I’m very pleased to have Sarah McMahon, a Sydney psychologist specialising in eating disorders, write another guest blog, this time on the way the radical treatment of gastric banding is being pitched to teens, with very little attention given to the potential risks.
Promoting gastric banding to 14-year-olds: malnutrition and maintenance on the menu
I am shocked that a research article published on Wednesday by the Journal of the American Medical Association has been picked up, mixed up and hyped up by mainstream media, suggesting that gastric banding is an appropriate solution for “obese” teenagers. The research is typical of what we are seeing coming from the obesity industry, which is looking to capitalise from the condition.
What the research really found
Given the media hype, we need to look at what the research really tells us. Two groups of teenagers were randomly assigned to either a “lifestyle” group, for exercise and a healthy diet, or a “gastric banding” group, for laparoscopic adjustable gastric banding surgery with the main aim weight loss.
The gastric banding group experienced dramatically more weight loss than the lifestyle‘ group. This is not surprising. I would expect that intrusive surgery resulting in necessary food rationing is far more motivating than the “suggestions and encouragement” regarding dietary changes prescribed to the lifestyle group.
And although the extent of compliance between the groups is not clearly reported in the journal article, it requires little imagination. The reflex of a banded stomach is to vomit if the food is not small and well chewed. Not only does this force malnutrition, there is generally limited opportunity for high calorific intake. Of course vomiting is a vastly different compliance measure than the “intermittent food diaries and food counts used to measure compliance in the “lifestyle” group.
The sample size of the study was hardly robust. Less than 50 participants completed the research trial, meaning that statistically no evaluation of single health problems could be generated. This is important when considering the value of the study’s public health significance, given that the scaremongering associated with the “obesity epidemic” has gained so much momentum by medicalising the problem.
It seems that medicalising obesity somehow justifies culturally sanctioned prejudice on the basis that any intervention is “in their own interests”. Interestingly the study determined that despite the vast difference in weight loss in the gastric banding group, both groups experienced significant improvements in general health.
Further, follow up of weight loss measures were conveniently limited to two years, despite overwhelming evidence in research that suggests significant weight regain occurs from three years post surgery.
Industry promoted research
The study was undertaken by Monash University’s Centre for Obesity Research and Education (CORE). Perhaps not surprisingly, CORE receives an unrestricted research support grant from Allergen, which happens to be Australia’s leading provider of gastric banding equipment.
The lead author and pioneer of the lap banding procedure in Australia is Professor Paul O’Brien, who has previously served on the Allergen Advisory Board. Another author of the study reported consultancy with Allergen and membership of advisory boards that include Allergen, Optifast and Bariatric Advantage – all heavy weights in the weight loss industry.
It seems as though the boundary between commercial methods of weight loss, such as weight loss pills and medical interventions, are becoming blurred. Medicalising obesity to justify surgery creates an instant industry, and there is no shortage of businesses lining up to profit from it. Allergen’s webpage proposes alternative payment options, given the surgery is not covered by Medicare. These include the early release of superannuation savings or bank loans via third party medical finance.
The other side of gastric banding
Gastric banding is framed as a quick fix solution to address obesity. But does it address the real problem? Whether it is compulsive eating, binging due to psychological issues, or poor nutritional education, reducing an individual’s stomach size does not reduce the significance of these factors.
For example, eating disorders are not contraindicated, meaning that many people undertaking gastric banding may have severe psychiatric problems that are contributing to their weight gain or pursuit of thinness. I expect that this is one reason why the weight loss from gastric banding ultimately is short term and generally not sustainable.
Further, there is no standardized screening tool for the surgery. I know of countless cases of people engaging in binge behaviour who are offered the opportunity of gastric banding, at huge cost to their health. In our culture of thinness-at-all-costs, it seems that health is a reasonable trade off for thinness. Complicating this further is the fact that the subtext of our culture is that thinness equals health.
The Australian Medical Association’s 2008 report, ‘Bariatric Surgery: A Weighty Issue’, warned against the potential and inherent risks associated with gastric banding.
The cost to health from gastric banding is huge. Studies suggest that patients require follow up procedures to correct secondary health issues such as hernias, gall stones, bleeding, blood clots, infections, gastritis, correcting loose skin etc. In every 1500 cases there is one death (which can’t be corrected).
Common post-surgery complications include:
- Frequent vomiting because the stomach is unable to hold so much food or because food is unable to pass out from the stomach;
- Dumping syndrome which occurs when food enters the digestive tract too quickly, leading to adrenalin that results in nausea, palpitations, sweating and diarrhoea;
- Nutritional deficiency due to malabsorption. This means that people need to follow a lifetime program of consuming nutritional supplements and vitamins;
- Requirement for further surgery due to slippage, repositioning, adjustments and need for replacement of the band. In the aforementioned study, over one quarter of participants required revisional procedures that consisted of removal and replacement of the band or replacement of the access port;
- Permanent eating difficulties including: an inability to digest particular foods, requirement for extensive chewing, difficulty in drinking at meal time, difficulty in eating at certain times during the day, and food becoming lodged in the throat.
These associated health concerns are frightening given that gastric banding is framed as the “next step” when diet, exercise and medication have failed. Descriptions on web pages, brochures and even research reports invariably begin with scaremongering about the “obesity epidemic” followed by cartoon-style drawings of the seemingly simple procedure that will not only make the person thin, but will solve all their problems. Not surprisingly, the “success stories” on brochures and the media focus on the life that was “saved” through gastric banding.
The ability of 14-year-olds to make this decision
Given the associated complications, it is not just me who believes that it is unsafe to be proposing this intervention for teenagers. In November 2009, the Dieticians Association of Australia (DAA) released a ’Position Paper on Bariatric Surgery in Children and Young People‘ which concluded that there is insufficient evidence of the surgery as a safe and long-term solution to weight loss in teenagers. Even Allergen normally requires patients to be over the age of 18 to undertake the surgery.
This begs the question: what teenager has the capacity to make a decision so significant, given the health risks and the lifetime maintenance of such a procedure? How can a teenager adhere to the strict requirements necessary to maintain the band? What happens when they experience other significant life changes, such as pregnancy?
We are talking about prescribing this intervention to people who are in high school who are legally unable to drink alcohol or drive because their brain is insufficiently developed to manage these responsibilities.
Frequent vomiting, permanent eating difficulties and soiling pants may not be the alternative to “obesity”’ that teens really need.