The challenges that face adolescents in their fight against obesity and the solutions available to help them, including weight-loss surgery.
Adolescents and Weight Loss
The adolescent population, generally accepted to be those between the ages of 13 and 19, face specific medical, nutritional and social challenges in their struggle with obesity and weight loss. Physicians and surgeons now offer customized solutions that are geared towards adolescents and address the specific issues that face this age group.
“Specifically what is challenging with adolescents is measuring success,” says Jennifer Rosenblum, MD, who is a board certified physician in adolescent medicine with a specialty in obesity medicine at MassGeneral Hospital for Children (MGHfC). “Typically the measure of success is the amount of weight loss, but with adolescents, you might find that they are not losing weight in the program, but they are not gaining weight either, which has been their trend. We consider even weight maintenance to be a success for adolescents. The reason is that they are still growing and their expected body mass index (BMI) is changing. So as they grow but maintain weight, their BMI will actually improve.”
Rosenblum adds that there are also modern day challenges facing adolescents. Portion sizes have increased along with consumption of sugary drinks while exercise and physical activity has decreased. Adolescents may also not be as autonomously motivated as adults to do the work that might be needed to lose the weight.
In addition to seeing patients at MGHfC, Rosenblum runs the MassGeneral for Children Weight Management Program at Newton-Wellesley Hospital. The program is a consultation service for adolescent and young adult patients with obesity.
“What we do for every patient in our program is a comprehensive evaluation, which includes a medical evaluation, nutritional evaluation, laboratory work and a psychological screen,” says Rosenblum. “As part of the psychological screen, we identify such issues as social isolation or teasing, body image and self-esteem, or binge eating problems. These are big parts of what adolescents face and if we feel that a certain patient might need more help, we’ll recommend therapy with a psychologist. There is a huge psycho-social aspect that is especially or significant in adolescents.”
Rosenblum’s team sets a customized plan for each patient, which typically involves nutritional counseling and evaluating the need for medications, and if appropriate the need for surgery. “While it is always a last resort, patients who don’t do well with the medical, nutritional or behavioral treatment and end up being diagnosed with serious or emergent conditions might be recommended for weight loss surgery,” says Rosenblum, who refers patients under 18 to the adolescent bariatric surgery program at MGH.
Surgery is an option for adolescents who face severe medical and health risks
Janey Pratt, MD, is the co-director for Surgery at the MGH Weight Center and head of the Adolescent Weight Loss Surgery Program (AWLS Program). The multidisciplinary pediatric medical weight loss program at the MGH Weight Center and Rosenblum’s program both refer into the AWLS program at the MGH Weight Center.
Pratt’s program is the first of its kind in New England, one that she considers very important because adolescents are a unique population and deserve to have this type of treatment available to them.
“Even though it is not the answer for most adolescents, there are some adolescents who suffer from severe obesity and have a very high chance of being obese as adults,” says Pratt. “Many of these adolescents have already developed complications from obesity and should be offered weight loss surgery without having to wait until they are 18 years old.”
“The adolescent who is going to be the right candidate for early surgery has to be self-motivated; it cannot be coming from their parents. They have to want surgery and have realistic expectations about what surgery can and cannot do for them. Our team decides who is ready and who is not based on many visits with each member.”
Medical conditions, which require treatment before surgery are occasionally the cause for delay in surgery; however, according to Pratt, most of the concerns are related to the patient’s level of maturity and motivation. In general, patients have to go through a six-month medically managed nutrition and behavior modification program before they are considered a candidate for weight-loss surgery. Exceptions are made for some patients – for example, those who come from Rosenblum’s program at Newton-Wellesley and have already had such a program, are immediately placed into the surgical program.
The surgical program involves monthly pre-operative visits leading up to the surgery. After the successful surgery, each patient is scheduled for monthly post-operative visits with a dietician and psychologist and a bi-monthly visit with the pediatrician or surgeon. They are kept on a liquid diet for 2-3 weeks before and after surgery and usually spend about three days in the hospital, and two weeks out of school, if surgery is done during the school year. Patients are often paired with other adolescents and surgeries are more commonly done over school break or in the summer.
There are patients who have a hard time adjusting to a new diet and lifestyle and find themselves adopting old habits. “Sometimes we will get calls from our adolescent patients who say that they are not doing well,” says Pratt. “However the difference is that adults will say directly that “I am not eating as well as I should,” whereas adolescents are more likely to call and say that their stomach hurts or that they have a headache. We then have to diagnose the real problem and schedule those patients for additional visits with the dietician or the psychologist.”
In addition to the clinical challenges, there has been some resistance among the general public to the idea of adolescent bariatric surgery. Pratt feels that many people are biased against weight loss surgery at any age because they feel that obesity is a choice and that patients can just stop eating and exercise to loose weight. She counters that research has shown that severe obesity is not under volitional control but rather a disease caused by storage of excess fat.
Finally, as a clinical practice, weight loss surgery is somewhat newly chartered territory, so each patient is treated with extra care. “For us, safety is paramount, and we wouldn’t develop this program if it weren’t safe and truly life saving for a section of the population that didn’t really have targeted programs in New England,” says Pratt. “The concept of pediatric transplant surgery went through almost the same path we are going through. There was controversy surrounding pediatric transplants until it was accepted that it was the only lifesaving treatment for organ failure and should be provided for children as well as adults. With education, awareness and time we can make great progress in adolescent bariatric surgery as well. It is lifesaving treatment and should be provided for adolescents as well as adults suffering from obesity.”