ATLANTA – The thought of bariatric surgery for obese pediatric patients makes Dr. Sarah Barlow, lead author of recommendations on the prevention, assessment, and treatment of obesity, uncomfortable.
"I have a little bit of a love/hate relationship with bariatric surgery," said Dr. Barlow. For some young people, the procedure can be life altering, "but there is a big jump [from] a behavior-based intervention to bariatric surgery," she said at the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Her reservation hinges upon the question that runs specialtywide for physicians who treat obesity: Just who "owns" the disease?
"Is this a health care problem that needs to be taken care of by doctors, or is this a community problem, and this is all about prevention?" was Dr. Barlow’s rhetorical question. "There are a lot of barriers. There are a lot of players, but not really any reimbursement," she said.
In the case of bariatric surgery for children, Dr. Barlow said she wonders whether obese youngsters are sometimes pushed into having medical treatments in order to skirt reimbursement issues, or because it’s just one more item to tick off for guideline-laden office practitioners who have limited time with patients but an ever-increasing list of precautionary pearls they are meant to dispense?
"The hate part of my relationship is that the bariatric results are so wonderful that I feel people aren’t putting resources into intensive [nonsurgical] treatments," said Dr. Barlow. "I think it’s an option that should be on the table, but I think that medication and behavioral interventions and other tertiary care type interventions should be considered," she noted, adding that bariatric surgery is certainly not the answer to severe obesity in a 10-year-old.
Dr. Barlow is the lead author of the oft-cited Expert Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity, published by the American Academy of Pediatrics in 2007, and jointly sponsored by the American Medical Association, the U.S. Health Resources and Service Administration, and the Centers for Disease Control and Prevention. The recommendations emphasize behavior modifications with techniques such as motivational interviewing and culturally oriented nutritional counseling.
However, while pediatricians are willing to talk to patients about eating habits and exercise, said Dr. Barlow, the discussion is "very superficial. It gets lost in the ultralong list of anticipatory guidance that has to get done in a very short time frame."
As for reimbursements, it is unclear whether the Affordable Care Act will help or hurt pediatricians faced with an obesity epidemic in their patients, but it may help, said Dr. Barlow of Baylor College of Medicine, Houston. The legislation emphasizes research, improved access to primary care, and community-oriented health care initiatives as ways that awareness may be raised, she noted.
As for the ACA’s impact on reimbursements, she said, "I believe the ACA says anything that the U.S. Preventative Services Task Force promotes should be covered." The group’s 2010 report said there is little evidence of impact from moderate to intensive behavior-based treatments, she added.
"The conclusion from that is that those kinds of programs should not be covered," said Dr. Barlow. "The question the task force was addressing was whether it was worth it [for pediatricians] to take the time to calculate [body mass index]. They want screening tests that are sensitive and once you have the answer, you can do something with."
When asked if the underlying problem will be identified any time soon, such as through genetics, food addiction, food environment, or lifestyle, Dr. Barlow said, "everyone wants to treat it as being black or white, using a very medical approach. But we just don’t know."