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Weight-loss surgery for teens?

by Gary A. Emmett, M.D.

The obesity "epidemic" is now old news, but it is scaring the heck out of medical practitioners since we know that the very heavy children we are now seeing will have chronic illnesses such as Type II diabetes, hypertension, fatty liver, gall bladder disease and chronic hip problems 20 to 30 years earlier than their parents did.

This change in disease patterns will change society.  Although all economic levels and all racial and ethnic groups are affected by trend toward being overweight, the Centers for Disease Control and Prevention reports that risk may be higher for kids from lower-income families. And University of Pennsylvania childhood obesity experts report that nearly a quarter of Mexican American adolescent boys were obese in 1999–2002, compared to 19 percent of African Americans and 15 percent of whites. And among teen-age girls, 24 percent of African Americans, 20 percent of Mexican Americans, and 13 percent of whites were obese.

The medical resources needed to treat the "metabolic syndrome (the sum of the side effects of chronic obesity)" will soar, permanent disability will occur at younger ages and even life expectancy could start going down again.

In addition, although reasonable diet and regular exercise will usually prevent unhealthy weight, the same regime is not that good for losing extra weight. The body defends its extra weight as it awaits for the next famine: The hormone ghrelin rises, giving us a big appetite, while the hormone leptin decreases and so does our metabolic rate and our ability to mobilize and lose fat, while the compound Peptide YY increases so we can never feel satisfied about eating enough.

Sometimes drastic measures are needed and I would like to report on a wonderful presentation I attended this week on Bariatric (means pertaining to overweight) Surgery for Adolescents.

Bariatric surgery is only used in adolescence for remarkably obese individuals (often 2 to 3 times the suggested healthiest weight). Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., has a model program that is keeping detailed data on the outcomes of weight-loss surgery in young people.

There are three common surgeries for weight reduction and only the two with the least side effects are done on these teenagers: Stomach banding and sleeve gastrectomy.  These two are reversible. To even be considered for the duPont program a patient must have morbid obesity (at 5 foot 4 inches, a weight of 240 pounds or more qualifies as morbid obesity, for example). The patient must have already failed at conventional weight loss, be able to understand what they are agreeing to the treatment, and be emotionally able to cope with major surgery, healing, following a careful diet – and with dropping to and maintaining a normal weight.

Why would patients and their parents resort to surgery with all its possible complications? For extremely overweight young people, surgery can reverse high risk for serious, life-threatening health conditions including:

  1. Diabetes – which also increases risk for heart disease, stroke, vision problems, kidney failure, nerve damage and even amputation.

  2. Fatty infiltration of the liver – a common "side effect" of overweight, a fatty liver boosts risk for diabetes, heart disease and more

  3. High blood pressure and high cholesterol – both of which boost risk for heart disease and stroke

  4. Verbal abuse and low self-confidence – returning to a healthier weight can increase self-esteem and help a young person enjoy social activities at school and in their community

But surgery doesn't fix everything:

  1. It does not make the patient thin. These patient lose fairly consistently about 30 to 40 percent of their excess weight – about 40 to 50 pounds in our 240-pound patient above – by exercising and eating carefully in the weeks, months and years after surgery.

  2. It does not stop gall stones and the gall bladder disease if the patient is prone to this problem

  3. Unless you are willing to work at healthy eating and regular exercise and stick with it, it does not keep the weight off entirely. The average patient who does not change their lifestyle gains back about one-third of the lost weight. A few others use it to lose more weight and get down to their recommended weight for height and build. A rare few even find ways to overeat after the surgery and gain all the lost weight back.

The average teenager in the duPont study had lost 65 pounds two years after surgery (weight loss ranged, at two years, from a high of 130 pounds lost to nearly no pounds lost in those who regained weight they'd taken off in the months after the procedure.)  There were also important health benefits. Most became more sensitive to insulin, the hormone that tells cells to absorb blood sugar. That's important because insulin resistance raises risk for type 2 diabetes.  They also had less general, body wide inflammation, another risk for diabetes. And in a test of fitness – the six-minute walk test (that I am currently doing research on this with normal-weight children) — these young people improved by 15 percent, walking 200 feet further.

Although this surgery seems to help the most obese adolescents a great deal in most cases, the important idea for society is to prevent the obesity with a healthy diet and regular exercise for every child and adult.  A good day is still when one reads for an hour and plays hard for a hour!

Gary A. Emmett, M.D., Nemours Pediatrics, Thomas Jefferson University Hospital, Jefferson Medical College, has been a primary care pediatrician in South Philadelphia and Center City since 1979.