When the American Academy of Pediatrics gave weight-loss surgery for severely obese teens an approving nod, bariatric surgeons were pleased. They had been quietly performing these procedures on those with the most need.
Long viewed as surgery for adults, bariatric surgery has not been easily accessible to severely obese teens. The AAP’s recommendations may now change that.
“It’s a huge step forward,” says Dr. Nestor de la Cruz-Munoz, medical director for bariatric surgery at the University of Miami Health System. “This is not a surgical society, but a medical society and medical societies tend to be much more conservative when it comes to recommending surgery.”
Dr. de la Cruz-Munoz first operated on a teenager 18 years ago. UHealth is one of only a handful of bariatric centers approved for pediatric patients.
The AAP’s public announcement proves that these procedures “are safe, viable and that they work,” he adds.
Published in the journal Pediatrics, the recommendations are the first-ever for surgical treatment for severely obese teens.
The report also called on insurance companies to cover such procedures — another big step because insurers tend to turn down requests by adolescent patients at a much higher rate. About 47% of young patients who meet the criteria receive insurance coverage in comparison to 85% of adults, according to the Teen-LABS study. Age was often cited as the reason for denial.
The recommendations also come at a time when childhood obesity is regarded as a serious health issue. It puts kids and adolescents at risk of many conditions, including diabetes, sleep apnea, and hypertension. Unfortunately, the prevalence trajectory rate for children has been climbing for years. According to the Centers for Disease Control and Prevention, 18.5% of children ages two to 19 years are obese. While the prevalence for younger children is lower – 13.9% among two to five-year-olds – it’s as high as 20.6% for adolescents. All told, that’s 13.7 million obese kids.
By 2050, up to 50% of U.S. children could be considered obese, according to some studies.
Childhood obesity is also more common among Hispanics (25.8%) and non-Hispanic blacks (22%). In comparison, about 14% of non-Hispanic white children were obese. These numbers mimic the rate for adults: 47% of Hispanics and almost as many non-Hispanic blacks were considered obese, followed by about 40% of non-Hispanic whites.
This statistic doesn’t surprise Dr. de la Cruz-Munoz. His Hispanic adolescent patients are usually the children of his former patients. Part of this is due to genetics, part of it to lifestyle, diet, and socioeconomics. But he warns parents who bring in their obese adolescents that there’s a high likelihood that diet and lifestyle changes will be only moderately successful and, in truth, rarely work for the severely obese.
“Children don’t grow out of it,” he says. “Obese adolescents become obese adults.”
The AAP describes severe obesity among children as an “epidemic within an epidemic” and notes that curtailing the possible remedies actually sentences kids to “a dramatically shortened life expectancy." The society did not recommend a minimum age for surgery candidates, though doctors agree that the child must be mature enough to follow the lifestyle recommendations that precede and follow surgery. Dr. de la Cruz-Munoz has performed the procedure on a child as young as 12, but most of his pediatric patients are teens.
To classify as a severely obese surgical candidate, a young person must have a body mass index (BMI) of at least 35 or 120% of the 95th percentile for age and sex. The candidate must also exhibit a clinically significant disease associated with obesity. In the case of no associated health conditions, the patient should have a BMI of at least 40 or 140% of the 95th percentile for his or her age and sex. But with adolescents, Dr. de la Cruz-Munoz looks at more than BMI.
“It’s very important to evaluate the maturity of the patient,” he says. “Do they understand the commitment and compliance that is required for the rest of their lives? Are they willing and able to do it? We also make sure that the family is ready. We want them involved in the pre-surgery counseling as well as the follow-ups.”
Family support is essential for the surgery to work.
This is because it’s usually one of the parents, or another adult, who does the grocery shopping, cooking, and ferrying to appointments.
In fact, not long ago, he had a teen patient whose weight loss was not what was expected. A little digging revealed the parents hadn’t changed the family diet.
Before surgery, every adolescent bariatric patient receives three to six months of dietary counseling targeted for that age group. “We tell them that surgery is just the beginning of the journey,” he explains.
For his adolescent patients, Dr. de la Cruz-Munoz prefers using a particular kind of weight loss surgery. This procedure, known as the vertical sleeve gastrectomy, removes about 80% of the stomach. This procedure limits the amount of food a patient can eat and also improves metabolism.
In addition to weight loss, patients also experience what he calls “incredible resolution of their co-morbidities."
“More than 90% of the patients who undergo surgery no longer suffer from type-2 diabetes, and sleep apnea and hypertension also disappear. Early intervention has the potential of eliminating the hip and joint pains overweight and obese people often suffer in adulthood.”
Dr. de la Cruz-Munoz, along with four pediatricians, recently published a study on the short and long term safety and efficacy of bariatric procedures on severely obese teens. They concluded that the psychological benefits of the surgery – while often overlooked – are just as important. Stigmas against obese teens lead to isolation and depression. A patient's mother brought her son in several years ago because he was suicidal. After the surgery and weight loss, the teen became more outgoing. He has stopped by the surgeon’s office several times and introduced his girlfriends.
“The earlier we get them, the better,” he says. “It can change their lives."
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