For obese teens, surgery of last resort

Eric DECKER knew at age 5 that he had a weight problem. “I was so much bigger than anyone else,” he recalled. “I could never wear children’s clothes as a kid.”

By age 10, Decker had seen dozens of doctors and nutritionists about his condition and was regularly attending meetings of Weight Watchers. A middle-school counselor once took him aside and advised: “Lose weight or grow a thick skin.”

He did lose weight but usually gained it back -- and then some. By age 17, Decker stood 5 feet 9 and weighed 385 pounds. He had a hormonal disorder, back and knee strain, and was at high risk of developing heart disease and diabetes, according to his doctors.

That’s when the South Carolina teen turned to bariatric surgery, an operation to reduce the size of his stomach and severely limit the amount of food he could ingest. The surgery took place 20 months ago at Cincinnati Children’s Hospital Medical Center. Today, Decker carries just 185 pounds on his 5-foot-10 frame.

“At first my mom was really apprehensive about my having this surgery,” said Decker, 19, who became interested in the procedure after he saw actress-singer Carnie Wilson talk about her experience with bariatric surgery on television. “But this was a last resort. I had tried everything. Doctors had told me I had to lose weight because it would eventually kill me.”

Bariatric surgery, once considered a drastic alternative for obese adults, is gaining acceptance among doctors who treat severely obese children, though it remains controversial in some medical circles. Although no one tracks the precise number of children and teens who have undergone the surgery, the number is thought to be small. Many surgeons who perform the procedure on adults now have patients who are children, and several pediatric medical centers nationwide, including one at Stanford University, are launching bariatric programs.

An estimated 140,000 American adults will undergo weight-loss surgery this year -- up from 75,000 last year. Ten years ago, the procedure was fairly uncommon in adults, and it’s growing popularity reflects a sobering reality: More Americans than ever before are severely -- or morbidly -- overweight. (Morbid obesity is usually defined as having a body mass index greater than 40; a score greater than 30 is considered obese.)

“If you look at the prevalence of morbid obesity, it’s twice as dramatic an increase as obesity alone,” says Dr. Thomas Harris Inge, a pediatrician who has performed the bariatric procedure on 42 adolescents since founding the child bariatric surgery center at Cincinnati Children’s Hospital two years ago.

Morbid obesity has risen rapidly in children and teenagers too. An estimated 127,000 to 255,000 teenagers have a body mass index of 40 or greater, Inge says.

Bariatric surgery reduces the stomach from about the size of a football to the size of an egg. If patients don’t adhere to permanent changes in their eating habits they will suffer from pain, diarrhea and vomiting. For example, sugar, high-fat foods and carbonated beverages should be avoided. Total calories are typically limited to 1,000 to 1,200 per day -- about a cup and a half of high-protein food. Vitamin and mineral supplements have to be taken every day to replace nutrients that no longer can be absorbed in the intestine.

And these changes must persist for the patient’s lifetime to maintain the weight loss.

It’s a tall order for someone who hasn’t yet graduated from high school. And bariatric surgery in children is certainly controversial.

“Children’s nutritional needs are different than adults’,” says Jeannie Moloo, a registered dietitian in Sacramento and a spokeswoman for the American Dietetic Assn. who works with adult bariatric surgery patients. “The surgery itself isn’t just shrinking the stomach size. Some of it is to bypass some of the absorption area of the intestine, and there is the potential for malnutrition. I strongly urge that parents try to pursue every other option available prior to surgery. But for some severely overweight children it may be the best option they have.”

According to Inge, some severely obese children develop such serious health problems that surgery is considered lifesaving. Inge spoke about his program earlier this month at the annual meeting of the American Dietetic Assn. in Anaheim.

“We’re not talking about cosmetic surgery here,” he says. “Severely obese adolescents are developing adult diseases.”

Many of his young patients, for example, have sleep apnea, liver disease, enlarged hearts and Type 2 diabetes. Studies show that, without significant weight loss, such children are at high risk for heart disease and osteoarthritis. They are also 10 times more likely to develop colon cancer than their normal-weight counterparts.

But the surgery itself is risky. The death rate from bariatric surgery is 0.5% to 1%, considered high compared with many other types of surgical procedures, and complications such as bleeding and gastrointestinal leaks can occur. Thus, Inge says his team carefully screens candidates for surgery. All must have a BMI of 40 or greater and have one serious health problem related to the obesity, such as diabetes or sleep apnea. Body mass index is a calculation based on height and weight.

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‘I never want to go back’

Decker and his parents sought Inge’s advice after an adult bariatric surgery practice turned him down because of his age. In Cincinnati, Decker underwent counseling and evaluations for a year before the surgery. Even with the risk of complications and death, Decker believed surgery was his only hope.

“I knew surgery was a risk. But I was going to die from being obese,” he said. “I used to sleep on my stomach because I was so afraid the fat would choke me during the night. I thought that if I died in surgery, at least I died trying to get better.”

After two surgeries -- the second to repair a leak in his stomach, a serious complication that delayed his recovery -- Decker began a new life that included a highly restricted diet of no more than 1,200 calories a day. To maintain a normal weight, the average adult consumes between 1,600 to 2,400 calories a day.

“It was hard to cope in the beginning,” he said. But after losing 70 pounds in the first month, he was exhilarated. He is a student at Coker College in Hartsville, S.C., where he is studying theater and hopes one day to perform on Broadway.

“I never want to go back to the way I was,” he says.

In data presented last week, the Cincinnati team reported success among 24 patients, ages 14 to 23. The group entered surgery with an average BMI of 57; many of the adolescents weighed more than 500 pounds. About one year after surgery, the patients, on average, had lost 63% of their excess body weight.

At last week’s meeting, Inge described one patient who underwent surgery six months ago. The girl, 15, weighed 540 pounds and had depression, sleep apnea and a pulmonary embolism, a blockage of an artery in the lung. Her family’s health insurer initially denied covering the surgery, which usually costs at least $20,000, but she successfully challenged the denial in court. After going ahead with the operation, she now weighs 180 pounds, no longer suffers from sleep apnea and has been taken off a blood-thinner used to treat the pulmonary embolism. And she has a boyfriend, Inge said.

Despite the progress, many questions about bariatric surgery in children remain, Inge acknowledges. For example, studies in adults show that at least some patients regain their pre-surgery weight. Whether a teenager or young adult can adhere to a strict diet and exercise program for many years remains to be seen, says Shelley Kirk, the lead dietitian in the Cincinnati program.

“We don’t want to say ‘Have this surgery and you’re home free,’ ” she says. “There are ways to eat around this surgery (and regain weight) if you don’t put into place the kinds of behaviors we advocate. The behavior piece is as important, if not more so.”

Children who undergo bariatric surgery need to be able to handle profound emotional and psychological changes, says Helmut R. Roehrig, a Cincinnati psychologist. There are few studies on the mental health issues affecting obese children before and after surgery, he says. His study of 21 adolescents requesting bariatric surgery found that 66% had sought mental health treatment, usually for anxiety or depression.

Doctors also aren’t certain which of the current methods for gastric bypass surgery are most appropriate for children. Most adolescents have a procedure called the Roux-en-Y gastric bypass, which is also the most common among adults. In gastric bypass, the size of the stomach is reduced and the connection between the stomach and small intestine is narrowed.

Another procedure is known as a lap band, in which a constricting ring is placed around the top end of the stomach. The lap band procedure may be safer for children, Inge says, because lap bands restrict food intake but don’t cause malabsorption.

While more health officials accept that some teenagers need bariatric surgery, a new controversy has developed over whether even younger children -- preteens -- should be candidates for the procedure.

Doctors generally avoid the surgery in children who have not completed their skeletal growth, usually around the time of puberty, because the surgery could disrupt growth.

But in his speech before the American Dietetic Assn., Inge argued that among children whose obesity has become life-threatening, age should not disqualify a child for surgery.

Families considering the option should seek advice at pediatric medical centers, says Dr. Thomas Robinson, director of the Pediatric Weight Control Program at Lucile Packard Children’s Hospital at Stanford University.

“We all want to see if [the surgery] is efficacious for teens,” he says. “But there are very different issues in operating on kids. Pediatricians need to examine kids before adult [bariatric] surgeons start cutting them up because they are just true believers in the surgery.”