Since the start of weight loss surgery in the 1950s, most patients have been adults with severe obesity. Nowadays adults aren't the only ones that struggle to lose weight and keep it off. Because obesity is on the rise among children and teenagers, pediatricians are now calling for weight loss surgery to be more accessible to this age demographic.
The American Academy of Pediatrics (AAP) decided that metabolic and bariatric surgery should be considered a safe treatment option for children and teens with severe obesity. They are also recommending that it be covered by insurance for young people. The AAP published this recommendation in its first policy statement on surgical treatments for children and teens with severe obesity which was published on October 27, 2019 in the medical journal Pediatrics.
"This policy statement focuses more upon acceptance of and access to appropriate care than anything else," said Dr. Kirk Reichard, surgical director of the Bariatric Surgery Program at Nemours/Alfred I. duPont Hospital for Children and co-author of the policy statement. "Right now there's a lot of variability in what's paid for. There are certain plans that simply consider bariatric surgery under the age of 18 as experimental, which means they're not going to be covered," Reichard said.
"This policy statement specifically says that there's no specific age guideline. Furthermore, we recognize that severe obesity in children disproportionally affects racial and ethnic minorities, and the economically disadvantaged, especially for girls."
Avery Feinstein is already reaping the benefits of this surgery. Last year, when Avery was just 18 years old, she underwent a gastrectomy. This is when surgeons remove part or all of the stomach. She called the new AAP recommendations “awesome”. Avery said that she hopes more awareness is raised around adolescent bariatric surgery for kids and teens.
"It changed my life and it's cool that they're going to try to help other people change their lives too at a young age," Feinstein said. "It's helped me so much with who I am now," she said. "If I did that in older age, I would miss my college years, living like how I am now and having the best time of my life."
Avery is now 19 years old and a sophomore at the University of Missouri. She said that she is thriving thanks to the surgery. The gastrectomy caused her to lose 70% of her excess body weight as well as helped her resolve her other health issues. Since the surgery, she has joined a sorority and is currently studying to be a psychiatrist.
Avery continues to eat a healthy diet and stay active by riding her horse, Rudy. Although Rudy is having the time of her life now, her journey to this point has been anything but easy. Feinstein said that she had struggled with her weight throughout her childhood. She tried going to a weight-loss camp in middle school but that didn’t help. She also tried going on a strict diet but that also wasn’t helpful. Avery was becoming more self-conscious and concerned about her health as she continued to gain weight.
"I was trapped in how big I was," she said.
When Avery was 17 years old, her mother took her to a nutritionist at Ann & Robert H. Lurie Children’s Hospital in Chicago. It was that nutritionist that recommended she visit the hospital’s bariatric surgery program.
Right away, Avery knew she wanted to do the surgery. She was hoping that with the help of the hospital staff and support from her mother that she could get the surgery before starting college in the fall. "I had no clue that this could have been an option," Avery said about the surgery. "I knew that I was going to go off to college and this was the perfect time to turn my life around," she said. "This was something that was going to help me become the person that I wanted to be, and not the person that I was."
Obesity currently affects 1 in 5 children and adolescents in the US. It has the ability to raise the risk for many other health problems like diabetes, heart disease, stroke, arthritis, breathing problems, and certain cancers.
When Avery was admitted to the bariatric surgery program, her body mass index (BMI) was 46 and she also suffered from sleep apnea. Dr. Ann O’Connor, a pediatric surgeon and director of the adolescent bariatric surgery program at Ann & Robert H. Lurie Children’s Hospital in Chicago, said that they use BMI to decide whether surgery is the best treatment approach for an obese person.
"People who have a BMI over 40, they normally would be people you would consider candidates for surgery," O'Connor said. "If the BMI is 35 and higher, and they have other health problems like diabetes or hypertension or sleep apnea, then they might be candidates as well,” said Dr. Ann. Another requirement of the program is that "teens must be 13 years or older and mature enough to understand the implications of surgery."
Avery said that the surgery isn’t just a magic solution. "You have to do most of the work and the surgery is just a little bit of help," she said.
In order to prepare for the surgery, Avery was required to participate in a six-month diet and exercise plan. This is set in place to encourage lifestyle changes that patients will continue once the surgery is completed. Avery also was required to stabilize her weight during that period. "If you're going to choose to do this surgery, you have to change your lifestyle. This surgery is not just 'here's a fix.' You have to do most of the work, and the surgery is just a little bit of help. You have to be mentally ready for it," Avery said.
While Avery was completing the six-month preparation program, her family still didn’t know whether the procedure would be covered by insurance. Avery said her mom had good insurance through her company but they still had to go through an extensive process to get it approved.
"Every day, I would be like, 'Mom, did they call? Do we know if insurance approved it?' And so that was definitely a huge factor for me and my family," she said. "It was nerve-racking." Averys insurance approved the procedure and agreed to pay a portion of the costs about a month before the surgery.
The procedure was performed robotically and removed 80% of the stomach which helps limit the amount of food eaten and helps improve metabolism. "She started off in the morbidly obese category and is now at a normal body weight," O'Connor said. "She's done great: zero complications and resolved all of her health issues."
Dr. Marc Michalsky, surgical director for the Center for Healthy Weight and Nutrition at Nationwide Children's Hospital in Columbus, Ohio, and an author of the AAP policy statement said, "There are a lot of misconceptions about the appropriateness of bariatric surgery in the pediatric world."
"At the end of the day, what this policy statement is saying is that bariatric surgery as a treatment strategy for severely obese pediatric patients is safe and effective and should be considered early in patients."
"As the rate of childhood obesity continues to increase, it's critical for us to identify whether weight loss procedures that are frequently performed on adults are also safe and effective options for adolescents," said Dr. Robert Swendiman, a sixth-year general surgery resident at Penn Medicine in Philadelphia. "For certain patients, surgical therapy may be the best option for long-term treatment."
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