2023-06-09 10:30:00
In extreme cases, overweight children may receive appetite suppressants or stomach reduction. This is stated in more and more treatment guidelines, including those in the Netherlands. When such an intervention is permitted is a difficult issue for doctors.
Adam steps into the consulting room. The 17-year-old boy feels his joints. They have been hurting for years. He weighs 196 kilograms, which equates to a BMI of 59 with a height of 1.82 meters. For more than ten years he has been attending a child obesity outpatient clinic. There he tries to lose weight under medical supervision. He starts in 2011 and loses some weight, but the kilos come back and he stops in 2016. A second attempt to lose weight in 2019 also fails. Eventually he is admitted to a clinic due to health problems. Even then he will not lose weight permanently, according to Maastricht UMC +, which shares its story with us.
According to doctors, children like Adam run such major health risks in the future that medically more robust treatments should be possible to prevent diabetes at a young age, for example. This concerns a stomach reduction or medication that suppresses appetite.
Those options are available in the Netherlands since 2020 in the directive, especially for teens who have already “grown up.” The medication is not reimbursed, insurers will only reimburse the lifestyle intervention from 2024. The operation is also not reimbursed and may only take place in combination with scientific research for the time being; that has only happened twice so far.
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Ronald Veldhuizen writes for de Volkskrant about medical research, psychology and (neuro)biology. Previously, he also wrote for the fact-checking column.
Tried everything
But when is such treatment permissible? While the new treatment options for childhood obesity caused little controversy in the Netherlands, earlier this year in the United States heated discussion after the American Academy of Pediatrics added stomach reduction and appetite suppressants to their guideline.
One reason for this is that the American guideline is less reserved, says pediatrician and professor of endocrinology Erica van den Akker of Erasmus MC, who co-wrote the Dutch guideline. “You can’t jump from zero to surgery here, you really have to have tried everything.”
For example, a Dutch condition is that the child must also have symptoms of diabetes, or type 2 diabetes, for example. The American guideline simply states that surgery should be discussed at a young age if a child has a BMI of 35 to 40.
Nevertheless, medicalization is also lurking in the Netherlands, say critics. ‘These are children who still have a whole life ahead of them,’ says Anne Roefs, professor of eating psychology at Maastricht University. ‘So they have to deal with the consequences of such treatments for life, such as possible complications or the need to take supplements for life.’
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Proponents and opponents agree on one thing: the new treatment options for children are anything but easy solutions. ‘You have to look at it on a case-by-case basis’, says Van den Akker. ‘Do the advantages outweigh the disadvantages?’
The benefits are great. People who take appetite suppressants or undergo stomach reduction lose more weight than any other way: after a year they weigh 20 to 40 kilograms less, which translates to a decrease of 10 to 15 BMI points.
There are also disadvantages. Take the new medication that suppresses appetite, called semaglutides. These agents stimulate satiety hormones. They also clean up the bloodstream, making the metabolism healthier. But in a recent study involving obese Finnish teenagers who received a weekly semaglutide injection, half of the children had regular nausea for a year and a half. Many of them had to vomit regularly. In slightly rarer cases, they suffered from gallstones.
Side effects can also occur with a stomach reduction. The good news is that teens lose many kilos and get healthier blood values studies from Scandinavia again in the United States to see. ‘It is the only proven effective treatment for obesity, with a long-term cure for diabetes and high blood pressure,’ says bariatric surgeon Maurits de Brauw, who performs stomach reduction on adults at Spaarne Gasthuis every day.
However, compared to psychological help or even medication, the treatment is relatively ‘terrifying and invasive’, says De Brauw. ‘In the first weeks after such an operation you really have to learn to eat again.’ Teenagers also have to take vitamin pills for the rest of their lives and occasionally get sick if they eat too much. Complications from the operation occur in 10 percent of cases: young people then have to go back to the hospital because, for example, extra bleeding occurs.
The question, says Van den Akker, is what makes an obese teenager worse off. She sees the treatment as a prevention to prevent the children from having to go to hospital even more often due to the consequences of obesity.
‘We are already seeing young people with high blood pressure and type 2 diabetes. They become seriously ill and can even develop heart problems in young adulthood if their weight changes too little. For that group we offer the last resorts. They face side effects and risks, but they may be smaller than if we had done nothing.’
Roefs knows that argument. ‘Yes, that they got rid of their diabetes and heart problems, that’s right. But what health problems will replace it? And couldn’t weight reduction really be achieved in any other way?’
Especially the stomach reduction, says Roefs, is a decision for young people in puberty, the consequences of which they are not yet able to foresee. ‘Of course the parents think along, but they then decide for that child.’
Van den Akker fully agrees with that last point. It remains a dilemma, she emphasises. ‘Do you really have to intervene early or can you wait? We do not know yet.’ Ongoing research should answer this question.
Hardest road
In addition to demonstrable health risks, a child in the Netherlands must have tried to lose weight for at least a year with what is called combined lifestyle intervention (GLI). On average once a month, children and their families discuss with psychologists and doctors what they can change in terms of lifestyle and behaviour. If that doesn’t work, medication and surgery come into view.
Of course, the control on this is as strict as possible, says Anita Vreugdenhil, professor of lifestyle-related diseases in children at Maastricht UMC +, which conducts gastric reduction research among young people in the Netherlands with the Máxima Center in Veldhoven. ‘Suppose a child suffered from depression during the process and a psychologist can still work on it, then it is not responsible to start with medication or surgery.’ In the gastric reduction study, each treatment process goes anonymously to an independent committee consisting of doctors and psychologists. ‘They can also say: continue with the lifestyle intervention first.’
Even then, the critics wonder: is lifestyle intervention a suitable brake on medicalisation? Surgeon Maurits de Brauw doubts it. Although he sees stomach reductions as a last resort, he is also critical of what can be achieved with lifestyle interventions. He points to one American review study by Erin LeBlancwhich shows that most participants in weight loss programs lose only 1 to 2 kilograms in the short term, and often gain it back later.
Roefs finds the dozen contact moments per year in the current lifestyle intervention in the Netherlands far too few. She fears that eventually too many children will still receive medication and operations.
‘Guidance has to be much more intensive’, she says, ‘that is what the research referred to in the American guideline shows. Not an appointment with the psychologist once a month, but at least fourteen times in the first six months, followed by years of intensive supervision. If children see a therapist for more than 52 hours in the first year, they lose about 5 to 10 kilos, calculates a review study by Elizabeth O’Connor in the leaf Jama for. The effect drops below 25 contact hours, to a few kilograms of weight loss per year.
According to Roefs, such intensive guidance is more expensive than the 600 euros per year that will be reimbursed from 2024, but it is a lot less expensive than the 10,000 euros that an operation costs.
According to Vreugdenhil, the lifestyle intervention will soon provide sufficient guidance and contact moments for many children to help them lose weight without surgery or medication. ‘And it is not said that the 30 percent who do not help will automatically get an intervention.’
In the end, it’s all about treating the symptoms, says De Brauw. ‘We’re on the wrong side. The medication to lose weight is now on the market and you can no longer stop it. It will soon be included in the treatment packages. I am afraid that this will reduce the government’s incentive to do something about prevention. That is the hardest way, but the only one. And the government simply fails to do so.’
Everyone agrees on prevention: the dining environment with accessible and cheap snack food is ultimately what makes the average American heavier than the average Japanese, with the Dutch somewhere in between. Doing something about this means, for example, a sugar tax, cheaper fruit and vegetables and more food education, experts say.
But we don’t live in that world at the moment, De Brauw admits. ‘So I understand that doctors want to do something. In that sense I am currently in favor of medical intervention.’ Vreugdenhil says so too. ‘There is always another child or young person sitting opposite me with a BMI of 40 or 50, diabetes and high blood pressure. What am I supposed to do as a doctor then?’
The name Adam has been fictitious. With his permission, Maastricht UMC+ shared his medical history with de Volkskrant. He was eligible for a gastric sleeve reduction in 2022 within a research context and underwent it in 2023. He has since lost 30 kilos.
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