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Pediatricians endorse weight loss surgery for severely obese kids and teens

Pediatricians endorse weight loss surgery for severely obese kids and teens
The world will have more than 250 million obese kids by 2030, a new report warnsThe world will have more than 250 million obese kids by 2030, a new report warns
The American Academy of Pediatrics now recommends that metabolic and bariatric surgery should be considered a safe treatment option for children and teens with severe obesity — and should be covered by insurance for young people. The AAP made the recommendation in its first-ever policy statement on surgical treatments for children and teens with severe obesity, published in the medical journal Pediatrics on Sunday.
“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 in Delaware, who was a 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,” he 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.”

Becoming the person she wanted to be

Avery Feinstein, who underwent a gastrectomy last year when she was 18 to treat her severe obesity, called the new AAP recommendations “awesome” and said she hopes that more awareness is raised around adolescent bariatric surgery. Gastrectomy is a surgical procedure to remove part or all of the stomach.

“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 Feinstein lost 70% of her excess body weight and resolved her other health issues after surgery at age 18.Avery Feinstein lost 70% of her excess body weight and resolved her other health issues after surgery at age 18.

As a 19-year-old college sophomore at the University of Missouri, Feinstein now says she’s thriving. She joined a sorority, maintained her studies to become a psychiatrist, and continued to eat a healthy diet and stay active. Her favorite pastime is riding her horse, Rudy, whom she houses in a barn just 15 minutes away from campus.

Yet the journey to this point in Feinstein’s life wasn’t easy.

Feinstein struggled with her weight throughout childhood. She went to a weight-loss camp in middle school and tried strict diets, but neither helped her manage a healthy weight. During that time, Feinstein felt self-conscious and concerned about her health.

“I was trapped in how big I was,” she said.

At age 17, Feinstein and her mother visited a nutritionist at Ann & Robert H. Lurie Children’s Hospital of Chicago, and the nutritionist recommended Feinstein to the hospital’s adolescent bariatric surgery program.

Immediately, Feinstein knew that — with support from her mother and the help of the hospital staff — she wanted to undergo surgery to improve her health, especially before starting college in the fall.

“I had no clue that this could have been an option,” Feinstein 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.”

Avery Feinstein with her horse Rudy before she underwent bariatric surgery. Rudy has been by Feinstein's side during her weight loss journey.Avery Feinstein with her horse Rudy before she underwent bariatric surgery. Rudy has been by Feinstein's side during her weight loss journey.
Obesity, which now affects 1 in 5 children and adolescents in the United States, can raise the risk for many health problems, including diabetes, heart disease, stroke, arthritis, breathing problems and certain cancers.
When Feinstein was admitted to the bariatric surgery program, she had a body mass index of 46 and had sleep apnea.
Body mass index, or BMI, is a person’s weight in kilograms divided by the square of their height in meters — and is used to screen for obesity. Obesity is defined as a BMI at or above the 95th percentile for children and teens of the same age and sex.
BMI is assessed when deciding whether surgery could be the best treatment approach for a person with severe obesity, said Dr. Ann O’Connor, a pediatric surgeon and director of the adolescent bariatric surgery program at Ann & Robert H. Lurie Children’s Hospital of Chicago. She performed Feinstein’s procedure.

“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.”

The program’s protocol also requires that “teens must be 13 years or older and mature enough to understand the implications of surgery.”
Avery Feinstein has maintained a healthy lifestyle since her weight loss surgery: "You have to do most of the work and the surgery is just a little bit of help," she says.Avery Feinstein has maintained a healthy lifestyle since her weight loss surgery: "You have to do most of the work and the surgery is just a little bit of help," she says.

‘This surgery is not just ‘here’s a fix’ ‘

The adolescent bariatric surgery program required Feinstein to complete a six-month diet and exercise plan before surgery, to encourage lifestyle changes that could continue after surgery — changes such as having salads for lunch instead of sandwiches. Feinstein was also required to stabilize her weight during that six-month period.

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“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,” Feinstein said. “You have to be mentally ready for it.”

During that six-month period, however, Feinstein and her family were unsure whether their insurance would cover the surgery, which can be expensive.

One cost estimate for adolescent bariatric surgery from 2010 to 2013 found the average total intervention cost to be $25,854. But studies suggest the procedure is a cost-effective treatment in the long-term.

Feinstein’s mother, who raised Feinstein and her two siblings as a single parent, had “pretty good insurance through her work,” Feinstein said, but the family still had to undergo an extensive process to get the procedure 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.”

About one month before the surgery, Feinstein’s insurance approved the procedure and agreed to pay a portion of the costs, she said.

Childhood obesity: America's 'true national crisis' measured state by stateChildhood obesity: America's 'true national crisis' measured state by state
Feinstein underwent a sleeve gastrectomy, which was performed robotically. The procedure involved removing about 80% of the stomach, which limits the amount of food eaten and helps improve metabolism, O’Connor said. The addition of the robot technology helped with visualization and improved postoperative pain.

In the months following her surgery, Feinstein lost about 70% of her excess body weight.

“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.”

‘The real power of these operations is the ability to alter physiology’

Bariatric surgery as a treatment strategy was developed around the the early 1960s, according to 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.
Then in 1991, the National Institutes of Health formalized clinical guidelines describing weight loss surgery as a treatment option for severe obesity, but those guidelines were just for adults.
Childhood obesity is getting worse, study saysChildhood obesity is getting worse, study says

Focused efforts to “analyze the application of bariatric surgery in the pediatric population” didn’t come until much later, Michalsky said.

“There are a lot of misconceptions about the appropriateness of bariatric surgery in the pediatric world,” he said. “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.”

Similar to adults, weight-loss surgery has been found to resolve health conditions, such as diabetes and hypertension, in adolescents with severe obesity.
The AAP policy statement noted that in an ongoing study of adolescents undergoing bariatric surgery, called the Teen-Longitudinal Assessment of Bariatric Surgery or Teen-LABS, young patients who underwent gastric bypass or a sleeve gastrectomy experienced an average weight reduction of 27% and resolved their obesity-related health issues within three years — including type 2 diabetes among 95% of the patients and high blood pressure among 74% of the patients. Those findings were based on 242 patients ages 12 to 28.
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The “real power” of these operations is the ability to eliminate these long-term and cumulative impacts of significant excess body weight, said Michalsky, an author of Teen-LABS.

“The data that we are seeing now is very encouraging and has shown a significant reduction and in some cases complete reversal of some of these disorders,” he said.

This data also could lead to more young people with severe obesity having access to surgery as a treatment option under insurance coverage.

According to the Teen-LABS study, less than half — 47% — of young patients who met the criteria to be candidates for surgery received insurance coverage. Being younger than 18 years old was cited as the most common reason for coverage denial among those patients.

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{“mini”:{“width”:220,”type”:”jpg”,”uri”:”//cdn.cnn.com/cnnnext/dam/assets/170919172823-health-care-cost-1-small-169.jpg”,”height”:124},”xsmall”:{“width”:307,”type”:”jpg”,”uri”:”//cdn.cnn.com/cnnnext/dam/assets/170919172823-health-care-cost-1-medium-plus-169.jpg”,”height”:173},”small”:{“width”:460,”type”:”jpg”,”uri”:”//cdn.cnn.com/cnnnext/dam/assets/170919172823-health-care-cost-1-large-169.jpg”,”height”:259},”medium”:{“width”:780,”type”:”jpg”,”uri”:”//cdn.cnn.com/cnnnext/dam/assets/170919172823-health-care-cost-1-exlarge-169.jpg”,”height”:438},”large”:{“width”:1100,”type”:”jpg”,”uri”:”//cdn.cnn.com/cnnnext/dam/assets/170919172823-health-care-cost-1-super-169.jpg”,”height”:619},”full16x9″:{“width”:1600,”type”:”jpg”,”uri”:”//cdn.cnn.com/cnnnext/dam/assets/170919172823-health-care-cost-1-full-169.jpg”,”height”:900},”mini1x1″:{“width”:120,”type”:”jpg”,”uri”:”//cdn.cnn.com/cnnnext/dam/assets/170919172823-health-care-cost-1-small-11.jpg”,”height”:120}}},autoStartVideo = false,isVideoReplayClicked = false,callbackObj,containerEl,currentVideoCollection = [],currentVideoCollectionId = ”,isLivePlayer = false,mediaMetadataCallbacks,mobilePinnedView = null,moveToNextTimeout,mutePlayerEnabled = false,nextVideoId = ”,nextVideoUrl = ”,turnOnFlashMessaging = false,videoPinner,videoEndSlateImpl;if (CNN.autoPlayVideoExist === false) {autoStartVideo = false;if (autoStartVideo === true) {if (turnOnFlashMessaging === true) {autoStartVideo = false;containerEl = jQuery(document.getElementById(configObj.markupId));CNN.VideoPlayer.showFlashSlate(containerEl);} else {CNN.autoPlayVideoExist = true;}}}configObj.autostart = CNN.Features.enableAutoplayBlock ? false : autoStartVideo;CNN.VideoPlayer.setPlayerProperties(configObj.markupId, autoStartVideo, isLivePlayer, isVideoReplayClicked, mutePlayerEnabled);CNN.VideoPlayer.setFirstVideoInCollection(currentVideoCollection, configObj.markupId);videoEndSlateImpl = new CNN.VideoEndSlate(‘body-text_56’);function findNextVideo(currentVideoId) {var i,vidObj;if (currentVideoId && jQuery.isArray(currentVideoCollection) && currentVideoCollection.length > 0) {for (i = 0; i 0) {videoEndSlateImpl.showEndSlateForContainer();if (mobilePinnedView) {mobilePinnedView.disable();}}}}callbackObj = {onPlayerReady: function (containerId) {var playerInstance,containerClassId = ‘#’ + containerId;CNN.VideoPlayer.handleInitialExpandableVideoState(containerId);CNN.VideoPlayer.handleAdOnCVPVisibilityChange(containerId, CNN.pageVis.isDocumentVisible());if (CNN.Features.enableMobileWebFloatingPlayer &&Modernizr &&(Modernizr.phone || Modernizr.mobile || Modernizr.tablet) &&CNN.VideoPlayer.getLibraryName(containerId) === ‘fave’ &&jQuery(containerClassId).parents(‘.js-pg-rail-tall__head’).length > 0 &&CNN.contentModel.pageType === ‘article’) {playerInstance = FAVE.player.getInstance(containerId);mobilePinnedView = new CNN.MobilePinnedView({element: jQuery(containerClassId),enabled: false,transition: CNN.MobileWebFloatingPlayer.transition,onPin: function () {playerInstance.hideUI();},onUnpin: function () {playerInstance.showUI();},onPlayerClick: function () {if (mobilePinnedView) {playerInstance.enterFullscreen();playerInstance.showUI();}},onDismiss: function() {CNN.Videx.mobile.pinnedPlayer.disable();playerInstance.pause();}});/* Storing pinned view on CNN.Videx.mobile.pinnedPlayer So that all players can see the single pinned player */CNN.Videx = CNN.Videx || {};CNN.Videx.mobile = CNN.Videx.mobile || {};CNN.Videx.mobile.pinnedPlayer = mobilePinnedView;}if (Modernizr && !Modernizr.phone && !Modernizr.mobile && !Modernizr.tablet) {if (jQuery(containerClassId).parents(‘.js-pg-rail-tall__head’).length) {videoPinner = new CNN.VideoPinner(containerClassId);videoPinner.init();} else {CNN.VideoPlayer.hideThumbnail(containerId);}}},onContentEntryLoad: function(containerId, playerId, contentid, isQueue) {CNN.VideoPlayer.showSpinner(containerId);},onContentPause: function (containerId, playerId, videoId, paused) {if (mobilePinnedView) {CNN.VideoPlayer.handleMobilePinnedPlayerStates(containerId, paused);}},onContentMetadata: function (containerId, playerId, metadata, contentId, duration, width, height) {var endSlateLen = jQuery(document.getElementById(containerId)).parent().find(‘.js-video__end-slate’).eq(0).length;CNN.VideoSourceUtils.updateSource(containerId, metadata);if (endSlateLen > 0) {videoEndSlateImpl.fetchAndShowRecommendedVideos(metadata);}},onAdPlay: function (containerId, cvpId, token, mode, id, duration, blockId, adType) {/* Dismissing the pinnedPlayer if another video players plays an Ad */CNN.VideoPlayer.dismissMobilePinnedPlayer(containerId);clearTimeout(moveToNextTimeout);CNN.VideoPlayer.hideSpinner(containerId);if (Modernizr && !Modernizr.phone && !Modernizr.mobile && !Modernizr.tablet) {if (typeof videoPinner !== ‘undefined’ && videoPinner !== null) {videoPinner.setIsPlaying(true);videoPinner.animateDown();}}},onAdPause: function (containerId, playerId, token, mode, id, duration, blockId, adType, instance, isAdPause) {if (mobilePinnedView) {CNN.VideoPlayer.handleMobilePinnedPlayerStates(containerId, isAdPause);}},onTrackingFullscreen: function (containerId, PlayerId, dataObj) {CNN.VideoPlayer.handleFullscreenChange(containerId, dataObj);if (mobilePinnedView &&typeof dataObj === ‘object’ &&FAVE.Utils.os === ‘iOS’ && !dataObj.fullscreen) {jQuery(document).scrollTop(mobilePinnedView.getScrollPosition());playerInstance.hideUI();}},onContentPlay: function (containerId, cvpId, event) {var playerInstance,prevVideoId;if (CNN.companion && typeof CNN.companion.updateCompanionLayout === ‘function’) {CNN.companion.updateCompanionLayout(‘restoreEpicAds’);}clearTimeout(moveToNextTimeout);CNN.VideoPlayer.hideSpinner(containerId);if (Modernizr && !Modernizr.phone && !Modernizr.mobile && !Modernizr.tablet) {if (typeof videoPinner !== ‘undefined’ && videoPinner !== null) {videoPinner.setIsPlaying(true);videoPinner.animateDown();}}},onContentReplayRequest: function (containerId, cvpId, contentId) {if (Modernizr && !Modernizr.phone && !Modernizr.mobile && !Modernizr.tablet) {if (typeof videoPinner !== ‘undefined’ && videoPinner !== null) {videoPinner.setIsPlaying(true);var $endSlate = jQuery(document.getElementById(containerId)).parent().find(‘.js-video__end-slate’).eq(0);if ($endSlate.length > 0) {$endSlate.removeClass(‘video__end-slate–active’).addClass(‘video__end-slate–inactive’);}}}},onContentBegin: function (containerId, cvpId, contentId) {if (mobilePinnedView) {mobilePinnedView.enable();}/* Dismissing the pinnedPlayer if another video players plays a video. */CNN.VideoPlayer.dismissMobilePinnedPlayer(containerId);CNN.VideoPlayer.mutePlayer(containerId);if (CNN.companion && typeof CNN.companion.updateCompanionLayout === ‘function’) {CNN.companion.updateCompanionLayout(‘removeEpicAds’);}CNN.VideoPlayer.hideSpinner(containerId);clearTimeout(moveToNextTimeout);CNN.VideoSourceUtils.clearSource(containerId);jQuery(document).triggerVideoContentStarted();},onContentComplete: function (containerId, cvpId, contentId) {if (CNN.companion && typeof CNN.companion.updateCompanionLayout === ‘function’) {CNN.companion.updateCompanionLayout(‘restoreFreewheel’);}navigateToNextVideo(contentId, containerId);},onContentEnd: function (containerId, cvpId, contentId) {if (Modernizr && !Modernizr.phone && !Modernizr.mobile && !Modernizr.tablet) {if (typeof videoPinner !== ‘undefined’ && videoPinner !== null) {videoPinner.setIsPlaying(false);}}},onCVPVisibilityChange: function (containerId, cvpId, visible) {CNN.VideoPlayer.handleAdOnCVPVisibilityChange(containerId, visible);}};if (typeof configObj.context !== ‘string’ || configObj.context.length 0) {configObj.adsection = window.ssid;}CNN.autoPlayVideoExist = (CNN.autoPlayVideoExist === true) ? true : false;CNN.VideoPlayer.getLibrary(configObj, callbackObj, isLivePlayer);});CNN.INJECTOR.scriptComplete(‘videodemanddust’);

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