Teen bariatric surgery offered at St. Mary s

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1 Post exclusive Obesity epidemic Teen bariatric surgery offered at St. Mary s Some children, even as young as 10, can t seem to overcome the weight battle, so surgeons say it s better to treat that than the bad effects. Kelly, a patient of Dr. Marc Michalsky, had bariatric surgery when she was 17. On the left is her in August Her after picture was taken in April Michalsky of Columbus, Ohio, says St. Mary s bariatric program for teens is one of a growing trend. (Courtesy of Dr. Marc Michalsky) Dr. Robert Cywes is a pediatric surgeon who moved to St. Mary s Medical Center to open a center for severely overweight adolescents. (Lannis Waters/The Palm Beach Post)

2 A before and after photo of an obese teenager that Dr. Robert Cywes performed surgery on in Jacksonville. In the past decade Cywes has performed 700 surgeries on children and young adults ages 10 to 20. (photo courtesy of Dr. Robert Cywes) By Sonja Isger Palm Beach Post Staff Writer Chloe was just 15 years old but already the specter of diabetes, high blood pressure and other maladies loomed, as it does when you re 5-foot-9 and about 300 pounds. Weight loss camps, support group diets and delivered-to-your-door meals all failed as the toll to her psyche mounted. Every day, I d come home crying, Chloe recalled. The low point came when one day she logged into her school s Facebook account. Someone had posted a photo from one of her classes and she was in it. Panic ensued as she tried to untag her photo, wipe her identity from the screen, but she couldn t. I thought, I can t deal with this anymore, she said. This summer, Chloe came to West Palm Beach to take what some consider a drastic measure surgery.

3 It is a measure that nonetheless is becoming more common and more accepted in the medical profession as a way to battle the nation s obesity crisis. About 1,000 children ages 10 to 19 go under the knife each year to attempt to address their weight, according to a study published this year in the journal Pediatrics. These aren t little chubby kids who just need to lose 10 pounds. The medical term is morbidly obese, said Davide Carbone, CEO at St. Mary s. Chloe was the first patient to seek help at a new counseling and surgical program for adolescents at St. Mary s Medical Center. We ve seen a proliferation of bariatric surgery programs that are specially designed for the adolescent population, said Dr. Marc Michalsky, a surgeon with the Center for Healthy Weight and Nutrition at Nationwide Children s Hospital in Columbus, Ohio. Physicians reluctant Though more institutions like St. Mary s are creating bariatric surgery programs tailored to teens, the practice isn t without its critics. National surveys indicate physicians are reluctant to refer obese teens to surgery. It can raise concerns about altering a child s digestive system potentially for life, and about making sure teens get the proper nutrition to develop into adults. Some may also harbor concerns about complications, though what research has been done on adolescent bariatric surgery indicates the complications are fewer in the younger population and the outcomes better.. Many doctors direct their young patients to counseling, diet and exercise instead. Chloe had her fill of all those things and was still unable to conquer her weight. I d lose 30 pounds in a five-week camp and then I d gain it back and then some. I learned a ton about nutrition, but I had trouble finding a lifestyle change, Chloe said. She was 300 pounds when medical charts say she should ve been 118 to 162 pounds. 17% of kids obese She is not alone.

4 Across the U.S., obesity rates doubled for adults and tripled for children between 1980 and While the growth in the nation s girth seems to have paused in the past couple years, some 17 percent of children are still obese. The data shows if you re a severely obese child, there s a great possibility you re going to be an obese adult and as the child gets older, the chances get stronger, Michalsky said. And the earlier a person becomes obese, the higher the risks of becoming seriously ill or dying later in life, the authors of the Pediatrics study note. Kids with gall stones The first reports of adolescent bariatric surgery surfaced in the 1980s, before increasing three- to five fold in the early 2000s as some procedures became less invasive. Chloe s surgeon, Dr. Robert Cywes, recalls operating on children with liver disease and gall stones and thinking a better strategy would be to operate in a way to address their obesity. In 2004, the national societies for surgeons and pediatric weight loss experts publicly advocated surgery. In the past decade, Cywes has performed 700 surgeries on children and young adults ages 10 to 20. (The 10-year-old was 4-foot-9 and 370 pounds.) For some, insurance covers the $10,000 to $15,000 bill as a way to address other illnesses associated with the child s weight. Others must pay out of pocket or delay surgery until 18, when insurance is more likely to pick up the tab. Though more and more teens are undergoing bariatric surgery, there are no national guidelines as to who is an acceptable candidate. That is expected to change in 2014, Michalsky said. For now, doctors typically refer to the adult guidelines: The patient should have a body mass index (BMI) of 40 or higher, or a BMI of 35 or greater with serious obesity-related health problems such as type 2 diabetes or severe sleep apnea. (BMI is a calculation based on a person s height and weight. A healthy BMI for adults is 19 to 24. It varies by age for children.)

5 Chloe s BMI was almost 44 when she and her parents sought Cywes, who offered a reversible surgery that folded her stomach in upon itself. Since her surgery in July, she s lost 50 pounds. Counseling is required Tracking the success of these surgeries in any population is difficult. While most bariatric weight loss programs require counseling both before and after the surgery, those who succeed sometimes stop coming because they ve met their goals. Those who regain the weight in spite of surgery sometimes shun the follow-ups out of shame. In adolescents, the population is still small, the practice still young. But there is a national effort to track their progress. One nationwide study of 890 adolescents ages 11 to 19 that came out in March found patients lost an average of 66 pounds. Gastric bypass surgery had a higher average of 107 pounds, while the less invasive adjustable band yielded an average of 44 pounds lost at a year after surgery. Some of those teens are being tracked by Sarah Messiah, an associate professor of pediatrics at the University of Miami Miller School of Medicine. About 18 to 24 months after surgery, there s a plateauing in terms of weight. They may even gain a bit back, Messiah said. But so far, the health benefits they reap, such as coming off diabetes medicine, have held. Surgery is a tool. Initially what it does is give you fairly rapid success, Cywes said. It limits calories. It makes you feel full quickly. It encourages you when you drop 50 pounds in four months, Cywes notes. Dr. Nestor de la Cruz-Munoz, who heads the division of bariatric surgery at University of Miami, believes there s even more to it, noting that his bypass patients see changes in their blood chemistry and hormones well before significant weight loss. Guidelines in 2014 But success can t be surgical alone, doctors agree.

6 Some 630 bariatric surgery centers for adults are accredited by the American Society for Metabolic & Bariatric Surgery. National guidelines for adolescent centers are on the horizon as well, expected to roll out next year, Michalsky said. Like the program at St. Mary s, these centers would have not only a surgeon, but a support team that likely would include psychologists or counselors and nutritionists or weight management experts. In Cywes practice, the children are first screened to be sure they re emotionally ready to make permanent changes. They are counseled with their families and spend an average of 11 months preparing for surgery, he said. The average age of his patients is 16. Cywes reports his patients drop 16.5 BMI points in just under two years for a 250-pound person, that s about 50 pounds. Nationally, studies indicate the surgery is seized upon most often by white girls, who represent 28 percent of the overweight teen population but constitute 65 percent of the procedures. The surgeon and his staff say the key to their success lies not in the operation room but in the counseling office. I want to be sure the reason the child is there is because the child is driving the ship. In other words, the child has to want to be there to succeed, Cywes said. Then he and his staff spend equal time determining the family dynamics that can help or hinder healthy habits leading up to and then following surgery. What is the child eating? What drives the child to eat? Unlike with an adult patient, the parents do the grocery shopping and set the tone in the home, which heavily influences what happens with the child, Cywes said. We have to educate the parents, and sometimes convince the parents to change their style, Cywes said. We teach kids to value effort over success. We ve got to give them tasks they can accomplish. Kids are very black and white in terms of blowing a diet, Cywes said. If they break and have a cookie or a soda, they figure the whole diet is blown and they splurge.

7 Instead we say, Ask yourself, where did I go wrong? I had a bag of chips. Where did that bag of chips come from? Well, I went to the store and got it. So maybe you can do something else walk somewhere else. Doctor s own battles In an effort not to alienate, Cywes often uses his own history with weight loss and bad habits to illustrate his points. Years ago, Cywes himself signed up for bariatric surgery. I was close to 300 pounds, said Cywes, who was able to postpone surgery dropping 90 pounds in the months leading up to the operation. He has sworn off carbohydrates and asks his patients do the same. The issue is not the obesity. The issue is what s making these kids heavy, Cywes said. He believes that to be the carb-centric American diet and an addictive craving for more carbs it fuels. Like a nicotine addict using a patch, Cywes sees surgery as a tool to help adolescents get a step beyond their cravings. A mother was the first to convince Munoz to perform bariatric surgery on a teen her 16-yearold son. She was crying. He was on the verge of being suicidal and she begged me to see him. I just couldn t say no, Munoz said. He was starting to get high blood pressure, having knee pains. He was a different child afterwards, Munoz said. There was a time he would come in he had a different girlfriend each time. In West Palm Beach, Cywes can flip through endless texted photographs the guy who could finally fit in an airplane seat and could fly to New Orleans and a woman climbing a rock wall who said, I never thought I could do this. Common types of obesity surgeries

8 Gastric bypass. Surgically creates a smaller stomach pouch and then, most commonly, reroutes the small intestine to it. Food bypasses most of your stomach and the first section of your small intestine. That reduces the amount of food you can eat and how much is absorbed by your system. Lap band. Restricts the size of the stomach by wrapping a device such as an adjustable band around part of the stomach, limiting how much food it can hold. When the band is inflated, it compresses the stomach, acting like a belt that tightens. The band can be adjusted so that it restricts more or less food. Common types of obesity surgeries Gastric bypass. Surgically creates a smaller stomach pouch and then, most commonly, reroutes the small intestine to it. Food bypasses most of your stomach and the first section of your small intestine. That reduces the amount of food you can eat and how much is absorbed by your system. Lap band. Restricts the size of the stomach by wrapping a device such as an adjustable band around part of the stomach, limiting how much food it can hold. When the band is inflated, it compresses the stomach, acting like a belt that tightens. The band can be adjusted so that it restricts more or less food. ONE CONSEQUENCE: TEEN PREGNANCY One perhaps unexpected risk that Dr. Robert Cywes of St. Mary s and other surgeons nationally report: an increased risk in teen pregnancy. Obesity can stifle an adolescent girl s reproductive system. Shedding the pounds restores that fertility at the very time she might be feeling more socially eager and accepted, Cywes said. One recent finding showed a two-fold increase in pregnancy after surgery. Cywes reports 12 percent of our kids get pregnant within the first two years. They start doing things other kids do.