An 'Obesogenic' Environment
As obesity rates continue to climb in adolescents across the United States, doctors are exploring surgical options to help these young patients lose the weight that threatens their health.
June 14, 2010
According to the Centers For Disease Control and Prevention (CDC), obesity in adolescents aged 12 to 19 has increased from five percent in 1976-1980 to 18.1 percent in 2007-2008. With rates of obesity climbing nationwide, alternatives to the traditional diet-and-exercise solution have surfaced to help adolescents lose weight—namely bariatric surgery. It’s a controversial issue among the health care community: Is a bariatric surgical procedure safe for an adolescent? Is it more effective in helping adolescents lose weight than lifestyle changes?
To help answer these questions, Professor Paul O’Brien, director of the Centre for Obesity Research and Education at Monash University Medical School at the Alfred Hospital in Melbourne, Australia, and national medical director of the American Institute of Gastric Banding in Texas, led and authored a study examining the efficacy of gastric banding in obese adolescents. Based on the findings, Dr. O’Brien says the procedure, also known as lap-band surgery, is an option for adolescents struggling to lose weight.
The study, conducted in Australia and published in the Journal of the American Medical Association in February 2010, was a randomized trial of 50 severely obese teenagers. According to Dr. O’Brien, the criteria for participation in the trial included:
- Age above 14.
- Body mass index (BMI) above 35, with no upper limits.
- The ability to define problems associated with obesity, including health, physical and psycho-social issues.
- Clear efforts made over time by the teenagers to control their weight problem by non-surgical means.
The study compared the outcomes of lap-band surgery, a procedure in which an adjustable band is wrapped around the stomach to give the patient a feeling of being full, to those of patients on a lifestyle program. The program involved individualized diet plans, behavioral modification, access to a personal trainer and advice from a dietician and adolescent physician.
In two years, teenagers who had undergone gastric banding lost an average of 79 percent of their excess body weight while those in the lifestyle group lost 13 percent. The teenagers receiving the surgery lost an average of 77 lbs. per patient, while the participants in the lifestyle group lost an average of 6.6 lbs. Furthermore, six teenagers in the control group withdrew before the study was completed after they gained weight.
The results imply the gastric banding procedure should be considered as an option for obese adolescents in which no other method of non-surgical weight loss seems to work.
Gastric Banding: A Viable Option
As Dr. O’Brien explains, a gastric banding surgery is essentially an outpatient procedure. It takes about a half-hour, and patients can generally be back to their normal activities within two to four days. In the procedure, an adjustable band is placed around the stomach to take away the person’s appetite, providing satiety. The person eats less because their interest in food is markedly reduced.
“They’re not looking for food, but they have to work with us,” Dr. O’Brien says. “It’s a partnership and they have to eat small amounts. It facilitates good eating.”
Currently, gastric banding is not available to adolescents in the United States because the LAP-BAND®, the adjustable band used in the procedure, is not yet FDA-approved for use in adolescents. For now, if an adolescent looks to undergo bariatric surgery in the United States, a gastric bypass must be performed.
According to Dr. O’Brien, gastric bypass has a number of issues working against adolescents. The procedure is high-risk in terms of complications compared to the lower-risk banding procedure. Secondly, gastric bypass changes the stomach permanently by bypassing the stomach and reorganizing the small bowel to connect to itself. It can only be partially reversed. Meanwhile, gastric banding is adjustable, controllable and completely reversible.
“What’s happening is these kids might be an average age of 16,” Dr. O’Brien explains. “Surely, in the next 20 years, better treatments will be developed than we have today. For example, we’ll get a drug that controls appetite as effectively as the band controls appetite. When we have that drug, people can go to it, and they can have the band taken out. It comes out easily and everything is back to normal. If they had a bypass, they can’t do that. That 16-year-old is only 36 at this time. They still have another 45 years of life.”
While gastric banding appears to be a gentler option for adolescent bariatric surgery, it does not come without risks. The procedure is still a significant surgery, and while, during the trial, none of the patients experienced perioperative complications, a quarter of the patients needed revisional procedures later, mostly due to improper eating.
“If patients eat too quickly, or if they eat too much food, they will stretch things, and we have to fix that up,” Dr. O’Brien says. “We had more problems with that in the trial than we would have had in a group of adults because kids just don’t absorb the message that they have to do their part quite as readily. So now, we work with them much more in making sure they understand that they have to stick to the rules.”
Still, bariatric surgery is a feasible, and perhaps the best, option for some adolescents to lose weight when the problem has been defined and other methods are not working. According to Dr. O’Brien, the reason why other methods may fail is the same for adolescents as adults—some times diet and exercise just does not work.
“It works for a very small number over a reasonable time,” he explains. “Most people can lose weight by eating less and doing more. But very few of us can do that day in and day out. The reality of life is almost nobody at one year or longer retains the weight loss that they’ve had. They simply put the weight back on. It’s easy to say, ‘Those kids are weak or those adults are weak,’ but the fact is that when two-thirds of adults now are either overweight or obese, this weakness is merely generalized.”
Furthermore, Dr. O’Brien says, the environment in which kids live is a large factor toward their weight, and they have less control of their environment than adults do. It is usually the parents determining what the family eats and what food is available in the house. On top of that, adolescents face peer pressure from their friends to enter into a pattern of eating more and exercising less—going to have a pizza after school, watching television, playing on the computer. All of these factors contribute to the rise in obesity among adolescents.
The Toll On Health
According to Dr. O’Brien, the health problems seen in obese adolescents are the same as those of obese adults. In fact, he says, it’s often underestimated just how early obesity-associated health problems can occur, particularly Type 2 diabetes, sleep apnea and hypertension.
In the trial, researchers measured a cluster of health problems associated with being overweight known as metabolic syndrome, a serious risk factor for heart disease later in life. According to Dr. O’Brien, metabolic syndrome looks at five aspects of the patients’ health:
1. Blood sugar, meaning the patient may trend towards diabetes even though they may not have diabetes at that the time.
2. Central obesity, or fatness in the abdomen area, which is worse for one’s health than peripheral obesity.
3. Blood pressure.
4. Triglycerides, which are found to be abnormally low in obese people.
5. HDL cholesterol, also found to be abnormally low in obese people.
“If you look across adults in the United States, you’ll find that about 25 to 30 percent of all adults will have a metabolic syndrome,” Dr. O’Brien says. “Now, recognizing that 34 percent of all adults have obesity, there is a very strong link between a metabolic syndrome and obesity.”
Thirty-eight percent of patients in the trial had a metabolic syndrome.
“It is really a pretty worrying thing,” Dr. O’Brien says, “to have a bunch of kids come out of the community, and nearly 4 out of 10 have this cluster of problems that we call metabolic syndrome.”
According to Dr. O’Brien, without a change, obese adolescents enter adulthood already with a very high risk of being obese as adults.
“We can also measure that they have already lost a predictable number of years of life,” he says. “A kid who is morbidly obese—say, a BMI of 40—going into adulthood at age 20 has already lost, on average, between eight to 10 years of life, depending on sex and ethnic background. That’s dreadful, that a 20-year-old who should live until 80, we say, ‘Ok, you might get to 70.’ It shouldn’t be tolerated.”
Despite thousands of programs established throughout the United States to prevent obesity in adolescents, the rates continue to increase.
“We have an environment that is ‘obesogenic,’ Dr. O’Brien says. “We have an environment where we have too much food available. It’s good. It’s very clean. It’s very low cost and available 24 hours a day. Fifty years ago, that didn’t exist.
You had to work harder for food. You had to pay more for food. We didn’t have food just lying around the house. We’ve created an environment that has its very good effects, but it also has side effects, and one of the side effects is obesity—obesity in adults, obesity in children.”
For now, Dr. O’Brien says the number of gastric banding procedures done in adolescents in countries where it is available, such as Australia, is very low. It represents only about one percent of cases at his facility. It’s a small number, he says, but for kids who truly need it, it’s a great help.
He anticipates FDA approval of the gastric banding device in the United States in the near future. With that would come a shift to doing gastric banding rather than gastric bypass in adolescents and it may gain some popularity. Overall, it’s likely the number of these weight loss procedures done in adolescents will remain small, but it would be an option in the struggle with weight for young patients who may really need it.
“It won’t be dramatic, it won’t be a huge number like the number of adults [who receive bariatric surgery], but it will grow because it works,” Dr. O’Brien says. “It gives better health. It gives better quality of life. It allows them to live a fairly normal life, and that is what health care is about.”