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 firstname.lastname@example.org
Thanks to Pete Cuomo for bringing this to the attention of the It’s Interesting community.