2023-05-01 15:33:41
Beau (23) was born as a giant baby. Big and heavy. And he stayed that way. He was about eight years old when he made his first attempts to lose weight. His parents visited “at least ten dietitians” with him, and he went through a hospital program in which he was guided by psychologists and nutrition and sports experts. Nothing worked.
Beau (he doesn’t want to enter his last name NRC): “Despite all the help I received, I just kept eating. There was a period when I only lasted a week and a half with a tray of those Energy cans. I ate what I felt like and not in the normal amounts.” And if his parents, consciously, had no crisps, sweets or biscuits in the house, he went to the supermarket. “I knew: I will not make it on my own.” At the age of sixteen he weighed more than 148 kilos. “An absurd weight.”
When nothing helps, there is sometimes one last resort: surgery. Children who are seriously overweight can also undergo gastric surgery in the Netherlands, for the time being only in a study context. If this shows that these children are healthier after surgery, it can be used more often as part of a treatment.
Beau, along with 58 other children (between 14 and 16 years old), participated in such a study, which was conducted between 2010 and 2020. The children received a combined lifestyle intervention: a program in which various experts guided them in healthy eating and exercise. to move. In addition, half of the children received a gastric band – after being selected by lottery. Beau, 16 years old at the time, was among the lucky ones. Because that’s how it felt to him. “I don’t want to call it my last save, because you don’t know if the button might have turned later. But at the time it felt that way.”
There are two types of gastric surgery: the placement of a gastric band, where a silicone band divides the stomach into a small forestomach and a larger ‘residual stomach’. And the final reduction of the stomach. In both cases, people can eat less because the stomach has less space. It’s a big step to perform such an operation on a child, but sometimes it’s a last chance to prevent serious health problems, say pediatricians who specialize in obese children.
Doctors and surgeons who NRC spoke believe that childhood obesity should be tackled much more aggressively. Don’t wait until it’s too late – it’s no longer uncommon for a young adult to need a liver transplant due to being overweight. Pediatrician Erica van den Akker of the Erasmus MC-Sophia Children’s Hospital in Rotterdam: “Real action in the Netherlands often only follows when it is too late. You cannot solve obesity with prevention. These children really need care.”
The recently introduced guidelines in the United States she thinks this is an interesting example of a more active approach. Particularly when it comes to intensive lifestyle counselling: American children with obesity can now receive this from the age of two. From the age of twelve they are prescribed anti-obesity medication and from the age of thirteen they are eligible for a gastric bypass.
Cementblok
In the Netherlands, about 2 percent of children are obese, and 12 to 15 percent are overweight. That’s half a million kids. From US research, de Bogalusa Heart Study, it turns out that they have an 80 percent chance of developing obesity later on. With all the associated risks of chronic diseases. And the numbers are probably even more alarming than currently thought: the latest national growth study, with the most reliable figures on overweight and obesity in children, dates from 2010. We don’t really know what the state of our youth is now, says Erica van den Akker. “But I can tell you that we clearly see many more children with severe obesity in hospitals every year.” This, she says, is a crisis. “We have our feet in the water, really.”
The results of the study Beau participated in have yet to be published. What research leader and pediatric surgeon Ernst van Heurn can already say about it: the children without a gastric band (but with lifestyle guidance) gained more weight and the children with a gastric band lost an average of 15 percent of their weight in the first year. That is not very much, but the sugar and fat levels in their blood did improve. Van Heurn: “If you weigh 120 kilos, and you lose 20 of them, you already have health effects, such as a lower risk of diabetes.” Beau lost 30 pounds in the first four months after his surgery. Now, six years later, he weighs “something like 250 pounds.” That is 35 kilos less than he weighed at his heaviest.
Beau has been sick with his gastric band countless times, he says, especially in the beginning. Now it only goes wrong every now and then. That happens at times when he eats too much or too fast, or doesn’t chew properly. “It feels like a cement block is getting stuck in your stomach opening, and your body wants to get rid of it. I feel sick, I want to vomit, but there is nothing I can vomit. Just a kind of tough mucus.” These are complaints that often occur after placing a gastric band.
He has also been to the hospital several times to inflate or loosen the tire. “I have to constantly explore what is and what is not possible.” Still, he’s happy with it. His weight is now stable and he feels good, better than before. Before the gastric band, for example, his overweight caused problems with his knees and ankles while playing football.
The gastric band study has been completed. Currently it is in another investigation a more drastic, but possibly also more effective variant for operating on seriously overweight young people: stomach reduction. The first two youngsters have now undergone surgery. Unlike a gastric band, depending on the type of gastric reduction, this operation is not or less easy to reverse. It also means a lifelong adjustment of other dietary habits and taking vitamin supplements.
Illustration Dewi van der Meulen
Strict selection
A stomach reduction is a complex but safe operation, says surgeon François van Dielen, who, together with pediatrician Anita Vreugdenhil, is leading research into stomach reductions in young people in a partnership between the Máxima MC in Veldhoven and Maastricht UMC+. Never before has he put his knife in a teenager. Technically it is no different than an adult: 120 kilos is 120 kilos – age makes no difference. But it does feel different, he says: this young person improves in health much sooner and has a better quality of life much sooner.
Everything has been done for the Dutch young people who have had or are still undergoing a stomach reduction, says surgeon Van Dielen. “They had their backs against the wall.” They have had a lifestyle intervention for at least a year, during which they are guided by a team of experts in adjusting eating and exercise habits. Children whose lifestyle improvement is hindered, for example, by an insufficiently treated mental disorder, such as ADHD, or who do not faithfully attend therapy sessions, do not pass the strict selection. Pediatrician Anita Vreugdenhil: “Having been to a dietitian three times is not enough.” A good motivation of the child and parents is crucial to be able to cope well with life after the gastric reduction. Because these young people have to adjust their diet for the rest of their lives and take vitamin supplements every day.
There remains a small group that has been ‘treated out’: young people who have tried everything but are unable to lose weight. Vreugdenhil estimates that there are about 5,000 to 10,000 young people in the Netherlands between the ages of 13 and 17 for whom this applies – younger children are not eligible for an operation.
One of the two young people who have been operated on by Van Dielen – there are now nine in the selection procedure – is Laura Punt, now 18 years old. Laura has been following all possible diets since she was nine years old and participated in various weight loss programs through the hospital. She was intensively supervised and was even admitted to an obesity clinic. Her lowest point was in corona time: in 2020 she was 15 years old and weighed 130 kilos. She no longer dared to go to school. After a long process with many conversations and examinations, she had a stomach reduction on June 29 last year. Van Dielen: “She is doing very well now. She has already lost almost 50 kilos. She has more self-confidence, she is proud, I really like to see that.”
The health gain after a stomach reduction is often great, as is known from many international studies on adults. People who are overweight run a higher risk of diabetes, high blood pressure, cardiovascular disease, certain types of cancer, back and joint complaints and sleep apnea, among other things. Those who have undergone a gastric bypass lose about 35 to 40 percent of their weight in a year and have a good chance that the health problems and risks will decrease.
Heavy surgery
But there is also a downside: a stomach reduction cannot always be reversed. Laura Punt will be able to eat only small amounts at one time for the rest of her life, spread over six to nine meals a day. What she eats should be as balanced as possible, with the help of a dietitian, to get enough nutrients. She has to take vitamin supplements for the rest of her life. During the first five years after the operation, Laura and the other (still to be operated) young people are guided in a lifestyle programme. That is necessary, say the doctors involved, because contracting a vitamin deficiency, for example, is a real danger. Their blood is regularly checked for iron levels, for example. And if they slowly arrive again, timely adjustments can be made.
For Erica van den Akker, shrinking a baby’s stomach is a complicated dilemma. “Everything in me as a pediatrician says: oh no, you don’t want that for a child. I think it’s a very intense operation at that age. You intervene irreversibly while you can wonder whether these young people can foresee the consequences in the long term.” The brain of an adolescent is still developing. “And at the same time I say: good that it is possible. If a child threatens to go completely wrong if it is not done, then the advantages outweigh the disadvantages. Then you want to have that opportunity.”
At the age of eighteen, Beau was offered a stomach reduction by his pediatrician, precisely because the gastric band had already proved so successful in his case. With a reduction, he could lose even more weight. He thought about it, but decided against it. His gastric band can be removed when he is “done with it”, but a reduction cannot be reversed. Moreover, he doesn’t trust himself when it comes to taking vitamins consistently every day. He is still overweight, but he feels good, has a stable weight and above all: no longer feel like “those struggles of paying close attention to what I eat”. “I am only 23. Such a stomach reduction is also possible if I think at the age of forty or fifty: it is still not healthy what I am doing.”
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