Even as a child, Natalie Moore, 19, was aware of her weight. When she announced to her Yoder, Ind., kindergarten that her favorite animals were pigs, a classmate shouted, "That's because you are a little piggy!" By age 10, Natalie, already a Size 28, had been called "pig, cow, hippo -- really any type of large animal," she says. "When I walked down the hall, kids would say, 'Here comes an earthquake!'"
Coming home from school in tears was bad enough, but in eighth grade, Natalie, weighing well over 250 pounds, began experiencing mild heart attacks. "It was very scary," she says. "My doctor told me I only had a year to live if I didn't lose weight."
Going on a strict 1,500-calorie-a-day diet, Natalie managed to lose 40 pounds in six months, but the weight -- due to a family history of obesity as well as a sedentary lifestyle and cravings for Mountain Dew and HoHos -- gradually crept back on. After reading about weight-loss surgery on the Internet, and then discussing the procedure with her parents and her pediatrician, Natalie went for a consultation at Cincinnati Children's Hospital's Comprehensive Weight Management Center, one of the only places in the country that performs gastric bypass surgery on adolescents. On May 18, 2001 -- a month before her 16th birthday -- Natalie's insurance paid for her to undergo a gastric bypass, in which her stomach was divided and stapled down to the size of an egg.
Despite medical complications -- including a distended bowel that required immediate follow-up surgery -- and a drastic change in lifestyle that requires Natalie to subsist primarily on skinless chicken breasts, sugar-free Flintstone vitamins, and 64 ounces of water or Crystal Light a day, the college freshman, who now weighs 150 lbs, is absolutely convinced the surgery was worth it.
"I would do it a hundred times again if I had to," she says.
The popularity of gastric bypass surgery has soared in recent years, thanks in part to the dramatic weight losses of celebrities such as Carnie Wilson and Al Roker. According to the American Society of Bariatric Surgery (ASBS), more than 100,000 adults underwent weight-loss surgery in 2003, up from only 16,200 in 1992. Many insurance companies now cover at least part of the cost, which averages $25,000. While there are no official statistics as to how many adolescents have undergone weight-loss surgery -- estimates range from 150 to 1,000 -- the numbers, like those for adults, appear to be on the rise. And with childhood and adolescent obesity a national epidemic, Dr. Thomas Inge, surgical director at Cincinnati Children's Comprehensive Weight Management Center, believes as many as 250,000 teenagers may be good candidates.
"Obviously, prevention of obesity is key," he says, "but prevention failed a decade ago for Johnny, who's now 400 pounds."
But the question remains: Do the results outweigh the risks? The fatality rates, at least among adults, are relatively high -- about one in 200 adult patients die from weight-loss surgery each year in the United States, and many develop hernias, blood clots and serious infections. During a gastric bypass operation, which typically lasts between one and three hours, doctors divide the stomach, stapling the lower section into a pouch. The gastric tract is then rerouted so digestion occurs in the lower small intestine, reducing the amount of calories and nutrients the body can absorb and making long-term nutritional deprivation a potential problem. Critics contend these complications may be exacerbated in adolescents, whose bodies aren't yet fully developed. They also worry that many young patients might not be mature enough to understand that by undergoing bypass surgery, they are signing up for a drastic lifestyle change.
"We're looking at a 50-year postoperative period," says Paul Ernsberger, associate professor of nutrition at Case Western Reserve University in Cleveland. "What are the chances the weight loss will last that long? What are the long-term consequences of deliberately sabotaging the digestive process? ... Teens are not qualified to make decisions that will affect their health for the rest of their lives."
Still, despite the risks, and the dearth of long-term data, gastric bypass surgery is one of the only proven methods for achieving rapid and significant weight loss. Which is why it's not surprising that teens are lining up to have the procedure. According to the American Obesity Association (AOA), about 15.5 percent of adolescents (ages 12-19) and 15.3 percent of children (ages 6-11) in the U.S. are obese. That's a dramatic rise since the late '70s, when the same numbers stood at 5 percent and 7 percent. And while experts argue over what's caused this alarming increase -- calorie-dense fast food? Increased TV watching? Reduction of physical education curriculum in schools? All of the above? -- many severely overweight adolescents just want a solution to their weight problems now.
Eighteen-year-old Eric Decker of Columbia, S.C., began dieting at age 10, when his weight had already climbed to 150 pounds. He tried at least 25 different weight-loss plans, including popping Dexatrim pills and accompanying his mother to Weight Watchers meetings. Each time, he'd lose 15 or 20 pounds, then gain 30 or 40 back. "The weight never came off," he says.
Soon, Eric's health began suffering as a result. He felt "suffocated" when he slept, had difficulty breathing when he climbed stairs, and developed chronic pain in his knees and back. Kids at school constantly ribbed him about his size, dubbing him "Double Decker" and "Fat Boy." While Eric always had a comeback ready -- "I learned early on I'd either have to lose the weight or gain a thick skin" -- the more teasing he endured, the more food he'd eat when he came home.
"I'd have a Supersize Big Mac meal, or nine pieces of pizza at one sitting," he says. "I would snack all day. It was never-ending."
After listening to Carnie Wilson praise her surgery on TV in 2002, Eric, then 17 years old and 385 pounds, proposed the idea of surgery to his parents.
"My immediate reaction was, 'No way in hell!'" says his mother, Karen Decker, 48, a commercial loan specialist. "I thought, there has to be a better way." Particularly unsettling to her was the high mortality rate. But attending support groups and reading more about the surgery soon changed her mind. "Yes, the death rates [still] scared me," Karen says, "but I think it was a bigger risk for him to be that obese and not have the surgery."
Last January, Eric's insurance company agreed to pay 80 percent of the costs for him to undergo gastric bypass surgery at Cincinnati Children's Hospital. And like Natalie, Eric had immediate complications. The day after the procedure, he underwent an emergency operation to fix an accidental puncture in his stomach. But despite a two-week hospital stay, having to return to school with two "embarrassing" drainage tubes in his stomach, and several classmates who accused him of "taking the easy way out," nothing put a damper on Eric's excitement at becoming thin.
"I lost 15 pounds the first week after my surgery, and to see the weight pouring off me like that was such a catalyst," he says. "I was ecstatic."
To date, he has lost 195 pounds and is only 10 pounds away from reaching his dream weight of 180. "Every time I look at him, I just can't believe it," says Karen. "I mean, now he loves to do things that before would be a major physical challenge. He walks the dog, rides a bike, hikes, exercises. He's a happier person because his focus is no longer how overweight he is, but what he can do to further himself."
Eric, an aspiring actor and freshman at Coker College in Hartsville, S.C., just won his first romantic lead: Curly, in his college's production of "Oklahoma!" "Before, in high school, my weight was always worked into the scripts," he says. "I'd have to say something like, 'If you don't do this, I'll sit on you!' Now, it's not an issue anymore. It's not, 'That kid's huge!' but 'Oh, look. There's Eric.'"
According to the American Obesity Association, obese children are at risk for Type 2 diabetes, hypertension, orthopedic complications, sleep apnea and "psychosocial effects and stigma," in other words, teasing and prejudice. But some critics argue that teens who opt for a surgical weight loss solution may only trade in these complications for others. While normal recovery time is relatively short -- two to three days in the hospital, followed by two to three weeks off from school -- patients must drastically alter their diet forever. Because of their newly resized stomachs, meals consist of less than one cup of food, well chewed to aid digestion. Sugars and high-fat foods must be severely limited, since ingesting too much can lead to violent vomiting and diarrhea, or what's known as "dumping syndrome." Patients are also put on a lifelong daily regimen of vitamins, calcium carbonate tablets (like Tums), iron and Vitamin B-12. All of these restrictions might make it awkward for teens to participate in everyday activities such as eating in the school lunchroom, attending birthday parties or ordering a box of Milk Duds at the movie theater.
Because of these extreme lifestyle changes, Inge, who co-authored adolescent weight-loss surgery guidelines to be published later this year in the journal Pediatrics, believes a child needs more than some extra pounds to be a good candidate for the surgery. Those approved at Cincinnati Children's must have a minimum body mass index (the ratio between height and weight) of 40, rather than 35, the adult standard of obesity. Doctors also look for signs of "co-morbidity," or physical conditions such as Type 2 diabetes or obstructive sleep apnea for which obesity might be an underlying cause. All patients also undergo a rigorous series of evaluations, including hand and wrist X-rays to test skeletal maturity, and meetings with a dietitian, psychologist, obesity specialist and pediatrician who gauge psychological maturity as well. "We want patients who can understand the nutritional regimen they have to follow," says Inge. "And have a family life which will support them."
Since he and his staff began performing the surgery in 2001, only 28 adolescents have been approved for and undergone the procedure, Inge says. Twice as many more have been turned away.
To critics, that number is still too high. "Any adolescent who has this surgery is a guinea pig," says Joanne P. Ikeda, co-director of the Center for Weight and Health at the University of California at Berkeley and an expert in pediatric obesity. "No one knows yet whether it will treat obesity, whether it will reduce chronic disease, or whether it will lengthen an adolescent's life span. And anyone who says they do know either has a crystal ball or is lying." Ikeda also worries that adolescents who undergo the procedure will suffer from long-term nutritional deficits that will lead to diseases such as osteoporosis and anemia.
To Dr. Jenn Berman, a Beverly Hills, Calif., psychotherapist who treats both pre- and post-gastric bypass adolescent patients, weight-loss surgery doesn't cure people of their food issues, it only gives them a different body in which to harbor them. "When a teen is overweight or obese, many times it's because they never learned emotional coping skills and turned to food [as comfort] instead. When you take that one coping skill away, it can be dangerous because the tendency is to look for another one. As harmful as overeating can be, it's way down the list compared to drugs, alcohol and acting out sexually. Kids aren't prepared to deal with such an extremely drastic change."
Still, among her patients who have undergone weight-loss surgery, Berman acknowledges a strange loyalty. "I've worked with people who've been hospitalized for malnutrition and people who've had to give up their lives as they knew it, and they still speak highly of the surgery," she says. "It's almost an anorexic-type mentality."
"This surgery may not be perfect, but it's a lot better than any other alternatives these kids have," says Dr. Louis Flancbaum, chief of bariatric surgery at St. Luke's-Roosevelt Hospital in New York, and the author of "The Doctor's Guide to Weight Loss Surgery: How to Make the Decision That Could Save Your Life." "No matter how sick or miserable they may be afterward, they never want to have their surgery reversed. That's as much a commentary on what it's like to be morbidly obese in our society as it is the surgery."
Two years ago, as a freshman at Rutgers University in New Brunswick, N.J., Jennifer Ortiz weighed 256 pounds. The excess weight put incredible stress on her 5-foot frame; the arches in her feet collapsed, and arthritis in her right knee made it painful for her to stand long enough to brush her teeth. Self-conscious about her weight and stressed about schoolwork, Jennifer isolated herself in her dorm room and subsisted primarily on junk food: gas station coffee with Irish Delight creamers, Hershey's chocolate bars from the campus vending machines. "It was a vicious cycle," she says. "Because the more I gained weight, the more I stayed home."
Still, it took months of soul-searching before she decided to have a consultation with Flancbaum that fall. "I was so scared to get it done," Jennifer, now 20, says. "Not so much because of the risk of dying, but because I didn't want to admit to myself or anyone else that I was that overweight."
On May 20, 2002, just two days after her final exams, Jennifer underwent the surgery, which her insurance paid for in full. The biggest complication she experienced was vomiting four days after her return home from the hospital. "I tried to eat steak," she says. "Not a very smart move."
Jennifer quickly learned her lesson, and began carefully following Flancbaum's orders: food and drink ingested separately at first, slowly, and in very small amounts. Within one month, she lost 30 pounds, and began feeling "normal" for the first time in her life. "Who I really was on the inside finally came out," she says.
Since October 2003, Jennifer has maintained her current weight of 140. She says she's now more active in school, and more willing to speak up in class. ("If I ask a stupid question, it's not like people will still look at me and go, 'Ugh. And she's fat, too.'") She goes dancing with friends and, for the first time, has guys falling over themselves to buy her apple martinis. Even her friendships have become more honest. "I won't let people walk all over me like they did before," she says. "Before, I would have done [anything] in a heartbeat to get you to like me."
But getting used to her new shape hasn't been entirely easy. Jennifer and her boyfriend of three years broke up a few months ago, and she acknowledges all the new attention she's getting may have been a factor. Last month, when she was too busy going clubbing with friends and doing schoolwork to follow her prescribed routine of four to six small meals a day and continuously sipping fluids, Jennifer passed out from dehydration and had to be rushed to the hospital.
Even so, "the hardest thing [about the surgery] is having my freedom and not taking advantage of it," she says. "I was stuck in that body for 18 years. Self-respect is what keeps me from sleeping with every guy I'm attracted to, doing drugs and going out drinking every night. The only bad thing I've done is pierce my tongue."
Feeling overwhelmed by opportunities is a typical reaction for patients who've undergone weight-loss surgery, according to Berman. "When you're placed in a new body, practically overnight, it can be overwhelming and anxiety-producing -- even if it's the body you've wanted for years," she says. "It takes a lot of energy to resist your impulses."
Now in college, Natalie Moore finds herself constantly invited to frat parties, where drinking beer is the activity of choice. Since even one cup would cause her system to "dump" -- that is, cause severe vomiting and diarrhea -- she's forced to abstain.
"It's not hard," she says. "It's more fun to sit around and make fun of the people who get drunk."
Late-night pizza in the dorm with her friends is still doable, so long as she eats a tiny amount and skips the crust entirely. And while there are days she still craves a nice, cold can of Mountain Dew, drinking only water or sugar-free Kool-Aid is a small price to pay for her new Size 6 body. Natalie can finally fit into the low-riding jeans and belly shirts she coveted throughout high school. "I have a big scar on my stomach from the surgery and some people ask me, 'Why are you wearing clothes like that?'" she says. "I say, 'Those are my battle scars. I'm proud of them.'"