中東開始流行給孩子手術減肥

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.

德伊法伊拉・阿爾－布加米(Daifailluh al-Bugami)的父母注意到孩子晚上睡覺時嘴脣會變藍的時候，他才一歲。醫生說，這是因爲他的體重給他脆弱的呼吸道帶來了壓力。

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.

現在德伊法伊拉三歲了，體重61磅（約27.7公斤），幾乎是一般同齡人體重的兩倍。所以布加米夫婦打算採取之前從不敢想象的措施：讓自己年幼的孩子接受減肥手術，永久切除一部分胃，希望降低他的食慾，讓他以後免受健康問題的困擾。

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.

美國外科醫生一般是不會給如此年幼的孩子進行減肥手術的。德伊法伊拉的父母做出這樣的決定凸顯了中東地區這種健康危機的加劇。大量接觸不健康食品，加上富裕生活衍生的久坐行爲，以及節食和鍛鍊文化的缺乏，導致沙特阿拉伯及許多其他海灣國家的肥胖水平接近甚至超過西方國家。

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.

雖然很難獲得可靠的全國性數據，但有專家說，肥胖症已經成爲沙特兒童一個嚴重的健康問題。《沙特肥胖症期刊》(Saudi Journal of Obesity)在2013年公佈的研究顯示，約9.3%的學齡兒童達到了世界衛生組織(World Health Organization)身體質量指數(BMI)中的肥胖標準。據美國疾病控制與預防中心(U.S. Centers for Disease Control and Prevention)統計，2010年美國約18%的學齡兒童肥胖。

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.

德伊法伊拉的醫生Aayed Alqahtani是倡導用激進手段解決該問題的領軍人物。沙特全國各地以及海灣地區很多病人都來找他看病。過去七年，他爲近100個14歲以下兒童做過減肥手術，這方面的專家認爲，沒有哪一個醫生做過這麼多例兒童減肥手術。

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.

全球各地對適宜做減肥手術的年齡存在爭議，因此Alqahtani的工作備受關注。在美國，一般認爲最小年齡是14歲。世界衛生組織在2012年的一份兒童減肥手術報告中總結道，目前有關減肥手術對兒童長期影響的數據相當匱乏，在進行長期研究之前需採用“保守治療”。

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.

對嚴重肥胖的成年人來說，減肥手術被認爲是一種有效並且相對安全的治療方法。兒童的問題主要在於非手術操作風險，比如營養上的突然改變對大腦的長期發育和性成熟會帶來何種影響。

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.'

Alqahtani說，由於德伊法伊拉的年齡小，所以給他做手術是一個艱難的決定。但在診所經過近兩年的會診後，德伊法伊拉肥胖症帶來的相關身體問題並無任何好轉。Alqahtani說：“我們不應該只根據年齡而剝奪病人做減肥手術的權利。如果他們有威脅到生命的病症，我們就不應該拒絕實施減肥手術。”

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.

中東地區肥胖症加劇的問題在其他方面也有體現。據國際糖尿病聯合會(International Diabetes Federation)統計，沙特約20%的成年人患有2型糖尿病，這種病與肥胖有關。而據美國疾病控制與預防中心統計，美國成年人患2型糖尿病的比例僅爲8.3%。《家庭及社區醫學期刊》(Journal of Family and Community Medicine)最近的一項研究顯示，沙特阿拉伯糖尿病的治療費用預計將在2015年增至24億美元，是2010年的三倍多。

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.

肥胖症在中東很多地區都很猖獗，特別是在石油豐富的海灣國家，而且女性人羣更爲嚴重。 據國際肥胖研究學會(International Association of the Study of Obesity)統計，在科威特，近一半成年女性屬於肥胖，沙特和卡塔爾肥胖女性比例分別爲44%和45%。專家說，沙特人攜帶某些與肥胖有關基因的可能性尤其大。

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.

減肥診所的醫生們表示，沙特的生活方式和孩子的養育方式可能會使肥胖問題加劇。家裏通常會僱傭保姆或廚師，所以父母不一定知道自己的孩子在吃什麼。沙特人在親戚朋友家做客時常會被勸說吃大量食物。

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.

在利雅得，體育活動是受到限制的，尤其是女孩子，高溫和綠地的稀少也使得步行很困難。學校裏一般每週只有一次體育課。西式快餐氾濫，特別是在兒童和家庭經常光顧的帶空調的商場。

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.

在沙特，減肥手術已經成爲肥胖成年人普遍接受的一種治療手段，並且費用由政府支付。Alqahtani表示，2012年，沙特人所做的減肥手術約有1.1萬例。

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.

減肥手術共有好幾種，一般都是縮胃，和通過某些技術重組消化路徑，讓食物繞開大部分腸道消化。有些手術是可逆的，但一般認爲效果比較差。手術後，患者三餐的攝入量必須非常少――最好是一輩子都保持。許多研究顯示，通常情況下成年人做完手術體重都會減掉50%。

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.

在中東，越來越多的兒童開始走向手術室，因爲父母看不到其他的選擇。目前Alqahtani醫生每週都會爲三到四個青少年做手術。

'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.

身爲沙特國王大學(King Saud University)醫學院教授以及肥胖症專家的Alqahtani說：“我的很多臨牀病人都沒法躺着睡覺，而是坐着睡覺，因爲他們有睡眠窒息症，他們才10歲，有些才5歲。”

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.

美國的兒科外科醫生說，他們也面臨許多家庭希望爲年幼患者做手術的需求。辛辛那提兒童醫院(Cincinnati Children's Hospital)青少年手術減肥項目(Surgical Weight Loss Program for Teens)外科主任托馬斯・英格(Thomas Inge)說，這個月月底他要給一個12歲的孩子做手術。他說，隨着被推薦過來做手術的孩子年齡越來越小，醫療團隊需要仔細權衡利弊。

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.

許多醫生表示他們還沒有準備好跟隨Alqahtani的步伐。美國代謝與減肥手術學會(American Society for Metabolic and Bariatric Surgery)兒科手術委員會主席科克・理查德(Kirk Reichard)指出，沒有數據顯示手術不會影響年幼兒童的長期性成熟發育或認知機能。大腦對營養很敏感，需要足夠的能量才能正常發育成熟，對成長中的孩子來說尤其如此。營養也有可能影響與性成熟有關的荷爾蒙水平。

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.

Alqahtani說，在他的病人中，很多14歲以下兒童做完手術後發育都很正常，很多人現在做完手術已經四年了。

'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.

理查德說：“我們肯定會借鑑他的經驗，但他的成果不會替代臨牀試驗。”

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.

對給14以下兒童做這種手術持批評態度的減肥專家的一個主要觀點是，飲食和鍛鍊上的變化會阻止進一步的體重增長。此外，理查德說，“還有其他很多不用手術的療法可以有助於控制”相關的症狀。

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.

沙特阿拉伯的Alqahtani說，他要求兒童患者至少參加六個月的減肥項目，因爲即使只能減掉一點點體重的患者在術後的情況都會更好。但他說，到家裏人來找他的時候，孩子的健康問題已經很嚴重了，一般僅靠節食和鍛鍊已經太晚了。

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.

Alqahtani畢業於蒙特利爾麥吉爾大學(McGill University)醫學專業，並在丹佛一家微創手術中心工作過。他說，2002年回到利雅得時，他接待了大量兒科患者，他們由於太過肥胖而遭受着晚期脂肪肝、糖尿病和睡眠窒息症的折磨――這些病一般情況下只有到中年纔會出現。患睡眠窒息症的人在睡覺時會不斷地短暫停止呼吸。

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.

Alqahtani所做的手術名叫袖狀胃切除，一部分胃會被切除，但消化道其他部分不受影響。這種手術越來越受歡迎，因爲減肥效果很好，而且副作用最小。該手術會在腹部切開微小切口，30分鐘就能完成。

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

最近的一個早晨，他給一個20歲的病人、兩個17歲的病人、一個12歲的病人、還有當時10歲的阿卜杜拉(Abdullah)做了手術。

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.

可能產生的併發症包括流血、吻合口裂開和血塊，約10%的病例會出現流血，後兩種情況的機率爲1%到2%。Alqahtani說，他在1,700例手術中只出現過兩例吻合口裂開的情況，而且都不是兒童患者。

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.

Alqahtani說，他的每一個兒科患者至少體重都有一定的下降，近四分之三的患者減重超過50%。阿卜杜拉29歲的哥哥艾哈邁德(Ahmad)說，阿卜杜拉從約兩個月前做完手術以來減了近50磅。

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.

Alqahtani在一篇論文中說，約90%的患者以前的糖尿病和高血壓等病症都有所好轉。該論文將發表在《肥胖及相關疾病手術》(Surgery for Obesity and Related Diseases)期刊上。2012年，他在同行評審期刊《外科學年鑑》(Annals of Surgery)上發表了對108名兒童的研究成果。

Recovery involves a six-week transition diet starting with clear liquids and pureed 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.

術後恢復需要六個星期的過渡飲食，從流質和泥狀食物開始。患者最後都會恢復固體食物，但量會減掉很多。最開始患者吃一兩勺東西就會有飽腹感，不過隨着胃的伸展，逐漸會吃的越來越多。

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.

有些減肥手術專家提出了質疑，比如兒童是否有能力在術後一直保持限制性的飲食，是否會在十幾歲對自己想吃的東西有更大自主權的時候破壞手術成果。有些專家質疑父母是否應該爲孩子做出如此極端的永久決定。

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.

對來自塔伊夫(Ta'if)的德伊法伊拉家庭來說，這個決定非常折磨人。德伊法伊拉是兩年前左右被推薦到Alqahtani醫生的診所的，之前他因爲呼吸困難被送到家鄉一所醫院的特護病房。診所的醫生診斷孩子嚴重超重。他的母親赫薩・薩勒姆・阿爾－布加米(Hessa Salem al-Bugami)說，她努力改善孩子的飲食，但在來Alqahtani醫生診所前沒有得到過很好的指導。從塔伊夫到利雅得有近500英里的路程。她說：“我覺得自己很失敗。”

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.

最初家裏人希望德伊法伊拉能夠不做手術減肥。布加米太太說，她的兒子總是胃口很好，從不會拒絕食物。她說她給他吃黑麪包和水煮雞肉米飯，限制他的飯量，把剩下的食物藏起來，但他的肥胖並沒有改善。

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.

她說，德伊法伊拉會哭，想吃的時候有時會發脾氣。她嘗試過用玩具分散他的注意力，把自己和兒子關在屋子裏玩兒，最後時間太長了，連她自己都想吃了。

'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.'

她說：“在他開始哭的時候，不給他任何食物是很難哄他不哭的。我覺得自己很努力，但壓力太大了。”

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.

德伊法伊拉後來又因爲肺部問題住過院。現在他正在等待手術日期，如果獲得Alqahtani最後的體檢合格結果，醫生就會給他安排手術。

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.

德伊法伊拉的家裏人都很擔心這次手術，尤其是麻醉的副作用，以及手術是否會把他的胃口減得太多。布加米太太還擔心兒子最後離家不再受到自己監護後會再度增重，但這是以後的問題。她說：“現在是最可怕的情形。”