Teenage Waistland (36 page)

Yet we all know skinny people who seem to be able to eat anything and never gain weight. They never seem to watch what they’re eating, and they don’t seem to exercise much. So maybe the answer
isn’t
so simple.

In fact, obesity is a very complex subject. For the most part, genetic factors determine how quickly and efficiently our bodies burn fuel. But hormones also play a part in determining our weight: some hormones make us feel hungry; others make us feel full. A host of factors influence how well our bodies absorb what we eat, how quickly food travels through our gastrointestinal tract, and how our hormones (particularly insulin) function. Metabolic factors go hand in hand with many eating disorders, some of which are associated with excessive weight gain (and some with excessive weight loss).

Most obese teenagers have an adult in the family who is also obese. That person may have heart disease or diabetes, trouble breathing, or less apparent problems like high cholesterol or fatty liver. Adults who are obese may first begin to address their weight problem seriously only when their health is in real jeopardy. Obese teenagers in the program at Columbia University Medical Center whom we have surveyed state that they, too, are concerned about their own health.

No doubt that’s true. But that’s not why most adolescents really want to lose weight.

Most obese adolescents who try to lose weight do so because their obesity is having a serious impact on their
social lives. For many, being fat means being made fun of. Their choice of clothes is limited. It may be difficult or even impossible to sit in a movie theater, or even in a desk at school. Trying to squeeze onto public transportation is embarrassing. They may feel that their weight is keeping them from getting dates, never mind steady boyfriends or girlfriends. They find it hard to exercise because they run out of breath quickly and their knees and ankles hurt. They become depressed. In short, obese adolescents have a tough time trying to lead the kind of lives their nonobese peers do.

There are many ways people try to lose weight. Most try to eat less and give up sweets or other “fattening” food while doing some exercise. Some try hypnosis, acupuncture, or meditation. Some join a gym or a school sports team or hire a personal trainer. Most people can lose ten to fifteen pounds, maybe even more, with these changes. Well-advertised diet programs can have similar results. Sleep-away camps for overweight kids often go further; kids who attend may lose thirty to fifty pounds or more. The end of camp, though, means less control over their environment, less structured support, and less physical activity; within a few months of returning home, many kids will regain some or even all of the weight. Indeed, the weight loss industry is huge and keeps growing. People can buy almost anything to supposedly help them lose weight, from dietary supplements to workout equipment to belts. Few of these products and services are
regulated by the FDA, and their effectiveness is mainly anecdotal.

A few medications have been approved by the FDA to help obese people lose weight, often by interfering with food absorption or by making the body burn more fuel. These medications can have side effects that range from unpleasant to intolerable. Recent studies suggest that people with underlying heart disease may be increasing the risk of a heart attack by using some of these medications. And remember: genetic factors heavily influence how easily a person can lose weight, with or without the use of medication. Bottom line: losing more than fifty pounds is
really
hard to do.

Surgery becomes a consideration when a person is morbidly obese and has not successfully lost weight in spite of a prolonged and concerted effort. The goal of obesity surgery is not to remove the fat (as is the goal of liposuction, which gets rid of some external body fat tissues but does not cure obesity) but to limit the number of calories that the body has available to absorb. Most such operations are categorized as
restrictive
or
malabsorptive
, though some use both mechanisms.

Gastric bypass is the most common operation used to treat obesity in the United States. During this operation the stomach is divided, leaving only a small pouch into which food passes from the esophagus. The intestine is also divided, and one end is attached to the little stomach pouch. The result: the small stomach pouch limits the
amount of food the person can eat (restriction), and the intestine bypasses the area where breakdown of that food normally takes place, so that less of it actually gets absorbed (malabsorption). People who have this operation can lose a lot of weight in a relatively short time, but they don’t absorb vitamins and minerals well and need to take nutritional supplements to avoid vitamin deficiencies. The operation itself is technically challenging and is best done by someone with considerable experience.

Gastric banding is an operation that has been used more in Europe, Australia, and South America than in the United States, in part because the bands have only been approved since 2001. Gastric bands have still not been approved by the FDA for use in the United States for anyone under the age of eighteen. As of this writing, just four centers in the United States are permitted to perform gastric band surgery, provided they follow an FDA-approved protocol. Banding is a purely restrictive procedure; by narrowing the inlet to the stomach, the band converts the stomach into an hourglass-like configuration. Food reaching the uppermost part of the stomach is held up, making the person feel full or “restricted” soon after starting to eat; the food then gradually passes into the stomach and then into the intestine, where it is digested in the normal way. There is no malabsorption. To benefit from gastric banding, though, a patient needs to learn how to eat in such a way that the band will help him or her lose weight. High-calorie juices or drinks like milk shakes will zip right
through, and all of those calories will be absorbed. Eating too much or too fast will cause food to get stuck, making the patient throw up—not the best way to lose weight. By using the gastric band to eat less, the patient can reduce the number of calories taken in without feeling hungry. Fewer calories, more weight loss.

Other operations for obesity, such as gastric sleeve resection and the duodenal switch, have been used successfully in a few teenagers. Regardless of the procedure, many teenagers who undergo weight-loss surgery are able to improve or correct their obesity. Anyone—teen or adult—who is considering such surgery needs to learn as much as possible about it. Information is available online, and high-volume obesity surgery programs are good resources for researching the procedures.

Weight-loss surgery is an option for teens who have been severely obese for many years; it is not intended for overweight individuals who want to lose a few pounds, nor is it an alternative to dieting and exercise. Surgery is really only for morbidly obese adolescents who have tried to lose weight other ways and have been unable to do so. Not every obese person will be a candidate for a surgical weight-loss procedure; criteria are available online at the NIH website.

Teenage candidates who enter a surgical weight-loss program undergo extensive screening by a multispecialty team. Specialists in endocrinology, gastroenterology, and adolescent medicine are often members of the team, and
consultants in pulmonary medicine, cardiology, and kidney disease may be asked to see the potential patient. A nutritionist’s evaluation is essential, especially if eating behavior may have a significant impact on a successful weight-loss procedure. A psychiatrist and/or a psychologist sees every candidate. After extensive testing and repeated evaluations, the team determines whether or not a candidate is likely to benefit from surgery, then discusses that assessment with the candidate and his or her family. Some teenagers have family members who have already undergone weight-loss surgery, providing some degree of experience and support. Other families have members who may be indifferent or even hostile to the teenager’s plans. In the best situation, the patient has lots of support and feels little pressure from family and friends, but ultimately the patient himself or herself needs to be motivated to lose the weight and to follow through with the changes necessary to keep the weight off.

In our program at Columbia University Medical Center, the teenager interested in gastric band surgery comes with at least one parent for an interview and to learn about the program. If they would like to enter and meet protocol-specific criteria, the teen and the parent sign a voluntary consent to participate. Over the next several weeks the patient is screened by a nutritionist, a pediatric endocrinologist, and a psychologist. Lab tests and imaging studies are obtained. Each patient is given an individualized diet and exercise program. Over the next three to six months
the patient is reevaluated to determine how well he or she is making changes and whether there are any problems. At the end of that period, the patient is offered surgery if (1) no significant weight loss has occurred, (2) the patient has followed instructions, and (3) no psychiatric or medical problems have emerged or worsened that would make surgery ill-advised. After the operation, we follow patients for five years, making band adjustments as necessary. We then move the patients into our adult weight-loss surgery program for long-term follow-up.

How much weight can you lose with surgery? How much weight
should
you lose? A doctor can calculate your ideal weight based on growth charts and give you an estimate of your excess weight (the percentage of excess weight lost is used as a measure of success in practice), but whether you want to lose forty pounds or more than a hundred, you must work to lose enough weight to allow you to lead the life you want to lead.

Weight-loss surgery does not guarantee weight loss. Individuals who have restrictive procedures often have to change how they eat to lose weight; some have great difficulty making these changes. Almost all patients who undergo bypass procedures lose weight for several years, but the loss may be insufficient for their goals, or they may regain some of the weight. Additional surgical procedures may be an option.

Most teenagers who undergo weight-loss surgery will lose weight, but results vary. In our program, the average
person loses about a third of the excess body weight by the end of the first year after the operation. Some lose more in that year, and some gain weight. The patient and his or her team must work together to be sure that he or she has every chance for an excellent long-term outcome. For the right patient, weight-loss surgery may be the key to overcoming obesity.

—Jeffrey L. Zitsman, MD
Director, Center for Adolescent Bariatric Surgery
Morgan Stanley Children’s Hospital
of New York Presbyterian
Columbia University Medical Center

LYNN BIEDERMAN
is the coauthor of the acclaimed young adult novel
Unraveling
, available from Laurel-Leaf. She has worked as a librarian and as a lawyer and has enjoyed intermittent periods of being a professional time waster (which rises to a profession when one excels at it as she does). Currently, Lynn is back in the field of law and, during free play, vacillating between two obsessions—tennis and cooking.

Among her many incarnations,
LISA PAZER
has been an economist and editor, a Wall Street analyst and market commentator, a consultant and lecturer, an inventor and entrepreneur. With
Teenage Waistland
, Lisa has finally come home to her first love—fiction.

Visit the authors at
teenagewaist-land.com
.