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Gastric banding isn't just for adults anymore -- many young obese patients at Alfred I. duPont Hospital for Children have found the procedure a success.

For most of her young life, forgetting to eat was not something Nicole Herman ever worried about. She often woke up with hunger pangs so intense they made her nauseous.

But these days, Herman has to remind herself to grab breakfast. Otherwise, it may be the afternoon until she gets those familiar stabs in her stomach to signal her body needs food. That feeling of always being hungry is gone.

So is 77 pounds -- and counting -- from her 5-foot-3 frame. After spending most of her teen years trying to lose weight, Herman has finally found success by exercising, watching what she eats -- and by having a silicone band inserted around her stomach to restrict the amount of food she can eat.

The 19-year-old college sophomore is one of 11 teenage patients who have undergone gastric banding surgery at the Alfred I. duPont Hospital for Children in the last year. The hospital is one of four nationwide participating in a five-year study by the Food and Drug Administration to evaluate the safety and effectiveness of gastric banding, also known as LAP-BAND, in teens.

"I wanted to have it done because I've been overweight ever since I was little," said Herman, who lives in Middletown when she's not attending the University of South Carolina in Columbia. "I had it done in hopes of trying to lose weight and keep it off."

Of the patients who have had the gastric banding procedure at A.I. duPont -- including Herman -- all have had similar levels of success with weight loss, said Dr. Kurt Reichard, a pediatric surgeon who performs the minimally invasive procedure at the hospital. About 50 more children ages 14 to 17 are in some stage of preparation for the surgery.

Although the LAP-BAND can radically change the life of a morbidly obese teen, it's not for everyone, Reichard reminds prospective patients and their families. The actual surgery is only one aspect of a multidisciplinary weight-loss effort that also includes psychological counseling, fitness assessments and training with an exercise physiologist, and extensive education in food nutrition with a registered dietitian before and after the operation.

"It's about what the kids can do for themselves," said registered dietitian Michell Fullmer, who works with teens in the weight management program. "The LAP-BAND, it's not a magic bullet. It's a tool. I hope we give them what they need to use this tool well."

For Herman, it was the right tool at the right time. After years of yo-yo dieting and feeling frustrated by her lack of success, she was ready for the challenge. "I realized it would be a big life change, but I was ready," she said. "I realized I have enough self-discipline to make this work."
A national problem

Nationwide, more than 1 million teens -- about one in six -- are obese. The effects of carrying that extra weight are more than just bigger waistbands. Many obese children also have other health problems such as diabetes, high blood pressure, sleep apnea and even worn-out joints.

The majority of obese teens can lose the extra weight through a combination of diet and exercise. But when an obese person becomes more than 100 pounds overweight, they are considered morbidly obese, and for them, it's much harder to lose the weight through traditional means.

Fortunately for Herman, she never suffered from high blood pressure, diabetes or other associated health problems. She ate well and got regular exercise as a dancer. "I was a healthy fat person," she said.

But she also has Ehlers-Danlos syndrome, a connective-tissue disorder that affects the joints and makes them more prone to dislocation. She has undergone 12 surgeries to address tissue and joint problems. Her most recent was this summer on her right ankle.

While the Ehlers-Danlos isn't directly affected by her weight, the excess pounds put pressure on her joints. For that reason, any weight loss would help her.

Still, losing weight proved to be a challenge over the years. By the time Herman was 9, she was considered obese. The last time she and a friend could wear matching clothes was the fifth grade. Among her family, she was the only one with a weight problem.

As a teenager, Herman tried Weight Watchers, Jenny Craig and NutriSystem. Such diets worked in the beginning, but soon she got bored and hungry. "It was like a roller coaster," she said. "I think probably I got frustrated with not succeeding."
'Off-label' use in teens

Gastric banding was approved by the FDA in 2001 for use in adults. In teenagers, it's considered an "off-label" use, meaning the operation wasn't intended for that purpose. The FDA trial, in which duPont Hospital is participating, aims to discover if gastric banding can be an effective tool in helping morbidly obese teens shed the weight that threatens to shorten their lives.

In the cases where gastric banding may be an option for teens, their youth may actually be a benefit. "Although there's a perception that teenagers are noncompliant and uncooperative, I don't find that to be the case," Reichard said. "Kids are more open to lifestyle changes."

Health professionals don't know what kind of long-term effects await obese teenagers as they age, particularly if they have other health problems, Reichard said. That's why it's important for them to try to lose any amount of weight they can.

Earlier this summer, Morgan Stanley Children's Hospital of New York-Presbyterian released preliminary data showing that teens who underwent gastric banding had improvements in their obesity-related medical complications just six months after the operation. The six boys and eight girls in the study lost an average of 20 pounds and saw significant reductions in abdominal fat, triglyceride and blood-sugar levels. Their liver function also improved.

Some of the teens who saw improvements in their blood-sugar and cholesterol levels didn't have excessively high numbers to begin with, said Dr. Ilene Fennoy, a pediatric endocrinologist with New York-Presbyterian, which is also part of the FDA study. That their health data were already within a normal range and still improved reaffirms that weight loss has beneficial effects beyond dropping a few clothing sizes, she said.

More data are needed to fully understand the benefits of gastric banding in teens and what potential long-term effects may result, but so far the results are mirroring the success found in adults, said Fennoy, lead author of the study and clinical professor of pediatrics at the Columbia University College of Physicians and Surgeons.

"This is early on but it's reassuring," said Fennoy, who presented the results in June to an annual meeting of the Endocrine Society in San Francisco. "It's showing we're already seeing changes in [symptoms of other ailments], even with not a huge amount of weight loss."
Making it work

In April 2007, after not finding success with any other weight-loss plans, Herman and her parents attended an informational meeting on gastric banding at A.I. duPont. She wasn't immediately sold. She was hesitant about having an operation to help her eat less, but the healthy eating and exercise components convinced her it could work if she believed in what she was doing. Her parents and friends pledged their support no matter the outcome.

"It helped that everyone was behind me on this," she said. "My family, especially my mom, has been so supportive of me."

Although her daughter has an outgoing personality, Sue Herman knew there were occasions where she felt singled out because of her size. She also she worried that her daughter's weight would impede her success in college and beyond.

"To watch her struggle was hard," she said.

When Nicole said she wanted to consider LAP-BAND, her mom went online and looked up information about the procedure. After extended discussions with the family's insurance company, which eventually agreed to cover the cost of the operation, they decided to pursue it.

Gastric banding works by making the stomach smaller. Unlike gastric bypass surgery, the stomach is not cut. Instead, a silicone band -- about the size of a shower curtain ring -- is inserted laparascopically around the top of the stomach. The band creates a small, egg-sized pouch for food consumption. It can be tightened or loosened by adding or removing saline solution into the band.

Compared with other weight-loss operations, gastric banding is less invasive. It also can be reversed, unlike gastric bypass surgery, which cannot. Still, like any operation, gastric banding carries some risks, including infection at the site of the incision. Gallstones also can occur in patients who undergo the surgery. Once the band is inserted, there is a small risk that it can slip out of place and cause pain and discomfort.

After the band is on, patients usually can eat only about 4 ounces of food at a time, far less than what they had been eating. Most of their meals are high in protein to prevent the loss of muscle mass. One of the first signs of not eating enough protein is hair loss, but later on, lost muscle mass from protein deficiency can effectively halt calorie loss.

Fullmer, the dietitian, holds monthly information meetings for prospective patients considering gastric banding. She said the first question asked is usually about the post-surgery diet.

"When I pull out a plate of what their diet is going to look like after surgery, I routinely get a gasp from the whole audience," she said. "It's sort of disbelief."

The first week after surgery, Herman was on an all-liquid diet while her swollen stomach adjusted to the band. She was still eating only liquids when she moved into her dorm. For the first months, she ate most of her meals in her room. She shared details of her surgery with only a few close friends.

Nowadays, a typical breakfast for Herman is a container of yogurt mixed with protein powder. Lunch may be a salad with half a piece of chicken. Dinner is a small portion of chicken or fish and vegetables. Post-surgery, she discovered she can no longer eat red meat, bread or rice because it upsets her digestion. She takes vitamin and calcium supplements to get enough nutrients and omega-3 fatty acids.

In addition to changing her diet, Herman has made exercise a priority. At school, the pre-med major fits in a workout no matter how crammed her schedule is, penciling it in as she would a class. The importance of working out was hammered in by exercise physiologist Lauren Falini, who tells patients exercise will not only help them lose weight but tone their bodies.

"Exercise is the other half of the equation," said Falini, who has patients keep track of their workouts with an exercise log. "It's about energy in and energy out."

The weight started disappearing rapidly within a month of Herman's surgery. By the time she stepped off the plane to visit her family in October, she was 40 pounds lighter. And she had already reached her first goal -- to fit in a size 18 pair of American Eagle jeans, something she had never done.

For Sue Herman, who hadn't seen her daughter since she left for college, the sight of her trimmer daughter was more than she expected.

"Beforehand I thought, 'What am I going to say if she's the same size? How am I going to inspire her to keep going?' " she said. "When I saw her, I couldn't stop looking at her."
A new person -- on the outside

Reichard attributes the early success of the gastric banding program to the extensive preparation the teens undergo before the procedure. Teens participating in the study spend about six months learning how to eat better, move their bodies more and understand the underlying emotional issues that may affect their success at keeping the weight off long term.

"We spend a huge amount of time getting to know them and their environments," he said. "It's the most important part of the program."

As part of the preparation, teens are expected to lose or maintain their weight before they have the gastric banding done. When the time comes for surgery, they must write a letter to the team requesting the procedure and laying out the reasons why they're a good candidate.

Working with the therapists in the weight management program, teens begin to realize the impact of the lifestyle changes they're incorporating, said Meredith Lutz Stehl, a clinical psychologist who works in the program. They begin to feel they have control over their weight, provided they follow the steps outlined by the weight management staff.

"It's such a crucial time to be able to get some hope, to believe they can feel like they can make some changes," Lutz Stehl said. "It's such a pivotal time for that, as opposed to people who have perhaps waited until their 20s or 30s to consider this."

In her letter, Herman spelled out some of the challenges in her path -- her Ehlers-Danlos, heading to college and adjusting to dorm life. But it's clear those are just small hurdles she intended to overcome.

"When I first heard about the LAP-BAND, I was a little skeptical and I wondered if it would really work and how hard it would be," she wrote. "You all changed that for me and made me believe that if I really want this as bad as I do, that I can work hard and get to where I want to be."

A year later, there's no denying Herman has changed from the 291-pound young woman who used to succumb to aching hunger pains. Now down eight pant sizes, she shops with friends at Old Navy and American Eagle, stores she bypassed on the way to plus-size clothier Lane Bryant. At her latest doctor's appointment this month, she weighed 214 pounds, down another 25 pounds from when she left school in May. She hopes to lose enough to wear a size 12 or 14 pants, about two sizes away.

Her megawatt smile is the same as it was before, but there's a new confidence that radiates from her, a self-assuredness strengthened by her weight-loss success. She feels healthy, strong, energized.

"Being overweight wasn't a big thing in my life. I've never wanted to be a size 2," she said. "I've always felt pretty good in my own skin."

But even she's surprised sometimes by the changes she sees.

"You catch a glimpse of yourself in the mirror, and you can't believe it's really you," she said.