I recently submitted a letter to the Archives of Disease in Childhood in response to their October article Bariatric surgery in severely obese adolescents: a single-centre experience, and its accompanying editorial Adolescent bariatric surgery in the United Kingdom; a call for continued study and open dialogue. Unfortunately they have declined to publish it, and in fact have not published any rapid responses on this topic. They point out on their submissions page that Responses are moderated before posting and publication is at the absolute discretion of BMJ Group. Fair enough, but as they do not reply to authors to explain their decision, I remain none the wiser as to their rationale.
Here is the transcript, reproduced below. I would be interested in your thoughts and criticisms (preferably constructive). Were they right to decline to publish this? Or was it a case of needing to be more careful what they wished for (“open dialogue”)…
Adolescent bariatric surgery may be effective for inducing weight loss, and consequently a reduction in obesity-related co-morbidities. However whether a 33% short-term complication rate is acceptable in a population with time on their side is another question. Adolescence may be the ideal time for supportive, education-based interventions aimed at achieving a lifelong change in dietary habits.
Sachdev P. et al report the NICE indication for bariatric surgery in young people: “all other appropriate non-surgical measures have failed”. How do we define “all other appropriate non-surgical measures” and how is it ascertained that they have been tried and failed?
Dr Garth Davis is a bariatric surgeon in the US who advocates a plant-based (95-100% of calories from whole plant foods) diet for adult patients post-operatively (1), and the value of whole-food, plant-based diets for achieving health benefit across a range of chronic conditions is being increasingly recognised (2).
Data from the Adventist Health Study-2 demonstrated that vegans have the lowest mean BMI, with values becoming incrementally higher in lacto-ovo vegetarians, pesco-vegetarians, semi-vegetarians and nonvegetarians (3).
In 2012 Dr Neal Barnard from the Physicians Committee for Responsible Medicine (PCRM) reported along with colleagues on the results of a randomised multicenter trial designed to determine the effects of a low-fat plant-based diet for eighteen weeks on anthropometric and biochemical measures in 292 adults who were overweight or had type 2 diabetes: “The mean reduction in body weight was 2.9 kg in the intervention group and 0.04 kg in the control group (P<0.01). Mean total cholesterol fell by 8.0 mg/dl in the intervention group and 0.01 mg/dl in the control group (P<0.01). Mean low density lipoprotein fell 8.1 mg/dl in the intervention group and 0.9 mg/dl in the control group (P<0.01). HbA1C fell by 0.6 percentage point in the intervention group and 0.1 percentage point in the control group (P<0.01)”(4)
Dr Davis is quoted on the PCRM website as saying “There’s a general belief among doctors that people won’t change […] but with proper education and guidance, people can and will change their habits […] Many people have no idea what in their diet has caused them to gain so much weight” (5).
Obese young people and their families need to receive education in such basics as micronutrient and calorie densities and the macronutrient ratio, and how our food choices affect these, as well as skills training in food acquisition and preparation, one-to-one mentoring and peer support utilising the latest evidence on motivation, and appropriate psychological or behavioural therapies where necessary. Financial constraints must also be taken into account where food poverty is an issue. It is not sufficient to simply tell overweight and obese patients to eat less and exercise more.
In the only randomised controlled trial to date comparing gastric banding with lifestyle interventions in adolescents, as referenced by Sachdev P. et al (6), the lifestyle program entailed a calorie-restricted diet and an exercise program, with contact with professionals occurring every six weeks. No further details are given as to exactly what patients were advised to eat (or why), or what coaching or psychotherapeutic methods were used to support them in their endeavours. Without detailed qualitative analysis of the nature of the interactions that occurred during consultations, it is very difficult to draw any conclusions as to the reasons for their limited success. The potential for bias in favour of surgery must also be recognised, as the trial could not have been conducted blind. If those delivering the lifestyle intervention doubted their program or their patient’s ability to comply even slightly, then this would have been subtly transmitted to participants, resulting in a foregone conclusion. Furthermore, no detailed analysis of the dietary changes that were recommended or achieved was given, in order that the efficacy of the motivational program could be separated from the efficacy of the diet.
Only when bariatric surgery has been pitted prospectively (and long term) against a well designed low fat, high raw, plant-based program incorporating all of the aforementioned elements and investing an equivalent budget to that incurred by surgery will it be possible to conclude that surgery is an appropriate therapeutic choice.
I recently presented my ideas for a plant-based dietary intervention study for childhood obesity to senior academics in my region. One response I received was that the study I was proposing would not be carried out in this country in the next fourteen years (why fourteen? I don’t know…). The reason given was that I would need a supervisor in order to apply for grant funding, and there is nobody in the UK at present with an interest in this field.
If this is true, I had better work hard to become that person in fourteen years time, but in the meantime it saddens me to think that we will be consigning a generation of young people to the choice between surgery or the challenge of losing weight more or less alone, based on poorly evidence-based advice to consume a “balanced” diet and do more exercise. At present it is understandable that many view surgery as the only option.
However, if anyone is interested in developing real alternatives to surgery for our children and young people, please get in touch. I continue to travel hopefully.
1 – Re: saturated fat is not the major issue. Dr Colin Walsh. BMJ 2013;347:f6340
2 – Nutritional update for physicians: plant-based diets. Tuso P.J. et al. Perm J 2013 Spring; 17(2):61-66
3 – Type of vegetarian diet, body weight and prevelance of type 2 diabetes. Tonstad S. et al. Diabetes Care 2009 May;32(5):791-6
4 – A plant-based diet reduces body weight and cardiovascular risk: The geico multicenter trial. Mishra S.,Barnard N.D.,Xu J.,Trap C. Diabetes, June 2012, vol./is. 61/(A192), 0012-1797
5 – Physicians Committee for Responsible Medicine. Healthy Foods and Healthy Bodies: Garth Davis, M.D: http://www.pcrm.org/good-medicine/2011/autumn2011/healthy-foods-and-healthy-bodies-garth-davis-md Accessed on 3rd October 2014
6 – Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. O’Brien P.E. et. al. JAMA, February 10 2010; Vol. 303, No. 6: 519-526