Overview
Gaining weight and becoming obese or morbidly obese has created an epidemic not only in the United States, but also internationally. According to the Centers for Disease Control, more than 2/3 of the US population is overweight, and nearly 1/3 is obese or morbidly obese.
Obesity is defined as having a body mass index of 30 to 39. Morbid obesity begins at a body mass index of 40. It has been shown that the higher the body mass index (BMI), the greater the risk for associated illnesses such as diabetes, hypertension, sleep apnea, high cholesterol, coronary artery disease and others. When morbidly obese individuals have one or more of the above diseases, their risk for death increases, and quality of life is severely diminished.
At the Bariatric & Metabolic Institute, world-class Cleveland Clinic doctors evaluate our patients with a thorough physical exam, which may require blood work and other diagnostic tools. With help from physicians in a variety of specialties, our doctors take into account your medical issues when determining the weight loss plan that’s right for you. Pioneering surgeons at the Bariatric & Metabolic Institute perform more than 95 percent of all procedures with minimally invasive (laparoscopic) techniques, improving our patients' healing and recovery time. Bariatric surgery options include the Roux-en-Y Gastric Bypass and sleeve gastrectomy.
The level of support provided at Cleveland Clinic’s Bariatric & Metabolic Institute is unparalleled. Each patient is assigned a patient navigator, who serve as a single point of contact throughout your weight loss surgery journey, offering encouragement and support every step of the way.
For patients who choose not to undergo surgery, or for those who are ineligible, Cleveland Clinic offers medical management for weight loss with access to dietitians, psychologists, and exercise physiologists. Patients can also find support from Cleveland Clinic specialists and other patients in our ongoing support groups and classes designed to help patients achieve the best outcome possible.
Patients We Treat
Cleveland Clinic's Bariatric and Metabolic Institute treats people from all walks of life. There is no one type of candidate for bariatric surgery. This includes high risk patients, adolescents, and older adults. There are a few criteria that all patients must meet.
You could be a candidate for surgical weight loss if you meet any of the following criteria:
- You are more than 100 lbs. over your ideal body weight.
- You have a Body Mass Index (BMI) of over 40.
- You have a BMI of over 35 and are experiencing severe negative health effects, such as high blood pressure or diabetes, related to being severely overweight.
- You are unable to achieve a healthy body weight for a sustained period of time, even through medically-supervised dieting.
Revision patients
Weight loss surgery is not a magic bullet and while most patients are successful after weight loss surgery, there are instances where revision weight loss surgery is required. Whether reasons for seeking revision weight loss surgery are due to inadequate weight loss/weight regain, unresolved co-morbidities and/or medical complications, there is likely a revision solution to these problems.
Revisional procedures overview
Revisional bariatric operations, regardless of the previous surgery, are always challenging for a surgeon. They require adequate expertise to achieve desired results. Bariatric Centers of Excellence certified by the American Society for Bariatric Surgery provide a multi-disciplinary team and facilities for managing patients requiring revision of their surgery. It is highly recommended that patients requiring gastric bypass revision or any other kind of revisional surgery find a surgeon at a bariatric center that has much experience with revisional bariatric surgery.
Adolescents
Childhood and adolescent obesity is an epidemic in the United States. The latest statistics from the U.S Surgeon General are sobering. They show that more than 12.5 million children and adolescents aged 2 to 19 are overweight. And these numbers are on the rise. As a result, growing numbers of children and teens are at increased risk for diseases traditionally seen only in adults, including heart disease and type 2 diabetes.
Despite the soaring rates of adolescent obesity, teen weight loss surgery remains uncommon. The number of adolescents undergoing weight loss surgery more than tripled between 2000 and 2003, but these surgeries are still relatively rare in adolescents. In fact, teens represent less than 1 percent of weight loss surgery patients, according to a report in the March 2007 issue of Archives of Pediatrics & Adolescent Medicine.
Some doctors will recommend this surgery if a child’s weight poses a greater health threat than the potential risks of the surgery. Risks of adolescent obesity include diabetes, high blood pressure, joint problems, liver problems, lung and breathing issues and increasing pressure in the brain that can cause vision impairment or blindness.
When is weight loss surgery the answer to adolescent obesity?
Weight loss surgery is not a panacea for obesity in teens. There are many unknowns. No studies document the long-term effects of weight loss surgery on a child’s future growth and development. What’s more, weight loss surgery does not guarantee that an adolescent will lose all of his or her excess weight and/or keep it off long-term. Weight loss surgery also doesn’t replace the long-term need for a healthy diet and regular physical activity.
If weight loss surgery is deemed an option for an adolescent, he or she should be referred to centers with multidisciplinary weight management teams. These teams should include specialists in adolescent obesity evaluation and management, such as psychologists, nutritionists, physical activity instructors and weight loss surgeons. Additional expertise in adolescent medicine, endocrinology, pulmonology, gastroenterology, cardiology and orthopedics may be helpful, too.
Exactly when an adolescent should undergo weight loss surgery is controversial. It depends on the severity of obesity-related health problems faced by the individual patients. This individualized decision should be made on a case-by-case basis with the medical team.
According to guidelines set forth by the American Academy of Pediatrics in 2004, adolescents under consideration for weight loss surgery should:
- Have failed six or more months of organized attempts at weight management. This should be determined with the assistance of a doctor.
- Have attained or nearly attained physiologic or skeletal maturity. This generally occurs at age 13 or older for girls and at age 15 or older for boys.
- Be severely obese, with a body mass index (BMI) of greater than 40, with serious obesity-related problems; or have a BMI of greater than 50 with less severe obesity-related problems. (Other organizations, including the American Society for Metabolic and Bariatric Surgery, have less stringent weight criteria for teens, due to the severity of medical problems that obese adolescents now face.)
BMI takes height and weight into account to measure body fatness. For children and teens, BMI is age- and sex-specific and is often referred to as BMI-for-age. After BMI is calculated for children and teens, the BMI number is plotted on the federal Centers for Disease Control and Prevention (CDC) BMI-for-age growth charts (for either girls or boys) to obtain a percentile ranking.
- Be committed to comprehensive medical and psychological evaluations that should occur before and after surgery.
- Agree to avoid pregnancy for at least one year after surgery. Pregnancies are safe after weight loss surgery, but reliable contraception should be used for at least the first year after the operation due to increased risk to the developing fetus posed by the rapid weight loss. After the period of rapid weight loss is over, pregnancies should be carefully planned and monitored.
- Be capable of and willing to adhere to a strict bariatric surgery nutrition program following your operation. For example, after gastric bypass surgery, patients must consume a very low-calorie, low-carbohydrate diet with more than 0.5 grams of protein per kilogram of body weight per day. Daily multivitamins, as well as supplements of key nutrients such as calcium, vitamin B12, folate, thiamine and iron (for menstruating females), may also be needed.
- Provide informed consent to surgical treatment.
- Demonstrate the ability to make sound decisions. Age is not necessarily the limiting factor here.
- Have a supportive family environment.
Weight loss surgery is not an option in certain adolescents, including those with:
- A medically correctable cause of obesity.
- A substance abuse problem within the preceding year.
- An inability or unwillingness of either the adolescent or the parents to fully comprehend the surgical procedure and its consequences.
- Current pregnancy or plans to become pregnant within two years after surgery. Also, adolescents who are currently lactating following a recent pregnancy must wait.
Diabetes cure?
Teens who had gastric bypass surgery showed dramatic, often immediate, remission of their type 2 diabetes following surgery, according to a study reported in the January 2009 issue of Pediatrics. In fact, many teens checked out of the hospital without any diabetes-related medications.
Previous studies have shown that weight loss surgery can induce remission of type 2 diabetes in adults, but this is the first study to show that the treatment may do the same in adolescents.
The new study included 78 adolescents with type 2 diabetes. Eleven teens had gastric bypass surgery at one of five participating medical centers, while the remaining 67 teens were part of a comparison group who received routine medical management for their diabetes, but did not have any surgery.
Extremely obese teens who underwent bariatric surgery had an average 34 percent reduction in weight one year after surgery, with all but one seeing their type 2 diabetes disappear. In comparison, obese teens who were medically managed saw their weight remain essentially the same, and all were still taking medication for their diabetes. The teens that had gastric bypass showed other improvements too, such as lower blood pressure and cholesterol levels.
Teens suffering with metabolic syndrome — which greatly increases their risk of heart attack, stroke and diabetes — who undergo Lap-band surgery may be cured as a result. The findings were presented at The Endocrine Society’s 91st Annual Meeting in Washington, D.C.
Tests for weight loss surgery eligibility
Along with a complete physical exam and counseling, your doctor will run several tests that can help determine whether the weight poses a greater health threat than the potential risks of weight loss surgery. They include:
- Fasting glucose and hemoglobin A1C measurement to look for blood sugar anomalies that suggest type 2 diabetes.
- Liver function tests.
- Lipid profile tests to see if blood cholesterol levels are elevated.
- Complete blood counts.
- Thyroid function tests.
- Pregnancy tests for female patients.
- Screening for nutrient deficiencies.
- Sleep study (polysomnography) for adolescents with sleep apnea (one or more pauses in breathing or shallow breaths while you sleep).
- Bone age assessment to document the degree of skeletal maturity.
Choosing a weight loss surgery procedure
Exactly which weight loss surgery is best for teens is not yet known. Both the Roux-en-Y gastric bypass and sleeve gastrectomy have been effective in treating adolescent obesity.
Risks of adolescent bariatric surgery
Weight loss surgery is risky business. Although these procedures can result in substantial weight loss, the long-term effects among teens are unknown. A recent study offers up some good news. It shows that the risks are no greater in teens than they are in adults. In fact, adolescents who undergo weight loss surgery have fewer complications and a faster rate of recovery than older patients, according to research published in the March 2007 issue of Archives of Pediatrics & Adolescent Medicine.
Scheduling weight loss surgery for a teen
Along with the physical recovery from surgery, adolescents undergoing surgery need this time to get used to eating solid foods. During the recovery period, they have to slowly reintroduce solid foods, starting with a liquid diet, then on to pureed food and finally, solids. Within four to six weeks, all patients are eating solid food regardless of which surgery they choose. Some physical restrictions also exist during the recovery period, such as avoiding heavy lifting and gym class for about a month.
Most adolescents who undergo weight loss surgery look forward to returning to school after surgery. They may look and feel different. Once they return to school, they find that they are not teased anymore. Surgeons and parents report that the vast majority of adolescents who undergo weight loss surgery are so happy, that their personality changes for the better.
Adolescent life after weight loss surgery
The journey is not over after weight loss surgery. Far from it. Some teens may need body contouring surgeries to get rid of the excess skin and flab that remain after massive weight loss. Unlike their peers, teens who have undergone weight loss surgery must be hypervigilant about what they eat, when they eat and how they eat it. Teens often want to fit in, and such regimented eating may make them stand out.
Long-term medical and psychological follow-up is also necessary after weight loss surgery. It is no quick fix. Weight loss surgery involves a deep commitment and intensive follow-through. In the right adolescent, however, weight loss surgery can improve overall quality of life and self-esteem.
Many of the questions regarding weight loss surgery in adolescents may be answered when the Teen Longitudinal Assessment of Bariatric Surgery (LABS) study, begun in 2006, is completed. This five-year, multi-center study of 200 adolescents aims to determine if weight loss surgery is an appropriate treatment option for extremely overweight teens.
Thinking about adolescent bariatric surgery?
Schedule an evaluation at the Be Well Kids Clinic.
Awards & Achievements
Cleveland Clinic is recognized both nationally and internationally for its exceptional expertise and patient care.
The Bariatric and Metabolic Institute at Cleveland Clinic is proud to be a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). This is awarded through a joint initiative by the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS).
This accreditation recognizes that the program that meet the highest standards for patient safety, care quality, and outcomes in metabolic and bariatric surgery.
Bariatric COE Certifications:
· MBSAQIP Accredited Level 1A Bariatric Center
· Anthem Blue Cross Blue Shield: Blue Distinction Program, Center of Excellence for Bariatric Services.
· Aetna: Aetna Preferred Bariatric Center Network.
· Medical Mutual of Ohio: Medical Mutual of Ohio Center of Excellence for Bariatric Surgery.
· Cigna: Center of Excellence Program for Bariatric Surgery.
