Doctor Shawn Stafford, MD, Metabolic/Bariatric Surgeon at Texas Children’s Hospital, talks about how childhood obesity is becoming a prominent issue in our youth and how surgery can change and save a child’s life.
Interview conducted by Ivanhoe Broadcast News in April 2022.
Have you seen a need? Did the need grow?
DR STAFFORD: We’re still not meeting the need. There’s so much need out there. There’s such an untapped population out there. Over 20 percent of the kids in the country are overweight. There’s a huge need for this and we’re seeing co-morbidities in these kids now that we never saw in people until their forties and fifties before. So early intervention is the key, and it’s a great opportunity for us to help them this way.
We talked to Harley, and she listed off a handful of co-morbidities that I’ve only talked to 40- and 50-year-olds who have this. Can you give more detail?
DR STAFFORD: We’re seeing it more and more. We’ve had eight-year-olds with hypertension. One of the first kids I operated on needed a kidney transplant at 15. Complete renal failure. Had to lose 150 pounds to get on the transplant list. That’s someone that if we could have intervened earlier, he could still have his own kidneys. That’s a big deal. But there’s a genetic component. There’s a metabolic component, and then, there’s a lifestyle component. And the combination of three makes it easy for us to have kids that get heavier faster. Losing the weight is a different story.
These problems accumulate for adults and when you’re starting that young, there’s no good outcome for these kids by the time they’re 25. What do you think of this?
DR STAFFORD: Yes, and all the data shows that that growth curve is not going to alter. It’s just going to go up. So, any kids that are obese are going to be morbidly obese by the time they’re teenagers. By the time they’re adults, they’re going to be super morbidly obese and it’s just a natural progression. We don’t really see a lot of variations in that curve.
If you can intervene with surgery, is that something that you’re seeing sustained throughout their lives or what do the studies show?
DR STAFFORD: It’s tough because the surgery is the same for everybody. What they do with the surgery is what determines how the outcome is going to be. And I tell them, outside of sewing your lips shut, there’s nothing I can do that can keep you from gaining all your weight back, if that’s what you want to do. You can eat through any surgery we have. But those kids that apply themselves and learn the lessons – and the most important part of our program, which is that six months before surgery, we address those lifestyle changes, making small changes that allow them to maintain their weight, which is so much easier than losing weight because you have to be hungry every night. They learn to maintain their weight. Once they lose it from the surgery, then they never get it back and we’ve had a lot of success with that. We’re very selective in our patient population, too. Everybody that rolls through the door doesn’t get surgery. They have to demonstrate over the course of this preoperative period that they’re motivated and that they’re capable of making mature decisions about changing their lifestyle and making it stick.
Do you screen them through that whole six months and what would turn someone away?
DR STAFFORD: There’s a lot of components to this. Part of that six months, we have a multidisciplinary team. So, we’re going to look at every possible thing that could be wrong with these kids. The risk of the surgery is very low. It’s very similar to getting your gallbladder taken out. It’s half the risk of getting a C-section. But if we’ve got some other co-morbidity we don’t know about, say, obstructive sleep apnea with some cardiac manifestations or a heart disease problem we don’t know about, maybe the risk is much, much higher. So, we want to identify those things ahead of time, and we want to mitigate those factors by having the appropriate subspecialists treat them and get them ready and optimized for surgery. Additionally, they’re working very intensively with our nutritionists and dieticians. We’re looking at what they’re doing now and coming up with an individualized program for that particular patient on where we need to make these small changes that are going to help them maintain their weight loss when it’s over. We don’t tell them that they have to lose 35 pounds in order to get an operation, because research shows that doesn’t work and it makes sense, too. If I told you, if you lose 35 pounds, I’ll buy you a Lamborghini, you’ll lose that weight. Right? But the first stop on the way home once you get those keys is going to be for fries at McDonald’s, right? I haven’t taught you anything. I’ve just made you do something to get something you want. That’s short-term gain. We want them to learn long term what to do to make these changes so that they can have a durable response to the surgery. And if they show that motivation, if they’re complying with what we’re asking them to do, those are the best kids. Those are the ones that are really going to make it work.
Would you say 10 percent of the kids that come in the door are turned away or?
DR STAFFORD: Well, I would say it’s much more than that. It’s not that we turn them away. They self-select. So, I’d say right now we’re at about 20 percent of kids coming through the program actually get surgery. A lot of that is just they drop off. Some kids are really motivated. They really want to do it. They have that maturity, and some aren’t quite there yet. And maybe later in life they can revisit this.
Can you talk about the things the kids have to give up for the surgery?
DR STAFFORD: Yeah, it’s tough. It is. But the way I kind of think of it is like surgery is like that post-op period is like rehab. You’re addicted to carbs. You’re addicted to sugars. You’re addicted to all those things you have every day. And then, in a post-op period, you can’t have them. You’re on that liquid diet with the protein shakes and all that. And after having been off it for a month, suddenly, you don’t really want it anymore. That urge, that craving is no longer there because you’ve beat that addiction. But just like an alcoholic, you don’t celebrate a month off the booze by going out and having a beer, right? If they don’t go out and start eating sweets again, they won’t need that. They won’t want it anymore. But staying off it makes it easier to just not need it anymore.
For the kids that can get the surgeries, do you think it’s almost easier than an adult that has the surgery because they haven’t had that 25 years of drinking Coca-Cola every day for lunch?
DR STAFFORD: Oh, without a doubt. If you think about it, these kids are at a point in their life when they’re going to change no matter what. Those who are going to go off to college are going to leave where they’re at. They’re going to have new surroundings, new friends. Those that go off into the workforce, they’re going to be working. They’re going to be meeting new people around there. Their whole life every day is going to change. If you think of who you were at like 16, 17 years old and who you were in your twenties and who you were in your thirties, I know nobody would recognize me if I went back to high school, right? I mean, nothing is the same. Change is normal at that period. You’d make those lifestyle changes there. It’s like what I always say is if your friends are eating Cheetos and drinking soda and playing Fortnite, what are you going to do when you get together with your friends? You’re going to eat Cheetos, drink sodas and play Fortnite. If you adopt that healthy lifestyle, you go off to college. Say you enjoy Zumba; you go to a Zumba class. That’s where you’re going to make your friends. You’re going to meet them there. And what are you going to do when you get together? What do you have in common? Zumba. Maybe you’ll go back to your place and cook something healthy, and you’ll have fun coming up with new recipes together. You can have your peer group reinforce these behavior changes because you’re starting to hang out with people that are interested in the things that you’re doing and the lifestyle that you’re leading now. And that reinforces it even more. But when you’re 40 or 50 and you get this done, you go home to the same husband, the same wife, the same kids, the same friends, going to the same restaurants, the routine is there. And it’s very hard to break and very hard to make those changes stick.
What are the two types of surgeries you perform on kids?
DR STAFFORD: We do the sleeve gastrectomy primarily, which is an operation where we remove about 80 percent of the outside of the stomach. So, the stomach that is left is about the size and shape of a banana. The second procedure is the classic one – the Roux-en-Y gastric bypass. That’s more involved. We form a pouch of the proximal stomach about the size of a boiled egg. We separate that from the rest of the stomach. We go downstream and we disconnect the intestines, bring up the far end and plug it into that pouch and the near end plugs into the side of that intestine downstream. So, you’re bypassing all that intestine the food was previously being absorbed in. That’s a more complicated operation. In our patient population, they’ve done a study looking at over 3,600 patients that had both operations. The outcomes for weight loss and comorbidity resolution, things like diabetes, high blood pressure, sleep apnea, are very similar in outcome. But the complication rate for the bypass was significantly higher, as high as four times higher. And the hospital readmission rate was about 60 percent higher. So, when we judge that and we look at the risk of the two procedures associated with the benefits, it makes more sense to do the sleeve in our patient population. Every now and then, we get somebody who’s got a medical contraindication to getting a sleeve. That’s happened a few times in our program and then those kids will get the bypass.
Is there any more risk for a kid to get this than an adult?
DR STAFFORD: The risk is about the same.
Can you talk about the big milestone that you hit?
DR STAFFORD: We broke our 100-case mark since we started this program almost three years ago now. I think now we’re over 125.
Does that put you in an elite group that’s accredited for doing this?
DR STAFFORD: We meet the qualifications for accreditation this year and we’ll be applying. And hopefully we’ll be the first accredited adolescent bariatric program in the state.
Is there anything else you want people to know?
DR STAFFORD: So, right now, I’m working with our representatives in our program at Baylor. We’re trying to address the Medicaid requirements for bariatric surgery. Right now, if you’re a Medicaid patient and you have a BMI over 40, we don’t have much difficulty getting you approved for the surgery. The problem is, those kids that have a BMI of less than 40 that have serious co-morbidities. Now, in the adult population, if you have a BMI of 35 or greater and you have two serious co-morbidities like diabetes, high blood pressure, then, you qualify for the surgery or a BMI of 40. Our kids are younger and oftentimes, in that BMI of 35 to 40 range sicker with multiple comorbidities, but they don’t qualify for surgery until they hit that 40 BMI mark. So, we’re looking at this and saying we’ve got kids that are sicker, younger. And we have to wait until they get bigger and older, even more sick before we can intervene? That’s counterintuitive and it goes against all the literature and all the research that’s been done. But the laws and all that always take a little time to catch up. And we’re trying to expedite that process. The other thing is very similar to what I was talking about with that transplant patient earlier. Typically, we’re waiting until about 15 years old to do these surgeries. There is a patient population that is sicker younger. And I have to say, when you get the surgery, there’s a limit to how much weight you’re going to lose. It’s going to be about 30 percent of your BMI on average or about 70 percent of your excess weight. If we catch you at a BMI of 60, 70, we get like “My 600-lb Life” big, we’re never going to get you down to a healthy BMI. But we take you from a really unhealthy BMI down to a less unhealthy BMI. We want these kids to get down to a normal BMI. Because if we can do that, the research has shown that the rest of their life, their risk of developing co-morbidities associated with obesity is the same as if they were never overweight to begin with, the damage is reversible whereas when you’re adult, that’s not the case. So, when those kids that are bigger are younger, we should be intervening younger to prevent them from getting to that point where we just can’t make that big an impact and we can’t get them back to the best possible health they could be in.
Now tell me about meeting Harley. Where was she at then and now?
DR STAFFORD: She’s done great. She’s done exactly like we would expect. She’s lost about 31 percent of her BMI. I mean, you talk to her and it’s amazing the changes. She’ll tell you it wasn’t an easy path to go. I mean, it took some work.
When you first met her, what was she like?
DR STAFFORD: Oh, my gosh. She was nothing like the girl that she is now. She was so quiet, introverted. It was very hard to get her to respond to me in the interview. We talk about an hour in the first visit and a lot of that time was me talking. And now it’s like a different woman. She’s really blossomed. And I think of these things, it gives me chills because it happens over and over again. You watch these kids grow as their self-esteem grows. Success breeds success. When they try this and they see they can do this, they say, well, what else can I do? Maybe I should apply to that college. Or maybe I should do this. And then you hear the success stories and how they’ve just grown, and their life has opened up. It makes it all worthwhile. We do this for the health and the health is going to happen no matter what. But all these side effects are wonderful. And the pictures we get and the prom dresses and things like that are just wonderful.
END OF INTERVIEW
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