Surgery provides hope for obese youngsters

Julia has been obese her entire life. She was fat when she was a baby, and as a young girl she gained 50 pounds in some years, despite repeated attempts to lose weight through diets, diet pills and diet camps. She is now 5-foot-5 and more than 100 pounds overweight.

Julia has been obese her entire life. She was fat when she was a baby, and as a young girl she gained 50 pounds in some years, despite repeated attempts to lose weight through diets, diet pills and diet camps. She is now 5-foot-5 and more than 100 pounds overweight.And she’s about to start the eighth grade.advertisement advertisement Three months ago, just before her 13th birthday, Julia, whose last name was withheld at her request, became one of a growing number of extremely obese youngsters to undergo gastric banding surgery in a desperate last-ditch effort to lose weight and improve, and possibly extend, their lives.A new NYU Medical Center program is offering the procedure, a reversible and less invasive operation than gastric bypass surgery, to teens as young as 12 whose obesity places their health in jeopardy.Eight adolescents are scheduled to have the operation next month, when Dr. George Fielding, an Australian pioneer in the field, joins the NYU practice, one of the first in the country with a gastric banding program tailored for teens. The program has opened an office in Hewlett.The procedure is viewed with skepticism by some physicians. But its proponents say the hour-long laparoscopic procedure is much safer than gastric bypass surgery, does not affect absorption of nutrients and is reversible — and the teenagers need relief.”It sounds drastic, but when you see a kid come in who’s 5-foot-6and weighs 350 pounds, you already forget the age,” said Dr. Christine Ren, assistant professor at NYU Medical Center and a leader in the field of such surgery.”These are big kids,” she said. “We’re not talking about ‘chubby.'”To qualify for the surgery, the adolescents must have a Body Mass Index — a measure of body fat based on height and weight — of at least 40, unless they have obesity-related illnesses, in which case they qualify with a BMI of 35, Ren said. A BMI of 35 reflects a weight of 210 pounds for someone who is 5-foot-5; at the same height, a weight of 240 pounds would yield a BMI of 40.The youngsters also must undergo a psychological evaluation and demonstrate they have tried — and failed — other weight loss programs.The operation involves placing a saline-filled Lap-Band around the upper part of the stomach to create a smaller stomach pouch, reducing the stomach from the size of a football to that of a golfball. The smaller stomach can hold a much smaller amount of food, and more quickly results in a feeling of fullness. There is no cutting of the stomach or intestines.The band can be adjusted by injections of saline into a port implanted underneath the skin. It also can be removed if necessary.The device was approved by the U.S. Food and Drug Administration in 2001for use in adults. It was not tested in patients under 18, an FDA spokeswoman said, and its use in teens is termed “off-label” — a practice in which medicines or procedures are used in situations other than those specified in the approval.For Julia, it was, well, a no-brainer.”There is nothing in the world I’ve ever wanted more than to be thin,” she said in a telephone interview. “I’ve had fantasies of being skinny my whole life. … My life was ruined from Day One because of my weight.”In addition to the humiliation of gym class, which she worries about all week, Julia said she is the butt of constant jokes. “No one wants to be friends with the heavyweight kid,” she said.Julia’s father said the decision to offer his daughter surgery was not taken lightly and was made in consideration for her health — she had been diagnosed as being at risk for developing diabetes — as well as concern for her happiness. “This is not a casual thing — this is a last resort kind of thing,” he said.Julia’s weight is such an emotionally charged issue that she would not reveal her current weight. The surgery is only offered if someone needs to lose more than 100 pounds to reach the maximum acceptable weight established by BMI tables; in Julia’s case, that weight would be 149 pounds.So far, Julia has lost 17 pounds; She expects to lose about 50 pounds this year and hopes to continue that pace for two more years.Though weight loss surgery for adults has become increasingly popular, it is still in the pioneering stages for adolescents. Some 140,000 weight-loss procedures will be done this year in the United States, up from 47,200 in 2001 and 103,200 last year, according to the American Society for Bariatric Surgeons. The vast majority are gastric bypass procedures, and only about 10 percent are what’s commonly known as gastric banding.And with obesity among teens on the rise, more adolescents and their parents are demanding a surgical solution as well. Ren says her practice gets half a dozen inquiries a week from teens. Fifteen percent of American children aged 12-19 are either overweight or obese, according to the 1999-2000 National Health and Nutrition Examination Survey, up from 11 percent a decade earlier and 5 percent in the late 1970s.”Doctors looking after these kids can’t fix them,” said Dr. Fielding, who has operated on more than 50 adolescents and was obese himself until he underwent the banding operation a few years ago. “A fat teenager’s life just cannot get worse.”Kids grab on to this with both hands — they know someone’s giving them a shot at being a normal teenager.”He said morbidly obese teens are not only at high risk of developing serious health problems — some already have been diagnosed with conditions typically not seen until middle age. “They have all the diseases their grandparents have got: diabetes and sleep apnea and high blood pressure and high cholesterol,” Fielding said. The conditions often improve after surgery, even with a relatively small loss of weight, he said.But skeptics say such surgery is not a cure-all. And they point to the downside: Though gastric banding has a significantly lower mortality rate than gastric bypass — one death in 2,000 procedures compared to one in 200 for bypass — deaths and complications do occur. Last month, a woman died after undergoing gastric banding surgery at Nassau University Medical Center.Worldwide, some 100,000 people worldwide have been treated with the band since the early 1990s, and studies have shown average long-term losses of 56 percent of excess weight after five years, as well as improvement in health. But there is no guarantee the surgery will be effective if it isn’t accompanied by changes in behavior, warns Dr. Michael Fleming, president of the American Academy of Family Physicians. “I can think of a number of my patients who’ve had surgery, mostly gastric bypass, and then gained all of the weight back,” Dr. Fleming said. “They never changed their activity level or what they ate, and now I’m treating them for the same problems they had before the surgery.”Surgeons say the decade-long experience with the gastric banding surgery outside the United States has provided reassurance: Patients have not suffered from malabsorption of nutrients, which is common after gastric bypass surgery. In addition, studies indicate a band in place before a woman becomes pregant hasn’t been shown to cause harm to the mother or fetus.Some patients fail to adapt to the band or experience complications, Fielding said, and 3 percent to 4 percent have it removed.But there are no long-term studies that have followed adolescents with gastric banding, noted Dr. Don Shifrin, a member of the American Academy of Pediatrics’ task force on obesity.”Drastic problems call for drastic solutions,” he said. But he added, “The jury is still out on whether it’s curative.”The surgery program at NYU operates in conjunction with the NYU Child Study Center’s Shape Down Program, a comprehensive weight loss program, Ren said. It adheres to the weight guidelines for adults undergoing bariatric surgery, she said.Some physicians have advocated more conservative criteria for adolescents, however, saying that teens without disease should only be operated on if they have a BMI of 50. For someone who is 5-foot-5, that would mean a weight of at least 300 pounds.Such recommendations were made in a paper published in the journal Pediatrics this month, and similar criteria were outlined by the International Pediatric Endosurgery Group. The authors of the Pediatrics paper, a group of more than half a dozen physicians from university medical centers, said youngsters should only be considered for surgery once they have attained skeletal maturity, which girls generally reach at age 13 or older and boys at 15 or older.Adoption of adult guidelines in a younger population “would overlook the unique metabolic, developmental and psychologic needs of adolescents and could result in inappropriate use and/or overuse of weight loss surgery for adolescents,” the authors of the paper concluded.But, Ren argued, the more stringent recommendations make no distinction between gastric banding and gastric bypass.Dr. Thomas Inge, a surgeon at Cincinnati Children’s Hospital Medical Center who helped draft both sets of guidelines, said that in experienced hands, banding is relatively safe, with fewer adverse effects and complications than gastric bypass surgery, a surgical reconstruction that bypasses the lower part of the stomach and top section of small intestineBut, he said, patients may not be able to shed as much weight as they might with bypass. “The biggest concern I have with the band is that it may not be as effective, long term, for the patient who weighs 350 pounds,” he said. “It might not be strong enough medicine.”Weight loss is more gradual with gastric banding than with bypass, and is much more dependent on patient motivation, Dr. Ren said. The band is placed loosely around the stomach during the operation; the patient returns to the doctor’s office a month later for the band to be tightened with a saline injection.At NYU, patients return for frequent visits so they can be weighed in and evaluated, and have the band tightened if needed. People have to dramatically change their way of eating with a Lap-Band, avoiding foods like steak and cold chicken white meat, the doctors said. Patients can trick the band — and consume more than they should — by drinking high-calorie milkshakes, which can slip through the band just as liquid might slip through the barrier of a twist-tie on a plastic garbage bag.Since gastric banding is fairly new, the lifelong effects cannot be known. But, Fielding and Ren said, waiting decades to find out won’t benefit today’s teens — who are crying out for help.(Source: Associated Press, July 2004)