Though Shani Gofman had been teased for being fat since the fourth grade, she had learned to deal with it. She was a B student and part of the drama club at school. She had good friends and a boyfriend she had met through Facebook.
When her paediatrician, Dr. Senya Vayner, first mentioned weight-loss surgery, Ms Gofman was 17, still living with her parents, her bedroom decorated with glow-in-the-dark stars because she was afraid of the dark. There was no question, at 5-foot-1 and more than 250 pounds, she was overweight. But she resisted, saying she could diet. “I'll lose weight,” she assured her doctor. Dr. Vayner said, prophetically, “It's not your fault, but you're not going to be able to do it.”
Along with the obesity epidemic in America has come an explosion in weight-loss surgery, with about 2,20,000 operations a year, a sevenfold leap in a decade, according to industry figures, costing more than $6 billion a year. And the newest frontier is young patients like Ms Gofman, who allowed The New York Times to follow her for a year as she had the operation and then embarked on a quest to lose weight, navigating challenges to her morale, self-image and relationships.
‘Pretty extreme'
But the long-term effectiveness of weight-loss surgery, particularly stomach banding, the procedure Ms Gofman had, is still in question. And the push toward surgery on the young has brought some resistance from doctors who say it is too drastic to operate on patients whose bodies might still be developing and who have not been given much time to lose pounds on their own.
“I think it's pretty extreme to change the anatomy of a child when you haven't even tackled the other elements,” said Dr. Wendy M. Scinta, a family practitioner in Manlius, New York, who specialises in paediatric weight loss. Unlike with older patients, she said, “There is not a huge rush to fix it or they will die.”
Outcomes of surgery
One per cent to 2 per cent of all weight-loss, or bariatric, operations are on patients under 21, but studies are under way to gauge the outcomes of surgery on children as young as 12. Allergan, the maker of the popular Lap-Band, a surgically inserted silicone band that constricts the stomach to make the patient feel full quickly, is seeking permission from the Food and Drug Administration to market it to patients as young as 14, four years younger than is now allowed. Hospitals across the U.S. have opened bariatric centres for adolescents in recent years.
Doctors who are open to operating on younger patients note that there is substantial evidence that dieting frequently fails. “Most of us have witnessed the medical establishment provide the same advice over and over again to kids who are overweight — they just need to diet and play more outside,” said Dr. Thomas Inge, a professor of surgery and paediatrics at the University of Cincinnati, who is participating in a National Institutes of Health study of weight-loss surgery on teenagers. “I wish it were that simple.”
Ms Gofman has been overweight for almost as long as she can remember. After her doctor proposed surgery, she tried to lose weight but failed miserably, gaining 30 pounds in eight months. Maybe, she said, she secretly wanted to qualify for “the easy way out”.
In December 2010, Ms Gofman, who had just turned 19, and her mother, arrived at the office of Dr. Danny Sherwinter, the wiry, fast-talking chief of bariatric surgery at Maimonides Medical Center in Brooklyn, for a consultation. Ms Gofman had been sold on the Lap-Band, the only operation Dr. Sherwinter performs, because it is reversible and relatively low risk.
She weighed in at 271 pounds — with a body mass index of 51, well above the minimum BMI of 40, or 35 for people with at least one other related health problem, that was required for the use of the Lap-Band. (In February, the FDA reduced the minimum BMI for patients with another problem to 30, the threshold of obesity.)
Liquid diet
Dr. Sherwinter told Ms Gofman that, going by the averages, she could expect to lose about 40 per cent of her excess weight, or 70 to 80 pounds. “Which is better than any diet out there,” he said. “We'd be looking for you to come in around 200.” But, he warned, “If you don't follow along the average way, like have a milkshake every night or don't exercise at all, you will end up in the worse half.” Dr. Sherwinter asked her to prepare for surgery by going on a liquid diet. But she privately reasoned, “I'm about to have surgery, so I might as well enjoy myself.”
Ms Gofman showed up at the hospital at 6 a.m. on Dec. 22, 2010, after staying up with friends the night before, too nervous to sleep. She kept asking the nurses and doctors to reassure her that she would wake up after the surgery. Her parents and her boyfriend, Abie Feldman, were by her side.
The operation took about 25 minutes. Child Health Plus, a state insurance plan for low-income families, covered the $21,369 cost. Medicaid in almost every State and many private health plans now cover bariatric surgery, often more readily than diet or exercise plans. On many days, Dr. Sherwinter performs three or four operations in a row.
Ms Gofman's procedure, called laparoscopic adjustable gastric banding, constitutes about 39 per cent of all bariatric surgeries. The other two main types are Roux-en-Y gastric bypass, which involves stapling the stomach into a tiny pouch and rearranging the bowel, and sleeve gastrectomy, which involves removing most of the stomach and turning what is left into a thin tube.
A Belgian study of adult patients found that nearly half had their bands removed within 12 years for various reasons, according to the study's principal author, Dr. Jacques Himpens: They did not lose much weight; they regained what they had lost; they endured frequent heartburn or vomiting; or the band would slip or perforate the stomach.
A German study found that 30 per cent of patients needed new operations within 14 years, some because they wanted their bands removed, and others because of complications like slippage.
Another study in Australia found that one-third of operations on teenagers required follow-up surgeries within two years, often because of “pouch dilation”, when the stomach above the band becomes enlarged, which can happen if the patient does not follow the regimen and tries to eat too much.
Cathy Taylor, a spokeswoman for Allergan, noted that the studies involved small sample sizes: the adult ones had fewer than 300 patients combined, and the Australian study, two dozen. Ms Taylor said that the adult studies did not reflect recent improvements in the band and in surgical techniques, and that the complications in the teenage study were not serious. Stomach enlargement, she said, “speaks to the importance of additional education for the adolescent to understand the importance of adhering to the new eating programme.”
‘Teenagers, bad candidates'
But that, said Diana Zuckerman, a psychologist and president of the National Research Center for Women and Families, goes to the heart of why teenagers are bad candidates for bariatric surgery: They are often immature, rebellious and uninterested in long-term consequences.
A more critical question is whether surgery can lead to malnutrition, particularly in bypass patients, because their shortened digestive tracts absorb fewer nutrients, which could affect bone growth, sexual maturation and other development.
Ms Gofman arrived for her first postoperative visit 13 days after the surgery, stylishly dressed in a bias-cut black sweater, blue pants and short snow boots. The scale read 251 pounds, 20 pounds below that of her last weigh-in. But her mood did not match. “You know how you said I can have mashed potatoes a little bit,” she told Dr. Sherwinter. “I measured it. I didn't feel full at all. Then I was bad. I ate a little bit more and a little bit more, and I still didn't feel full, but I stopped.”
Ms Gofman wanted a “fill” of her band, an infusion of saline to make it even more constricting, even though Dr. Sherwinter had told her to wait six weeks before tightening it. She then confessed that she had also eaten a dumpling skin.
“That's probably not the best thing to do,” Dr. Sherwinter said. “Dumplings are fried and have mongo calories.”
Then summer came. Ms Gofman took a free trip to Israel with other teenagers. She missed her clinic visits, and often ate on the run. By fall, she had cancelled her gym membership because it was too expensive. When the hospital urged her to come in for a visit, she said she was busy. But the truth was that she had aged out of the child health insurance programme, and she was embarrassed to be gaining weight. She finally confessed to the hospital that she could not pay. The physician assistant told her they would “work it out.”
Regaining lost weight
Ms Gofman, who has just turned 20, saw Dr. Sherwinter in November. She had regained not quite half of what she had lost. He did not scold or blame her. He tightened her band, so it now took an hour-and-a-half to force down two scrambled eggs.
She does not want to reveal how much she weighs, but she is fighting constant hunger, and progress is slow.
Her boyfriend consoles her, she said: “I say, ‘I can't wait till I'm skinny,' and he says, ‘You're beautiful the way you are'.” — New York Times News Service
