One out of ten Indian adults are obese and childhood obesity has more than doubled in the past 10 years. It’s an epidemic with very serious health risks like heart diseases, diabetes, cancer, and infertility.
In Delhi NCR, 45 percent of males and 55 percent of the females are suffering from obesity. The most important factor that contributes to this is a changing lifestyle. Increasing affluence has resulted in a change in eating habits; decrease in dietary fibers, consumption of packaged foods and an increasingly sedentary lifestyle.
When obesity runs in the family it implies a genetic predisposition. Certain hormonal disorders like hypogonadism, hypothyroidism and Cushing’s syndrome are all associated with obesity.
Another major problem that requires urgent attention is the increasing prevalence of obesity in children. Although obese children have fewer associated co-morbid conditions, they are likely to grow up as obese adults. They also suffer from prejudice and ridicule and are likely to suffer from psycho-social problems.
In order to calculate an individual’s body fat, the BMI (body mass index)- a mathematical equation—wherein the individual’s weight (in kgs) is divided by the height (in meters) squared. In India, an adult with a BMI of 27.5Kg/m2 or higher, for instance, is considered obese. The most alarming picture to have emerged is that the onset of obesity-related medical conditions like hypertension, diabetes and heart diseases of patients with low BMI is much higher in Asia than of patients in the West. For Asians, the co-morbidities start at 32.5 kg/m2 which would start at 35 kg/m2 in the West. For a similar BMI, the Asians would have much higher fat content than Caucasians. BMI does not establish fat distribution and also fails to distinguish between fat and muscle. Therefore, an athlete with more muscle mass and stronger bones could have a high BMI and may be categorized as overweight or even obese. On the other hand, older people who have lost muscle may have a deceptively lower BMI.
One simple alternative to BMI is measuring waist circumference indicative of obesity-related diseases. Men with a waist circumference of more than 40 inches and women with a circumference of more than 35 inches are at a higher risk for developing conditions like type 2 diabetes, high blood pressure and high cholesterol. According to a new study, ‘apple-shaped’ people who carry more fat around their bellies are at a higher risk for kidney disease.
It is high time that we recognize that obesity is a disease and requires treatment. It has medical, physical, social and psychological ramifications. It is important that this disease is treated early and preventive measures are taken to check its escalating numbers.
Obesity is also a well-recognized cause of insulin resistance that leads to impaired glucose tolerance. Incidence of Type II Diabetes is increasing in Asia and India is predicted to be the global capital for Diabetes. The multiple diseases and co-morbidities associated with central obesity are termed as ‘Metabolic Syndrome’. Despite aggressive management, current therapies have failed to achieve long term satisfactory control in the majority of patients. However, surgical treatment has been seen to help patients attain their goals as it not only induces significant weight loss but also has an impact on the course of the Metabolic Syndrome and Type II Diabetes. The procedure, therefore, appears to work beyond weight loss, having a key impact on the improvement of obesity related co-morbidities.
GOALS OF THE TREATMENT: Treatment for morbid obesity is to reduce the excess body weight with maximum safety and minimum side effects. The treatment is directed at decreasing the energy intake and increasing the energy output. The treatment protocol for treating obesity is as follows:
Lifestyle modification:
Diet, exercise with BMI more than 23
Drugs when BMI > 23 and when lifestyle changes fail
Surgery when BMI is > 32.5 with co-morbidities and 37.5 without co-morbidities
DIET: Dietary restrictions follow a pattern of altering the quality and decreasing the quantity of intake. Lowering carbohydrate or fat content of the diet, along with a decrease in the size of each meal results in weight loss. A majority of patients regain weight if they fall off the diet. This is called the Yo-yo effect.
EXERCISE: Exercise works by increasing energy output. But, no amount of exercise, however strenuous and prolonged can induce weight loss. Exercise tones the body and augments the weight loss.
EFFECT RESTRICTION: however it alone cannot cause weight loss.
DRUGS: Certain drugs like Sibutramine, Orlistat, Phentermine, Bupropion, Metformin, etc cause loss of appetite. However, they may have side effects such as nausea, bloating, oily stools, flatulence, etc. Drugs, however, induce a weight loss of only about 10 percent and may not help patients requiring a large amount of weight loss.
SURGERY: Bariatric surgery is not a cosmetic but lifesaving surgery.
BARIATRIC SURGERY
HAS EVOLVED OVER THE DECADES AND TODAY IT OFFERS THE MOST EFFECTIVE MEANS OF PROPHYLAXIS. IT PROVIDES THE FRAMEWORK WHEREIN THE PATIENT IS ABLE TO EASILY FOLLOW DIETARY RESTRICTIONS REQUIRED FOR INDUCING AND MAINTAINING WEIGHT LOSS.
It is broadly categorized as surgery of restriction eg. banding and sleeve gastrectomy and restrictive combined with malabsorption i.e. intestinal bypass or the combination of the two procedures. All surgeries are done laparoscopically.
GASTRIC BANDING: This is a procedure in which a band is placed in the upper stomach dividing it into two parts, creating a small pouch which is connected to the rest of the stomach. The section above the band acts like the stomach that fills quickly. As this section fills, signals are sent to the satiety centre in the brain causing you to feel satisfied over several hours.
GASTRIC BYPASS: This procedure is both restrictive and malabsorptive. In this procedure, stapling creates a small stomach pouch (15-20ml) and this forms the restrictive element. The outlet from this newly formed pouch empties directly into the lower portion of the small intestine, bypassing a certain length of the intestine. This forms the malabsorptive element as no absorption of food occurs in this segment of the intestine bypassed. Its other advantages are an improvement in treating diabetes mellitus, blood pressure and metabolic syndrome.
SLEEVE GASTRECTOMY: In this procedure, the stomach is reduced to 25 percent of the original size, by surgical removal of the large portion along a major curve. The surgery permanently reduces the size of the stomach. Few patients may later require a gastric pass or a duodenal switch procedure.
The write of this article,Dr. Vikas Kapur, is a Senior Consultant and Clinical Lead – GI, MAS and Bariatric Surgery aNarayana Superspeciality Hospital, Gurugram