Bariatric Surgery: It’s a big deal

In Kerala, the diabetes capital of India, at the Amrita Institute of Medical Sciences, Kochi, bariatric surgeon O.V. Sudheer is cautiously optimistic. “It has been observed that diabetics who have undergone this operation have stopped taking insulin within a month or two," he says. He adds that bariatric surgeons the world over are wondering if they can perform similar operations on diabetics who are not morbidly obese but just overweight, and get the same results. “We have seen that it is effective in cases of patients with body mass index (BMI) over 35. The challenge is to perform it on cases with lower BMI," says Dr Schauer.

But, that’s the big issue—and the reason why diabetologists are so sceptical about the claims being made by bariatric surgeons. Although surgical techniques have improved greatly over the years, bariatric surgery is still clouded in controversy and risk.

Bombay-based obesity consultant and nutrition specialist Naini Setalvad, who herself lost weight by natural means—a whopping 100kg over two years through a diet and exercise regimen—warns about side effects of bariatric surgery, such as chronic diarrhoea and loss of vital minerals, formation of kidney stones and a generally awful feeling.

Leading Delhi-based fitness consultant, Gaurav Sharma echoes this: “There are a lot of side effects of bariatric surgery, and the benefits do not outweigh the risk factors. It can only be suggested to a person who is not willing to exercise and is looking for a short cut. But, there are no short cuts in life. After the surgery the person still has to exercise."

Yet, an increasing number of people are opting for the surgery. In the US, since the 1990s, obesity surgeries have seen a rapid growth. Last year, an estimated 177,600 were performed, according to the American Society for Bariatric Surgery, up from 103,200 in 2003. What’s more, many of these have been on teenagers. At Sir Ganga Ram Hospital, over 200 surgeries have been performed, and Dr Chowbey reports that he gets four to five enquiries every week.

To popularize the procedure and help it gain respectability, hospitals in Delhi are setting up special obesity clinics. Though this could sometimes be taken to ridiculous lengths—in Mumbai, Breach Candy Hospital has reportedly launched a hunt for the fattest person in the city, promising free surgery.

According to Dr Schauer, in the US the surgery is gaining acceptance because obesity is no longer regarded as a cosmetic problem, but a serious disease. An estimated 65% of the population is overweight. In India too, where 5% of the population is estimated to be in the high-risk group, awareness is increasing—especially after a recent study showed that 30% of children in urban India are obese and the problem is reaching epidemic proportions.

Atul Peters of Max Healthcare, New Delhi, says, “Increasing awareness about the dangers of obesity coupled with advanced surgical techniques, has led to this gaining gradual acceptance".

Dr Sudheer points out that there are at least 30 conditions associated with obesity including hypertension, infertility and diabetes. “Obese people don’t live long," he says bluntly. “By means of these surgeries, associated disorders could be reversed and longevity increased," he says.

The other reason for the popularity of this surgery, says Dr Chowbey, is that weight loss programmes run by fitness consultants have not had a very high success rate as far as the morbidly obese are concerned. This is because such people are trapped in a vicious cycle—their legs cannot support their weight, inhibiting them from prolonged exercise—and the lack of exercise then leads to weight gain. “That’s true enough—when I was over 150kg, I could not walk for more than five minutes, but I succeeded in shedding the excess kilos," says Setalvad. She describes how she started out with five-minute walks and by sheer willpower kept increasing the time period.

At the Amrita Institute of Medical Sciences, which has an anti-obesity programme, endocrinologists, physiotherapists and gastroenterology surgeons counsel the severely obese to undertake this procedure. Those who have successfully undergone the surgery also help to motivate others. For instance, a 24-year-old architect, based in West Asia, who recently underwent this surgery, shed 30kg, and has become a great source of inspiration to others contemplating the surgery.

She reports feeling lighter and being able to walk 2km a day now. Dr Sudheer says she might lose another 10kg over the next six months and get to a manageable 80kg.

Most people who have gastric bypass surgery continue to lose weight for up to 12 months. “Rarely is weight regained," says Dr Schauer, pointing out that there are multiple pathways in our body that regulate appetite and satiety. The surgery succeeds in interrupting almost all the pathways and is therefore more effective than diet and exercise regimens.

How it works is that the stomach is made smaller by creating a small pouch at the top using surgical staples or a plastic band. The smaller stomach is connected directly to the middle portion of the small intestine, bypassing the rest of the stomach and the upper portion of the small intestine. As a result, the patient feels full more quickly, and the intake of food is drastically reduced. Bypassing part of the intestine also results in fewer calories being absorbed. All this leads to weight loss.

On the flip side, this is also the biggest reason why consultants like Setalvad are uncomfortable with bariatric surgery, as the patients have to make compromises for their entire lifetime. Even minimal sugar intake could lead to nausea and vomiting.

Nutritional deficiency is also a potential risk as the part of the intestine where many minerals and vitamins are most easily absorbed is “bypassed". Vitamin and mineral supplements have to be taken throughout one’s life.

Also, it’s too early to understand the long-term implications of the surgery—in the US, five-year studies have just been initiated to find out the psychological impact of obesity surgeries on teenagers.

Dr Schauer and Dr Chowbey are the first to admit that surgical options should be the last resort, and that the stress should be on prevention. “In fact, we have told officials from the ministry of health that a national strategy needs to be adopted," says Dr Chowbey.

But, as Dr Schauer says, it’s a challenging task. “It took 70 years of sustained campaigns to bring down smoking from 70% to 20% today. Obesity is a far more complex issue. After all, how do you stop people from eating?"

WHO NEEDS IT

Overweight (according to the World Health Organization, those with a body mass index equal to, or more than, 25) and obese individuals (those with a BMI equal to, or more than, 30). BMI is defined as the weight in kilograms divided by the square of the height in metres (kg/m2)

HOW IT WORKS

By far the most common procedure is gastric bypass surgery: it makes the stomach smaller and allows food to bypass part of the small intestine. Most people can return to their normal activities within three to five weeks

THE RISKS

Nausea, weakness, sweating, faintness and diarrhoea soon after eating. Ulcers and hernia problems have also been reported. The bypassed stomach may enlarge, resulting in hiccups and a bloated feeling. A highly disciplined lifestyle is required

THE COSTS

In India, about Rs1.5 lakh. However, insurance cover is not available

FOLLOW-UPS

The surgery leads to a deficiency in iron, calcium, magnesium, and may lead to problems such as osteoporosis. This means life-long supplementation. The sagging skin too needs to be fixed by cosmetic surgery after two years

Write to us at businessoflife@livemint.com

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