Thursday, November 5, 2009

Bariatric Surgery for Children = A Terrifying Idea

Recently, I had a shocking conversation with two health care providers from Baltimore. They work in an inner-city hospital that soon is planning to do bariatric surgery, such as gastric bypass, on children as young as five, and it hopes to do the procedures on babies as young as two in the next few years. How is this horrifying? Oh, let me count the ways! But first, some background.

I am a grateful member of Overeater's Anonymous, which has helped me lose 99 pounds and has given me the support to not eat compulsively since Dec. 31, 2005. The program is patterned after that of Alcoholics Anonymous, but helps people who have any kind of disordered eating whether they are compulsive overeaters, anorexics, bulimics, or some combination of all three. All of the local OA meetings are under the umbrella of the D.C. Intergroup, which purchased a booth in the exhibit hall of the Obesity Society's annual meeting in Washington, D.C. I was the co-chairwoman of this project, primarily taking care of scheduling and working with volunteers from OA who handed out OA literature and spoke with conference participants about the program and how it can complement their practices and help them help patients with eating disorders.

I felt like the Obesity Society booth was an amazing project to work on, because we were talking with doctors, therapists, nurses, researchers, nutritionists, and anyone who works to cure or manage obesity. They came from as far away as Argentina, Australia, Saudi Arabia, South Korea, and the United Kingdom. I asked each person I spoke with about their jobs so I could give them relevant information about OA. This is how I learned about the Baltimore hospital's plans for pediatric bariatric surgery. Until then, when I've heard the adjective "pediatric" modifying bariatric surgery, it has referred to teenagers aged 14-17. Note that it is controversial to do bariatric surgery on kids in this age range, and it's tough for teenagers to find docs willing to operate on them at that age. So, when the women told me they plan to do this surgery on two year-olds I repeated what they said to make sure I heard them right.

When someone has gastric bypass surgery, a surgeon sections off part of the stomach to make a tiny pouch that can hold very little food, and rearranges the intestines to join that pouch. There are other forms of bariatric surgery, like the Lap-band, an inflatable device that goes around the top of the stomach and that the doctor inflates with saline to reduce the amount of food the stomach can hold at one time. Bariatric surgery, especially gastric-bypass, is a serious procedure with a not-insubstantial risk of severe complications and death. Of course, since it's only performed on people who are morbidly obese (typically defined as being 100 pounds or more overweight), one could argue that the patients were dying from their obesity anyway and that their obesity puts them at risk for surgical complications. Even if it's true, I don't think even that warrants surgery with high complications and spotty efficacy.

People who work 12-step programs have sponsors, who are like your guides on your recovery journey. I have sponsored several women who have had bypass surgery, and guess what? They're all doing the same work I'm doing every day for my recovery, like making 3 phone call to other food addicts, doing a daily reading and writing assignment, and weighing their food, but they struggle with nausea and/or diarrhea and/or vomiting, and have to get intravenous iron infusions because they're anemic as a result of their surgeries. Moreover, all of my sponsees who have had bypasses have gained nearly all or all of their weight back, which shouldn't surprise you, because the things that cause someone to be eligible for bariatric surgery are not in the stomach. They are in the mind, heart, and soul, and no surgeon can fix those things.

I have several friends who have had gastric bypass, and all of them suffer complications -- some major. My friend, H, lost more than 200 pounds in OA and had so much hanging skin, she had to walk with a cane. She had to get that extra skin removed via a body lift, which is a really nasty and drastic surgery. She was hospitalized for nearly two months because her wounds wouldn't heal. Granted, they are enormous -- they cut from both sides of your navel and cut all the way around your circumference, stopping just before your butt crack. But one of the reasons she wouldn't heal is that she couldn't assimilate enough protein to heal because of her bypass surgery.

The women from the hospital in Baltimore told me that they have two year-old patients who weigh 80 pounds (normal is up to 30 lbs.) How did these babies get so fat? They're not in the kitchen baking lasagnas or going to CVS for Ben N' Jerry's and Oreos. Their caretakers are overfeeding the kids and making them obese, and unless these kids are reassigned to foster care after their bariatric surgery, the same parents are going to overstuff their kids post-operatively. Why would this be different with children?

I think if this trend of operating on very young children catches on, we're going to see a lot of kids who are both fat and sick. It's one thing for an adult to choose a life disrupted by potential diarrhea or vomiting, yet another to impose it on helpless kids. We also should be freaked out about this because we have no idea how weight-loss surgery will affect growth and development when done on a young child. What will be the consequences of limiting dietary calcium on bones that are still growing? Bariatric surgeons will tell you that patients will take supplements, but we already know that the body does not integrate nutrients from dietary supplements the same way it does from food (duh). Could limiting food quantities adversely affect neurological development? We don't know, and the professional hubris that says it's safe to do gastric bypass on 2 year-olds is really galling.

If you're thinking, "Kids are fatter than ever and getting comorbidities of obesity like Type 2 diabetes, which was unheard of 20 years ago. So, what would you propose instead of pediatric bypass surgery?" First of all, I'd tell you to chill with the obesity horror stories -- I think it has become the healthcare boogeyman, which I'll discuss in another post. I won't solve the obesity crisis on my blog, though I hope to explore its many facets. But I did read a summary of a clinical study with impressive outcomes that might be a step in the right direction. A facility in West Virginia created a summer camp for overweight kids that was followed up with family programming throughout the year. So after the camp, the entire family participated in healthy cooking and exercise classes. The kids responded really well, both losing weight and keeping it off. I don't think that cooking and exercises classes are of much use to true food addicts, but hopefully we can intervene with overweight kids before they become addicted. I strongly believe that bariatric surgery on two year-olds is most definitely NOT the answer to our obesity problem.


elanit said...

Not all gastric bypass patients fail at keeping the weight off. But you are right-- the bypass is just step one. The rest of it is all about attitude and actions. It's not a cure-all and most definitely must be paired with healthy eating and exercise. I know two people who had this surgery and it made a tremendous positive impact on their lives. Sure, every once in a while they suffer from "dumping" (drastic drop in sugar levels), nausea, etc., but it's certainly not a normal occurrence, at least for them.

It's a complicated subject. But definitely NOT something that should be foisted on children. Their guardians should do a better job at taking care of them and helping them make responsible choices.

Elise said...

I originally found your blog via Megan McArdle. Around the same time she recommended you she also recommended two books: The Obesity Myth by Paul Campos and Rethinking Thin by Gina Kolata. Campos has some interesting chapters on childhood obesity.

More generally I just wanted to say that while I find all your posts interesting I really appreciate your writing on the topics of weight, obesity, health myths, and OA.

Sarah said...

Thanks. This is a subject near to my heart and soul. I'm not uniformly against bariatric surgery for adults, but I can't get my head around operating on 2 year-olds.

Steven said...

Thank you, Sarah, for expressing your opinion so strongly on this subject. I agree that bariatric surgery on children is terrifying.

Thanks also for ending your post by mentioning the West Virginia program, which shows what's so wrong with the surgical approach. People learn, particularly children, but surgical approaches for behavioral conditions condition people to be passive. It sounds like Overeater's Anonymous does a very good job with educating people to be more responsible, and with providing social support to reinforce personal responsibility.

My sister-in-law had a very successful bariatric surgery, and has managed to keep her weight off for several years. I'll see her at Thanksgiving.

From what I know and have seen with people who are seriously obese, self-image is a key aspect of the condition. People have to be encouraged to feel good about themselves, not abstractly, in the way so many people speak of self-image, but concretely, in the way we breathe, and move, and actively engage with the world. I've seen a lot of people lose weight rather easily when they learned to breathe and move more skillfully with FlexAware(R) and Feldenkrais, and I attribute that progress to the change in self-image.

Anonymous said...

My first reaction was "oh my gosh". I really think you hit on a lot of what I was thinking. The whole thing about losing weight and keeping it off is making the change. Diets don't work. Changing your lifestyle is what works. And it is tough. However, unless one makes the change, then they will go back to the way that they were before. A child can't make the change on their own and they didn't get to their weight on their own. I'm glad that you wrote out this well presented post.