For teens with severe obesity, bariatric surgery works, but is rarely used. Experts say that needs to change
Philadelphia -- Gavin Perrin has his work cut out for him this semester. The Susquehanna University sophomore is taking a hefty 22 credits in a demanding accounting program. But as he planned to head back to campus this month, the pandemic permitting, Perrin was thinking about the fun stuff: seeing all the friends he made last year, moving in with his new roommates, playing sports.
It's a far cry from Perrin's high school days.
"I was that type of kid in high school who would rather be anywhere else," Perrin said.
It's not that his high school was a bad place. The difference is him: "I feel like a new man."
Between his junior year of high school and his freshman year of college, Perrin lost more than 200 pounds. At 5-foot-10, the 19-year-old from Turbotville, Northumberland County, is down to 230 pounds. He says he feels healthier, more confident.
Perrin accomplished that through a lot of hard work that included diet change and exercise. But it probably wouldn't have happened so quickly without another strategy that's used to help only a small number of the estimated 4.5 million American children and teenagers with severe obesity: bariatric surgery. That's despite growing research that it is an effective, safe way to deal with a health problem that has reached epidemic proportions. Obesity increases the risk of hypertension, liver disease, diabetes, sleep apnea, and many other health problems, even among teens.
The American Academy of Pediatrics in December came out in support of bariatric surgery as an "evidence-based effective treatment of severe obesity" and said greater access to the surgery for pediatric patients ages 13 and older "is urgently needed." There is no authoritative count of how many of these surgeries are performed each year on teenagers, but estimates range from 450 to about 1,600. Most experts agree it's less than 1% of the youngsters who might benefit.
"It's definitely underutilized," said Elizabeth Parks Prout, medical director of Children's Hospital of Philadelphia's Adolescent Bariatric Surgery Program, a joint effort with the Hospital of the University of Pennsylvania. "We're not treating everyone who needs treatment, unfortunately."
'A tool for change'
Most teens who undergo bariatric surgery, like Perrin, have the gastric sleeve procedure, in which 70% to 80% of the stomach is permanently removed. Not only is the size of the stomach greatly reduced, but, especially significant, the surgery also affects hormonal balance, including the production of ghrelin, often referred to as the hunger hormone.
Surgery along with lifestyle changes result in a 20% to 30% average weight loss for adolescent patients, Prout said. Lifestyle changes alone aren't effective for long-term obesity treatment, many experts say.
A growing body of research shows there are few post-bariatric surgery complications, though many programs recommend nutritional supplements in response to concerns about postsurgery deficiencies.
Money, not safety, is one reason few teens get this surgery. It's not unusual for insurers to turn down adolescents for the surgery, according to the AAP, especially children from low-income families and children of color who may be stymied by complex, and at times costly, insurance appeals, or inconsistent coverage policies. These families may also lack access to a bariatric surgery program near them.
Some parents and patients fear going under the knife for something they might think could be handled without surgery. In addition, doctors involved in bariatric programs say other physicians often hesitate to refer younger patients, in part due to misunderstanding about the surgery.
"It's a surgery to help you to be able to be effective in the changes in your diet and exercise," Prout said. "The surgery is not a cure. The surgery is a tool for change."
Ann Rogers, director of the Penn State Surgical Weight Loss Program, said she thinks the stigma of obesity can extend to its treatment.
"Obesity isn't a choice. It's not a lifestyle people want to embrace," Rogers said. "It's a chronic and recurring medical condition, just like cancer. So if we have medical therapies that are designed to treat medical problems, we should use them."
'What am I waiting for?'
Lyndsey Gibb, 17, said she's always been "a bigger kid," at least since she was a toddler. "It was something that continued to get out of control as I grew when I hit the teenage years. That's especially when it got bad," she said.
The Dillsburg, York County, teenager tried various diet and exercise programs and went to multiple nutritionists, but nothing ever kept the weight off. Then a couple of years ago, her father had bariatric surgery. As her dad shed weight, she noticed other changes in him. He was more confident, less self-conscious about what he wore, less restricted in the things he would do. She decided she wanted that for herself.
Gibb had her surgery last December at Hershey Medical Center with Rogers. Since then, she's lost 115 pounds and intends to shed another 60. Her BMI went from almost 53 to 36. (Severely obese is considered to start at a BMI of 35 to 40.)
"I definitely feel a lot better, more so confidence-wise than health-wise," Gibb said. "Health-wise, I feel like I can do more, but just being more comfortable with what I look like and what I can wear makes me feel a lot better."
Gibb said she is excited that she can now wear stylish brands like Simply Southern that she always liked, but didn't come in her old size. She gave up riding horses because of her weight. She thinks that could be an option again. Just walking is more enjoyable.
She's beginning her senior year at Northern York High School. COVID-19 permitting, she's looking forward to the prom. Growing up in a rural area, Future Farmers of America is an important activity for her. It involves speaking in front of large groups of people.
"It will help if I feel better about how I look," she said. "I'll be more confident in what I'm doing, and hopefully I can even be better at what I'm doing because of it."
To those who would say she was too young to have this kind of surgery, she has a ready answer.
"What am I waiting for in my life? I've dealt with this for how many years now? My dad got it when he was 40-something years old. It's either I live with how I am and continue to go up and down, or give this a shot and be able to improve my quality of life sooner."
A new start
Perrin started his battle with weight at a young age, too. From ages 4 to 15, he participated in a medical weight-loss clinic program where he was given nutrition counseling. Finally, he was told there was nothing more they could do for him. By the time he got to the CHOP bariatric program, his BMI was 65.
"I had high blood pressure. I was borderline diabetic. Even walking around, my feet would burn up. I'd get tired really quick. I did try to play sports, but I couldn't last," Perrin said. "My size definitely bothered me. I could tell from a young age there were these differences, and I wasn't the same as everybody else."
Eating in public places made him feel self-conscious. "Even if they're not looking at you, you felt as if all eyes were on you."
In elementary and middle school, he had temper problems. He thinks his weight had something to do with it.
In high school, he found himself not wanting to go most of the time. He didn't ask anyone to the prom, and no one asked him.
He was a sophomore when he entered CHOP's program. He spent about a year in the presurgery program, which included education and lifestyle changes like a high-protein diet, vitamins, and medication. He had his doubts, given his past experiences. But for the first time, the pounds started coming off _ and staying off. He also was no longer prediabetic, and his blood pressure returned to normal.
"I thought, 'These are people I can trust.'"
By the time he arrived for freshman year at Susquehanna University, Perrin was very different from the kid who underwent weight-loss surgery.
"No one knew me. I could kind of reinvent myself," Perrin said.
After taking charge of his body and his health, "I felt like I could really talk to anybody. I didn't have trouble going out and meeting new people."
The high schooler who preferred to stay in his room became a college student who set goals of meeting as many people as he could. He was a regular at the campus gym. He joined the rugby team and played pickup basketball.
Last month, classes at Susquehanna started online, and Sept. 20 is his back-to-campus day. His roommates will be waiting. He's got a new job as an academic coach for freshman business students. Perrin's ready for whatever the future might bring.
"As long as coronavirus doesn't get in the way," he said, "I think these next couple years are going to be the best time of my life."