Wednesday, May 23, 2018

To fight teen obesity, Tampa Bay doctors are turning to bariatric surgery

Walking up a flight of stairs left Amanda Rodriguez gasping for breath, her ankles and knees throbbing with pain. She was prediabetic and hypertensive. She couldn't sleep. She was being treated for depression.

At age 15, Amanda weighed nearly 300 pounds.

For two years she tried various diets and exercise regimens. She saw doctors and a nutritionist.

Her weight kept climbing.

"I knew I was really unhealthy. I was in pain all the time, physically and emotionally," said the Hialeah teen.

At her peak weight, she had to be given a key to use her high school's staff elevator so she could get to class.

"It was so embarrassing,'' she said.

That's when Amanda and her parents decided it was time to try something radical: surgery to permanently shrink her stomach, help her lose weight — and even save her life.

Bariatric, or weight loss, surgery has become almost routine among morbidly obese adults. Even smaller adults are getting the procedure for its power to reverse Type 2 diabetes.

But doctors long were reluctant to try it on adolescents, because changing the way food is digested and metabolized is thought to be far riskier while the body is still developing.

A decade after it became more available in some parts of the country, the procedure is not yet offered to adolescents in the Tampa Bay area. But that's about to change.

"The pediatricians and pediatric endocrinologists are at their wits' end with trying to help their young patients lose weight,'' said Dr. Michel Murr, director of metabolic and bariatric surgery at USF Health and Tampa General Hospital.

"These are kids in high school weighing 350 pounds who have high blood pressure, diabetes, sleep apnea and other adult diseases," said Murr. He has been hiring surgeons and other medical staff to expand USF's bariatric surgery program to include children in the second quarter of 2013.

"These kids are a ticking time bomb and their doctors are asking for a local program.''

• • •

As the obesity epidemic gathered steam, just a handful of children received bariatric surgery in the 1970s and 1980s.

Today, more than 360 institutions across the United States — including the University of Florida and the University of Miami — offer special programs for patients younger than 18.

"In the last 10 years we began to see that these kids are not just obese, they are really sick and many have conditions that could shorten their lives," said Dr. Marc Michalsky, director of bariatric surgery at Nationwide Children's Hospital in Columbus, Ohio. He also is chairman of the pediatric committee for the American Society for Metabolic & Bariatric Surgery.

Candidates for bariatric surgery are 100 or more pounds over their ideal weight, with obesity-related problems such as high cholesterol, high blood pressure, angina, Type 2 diabetes, liver and gallbladder disease, sleep apnea, joint and back pain, and difficulty breathing.

They have trouble buying clothes — and making friends. Depression is common.

So is hearing, over and over again, that they ought to be able to lose weight on their own.

USF's Murr long opposed bariatric surgery for kids. Now he has seen more long-term data on the surgery — and the dismal success rates of traditional weight loss methods.

"I think it's a reasonable and effective approach for adolescents who have not been able to lose weight with other means, if they have obesity-related health problems and as long as their families, pediatricians and primary care doctors are involved," said Murr.

Cincinnati Children's Hospital has been a pioneer in pediatric bariatric surgeries, performing nearly 200 since 2001.

"Obesity in kids has tripled in the past 30 years. Eighteen percent of adolescents are obese," said Dr. Sean Barnett, an assistant professor of surgery and pediatrics at Cincinnati Children's Hospital and a specialist in adolescent bariatric surgery.

He bats aside suggestions that these kids ought to just go on a diet.

"Studies show that morbidly obese adolescents treated nonsurgically lose on average 5 pounds. And a third to a half can't even complete the program," said Barnett. "They just aren't successful."

• • •

At 262 pounds, 16-year-old Natassia Elias couldn't hide her size. But she tried to conceal the misery it caused her every time the bell rang and she had to climb the stairs at her South Florida high school.

"It would have been too embarrassing to stop and catch my breath, so I would just go straight up, breathing heavy," she said.

After gastric sleeve surgery in August, she is 50 pounds lighter.

"I suggested it because our whole family is obese," said her mother, Natasa Elias, 42. "It was the obvious thing for my daughter. I didn't want her to keep getting bigger and bigger."

Now she is navigating those stairs with ease. But don't suggest she took the easy way out.

Post-surgical pain was so bad, Natassia says the first week "was hell.'' She wished she'd never done it.

But as the pain faded, so did the second thoughts. "It's awesome," said the now-17-year-old high school senior. "I'm getting compliments on a daily basis. People tell me I look good."

The pre-surgery nutrition and exercise program required of all patients in the University of Miami program got her accustomed to her new lifestyle. But the post-surgery portion sizes are even smaller: 4 ounces of food, every three hours with strict limits on sugars and fats. Natassia also takes five vitamin pills a day to ensure she's getting adequate nutrition.

The consequences of not following the regimen can be dire.

One of the more unpleasant side effects of surgery is dumping syndrome, when undigested food moves too quickly into the small bowel. It happens after bariatric surgery if patients eat too much or foods high in fat and sugar. Result: Fever, diarrhea and vomiting that can last for days.

Natassia reports she has had more trouble remembering to eat, since she doesn't feel so hungry. She is elated at her weight loss.

"Moving around is easier. I'm not as tired as before. And, now, I look forward to going clothes shopping," she said.

• • •

The long-term health effects of weight loss surgery in children are not yet fully understood. The National Institutes of Health is following a group of 250 adolescent patients for 10 years to find out whether severely restricting nutrition has long-term effects on development. Results are expected in 2016.

What doctors do know is that even bariatric surgery is not a guaranteed route to lasting weight loss.

Natassia's surgeon is Nestor de la Cruz-Munoz, chief of laparoendoscopic and bariatric surgery at the Miller School of Medicine at the University of Miami. He added teens to his bariatric practice in 2009 after a woman came to him in tears.

She told him her 16-year-old son was morbidly obese, and so desperate he wanted to kill himself. She begged for help.

After surgery, "he lost 75 to 80 pounds and was a changed kid. He lost all his excess weight and had a great result."

But, the surgeon said, not all his patients — teens or adults — have such an outcome.

"Even with the procedure, many are still overweight or obese," said de la Cruz-Munoz "We aim for 5 to 10 percent weight loss to achieve medical benefits, meaning high blood pressure, diabetes and apnea resolve.''

Most of his patients lose about 30 percent of their excess weight, he said. That's a major health improvement, but perhaps not the transformation most teens have in mind.

• • •

Surgery makes it tougher to overeat, but not impossible. Over time, the smaller stomach that pouch surgery creates can be stretched so that patients regain weight.

Amanda Rodriguez, the Hialeah teen who had so many health problems due to obesity, is another patient of de la Cruz-Munoz,

Now a 19-year-old college sophomore, Rodriguez lost 122 pounds after her 2009 surgery, putting her at about 180 pounds.

As careful as she tries to be, it doesn't take much to upset her system. She still can't eat and drink at the same meal without becoming ill, and has suffered a number of "dumping'' episodes. She must wait a full hour after eating before taking a few sips of water, or she becomes ill.

Even though she wishes she could lose more, she says the sacrifices have been well worth it.

Her health problems have all been resolved, and the girl who needed an elevator pass today performs in the marching band and goes to Zumba class.

But weight will always be a struggle.

"I'm a little frustrated with myself because I didn't stay on task,'' said Rodriguez, explaining that she added about 10 pounds over the summer.

"Still, I'm a lot happier than I was when I was in high school.''

• • •

Both Amanda and Natassia went through extensive screening and preparation at the University of Miami to determine if they could stick to the program for life. Experts say that's typical.

"It's very important to be very selective about who is offered surgery," said Dr. Jeffrey Zitsman, director of the Center for Adolescent Bariatric Surgery at New York-Presbyterian Morgan Stanley Children's Hospital. That program started in 2006 and has treated 150 patients.

"If they aren't going to change from the outset, there's no point in having them undergo an operation."

The changes go well beyond the menu.

"Something happened to get them to that weight," said Dr. Denise Edwards, medical director of USF Health's Healthy Weight Clinic based at Tampa General Hospital.

"Poor nutrition, poor coping skills — something was going on and until that is addressed, they won't be able to keep the weight off."

Norma Vargas-Suarez, a registered dietitian with Why Weight at St. Joseph's Children's Hospital in Tampa, has similar concerns, especially when it comes to young adolescents.

"We're talking about sixth- and seventh-graders making a lifelong change that can come with complications, like losing their hair from vitamin deficiency and uncontrolled vomiting when they go off the diet.''

But Edwards says she can see cases where surgery is appropriate — after underlying issues are resolved.

"Sometimes the solution is to work on those contributing issues first, see how growth balances out their weight and then we can talk about surgery," she said.

Irene Maher can be contacted at [email protected]

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