Adolescent Bariatric Surgery: “You May Ask Yourself: How Did I Get Here?”

The prevention and treatment of pediatric obesity are public health priorities. Not only do obese youth carry a heightened risk of obesity-related medical comorbidities once only seen as “adult” diseases (e.g., hypertension, obstructive sleep apnea, type II diabetes), the psychosocial impact is considerably high (Freedman, Mei, Sriniavasan, Berenson, & Dietz, 2007; Kalra et al., 2008; Modi et al., 2008; Pinhas-Hamiel et al., 1996). Unfortunately, an alarming 6% of today’s teenagers have progressed beyond “mere” obesity (body mass index [BMI] or kg/m² ≥95th percentile for age and gender) to a level of extreme obesity (BMI ≥99th percentile) (Koebnick et al., 2010). Worse yet, empirically supported pediatric weight loss interventions targeting lifestyle modification, even with adjunctive pharmacologic agents, have insufficient impact for youth with extreme obesity, as typical outcomes reflect a reduction of only 5–10% of their marked excess weight (Berkowitz et al., 2006; Levine, Ringham, Kalarchian, Wisniewski, & Marcus, 2001; O′Brien et al., 2010). Accordingly, the vast majority of teens who are extremely obese today will carry their excess weight and disease burden forward into their adult years. With concern mounting and the known safety and efficacy of bariatric (e.g., weight loss) surgery for adult patients, the beginning of this century marked the emergence of a new and growing literature characterizing the psychosocial health of the subpopulation of adolescents with extreme obesity, those seeking surgical weight loss, and the initial psychosocial outcomes of adolescent bariatric surgery.

As a pediatric psychologist, I have been uniquely positioned to focus my academic career on this subpopulation of adolescents with extreme obesity. Was this a well-thought out plan? In part, “yes,” but more importantly, “no.” I say that frequently to trainees or junior faculty who cross my mentoring path, or even in conversations with colleagues when we ask ourselves, aka David Byrne of Talking Heads (Byrne, Eno, Frantz, Harrison, & Weymouth, 1980), “Well, how did I get here?” I think we all lose sight of how our contributions to the field are not just attributable to our hard work and those we have the pleasure of learning from and working with along the way. There is a heavy dose of “being at the right place at the right time.” That kind of “luck and timing” is something you can not plan for. It just happens. It may not even seem “the right time” when it presents itself. As mentors, we have a hard time preparing trainees and junior faculty for this aspect of career development. But I would imagine any mentor who reads this can share a story or two of how they did not fully plan for all the directions their career has taken them. And then, there is medical progress. Again, something we can expect but not always plan for, which sure makes what we do more interesting.

How Did I Get Here?

I was hired as the pediatric psychologist for a new hospital-based pediatric weight management clinic at Cincinnati Children’s Hospital Medical Center (CCHMC) as the obesity epidemic was hitting the headlines in 1999. Was this the logical next step from my earlier training? Not really. I needed a job in Cincinnati for personal reasons—“location” was the driver of my job search. As I was closing out my postdoctoral fellowship in Hematology/Oncology at CCHMC, I had the potential choice of staying in that Division, continuing work in a research lab where I had “grown up” as a graduate student and fellow (Mentors: Bob Noll, PhD, Kathy Vannatta, PhD). I weighed the pros/cons of remaining “in the family” and realized it was the right time to go. Pediatric obesity sounded like a new and interesting challenge and the medical director of the new program, a pediatric cardiologist, was eager for my involvement. I also knew the institution, with a newly hired Division Director for Behavioral Medicine and Clinical Psychology, Lori Stark, PhD., had increased its focus and support of building a successful research portfolio in pediatric psychology. I took a leap of faith and accepted the position.

I was quickly set on task to bring an academic focus on the psychosocial correlates of pediatric obesity that may serve as potentially modifiable barriers to treatment. My graduate school and fellowship research training had prepared me well for this, as I knew how to design and execute controlled observational studies (cross sectional and longitudinal), which assessed youth and family psychosocial health when a child or adolescent had a pediatric chronic condition. Like many junior faculty diligently on the path of an independent line of clinical research, there was internal pilot funding that led to a mentored career development award (K23DK60031) from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Unexpectedly, in the growing field of pediatric obesity research (amidst my then growing family), our clinical program began discussions with a new pediatric surgeon, Tom Inge, MD, PhD, who had interest in developing a bariatric surgery program for adolescents. “What?! Reducing the size of an adolescent’s stomach so they can’t eat as much? Are they ready to make such a decision? If they are nonadherent to lifestyle modification now, won’t they also be then? How do we know who the best candidates are? Is this safe? We know adults generally have improved psychosocial health, but we are talking about adolescence—a known period of psychosocial risk!” How did we get here?.

My genuine concern regarding the psychosocial health of the adolescent with obesity, and the essentially unknown outcomes of a bariatric intervention for that age group, along with hard work, good colleagues, great research staff, a supportive (albeit at times, skeptical) Division Director, a sound and logical research idea, funding opportunities, and truly being at the right place at the right time, all converged into an academic career path (that I never could have anticipated). I signed on as the pediatric psychologist for the new CCHMC adolescent bariatric program to provide preoperative psychological evaluations and consultation, again immersing myself in a new clinical population and most certainly, unchartered waters.

From a clinical care perspective, our initial approach was deliberately simple, yet comprehensive and age-salient in scope (Inge et al., 2004). I wore a pediatric psychology hat while considering the existing adult bariatric literature (Wadden et al., 2001) We designed a preoperative clinical psychosocial evaluation that targeted the adolescent patients and their caregivers, and assessed psychiatric and developmental history, current psychological status, the patients’ and families’ adherence patterns to current and past required medical regimens (e.g., medications, glucose monitoring, continuous positive airway pressure therapy) in addition to attempts at lifestyle change, as well as understanding family supports and potential barriers. As the team pediatric psychologist, I was in no way a gatekeeper controlling access to surgery. While I did screen for the established rule-outs in the adult bariatric literature (e.g., current suicidality, active psychosis, active and untreated substance abuse disorder), like adult care models, my primary role was to provide recommendations of necessary components to be addressed in the individualized comprehensive care of the patient if they proceeded to surgery. Examples included, requiring the establishment of collaborative care with mental health and prescribing providers already working with the adolescent, or initiating those links for adolescents newly identified as in need of mental health intervention. Our multi-disciplinary team (dietician, social worker, nurse practitioner, pediatrician, pediatric surgeon) then led the patient and family toward surgery, via education and active engagement in lifestyle change behaviors. Approval for surgery necessitated adherence to preoperative clinic appointments and treatment recommendations.

As initially developed, our program only offered one procedure: the Roux-en-Y gastric bypass (RYGB). The RYGB procedure reduces the size of the stomach, thereby restricting the amount of food that can be eaten at one time. The new smaller stomach pouch is reconnected at the lower part of the small intestine, bypassing the majority of the stomach and the upper small intestine, thus also lessening nutrient absorption of food eaten. The prescribed postoperative course, assumed to be lifetime behavioral changes, focuses on the diet (e.g., amount, timing, quantity, type of food eaten), vitamin supplementation, as well as recommendations for increasing physical activity to support weight loss and maintenance. Thus, the surgery itself is only one piece of the equation.

Patients and families came to our center from all over the country to be evaluated for candidacy. While this may sound like an opening of the floodgates, it is better characterized as a trickle: a slow and steady flow of patients (3–4 intakes per month), a good percentage of who did not proceed to surgery owing to insurance denials. While bariatric surgery for the adolescent patient was known to be on the rise (Tsai, Inge, & Burd, 2007), it was clear that our building research program would be critically important, yet small in sample size.

Launching an Empirical Literature

As there was no adolescent bariatric literature to draw from, our initial research focused on the key psychosocial outcome areas targeted in adult bariatric literature (e.g., depression, binge eating disorder, and health-related quality of life [HRQOL]). We also included examination of psychosocial correlates we identified to be salient to treatment-seeking youth with obesity in general, such as low perceived competence (Reiter-Purtill, Ridel, Jordan, & Zeller, 2010), family dysfunction (Zeller, Boles, & Reiter-Purtill, 2008; Zeller et al., 2007), and parenting stress (Guilfoyle, Zeller, & Modi, 2010). We quickly recognized that HRQOL would be an essential patient-reported outcome in our planned longitudinal observational studies of bariatric health and psychosocial outcomes. However, no condition-specific (e.g., obesity or weight-related) HRQOL measures existed for pediatric populations. Accordingly, this good idea, and in the context of good timing of a new collaboration with colleague Avani Modi, PhD, resulted in the development of three psychometrically sound condition-specific HRQOL measures (Kolotkin et al., 2006; Modi & Zeller, 2008; Zeller & Modi, 2009), all of which are actively being used in clinical programs, clinical trials, and longitudinal outcome studies within and outside of our study group.

Our initial pilot bariatric studies, supported by internal award and subsequent NIH funding (R03DK070889), were highly informative and established a much needed research foundation. Using a prospective design, we successfully recruited 91% of eligible (ages, 14–17) and consecutive bariatric surgery patients at CCHMC between May 2004 and January 2007 to achieve a pilot sample of 31 patient participants and their female primary caregiver. Adolescents and caregivers completed a series of questionnaires within one month before surgery, and again at 6 and 12 months postoperatively. Funding supported additional follow-up visits of the first 16 participants out to 18 and 24 months. Across time-points, our retention rates were strong (e.g., 88% at 24-months), with credit owing to highly motivated research coordinators and our flexibility in the execution of study procedures to meet participating families’ needs (data collections performed in clinical research space, the family home, or via mailed questionnaires administered by phone). As detailed below, these prospective data were disseminated in several published papers. In addition, as those data matured, we published retrospective chart reviews that focused on the clinic data and, in particular, the preoperative psychological assessment. For the first time in the literature, we had a glimpse of the psychosocial health status of the adolescent with extreme obesity considering bariatric surgery as a potential weight loss tool.

Taken together, what did we learn? Based on a retrospective chart review from our clinical center, present psychopathology was low before surgery, although many adolescent candidates reported a past history of previous treatment (e.g., 52% therapy, 36% medication) for mental health reasons (e.g., internalizing symptoms, ADHD) (Zeller, Roehrig, Modi, Daniels, & Inge, 2006). Mood disorders are the most common psychiatric condition reported in adults presenting for bariatric surgery. However, adolescents presenting for consideration for bariatric surgery were generally low in prevalence of clinical range depressive symptoms (30% had a Beck Depression Inventory raw score ≥17) (Zeller et al., 2006). Thus, as I frequently point out, while the term “depressed” is often used to describe an adolescent with extreme obesity, the data suggest this is only true for a minority of patients. In fact, even a recent study by Goodman and colleagues (Goodman & Must, 2011) using a nonclinical sample demonstrated that adolescents with extreme obesity were no more likely to report greater depressive symptoms than youth of healthy weight. What may best capture the psychosocial impact of extreme obesity in adolescents are the marked impairments in HRQOL, across domains (i.e., physical, social, emotional, school, body-esteem), and whether assessed via generic or weight-related measures (Zeller et al., 2006; Zeller, Modi, Noll, Long, & Inge, 2009).

The preliminary data on adolescent RYGB weight loss outcomes based on our single site RYGB experience were overwhelmingly positive and generally consistent with adult bariatric studies (Inge et al., 2010). Not only did this initial study demonstrate the safety of RYGB, but also the short-term efficacy was impressive, with an ∼37.4% reduction in BMI within the first 12-months. Furthermore, there was increasing empirical support emerging in the literature that following RYGB and in the context of weight loss, medical comorbidities were either resolved or the disease burden considerably lessened. Interestingly, based on our smaller research cohort (N = 16) and using appropriate statistical modeling techniques, the most dramatic weight loss following RYGB occurred during the first 6 months, followed by a slowing in the rate of change, as well as initial evidence of the potential for modest weight regain by the 24-month postoperative time-point (Zeller, Reiter-Purtill, Ratcliff, Inge, & Noll, 2011). Thus, while there was an impressive net BMI loss of 35% at 24 months, the question of weight loss durability emerged. Was this surprising? “No.” The adult literature consistently shows trends for weight regain for some surgical patients, beginning as early as the second postoperative year (Sjostrom et al., 2004).

The preliminary RYGB psychosocial outcome data were equally as compelling. Net gains in psychosocial health at 12 and 24 months were noted in lower levels of depressive symptoms, as well as improved perceived competence and HRQOL (Zeller et al., 2009; Zeller, Reiter-Purtill, Ratcliff, Inge, & Noll, 2011). However, statistical modeling revealed that, in parallel with weight regain in year 2, there was slight increase in depressive symptoms. Similarly, HRQOL improvements began to dissipate somewhat, as did the gains in most domains of perceived competence (e.g., appearance, close friendship, and social acceptance). Knowing our a priori power analyses determined only large effect sizes (δ>.85) would be detectable with a sample of 16 individuals (Cohen, 1988), our effect sizes were very large, ranging from ranging from δ = 4.26 (BMI change) to δ = 1.62 (Job Competence), suggesting observed changes over 24 months are indeed substantial. Were these findings surprising? Again, “No.” These initial adolescent findings are consistent with adult RYGB outcomes that suggest psychosocial changes parallel weight change and stability (Karlsson, Taft, Ryden, Sjostrom, & Sullivan, 2007).

Several additional interesting and unanticipated preliminary findings emerged. When looking at the 24-month outcome data in isolation, parameters indicated psychosocial functioning more typical of “healthy” or nonoverweight youth based on respective instrument normative data. However, the overwhelming majority of these teens, even with massive weight loss, remained obese, if not extremely obese (Zeller, Reiter-Purtill, Ratcliff, Inge, & Noll, 2011). Within the HRQOL literature it has been suggested that a change in health status may “recalibrate” a person’s conceptualization, values, and internal standards for how they evaluate themselves (e.g., response shift [Sprangers & Schwartz, 1999]). Perhaps then, an adolescent’s experience of a significant change in weight (e.g., net loss) or potentially, change in health status (e.g., resolution of comorbid conditions), may prove to be the more important contributors to psychosocial health status than the actual weight status level achieved, at least during the first two postoperative years.

Finally, we knew from the broader pediatric obesity literature that adolescents with extreme obesity would likely be living in a family environment where the primary caregivers were also obese. In fact, we found the overwhelming majority of female caregivers at the time of their adolescents’ surgeries were not only obese (86%), but many shared the adolescent’s condition of being extremely obese (47% BMI: >40 kg/m²) ((Zeller, Guilfoyle, Reiter-Purtill et al., 2011). While it is accepted that there is a genetic component in a family’s transmission of obesity, there is an undeniable family environmental component (e.g., food availability within the home, family meal structure/planning, cultural preferences, engagement in exercise) that maintains obesity and fuels its progression to extreme levels. An adolescent undergoing bariatric surgery must function within a family environment that has contributed to their presurgery health and psychosocial impairment. Unfortunately, we are only beginning to identify the parent and family characteristics of the obesigenic family environment, and specifically, that of the adolescent with extreme obesity considering or undergoing bariatric surgery. Previous work demonstrated many female primary caregivers who seek weight management intervention for their obese child or adolescent self-report clinical levels of psychological distress (28–50%) (Zeller et al., 2007; Zeller, Saelens, Roehrig, Kirk, & Daniels, 2004), elevated levels of parenting stress (18%) (Guilfoyle et al., 2010), and problematic family functioning (Zeller et al., 2007, 2008). Therefore, it was unexpected that our pilot study found limited family or caregiver dysfunction at the time of the adolescent’s surgery. Further, there was no detectable change in these family factors across the initial 12-months following the adolescent’s RYGB (Zeller, Guilfoyle, Reiter-Purtill et al., 2011). Thus, these preliminary data suggested that as the adolescent experienced a significant change in weight and improved psychosocial health, the family appeared to remain stable.

Our preliminary studies set the stage for future research. In addition, psychosocial data coming from other centers were remarkably similar and positive (Abu-Abeid, Gavert, Klausner, & Szoid, 2003; Collins et al., 2007; Holterman et al., 2007; Loux et al., 2008; O'Brien et al., 2010; Sysko, Zakarin, Devlin, Bush, & Walsh, 2011; Widhalm et al., 2008). Unfortunately, however, all of these important preliminary studies shared methodological challenges related to reliance on small sample sizes and patients from single institutions. Thus, our current knowledge remains limited not only in terms of generalizability of published data, but also the statistical power available to test more complex and informative questions regarding psychosocial health and its association with health outcomes. For example, the minority of adolescents who present within the clinical range of severity for depressive symptoms may prove to be a “significant minority” if depressive symptom severity before surgery is empirically linked to less optimal weight loss outcomes or increased psychosocial morbidity along the postoperative course. Or, while we demonstrated family functioning may not change over time, the level of family dysfunction may determine unique adolescent outcome pathways. Finally, our early understanding of psychosocial outcomes of adolescent bariatric surgery is limited to the two postoperative years, when weight change trajectories may begin to diverge. Only prospective and larger sample studies that are longer-term (e.g., beyond 24 months) will provide sufficient evidence of the durability of weight loss over time and a context to evaluate the relative impact of bariatric surgery on the long-term health and psychosocial well being of these adolescents as they transition to young adulthood.

Teen-Longitudinal Assessment of Bariatric Surgery

As interest in adolescent bariatric surgery heightened, and in cooperation with the NIDDK, our work led to the Teen-Longitudinal Assessment of Bariatric Surgery consortium (Teen-LABS) (Inge et al., 2007). The main focus of Teen-LABS is to execute a comprehensive study of bariatric surgery outcomes for adolescents across five clinical centers in the United States (CCHMC, Nationwide Children’s Hospital, Children’s Hospital of Alabama, Texas Children’s Hospital, and the University of Pittsburgh College of Medicine). Years 1–5 (2007-2011:U01DK072493; PI:Inge) established the solid multi-site research infrastructure, an administrative organization of committees/work groups, and a full-service Data Coordinating Center. Teen-LABS would prove to be the first prospective longitudinal observational cohort study to document the immediate safety of bariatric procedures and the associated trajectories of weight loss, medical comorbidities, and HRQOL in the adolescent patient. Further, Teen-LABS was designed to compare outcomes to adults in the parallel Longitudinal Assessment of Bariatric Surgery (LABS) (Belle et al., 2007). With enrollment closing at the end of 2011, we successfully established a cohort of 242 adolescents before surgery and for participation in short-(30-day, 6-month) and mid-term (annual) follow-up assessments. Our consortium was recently awarded a renewal (2011-2016:UM1-DK072493; PI: Inge) to continue annual follow-up of the Teen-LABS cohort for an understanding of longer-term outcomes (48+ months). I was uniquely positioned to serve as the “Behavioral Science lead” in the launch and ongoing management of the consortium, which is coordinated centrally from CCHMC. I also serve as one of the only nonsurgeon members of the consortium steering committee.

Being at the right place at the right time, additional funding opportunities also emerged via a program announcement for ancillary studies to major ongoing clinical research studies supported by the NIDDK, such as Teen-LABS. As I considered my preliminary findings I also had the benefit of clinical exposure to adolescent patients, their families, and their experience postoperatively and at further time-points beyond 24 months and as the patient matured. In sum, it seemed likely that the significant improvement in health and psychosocial functioning following bariatric surgery would create conditions for changing the developmental course of these at-risk adolescents in a positive direction. However, whether new risk factors emerge, whether improvements are sustained or erode over time, and how this relates to weight loss, maintenance, and regain remained unknown. An age-salient approach was needed.

Adolescent Bariatric Surgery: Improved Developmental Outcomes or the “Perfect Storm?”

Unlike the adult patient, adolescent bariatric surgery occurs at a critically important time in psychosocial development. Adolescence is a period of rapid change in emotional, interpersonal, social, and educational and vocational domains, when good adaptation bodes well for continued positive transition into young adulthood (Roisman, Masten, Coatsworth, & Tellegen, 2004). Further, as a patient matures, their postoperative course co-occurs with a challenging developmental transition: “emerging adulthood.” The distinct period between adolescence and young adulthood (ages 18–25 years) is seen as one of the most “volitional” periods of life, characterized by increasing independence (financial, residential) and exploration in relationships (e.g., peers, family, romantic relationships) and identity (Arnett, 2000). Within this context, adolescence and emerging adulthood are also distinguished by an increase in behaviors considered to be risky, harmful, or even antisocial. For example, alcohol/tobacco/drug use, sexual risk behaviors, and suicidal behaviors typically have initial onset and increasing rates in adolescence, followed by a peak in emerging adulthood (e.g., Harris, Gordon-Larsen, Chantala, & Udry, 2006). Certainly our recent examinations of such high-risk behaviors in a nationally representative epidemiological dataset (Youth Risk Behavior Survey; [Brener et al., 2004]) suggested extremely obese adolescents are no less at risk (Benoit Ratcliff, Jenkins, Reiter-Purtill, Noll, & Zeller, 2011; Zeller, Reiter-Purtill, Jenkins, & Ratcliff, in press). Understanding the high-risk behaviors of the adolescent patient became increasingly paramount in light of recent adult bariatric literature examining links between bariatric surgery and alcohol and substance use/abuse (e.g., King et al., 2012), as well as associations with increased risk of death by suicide (e.g., Mukamal & Miller, 2009). These normative developmental transitions and challenges are a lot to consider in the context of dramatic weight loss! Was this setting the stage for improved developmental outcomes or for some, the “perfect storm?”.

Subsequently, and with all stars aligned, the “TeenView Ancillary Series” was launched, establishing an empirical foundation for understanding trajectories of psychosocial health and risk behaviors for adolescent bariatric patients and as they transition to emerging adulthood (TeenView: R01DK080020; PI: TeenView2: National Institute on Drug Abuse supplement; TeenView3: R01DA033415). I have the great privilege of working with a team of Co-Investigators/psychologists both locally at CCHMC (Jennifer Reiter-Purtill, PhD, Jennie G. Noll, PhD, Chad Shenk, PhD) and at each of the Teen-LABS consortium sites (Dana Rofey, PhD, Children’s Hospital of Pittsburgh; Heather Austin, PhD, Children’s Hospital of Alabama; Amy Baughcum, PhD, and Kevin Smith, PhD, Nationwide Children’s Hospital; Gia Washington, PhD, Carmen Mikhail, PhD, and Beth Garland, PhD, Texas Children’s Hospital). Further expertise comes from those who bring adult bariatric psychosocial expertise (David Sarwer, PhD, University of Pennsylvania; James Mitchell, MD, Neuropsychiatric Research Institute) as well as expertise in substance abuse (Ken Winters, PhD, University of Minnesota; Matthew Johnson, John’s Hopkins University). And as we all know, tremendous credit must always go to our highly competent research coordinators, in this case across the five sites, who get the job done every day. Together, we are contributing new and critical science to the Teen-LABS consortium by placing adolescent extreme obesity and the short- and longer-term (6-, 12-, 24-, 36-, 48-month) outcomes of bariatric surgery within age-salient psychosocial and developmental paradigms. Furthermore, our inclusion of a demographically similar, nonoperative, extremely obese (BMI: ≥40 kg/m²) comparison group recruited across the five Teen-LABS sites provide a context in which to evaluate the relative impact of bariatric surgery as compared with the natural course of extreme obesity on psychosocial and developmental well-being over time.

Our goal is that our broad and developmentally salient approach will help explain the positive as well as any negative adolescent bariatric outcomes, thereby preventing simple explanations (i.e., “bariatric surgery is the cause”) from permeating the literature. Furthermore, the TeenView series data will be adequately powered to provide the first comprehensive evidence of whether there are presurgical psychosocial factors that are predictive of poorer adolescent weight-loss outcomes. Findings from the TeenView series therefore have the potential to markedly influence adolescent clinical guidelines and define postoperative care models. We have much work ahead!.

The adolescent bariatric surgery literature is in its infancy but also occurring in the context of medical progress. For example, there may be different psychosocial indicators or outcomes for different bariatric procedures, such as the laparoscopic sleeve gastrectomy (LSG), and while not yet Food and Drug Administration (FDA) approved for patients below the age of 18 years, the laparoscopic gastric band (LAGB), currently used only when clinical centers have obtained an FDA Investigational Device Exemption. At the most basic level, all of these bariatric procedures result in a restriction in the amount of food that can be eaten at one time by reducing the size of the stomach. In a RYGB or LSG, the stomach is surgically made smaller, whereas the LAGB involves the insertion of an inflatable silicone band to create a smaller stomach pouch that can then be adjusted (e.g., made tighter or looser) via periodic saline injections. Further, the mechanistic aspects of different procedures (e.g., impact on satiety and taste, hormonal mediation) or the role of genetics are, to date, not clearly understood but the focus of considerable work at the present time.

Is bariatric surgery the answer? Without effective intervention, youth who are extremely obese (remember, that is estimated at roughly 6% of today’s youth) will carry their physical and psychological disease burden forward into adulthood. Adults with extreme obesity face many additional challenges in education, the workplace, and in establishing romantic relationships. This is a bleak picture of health and well being. And for those who progress to parenthood, the vicious cycle will most likely begin again (i.e., obese offspring). Bariatric surgery, while a promising treatment option, is clearly not the only answer. Critical gaps in the empirical literature remain. Innovative intervention and prevention efforts are clearly needed. For example, investigators must test more complex models of the relation between parent and child characteristics and their mutual role in the development of obesity and its progression to extreme levels that, in turn, can inform weight-related behavior change models for youth. I am hopeful that with increased focus in such areas, we can break this cycle and prevent the next generation from experiencing health and psychosocial risk at such extremes.

Conclusions

I am often reminded of something my graduate school mentor Bob Noll, PhD, said in a discussion he was having with me regarding time management. “Meg, each week you are given 40 gold nuggets (hours) to use to get your work done,” encouraging me to protect them and spend them wisely. I am not sure what bucket of academic gold nuggets he had in mind, as we all know there are more than 40 nuggets worth of expectation each week to be successful in this academic market. That being said, I feel lucky that those nuggets are indeed golden, as I love what I do, and that our work has the potential to have an impact on the lives of adolescents now and in the future.

Often said to be “modest to a fault,” I will admit I initially declined the award when I got the email informing me of being chosen, having thought they must have made a mistake. There is more to that story, of course. Moreover, it is not an easy task to write about why your work has “contributed to the scientific base of pediatric psychology” without sounding incredibly self-important. It is true that I found myself at the right place at the right time. I also come from great training, and have supportive mentors, a collaborative spirit, and a strong empirical base in pediatric psychology. And above all, I am perseverant. I have to believe I belong at the table, even if I am not always welcomed or an expected guest. Great colleagues in our field make that belief easier to hold and maintain.

What I hope a reader gains from my writing is an appreciation that not all lines of “success” are straight and predictable, nor do you blaze a trail alone. A career path is not always smooth either. And then, there is also a lot of “life” that happens along the way (i.e., my early career babies have grown into tweens and a teen). There may be unanticipated zigs and zags, wonderful or challenging, that are equally important to attend to. Thus, I remind myself often that “work/life balance” is not a noun or an achievement; it is an active and ongoing process. Thank you for this opportunity. I am honored to receive such an award and, in particular, from my colleagues in pediatric psychology.

Funding

This work was supported by the National Institute of Diabetes, Digestive and Kidney Disorders (K23DK60031; R03DK0788901; R01DK080020) and the National Institute of Drug Abuse (R01DA033415) of the National Institutes of Health, CReFF funding from Cincinnati Children's Hospital Medical Center—General Clinical Research Center (USPHS Grant #M01 RR 08084 from the General Clinical Research Centers Program, National Center for Research Resources/NIH) awarded to the author and the Teen-LABS consortium (U01DK07249301; UM1-DK072493-06 Inge, PI).