Bariatric Surgery Works, But Isn't Offered To Most Teens Who Have Severe Obesity
By kindergarten, Kayla Northam's body had become a battleground. She and her mother fought daily over what she should eat and how much.
It was a message reinforced by her pediatrician: "He'd be telling us, 'She's overweight. You've got to get her to diet,' " Northam recalls from age 5 or 6. "I remember these conversations. But I was just always hungry. It was just never enough."
Every diet backfired. As a teen, Northam topped 300 pounds, and started developing diabetes, and liver and joint problems. Growing up outside Boston, she couldn't shop for clothes with friends. Boys rejected her. Her weight disqualified her from playing lacrosse or horseback riding. All that took a toll on her mental health.
"I was extremely depressed over my weight and what I looked like," she remembers.
One day, she heard her mother disparage a family friend's decision to get bariatric surgery. "In her mind, it's a cheap attempt to lose weight," Northam says. " 'You could do this if you just worked harder. It's a waste of time because you won't change your habits, and it's extremely dangerous.' "
But the idea stuck in Northam's head.
The most effective, long-lasting treatment
Obesity specialists, and the American Academy of Pediatrics, now strongly endorse bariatric surgery as a good option for teenagers who are struggling with severe obesity, a condition roughly defined in adults as having a basal metabolic index of 35 to 40 or higher. That describes about 6% of children between 2 and 19.
This surgical procedure is reliably effective in treating extreme obesity and can reverse the condition's life-threatening effects: diabetes, hypertension and liver disease, these medical specialists say.
"The effective treatments for severe obesity in adolescents are really just one: That is bariatric surgery," says Dr. Thomas Inge, a director of adolescent bariatric surgery at Children's Hospital Colorado and a lead scientist on a multiyear National Institutes of Health study tracking young bariatric patients. "The unwritten story here is the remarkable disparity between the number of teenagers that are eligible for the surgery versus the number that are getting it."
Inge estimates that only a tiny fraction of the young people eligible in the U.S — perhaps 2,000 adolescents a year — get bariatric surgery. Barriers to the treatment include its high cost if not covered by a particular health plan, a lack of access to health care in general by many teens, and stigma. Also, research shows, the procedure is offered much less frequently to people of color, who disproportionately experience severe obesity and yet are less likely to be referred for treatment.
Proponents of bariatric surgery point out that its cost — about $20,000 — is far less than the cost of treating later-stage effects of obesity, which can include dialysis or heart transplant. Nevertheless, payment is a barrier: Health insurers deny about half of teens' initial requests for the surgery, though Medicaid programs do sometimes approve the procedure in this age group.
When teens first started getting the surgery two decades ago, doctors evaluated it to ensure it would be as effective in these youths as in adults, says Dr. Sandra Hassink, medical director of the American Academy of Pediatrics' Institute for Healthy Childhood Weight. Now, obesity specialists say, the risks are dwarfed by the potentially lifesaving benefits.
Cases of severe obesity continue to rise among adolescents, and the surgery is proving far more effective for this group — and longer lasting — than medication or diet and exercise alone.
Still, surgery's not for everyone
The potential downsides, beyond the complications of any surgery, can include vitamin deficiency or weight regain. Not everyone who qualifies by weight is eligible — patients with psychiatric or emotional conditions may need to address those before undergoing the procedure, say doctors who also note that addressing exercise, diet and other lifestyle issues is a part of any surgical program.
The typical teen bariatric patient is 15 or 16, and about 100 pounds overweight, says Dr. Marc Michalsky, a pediatric surgeon at Nationwide Children's Hospital at Ohio State University and another researcher on the NIH study. A large majority suffer from related health problems, he adds.
"These operations were not specifically designed with children in mind," Michalsky says, and there's still a lot of skepticism and resistance — even among many pediatricians — to using an invasive surgery. But, he says, "we're now seeing data that shows that there may be a protective effect of youth; adolescents undergoing these operations are actually having a more robust improvement in things like diabetes and hypertension," he says. Sometimes those conditions resolve within days of getting the procedure.
Those successes, Michalsky says, argue for not waiting until the patient is older. "You're talking potentially about a lifetime of that patient not suffering from the cumulative impact of having those diseases, had nothing been done in the first place."
One patient's success story
The decision to have surgery became especially stark two years ago for Sarah Swisher, who at age 15, faced stage 4 liver failure brought on by severe obesity. At 5 feet, 2 inches and 260 pounds, she was told she could try bariatric surgery or, alternatively, would likely require a liver transplant to survive.
Liver transplant. "That's one of the worst words to hear, especially at a young age," Swisher says. "It terrifies you."
Her health was bad enough that it made dealing with insurance oddly easier. After Ohio's Medicaid program rejected her initial claim, Swisher's doctor wrote a letter, explaining that the transplant alternative would be more costly and more dangerous. Swisher's surgery was approved, and her family did not have to pay for it out-of-pocket.
Sarah's mother, Kay Swisher, says she recognized bariatric surgery was necessary, but it also triggered terrifying memories. Decades earlier, her own mother — Sarah's late grandmother — had undergone bariatric surgery and developed complications that kept her in the hospital for a month. "It brought back a lot of memories involving all those feeding tubes," Kay Swisher says.
But medically, all agreed, Sarah had no good alternative. She underwent the surgery in August 2019.
"I was in so much pain," Sarah says of her recovery period — pain that lasted for a few days. But that discomfort was well worth it, Sarah says, and she's doing what she can to make sure the treatment's successful.
She has traded in her habit of eating chips and sodas for, at most, a cup of eggs, meat or cauliflower or broccoli as a meal. She no longer senses hunger, she says, so she has to remind herself to consume tiny meals, four to six times a day.
She's lost 80 pounds to date and — most critically — her liver is functioning normally. Plus, she says: "I feel more confident in my body, and it shows in how I act."
How surgery can change the body's ''set point'' for weight
Northam, the Boston woman whose mother pushed diet and exercise, never won approval from her mother to move ahead with surgery. Instead, Northam bided her time until the moment she turned 18 — and legally became an adult. She drove herself to the clinic, where she met in secret with Dr. Fatima Cody Stanford, an obesity expert at Harvard and Massachusetts General Hospital.
"I remember it very clearly," Stanford says. "It was like the day after her birthday — as soon as she could get in."
That day, Stanford explained to Northam that obesity is widely misunderstood: "Obesity is a disease of the brain, and people don't recognize that; they think it's a disease of willpower."
Every person's brain tends to maintain the body at a certain weight, or "set point," Stanford says. That can be affected or shifted higher by at least 100 factors, including genetics; stresses, such as working the night shift or family conflict; or by physical ailments such as chronic inflammation.
Diets are often counterproductive for any of us, Stanford says, because they trigger the brain into thinking there's a famine, so it reacts by resetting itself to a higher set point. The problem is, once a person is obese and the set point is high, it becomes extremely difficult to lower it.
Bariatric surgery, Stanford explained to Northam, can change that set point. It removes or bypasses most of the stomach, where some hunger-stimulating hormones are produced. It works, not because it shrinks the stomach, but because it alters how the brain interprets hunger messages, helping to lower the body's satiety set point.
"Bariatric surgery is the best treatment that we have anywhere in the world for severe obesity — it drastically changes the set point in a way that nothing else does," Stanford says.
Listening to Stanford gave Northam a possible solution to a struggle that had been lifelong.
"I jumped onto her like a life raft; I had so much hope after meeting with her," Northam says. Her father helped her navigate insurance issues. The family had to pay the $4,000 annual deductible in a health plan, but the remaining cost of surgery was covered. Northam knew her mother was not in favor of the procedure, so she kept her plans mostly under wraps until just before the surgery.
By then, Northam felt she was about to turn a chapter, leaving a life lived on the sidelines.
"I've loved playing sports my whole life," she says, but "I just physically couldn't keep up with my peers."
The emotional toll of obesity had rivaled the physical challenges.
"I wanted to date," she says. "Oh my God, I was boy crazy — there was nothing I wanted more — but none of the boys wanted anything to do with me."
Counseling before surgery is crucial, too
Northam hoped to recast her life after surgery. But it wasn't a quick fix. Preparing for the procedure meant undergoing, in her case, about two years of extensive psychological and medical evaluations, including counseling and nutrition classes.
The screening process is far longer and more rigorous for teens because of their youth. Successful outcomes require a lifelong commitment to drastic changes in diet — both in quantity and healthfulness of foods. For the rest of their lives, to maintain adequate nutrition they must consume a large handful of vitamins daily — about seven large pills including calcium, iron and vitamin B, C and D. And they need follow-up appointments with their health care team every six months or a year to ensure there are no dietary or weight complications post-surgery. They are also regularly reminded: If the weight comes back, there's no option for a second surgery.
"You have to prove that one, you have the knowledge, and two, you have the drive to succeed at it," Northam says of the long wait that separated her request for the procedure and actually getting it.
Finally, at age 20, Northam got the green light, and underwent bariatric surgery. The effects were nearly immediate. Within days, she lost 25 pounds.
"I thought my scale was broken," she says. And she no longer felt prisoner to hunger. She'd learned to eat meals measured in spoonfuls, she says; if she ate more, she felt sick to her stomach.
"As hard as it is to imagine someone loving being nauseous because they're so full, I loved it," she laughs. "I was like, 'Oh, my God, this is what normal people feel like when they eat too much.' " She would request doggie bags to take home most of the meals she ordered at restaurants and explained to waiters that it wasn't because she disliked the food.
In all, Northam — who is now 28 — lost 150 pounds. She is tall, with a passing resemblance to actress Anne Hathaway. Men now flock to her, she says.
"I, all of a sudden, was having people offer to buy me drinks," she says. "Luckily, I would always go out with friends who would be like, 'No, you don't accept that,' " so she had to learn new social behaviors.
That's not uncommon.
Inge, the bariatric surgeon at Children's Hospital Colorado, says some of the unanticipated risks arise when these young people who are no longer obese suddenly find themselves in the social mainstream. They're less depressed and more social and begin to date. With those changes can come newfound exposure to drugs, alcohol and sexually transmitted disease.
"Suddenly, over a very short period of time, they see these risks that they're not at all prepared for," Inge says.
Nevertheless, he says, overall the mental health benefits heavily favor surgery. "It really does dramatically improve over the first year, right along with weight loss," he says.
Northam agrees. She's now a married mother, working as a gastroenterology nurse, where she says patients seek her out because she can relate to their experience. She wishes more pediatricians and families would embrace bariatric surgery for certain children.
"Because," she says, "you have kids like I was — struggling with depression, struggling with their peer groups, not being the person they want to be, not reaching their fullest potential."