There are more than 62 million diabetics in India; at least 30 million of them are obese, suffering from multiple health complications of both conditions.
"Bariatric surgery has been accepted by people and has become safer because of better devices. There are also advances in critical care which are making the surgery safer" - Dr Deep Goel, director, minimal access, bariatric and surgical gastroenterology, BLK Super Specialty Hospital, Delhi
"For highly obese people significant weight loss is extremely difficult to achieve without medical intervention" - Dr Pradeep Chaubey, director of minimal access and bariatric surgery at Max Healthcare Institute, Delhi
Bariatric surgery, where the size of the stomach is reduced to attain weight loss, is not usually performed as an emergency procedure. However, it turned out to be a lifesaver for Munish Chadha in December 2011, when he was brought unconscious with acute lung failure to the BLK Super Specialty Hospital in Delhi. The doctors realised that Chadha’s obesity was proving fatal for him. He weighed a whopping 167kg and suffered from diabetes and hypertension. He also suffered from obstructive sleep apnoea, a condition common in morbidly obese patients. His lungs had failed during one of those brief spells of temporary cessation of breath during sleep. In a three-hour emergency bariatric surgery, the doctors stapled his stomach and created a hole in his wind pipe to help him breathe. Chadha has lost more than 80kg since the surgery. “My health problems have disappeared and I feel like I have a new life,” says Chadha, 35, who now follows a low-calorie diet, and keeps himself motivated by being an active member of a patient support group.
Metabolic syndrome is a group of factors that raise the risk of problems like heart disease, diabetes and stroke. Obesity is a key factor. According to the Global Burden of Disease Study 2013, published by the UK medical journal The Lancet, India has the third largest obese population, with 11 per cent—30 million—being obese. As a consequence, these individuals suffer from a number of ailments including hypertension, diabetes, dyslipidemia, sleep apnoea, polycystic ovarian syndrome, infertility, osteoarthritis and fatty liver disease. Experts blame poor diet, lack of exercise and an unhealthy lifestyle for the surge in obesity. While there is increasing awareness about healthy living, most people struggle to lose kilos once they gain weight. “For highly obese people—with a Body Mass Index (BMI) of more than 32—significant weight loss is extremely difficult to achieve without medical intervention,” says Dr Pradeep Chaubey, director of minimal access and bariatric surgery at Max Healthcare Institute, Delhi. “Just like it is difficult for someone with coronary artery disease with 90 per cent blockage to have an unclogged artery without medical intervention, it is extremely difficult for a morbidly obese individual to lose all the weight permanently, without bariatric surgery. It is proven that for every 10kg you gain, you lose three years of your life. With the surgery, you are increasing your lifespan.”
Marketing executive Zaid Multani, 35, opted for bariatric surgery to control his diabetes and other ailments that came with his being overweight. “My mother is overweight and had to undergo a knee replacement surgery,” says Multani. “Both my father and mother suffer from diabetes and I knew I would, too. I was 125kg and struggling to stay awake at work due do my weight.” He had the surgery in September 2014 and now weighs 79kg. He says he feels more confident, is performing better at work, and that his health has improved. He is also happy that he has prevented long-term damage to his body.
With increasing awareness about bariatric surgery, and evidence to prove its effectiveness, the procedure has become much more common. While it has been performed since the 1950s, the procedure is far more advanced today and has a high success rate. Since it is done laparoscopically, it is far less invasive than it used to be, leading to minimal risk and fewer complications. “Bariatric surgery has been accepted by people and has become safer because of better devices,” says Dr Deep Goel, director, minimal access, bariatric and surgical gastroenterology at BLK Super Specialty Hospital. “There are also advances in critical care which are making the surgery safer.”
Globally, there is 0.1 per cent risk of death within 30 days of a gastric bypass, says a 2014 study published in medical journal Annals of Surgery. The risk of complications is lower in high-volume centres—those that conduct more than 100 surgeries a year—and in centres of excellence. Advanced power staplers ensure precision, and articulating instruments, which can change direction once inside the pouch, help surgeons perform better.
There are two types of bariatric surgery—sleeve gastrectomy and gastric bypass. Dr Avinash Katara, consultant, minimal access surgeon, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, says that having a gastric bypass can lead to a deficiency of some essential vitamins and minerals. “A sleeve gastrectomy does not create malabsorption, but it may not be effective for those who are morbidly obese,” says he. “Since you only reduce the size of the stomach to about 60 cubic centimetres, it may not lead to enough weight loss for some. Also, with time, overeating increases the size of the stomach and the lost weight may be gained back.”
International guidelines permit bariatric surgery for persons with a BMI of more than 40, without co-morbidity; for those with at least two co-morbidities, the BMI needs to be 35 or more. For Asians, however, the figure has been reduced to 37.5 without co-morbidity, and 32.5 for those with at least two co-morbidities. This has led to a spurt in the number of procedures. Last year alone, more than 13,000 bariatric surgeries were performed in India, and the figure for this year is expected to be 15,000.
The increase can also be attributed to the fact that bariatric surgery is no longer simply considered a weight-loss surgery, but a metabolic surgery to prevent long-term damage to the body. It has been proven that the surgery can lead to a reduction or reversal of type 2 diabetes, as well as improvements in polycystic ovarian syndrome, metabolic syndrome, liver disease, high lipid levels, asthma, cardiovascular disease, hypertension, sleep apnoea and joint diseases. The International Diabetes Federation supports the use of bariatric surgery as an early form of treatment to stem serious complications of the disease. It recommends the surgery for diabetes patients with BMIs between 30 and 35.
There are more than 62 million diabetics in India; at least 30 million of them are obese, suffering from multiple health complications of both conditions. “Previously, every case of diabetes had a fixed treatment,” says Chaubey. “But diabetes should be divided into the regular type and the type caused by obesity, which is commonly called 'diabesity'. Sixty per cent of those who are obese have diabetes, and it can be cured through surgery.”
Dr Jayshree Todkar, laparoscopic and bariatric surgeon, Hiranandani Hospital, Mumbai, says it is better that a patient does not wait until obesity and diabetes reach uncontrollable limits as this will only exhaust the system. “When hypertension, sleep apnoea and diabetes are associated with obesity, surgery should be considered the first option as there is no equivalent treatment that takes care of the metabolic syndrome,” says Todkar. “With every 15kg of extra weight, the body has to deal with 30 miles of vascularisation and additional burden on the heart and other vital organs.”
Dr Randeep Wadhwan, director of minimal access surgery and bariatric surgery, Fortis Hospital, Delhi, says that at least 20 per cent of all bariatric procedures conducted in India are for treating metabolic syndrome. “If the patient comes to us [for surgery] in the early stages of diabetes, he can expect remission and can have his blood sugar under control without any oral medications,” says Wadhwan. “For those who have had the disease for many years, diabetes can be brought under control [after surgery] with oral medication. Insulin shots would no longer be required.”
While becoming increasingly popular, bariatric surgery must still be approached with caution. It is an expensive procedure that requires long-term follow-up. It is imperative that the surgery be done at a centre of excellence which has a multi-disciplinary team of physicians, surgeons, psychiatrists, physiotherapists and nutritionists. Also, unless there is a lifestyle change post-surgery, with a focus on daily exercise and healthier eating, the weight and its associated problems will, most likely, come back.