Pat Hartman | Childhood Obesity News

Who Is Ready for Bariatric Surgery?

Pat Hartman December 5, 2019 1 Comment

The illustration on this page is derived from the schedule of the World Obesity Federation Regional Conference, where Dr. Pretlow is on today’s program. As for his past public appearances, they may be explored from this link to a “roundup” page. Readers may also consult the right-hand side of the Childhood Obesity News home page for a collection of presentations viewable via Adobe Flash Player.

This series of posts looks back over the development of thought about weight-loss surgery for children and adolescents. Perhaps because about 70% of its people are obese, Saudi Arabia is becoming one of the world centers of bariatric surgery, and in fact holds one of the four esteemed registries of adolescent bariatric surgery.

There, obesity affects many more women than men, and it causes an estimated 20,000 deaths per year. By coincidence, around 20,000 weight-loss surgeries are performed every year. The country’s 2018 move was to add weight-loss surgery to the options available under its citizens’ standard insurance policy. A staff writer for Alarabiya.net explains,

Although insurance companies will have to bear a large cost to carry out the new insurance policy decision, they will save on having to cover other treatments that accompany obesity like diabetes, stress and many other diseases.

An uncredited writer for NDTV.com enumerates the steps for evaluating the suitability of any patient for interventions of this kind. First, they need to be aware of the risks and possible side effects, which are not trivial. The big question is, will the benefits outweigh the risks? The screening process is extensive, involving a whole team of professionals including surgeon, psychologist, and dietician.

First, the prospective patient’s entire history is reviewed. What weight-loss measures have been tried? What kind of nutritional standards has this person been following? What kind of stress situation is this person in the midst of? How motivated is this individual? Motivated enough to accept and stay within the limits of a very, very different kind of life?

Next, as this author states, and it is impossible to emphasize these concepts too much, “Obesity is also a result of an underlying mental health condition… Substance abuse, binge-eating disorder, major depression, schizophrenia and severe bipolar disorder may be responsible.”

More steps to patient eligibility evaluation

A very complete medical exam has to be completed. Important factors are the patient’s medications as well as general condition and existing co-morbidities. Nobody wants to make things worse with possible complications like nutritional deficiencies, kidney stones, liver disease, heart malfunction, and blood clots.

The age of eligibility depends on several factors including an individual surgeon’s standards. One doctor may decline a case that leads to operating on a 2-year-old, but another will be found. Even after taking a case, the doctor is alert to the possibility that surgery will have to be delayed or cancelled.

A patient is supposed to be losing weight by traditional means, during this evaluation period, and one who gains instead may very well be refused the surgical remedy. But, again, if the patient has the means to pay, another clinic can always be found.

Your responses and feedback are welcome!

Source: “Why is Saudi Arabia designating $133 million to cover weight loss surgeries?,” Alarabiya.net, 02/04/18
Source: “Thinking Of Getting A Bariatric Surgery? Read This First!,” NDTV.com, 10/18/18
Image by World Obesity Federation Regional Conference

Weight-Loss Surgery and Non-Adults

Pat Hartman December 4, 2019 1 Comment

Before looking at some topics connected with bariatric surgery for minors, the illustration on this page announces tomorrow’s event in Oman, a lovely city located on the Persian Gulf. Dr. Pretlow will be speaking about exciting new ideas, and participating in a panel, at the World Obesity Federation Regional Conference.

This is an opportune time to note that Dr. Pretlow’s many public appearances over the years are conveniently organized and described on another Childhood Obesity News page.

Five years ago, it was apparent to the medical world that bariatric surgery could produce impressive outcomes. Patients’ cardiovascular situations improved, especially in the reduction of strokes and myocardial infarctions. With surgery, plus intensive medical therapy, patients with uncontrolled type 2 diabetes achieved much better glycemic control than those with just the intensive medical therapy.

Weight loss is considered in different ways. Statistics showed that patients with gastric bypass surgery lost a larger percentage of their baseline weight than did those with sleeve-gastrectomy. Concerning the Roux-en-Y (RYGB) gastric bypass, a 16-year post-op followup study showed that “patients mean weight loss was 55% of excess body weight,” which is different from measuring relative to baseline weight.

Many patients previously afflicted by such conditions as type 2 diabetes, hypertension, asthma, stress incontinence, and sleep apnea found relief. Morgan Downey of the Downey Obesity Report wrote,

How bariatric surgery resolves type 2 diabetes in over 80% of patients still remains to be determined. It has been observed that bariatric surgery blunts adaptive thermogenesis which takes place with other weight loss interventions, resulting in greater, more durable weight loss. Changes in gut hormones may also play a key role… Researchers believe that it is bile acids in the blood, not the reduction in size of the stomach that produce the weight loss effects.

An interesting thing about RYGB surgery is that the patient experiences changes in taste, smell, and appetite. An amazing three-quarters of the post-op patients “developed aversions to specific foods with meat, sweets, dairy and junk/fried foods leading the aversion list.” At the same time, there was great anticipation for the development of drugs that could accomplish the same results as bariatric surgery, without the surgery.

A 2018 study of “Teen Longitudinal Assessment of Bariatric Surgery” (also known as “Teen-LABS”) looked at data from 242 subjects. 161 of them had the Roux-en-Y procedure. Sixty-seven had vertical sleeve gastrectomy, and 14 had undergone adjustable gastric banding. Three years after surgery, only 5% still had three or more risk factors.

By that time, in the United States, children as young as seven had experienced weight-loss surgery. The Kids’ Inpatient Database held records on 78,649 obese children, of whom 1,600 or about 2% have had bariatric surgery. According to the database, the average age was slightly more than 18 years, but there were also participants as young as seven years old. In any age group, it became more and more obvious that adequate after-care is crucial.

Your responses and feedback are welcome!

Source: “Keeping Up with Bariatric Surgery,” DowneyObesityReport.com, 05/12/14
Source: “Should Children Have Weight Loss Surgery?,” Healthline.com, 01/09/18
Image by World Obesity Federation Regional Conference

Bariatric Surgery for Children — A Desperate Case

Pat Hartman December 3, 2019 No Comments

First, a disclaimer. The photo on this page has nothing to do with the subject of the post. It is the interior of a building in Muscat, Oman, and reminds us that in only a couple of days, on December 5, Dr. Pretlow will be in that city, speaking and participating as a panelist at the World Obesity Federation 2019 Regional Conference.

Now, on to the story of Zoya Khan of Mumbai, India. At birth, in December of 2010, the baby girl weighed around 6.5 pounds, which is within normal range. Only two days later, her weight was closer to 15 pounds, or far too much for anyone’s peace of mind, all because of a single rogue gene. DNAIndia.com reported,

She was found to be suffering from morbid obesity caused by a genetic disorder passed on to her by her parents […] who are first cousins.

The couple had already lost a child to this same affliction, a boy who weighed close to 50 pounds at age two, and died from obesity-related respiratory issues. When Zoya was almost a year old, and weighed around 40 pounds, she became the youngest patient ever to undergo bariatric surgery. A medical team performed a sleeve gastrectomy, removing about 85% of her stomach, resulting in “the virtual elimination of ghrelin hormones, which stimulate hunger.” But it didn’t work.

By age seven, the child weighed in at around 87 pounds, having made medical history by not benefitting from this operation. She still needed a meal every half hour, and the remnant of her stomach had stretched to a one-liter (one-quart) capacity. She was able to stand only with support, and usually stuck to crawling. One of her doctors said,

She hasn’t been walking for over two years and her parents carry her to the toilet.

A week before her eights birthday, the surgical procedure was repeated, this time by a different team. Agreement about the wisdom of the decision was not universal. Dr. Sanjay Borude, who had performed the first surgery, told the press that he would have waited until Zoya reached puberty to operate again.

But Dr. Mohit Bhandari, who did the honors the second time around, was of a different opinion. Zoya told him that she wanted to go to school, and he wanted to make that possible. He wrote,

Last month, she underwent a revision surgery which involved further reducing the size of the stomach and putting a non-adjustable silicon ring around it so that it does not expand.

After the second surgery, Zoya lost nearly 17 pounds in only 20 days. Her mother said that for the first time, the little girl was able to walk with the help of a walker.

Of course physiotherapy is part of the package, and in January Zoya was able to stay upright with the walker for as long as 10 minutes, and to walk in the hospital hallways five or six times a day. Dr. Bhandari expected at the time that it would take six months for her weight to normalize, and maybe three years before she could walk normally, without assistance. He described her new nutritional regime as “juices, soups, milk, and pureed food,” and said,

Before the revision surgery, her diet consisted of tea and biscuits twice a day, daal, rice, vegetables, and chapati four times a day. Her rice consumption during each serving would be like an adult’s. In between the meals, Zoya would eat chips, biscuits, chocolates, and ice cream.

This is troubling. How does a non-ambulatory child from a desperately poor family get hold of these treats? Over all those years, surely there was counseling? Surely there were followup visits, and some attempt to curb consumption?

We are not here to parent-blame, but after seeing their infant daughter undergo a serious and life-changing procedure, how were these parents not aware that they would have to police her forever? If things got so badly out of control the first time, how different can the circumstances be after the second surgery? It would be helpful if Dr. Bhandari had gone into that aspect more thoroughly.

Your responses and feedback are welcome!

Source: “Obese Bandra girl continues to baffle doctors, may become subject of global talk,” DNAIndia.com, 04/14/15
Source: “Morbidly obese child loses weight for the first time after surgery,” Bariatrics-India.com,” 09/23/19
Source: “Mumbai girl undergoes second weight-loss surgery week before eighth birthday,” IndiaTimes.com, 12/17/18
Source: “Bariatric Surgery helped 8 year old Zoya,” Medium.com, 01/08/19
Image by Achilli Family/Attribution 2.0 Generic (CC BY 2.0)

Bariatric Surgery in a Less Than Ideal World

Pat Hartman December 2, 2019 No Comments

There are, as it turns out, four important registries of adolescent bariatric surgery: AMOS, Teen-LABS, Saudi Arabia, and the Germany Obesity Registry. Their studies about bariatric surgery were described by Natalie Durkin and Ashish P. Desai.

Childhood Obesity News noted that there is universal agreement over the importance of the multi-disciplinary team. Another thing that strikes everybody as an urgent need, for the benefit of both patients and Science, is diligent and conscientious long-term followup. What other insights did the study from King’s Hospital, London, publish?

It had a lot to say about psychosocial well-being, and the effects of obesity on that state in children and teenagers. They get depressed, perform badly in school, and are prone to leaving without credentials. However,

The AMOS collaboration demonstrated a substantial improvement in psychosocial well-being in adolescents 2 years post-gastric bypass vs controls. Symptoms of anxiety, depression, anger and disruptive behaviour were significantly reduced and self-esteem, self-concept and overall mood significantly improved.

But wait. Also, at the two-year mark, symptoms of clinical depression were observed in 19% of the subjects, which is almost one in five. And there were two attempted suicides. The corresponding report from Teen-LABS also documented a mixed bag of results:

Of 11 patients presenting with ≥1 mental health symptoms pre-surgery, remission was only found in 45%, although no new cases developed. These findings suggest that not all adolescents benefit psychologically from bariatric surgery, and the role of psychological screening prior to operation is essential.

Teen-LABS also sees a need for earlier intervention in the psychosocial consequences department, a sentiment shared by Dr. Pretlow. Unless underlying causes can be expressed and addressed, the likelihood of avoiding morbid obesity shrinks, as the patients continue to enlarge.

It’s complicated

Compared to adults, adolescents suffer roughly twice as many complications, an umbrella term that extends far enough to cover additional surgeries. The writers supply a protracted discussion of complications, both short- and long-term.

In some people’s minds, nutrition appears to be almost an afterthought, but ignoring it could be deadly. Without the right amounts of calcium, iron, and various vitamins, big trouble can ensue. We’re talking peripheral neuropathy, beriberi, anemia, osteoporosis — and these are only a few of the potential problems mentioned.

A familiar refrain is repeated:

This emphasises the importance of the role of the nutritionists and psychologists post-operatively to encourage compliance in this group of patients.

No matter how any one individual may feel about the issue, pediatric bariatric surgery is a growth industry that will very probably not go away, so we may as well learn to live with it, understand it, and try to put it out of business.

It’s holistic

Regarding weight loss and the resolution of co-morbidities, the writers conclude that so far, the results with adolescents are no worse than those with adults. To ensure safe and excellent clinical care, they wind up by emphasizing once more the prime importance of multi-disciplinary specialist teams.

Your responses and feedback are welcome!

Source: “What Is the Evidence for Paediatric/Adolescent Bariatric Surgery?,” NIH.gov, 08/16/17
Image by Russ Sanderlin/Attribution-ShareAlike 2.0 Generic (CC BY-SA 2.0)

The Aspirations of Bariatric Surgery

Pat Hartman November 29, 2019 No Comments

What is the position of Dr. Pretlow, originator of the W8Loss2Go smartphone app?

I’m not an advocate of bariatric surgery, particularly in the pediatric population, except for life-threatening cases. I feel strongly that overeating/obesity is an addictive process and should be treated with addiction medicine methods. Our research results support this position.

In our previous post, Childhood Obesity News began discussing a report published two years ago, titled “What Is the Evidence for Paediatric/Adolescent Bariatric Surgery?” Surgeries intended to accomplish weight loss are performed in many countries, and the researchers examined current guidelines from major medical centers. They found that agreement about an appropriate age range is not unanimous. There is also uncertainty about the severity of obesity the patient must be up against, in order to qualify.

There is said to be agreement everywhere, however, over a principle that may not always be possible to follow in each individual case, but which is honored as a Best Practice. The multidisciplinary team, or MDT, is universally acclaimed and recommended, despite the lack of an element that science usually insists on, namely, hard evidence.

The authors say,

There is no specific evidence for the use of a multidisciplinary team either for adults or adolescents undergoing bariatric surgery. Considering the complex nature of intervention, however, particularly at the vulnerable age of these patients, the MDT has become well established as the gold standard of care necessary to provide a safe and efficient service.

One reason for lack of satisfactory evidence is the paucity of information about long-term results, because this kind of intervention, especially on children, has not been underway long enough to generate a large body of data. The authors speak of two consortiums that are interested in “the sustainability of weight loss, long-term effects on co-morbidities and the safety of bariatric surgery in childhood.”

They are AMOS, named for adolescent morbid obesity surgery, and Teen-LABS, also known as Teen-Longitudinal Assessment of Bariatric Surgery. When the report was written, both had only recently published their first sets of prospective long-term outcomes; and long-term in this instance means less than four years.

The multi-disciplinary team

As defined by the American Society of Metabolic and Obesity Surgeons, the MDT ideally includes:

1. An experienced bariatric surgeon

2. A paediatric specialist; either a paediatrician with a specialty in endocrinology, gastroenterology, nutrition, and/or adolescence, or an internist, or family practitioner with training in adolescent medicine.

3. A registered dietician with experience in treating obesity and working with children and families.

4. A mental health specialist; a psychiatrist or psychologist with specialty training in paediatrics +/− adolescents and particular experience in treating eating disorders and obesity.

The fourth item on that list is strongly approved by Dr. Pretlow, who would like to see mental health professionals more involved in every aspect of the struggle against obesity. Even a child who comes to surgery psychologically unimpaired (unlikely as that might be) will need help afterward. The challenge of reinventing oneself to conform to the needs of the post-op protocol (not to mention the subsequent 60 or 80 years of life) is, as they say, “a lot.”

Dr. Pretlow writes,

Psychologists in the obesity field seem to be treating only the psychological effects of being obese, rather than the psychological causes of obesity.

Having surgery is both a physical and psychological effect of obesity — neither of which might be needed if professionals spent more time beforehand on the psychological causes.

Your responses and feedback are welcome!

Source: “What Is the Evidence for Paediatric/Adolescent Bariatric Surgery?,” NIH.gov, 08/16/17
Image by Matthias Ripp via Flickr

The Evolution of Thought About Pediatric Bariatric Surgery

Pat Hartman November 27, 2019 2 Comments

In early 2017, the National Law Review listed the 15 most common types of pediatric surgery. Lawyers need to know this sort of thing because…

Surgical errors occurring during these procedures may have a profound impact on the child’s physical and mental development and could severely alter his or her quality of living.

One type of pediatric surgery is bariatric, described as “a treatment for childhood obesity where a balloon is inserted into the esophagus to narrow the opening and reduce appetite.” Readers of Childhood Obesity News know there is so much more to it. A ballon is not the only option, nor was it in 2017. Staying within the same word count, it would have been much more accurate to say that there are several surgical alternatives.

It would seem important, too, for attorneys to know that bariatric surgery is not only about reducing appetite, which is so basic. Indeed, the only justification for inflicting this kind of surgery on a child is that it will prevent the degree of obesity that ushers in one or more complications, known as co-morbidities.

“What Is the Evidence for Paediatric/Adolescent Bariatric Surgery?” is a promising title, and the material lives up to it. Written by Natalie Durkin and Ashish P. Desai of King’s College Hospital, London, it begins by stating that such intervention is “still not widely accepted.” Among those in favor, the trend is\was to operate as early as possible in the child’s life. The previous year had seen the publication of two “prospective long-term outcome studies […] aiding our understanding of the efficacy and safety of bariatric surgery within the adolescent population.”

Good news, bad news

The study’s summary has two parts. First the good news:

It is increasingly clear that adolescent bariatric surgery outcomes are comparable to adults, with similar sustainable weight loss, resolution of co-morbidities and complication rates.

And the inevitable downside:

However, these studies are solely from dedicated specialist adolescent centres and results may not be reproducible if not performed in regulated environments with specialist multi-disciplinary teams.

That is a pretty big caveat. The facilities that can handle procedures of this kind are only located in major population centers, and the bills are enormous. There is a lot of prep beforehand, and eternal followups, because a lot of things can go wrong, and because there are still not enough long-term survivors to make really helpful generalizations.

Around that time, friend of the blog Amy Connor commented,

The only surgery appropriate for kids is the severance of food before it reaches the lips (of course not beyond the point of giving them adequate nutrition)… Sometimes I wonder if over eating is to compensate for a fear that they will never have enough in this crazy crazy world.

Something psychological is going on, for sure. Dr. Pretlow often wonders why the mental health professions are not taking more ownership of the obvious connection between problems that originate in the brain and the obesity epidemic.

Your responses and feedback are welcome!

Source: “15 Most Common Types of Pediatric Surgery,” NatLawReview.com, 03/13/17
Source: “What Is the Evidence for Paediatric/Adolescent Bariatric Surgery?,” NIH.gov, 08/16/17
Image by Marco Verch/Attribution 2.0 Generic (CC BY 2.0)

Bariatric Surgery for Children

Pat Hartman November 26, 2019 1 Comment

This post looks back at the last few years of progress in the area of weight loss surgery for children. As of 2012, the idea was gaining traction in some quarters, and cases of children as young as 12 were being studied.

In the same year, writer S.E. Smith wrote that marketing weight loss surgery to children is wrong because it is invasive and dangerous, and can irreversibly transform the metabolic system. The very fact that opinion is so divided is one of the ways in which children are hurt. Smith feels that it is a no-win situation, where you’re not supposed to be fat, but elective surgery isn’t exactly cool either. Smith writes,

When they get surgery, they’re told they are cheating and taking the easy way out. Because nothing says “easy way out” like having a chunk of your stomach removed and your intestines rerouted, as is the case with extreme procedures.

Smith is repulsed by the advertising of bariatric surgery, especially to children; and characterizes it as disgusting, and would like to see stricter federal regulations against it. The writer also described the obesity epidemic as a mythical construct that legitimizes bullying, stoked by rhetoric that is damaging, hateful, awful, and vile:

Fat hatred kills… When fat children are so bullied that they commit suicide… It kills when fat children go on extreme diets that are unhealthy for growing bodies, or when they descend into disordered eating because all they want, the only thing they want, the thing they need most in the world, is to not be fat anymore.

In 2013, the Downey Obesity Report mentioned a meta-analysis published in JAMA Surgery about adult bariatric surgeries. The researchers waded through 164 studies concerning 161,756 patients with a mean age of 44 years, and found a complication rate of 17% and a re-operation rate of 7%, figures that should have made everybody think twice about putting children through this ordeal.

Dr. David L. Katz wrote in 2014 about surgery being an acceptable way to reduce what he called the “worsening global obesity pandemic,” and said he recommended it for patients that were appropriate candidates. But he seemed to feel that in many cases, appropriate candidates have been misidentified — particularly in the Middle East, especially Saudi Arabia, which had jumped on the pediatric bariatric surgery bandwagon with great enthusiasm.

Dr. Katz wrote,

Lacking the capacity and resolve to feed our children less or better, or get them to exercise more, we send them through the operating room doors instead…
What does it say about modern culture […] that it sanctions putting children under general anesthesia to compensate for its anachronisms, profit-driven excesses and exploitations? Nothing very flattering.

Epidemic childhood obesity is a cultural crisis. Turning to the literal cutting edge of biomedical advance to address it is not a solution, but an abdication.

Your responses and feedback are welcome!

Source: “Young, Obese and in Surgery,” NYTimes.com, 01/07/12
Source: “Fat Hatred Kills: Marketing Weight Loss Surgery to Children Has Got to Stop,” Meloukhia.net, 03/12/12
Source: “Bariatric Surgery Safety and Effectiveness Supported,” DowneyObesityReport.com, 12/20/13
Source: “Childhood Obesity: Just Cut It Out,” USNews.com, 02/18/14
Image by C.J. Sorg/Attribution-ShareAlike 2.0 Generic (CC BY-SA 2.0)

Bariatric Surgery and Very Young Children

Pat Hartman November 25, 2019 No Comments

How great of an idea is it to do major surgery on kids who eat too much? Not very, in Dr. Pretlow’s estimation. The underlying reasons for child obesity are not understood, and bariatric surgery is a very poor substitute for comprehension and prevention. At its worst it can be horrific. Especially alarming is that the American Academy of Pediatrics (AAP) has begun to recommend it for children as young as 10.

One reason given by the AAP for their endorsement is that non-surgical methods of weight loss for morbidly obese kids do not seem to work out well. Dr. Pretlow comments,

If non-surgical methods were effective, then bariatric surgery would be unwarranted. Therefore, we need to figure out exactly why non-surgical methods are ineffective, and create non-surgical methods that ARE effective, like addiction-based and displacement-based methods.

Last month, the American Academy of Pediatrics went on record as “calling for greater access to metabolic and bariatric surgery” for morbidly obese kids, touting it as “one of the few strategies that has been shown to be effective” in combatting the chronic disease of obesity.

Obesity was defined as a disease only about six years ago. Of course the appropriate thing to do about a disease is to find a cure, and maybe that is part of the problem. The factions looking for a cure and the faction more interested in prevention have to compete for limited resources in the form of public attention and public willingness to fund their endeavors.

Then, among the cure-seekers there is further competition. For childhood obesity, surgery has always been regarded as a last resort, a desperate measure for intractable, life-threatening cases. Now, we are invited to see it as no more extreme than braces on the teeth. That the AAP might seem overly eager to communicate this point of view could be a matter for concern.

How young?

Once upon a time in Saudi Arabia, a very small child was burdened by sleep apnea and legs that were bowed by his weight when he attempted to walk. Despite the application of traditional weight-loss methods, he weighed 73 pounds at the age of two. It was not announced at the time, but in 2010 this two-year-old underwent a laparoscopic sleeve gastrectomy.

When the news got around, obesity experts were very concerned. But by age four, the boy’s weight was down to about 50 pounds.

An Indonesian boy, Arya Permana, who weighed 450 pounds at age 10, had the sleeve surgery and lost 70 pounds in a month, so he seems to have gotten off to a great start.

From India comes the story of three siblings born a year apart who inexplicably became grossly overweight. Crowdfunding raised money for surgery, but after a very short period of optimism, all three children commenced to gain weight, faster than ever. Maha Rehman writes, “Their father now plans to sell his kidney to afford proper treatment for his little ones.”

A Chinese boy named Li Hang, afflicted with Prader-Willi Syndrome, weighed 330 pounds at age 11. Although he had surgery at a highly respected hospital, he only lost 15 pounds and then started gaining again.

There does not seem to be any recent news about another Chinese boy, Lu Hao. In the many photographs taken of him, he does not seem able to open his eyes because of the surrounding fat. In 2011 when Lu Hao was 3, Isabel Jensen wrote,

He is getting so big his family are frightened of him and have given up trying to stop the youngster from gorging on huge plates of ribs and rice… His parents claim he throws vicious tantrums if he doesn’t get third or fourth helpings of dinner… He has already been banned from nursery over fears his size might be a danger to other children…

Medical considerations aside, the behavioral problems described here suggest that he would not be a good candidate for surgery or the disciplined lifestyle required afterward. In all the articles written about Lu Hao, there is no mention of any doctor ever suggesting surgery.

Your responses and feedback are welcome!

Source: “American Academy Of Pediatrics Recommends Greater Access To Surgical Treatments For Severe Obesity” AAP.org, 10/27/19
Source: “Laparoscopic sleeve gastrectomy for a two-and half year old morbidly obese child,” NIH.gov, 09/12/13
Source: “18 Most Obese Kids From Around The World,” BabyGaga.com, 09/11/17
Source: “Tragic toddler weighs nine stone,” TheSun.co.uk, 03/23/11
Image by Jesper Sehested/PlusLexia.com

Contemplating Bariatric Surgery

Pat Hartman November 22, 2019 No Comments

Weight loss surgery has garnered a lot of bad press, but not all of it is as hilarious as a piece titled “6 Bizarre Things Nobody Tells You About Weight Loss Surgery.” Here is a quotation from the tongue-in-cheek article variously attributed to Amanda Mannen, Alexandra, and Anonymous:

When you hear about all the horrifying problems that can arise after surgery — including leakages, blood clots, abdominal pain, bowel obstructions, osteoporosis, gallstones, vomiting, hernias, anemia, and malnutrition, to name a few — death on the operating table can start to sound like the best-case scenario.

The authors call out advertising that makes surgery sound as innocuous and delightful as a spa day. In reality, this is not “the kind of thing you can shrug off in a weekend.” The preliminary tests can feel very demanding, and might include endoscopy, ultrasound, and even colonoscopy, in addition to the drawing of what can seem like quarts of blood for lab work.

Then, two weeks before S-Day, the required diet changes to protein powder and a limited menu of vegetables. This is said to reduce the size of the liver, making the stomach easier to operate on.

On a more abstract level, insurance companies have mixed feelings. They might pay, but the cost in bureaucratic form-filling is high, and applicants sensitive to privacy can feel very invaded. Some mention the other time-sucking requirements like educational classes and support groups. Emotional affinity groups, built around the common background of weight loss surgery, can also be forever, which is probably the best idea.

Long-term, people who use traditional weight-loss methods based on the energy balance paradigm, tend to put the pounds back on. Those who opt for surgery maintain more successfully, but it is an unrelenting job that is reportedly more bearable when talked over with fellow patients. If a real-life meeting is not practical, Facebook and other social media offer a slew of bariatric support groups that it might be smart to consult before making a commitment.

Life goes on

And what is “dumping syndrome”? You don’t want to know. Or rather, you do, if contemplating gastric bypass surgery. Sugar and simple carbohydrates just rush right on through, and the patient has to stay close to a bathroom. Dumping syndrome may also include sweating, shaking, and cramps. It is said to be avoidable through keeping meticulous records of substances consumed, followed by avoiding those foods and beverages forever.

Life subsequent to surgery might involve choking down “a giant handful of vitamins every day” and frequent lab tests to assure that the vitamins are begin assimilated. Apparently, things can go along smoothly for years before complications arise. The author says,

I was warned that I could be minding my own business weeks or months or years later when the tiny tube that was now my stomach would stop handling anything but liquid. That’s because as it heals, it can develop scar tissue to the point that it constricts without warning.

Veterans of weight loss surgery warn that it can extensively affect a person’s social life, including their marriage, and that “bariatric divorce” is a thing. If both partners are obese, it is recommended that they both have surgery so their drastically reformed lifestyles will be in alignment, and so nobody can get jealous when the other one slims down.

Going through the process together also lessen the possibility of partner sabotage. This dynamic might be difficult for non-addicts to understand, but when John Lennon and Yoko Ono wanted to have a child, they both got off heroin.

Other people, especially close relatives, can have a hard time accepting the “new you.” Chances are, siblings and parents might be dangerously overweight too. A big change can unleash a storm of psychological disturbances. When a patient does something as radical as surgery, it can be perceived by family members as threat, accusation, declaration of independence, or rejection.

Unrelated people will have something to say, too, especially if the patient is a professional comedian, and even more so if his or her material is largely size-related. Losing weight can draw some serious blowback from agents, managers, casting directors, and fans.

The illustration on this page shows the aftermath of duodenal switch surgery which, as Childhood Obesity News has noted, is a type reserved for the super-obese. If the patient is meticulous about lifestyle, it can work out fine, except for a greater mortality rate, the possibility of not absorbing enough nutrients, and a severe chronic gas problem.

Your responses and feedback are welcome!

Source: “6 Bizarre Things Nobody Tells You About Weight Loss Surgery,” Cracked.com, 12/15/14
Image by Dale Leschnitzer via Flickr

Bariatric Surgery’s Progress

Pat Hartman November 21, 2019 No Comments

Things have been happening in the world of bariatric surgery. Before catching up with recent developments, let’s take a peek at some of the highlights from past discussions. For the convenience of readers, Childhood Obesity News has gathered much of the information from individual posts that have already appeared in three “roundups,” so let’s start by plucking from them some of the main ideas.

The notion of bariatric surgery for young people was kept in the “experimental” category for quite some time, but about 10 years into this century, the rules have changed and the anxiety levels around the previously controversial practice began to subside.

One of the main sticking points is the legal limits our society sets with regard to age. If a person is considered too young to drive, drink, marry, or vote, should we be letting them have life-altering elective surgery?

One of the enduring problems has been lack of long-term followup, because there are not enough patients who had this kind of surgery 10, 20, 30, or 40 years ago. From short-term observation, the failure rate was hovering around 20% or worse. The majority of teens who undergo surgery come out the other side with the same emotional problems that led them into obesity in the first place, because the psychological infrastructure to help them is simply not there.

In 2010 a survey of doctors revealed that half of them would not even consider recommending bariatric surgery for an adolescent. Ideological disagreements have existed ever since this kind of intervention became a possibility. While recognizing that something needs to be done before an individual’s obesity progresses too far, the reluctance to have that something be surgery is almost instinctual.

When surgery was recommended, several different options were open, and it took a while for consensus to form around the question of “best practice” in this area. By 2016, the AGB, or adjustable gastric band, minimally invasive and potentially reversible, had become the procedure of choice. At the same time, the duodenal switch surgery was recognized as more effective overall, but also as demanding of commitment from the patient that is not always present.

Whenever the topic of bariatric surgery for teenagers is broached, two conditions must be thoroughly understood. A preparation period is required, because the patient needs to either lose a certain amount of weight through conventional means first, or to demonstrate that they are incapable of losing weight through conventional means. Then, afterward, every day of life will be lived a certain way, forever, for 30, 40, 50 years or more.

It is a lot to sign up for, and of course we always mention that in both the period leading up to surgery and the subsequent decades of constant maintenance efforts, Dr. Pretlow’s W8Loss2Go program (via a smartphone application) can make the difference between failure and fabulous success.

Stay tuned for updates on the bariatric surgery field.

Your responses and feedback are welcome!

Image by Kevin Old/Attribution 2.0 Generic (CC BY 2.0)

Who Is Ready for Bariatric Surgery?

More steps to patient eligibility evaluation

Weight-Loss Surgery and Non-Adults

Bariatric Surgery for Children — A Desperate Case

Bariatric Surgery in a Less Than Ideal World

It’s complicated

It’s holistic

The Aspirations of Bariatric Surgery

The multi-disciplinary team

The Evolution of Thought About Pediatric Bariatric Surgery

Good news, bad news

Bariatric Surgery for Children

Bariatric Surgery and Very Young Children

How young?

Contemplating Bariatric Surgery

Life goes on

Bariatric Surgery’s Progress

Profiles: Kids Struggling with Weight

The Book

About Dr. Robert A. Pretlow

Presentations

Food & Health Resources