietician, who give them intensive diet advice and an exercise regime. Comorbidities such as diabetes and hypertension are also investigated. By the time obese youngsters hit 14 or 15, they are already starting to damage their health, Mr Desai explains.

If the teenagers continue to fail to lose weight, surgery is considered. Patients have at least two meetings with Mr Desai to discuss surgery; they also meet with an experienced adult bariatric surgeon, who has to be satisfied that surgery is necessary. All patients undergo a psychological assessment.

"This is a major surgery and it is a lifelong commitment," says Mr Desai. "If they have gastric bypass, they will be on supplements for the rest of their lives and the food they are able to eat goes down in quantity."

At least four patients have gone through the process and not been offered surgery, he says.

Two of his patients are now six and three months on, respectively, from their bariatric surgery.

"Their quality of life is much improved and they are both happy that they had the surgery," he says.

He has yet to operate on a child from Scotland, but given that the country has a worse childhood obesity problem than England, the procedure should be made available to teenagers north of the border, he argues.

The intensive support required before and after bariatric surgery is best delivered locally, he says. The King's College Hospital service plans to keep patients under observation for five years after any surgical procedure.

Original headline: Surgical solution goes on the table to combat child obesity


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