As obesity among young people continues to rise, a growing number of clinicians and researchers say that weight-loss surgery may be their best chance to take off significant weight and either correct or avoid conditions like diabetes and heart disease, which often go hand-in-hand with obesity. But although health plans frequently cover bariatric surgery in adults, insurance coverage for the procedure in patients under age 18 is spotty.
Experts in pediatric obesity say that caution is warranted and that insurers shouldn't just rubber-stamp such surgery in adolescents. But they say emerging research may lead to more coverage for young people.
Americans generally are getting fatter; more than a third of adults qualify as obese, with a body mass index of 30 or higher, according to the Centers for Disease Control and Prevention. But kids are putting on the pounds even faster than adults. Between 1980 and 2008, while the rate of obesity doubled in adults, it tripled for children, and 17 percent of them are now obese.
Bariatric surgery has found growing acceptance as an effective weight-loss strategy for adults. About 220,000 people had weight-loss surgery in 2009, according to the American Society for Metabolic & Bariatric Surgery. Three-quarters of companies with more than 20,000 employees cover the procedure for qualified patients. At firms with fewer than 1,000 workers, the figure is lower but still substantial: 46 percent, according to a 2011survey by human resources consultant Mercer. Almost all Medicaid programs cover it.
But coverage for the procedures often excludes teenagers. "It's harder to get teens covered," says Robin Blackstone, a bariatric surgeon who is president of the ASMBS. "Plans just say they cover people 18 and over."
Susan Pisano, a spokeswoman for America's Health Insurance Plans, an industry trade group, said she did not believe there was a consensus among physicians on how appropriate bariatric procedures are for younger patients. "There are also concerns about whether adolescents are mature enough to agree to surgery that will require behavior modifications for the rest of their lives."
A Smaller Stomach
The most common weight-loss surgeries involve either placing an adjustable silicone band around the stomach to make it smaller or shrinking the stomach and reattaching it to the intestine so that it bypasses a portion of the digestive tract, thus reducing the absorption of calories and nutrients. Although generally considered safe, long-term complications such as malnutrition, low blood sugar and bowel obstruction may occur.
To qualify for surgery, adults generally must have a BMI of 40 or more, or a BMI of 30 to 35 with a weight-related disease. Before surgery is approved, prospective patients typically must have attempted to lose weight through diet and exercise for at least six months, among other criteria.
Similar or even more conservative guidelines are usually applied to adolescents. But bariatric surgery is still very rare in this group; according to one estimate, no more than 1 percent of surgeries involve patients younger than 18.
There are good reasons to be cautious, experts agree. There are no strict age limits, but adolescents need to be both physically and emotionally mature before undergoing the surgery: They must have reached their adult height and be prepared to follow a strict dietary regimen for the rest of their lives or they risk regaining the weight they lost. Family support is important; if the child's family doesn't eat healthful meals, it will be almost impossible for the child to do so.
In addition, no one knows the long-term effects of interfering with adolescents' digestive systems and nutrient intake.
But many experts believe that the benefits of surgery could trump the possible risks.
"These kids are remarkably ill," says Marc P. Michalsky, surgical director at the Center for Healthy Weight and Nutrition at Nationwide Children's Hospital in Columbus, Ohio. Many children he sees already have BMIs in the high 40s and 50s and have developed several medical conditions related to obesity, he says. Many researchers believe that surgical intervention when the children are still young will allow their bodies to recover from the adverse effects of disease.
"The longer you have a disease, the more of a permanent toll it takes on your body," says Michalsky.
Nothing Else Worked
A small study published in the Journal of the American Medical Association last year found that adolescents who had bariatric surgery lost on average 79 percent of their excess weight, compared with 13 percent in a "lifestyle" control group enrolled in a traditional weight management program involving diet and exercise. After two years, none of the participants who had surgery had metabolic syndrome -- a group of risk factors for heart disease and diabetes, including high blood pressure, high cholesterol and insulin resistance -- but 22 percent of the patients in the lifestyle group did.
Risley, before and after bariatric surgery (Photos provided by Risley)
When Jackie Risley, 18, became a patient at Texas Children's Hospital in Houston a little over a year ago, she had a BMI of 48 and was carrying 280 pounds on her 5-foot-4 frame. She had Type 2 diabetes, high blood pressure and polycystic ovarian syndrome.
Risley had been seeing a nutritionist since third grade and had been on many, many diets. Nothing seemed to work; she never dropped more than 10 pounds. Food, she knows now, was a way to comfort herself when she felt unhappy or sad. But even food couldn't buoy her spirits as she watched her dad, who also has Type 2 diabetes, struggle with kidney failure. "He said, 'If you don't start losing weight, you're going to have these problems in your 20s,' " she remembers.
In November 2010, Risley had gastric bypass surgery. Now she weighs 140 pounds and no longer has diabetes. She's optimistic that her other obesity-related conditions will improve with time. A college freshman, she says sticking to her diet, even at the student dining hall, isn't hard. "It's just knowing your limits," she says. "I know I can only eat little bits at a time."
Risley was fortunate: Her parents' insurance policy covered the roughly $25,000 surgery. That's not true for many young patients, says Mary Brandt, surgical director for adolescent bariatric surgery at Texas Children's. "A lot of kids that we think are excellent candidates, insurance companies hold fast to their exceptions and refuse to cover them," she says.
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