Obesity has only recently been labeled a medical condition. Despite its now formal classification, the medical community is still conflicted about the appropriate way to treat this tenacious disease, especially when it comes to children and teens. Bariatric surgery is now an accepted treatment for adults who meet certain set weight and health criteria. Each type of weight loss surgery has its own set of possible negative outcomes. When it comes to teens living with a severe form of obesity, is surgery the right answer?
One small 2017 study published in The Lancet found that 58 out of 74 teens ages 13 to 21 who underwent gastric bypass surgery, had reduction in body mass index (BMI), blood pressure, dyslipidemia, and type 2 diabetes rates. The teens were followed for between five to 12 years, and some did develop anemia, hyperparathyroidism, and low levels of vitamin B12. Though BMI (on average 58) did drop over 19 points (on average 41), all of the subjects still remained in the obese range. A Swedish study involving 84 teens offered similar weight and health outcomes; however, there were complications noted including bowel obstruction and gallstones.
Are the risks worth the benefits that bariatric surgery can offer to young patients diagnosed with obesity?
Rates of childhood and teen obesity have seemed to level off a bit in recent years, according to the most recent data sets, yet the number of severe or morbidly obese teens has nearly doubled between 1999 and 2014. Doctors recognize the public health crisis and realize that they need effective tools to deal with this worrisome health situation. Experts also recognize that the sooner you intercept obesity, the more likely the chance of limiting the disease and preventing lifelong battles with weight.
It seems apparent that by the time a child with obesity hits adolescence, the disease will likely become a chronic problem. Children and teens are considered too young for the medications currently available to treat obesity, as their impact on the physical and mental development in this younger subset is unknown. Lifestyle counseling is rarely successful long term, and requires dedicated commitment from teens and their parents at a time when relationships are anything but optimal. On rare occasions lifestyle intervention may work long-term when children are very young.
If you’re familiar with reality television, then you likely know Alana “Honey Boo Boo” Thompson and her “Mama June” Shannon. The child was seriously overweight and subsisting on a diet of soda, fried foods, cakes, and candy. Though her mom initially was resistant to recognizing the serious nature of her own weight issue and that of her child’s, an intervention by Travis Stork, M.D., from the show The Doctors was somewhat successful, with Honey Boo Boo losing quite a bit of weight while learning healthier lifestyle habits. In 2016, Shannon underwent bariatric surgery, committed to working out with a personal trainer, and ultimately had skin removal surgery, a tummy tuck, and other cosmetic procedures. It’s unclear how well Thompson and Shannon will fare into the future, so the question that begs to be asked is – with their family history of serious obesity, might bariatric surgery be a good choice for Thompson if she is still overweight as a teen, as well?
Currently about 1,000 teens have some type of bariatric surgery yearly. In the U.S., 3 to 4 million teens would be eligible for bariatric surgery, based on current criteria. We know that obesity significantly raises the risk of diabetes, heart disease, stroke, and certain cancers, and many teens that are severely overweight will develop knee and ankle challenges due to the excess weight they carry. From a lifetime health care cost perspective, it would seem well worth the investment in bariatric surgery, ongoing post-surgical support, and cost of the management of nutritional needs required after surgery, versus the lifetime cost that a chronic disease like obesity and its comorbid conditions and complications entail.
According to a February, 2017 story in the Health section of The New York Times, most insurers turn down the first, second, and even third request that a bariatric surgeon makes on behalf of a teen with severe obesity. With appeals, most surgeries will be approved and covered, but clearly easy acceptance is far from the standard. Medicaid coverage for teens varies state by state. The surgical options alter appetite and satiation, also affecting hormone levels that drive these two behaviors. The more common choices are sleeve gastrectomy and Roux-En-Y surgery. Some experts feel that these two five-year post-operative studies on teens still don’t supply the whole picture in terms of long-term complications, while others seem to feel that the age for surgery (in kids and teens) should be lowered in the presence of severe or morbid obesity.
Currently, Saudi Arabia is the one country where bariatric surgery is performed on children with severe obesity, according to The New York Times health story.
Experts caution that teens and parents may have unrealistic expectations from the surgery. The heaviest among these patients will likely never achieve normal weights. There is a lifelong requirement of adhering to strict dietary guidelines. On the other hand, we know that many of these kids may be primed genetically to develop obesity and they are likely to be ostracized and bullied (as kids and adults), face increasing quality of life issues, and will likely develop several additional long term health issues. Pediatricians and the public health sector need to drive more research on the efficacy of bariatric surgery in children and teens, striving to identify best practices, best timing (which may remain an individualized decision), and the best candidates for each procedure.
For now, bariatric surgery should at least be included in the tool box of treatment for teen obesity, and evaluated on a case-by-case basis.