Weight, Weight, Don't Tell Me
At age 15, Charlie Fabrikant opted for the knife. Gastric bypass surgery was about the only thing the suburban Chicago teen hadn't yet tried, to lose some of the 350 pounds that were literally making him sick.
"Joint pain was a killer," says Fabrikant, who loves sports but found that "every time I'd try to play, I'd really hurt." Severe heartburn plagued his days, and at night, "I'd wake up gasping for breath because of sleep apnea."
The unrelenting physical effects of the weight pressing down on his bones, stomach, and lungs was compounded by the mounting depression of always being the fat "outsider," an ache that had him returning to food for comfort. "I've been on diets since third grade," Fabrikant says, including hospital supervised diets, Weight Watchers, and diet drugs such as Meridia, the antidepressant Wellbutrin, and the epilepsy drug Topimax. "I'd lose a few pounds each time, but then I'd gain back more."
Last December's surgery, which stapled off all but an egg-sized part of his stomach that was reconnected to his small intestine, "changed my life," says Fabrikant. "I've lost 130 pounds and I've only got 40 more to go to my target weight!"
He's ecstatic that he feels satisfied after eating one of the six half-cup portions that make up his daily meals. "Before, I'd have two Big Macs and still be hungry," he recalls. He's playing sports again, and rides an exercise bike six miles a day. "My bone pain, the heartburn, and the apnea have all disappeared," he says proudly.
Rise In Surgery
Obese teens are a thriving slice of the dramatic rise in gastric bypass surgeries that soared from 16,200 in 1992 to an estimated 140,000 in 2004. Over 1,000 teens had surgeries last year, estimates Dr. Thomas Inge, director of the Comprehensive Weight Management Center at Cincinnati Children's Hospital.
The idea of a kid as young as 13 undergoing permanent stomach surgery sounds shocking to many. But surgery advocates such as Dr. Richard Atkinson, president of the American Obesity Association, defend the choice as a necessity: "Statistically speaking, obesity prevention and dieting simply hasn't worked."
American children lead the world's ranks in obesity, with 15 percent obese and another 30 percent overweight. Some 250,000 teens are at least 100 pounds overweight, a guideline often used for adult surgery criteria.
Kids as young as elementary school are developing the first stages of diabetes, heart disease, osteoarthritis, liver dysfunction and other illnesses that are typically paired with obesity. "We don't think of surgery as a weight-loss option," says Dr. Joey Skelton, director of the weight management program at the Children's Hospital of Wisconsin. "It's a last-ditch effort to address illness."
The teen surgery rise "is very appropriate," says Atkinson. "For the morbidly obese, nothing is anywhere near as effective." And when the weight stays off, patients who had diabetes or hypertension can sometimes reduce or eliminate medications.
But if many more teens head for the operating table, critics fear that they'll be subject to the same disturbing trends affecting the thousands of adults who have had surgery. The rate of complications and death from the procedure has edged up, as inexperienced surgeons flock to an industry valued at an annual $3 billion. Many patients regain some or all of their weight, and need re-operations.
And the long-term effects on kids "are a huge unknown," says Dr. Paul Ernsberger, associate professor of nutrition at Case Western Reserve University. Ernsberger and other critics worry about the eventual effects on brain, bone and muscle growth and health when a major source of nutrient absorption is bypassed during the teen years. "What will kids be experiencing 20 or 40 or 60 years from now?" Ernsberger wonders.
The Obesity Tradeoff
For now, weight-loss surgery is a hot property, pushed by several potent factors. Marketing is at a fever pitch. Consumer demand is very high, with many hospitals booked months in advance with adults and teens, and insurers inundated by coverage requests. The ranks of the American Society of Bariatric Surgeons have swelled from 168 in 1993 to 860 in 2003, and critics complain that many hang out their shingle after a single weekend training.
While successful surgery scenarios – well trained, experienced surgeons with lots of hospital backup – have low complication and death rates, other situations can produce tragic results. Houston attorney Richard Mitloff represents 28 surgery patients who got their surgeries at facilities owned by a major Texas hospital chain.
"They marketed the surgery very aggressively," Mitloff charges. "They'd pay the airfare for patients, bring them in by limo, with an elaborate last meal before the surgery." After the surgeries, four patients died, and the others experienced major infections, stomach leakages, and other complications requiring more surgeries and leaving permanent injuries.
"Surgery can be very beneficial in the right circumstances," says Mitloff. "But this is a very lucrative business with procedures getting $30,000 to $40,000 each. A number of hospitals see nothing but dollar signs."
Even though bariatric surgeries are relatively expensive, their potential to decrease disease – particularly diabetes and some heart diseases – is increasingly seen as a potential cost-cutter by health policy makers alarmed at the annual $93 billion bill for obesity-related illnesses. Surgery also scores much higher weight losses than diets or drugs, and that combo has sparked new interest among federal health regulators.
Surgery is "the most effective means" of losing and keeping off weight for the severely obese, according to a National Institutes of Health $15 million, five-year study of bariatric surgery efficacy now enrolling patients. Surgery topped the list of solutions in a September analysis of obesity treatments by the Health and Human Services' Agency for Health Care Quality.
Recent policy decisions stopped short of approving Medicaid and Medicare coverage of surgeries for weight-loss purposes only – currently the coverage has been limited to patients suffering "co-morbid" conditions such as diabetes and heart disease. Some 13 percent of surgeries are paid for by Medicaid and Medicare, says Dr. Edward Livingston, surgery chair at the University of Texas Southwestern Medical Center at Dallas.
Public policy decisions on coverage typically influence private insurer policies. But with demand continuing to spiral, more insurance companies are balking at covering roughly three-fourths of surgeries. "Surgery is a part of the obesity solution," says Susan Pisano, spokesperson for the insurance trade association America's Health Insurance Plans. "But how much is it actually working?"
There's no question that for a teen or adult with plenty of motivation, surgery can work. Fabrikant is a best-case scenario: Having seen his mother lose weight with surgery, "I saw up close exactly what kinds of diet and exercise changes I'd have to make to keep the weight off," he says. Thus far, he's content with foregoing typical teen staples such as soda and pizza – foods high in fat and sugar, that can sometimes cause "dumping" symptoms of vomiting and diarrhea in many who've received surgery.
But best-case scenarios are not the norm. Despite reassuring industry statistics that typically put the death rate at 0.5 percent, risks are significant and can show up for years afterward. One study of 3,000 surgeries found a mortality rate of 5 percent with inexperienced surgeons, and analyses by the NIH and other agencies report that some 25 percent of patients suffer serious complications such as blood clots, infections, hernias, gastrointestinal leaks and bowel obstruction.
"Bariatric surgeries can be performed with reasonably low risks," says Livingston, who has performed thousands of them. "But the data doesn't always include problems that show up later."
He's concerned about reports of a 20-30 percent rate of major complications in California patients soon to be published; an August report from a Pennsylvania health agency found that 39 percent of the nearly 7,000 surgery patients in 2003 required re-hospitalization.
Many patients are unable to stick to a radically different eating regimen and needed exercise, and all or part of the weight is regained in anywhere from 25 percent to the majority of cases, according to several studies. "Revisions" – surgeries redone because the patient stretches out the stomach pocket by falling back into old eating patterns – are common and even riskier.
Like adults, teens who lose weight through surgery do find illness symptoms diminished. But while surgery guidelines call for waiting until growth has nearly stopped – typically the age of 13 for girls and 15 for boys – malnutrition issues are routine.
"Kids are supposed to take vitamins every day, but that can't replace everything a fully functioning stomach provides," says Ernsberger. He's concerned about widespread anemia and vitamin deficiencies that cause hair loss, nerve damage, and formerly obscure conditions such as beriberi. He worries that kids will get more infections and food poisoning because surgeries cut down the bacteria-killing role of stomach acid.
As for the surgery's potential to reduce disease? "We can treat kids with medications for diseases as they may appear – or not, if health changes are made – rather than have them undergo a permanent, life-altering surgery at a young age," says Ernsberger.
And can kids maintain the lifestyle changes needed to stay healthy and maintain weight loss? "I've evaluated a lot of kids and only found one I thought was mature enough to handle something as permanent as a surgery," says Livingston. "Most kids are not emotionally ready to make life-long changes."
One study showed fewer than 15 percent of teens followed their vitamin and calcium recommendations, and other studies show poor teen adherence to eating and exercise recommendations as well.
These downsides make some question whether surgery can live up to its healthcare cost-cutting potential. "I'm not sure it reduces costs, when the cost of complications are included," says Livingston. A Swedish study showed surgery patients still incurred higher costs than equally obese counterparts after six years, with reduced costs for diabetes and heart problems but increased costs for anemia and gastrointestinal disorders.
Buffet of Drug Options
So what are the best healthcare options for obese kids? Some say every tool should be used – surgery and weight-loss pills included – just as they're used for any other disease. To do otherwise is plain discrimination against fat kids and adults who have a condition judged to be a result of "bad" behavior, charges American Obesity Association's Atkinson.
He makes a good point: Other major illnesses such as lung cancer and heart disease are often a result of poor health choices such as smoking and lousy diets and lack of exercise. "Yet if those people were denied a surgery or drug – even if it was one that had risks or didn't always 'work' – there'd be a huge outcry," he says.
Atkinson believes the future for weight loss isn't surgery, but rather drugs that target hormones governing appetite. But until they're developed, he believes in drug use, favoring America's #1 diet drug, phentermine (the still-legal half of the now-banned diet drug phen-fen) for kids and adults despite the heart risks of the amphetamine-derived drug. "Millions of kids get amphetamines every day with ADD drugs, and nobody bats an eye," he notes.
Thousands of children and teens are taking several weight-loss drugs, including Xenical, the only prescription weight-loss drug approved for 12-16 year olds, Meridia, and the diabetes drug Metformin. Makers of Accomplia, the newest weight-loss entry, hope it will reach a $6 billion yearly blockbuster drug status by blocking the same brain chemicals that give pot smokers the munchies.
In addition to side effects – increased heart rate with Meridia and embarrassing bowel problems with Xenical – teens experience the same lackluster weight losses that adults experience, of an average 5-10 pounds, typically regained after drug use stops. Obesity experts say the small weight loss is enough to lower disease markers such as insulin levels and hypertension, but the gains are lost if weight returns.
Lose It, Keep It Off
Kids can, of course, lose even large amounts of weight through healthy eating and exercise. Adults do it: one Maine elementary school teacher dropped from 763 pounds to 279 by eating better and moving more over a three-year period. And National Weight Loss Registry members – now numbering over 4,000 – lost an average 66 pounds and kept it off for five years with an improved diet and increased exercise.
Traditional weight loss is a very difficult challenge for obese kids, says Noel Gonzalez, a counselor to obese kids at Texas Children's Hospital. "Our kids can barely walk a few blocks at a very slow pace, their feet and legs hurt, and they're embarrassed to be seen outside because they get teased so much," he notes. Kids can easily feel defeated, he notes – it's hard to get excited over a few lost pounds when there's 200 more to go.
But many who work with obese children insist that significant weight loss can happen with the proper support.
"The money that would be spent on surgery could go a long way to support comprehensive weight management programs for kids and their families," says Dr. Sarah Barlow, a childhood obesity specialist and pediatrics professor at St. Louis University School of Medicine. With one such eight-month program, a third of the kids reached and maintained normal weight in a 10-year follow-up study, she notes.
Will the future include more funding and insurance coverage for this solution? "It's certainly possible," says Barlow. With more programs, even if a child did end up with surgery, "at least that child would have learned healthy patterns that would help her maintain the weight loss."
But even as such programs chip away at childhood obesity, every day more desperate obese teens face the same decision Fabrikant faced last year. It's hard to fault kids like one of Inge's patients, a 506-pound 16-year-old suffering from sleep apnea, joint pains, and headed for a heart attack. Haunted by the memory of his obese mother dying at age 26 from sleep apnea, he opted for surgery, which brought about a 220-pound weight loss and mobility changed from a laborious walk to going out for football.
For Leslie, now a second-year college student, the surgery decision was cemented at age 18. For years, she'd watched her overweight mom and aunts develop diabetes and saw her obese dad struggle with the debilitating stomach ailment, Crohn's disease.
"I didn't want to wait until I got sick," says Leslie, who dropped 137 pounds from 278. "I feel so much happier and healthier now. I would do it all again in a heartbeat."