December 14, 2010 - 10:00 pm
By KRISTI EATON
VIEW ON HEALTH
Randall Dannen says he was always overweight growing up, but a year ago the 19-year-old University of Nevada-Las Vegas student’s life changed forever when he got a bad case of pneumonia. His nearly 500-pound body, coupled with the respiratory condition, made it extremely difficult for him to breathe, forcing him to spend three and a half weeks in the hospital.
“Not being able to breathe wasn’t very fun,” he says. “I almost died from the respiratory problems, so that was sort of stressful for a while.”
The incident would eventually lead Dannen to Dr. Shawn Tsuda from the University of Nevada School of Medicine’s University Weight Loss Surgery Center who will be performing gastric bypass on him in a few weeks.
The number of overweight and obese teenagers in America has swelled to 12.5 million, a number Tsuda calls “alarming.”
“It’s concerning,” he says. “While it’s believed in the field that obesity is multifactorial, it’s probably primarily because of the way we live.”
While the number of obese teenagers increases, so too does the number of teenagers undergoing weight loss surgery. Once strictly a surgery for adults, recent studies have shown that teenagers who are severely obese can see dramatic health improvements from weight loss surgery. But performing the procedure on teenagers is still a new frontier, and many physicians are hesitant to do it with so many unanswered questions and a lack of hard data.
TYPES OF SURGERY
The University of Nevada School of Medicine’s University Weight Loss Surgery Center performs three of the most common weight loss surgery procedures today. All are laparoscopic surgeries, where surgeons perform the procedure using a tiny camera inserted through tiny incisions. Laparoscopic procedures are less invasive, leading to shorter recovery time and less time in the hospital, says Dr. Tsuda, a bariatric surgeon.
Gastric bypass, the most popular weight loss surgery performed in the U.S., alters the process of digestion. It is the only procedure for morbid obesity, which is when someone is more than 100 pounds overweight or has a body mass index — a measure of weight vs. height — of 40 or more. (A normal BMI is between 18.5 and 24. 9.) There are several different types of gastric bypass, where the stomach is divided into a small upper pouch and a larger lower pouch. In Roux-en-Y gastric bypass, a portion of the small intestine is shaped into a “Y” and reconnected to the stomach, bypassing sections of the intestine so nutrients and calories are restricted and not absorbed. Patients are expected to lose two-thirds of their excess weight within two years of the procedure.
The laparoscopic adjustable band surgery works by placing a band around the upper most part of the stomach, separating the stomach into one small and one large portion. The band can then be adjusted to make the stomach portion smaller or larger, allowing for more room for food. Unlike with the gastric bypass procedure, the band is not permanent and can be removed. Weight loss is slower with the laparoscopic band surgery compared to gastric bypass, with patients expected to lose 50 percent of their excess weight in two years.
The newest weight loss surgery procedure is sleeve gastrectomy. Weight loss from sleeve gastrectomy is anticipated at 50 to 60 percent of excess weight at the one-year mark. There are advantages using the sleeve procedure, and complications from it appear to be fewer than gastric bypass, but because the procedure is new, there is a lack of long-term data to really compare.
IS SURGERY THE ANSWER?
Less than one percent of obese adolescents will undergo surgery, Tsuda notes, because of the strict guidelines. Surgery is not the quick fix — it is the last resort for patients who are feeling their day-to-day life impacted negatively and their health suffering.
At the University of Nevada School of Medicine’s University Weight Loss Surgery Center, doctors will consider operating on a teenager if they are over the age of 16 and exhausted other methods, like traditional diet and exercise. Many of the patients Tsuda sees are able to lose some weight but quickly gain it back, along with the health complications associated with obesity.
That is the case with Randall Dannen. When he was in eight or ninth grade, Dannen got a personal trainer, “but that didn’t work too well,” Dannen says.
He did lose weight, but only about 10 pounds, a tiny percentage of the 200 or more than he needs to lose.
He really began considering having weight loss surgery when he was 18. It was at that point that he began the screening process. Many teenagers will be screened for surgery, but only two or three will undergo the procedure at the University of Nevada School of Medicine each year, Tsuda says. The screening process includes a 12-week intense weight loss program to make sure they have the mentality to lose the weight, because the surgery is just the first step. Afterward, they must change what they eat and how much. After gastric bypass surgery, for example, the stomach can hold only a tiny percentage of what it once could, so understanding the lifestyle change is important. Moreover, the changes that come with the weight loss can be overwhelming, so patients who are screened for the surgery undergo a psychological evaluation, a “very important” aspect, Tsuda says.
“All patients undergo mandatory psycho-social evaluation,” he says. “There’s some evidence that losing a lot of weight can be a great stress on people — even if it’s a good stress — because the change can be so extreme.”
Tsuda notes that weight loss surgery is not for everyone.
“It’s for a select group of patients,” he says. “At least for us, we emphasize not just the operation, but that it’s a whole lifetime treatment plan. There are a lot of people doing surgery, but we have to be careful that it’s not a quick fix. It has to be a lifelong process.”
For those teenagers who do opt and are selected for weight loss surgery, several recent studies have shown it’s effective in helping with the health complications like diabetes, high cholesterol and high blood pressure that physicians are now seeing in younger and younger patients.
A study by Morgan Stanley Children’s Hospital and Columbia University Medical Center showed that a small group of extremely obese teenagers who underwent Lap-Band surgery lost an average of 20 pounds six months after surgery in addition to seeing improvements in abdominal fat, triglyceride measurements, or the levels of fat in the blood, and blood sugar levels, which are all risk factors for diabetes and heart disease.
“Extremely obese teenagers have obesity-related health problems, particularly diabetes and increased cardiovascular risk. Laparoscopic gastric banding, which has been shown to be a safe and effective way to lose weight, now offers the possibility of reducing obesity’s medical complications,” says the study’s lead author, Dr. Ilene Fennoy, a pediatric endocrinologist at Morgan Stanley Children’s Hospital of New York-Presbyterian and clinical professor of pediatrics at the Columbia University College of Physicians and Surgeons. “Until recently, these patients have had to rely primarily on non-surgical methods or higher-risk surgeries to lose weight, and few of these treatments have succeeded in achieving major weight loss or greatly improving their overall health.”
Another study published in the Journal of the American Medical Association found that obese teenagers who had weight loss surgery shed significantly more weight than those teens that just did diet and exercise. The 24 patients who had surgery in the study lost an average of 76.3 pounds, about 28 percent of their total body weight, compared to the diet and exercise group who lose 6.6 pound on average, or about 3 percent of their body weight.
COMPLICATIONS AND BARRIERS
In June, 18-year-old Brittany Lewis was the first patient to undergo the gastric banding procedure as part of a new bariatric surgery program for adolescents that opened in St. Louis. The program, a partnership between Washington University School of Medicine, Barnes-Jewish Hospital and St. Louis Children’s Hospital, is the first of its kind in the area.
“It is known that the obesity problem has increased not only for adults but for adolescents. Bariatric surgery is the most effective way known for weight loss,” said Washington University bariatric surgeon Esteban Varela, MD, who directs the program,. “We want to apply the same therapies and techniques that we’ve been performing for adults to the adolescent population.”
Lewis, who lives in Illinois, weighed 298 pounds before the surgery. Four months after surgery, she had already shed 60 pounds.
Losing the weight has changed Lewis’ outlook on life, Varela says. Before she was inhibited socially and afraid to go out. She had tried several weight loss programs to no avail. This was her last option, basically, he says. Since the surgery and losing the weight, “she’s happier. She’s going to college now,” Varela says.
Although Lewis’ case shows the success stories of weight loss surgery for teenagers, there is still much that is not known because it is so new, leading many physicians to say they would not recommend the surgery to obese patients who are adolescents.. In fact, a study released in May from the University of Michigan shows that half of the randomly selected pediatricians and family physicians would not recommend bariatric surgery to their patients who are under 18.
“Physicians worry whether the risks will outweigh the benefits,” says Susan Woolford, medical director of the Pediatric Comprehensive Weight Management Center at the University of Michigan. “How long adolescents will be able to sustain the weight loss and what the psychological outcomes would be in their future are questions that are still being explored. If findings are similar to those in adults, there could be significant weight loss and health benefits.”
The study showed that almost all of the physicians responding supported a monitored weight loss program as a prerequisite for surgery, although the amount of time devoted to such a program differed, with physicians saying patients needed to be on one for as little as three months to as much as five years.
Varela admits that surgery for weight loss in kids is seen as drastic, but he adds, the obesity problem among adolescents in the U.S. is a very drastic problem.
As with any other surgery, there are dangers with anesthesia and possible complications like bleeding, infection and leaks from staple lines, Varela notes, but adds that complications occur in only 1 to 2 percent of cases.
“There’s still a lot of controversy,” says Varela, “although we know it works well and is safe because we’ve gained experience with adults. But with children, it’s a more sensitive topic.”
Many insurance companies are still hesitant to cover weight loss surgery for teenagers. Varela says most companies won’t cover someone until they are at least 18 years old, but even then, it’s not a guarantee. Dannen’s insurance provider, for instance, will not cover his surgery. His grandfather is paying for the procedure out of pocket because he is concerned for his grandson’s health.
Tsuda, for one, believes there needs to be more public health initiatives to combat obesity in teenagers.
“We know this is a severe epidemic, just like people with diabetes or cancer deserve to be treated, people with obesity deserve to be treated optimally,” he says.