Just Kids: A Multidisciplinary Look at Treating the Laparoscopic Adjustable Gastric Band Adolescent Patient

by Nancy Tkacz Browne, RN, MS, CPNP, CBN; Allen Browne, MD; Mark J. Holterman, MD; Ai-Xuan L. Holterman, MD; Nilda Nagle; Christiane Stahl, MD; Amanda Guide, RD; Susan Hollingsworth, PT; April Clark, PT; Kelly Piepenbrink, PT; Amy Phipps, RN, MS, CPNP; Barbara Sherrill, CMA; Larry Turner, Erin Tobin, LCSW; Lilia Gomez, CSR; Sandra Gomez; and Lisa Tussing

Introduction
The current epidemic of childhood and adolescent obesity represents a significant health threat to our nation’s youth. This epidemic spans cultures, genders, socioeconomic levels, and communities. Obesity threatens all children, whether they are of normal weight or at the extreme end of the obesity spectrum. The primary goal of a weight management policy is to prevent obesity in our youth. However, if severe obesity is present, a comprehensive approach to the treatment of obesity and its comorbidities is needed.

After a brief overview of the problem of adolescent obesity, this article will focus on the development and philosophy of the New Hope Pediatric & Adolescent Weight Management Project at the University of Illinois Medical Center at Chicago. The New Hope program represents a growing number of adolescent weight management programs that have a bariatric surgery treatment arm, and was featured in the June 2006 issue of Bariatric Times for its Food and Drug Administration (FDA) Protocol for Adjustable Gastric Banding in Adolescents Clinical Trial.

Definition and Prevalence
The Centers for Disease Control and Prevention (CDC) recommend using the percentile body mass index-for-age and gender (BMI-for-age) charts to screen children who are at risk for becoming, or who actually are, obese. Children with a BMI-for-age above the 85th percentile are considered at risk for obesity and those with a BMI-for-age above the 95th percentile are considered obese.

The CDC report that the percent of adolescents (ages 12–19) in the US who are obese (above the 95th percentile) continues to increase. CDC data from the National Health and Nutrition Examination Survey: 1999–2000 (NHANES 1999–2000) reveal an overall obesity rate of 15.5 percent in 12 to 19-year-olds or almost nine million adolescents.1 This percentage has tripled since 1980.2 Another 30 percent of adolescents are at risk for becoming obese.

The prevalence of adolescent obesity is not restricted to the US. Increasing rates of overweight are seen throughout the world, including developing countries in the Middle East, northern Africa, and Latin America. The highest percentage of overweight is seen in Ireland, Greece, Portugal, and Australia.3

Etiology and Pathophysiology
Obesity is a chronic disease with multiple factors contributing to its etiology. The relative contribution of an individual’s genetics, culture, lifestyle behaviors, psychology, environment, and metabolism in explaining the individual’s obesity physiology is an ongoing debate.4 However, most experts agree that increased caloric intake and decreased physical activity in the last three decades have contributed to the obesity epidemic in our youth.

High-calorie food consumption, increased portion size, increase in sedentary activities, and decrease in exercise opportunity all contribute to weight gain.

Appetite, satiety, energy expenditure, and the regulation of subcutaneous and visceral fat stores are regulated by a complex interaction of the body’s central nervous system, gastrointestinal tract, and fat cells, including hormones, proteins, and neuropeptides.5

Currently, a limited understanding of the physiology of these interactions exists, and therefore the pathophysiology of these interactions is poorly explained. As the relationship between these physiological mechanisms and social and environmental influences are better understood, better treatment options will be developed for the overweight and obese child and adolescent.

Comorbidities
With increasing frequency, obesity-related comorbidities that are seen primarily in the older adult are being diagnosed in childhood and adolescence. The overweight or obese adolescent is also at risk for emotional and social comorbidities. One hundred percent of the morbidly obese adolescents treated in our program have at least one serious obesity-related comorbidity—the average is four. These comorbidities include (but are not limited to) asthma, hypertension, polycystic ovarian syndrome (PCOS), type II diabetes, sleep apnea, orthopedic injuries, dyslipidemia, non-alcoholic steatohepatitis (NASH), and metabolic syndrome. The range of psychosocial comorbidities is no less disabling. These comorbidities include depression, stereotypes, discrimination, and social teasing.

Prevention and Treatment of Obesity in Adolescents
A partnership of family, community, schools, and healthcare professionals is necessary to address the complexities of the problem of childhood and adolescent obesity in our society. Models and guidelines exist for the prevention and treatment of childhood overweight and obesity.3,4 Included in these guidelines for the treatment of adolescent obesity is the use of behavioral therapy, restrictive diets, and medications.

Long-term results in a comprehensive, medically directed weight management program are reported by Epstein and colleagues in a series of articles.6-8 Thirty to 35 percent of children maintained a reduction of 20 percent of excess weight after 10 years of follow-up. While these results are encouraging when contrasted with adults studied in these series, there remains 70 percent of overweight children who are faced with the threat of psychological and physical comorbidities.

Sixty to 70 percent excess weight loss (EWL) can be achieved and sustained when a bariatric surgical procedure is added to the components of a standard medical weight management program.9 Bariatric surgery should be considered for adolescents who are greater than the 95th percentile and/or have severe effects from obesity-related comorbidities.10-12

Program Background
After a successful adult bariatric program was established at the University of Illinois at Chicago (UIC) in the late 1990s (utilizing both gastric bypass and the adjustable gastric band as surgical options), UIC developed an adolescent weight management program with the the following components: the traditional behavioral, nutritional, and activity treatment arms; a multidisciplinary treatment team; the surgical option of laparoscopic adjustable gastric band (LAGB) for select adolescents in addition to traditional treatment; and a monthly-attended adolescent clinic that emphasizes chronic treatment nature of the obesity condition.

Because of the safety, adjustability, and reversibility of LAGB, surgeons at the New Hope Pediatric & Adolescent Weight Management Project at UIC applied to the FDA in 2003 to obtain an Investigational Device Exemption (IDE) to place the LAGB on adolescents. Concurrently the New Hope Pediatric and Adolescent Weight Management Program was created. In 2004, the IDE was granted to place 50 LAGBs on 50 adolescents ages 14 to 17. The Internal Review Board (IRB) approval was also obtained. Three other US centers have since obtained their own IDEs (with IRB approval also).

In 2007, the FDA authorized a seven-center, multi-institutional safety and efficacy trial to study the safety and efficacy of approximately 150 adolescents (ages 14–17). The UIC original protocol served as the basis for this multi-institutional trial. All sites have IRB approval. Enrollment closed in November, 2007. All studies (either individual or multi-institutional) will follow the adolescents for five years with annual reports to the FDA.

Clinical care. All children in the clinic are followed by a psychologist, social worker, dietitian, pediatric nurse practitioner, adolescent medicine specialist, physical therapist, and medical assistant, and adolescents with LAGB are managed by a pediatric surgeon with expertise in LAGB placement. Adolescents meet with each professional for 30 minutes monthly, averaging four hours per clinic visit. The patients also meet each other in the waiting room and coffee room, adding to the supportive nature of the clinic.

For patients who have received LAGB, adjustments are done either by fluoroscopy in the radiology department during their visit or at the clinic itself. LAGB adolescents are typically in the program from 4 to 6 months before a band is placed—a determination made by the clinicians as a team, along with patient and family. The emphasis is on preparation and follow-up, not surgery. Adolescents with LAGB continue to come to monthly clinic visits after the LAGB is placed.

Patient Summary
As of November, 2007, New Hope has screened over 170 adolescents with approximately 100 patients actively seen in the program on a regular basis. To date, 54 bands are in place with a total of 58 anticipated by the end of 2007. BMI ranges are 35 to 81.

Severe Overweight as a Chronic Illness: Implications for the Adolescent
The adolescent with chronic illness is vulnerable to specific developmental risks. These risks include interruption toward independence from parents, altered body image, poor peer group relationships, and difficulty in consolidating a mature identity. Coping mechanisms can be either adaptive and helpful or maladaptive. The stress and uncertainty of chronic illness can lead to a breakdown of positive coping strategies. A multidisciplinary healthcare team that provides consistency, support, education, empathy, and guidance can assist adolescent and family in optimally progressing through the developmental tasks of adolescence.

Caring for Teens in a Weight Management Program
Our multidisciplinary team strives to care for each adolescent with a personalized treatment plan. Each professional has his or her own style and approach that guides their interactions with the teens. The following are insights shared by staff regarding their particular disciplines.
Receptionist/scheduler. Lilia Gomez is the first person that a family speaks with on the phone and meets in clinic. Empathy and understanding are crucial as she very frequently speaks with families who can best be described as “desperate,” having been hung up on or sent away by other medical offices, and are afraid of denial of access to treatment. Lilia makes an effort to know each child by name and remember a personal detail to put patients at ease at their first appointment. Although she tries to meet everyone’s needs, it is often necessary to ask for flexibility from the team regarding the difficulties of patient scheduling with several staff in one day. Lilia sets an attitude that “the kids come first,” which is adhered to by staff. She carefully introduces new patients to staff and sets the tone of a safe atmosphere. Her goal is initiating the best possible experience for patient and family.

Medical assistant. As the medical assistant, Barbara Sherrill is responsible for weighing in the teens, a sensitive time that Barbara respects with a privacy protocol referred to as “Vegas,” because what happens there, stays there. Despite whatever struggles teens face in the weight room, they emerge feeling supported. A decision by a teen not to be weighed is always respected, although refusal to be weighed rarely happens once they know that the weight number is not the team’s focus.

Dietitian. As the dietitian, Mandy Guide is cognizant of the fact that on a patient’s first day, he or she often does not know what he or she wants or what to expect. Mandy therefore tries to assess their goals first, and then begins counseling, probing existing knowledge, giving an overview of LAGB, determining level of surgical interest, recording reasons for desire to lose weight, reiterating the importance of their health and future, and sharing an overview of her expectations. This expectations overview is not about dieting (and a list of forbidden foods), but rather about learning how to eat healthy, live healthy, and feel good doing it, as well as about emphasis on the role of behaviors.

Mandy and the patient then review the teen’s typical daily eating and develop goals to work on for the next month, reminding them that they didn’t gain weight overnight, so the expectation is not to lose weight overnight. The goal is to achieve slow, steady, healthy weight loss. The individuality of teens and their parents take the rest of a session in many different directions. But Mandy’s most important goal upon meeting patients is to help them feel comfortable, let them know they won’t be judged, answer their questions, and give them tips. Feedback that a patient is doing what’s been taught and that it is helping—and that they are genuinely happy and appreciative—makes the job rewarding.

Physical therapy. New Hope has three physical therapists, April Clark, Kelly Piepenbrink, and Susie Hollingsworth, who work with the teens in clinic. A teen with a BMI of 50 typically cannot run a mile or work out on a treadmill often. The physical therapists evaluate and treat the teens where they are now—not where they hope they will be in the future.

The key to working with adolescents is to be a friend and not an authority figure. These kids just need to be given a chance to talk. They are judged all day, and the clinic becomes a safe place where they know they are not alone. We need to choose activities that will help allow these kids to succeed. Often the smallest change, such as getting up to go to the kitchen to get a drink versus asking someone else to do it, can make all the difference in the world. In general, they come to us with a feeling of lost hope on weight loss and in social situations. Even helping the teens to avoid gaining weight for a few months is a success that may propel them to make a larger change. Interaction on a level playing field is also a key point of treatment; the the therapists suggest fun ways to incorporate activity into daily practice, such as lifting weights and doing 10 jumping jacks during commercials, and talk about their own struggles in doing these things at home. Simple, small changes can be effective in leading to larger changes in this population of adolescents, especially when teens realize that the small changes necessary are many times challenging for all people.

Also, working to be creative and starting with small goals avoids immediate failure. For numerous reasons, from socioeconomics to self-image to joint pain to body habitus, telling these adolescents to run on treadmill or ride a bike for 45 minutes is not practical. One mainstay of physical therapy is identifying patients’ interests and finding activities that match their interests. Once they are more active and begin to feel better, have more confidence, and get praised for reaching goals, challenges can be increased.

Another key to success is getting family involved. These children are tired of being isolated and alone, so a parent or sibling who not only believes in them but is willing to participate alongside them is a motivational booster as well as improvement in comfort level.

Adolescent medicine specialist. Christiane Stahl, MD, addresses concerns about body image, romance and sexual activity, teasing, moodiness and self-injurious behaviors, and problematic interactions with parents with a dual focus on physical and mental health. Many of these issues require respecting confidentiality of disclosures while working with teens to maintain and build connections with the important adults in their lives. Transitioning to adulthood means a change of settings for many patients, and this disruption of routine and support can be very challenging for youth with chronic illnesses. Helping teens plan for transitions and maintaining contact with them is an important step in helping them to be successful with weight management.

Nurse practitioner. Amy Phipps, RN, MS, CPNP, counsels the teens in clinic and follows them between visits by email, cell phone, or My Space. Key points of working with her patients are 1) communicating with an understanding of developmental age and tasks, and recognition that this stage of some teens’ lives includes formation of their own identities and growth of independent thought and action; 2) recognition of past and current stress on the parent and parent/child relationship and the individual dynamics involved with each family; 3) self-forgiveness—teens must realize that obesity is a chronic disease for which there is no cure and also no fault; 4) mother/child continuum—success requires a shift in responsibility from parent to child, and parents need to surrender control; 5) remembering that they are just kids, not adults (though some look and act grown), and that body consciousness and body image are some of the predominant emotions as well as a desire to please; and 6) patience—every patient is different, and success for one is not the same as success for another.

Social worker. Erin Tobin, LCSW, meets with patients to complete psychosocial assessments, follow up on former assessments, and conduct individual counseling. In addition, she makes referrals for counseling, performs case management work, and tries to establish links between New Hope and other providers, schools, families, social service agencies, etc. Erin aims to find strengths in clients and advocate for them, the former being easier than the latter. They are discriminated against by insurance companies, schools, transportation companies, other clinicians, peers, and employers.

Assistant director. As assistant director, Nilda Nagle’s task is to oversee financial and organizational issues. She advocates for families with insurance companies, other payers, primary care physicians, and other agencies. Nilda coordinates a team that finds payment strategies, not only for New Hope teens having LAGB, but also for those receiving weight management care in the clinic. Being resourceful, determined, and unwilling to take no for an answer makes her successful.

Psychologist. Dr. Larry Turner sees that many teens in the weight clinic have been traumatized by prolonged stares, facial expressions, unkind words, and internal fears. Being overweight is a stigma that is impossible to hide. At times this stigma can be overwhelming, resulting in severe emotional overload, but many adolescents develop a magnificent resilience that protects, matures, and guides them through this tumultuous time. These protective factors and coping strategies are part of their groundwork for adulthood. Family members who continue to nurture patients on this journey are a very important part of the equation.

Pediatric surgeon. Allen Browne, MD, writes that what he typically hears in his work are the following types of statements: “A chronic incurable disease,” “I don’t want to die,” “I want to be able to look in a mirror and smile,” “Please don’t hang up,” “You’ll talk to me?” “You’ll see my child?” and “I have to learn to help my band.”

Dr. Browne explains that, “I’ve been practicing pediatric surgery for 28 years, but until four years ago, I had ignored obesity. Then, one day, I realized the terrible quality of life experienced by obese children. I knew bariatric surgery could help obese patients. I decided to help them. Four years later, I have truly been blessed. Obese kids are just kids. If you close your eyes and listen to them talk, they are just kids. If you open your eyes, you see a person trapped by a chronic, incurable disease.”

“The New Hope team gets it. It is our job, our responsibility, and our opportunity to help these children and their families. We can save whole lives. We know the tools of weight loss. Collectively, we know behavior modification, nutrition, activity, and the adjustable gastric band. None of the kids flunk, none of them fail, and none of them are fired. Each time they come to clinic, they give us a chance to help them.”

Conclusion
The ultimate goal of the program is to create a haven where children and teens who struggle with overweight can come together and learn, become healthier, and be accepted. Our atmosphere has to be positive and open if we expect the patients to return. We realized early on that most of our patients’ experiences in healthcare have been negative. Recognizing that no one wants to return to a place where one felt humiliated and had failed, we strive to keep our clinic a safe haven for our patients so that they will return to continue treatment. Rather than asking a teen who’s returned for a band adjustment due to stalled weight loss, “What have you been eating or doing wrong?” we ask, “Isn’t it great that you returned for a needed adjustment of your band?”

Overweight teens suffer from two stereotypes: Being overweight and being a teenager. Both stereotypes are wrong. As adolescent clinicians, we must champion these children through a very difficult time in their lives. Our best care of the overweight teen can simply be a self-examination of our beliefs and prejudices of this group of children. In the end, every teen tells us that all they want is to be like other kids. After all, they are just kids.

References
1. Ogden CL, Flegal, KM, Carroll, MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002; 288(14):1728–32.
2. National Center for Health Statistics. Centers for Disease Control & Prevention. www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm.
3. Speiser PW, Rudolf MC, Anhalt H, et al. Consensus statement: Childhood obesity. J Clin Endocrinol & Metab 2005;90(3):1871-87.
4. Baker S, Barlow S, Cochran W, et al. Overweight children and adolescents: A clinical report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol and Nutr 2005;40:533–43.
5. Greenway RL, Greenway SE, Raum WJ. The physiology of the brain, the gut, and the fat cells in the morbidly obese. In: Martin LE (ed). Obesity Surgery. New York: McGraw, 2004:49–61.
6. Epstein LH, Myers MD, Raynor HA, Saelens BE. Treatment of pediatric obesity. Pediatrics 1998; 101(3):554–70.
7. Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year follow-up of behavioral, family-based treatment for obese children. JAMA 1990; 264(19):2519–23.
8. Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychol 1994;13(5):373–83.
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12. Inge TH, Zeller MH, Lawson ML & Daniels SR. A critical appraisal of evidence supporting a bariatric surgical approach to weight management for adolescents. J Pediatr 2005;147:10–19.

Suggested Readings
1. Browne N, Haynes B. Bariatric surgery in a weight management program. In: Browne N, Flanigan L, McComiskey C, Pieper P (eds). Nursing Care of the Pediatric General Surgery Patient, Second Edition. Boston: Jones & Bartlett, 2007.
2. Dillard B, Gorodner V, Galvani C, et al. The initial US experience with the adjustable gastric band in morbidly obese adolescents and recommendations for further investigation. J Pediatr Gastroenterol & Nutrit 2007;45(2):240–6.
3. Holterman MJ, Browne AF. Technique in application of the adjustable gastric band in adolescents. In: Holcomb G, (ed). Atlas of Pediatric Laparoscopy and Thoracoscopy. In press.
4. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: Concerns and recommendations. Pediatrics 2004; 114(1): 217–23.
5. Inge TH, Zeller MH, Lawson ML, Daniels SR. A critical appraisal of evidence supporting a bariatric surgical approach to weight management for adolescents. J Pediatr 2005;147:10–19.
6. Lerner RM. The Good Teen. New York: Crown Publishers 2007.
7. MacKenzie RG, Neinstein LS. Obesity. In: Neinstein LS (ed). Adolescent Healthcare, A Practical Guide, Fourth Edition. Philadelphia: Lippincott, 2002.
8. Nadler E, Holterman AL, Wulkan M, Inge T. The current state of surgical
weight loss for morbidly obese adolescents. J Adolesc Health Rev. In press.

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