Last month, the already grim prognosis for heavy kids took a turn for the even worse. A study of more than 100,000 women, published in the Annals of Internal Medicine, found that those who were overweight at age 18 were more likely to die prematurely in middle age. And research published in the Journal of the American Medical Association showed that people who develop type 2 diabetes—a condition associated with obesity—before the age of 20, as opposed to later, are at greater risk of end-stage kidney disease and death before the age of 55. Obesity at any age is associated with health woes like sleep apnea, fatty liver disease, atherosclerosis, loss of vision, and some types of cancer, in addition to diabetes. But when these conditions appear in the young obese, the long-term ramifications are just scary.
How about a radical solution—stomach stapling for teenagers? It may sound crazy and desperate, but several major children's hospitals, including Cincinnati Children's Hospital Medical Center, Texas Children's Hospital, and Lucile Packard Children's Hospital at Stanford, have started offering obesity surgery in recent years. Nightline recently followed a 16-year-old Texas girl who underwent stomach stapling and lost 129 pounds in six months, down from a starting weight of 368.
The worry is that such stories distract from workaday efforts to improve school lunches, promote exercise, and establish good eating habits for kids. Critics also point out that stomach stapling is expensive and can cause serious complications, like intestinal leakage, bowel obstruction, and nutritional deficiencies. But for extremely obese teens—especially those who already have a related health problem—less radical treatment options may not work, or at least not work fast enough. Surgery, by contrast, can not only lead to dramatic weight loss but also improve or reverse conditions like sleep apnea and diabetes. Only a small group of kids should be eligible for the surgery, but for these few, it can be a very good thing.
In a stomach-stapling operation (the medical term is gastric bypass), a small pouch is created in the upper portion of the stomach, and the small intestine is rerouted to connect with it. The benefit is that a downsized stomach will hold less food and may release fewer hunger-inducing hormones, causing patients to feel full more quickly and stop eating.
To be sure, obesity surgery is a risky proposition. One small study, published earlier this year in the Journal of Pediatric Surgery, found that roughly 40 percent of kids who underwent gastric bypass experienced some kind of complication, such as intestinal leakage, dumping syndrome, bowel obstruction, wound infection, or a nutritional deficiency. (A similar complication rate has been found in adults.) Nutritional deficiencies, especially of calcium, iron, vitamin B-1 and vitamin B-12, may occur partly because patients are eating less and partly because the operation bypasses a portion of the digestive tract that efficiently absorbs many vitamins and minerals.
The potential for deficiencies means that patients must adhere to strict guidelines. All patients must eat more lean, high-quality protein; exercise; and take vitamins and minerals for the rest of their lives. Teenage girls must take additional calcium and iron.
Critics argue that teens are less likely than adults to follow these rules and are too young to make a decision to undergo major elective surgery. They also argue that the surgery takes on a different social meaning when performed on young people: It seems like giving up and is hard to reconcile with the cherished notion that kids can always grow and change.
There's no sense in soft-pedaling these issues. But Thomas Inge, co-founder of the obesity surgery program at Cincinnati Children's Hospital, points out that when teens are more than 100 pounds overweight, the chances are vanishingly small that they will shed the necessary pounds on their own and keep them off. Programs that focus on changing diet and behavior may work for younger children whose eating habits and behavioral patterns are less ingrained; for teenagers, though, the results are often disappointing.
Inge has developed guidelines to identify the small group of teens he and other doctors think should be eligible for stomach stapling. (Here's a brief summary.) Preliminary data show that surgery can really help these adolescents. In one study, teens who underwent gastric bypass lost an average of 37 percent of their body mass index by the end of the first year. Other research suggests that the procedure can reverse or improve sleep apnea and type 2 diabetes.
Similar health gains have been noted in adults. But that's not necessarily a reason to delay the surgery. Inge points out that the longer a patient has had diabetes, the harder it may be to reverse the condition. The same may turn out to be true for cardiovascular disease, though the data on this are not well-established. Stomach stapling also seems to get riskier the more obese a patient is. So, an extremely heavy teen who is likely to grow into an even heavier adult might be better off opting for surgery sooner rather than later.
A procedure that's less risky than stapling, known as adjustable gastric banding, may also soon make surgery a better option. During this procedure, a flexible silicone band is placed, inside the body, around the upper part of the stomach. At follow-up office visits, the band is progressively tightened (here's how). This appears to suppress appetite (perhaps by stimulating stomach fibers associated with feeling full). Gastric banding seems to cause adults to lose weight more gradually on average than gastric bypass. But it has a lower rate of complications. And it's reversible.
In 2001, the Food and Drug Administration approved adjustable gastric banding for people over 18. Now a small number of researchers have received permission from the FDA to study it in teens. At NYU Medical Center, about 100 teens have undergone the procedure. About 5 percent have required a second operation because the band slipped out of position. But according to NYU lead surgeon Christine Ren, that's the most frequent complication. To date, there have been no deaths and no hospital readmissions for acute complications. Patients, who weighed 300 pounds on average before surgery, report a decrease in appetite. And they appear to be losing a lot of weight—an average of 95 pounds in the first year. Ren says that adolescents who undergo gastric banding seem to lose weight faster than adults do, perhaps because of differences in metabolism or because they're more, not less, diligent about following the post-surgery rules.
There's a lot we still don't know about stomach surgery and its long-term effects when performed on young people. But for kids whose obesity is likely to be life-shortening, not to mention a source of diminished self-confidence and opportunity, the benefits may well outweigh the risks. It's heartening to have a possible life raft to offer them, however bizarre it seems.