As World’s Kids Get Fatter, Doctors Turn to the Knife

Daifailluh al-Bugami was just a year old when his parents noticed that his lips turned blue as he slept at night. It was his weight, doctors said, putting pressure on his delicate airways.

Now Daifailluh is 3, and at 61 pounds he is nearly double the typical weight of a child his age. So the Bugamis are planning the once unthinkable: To have their toddler undergo bariatric surgery to permanently remove part of his stomach in hopes of reducing his appetite and staving off a lifetime of health problems.

That such a young child would be considered for weight-loss surgery—something U.S. surgeons generally won’t do—underscores the growing health crisis here and elsewhere in the Middle East. Widespread access to unhealthy foods, coupled with sedentary behavior brought on by wealth and the absence of a dieting and exercise culture, have caused obesity levels in Saudi Arabia and many other Gulf states to approach or even exceed those in Western countries.

While solid national data are hard to come by, some experts say that obesity has turned into a serious health problem for Saudi children, with an estimated 9.3% of school-age youths meeting the World Health Organization’s body-mass-index criteria for obesity, according to research published in 2013 in the Saudi Journal of Obesity. About 18% of school-age children in the U.S. were considered obese in 2010, according to the Centers for Disease Control and Prevention.

Daifailluh’s doctor, Aayed Alqahtani, is a leading advocate of a radical approach to the problem. Patients travel to him from across the country and the Gulf region. Over the past seven years, he has performed bariatric surgery on nearly 100 children under the age of 14, which experts on the procedure believe is the largest number performed by one doctor on young children.

Dr. Alqahtani’s work is being watched amid a global debate about the appropriate age for bariatric surgery. In the U.S., the minimum is generally considered 14. The World Health Organization, in a 2012 report on pediatric bariatric surgery, concluded that there is a dearth of data available on the long-term outcomes of the procedure in children and that a “conservative approach” is necessary until long-term studies are conducted.

Bariatric surgery has been embraced as an effective and relatively safe procedure for morbidly obese adults. The concern with children revolves mostly around nonsurgical risks, such as how the abrupt change in nutrition could affect long-term brain development and sexual maturation.

Dr. Alqahtani says the decision to operate on Daifailluh is a difficult one because of his age. But after nearly two years of consultation with the clinic, Daifailluh’s obesity-related medical problems haven’t gotten any better. “We should not deprive our patients from bariatric surgery based on their age alone,” the surgeon says. “If they have [medical] conditions that threaten their lives, then we should not deny the bariatric surgery.”

The worsening obesity problem here also is manifesting itself in other ways. Some 20% of the Saudi adult population has Type 2 diabetes, a condition linked to obesity, according to the International Diabetes Federation, compared with 8.3% in the U.S., according to the CDC. The cost of diabetes treatment in Saudi Arabia is expected to rise to $2.4 billion in 2015, more than triple that spent in 2010, according to a recent study in the Journal of Family and Community Medicine.

Obesity, particularly among women, has become rampant across much of the Middle East, particularly in oil-rich Gulf nations. In Kuwait, almost half of adult women are considered obese, while 44% of Saudi women and 45% of Qatari women meet the criteria, according to the International Association of the Study of Obesity. Experts says Saudis, in particular, are more likely to carry certain genes linked to obesity.

Saudi lifestyle and parenting practices may exacerbate the problem, according to doctors at weight-loss clinics. Nannies or cooks are often employed, so parents may not know what their children are eating. Saudis often are coaxed to eat large quantities of food when visiting relatives and friends.

In Riyadh, physical activity is limited, particularly for girls, and high temperatures and few green spaces make walking difficult. School gym classes generally take place just once a week. Western-style fast food is abundant, particularly at the air-conditioned malls frequented by children and families.

Bariatric surgery has become an accepted treatment among obese Saudi adults and is paid for by the government. An estimated 11,000 bariatric surgeries were performed on Saudis in 2012, according to Dr. Alqahtani.

The surgery, of which there are several types, generally reduces the size of the stomach and, with some techniques, rearranges the digestive path to bypass much of the intestines. Some types are reversible but generally considered less effective. After the surgery, patients must eat very small meals—ideally for the rest of their lives. Many studies have shown that adults, on average, lose over 50% of their body weight after surgery.

Increasingly, youngsters are heading to the operating room here, where parents see no other options. These days, Dr. Alqahtani performs surgery on three to four youths a week.

“I have seen in my clinic patients who cannot sleep lying down—they sleep sitting—because of sleep apnea, and their age is 10 years, sometimes 5 years,” says Dr. Alqahtani, a professor in the college of medicine and an obesity specialist at King Saud University.

Pediatric surgeons in the U.S. say they also are facing demands from families to operate on younger patients. Thomas Inge, surgical director of the Surgical Weight Loss Program for Teens at Cincinnati Children’s Hospital, says he will be operating on a 12-year-old later this month. He says that as younger and younger children are referred for consideration of surgery, care teams will need to carefully weigh the pros and cons.

Evan Nadler, a pediatric surgeon at Children’s National Medical Center in Washington, D.C., is considering doing the operation on two young children. He and the family of a 7-year-old D.C. boy have agreed that surgery likely is the best option, he says. The family of an 8-year-old from the Middle East has decided to wait until their daughter is older and can better understand the surgery, he says.

Many doctors say they aren’t ready to follow Dr. Alqahtani yet. Kirk Reichard, chairman of the pediatric-surgery committee for the American Society for Metabolic and Bariatric Surgery, notes that there are no data to show that surgery doesn’t affect young children’s long-term sexual maturation or cognitive functioning. The brain, particularly in growing children, is sensitive to nutrition and needs enough energy to mature properly. Nutrition also has the potential to affect hormones linked to sexual maturation.

Dr. Alqahtani says he has seen evidence of normal growth following the procedure in his under-14 patients, many of whom are now four years postsurgery.

“We will certainly use his experience to inform us in some ways, but [Dr. Alqahtani’s work] won’t take the place of trials,” says Dr. Reichard.

One of the main criticisms from some weight-loss experts about performing the surgery on those under 14 is that changes in diet and exercise can prevent further weight gain. In addition, says Dr. Reichard, “there are a lot of other therapies short of surgery that can be helpful in managing” related medical conditions.

Saudi Arabia’s Dr. Alqahtani says he requires his child patients to enroll in a weight-loss program for at least six months because patients able to lose even a bit tend to have better outcomes after surgery. But he says that by the time families come to him, their children have such substantial health problems it is generally too late for diet and exercise alone.

Dr. Alqahtani was trained as a surgeon at McGill University in Montreal and at a minimally invasive surgery center in Denver. When he returned home to Riyadh in 2002, he says, he was inundated with pediatric patients so obese they were suffering from advanced stages fatty liver disease, diabetes and sleep apnea, a disorder in which patients repeatedly stop breathing for short periods during sleep—all diseases typically not seen until middle age.

Om Abdullah Asiri says she tried to help her 11-year-old son lose weight by restricting his eating at home. But he would eat fast food while out with his friends and plays videogames for hours on end, she says. “I can’t control him outside the home,” she says.

He grew to 250 pounds. His body-mass index—a calculation that uses weight and height to estimate percentage of body fat—was 61. A BMI of 40 or above is the most severe obesity category, according to the World Health Organization.

Ms. Asiri traveled with her son, Abdullah, from their home in Abha, more than 600 miles south of Riyadh, to see Dr. Alqahtani for the operation. Lying on a hospital bed the day before his surgery, Abdullah said he is “happy and ready” for the surgery.

His mother says surgery is the best solution for Abdullah, who has high blood pressure, fatty liver, hip pain and severe sleep apnea. Afterward, he won’t have a choice but to eat better, she says. “The surgery will make him change.” She says he dreams of playing soccer with his friends.

The procedure Dr. Alqahtani performs is called the gastric sleeve, which slices off a portion of the stomach but leaves the rest of the digestive tract intact. It is gaining in popularity because of its good weight-loss results and minimal side effects. The operation, conducted through tiny incisions in the abdomen, takes him just 30 minutes.

One recent morning, he operated on a 20-year-old, two 17-year-olds, a 12-year-old, then Abdullah, who was then 10.

Complications can include bleeding in about 10% of cases, and leaking and blood clots in 1% to 2%. Dr. Alqahtani says he has had only two leaks in 1,700 cases, neither in children.

Dr. Alqahtani says each of his pediatric patients has lost at least some weight, and nearly three-quarters have lost more than 50% of their initial body weight. Abdullah has lost close to 50 pounds since his surgery about two months ago, according to his 29-year-old brother, Ahmad.

Dr. Alqahtani says about 90% of his patients have seen medical conditions such as diabetes and hypertension clear up, according to a paper scheduled for publication in the journal Surgery for Obesity and Related Diseases. He published outcomes on 108 children in the peer-reviewed Annals of Surgery journal in 2012.

Recovery involves a six-week transition diet starting with clear liquids and puréed food. Patients eventually can resume solid foods at much-reduced quantities. At first, patients feel full after just 1 to 2 spoonfuls of food, though they gradually can eat more as their stomachs stretch.

Some bariatric-surgery experts have raised questions about whether children are capable of maintaining the restrictive lifetime diet after surgery or whether they will sabotage the procedure when they become teenagers and have a greater autonomy to eat what they want. Some experts question whether parents should make such a drastic and permanent decision for a child.

The decision has been excruciating for the family of Daifailluh, the toddler from Ta’if. Daifailluh was referred to Dr. Alqahtani’s clinic about two years ago after difficulty breathing sent him to the intensive-care unit at a hospital in his hometown. Doctors there determined the toddler was seriously overweight. His mother, Hessa Salem al-Bugami, says she tried to improve his diet but didn’t have good guidance until she came to Dr. Alqahtani’s clinic, a trip of nearly 500 miles from Ta’if. “I feel like I failed,” she says.

At first, the family wanted Daifailluh to lose weight without the operation. Ms. Bugami says her son has always had an “open appetite” and never refuses food. She says she feeds him brown bread and boiled chicken and rice, and limits his portions, hiding the rest of the food. But his obesity hasn’t improved, she says.

Daifailluh will cry and sometimes throw temper tantrums when he wants food, she says. She has tried distracting him with toys, locking the two of them in a room to play for so long she ended up missing her own meal.

“When he starts crying, it’s hard not to give him any of the food, to make the crying stop,” she says. “I feel like I work really hard, but it’s just too much on me.”

Daifailluh, who was hospitalized again for pulmonary problems, is waiting for a surgery date, which will come if he gets final medical clearance from Dr. Alqahtani.

The entire family is worried about the surgery, particularly the effects of anesthesia and whether the surgery will reduce his appetite too much. Ms. Bugami also worries that her son will regain the weight when he leaves the house eventually and is no longer under her watch.

But that is a concern for another day. “Right now is the most scary situation,” she says.

Write to Shirley S. Wang at shirley.wang@wsj.com

http://online.wsj.com/news/articles/SB10001424052702304851104579360992538215578?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304851104579360992538215578.html

Thanks to Pete Cuomo for bringing this to the attention of the It’s Interesting community.

New SARS-like virus can infect both humans and animals

sn-coronavirus

 

A SARS-like virus discovered this summer in the Middle East may infect more than just humans. The pathogen, a close cousin to the one that caused the 2002 to 2003 SARS outbreak, may also be able to infect cells from pigs and a wide range of bat species, researchers report today. The findings may help public health officials track the source of the outbreak and identify the role of wild animals and livestock in spreading the virus, researchers say.

Scientists first detected the virus in a 60-year-old man from Jeddah, Saudi Arabia, who developed severe pneumonia this past spring. Unable to identify the microbe causing the illness, doctors sent samples to Erasmus MC in Rotterdam, the Netherlands. There, scientists identified the infectious agent as a coronavirus, a group known to cause many ailments, such as the common cold and a variety of gastrointestinal infections. Cases have popped up in Qatar and Jordan as well; in total, researchers have so far confirmed nine infections, including five deaths. Several other cases are suspected but haven’t been confirmed.

Researchers have fully sequenced the virus, which they dubbed hCoV-EMC (short for human coronavirus-Erasmus Medical Center). The genome revealed that it is closely related to the SARS coronavirus.

The new study, published online in mBio, is an attempt to answer other basic questions, such as where the virus originated, how it enters cells, and what other animals it might infect, says Christian Drosten, a virologist at the University of Bonn Medical Center in Germany and one of the lead authors.

Scientists knew that the SARS virus uses a receptor called ACE2 to pry open cells. Because these receptors are mainly found deep inside the human lung, patients developed very severe illness that frequently left them too sick to spread SARS to many others; the people most at risk were health care workers who take care of patients. If hCoV-EMC used the same receptor, researchers would have a head start in understanding how it spreads and how to stop it—primarily by protecting health care workers. It might also help them in the development of drugs and vaccines.

To find out, the team engineered baby hamster kidney cells to express the human ACE2 receptor. These cells could be infected with the SARS coronavirus, as expected, but not hCoV-EMC. That finding, supported by additional experiments, led them to conclude that the new coronavirus does not use ACE2 to get in. Which receptor it uses instead is still unclear, which is a “downside” of the new study, says Larry Anderson, an infectious disease specialist at Emory University in Atlanta.

Epidemiologists also want to know which species of animals it is capable of infecting to keep the new coronavirus from spreading further. To determine what types of animals hCoV-EMC can infect, Drosten and colleagues infected cells from humans, pigs, and a wide variety of bats, the key natural reservoirs of coronaviruses. The new virus could infect all of these types of cells. “It’s unusual for a coronavirus to easily go back to bats,” Drosten says. “Most coronaviruses come from bats, but once they jump to other species, you could never get them to reinfect bat cells.” The SARS virus, for instance, originated in Chinese horseshoe bats, but once it ended up in humans, it had changed so much that scientists were unable to infect bat cells with it.

“The fact that [hCoV-EMC] can infect bat cells is consistent with the hypothesis that bats might be the origin of this virus, but this finding doesn’t prove it,” Anderson says. “This virus had to come from an animal source—there’s no other explanation for what’s going on. But we still don’t know what that source is.”

Based on the findings, however, it seems likely that the new coronavirus can infect a wide range of species, Drosten says. That means public health officials may have to start looking for infections and deaths in local wild animal and livestock populations to keep the virus in check, he says.

http://news.sciencemag.org/sciencenow/2012/12/new-sars-like-virus-infects-both.html?ref=hp

Kuwait Death Penalty for Cursing God

Kuwait’s parliament on Thursday provisionally passed amendments to the Gulf state’s penal code stipulating the death penalty for those who curse God, Islam’s Prophet Mohammed or his wives.

Forty-six MPs, including cabinet ministers, voted for the key amendments that will come into effect only after another round of voting and government approval. The second and final vote will take place in two weeks.

Four Shiite MPs voted against the law, a pro-Shiite Sunni lawmaker abstained, while two MPs refused to vote.

Shiite MPs have demanded that the new amendments also enforce the death penalty for anyone who curses their sect’s 12 revered Imams, but the Sunni- dominated parliament rejected their requests.

The move to stiffen penalties for religious crimes came after authorities last month arrested a Shiite tweeter for allegedly cursing the Prophet Mohammed, his wife and some companions.

The suspect, Hamad al-Naqi, is being detained pending further interrogation and trial.

Sectarian tensions have flared in Kuwait between the Sunni majority and Shiites, who form about a third of the native population of 1.17 million, reflecting rising regional tensions between the two Islamic sects.

http://www.france24.com/en/20120412-kuwait-mps-okay-death-penalty-cursing-god

U.S. Security Will Be Put at Risk With Future Water Shortages

 

Water shortages, polluted water and floods will increase the risk of instability in nations important to U.S. national security interests, according to a new U.S. intelligence community assessment released Thursday.

“During the next 10 years, many countries important to the United States will almost certainly experience water problems – shortages, poor water quality, or floods – that will contribute to the risk of instability and state failure and increase regional tensions,” the report from the office of the director of national intelligence states.

 

The assessment focused on seven key river basins located in the Middle East, Asia and Africa that are considered strategically important to the United States: the Indus, Jordan, Mekong, Nile, Tigris-Euphrates, Amu Darya and Brahmaputra basins.

The intelligence report indicates conflict between nations over water problems is unlikely in the next 10 years, but after that, water in shared basins will increasingly be used by some nations as leverage over their neighbors, the report says.

A senior U.S. intelligence official who briefed reporters on the report said, “It’s very difficult to be specific about where because it depends upon what individual states do and what actions are taken on water issues between states.”

The study also warns of the potential for water to be used as a weapon, “with more powerful upstream nations impeding or cutting off downstream flow.”

Water could also become a terrorist tool, according to the report. The U.S. official said that, “because terrorists are seeking more high visibility items to attack, in some cases we identified fragile water infrastructure that could potentially be a target for terrorism activity.” A likely target would be dams.

The official also said terrorist groups could take advantage of large movements of people displaced by water issues in vulnerable nations.

The report indicates water supplies will not keep up with the increasing demand posed by a growing world population.

Climate change will further aggravate the water problems in many areas, as will continued economic development, the report says.

“The lack of adequate water,” it says, “will be destabilizing factor in some countries because they do not have the financial resources or the technical ability to solve their internal water problems.”

Food markets are threatened by depletion of ground water in some agriculture areas of the world. Unless corrective steps are taken, food production will decline, increasing the stress on global markets, the report predicts.

The intelligence community assessed that by 2040, water shortages and pollution will harm the economic performance of important trading partners.

The study does not name specific countries, because it is based on a classified national intelligence estimate.

But the report indicates that increasing populations, industrial development and climate change in South Asia, the Middle East and North Africa will make it difficult for those regions to deal with water problems.

The report does say that improved water management and investment in water-related sectors, such as agriculture, hydroelectric power and water treatment, could compensate for increased demand over next 30 years.

Since agriculture uses nearly 70% of all ground water, the report states it has the most potential to provide relief if technological changes are implemented such as large-scale drip irrigation systems.

The intelligence study suggests developing countries are likely to turn to the United States to lead the effort to resolve water problems, because of its technological capabilities.

Secretary of State Hillary Clinton, who was concerned about how global water problems could affect U.S. security interests over the next 30 years, requested the study on global water security. The National Intelligence Council prepared the assessment with contributions from 10 intelligence organizations.  

At a World Water Day event at the State Department on Thursday,  Clinton labeled the report “sobering,” and called on everyone to read it to “see how imperative clean water and access to water is to future peace, security, and prosperity, globally.” 

The Secretary also used the occasion to announce a new effort called the U.S. Water Partnership which bring together experts in the private sector and government to find system wide solutions to water problems.

http://security.blogs.cnn.com/2012/03/22/u-s-security-at-risk-over-water/?hpt=hp_t3