From Our 2013 Archives
Weight Loss Surgery for Severely Obese Teens
By Rita Rubin
Reviewed by Hansa D. Bhargava, MD
Dec. 10, 2013 (Washington, D.C.) -- Fifteen-year-old Jacob Miller's body mass index, or BMI, was off the charts.
More than 6 feet tall, Jacob weighed 702 pounds at his heaviest. An online BMI chart from the National Heart, Lung, and Blood Institute goes up to 443 pounds, which, for a 6-foot-4 individual, means a BMI of 54.
Anything over 40 is "extreme obesity," according to the chart. Doctors said Jacob's was 83.
But 6 months after getting weight loss surgery, Jacob's weight has dropped to 535 and his BMI to 64. Those changes have led to improvements in his health, his surgeon, Thomas Inge, MD, PhD, told an audience Friday at a meeting of the American Society for Nutrition. Inge is surgical director for the Surgical Weight Loss Program for Teens at Cincinnati Children's Hospital.
"How do we tackle pediatric obesity?" he asked. "We don't have a great deal of success."
Weight Loss Surgery Pros and Cons
For obese teens, especially the severely obese, simply trying to eat less and exercise more doesn't seem to work, Inge says. He cites a 2012 Swedish study of 14- to 16-year-olds in which researchers found that after 3 years, lifestyle changes led to a meaningful BMI drop in only 2% of participants.
Meridia had been the most effective weight loss drug, Inge said, but manufacturer Abbott Laboratories took it off the market in 2010 after research raised concerns about risks of heart attack and stroke.
Inge says weight loss surgery "is costly and does have treatment risks," but studies in adults have found that it has long-term health benefits. While the number of severely obese children and teens has grown for the last decade, the number undergoing weight loss surgery each year has remained stable at about 1,000.
In 2004, his team published the first recommendations about weight loss surgery in teens. They advised that surgery be considered for adolescents with a BMI of 35 or greater who had serious obesity-related conditions, such as type 2 diabetes or obstructive sleep apnea. Among obese teens with less-serious conditions, such as insulin resistance and mild apnea, Inge's team recommended considering surgery for those whose BMI is over 40.
Jacob, who allowed Inge to discuss his case and show before-and-after photos, had a variety of ailments related to his weight, including type 2 diabetes, depression, stage 2 chronic kidney disease, sleep apnea, high blood pressure, chronic fluid buildup in his legs, high cholesterol, and a weakened heart, Inge says. The fluid buildup and diabetes raised his risk of cellulitis, a bacterial infection of the skin, and he required multiple hospital stays for treatment.
Jacob chose gastric bypass surgery, which has the longest track record -- more than 30 years -- of the three main weight loss operations. The surgeon creates a small pouch in the stomach, disconnects it from the first section of the small intestine, and reconnects it lower down. With Jacob, as with most gastric bypass patients, the operation was done with tools passed through tiny incisions in the abdomen.
A popular alternative is called laparoscopic "sleeve gastrectomy," Inge says. Surgeons remove 80% of the stomach. What's left is shaped like a sleeve or tube.
A third weight loss operation is gastric banding. An implantable band that can be loosened or tightened closes off part of the stomach. It is approved only for people 18 and older.
Six months out from his surgery, Jacob no longer has diabetes or high cholesterol, but he'll probably never have a normal BMI, Inge says. He thinks there might be an undetected medical problem that caused Jacob's weight to balloon.
Risks and Benefits of Surgery
Teens like Jacob and their families might take heart from a study Inge and his team published last month in JAMA Pediatrics. The study covers problems within the first 30 days after weight loss surgery in 242 adolescents, whose average age was about 17 and average BMI 50.5.
While 19 people, or 8%, had major complications, including the need to reoperate, minor complications (such as readmission to the hospital for dehydration) were seen in 36 of the adolescents, or 15%. There were no deaths during the study period.
Inge and his team are continuing to follow this group to study the long-term risks and benefits of weight loss surgery.
In an accompanying editorial, Michael Sarr, MD, a surgeon at the Mayo Clinic in Rochester, Minn., noted that weight loss surgery can improve teens' physical and mental health, which is especially important during adolescence. "Those of us who treat these patients, both as adolescents and adults, appreciate the problem of social isolation (the important elephant in the room not often acknowledged)," Sarr writes.
To support Sarr's point, the "after" photo Inge showed the audience at the nutrition meeting featured Jacob with his homecoming date.
SOURCES: Thomas Inge, MD, surgical director, Surgical Weight Loss Program for Teens; director, Center for Bariatric Research and Innovation, Cincinnati Children's Hospital. Michael Sarr MD, Mayo Clinic, Rochester, Minn.
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