One callous question turned Brittany Caesar into a medical pioneer: “Why do you eat so much? It’s not normal.”
At that moment, she was in the Campbell middle school cafeteria, sitting down to her usual lunch: two cheeseburgers, two orders of fries and a Coke. She knew she weighed too much. Her whole family weighed too much. But her world revolved around food, and she could not imagine any other existence.
“Food was my best friend,” she said. “It was always there for me.” Somehow, her classmate’s taunt, back in 2003, wounded her in a way the usual fat jokes never had. She fled to the bathroom and wept, vowing to lose weight. Her salvation did not arrive until more than a year later when, at age 14, doctors at Texas children’s hospital performed a gastric bypass that left her stomach the size of an egg. On the day of surgery, she weighed 404 pounds.
Caesar, now 20 years old and 175 pounds, was the first teenager to undergo a gastric bypass at Texas children’s, but more quickly followed. Today, it maintains one of the busiest bariatric practices for adolescents in the country, performing one or two bypasses each month. Although the procedure is still considered experimental for children, it is fast becoming the next front in the battle against pediatric obesity.
“I honestly believe that in 5 to 10 years you’ll see as many children getting weight-loss procedures as adults,” said Dr Evan Nadler, co-director of the Obesity Institute at Children's National Medical Centre in Washington.
But many doctors say research has yet to establish whether immediate improvements from surgery justify altering a child’s digestive system, probably for life. “You don’t really know what the outcome is,” said Dr Edward Livingston, chairman of gastrointestinal and endocrine surgery at the University of Texas Southwestern Medical Centre at Dallas. “You talk about the benefit being that it prevents kids from terrible chronic disease later in life. But some of them are going to regain weight. Some of them are going to have long-term complications and we won't find out until later.”
Surgery in teenagers
No one knows exactly how many adolescents are turning to surgery to get thinner. One of the few studies, published in 2007, reported that bariatric surgery in teenagers was relatively rare but rising fast: from 2000 to 2003 (the last year examined), the number of operations tripled, to about 800. There is little reason to think the trajectory has changed. Just last month, for example, the bariatric service at Rose Medical Centre in Denver opened a programme for teenagers.
The manufacturer of the Lap-Band System — a popular alternative to gastric bypass — is seeking approval from the Food and Drug Administration for pediatric use. That would allow the device to be marketed directly to adolescents, and could make it easier for patients to get insurance reimbursement.
Like a tiny inner tube around a balloon, the Lap-Band cinches the top part of the stomach so it cannot hold as much food in one sitting. Gastric bypass also reduces stomach capacity, and detours food around the first part of the small intestine so less will be absorbed.
The most extensive scientific studies of both these methods in children have appeared in just the past four months, and few studies have followed patients for more than about two years after surgery. The data provide reason for both encouragement and caution. Children do tend to dramatically shed excess weight during the first year. But as with adults, the weight loss tends to slow over time, with the body mass index levelling off in Year 2 at a point that remains above normal.
One of the latest studies appeared last week in The Journal of the American Medical Association. Researchers in Australia followed 50 adolescents; half underwent an intensive, supervised programme for lifestyle change, and half underwent gastric banding. After two years, those teenagers who had the surgery lost considerably more weight: 21 of 25 had lost more than half their extra body weight, compared with only 3 of the 25 who did not have it.
“They end up in a place that is still abnormally high, but below the danger zone,” said Dr Thomas H Inge, director of the surgical weight loss programme at Cincinnati Children's. Obese children can suffer from a long list of problems better known in adults: insulin resistance, high blood pressure, fatty liver, a thickening of the left side of the heart, and even depression.
Body repair
So far, the studies have found that the body starts to repair itself as the weight falls. For example, two years after gastric bypass, the left side of the heart has started to return to normal in most adolescents, according to cardiologists at Cincinnati Children’s.
Surgeons still don’t agree on which of the two procedures used most — banding or bypass — is more appropriate for youths. Nadler, of Children's National Medical Centre, prefers banding, saying it is less radical and can be more easily undone if need be. In November, in The Journal of the American College of Surgeons, he described a study finding that among 41 teenagers followed for two years after gastric banding, their excess body weight had dropped by about half, on average, and other measures of their health had improved.
And no matter the method, researchers fear that as weight-loss surgery for teenagers becomes more popular, some doctors will operate on patients who should not have the surgery -- whether tempted by a potentially lucrative market or motivated by a sincere desire to help.
Nadler says such concerns are especially potent when it comes to gastric banding, which is seemingly more benign. If the FDA approves it, some doctors “might start doing it who shouldn't be doing it” because they do not provide necessary counselling, he said. “You’re going to see the adult surgeons start to do 17- and 16-year-olds, because the surgery itself is no different from adults.”
Brittany Caesar had to wait a year before the surgical team granted permission for a bypass, and Brandt estimated that her hospital has refused 9 out of every 10 requests for surgery on obese adolescents because of doubts about their ability to follow through. “If you don't follow the rules afterward, you can die,” she said.
And Brandt worries that even if her team refuses, others will give in, especially as more parents start demanding the surgery for their children. Just last month, one mother called her office wanting a gastric band for her 8-year-old daughter. Such requests make Brandt uneasy about the future. Some days, she says, she is appalled to be doing bariatrics at all, seeing so many children raised on foods that are calorie-rich and nutrition-poor. “But these kids are dying,” she said. “We've created something in our society we have to undo.”