People and more people are becoming fat …fat …fat across the world! This is more seen in the developed countries than in the developing countries. This will have an impact on the social, physical, medical and financial aspects of the individual and the country¹.

Obesity is a global problem and in India, the number of obese people is significant because of the huge population. It is a largely urban problem and in almost all cases, it is because of over-eating. Only in one per cent of the cases obesity is because of a hormonal imbalance.

The basic definition of obesity is the accumulation of abnormal or excess body fat. It is a complex, multifactorial disease that results from the interaction of genetic and environmental factors. Excess body weight is associated with increased morbidity and mortality, including increased risk of type 2 diabetes mellitus, heart disease, dyslipidemia, osteoarthritis, sleep apnea syndrome, and some cancers. The most commonly used measurement that closely correlates with body fat is the body mass index (BMI), defined as the weight in kilograms divided by the square of the height in meters (kg/m2). According to the World Health Organization (WHO), overweight and obesity are defined as a BMI equal to or greater than 25 kg/m2 and 30 kg/m2, respectively. For Asian population a healthy BMI is between 18.5 and 22.9, borderline obesity is above 23, obesity is above.

 

Type 2 diabetes mellitus is a worldwide epidemic, with its incidence increasing in the past few years. It is estimated that 285 million people currently have diabetes and that this figure will increase to 438 million (7.8% of the world adult population) by 2030.Increases in the incidence of diabetes correlate with improvement in national socioeconomic status, as shown by sharp increases in obesity and diabetes in India and China.Currently, India ranks highest in the prevalence of diabetes, with 51 million cases, followed by China, with 43 million cases, and then the United States, with 25.8 million cases.29 It has been projected that, by the year 2030, the prevalence of diabetes will almost double ².

Ref 1: Hazem Shamseddeen, MD , Jorge Zelada Getty, MD , Mohamed R. Ali, MD* Surg Clin N Am 91 (2011) 1163–1172

Ref 2: IDF. IDF diabetes atlas. 4th edition. Brussels (Belgium): International Diabetes Federation; 2009

 

The health risks of obesity diminish with weight loss. Even a modest weight loss can result in a 20% reduction in all-cause mortality.A weight gain of 5 to 7 kg can increase the risk of diabetes by 50%, whereas a reduction of as little as 5 kg decreases the risk by the same amount.When considering obesity in the context of type 2 diabetes, management has to integrate good glycemic control with weight loss. As soon as diabetes is diagnosed, effective therapies for weight management should be implemented. By the same principle, in diabetic patients or patients with impaired glucose tolerance, the prevention of weight gain should be one of the main goals when deciding on therapy.Conventional medical therapy for diabetes includes the use of insulin and anti diabetic medication. Weight loss therapy is recommended for patients with BMI of 20 kg/m2 or greater. Diet should consist of low-calorie, low-fat foods with a caloric goal of 1000 to 1200 kcal/d for most women, and 1200 to 1600 kcal/d for men.Physical activity increases energy expenditure, helps with weight maintenance, and reduces the risk of heart disease ³.

3 NIH-NHLBI. North American Association for the Study of Obesity. The practical guide: identification, valuation, and treatment of overweight and obesity in adults. Bethesda (MD): National Institutes of Health; 2000.

 

Weight Reducing Medication can be added if lifestyle modifications are not successful in achieving weight loss. Currently, the only medication approved for the long-term treatment of obesity is orlistat, which inhibits pancreatic lipases and, thereby, decreases fat absorption from the gastrointestinal tract.A systematic review of orlistat showed that the mean weight loss at 1 year was 2.9 kg.Although this minor weight loss is insufficient to make any clinical difference, it may be useful as an adjunct in patients waiting for bariatric surgery ^{4, 5}.

⁴ Padwal RS, Majumdar SR. Drug treatments for obesity: orlistat, sibutramine, and rimonabant. Lancet 2007; 369:71–7.

⁵ Monkhouse SJ, Morgan JD, Bates SE, et al. An overview of the management of morbid obesity. Postgrad Med J 2009;85:678–81.

 

Nonoperative management of obesity with diet, exercise, behavioral modification, and medications rarely achieves adequate durable weight loss ⁶.

⁶ Goodrick GK, Poston WS 2nd, Foreyt JP. Methods for voluntary weight loss and control: update 1996. Nutrition 1996;12:672–6.

 

The most effective way to lose weight and improve or resolve comorbidities is bariatric surgery. In a prospective, randomized trial, bariatric surgery achieved considerably better weight loss and improvement in comorbidities than medical therapy at 10-year follow-up.A meta-analysis by Buchwald and colleaguesin 2004 reported a mean excess weight loss of 61% with bariatric surgery and substantial improvement or complete resolution of diabetes mellitus, hypertension, dyslipidemia, and obstructive sleep apnea. This study also found a low operative 30-day mortality of 0.5% for patients who underwent bariatric surgery. In addition, bariatric surgery has been shown a decrease of overall mortality in obese individuals in the long-term ^{7, 8, 9}.

⁷ Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683–93.

⁸ Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–37.

⁹ Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741–52.

 

The following example illustrates how Bariatric Surgery can change the life of obese individuals. If you are obese and cannot lose weight with a healthy diet and exercise program, bariatric surgery might be a good option.

A 28-year-old boy, who was 170 kg, lost 72 kg in two years. With every few kilos lost, he gained more confidence and felt happier. He has now enrolled in an MBA programme. He is hoping to do something that most people take for granted – to get into readymade clothes.

A 40-year-oldmonk is so upbeat about the prospect of shedding his extra kilos that he is already dreaming big. He was 150 kg and is hoping to lose at least 50 kg in the next couple of years. Now, going to the Himalayas is not such a distant dream for him anymore.

Their dreams and aspirations can come true because of a surgery that they underwent to treat obesity. Bariatric surgery is one of the most effective and permanent ways to treat obesity. Obesity is not just about weighing big at the scales and feeling heavy. It also takes a heavy toll on the person’s psyche and all the systems of the body.

Obesity is not a simple problem. It is the primary cause of many non-communicable diseases and can trigger at least 53 diseases. Obesity is known to alter blood pressure, cholesterol levels and triglycerides, all of which can trigger life-threatening health conditions. Insulin resistance of the body can go haywire causing a major lifestyle disease – Diabetes. The extra kilos put a lot of burden on the system and affect almost every organ in the body. Severe joint pain, backache, menstrual problems, infertility and social and psychological problems are also seen as a result of excess weight. Obesity also cuts short a person’s lifespan.

A study which looked at the health repercussions of obesity, published in the Lancet, has revealed that “by 2030, non communicable disease will account for nearly 70% of all global deaths and 80% of these deaths will occur in developing countries like India”.

Research also shows that South Asians must watch their weight as their genes increase their risk of heart disease and diabetes – both of which are a deadly offshoot of obesity. If most Indians have ample waistlines, it is a predictable part of their Indian genetic history and we must do much more than blame our forefathers!

Bariatric surgery is not new. It has become popular in last 10 years because of minimal access (laparoscopy or key hole) surgery. Surgeons can now conduct these surgeries at low risk with small incisions, less pain, quick recovery and early return to work.

Bariatric surgery offers permanent solution to weight loss in obese and morbidly obese people. The weight loss is achieved by restricting eating, reducing absorption of food or a combination of the two. The different methods used in Laparoscopic Bariatric Surgery are Adjustable Gastric Band, Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with a duodenal switch (BPD-DS), and vertical sleeve gastrectomy (VSG).

The most popular amongst the bariatric surgery is the laparoscopic sleeve gastrectomy. This operation reduces the capacity of the stomach by 80% and thus restricts intake of food. Most people lose 30 per cent of their weight in the first three years after surgery. But surgery does not mean the person is now free to eat anything. Lifetime benefit requires a lifetime commitment towards healthy eating.

Dr. M G Bhat
MBBS,MS,FRCS(England), FRCS(Edinburgh), DMLE(Law), DMIRCSEd(Informatics)
Consultant Surgeon (Laparoscopy & Obesity)
Nova Specialty Surgery, Koramangala, Bangalore
www.drmgbhat.com