Severe obesity for kids is reaching a crisis point. Is weight loss surgery the answer?
The nation’s leading group of pediatricians says weight loss surgery should be an option for more children with severe obesity. A Utah mother explains why she allowed four of her children to have this life-altering procedure despite uncertainty about long-term risks.
SALT LAKE CITY — When she was 8 years old, Mary was writing about diets in her journal. She did Optifast like Oprah Winfrey. She was always eating too much or eating too little, always thinking about what she was eating and what the scale said.
Only as a mom in her 40s was she able to stop obsessing about her weight, after having surgery that removed 80% of her stomach.
“Surgery, for me, has really been a blessing, physically and emotionally. I feel free from the physical and emotional burden that I felt when I weighed so much more,” the Utah mom said.
That’s why Mary was willing to consider bariatric surgery for her children when they, too, became extremely overweight. Four of her seven children have had their digestive system reordered, severely restricting what and how much they eat and drink.
The surgery is controversial and only rarely performed on minors, but that could change now that the leading group of pediatricians has issued a policy statement urging more access to metabolic and bariatric surgery for adolescents.
In a report released Sunday, the American Academy of Pediatrics said age should not be a barrier to surgery for a child with extreme obesity and that insurance companies should cover the procedure.
“Although behavioral and lifestyle interventions will be successful for certain individuals, the overall outcomes of behavioral and lifestyle interventions are discouraging when viewed as a solution for a larger number of patients with severe obesity. Youth with severe obesity require effective intervention to prevent a lifetime of illness and poor quality of life,” the AAP statement said.
Mary, who did not want to be identified because of potential problems with health insurance coverage, said that parents of extremely overweight adolescents should consider weight loss surgery if the child wants it, even though the procedure is rarely covered by insurance and can cost upwards of $10,000. She wishes she’d had the option when she was a child and believes it would have radically changed her life for the better.
“Think about how many parents are willing to shell out big bucks for braces, and that’s primarily a cosmetic thing,” Mary said. “This is someone’s health. This is their longevity.”
Goodbye, soda pop
Weight loss surgery has lifelong implications, but so does obesity.
Obesity is associated with cardiovascular disease, Type 2 diabetes, sleep apnea, fatty liver disease and gastroesophageal reflux disease, among others. It is also increasingly implicated in 12 types of cancer.
And the number of American children with severe obesity has nearly doubled since 1999. Nearly 10% of 12- to 15-year-olds have obesity, and 14% of 16- to 19-year-olds do.
Even in Utah, where childhood obesity rates are historically among the lowest in the nation, obesity is increasing, said Dr. Eric Volckmann, director of the University of Utah Health Care Bariatric Surgery Program in Salt Lake City.
While behavioral changes can provide “moderate, short-term success” for young children and those at lower weights, for children whose obesity is severe, metabolic changes make it more difficult to lose weight and to keep it off, the AAP said.
There are a variety of ways to alter the digestive system so that people don’t overeat. The most common are the gastric bypass, sleeve gastrectomy, adjustable gastric band and biliopancreatic diversion with duodenal switch, according to the American Society for Metabolic and Bariatric Surgery.
Most people will have to make changes beyond how much they eat, however. For example, carbonated beverages can cause discomfort after some types of surgery, which means soda pop is history. Alcohol potency goes up by 300% in people who have had a gastric bypass. And most people will have to take vitamins and supplements for the rest of their lives, lest they become severely malnourished.
“Anyone considering weight loss surgery needs to understand that the surgeries are just a tool and they all require patients to make dietary changes and lifestyle modifications to be successful and to maintain weight loss. None of the operations are a quick fix,” Volckmann said.
The surgery is controversial for adults and rare among children or teens. The American Society for Metabolic and Bariatric Surgery says that of 227,000 procedures performed by its member surgeons in 2017, only about 300 involved people under the age of 18.
Dr. Daniel Cottam of the Bariatric Medicine Institute in Salt Lake City said he operates on a dozen or fewer teens every year.
Bariatric surgery appears to be a “valuable tool” in treatment of obesity, Dr. Jacob M. Appel, an assistant professor and director of ethics education in psychiatry at Icahn School of Medicine at Mount Sinai in New York City, said in an email. But, he added, “It is only one tool in that arsenal. which should also include efforts at the societal level to improve the food environment for children and to address the nutritional deserts in which many low-income children are forced to live.”
Are parents to blame?
Had she not had the surgery herself, Mary said she probably would never have considered it as an option for her children, even when several of them became more than 100 pounds overweight.
“I spent so many decades of my life dieting and trying to lose weight and feeling like a failure every time the weight came back on. It has been refreshing for me to be free of that constant pressure I put on myself,” she said.
Mary said she knows that some people will judge her parenting and blame her for what she fed her children when they were young. But she notes that many nutrition scientists have come to realize that her generation, and her parents’, were given bad information about what comprises a healthy diet. And Mary said that her family is prone to gaining weight on a high-carbohydrate diet, even if the carbohydrates are nutrient-rich.
“If I could do it over, I wouldn’t have followed the food pyramid, which has so much focus on bread and rice and cereal and grain,” she said. “We are very carb-sensitive; we don’t process carbs like most people do.”
While some people still believe obesity is caused by a sedentary lifestyle and poor food choices, that hasn’t been the position of the American Medical Association since 2003, when the AMA declared obesity a disease.
“Skinny people believe obesity is caused by life choices. That’s only partly true,” Cottam said. “Most people who become really obese, especially children, they have metabolisms that predispose them to this.”
In its 2018 best-practice guidelines for pediatric surgery, the American Society for Metabolic & Bariatric Surgery said that, like cancer, obesity is a “multifactorial disease” caused by a combination of genetics, environment and metabolic programming. The group said that surgery shouldn’t be a treatment of last resort but should be “readily offered” to adolescents who are extremely obese.
In its new policy statement, the AAP said that its recommendations are for adolescents between the ages of 13 and 18 whose body mass index is 35 or greater, or a BMI that is 120% or greater of the 95th percentile for their age and sex.
Appel, the author of a new book on medical ethics, “Who Says You’re Dead?”, said all elective surgery should be approached with care, especially when children and adolescents are involved.
“At a minimum, minors should assent to the surgery and be given sufficient time to reflect upon the decision and its implications. At the same time, delay until the age of majority —while appropriate for some conditions — may not be suitable here,” he said.
“Extreme obesity has both physical and psychological implications for many youths that cannot be reversed by surgery as adults, so pushing off interventions until the age of majority is often not in the best interests of the child or teen.”
Safer than gallbladder surgery
No matter how effective, surgery of any kind comes with risk.
Death resulting from weight loss surgery is extremely rare; one study published in 2011 found 18 deaths within 30 days of bariatric surgery among 6,118 patients, despite the fact that “bariatric surgical patients are virtually by definition high risk surgical candidates.”
A study of 60,000 patients from physicians affiliated with the ASMBS had even lower one-month mortality rates: one out of 1,000 patients, or 0.13%.
“This rate is considerably less than most other operations, including gallbladder and hip replacement surgery,” the society says on its website.
But there are other risks, among them, a greater chance of developing an alcohol abuse disorder because the body develops a greater sensitivity to alcohol and some procedures result in higher levels of blood alcohol compared to people who have not had the procedure. Girls who have metabolic and bariatric surgery have a higher risk for pregnancy than their peers and may be at risk for complications during pregnancy and premature birth.
Some people report depression or sadness after having the procedure, and two studies have shown a “small but significant” increase in suicide.
The writer Roxane Gay, who had a sleeve gastrectomy in 2018, wrote about the experience, saying she was depressed and miserable.
Gay said that it is “maddening” that she can only eat tiny portions of the food that used to bring her comfort. “After a few bites of anything, the discomfort begins, and then that discomfort evolves into pain,” she wrote.
Besides the physical changes that weight loss surgery brings, it also shuts off or restricts a major source of human pleasure. That is one reason that Paige Fieldsted, a mother of two in Taylorsville, Utah, said that she has not seriously considered weight loss surgery and wouldn’t have wanted it as a teen, even though she has struggled with weight issues since she was a child.
“Food is very much for me, and for most people, a connector. Holidays center around food, and I want to be able to enjoy it,” said Fieldsted, the author of “Confessions From Your Fat Friend.”
“I understand what it’s like to be the biggest one in the room, to feel like the only way that things are going to get better for you is to get skinny. But I can also tell you from experience that that’s not true,” she said.
Mary also agreed that it’s important that parents of children with obesity focus on the positive things about their children and not just their weight. “I wish I had focused more on their worth and self-esteem, all the great things about them. You have to be sure that they know you love them for who they are, that your love is not dependent on their weight.”
Concerns about how a person will adapt to life-altering surgery is one reason that the American Academy of Pediatrics — and most surgeons — require an extensive period of preparation, especially for young patients. “A comprehensive evaluation by a behavioral health clinician is essential early in the process to document the child’s psychological well-being” and to to assure “that the child has the necessary social and emotional support to follow through with required postoperative lifestyle modifications.”
Despite the risks she and her children assumed, Mary said her family has no regrets about having had the surgery, which Mary and her husband paid for out-of-pocket. While she has not kept the surgery a secret from close family members and friends, she does not want to be publicly identified because of the possibility that her health insurance companies might not pay for any future complications that they might say were connected to the surgery, which they do not cover.
The possibility of complications is one reason that Volckmann in Salt Lake City warns people not to seek bariatric surgery for themselves or their children out of the country.
One adult from Utahdiedearlier this year after undergoing bariatric surgery in Mexico, and eight others were sickened by bacteria. But back at home, even minor complications will likely not be covered by any insurer who did not cover the initial surgery, Volckmann said. “I would not allow a relative to have any type of surgical procedure where complications from that procedure weren’t covered. The financial risks would be too high. I don’t think people understand that when they go to Mexico,” he said, adding that he knows people who have had to declare bankruptcy because of medical bills stemming from complications from surgery.
The growth of medical tourism underscores the need for insurance companies to provide coverage for weight loss surgery, as the AAP recommends, he said. While the University Hospital does not offer bariatric surgery for anyone under the age of 18, he believes that “if done in a well-developed program and done properly, it is appropriate to offer.”
“It’s probably not for all adolescents, but it’s appropriate for some.”
Volckmann said that insurance companies have resisted paying for weight loss surgery in part because there is no immediate benefit to them; a child will likely be off her parents’ policy before there is any payoff in improved health and lowered costs. “But for society as a whole, there is a great return in terms of medical problems that can develop over time,” Volckmann said.
At the Bariatric Medicine Institute, Cottam, too, expressed frustration with the lack of coverage. “Why would you cover someone’s heart attack and not cover something that would prevent someone’s heart attack?”
Mary, meanwhile, is happy with her choice to have surgery and to allow her children to do so. She notes, however, that her children were teenagers at the time of their surgery, and they made the decision without pressure from her.
That’s important for any family, she said.
“If your child doesn’t feel good about it, don’t do it. But if the child is really wanting it and is determined and responsible and can be compliant, then I think that it can be a great blessing,” she said.
Mary said that sometimes she will hear people making jokes about overweight people, and she sees it as a teachable moment. She will get out her phone and show them pictures of herself 110 pounds heavier. Despite the fact that she can’t eat much without getting uncomfortable, she’s comfortable now in ways she never was before. Never an athlete, she now hikes, runs and rappels.
“It’s not for everyone. I know people whose weight doesn’t bother them,” she said. “But if I could have had that surgery as a teenager, I would have jumped at the chance.”