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Should surgery be an option for obese adolescents?
Expert opinions differ about permanent procedure for weight loss
With a significant percentage of the U.S. population deemed overweight, surgical treatments for obesity have become much more widespread.
The most common, and most successful, is a surgical procedure known as the gastric bypass. Developed in the late 1960s, the operation involves surgically isolating a small pouch at the top of the stomach and reattaching the small intestine to this pouch in order to bypass the lower stomach.
According to the American Society of Bariatric Surgery (ASBS), more than 100,000 procedures will be performed this year.
Long used as a last resort in adults for whom other weight-loss options have failed and who have significant weight-related health problems, the procedure is becoming more common in people younger than 18.
"This is a controversial hot topic in medicine and in society," notes Atul K. Madan, MD, a bariatric surgeon with the University of Tennessee Medical Group in Memphis. "There are no established guidelines for pediatric patients, those below the age of 18, although some are currently being developed."
Although the surgery poses significant risks for patients, including death, serious nutritional deficiencies, and tissue damage, severely obese patients — including adolescents — often have life-threatening medical conditions that may outweigh such risks, he says.
With the number of overweight children and teens increasing at an alarming rate, these procedures will continue to be a needed option for some young patients, Madan says.
"We see 18-year-olds who are diabetic, who have congestive heart failure, illnesses that you would expect to see in patients who are 30-40 years older," he says. "These are problems that cannot be ignored. The best treatment for morbid obesity is prevention, but that is very difficult in our society right now."
Bariatric surgery — surgical techniques to treat obesity — evolved after surgeons noticed that certain gastrointestinal procedures used to treat cancer or severe ulcers resulted in significant long-term weight loss in patients who underwent them.
These initial procedures involved removal of large portions of the stomach or small intestine.
The first procedure widely used for severe obesity was the intestinal bypass, first used 40 years ago, which produced weight loss by preventing the body from absorbing too many calories. However, this procedure caused many patients to suffer loss of essential nutrients. Side effects were often unpredictable and sometimes fatal. The original procedure is no longer performed.
The modern version, gastric bypass, also is a "malabsorption" procedure, which works primarily by reducing the amount of food a person can hold in the stomach and by preventing the absorption of most of the calories in the food.
The surgery is recommended only for patients who have at least one of the following:
Most surgeons also say the procedure should only be considered in patients (adults and adolescents) who have tried other weight-loss options unsuccessfully.
"The patient should have failed to lose weight following more conservative measures such as structured diet, increased physical activity, and behavior changes," says Michele Bachhuber, MD, internal medicine specialist with the Marshfield (WI) Clinic. "They also need to be fully informed about the side effects of this procedure."
Once the surgery, a permanent procedure, is performed, the patient’s stomach can hold only approximately four ounces of food at one time. Eating more than this amount can result in nausea, a blockage, or extreme gastrointestinal distress. Normally, a person can consume only three-quarters to one cup of food at a time without discomfort. And heavy, hard-to-digest foods cannot be consumed at all.
Vomiting also is a common side effect because the smaller stomach can be stressed by food particles that are not chewed well.
There also is a significant risk of nutritional deficiency with this procedure because it bypasses the duodenum and jejunum, where the body absorbs the most calcium and iron. Menstruating women may develop anemia because not enough vitamin B12 and iron are absorbed. Decreased absorption of calcium also may bring on osteoporosis and metabolic bone disease. To have successful results, patients must comply with a strict diet, exercise, and vitamin regimen.
"This procedure is not a magic pill," Madan notes. "It does not — as many people think — automatically make you lose weight."
The procedure gives patients physiological feedback that makes them feel full after consuming about four ounces of food, but the surgery itself will not resolve the complex emotional and social reasons why people overeat.
"Patients can still not lose the weight if they don’t adhere to the dietary restrictions," Madan continues. "And they can cheat. You can’t sit down and eat a 12-ounce steak, because your body physically can’t take that. But some patients can still tolerate forbidden foods and they can cheat."
The procedure still has an overall failure rate approaching 20% — sometimes due to technical issues with the surgery, but often due to patient noncompliance.
Appropriate for teens?
Because the surgery carries high risks and is permanently life-altering, some physicians feel its use in minors should be restricted.
"Gastric bypass is more accepted for adult patients than adolescents," says Bachhuber. "There are still some questions regarding long-term side effects, and it is more controversial for the adolescent population. The procedure is considered an accepted treatment for adults, but only for a select group of adults."
She would be hesitant to recommend the procedure for adolescents because they may not have reached their adult height, and nutritional deficiencies could be much more problematic in individuals who are still growing.
"With adolescents, there are also more variables — you have a parent or school personnel responsible for preparing food, and they are dependent on others for so many things," she says. "There are many more people that need to be involved in coordinating care to make the surgery successful, and a younger person’s ability to understand all issues surrounding the surgery and lifestyle changes after surgery could be problematic."
However, Madan contends it is more important to carefully select patients and consider many individual factors besides the patient’s age.
"A lot of the concerns we think of in adolescent patients can also be true of adult patients," he notes. "The real fact is that you can get a 35-year-old patient or a 15-year-old patient and, if you don’t choose them carefully, they won’t do well. You have to be very strict and have a low threshold for holding off on doing the operation if you don’t think they are psychologically ready."
A specific concern in pediatric patients, however, is that they may not want the procedure.
"You need to carefully watch the interaction between the patient and family," he notes. "If it seems like the family is pushing it on [the patient] — and that is why you should do a psychological evaluation of both the patient and the family — you should not do it. Although the parents are the ones to give legal consent, I absolutely think you must get the consent of the patient as well, even if they are not the ones to legally consent. They must be told of the potential risks and benefits and take the responsibility of the surgery."
Not all patients who are good candidates for the procedure should have the surgery, Madan says. "I have had other physicians see patients that I have operated on, and they see that they have lost their diabetes, lost the sleep apnea, or they’re only on half the hypertension medication they were on before, and they say, This is great,’" he relates. "Then, they send over all of their obese patients. You talk to the patients and find out they don’t even want the surgery. It’s something that physicians and hospitals considering this must understand — not every obese patient is a candidate or even desires the procedure."
Research examines results
Researchers are beginning to study the impact that gastric bypass procedures have on pediatric patients.
A study performed at Alvarado Hospital Medical Center in San Diego tracked 37 teens ages 14-18 who underwent laparoscopic bypass surgery.1 Investigator Alan Wittgrove, MD, the medical director of the center’s bariatric program, found they lost an average of 82 pounds of excess body weight within a year of surgery, with no poor outcomes.
He recommended the procedure be performed only in adolescents who have reached their full height and sexual maturity, are extremely overweight, and have a family environment that is supportive of the new dietary restrictions and weight loss.
Madan also recommends a full psychological evaluation of the patient and the patient’s immediate family.
"Eating habits are, a lot of times, determined by where you live," he says. "If someone is under 18, they don’t buy the food. So, you have to feel assured that they will be able to support the person’s new lifestyle."
He also makes all patients take a true-false quiz before they can be considered for the procedure. The quiz covers information about the potential side effects and risks of the surgery and is designed to help ensure patients understand what they are agreeing to do.
"They take it once, and if they get any answers wrong, we talk about it, and then they can take the test again," he says. "If they can’t get the answers right the second time, they are definitely not appropriate candidates for surgery."
The patient takes the test alone in a room, so it better evaluates his or her level of knowledge, he adds. "They aren’t sitting in front of you, trying to tell you what you want to hear."
Bariatric programs also should have a multifaceted support and counseling program in place to help patients adopt a healthy lifestyle post-surgery, Bachhuber says.
"Social support is very important for the patient to have no matter what measures they use to lose weight," she says.
Both Bachhuber and Madan say the surgical procedures are an example of extreme measures needed to cope with society’s problem with obesity.
According to statistics published by the Centers for Disease Control and Prevention, approximately 61% of the population is overweight or obese, defined as having a BMI of 25 or more.
Among U.S. adults ages 20-74 years, the prevalence of overweight persons has increased an estimated 2% since 1980, increasing from 33% of the population to 35% in 1999. In the same population, obesity has nearly doubled from approximately 15% of the population in 1980 to an estimated 27% by 1999.
Of particular concern, however, are the rates of obese and overweight children.
According to the same study, the percentage of children and adolescents who are defined as overweight has more than doubled since the 1970s. Approximately 15% of U.S. children and adolescents are now overweight.
Halting and reversing the obesity epidemic will require a comprehensive effort by all segments of society, says Madan.
"The medical community can only do so much," he notes. "The best way to address obesity is certainly not this. The best solution would be prevention. But there comes a point for some individuals where it is almost impossible to reverse the weight gain. If someone is 100-200 pounds overweight — and these are the patients we are talking about — it is very difficult for them to exercise, and the motivation is not there because they won’t see significant results if they can’t alter their eating habits."
Society needs to focus efforts on prevention and make it easier for people to adopt healthy lifestyles, Bachhuber adds.
"As health care providers, we need to increase awareness of rising rates of obesity and the importance of lifestyle changes," she says. "We as individuals need to take the lead in making these lifestyle changes so that our society can reduce the rates of obesity."
1. Hellmich N. Obese teenagers seen as candidates for gastric bypass. USA Today, July 6, 2003.
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