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An interview with Dr. Thomas Inge

Learn about the Surgical Weight Loss Program for Teens at Cincinnati Children's Hospital Medical Center and get answers to some frequently asked questions by reading an interview with Thomas Inge, MD, the Surgical Director of the program.

Question: How much of a problem is childhood obesity for us?

Dr. Inge: Our best estimates suggest that about 18% of children and adolescents currently suffer from obesity1. A lot of attention has been focused on childhood obesity over the years. What is amazing though is that some teenagers are even developing what is termed “extreme obesity” or “morbid obesity.” This condition is present when someone’s weight for height (also known as body mass index or “BMI”) is higher than 99 percent of children their age. In fact, today more than two million children and teenagers are affected by extreme obesity2. This is more children than currently suffer from cancer or other major diseases of childhood. And believe it or not, these extremely obese kids are also developing adult-like complications of obesity. We worry about the fact that, even for children and teenagers, obesity is a progressive disease, which will very likely lead to continuing health problems and early death3,4. And one other little known fact is that obese teenagers are far more likely to carry obesity into adulthood than to outgrow obesity.

Question: So what are these health problems that obese kids are getting?

Dr. Inge: Children and adolescents with extreme obesity are coming to see us everyday with health problems, also know as “comorbidities” due to obesity. These include respiratory problems, such as obstructive sleep apnea. Obstructive sleep apnea is the term given to the condition when a child stops breathing during sleep, or when the child slows the rate of breathing down to critically low levels. Either way, it is quite a strain on the system, including the heart, the lungs and the entire body as the oxygen level falls to dangerously low levels.

In addition, we see teens who have developed type 2 diabetes. Type 2 diabetes is what was in the past called adult onset diabetes. Well, it is not just for adults anymore. So now we know that this disease is rapidly spreading in pediatric age groups, most notably obese teenagers. With this type of diabetes, the body is not able to use sugar properly. The pancreas is overworked to try to make enough insulin to be able to use the sugar. When the pancreas can’t keep up any more, the sugar builds up in the bloodstream and leads to excessive thirst, excessive urination and, ultimately, tiredness and weakness.

In addition, we see children and teens come in with:

  • High blood pressure (hypertension)
  • Enlargement of the heart (cardiac hypertrophy)
  • Fatty liver disease (nonalcoholic steatohepatitis)

Most important to the patients of course are the aches and pains they feel daily in their back, their hips, their knees, and their feet. The teens that come to see us commonly do not fit into desks at school and are put-down. They often end up home-schooled as a result. All of these things lead to a major effect on their overall quality of life.

Often quality of life, depression, and the difficulty that these teens have in fitting into society are overlooked by doctors who treat them. We have found that quality of life in these teenage patients who are coming in for weight loss surgery is worse than that of teens with less extreme obesity and worse than pediatric cancer patients5. We also know that these kids who are coming to see us have a lower chance of being married, staying married, going to college, and having a decent job, and these social and economic consequences of teenage obesity are greater than those seen with other chronic diseases of childhood6. Opportunities for socialization missed in adolescence may represent losses that cannot be replaced. These “comorbidities” are hard to quantify and judge but are real and must be considered.

Question: How do kids become obese in the first place?

Dr. Inge: That is certainly the question that everyone wants and answer to. And if I knew it, I could probably retire soon. The potential causes of obesity are many. Most scientists who study this disease firmly believe that obesity comes about due to many factors, not just one or two in a person’s life. Most scientists point to a very complex interaction between the genetic makeup of a person, the person’s individual body chemistry and hormones (metabolism) and things in their immediate environment. The environment is the thing that has probably changed the most in the last 30 years. It is after all the last 30 years that we have seen the major increase in this problem of adult and childhood obesity. So, what is it in the environment? Our lifestyles have certainly changed over the years, and fewer children have access to parks and physical education programs at school. Other factors in the environment are the quality and the quantity of food available to us all. For instance, it is nearly impossible to find food that has not been filled with high fructose corn syrup. This food additive is perhaps one of the major problems we have today. It is much harder today to get the right amount of fiber into our bodies as well, given the fact that food processing removes the beneficial fiber so that food can be stored longer. So, with so many potential causes for obesity, and the complex interplay of these causes, successful treatment and prevention of obesity are equally hard to accomplish. It is unlikely that we will find a simple, single method that will be successful for everyone affected with obesity.

Question: What we can do about pediatric obesity?

Dr. Inge: Ok, for starters, when we have a medical problem that needs to be addressed, we always try to think about the least invasive and least risky way to go first, right? Obesity is no different. We would like to think that we could be successful with dieting or with a miracle drug treatment for obesity.

The first line of treatment is typically to try our best to identify the things in your lifestyle that are promoting weight gain and do something about these behaviors. So, we use the term “behavioral modification” to indicate that those things that someone is doing that are leading to obesity have to be changed. This usually means that we aim to decrease intake of calories. This doesn’t mean we starve people. But there is so much that the typical family does not understand about nutrition and about reading food labels, and how to make better food choices. Sometimes, the “quick fix” is to simple cut way back on sugared drinks. Sometimes it is looking for the other major sources of calories that can be cut. Sometimes it is simply getting someone to eat breakfast, which research has shown over and over to be helpful for reversing a weight problem. We also like to get people to think about ways they can increase their activity level throughout the day. We firmly believe the old adage “what you eat, you have to burn, or else you gain weight.” So, if we burn just a little bit more than we eat each day, we can get gradual weight loss.

In some adolescents and adults, drugs for weight loss have also been tried. Some of the drugs decrease appetite. Some of them let fat that has been eaten pass through the body instead of entering the body.

Unfortunately, long term studies have not shown any major weight loss using dieting or drugs for the majority of obese adults or teenagers. The best non-surgical treatments for pediatric obesity have high drop-out rates, and typically result in less than 5% weight loss7-9.

Question: What treatment is effective then?

Dr. Inge: Because dieting and “medical” weight loss is so ineffective for the vast majority of teens who are extremely overweight, it has become increasingly important to consider how best to help them. What we know from adults who have had weight loss surgery is that surgery can cure morbid obesity. So, figuring out the best way to take care of these teenagers using surgery has been a major emphasis at Cincinnati Children’s Hospital Medical Center since 2001. At Cincinnati Children’s, we like to believe that weight loss surgery can provide an early and effective tool for the patient to help them prevent serious health problems due to their weight.

Question: What has the research shown us about surgery for obesity in adults?

Dr. Inge: During the past 30 to 40 years, research into the effect of weight loss surgery has clearly shown us that significant and sustained weight loss occurs following surgery. Most notably, gastric bypass surgery has been studied. The patients who have undergone gastric bypass have typically lost about a third of their weight, and 80-85% of them keep the weight off. That is not a bad result, especially since 95% of people cannot manage to lose weight and keep it off any other way. What is even more impressive is that when the weight is lost, the health problems that come with obesity are lost as well. There is even new research from Canada, the United States, and Sweden that shows that surgery can absolutely reduce the number of deaths due to obesity. So, the good research that has been done shows us a lot of benefits to having surgery. There are at the same time risks that come along with any major surgical procedure of course. I am sure you will also ask about these.

Question: Has surgery been done successfully for teens who are obese?

Dr. Inge:

Yes, the numbers show that about 0.7% of the weight loss surgery cases in the United involve teenagers10. But when you look at information collected from dozens of hospitals across the United States, the rate of teenage obesity surgery has increased three-fold over the past decade, and there have been well over 3,000 adolescent bariatric cases performed in the United States as of 200310. We have to believe that this rise in use of surgery has to be prompted by something significant. I think it is due to a realization that surgery does work for weight loss. I think it also is due to a realization that surgery can reverse some of the really significant health problems that obese people suffer with.

Question: How many surgeries have been done for adolescents at Cincinnati Children’s?

Dr. Inge: Cincinnati Children’s was the first pediatric hospital in the world to set up a surgical treatment program specifically tailored to the needs of the extremely obese teenager. The program is called the Surgical Weight Loss Program for Teens. Since we started in 2001, we have performed nearly 100 operations as of the summer of 2008. This is the largest amount of encounters at a single hospital in the world. We have done a fair bit of our own research and have published our findings in some of the most recognized medical journals. We have also been fortunate to have grants from the National Institutes of Health to help us with our research now and into the future. In fact, we lead the most comprehensive study to date on this topic. This is the Teen-LABS study that will run until 2012. Learn more about this study.

Question: What things do you think about when considering surgery for teenagers who are obese?

Dr. Inge: Experienced weight loss surgeons know that proper patient selection is critical. Who is eligible, who is not eligible, and what should be done before surgery to best prepare patients and families?

So, when considering the use of weight loss surgery, if you are an adult, there are clear-cut guidelines that were developed in 1991 by a group of experts that came together at the National Institutes of Health11. Based in large part on this conference, there has been broad agreement that adults with extreme obesity who had not been successful with prior weight loss attempt should be seen as candidates for surgical weight loss. Bariatric surgery has now been shown to be safe12, effective13, and durable14 in adults. However, a lot of people, including pediatricians, think there are good reasons to be a little more conservative when thinking about an operation in teenagers15. Why? There are fewer studies that show us the exact outcomes we should expect (safety and effectiveness). Some are also concerned about the willingness of teenagers to adhere to postoperative dietary, physical activity, and other nutritional recommendations. Best outcomes are expected in patients who are adherent with the dietary, vitamin/mineral supplement, and physical activity recommendations, using the surgery as a “tool.”

That said, we have seen that most teenagers will loose one third (yes, 33%) of their weight over the first year. With this, we have seen significant improvement or resolution of major health problems related to obesity including for instance type 2 diabetes, obstructive sleep apnea, fatty liver disease, high cholesterol, high insulin levels, and high blood pressure. We have also seen major improvements in quality of life after surgery.

Question: Can weight loss surgery be used to treat type 2 diabetes in teenagers?

Dr. Inge: Yes, our research has shown significant treatment results for diabetics. Type 2 diabetes has traditionally been considered an adult disease. But currently, nearly half of all new pediatric diagnoses of diabetes mellitus have features most consistent with type 2 diabetes, representing a more than 10-fold increase in incidence over the last two decades. We knew that surgical weight loss has resulted in significant improvement in diabetes in adults. So, to see the results in teenagers, we carefully evaluated 11 teenagers with type 2 diabetes before and one year after they underwent Roux en Y gastric bypass. We looked at their weights, blood pressures, and blood chemistries, and diabetes medication usage. What we found was that all but one of the teenagers who underwent gastric bypass had remission of diabetes (normal sugar levels without need for diabetic medications). Significant improvements in weight (loss of 34%), fasting blood glucose (41% improvement), fasting insulin concentrations (81% improvement), and hemoglobin A1C levels (7.3% to 5.6%) were also seen. There were also significant improvements in serum lipids (eg., cholesterol) and blood pressure.

In comparison, we know that teens with type 2 diabetes who do not undergo surgery are highly likely to remain severely obese and are likely to see progression of their diabetes. So, we do feel as though extremely obese diabetic teens do stand to benefit greatly from gastric bypass and can see significant weight loss and remission of type 2 diabetes due to the surgery. Our experience suggests to us that gastric bypass is an intervention that basically improves the health of these adolescents. Although the long-term effectiveness of gastric bypass is not known, these findings suggest that surgery should be viewed as an effective option for the treatment of extremely obese adolescents with type 2 diabetes.

Question: Does sleep improve also after weight loss surgery in teenagers?

Dr. Inge: Yes, in research that has been conducted by Dr. Maninder Kalra in our sleep laboratory here at Cincinnati Children’s, we have found out some very interesting and reassuring things. It turns out that sleep and obesity are very inter-related. Sleep duration as well as sleep quality (eg., the lack of fragmented sleep) most likely play a role in the development and progression of obesity and obesity-related health problems. So when we set out to determine the effect of weight loss on sleep quality in teenagers with severe obesity, this is what we found. First, we conducted a very detailed look at sleep patterns by measuring brainwave activity during sleep and by measuring breathing during sleep in teens before and after weight loss surgery. These sleep studies were conducted in 19 patients with an average age of 16.5 years old who were about 200% over their ideal body weight. We found that three quarters (74%) of the patients had episodes of airway obstruction (obstructive sleep apnea) before surgery. At about 1 year after surgery, these patients had lost about 130 pounds on average. They also demonstrated a 3-fold improvement in sleep apnea. They had increased sleep quality and fewer unexpected awakenings from deep sleep. So, this research does show that teens should expect a significant decrease in sleep apnea symptoms (mainly snoring and daytime sleepiness), as well as major improvements in sleep quality after surgical weight loss.

Question: What is the process that a family can expect when they come to the Surgical Weight Loss Program for Teens?

Dr. Inge: We stress to families that we don’t just offer an operation for weight loss. What we offer is an entire program for weight loss, using the most effective, modern, and safe procedures available. So there are a lot of things we need to look at along the way to the operating room. Does the teen and mom or dad understand fundamental concepts about what causes weight gain and weight loss? Do they know what foods are nutritious and which are not? Are there things at home that will be challenges to the success of the teenage weight loss surgery patient? How is this treatment viewed by other family members? Is everyone on-board with this and willing to help the patient be successful? We would like to have some indication that the patient’s or family’s circumstances will not increase the risk of a poor outcome (eg., weight regain, nutritional problems) if the surgery is done. Many of these issues are easy to address. Others may take more time.

On this point, we have seen many 14 and 15 year olds who are mature, have an understanding of what we are talking about, and can clearly participate in the making decisions about their treatment. These kids have a high likelihood of success following weight loss surgery. On the other hand, we have also seen even older teens, for instance, 18 and 19 year olds, who are of legal age to make their own decisions, but who are not yet mature enough or capable enough in their living situation to have success with surgery.

So, from this, the topic of patient selection is actually very individualized, and complex. “Guidelines” only take us so far, and our experience is such that we know that we have to consider unique circumstances in every case. This takes a team approach with a number of experts involved. At Cincinnati Children’s we offer that kind of “family-centered” care. You see, the decision to operate for extreme obesity in teens requires what we call a “multi-disciplinary” approach. One must take in account medical and psychological health and the ability and willingness of a patient to be adherent to health care recommendations.

Question: Tell us about some of the common operations and the risks associated with them….Let’s start with the Band.

Dr. Inge: Matching a patient to an ideal operation is not an exact science. Admittedly, it is difficult to make decisions sometimes.

One procedure is the adjustable gastric band. The FDA approved this device in 2001 for adults. But the FDA has not yet approved the adjustable gastric band for people less than 18 years of age. The gastric band has received tremendous popularity it is an encouraging tool across the board for management of obesity16. Its use is expected to continue to grow in adults, and many believe it will be useful to some teens. But others say that despite the simplicity of the band operation, they worry about how it will work for children and adolescents. Does it keep its position with growth of the child? How do you select the correct size?

An important consideration for band usage is that there are a limited number of hospitals in the United States that have done research on it for use in adolescents. It is removable, which is not the same as reversible. For the band, there is a low risk of death due to the operation, likely the lowest risk of any bariatric operation17. There should be no vitamin deficiencies and the absence of vomiting. Prolonged vomiting has been associated with micronutrient deficiencies after bariatric procedures18.

The incidence of complications after use of the band increases with time, particularly gastric slippage and stomach erosion. And these problems are not insignificant. The risk of these problems does not seem to decrease with the surgeon or hospital volume. The slippage incidence is probably 2% when the best technique of operation has been used. Erosion risk is around 2% also. The band is a foreign body. There is less weight loss with the band than with other operations. Some studies show significant weight loss, but that is not uniformly observed. But is absolute weight loss the most important outcome or is resolution of obesity related health problems equally important? Bands require adjustments. In some young teenagers, there can be objections to shots and needles in general. So, for patients who may need several band adjustments within the first year, using a needle to do the adjustment, how will young patients comply?

Finally, with the band, there’s no protection from the sweets. Kids are sweet-eaters; they like sweets. Everything from catsup on is a sweet nowadays. And sweets are not well restricted by a band.

These concerns do not necessarily mean that the band is a bad choice. As yet, we just do not have an abundance of good research to help us to make important decisions. There are some major studies in progress now, which will be very useful.

Question: What about the Roux en Y Gastric Bypass?

Dr. Inge: The gastric bypass is the operation that we have the longest to follow-up and it is the standard against which all procedures should be judged. It is not easy to reverse, but it is reversible. Weight loss is rapid, about 5 pounds per week initially. Most teens will lose the majority of their weight within the first 12 months after surgery. An advantage is that there is no need for adjustments. For patients with insulin resistance and type 2 diabetes, we see 99% improvement and over 90% complete reversal of type 2 diabetes. This is significant because this will be the most common type of diabetes that we see in the next decade in adolescents, not Type 1 as was the case before now.

The risks for gastric bypass are numerous. Gastrointestinal leaks are one of the most significant complications. Bleeding is a serious complication, but is also fortunately rare. Ulcers are a risk for people who take pain medicines like Ibuprofen after the operation. Internal hernias are significant long-term potential complication.

Nutritional deficiencies, especially with the B complex vitamins, are another concern. The younger patients, 12, 13, and 14-year-olds, may have better adherence than older adolescents. They tend to do what they’re told and are even better than the adults in many cases. All nutrient deficiencies following the gastric bypass can be treated with oral administration.

Question: What about other operations that short-circuit the gut?

Dr. Inge: We generally do not perform malabsorptive procedures for adolescents. After the duodenal switch or biliopancreatic diversion, very high risks of nutritional problems are present. In addition to poor calcium absorption, patients are at considerable risk of vitamin A, D, E, and K deficiencies. The need for protein intake to prevent malnutrition is also a significant consideration19. Dietary choices and behavior in teens can be difficult to predict. The published risk for revision from malnutrition is 4%. The incidence of diarrhea is 3%. This is difficult to manage in school where one needs a hall pass to go to the bathroom because patients can have several bowel movements per day, it’s not likely to be a good option for adolescents.

Question: What about the Sleeve Gastrectomy?

Dr. Inge: The “Sleeve Gastretomy” has been gaining in popularity despite having the least research available about what to expect after the operation. The sleeve is not a new operation; it represents the first stage of the duodenal switch. Physiologically, it can be justified based on the Magenstrasse-Mill operation done in England, published in the 1980s20. The largest part of the stomach is removed, leaving the bottom part (the antral pump) intact to continue to move things along and preserve the churning, mechanical aspects of digestion. There’s a long staple line that is a leak risk. The weight loss recorded for one to three years, and now even up to five years, is impressive with the majority of patients achieving 20-30% weight loss. So this is much better than any drug or dieting plan.

There is no need for adjustments and it is pretty straightforward to convert a sleeve to other standard operations if the need arises. For instance, a sleeve can be converted to a duodenal switch, gastric bypass or band. So, if weight regain occurs in the intermediate or longer term, it may be relatively straightforward to convert to an alternative reconstruction or device. Long-term results are unknown, but this is probably true for all the operations for adolescents. There’s probably a need for more than one operation for adolescents, just as is the case for adults.

Question: What can you say in summary about what operation to do for teens?

Dr. Inge: What we know is that surgery is a tool and is not a cure for obesity. Used correctly, this tool can be an enormous benefit for adults and teens alike. But it must be used in the context of a multi-disciplinary program to help the teen get their mind around not only their weight but any number of other issues that might affect their success. Specifically, the band is the least invasive tool but the potential need for more operations and revisions down the road must be recognized. The gastric bypass is the best known operation in terms of outcomes including long term weight loss but the immediate risks of the operation (days 1-30 after the procedure) are greater compared to the band. If you cannot have a reasonable expectation of adherence, nutritional risks, including beriberi and bone health, may be considerable. The weight loss is greater with gastric bypass than that seen with the band. The duodenal switch and related malabsorptive procedures probably should be avoided in teens based on what we know now. And the sleeve gastrectomy is the most unknown, although it has a lot of promise.

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