Being fat does not mean good health. Obesity is no more a cosmetic issue and is proven beyond doubt to be a disease per se. Obesity is associated with many co-morbidities including type 2 diabetes, high BP, high cholesterol, fatty liver, sleep apnoea, PCOD/ infertility, knee joint pain and Back pain, etc.

Obesity is now emerging as the leading cause of death. It is expected sooner to overtake smoking as the leading cause of cancer.

In this article, let us discuss a few basic insights regarding obesity, its complications and the management options including the time tested Bariatric Metabolic surgery.

I come across many questions from my patients and this is an attempt to answer various queries.

Why Do We Become Obese?

Unhealthy eating habits, lifestyle, lack of physical activity, stress, poor sleep pattern, drugs, hormonal imbalance, genetic/familial

Above said are the common reasons for someone to become obese. Apart from this any individual can become obese as our genetic makeup is designed to make human beings obese.

Am I Fat / Obese?

For every individual person, the ideal body weight depends on his/ her height. To know exactly, doctors calculate the Body Mass Index (BMI) taking their weight and height. BMI of a normal person ranges from 18.5 to 24.9 Kg/m2.

Being Fat Is Healthier. Why Do I Worry?

Being fatter is not being healthier. Obesity is also considered as malnutrition. Moreover, obesity leads to the development of Type 2 diabetes, High blood pressure, high cholesterol, increased risk of heart attack and stroke, joint pains, sleep apnoea, fatty liver causing liver failure, gall stones, menstrual disturbances in women, PCOD/ infertility issues, Depression and many other problems.

Obese people are at increased risk of developing various cancers including food pipe (esophagus), stomach, liver, pancreas, colon, rectum, kidney, ovary, breast and uterus. By reducing weight, the risk is significantly reduced.

How To Check My BMI?

BMI refers to Body Mass Index. It is derived by dividing the body weight in kilograms by the height in m2.

Eg: a person with height 170 cm, weight is 120 kg

BMI = 120/ 1.7 x 1.7

        = 120/ 2.89

        = 41.52 kg/m2

What Is The Normal BMI Range?

World health organisation has classified BMI as follows

18.5 to 24.9 – normal weight

25 – 29.9 – overweight

30 – 34.9 – class 1 or mild obesity

35- 39.9 – class 2 or severe obesity

40 – 49.9 – morbid obesity

>50 – super obese

>70 – mega obese

Do The Same Criteria Suit Me?

If you are an Indian or from Asia Pacific region, the BMI criteria are as follows

18.5 to 22.9 – normal

23 – 27.49 – overweight

27.5  - 32.49 – class 1 or mild obesity

32.5 – 37.49 – class 2 or severe obesity

37.5 or more – morbid obesity

Why Is There A Separate Criteria For Asians?

This is because, genetically, Asians are prone to have more visceral (internal) fat compared to the Western population. The internal fat is more dangerous and leads to all the ill effects of obesity. Considering this, the criteria is modified to address the problem at the right time.

Oops!!!  My Weight Is More. What Should I Do Now?

Don’t worry!  An expert doctor can fix it.

Consult our weight-loss specialist at the earliest. He will analyse your records and will suggest the best solution.

What Are The Management Options For Overweight/ Obesity?

A healthy diet and being physically active are the most important things to be followed. Lifestyle changes should be strictly followed. Additionally, there are few medications that might help you in shedding your extra calories. There are also endoscopic procedures and keyhole procedures that will make you lose weight in a larger extent.

So, our nutritionist will guide you for the diet protocol and our Weight loss consultant will discuss the physical activity, medications and surgical options available.

Will These Options Work For Me?

All weight loss measures are beneficial. However, the extent depends on the amount of excess body weight. So, feel free to discuss your diet, activity and lifestyle with our experts to help you.

Am Following Strict Diet. Still Am Unable To Lose Weight!  But Why?

Our body weight is determined by our brain called “set point theory”. Beyond a certain weight, the body will resist our efforts to lose weight. The body’s metabolism will also be on the lower side. So a crash diet or fasting will not be useful to reduce the required amount of weight.

What If These Options Fail?

Diet, activity, lifestyle modifications are the first line of treatment for excess weight. Additionally, some medications may be useful. However, if these fail then bariatric surgery will give the best result.

I Prefer Medicines To Surgery

Medicines can reduce the maximum 10% of excess body weight if taken continuously. Once stopped, the weight regain happens. So, for overweight or mild obesity it will be a good option. But for severe obesity and morbid obesity, it is not cost-effective. The desired target weight can’t be achieved and also the comorbidity resolution does not happen. So, medicines can’t be the answer to all patients.

What Is Bariatric Surgery?

‘Baros’ in Greek means weight. Bariatric is derived from the Greek word meaning surgery for reducing weight. It is a minimally invasive, laparoscopic (keyhole) procedure that increases the body metabolism by increasing gut hormones called ‘ incretins’ which acts in the brain to reset the weight. This is achieved by modifying the stomach size and the food passage in the intestine.

I Have Heard Of Liposuction. Is It Same As Bariatric Surgery?

A big NO! Liposuction is a procedure where fat beneath the skin is sucked out using a special technique. A maximum of 5 -8 kg of fat can be removed. It’s purely a cosmetic procedure. There is no weight loss involved in this. There is no improvement in comorbidities. On the other hand, Bariatric procedure is a keyhole procedure that stimulates the body’s metabolism to lose weight. Here no fat is removed. The body inherently burns all the excess fat over a period of a few months.

Am I A Candidate For Bariatric Surgery?

As per international guidelines, if someone’s BMI is >35 (Asia pacific 32.5) i.e. class 2 or severe obesity and is suffering from any one comorbidity like Type 2 diabetes, high BP, high cholesterol, cardiac disease, sleep apnoea, NAFLD, PCOD, infertility etc…  they can undergo a bariatric surgery.

If someone’s BMI is >40 (Asia pacific 37.5) i.e morbid obesity, then they can undergo Bariatric surgery irrespective of the presence or absence of comorbidities.

Am Afraid Of Surgery. It's More Painful!

It’s done completely through the keyhole technique. So, there is absolutely no pain. Patients are out of bed 2 hours after surgery walking normally.

Undergoing Surgery Will Affect My Duties. How Can I Spare So Many Days?

We adopt a special LapROSE technique whereby patient recovers very fast after surgery. He/ she is fit on the next day to go home. As a protocol, patients are discharged on the second day after surgery.  It’s called “weekend weight loss surgery” as most of them are fit to be on work by Monday after the procedure during the previous weekend.

Will I Be Bedridden After Surgery?

Absolutely not. You will be walking for 2 hours post-surgery. There is no role or requirement for bed rest.

Is It Risky To Undergo Bariatric Surgery?

It’s a very safe surgery to undergo. The risk associated with bariatric surgery is the same as for Gallbladder and appendix surgery

Is It New To The Medical Field?

It’s not new to the medical field. The surgery is being done since the 1960’s. Initially, it was done by open technique. From the 1990’s the surgery is completely done laparoscopically i.e by keyhole technique.

How Is The Surgery Done?

Surgery is done by keyhole or scar less laparoscopic technique. There are no big incisions and hence no pain. Recovery is very fast after the surgery.

How Long Should I Stay In The Hospital?

Usually, patients are fit to get discharged on the second day after surgery. Rarely some patients may need to stay a couple of more days

How Does Surgery Help?

The surgery increases the body’s metabolism by stimulating the gut hormone secretion. This directly signals the brain to send weight loss signals. Also, there is a reduced intake of calories and some malabsorption which aids in weight loss.

How Much Weight Would I Lose?

On average one can lose 60% to 80% of the excess body weight. If the diet and activity protocol is strictly followed more than 80% of excess body weight is lost.

Eg. If the patient has 50 kg extra body weight, he/she is expected to lose 30 to 40 kgs on average.

Will I Feel Weak And Tired?

Surgery as such will not make you feel weak or tired. If you consume enough liquids daily and take a proper protein supplement, you will not feel any weakness or tiredness.

Can I Eat Normal Diet After Surgery?

After one month you will be able to take a normal diet. Immediately after surgery, you will be on a liquid diet which will be changed to a pureed diet and then to a normal diet.

How Do I Feel After Surgery? Life After Surgery

There will be a significant improvement in the quality of life after bariatric surgery. Losing weight makes you feel lighter and brisker. Weight loss surgery patients gain back their self-confidence and energy levels. There is also a significant remission or cure of comorbidities like diabetes, hypertension, cholesterol, sleep apnoea, joint pain, PCOD, etc..

How Long Will It Take To Lose My Excess Weight?

The weight loss will happen for 12 months after the surgery. However, most of the weight loss happens in the initial 6 months. After 12 months the weight loss generally stops.

Will My Diabetes And Other Problems Settle After Surgery?

Yes. Most of the diabetic patients can stop their medications immediately after surgery. Few patients may need to continue medications for a few months. The duration and severity of diabetes, as well as the existing pancreatic function, determines the outcome.

Is The Resolution Of Problems Permanent?

Most of the problems are cured permanently. Long term follows up studies up to 10 years have shown good results.

Can I Recommend It For Type 1 Diabetes?

Till now this surgery is not approved for type 1 diabetes patients. Many procedures are still in the trial phase.

Can I Become Pregnant After Surgery?

Yes. One can become pregnant after 1 year. During the first year, though the fertility rate rises tremendously, the body is losing weight and will not be suitable to support a growing foetus. So, it’s always advisable to become pregnant after the weight loss stops.

When Can I Go To My Gym?

Six to eight weeks after the surgery you will be fit to go to the gym.

Will I Have To Loose Skin After Surgery?

The majority of the patients do not complain about this problem. Very few patients feel their skin to be loose which can be corrected after one year.

Are There Any Complications After Surgery?

Any surgery will have complications. However, the complication rate is very less for bariatric surgery. In fact, it is comparable to the commonly done gallbladder and appendix surgeries. You can discuss this with the doctor to clearly understand this.

What Are The Side Effects?

Usually, there are not many side effects. Missing the supplements and protein drinks can lead to vitamin and mineral deficiencies. Also consuming fewer fluids after surgery can cause some side effects like weakness and tiredness. 

What Are The Different Types Of Surgeries Available?

The surgeries are usually divided as restrictive, malabsorptive and hybrid (combined restrictive and malabsorptive). This classification was done long back and is still followed. However, all the surgeries primarily have a hormonal effect leading to weight loss. Hence the term Bariatric Metabolic surgery has come into use.

Most of the procedures are done to lose extra body weight. However, the surgeries for curing diabetes can be done for patients with BMI in the class 1 obesity range.

Lap Adjustable Gastric Banding (Restrictive)

An adjustable band is placed around the uppermost part of the stomach separating the stomach into a small and large portion.

Advantages:

Reversible

Digestion and absorption are normal

Sleeve Gastrectomy (Restrictive)

The stomach is reduced to about 25% of its original size by surgical removal of a large portion of the stomach along the greater curvature. It is a combination of stomach restriction and appetite suppression as the ghrelin hormone-secreting fundus is removed.

Advantages:

Excellent weight loss within one year

Great appetite suppression

Low risk of peptic ulcer

No vitamin or drug malabsorption

Banded Sleeve Gastrectomy (Restrictive)

A loose band is applied over the completed sleeve gastrectomy tube. This ensures that the restrictive effect of the sleeve is maintained in the long run preventing the sleeve dilatation

Advantages:

Avoids weight regain

Weight loss is excellent

Roux-en-y Gastric Bypass  (combined – Restrictive/Malabsorptive)

A small pouch of stomach is created using staplers which restricts the amount of food consumed. Additionally, a portion of the small bowel is bypassed thus delaying food from mixing with the digestive juices.

Advantages:

About 95 % of co-existing health problems including type 2 diabetes, high BP, high cholesterol, sleep apnoea, depression, back pain were improved or resolved.

Also, the risk of developing a heart attack and stroke is significantly lowered.

Durable Weight Loss

Maintenance of weight, in the long run, is easier.

A loose band is applied over the completed pouch in Gastric Bypass. This prevents pouch dilatation that can happen later thus preventing weight regain.

Advantages:

Same as standard gastric bypass.

Weight regain avoided

Mini gastric Bypass/ One anastomosis gastric bypass  (combined – Restrictive/Malabsorptive)

MGB is a technical modification of the standard gastric bypass with the same results. The surgery is simpler compared to the RYGB and hence less time-consuming.

Advantages:

Excellent weight loss

Reversible

Bilio Pancreatic Diversion With Duodenal Switch (Malabsorptive)

A sleeve of the stomach is created retaining the natural stomach outlet. The majority of the small intestine is bypassed causing near-complete malabsorption of food contents.

Advantages:

Provides the highest level of weight loss

The best outcome for Type 2 DM and High cholesterol patients.

DIABETES SURGERIES

Short duodenal switch / Loop duodenal switch (combined – Restrictive/Malabsorptive)

A technical modification of the standard BPD wherein the malabsorptive component is less. There is a single anastomosis making the surgery less time-consuming.

Advantages :

Excellent resolution of type 2 Diabetes.

Good weight loss in obese patients

Ileal interposition

A long segment of the last portion of the small intestine (ileum ) is cut and joined very close to the stomach. Undigested food now first enters ileum to stimulate gut hormones called GLP-1 which acts along with insulin to reduce blood sugar.

Advantages:

Non-obese diabetic patients

Endoscopic Procedures:

Intragastric Balloon

An adjustable balloon is placed through an endoscope and inflated with saline inside the stomach. Its left in the stomach for 6 months to 1 year till weight loss happens.

Advantages:

Daycare procedure – can be discharged the same day

Non-surgical procedure

Endoscopic Sleeve Gastroplasty

Using an endoscope, the size of the stomach is reduced. This is a newer procedure and is gaining popularity

Advantages:

Nonsurgical

Good weight loss

What Is The Pre-Operative Schedule?

A thorough body check-up is done which includes blood investigations, heart and lung function evaluation. Our anesthetist will check you for fitness. Once fit, the surgery can be done at any time. You can get admitted the day before surgery to get prepared.

How Will Be The Day Of Surgery?

You can walk into the operation theatre. You will be comfortable there. A small injection is given to induce sleep. After that, you will be given general anesthesia and following which surgery is done. After the surgery, you will be in the observation room for 2 hours. You will be made to walk after 2 hours and can walk back to your room comfortably. 

When Do I Feel Normal After Surgery?

After 2 hours of surgery, you will feel near normal. Within 24 hours you should be feeling perfectly okay.

After Discharge, What Are The Things To Be Followed?

You will be given discharge medications to be taken properly. You need to come for review after one week when your sutures are removed.

Can I Skip My Medications?

It is not advisable to skip your medications. Occasionally missing once is acceptable.

Will I Regain Weight After Surgery?

Bariatric surgery gives a durable and sustained weight loss. Rarely there is a chance of weight regain after a few years of surgery. The chance of weight regain is more after sleeve gastrectomy compared to a gastric bypass. Discuss with your doctor to select the best procedure that suits you.

- Dr. Perungo T is a Consultant, Bariatric and Metabolic Surgery, Dr. Rela Institute & Medical Centre, Chennai