17-19 Segment 1: Bariatric Surgery in Teenagers

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The proportion of severely obese teenagers continues to rise. Doctors increasingly understand that only weight loss surgery is likely to help them lose weight and avoid health consequences of obesity. But teens are often held back until they’re so heavy that even bariatric surgery isn’t enough to return them to normal weight.

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Guests:

  • Dr. Thomas Inge, Chief of Pediatric Surgery, Children’s Hospital Colorado and Professor of Surgery, University of Colorado Denver
  • Dr. Fatima Cody Stanford, obesity medicine physician, Massachusetts General Hospital and Harvard Medical School
  • Dr. Meg Zeller, Professor of Pediatrics, Cincinnati Children’s Hospital Medical Center

Links for more information:

Teenage Obesity Surgery

Reed Pence: The proportion of school age children who are overweight has finally stopped climbing in the last few years. But experts say in one major way, the problem is still getting worse. The proportion of adolescents who suffer from severe obesity, and are roughly 100 pounds or more above their ideal weight—has doubled in the last 15 years, to about 10 percent, and that’s still going up. Those teenagers—three million or more of them—face a myriad of health problems in spite of their youth.

Dr. Thomas Inge: Typically type two diabetes and many cases sleep apnea and many cases high blood pressure and even conditions that females get such as polycystic ovarian syndrome are linked to obesity and are greatly improved or remedied entirely by substantial weight loss.

Pence: However, for most of them, “substantial weight loss” won’t come easily. That’s why bariatric surgery is starting to be accepted for teenagers. However, it can be a hard sell. Dr. Thomas Inge is chief of pediatric surgery at Children’s Hospital Colorado and professor of surgery at the University of Colorado Denver.  

Inge: Most people when we’re thinking about offering surgery to a teenager are quite conservatively minded and so there’s this hope-springs-eternal type of attitude that this little girl is just going to outgrow this weight problem. She’s going to get taller and thinner with time. Or this one is going to be very responsive to the next diet fad that’s being reported in The New York Times on the bestseller list.

Dr. Fatima Cody Stanford: People still think it’s as simple as just reducing calories and increasing exercise and that will solve all of obesity. What we do know is that’s not the case. Especially for these patients that have sever obesity they often need multiple treatment modalities — behavior, medication, a combination thereof to treat their obesity.

Pence: That’s Dr. Fatima (fa-tee-ma) Cody Stanford, an obesity medicine physician at Massachusetts General Hospital and at the Harvard Medical School. She says relatively few centers do bariatric surgery on adolescents. While nearly 200,000 American adults will have weight loss surgery this year, only about a thousand teens will get the surgery. But for those who do… Inge says it works.

Inge: What we see is a weight loss pattern that is practically identical to what you would expect with adults. Many people worry that they’re going to, for instance, sabotage themselves by going back to habits that are not healthy and that just doesn’t seem to be the case. When we look at the individuals that undergo surgery as teenagers and become adults roughly eight to ten years later have maintained that weight loss just as adults would. So really the findings of the long term studies that we’ve done debunk that concern that teenagers will lose a hundred pounds and then regain it all back.

Pence: Often, younger patients also haven’t yet developed some of the chronic diseases that eventually come with extra weight, such as diabetes and high blood pressure. And Inge says those who have developed those diseases seem to respond better to surgery.

Inge: Our suspicion was that if we operated on patients that have type 2 diabetes and severe obesity as teenagers, that they would in fact have a better outcome of the surgery on their diabetes than if they were adults. That seems to be true. The studies that we’ve done that have looked at diabetes, that have looked at high blood pressure, that have looked at high cholesterol, what we see is a response of these diseases associated with obesity that is in excess of what we would have expected based on similar operations done in adults.

Pence: However, one unfortunate factor is very different between the average adult patient and the average teen patient. By the time they have surgery, adolescents are usually much heavier than the typical adult.  

Stanford: The average BMI for our patients that are adolescent age range set undergo surgery is about 54, whereas the average BMI for our adult patients that are undergo survey is about 44. So you can see that we’re waiting longer, that obesity is much more severe in our pediatric patients who undergo surgery.

Pence: Stanford says that’s where weight loss surgery shows its limits, despite its well-deserved reputation for prompting significant weight loss. Usually patients will lose 50 to 60 percent of their excess weight, depending on the procedure. So the heavier a patient is to start, the less likely they are to reach normal.

Inge: One of the risks that I’m increasingly telling people about is the risk of doing nothing. After a certain point of weight gain even with surgery we cannot reverse severe obesity. And that’s a sobering message on the one hand and it’s a call to action on the other hand. I think that as patients are gaining massive amounts of weight, and I’m talking about patients that are in the 350-400 pound and even higher ranges, we, even with the best of surgery and the most successful operations that we can do, we can’t get them back to a weight that is in a healthy range.

Pence: So it may be that weight loss surgery has to be considered sooner rather than later. But how far can we take that? Psychologist Dr. Meg Zeller is professor of pediatrics at Cincinnati Children’s Hospital Medical Center.

Dr. Meg Zeller: I agree that it suggests that teens should be referred earlier to surgery in their weight gain. I don’t think that says necessarily when they are younger than 13. The average age of an adolescent patient is roughly 17, so what we know most about our kids who are older adolescents, so I feel until we know more about the younger adolescents we should be careful about talking about younger patients.

Pence: So while Zeller says age 13 is the floor she’s comfortable with for now… many experts haven’t settled on “how young is too young?”

Inge: Across the globe we’ve seen the boundaries challenged for age and we’ve seen things that seem almost incredible to believe done in kids that are really quite young, toddlers if you will. These operations do have consequences and we don’t understand quite all the consequences yet and we’ve taken a step-wise approach to say, you know what? Teenagers who have completed the majority of their growth, who are suffering from these diseases of obesity that are certainly going to affect them in an adverse way over the next decade or two, we need to be offering modern solutions to this problem. But if I’m referred a three or four year old with severe obesity, I’m going to take a much different look at that patient than a patient who’s a teenager.

Pence: Many doctors say they prefer that a patient at least be through puberty before receiving weight loss surgery, so as to not interfere with growth and hormonal changes. Psychological screening is also extremely important. One aspect is the difficulty a teen may be having with everyday life.

Zeller: Physical spaces in our lives don’t necessarily work as easily for people who carry severe excess weight. For adults we hear things a lot about the seats on an airplane or needing seatbelt extenders. For younger people in adolescence what we hear about is their day to day challenges of things like fitting in a desk at school, the seats in a school cafeteria, not being able to fit on amusement park rides, having to walk from class to class in a school environment which may involve walking up and down stairs and sometimes having a time limit to it between bells and being able to do that quickly. So when you carry excess weight it can be physically taxing and these things are very public and they are observed by other teens. So it can make them feel conspicuously different and for some there is a lot of shame and embarrassment.

Pence: Zeller says some teens expect all those problems to be solved by weight loss surgery. But those expectations have to be dampened to be more realistic.

Zeller: We try to get that point across preoperatively, but like most adolescents they think, not me. I’m going to be different and if I only have the surgery everything’s going to be solved. So working hard for them to be realistic about what are solvable problems in this scenario and what aren’t, and that is going to be hard work. What I think, as much as we can prepare someone for that preoperatively before they have surgery, I think it’s important that they have continued follow-up with their medical team to support them as the start to realize, “maybe I am still going to struggle with depression or anxiety” or “my family is challenging and they are still challenging.” That’s why I feel it’s important the mental health providers remain available to them in their postoperative care.

Pence: The presence of the family in a teen’s life is another variable, and can be either a positive or negative influence. It’s part of the psychologist’s evaluation of a teen’s qualifications for having surgery in the first place.

Zeller: We see a lot of different views. Some families are angry that their teen got referred in the first place. Some families are struggling with severe obesity themselves, so we see a lot of obesity in parents if not severe obesity. So it’s a family disease, which isn’t always the case in other chronic medical conditions. They provide transportation to appointments, they buy the food that support the eating behavior changes; they can be saboteurs as well as supporters. So it’s a different factor that I think adult care doesn’t have to consider as much and it makes the psychological evaluation for an adolescent a trickier one.

Pence: A gastric bypass can also leave patients unable to absorb vitamins adequately, so lifelong supplementation is required. Will teens be compliant with it? Psychologists try to predict with each patient, but Inge says studies now show many teens don’t do well. But he says adults aren’t that compliant, either. So doctors have changed their strategy.

Inge: We’ve seen in fact over the past eight to ten years a about-face in the field from the standpoint of what operation is being done most commonly? So operations that truly do have a lower predictable requirement for lifelong vitamin and mineral supplementation have emerged as a dominant operation. Now I’m talking specifically about vertical sleeve gastrectomy. Whereas compared to gastric bypass. We’re not taking out of the circuit if you will the most important part of the GI tract for absorbing vitamins and minerals and that’s the duodenum, the first part of the small intestine after the stomach.  

Pence: However, even having to take supplements forever has little downside to many young patients. The success rate for teenagers getting bariatric surgery is similar to adults. And Inge says it’s often life changing.

Inge: Of all the patients I’ve treated with these variety of conditions that pediatric surgeons take care of, this is a population that is the most grateful. This is the group that has struggled with the fat bias that we talked about earlier, has struggled with the sometimes just very painful consequences. We see these patients have a different outlook on life entirely when they can shed 100, 150, 200 pounds, and we see them emerge into adulthood as people who feel like they are ready for life in a way they couldn’t imagine.

Pence: You can find out about all our guests through links on our website, radiohealthjournal.net. You can also find archives of our programs there, as well as on iTunes and Stitcher.  I’m Reed Pence.

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