CHENNAI: Though bariatric surgery can drastically reduce that expanding waistline, the weight loss surgeon's calling should involve treating the morbidly obese rather than managing the overweight, bariatric specialists have said.

Low awareness

Though various techniques of bariatric surgery have been available at a few city hospitals since the mid-nineties, weight loss surgeons concede that lack of guidelines for these procedures had an inherent potential for abuse, especially given the low public awareness and the desperation of the obese. In this context, it is also significant that hormonal predisposition put women at higher risk of obesity compared to men.

The obesity condition by BMI (body mass index) value is classified ranging from the overweight (BMI 25 to 30) category to the morbidly obese (BMI 40 and above). Persons with a BMI in the 35-40 range having a co-morbid factor such as diabetes are also considered candidates for surgery.

"There is a growing feeling that the Indian context requires lowering of the BMI in selecting surgery candidates," says J.S. Rajkumar, chairman, Lifeline Hospitals.

Discussion

A discussion on this issue will be part of the agenda when the Indian Obesity Society meets in New Delhi on January 16 and 17. There is an indication that the BMI criterion for candidates with a co-morbid factor could be reduced to 32 or 33. This is to account for the thinner blood vessels in Indians that make the population more at risk of vascular catastrophe, Dr. Rajkumar said.

Though obesity statistics is not available in India, rough projections put the number of new cases of obese here at one lakh every year — 50 per cent of them morbidly obese. In the U.S., an estimated 5 per cent of the adult population has a BMI value of 40 plus. Obesity-related complications resulting in heart attacks, stroke and diabetes, account for three lakh deaths every year in the U.S

Multidisciplinary approach

The morbidly obese carry a three-fold higher risk of developing Coronary Artery Disease and a 30 times increased risk of developing diabetes. They can also develop cancers (breast cancer in women and prostate cancer in men), osteoarthritis, liver disease, reduced fertility and sleep apnoea.

Ideally, bariatric surgery should involve a multidisciplinary approach involving a dietician, mental health professional, endocrinologist, gastroenterologist and the surgeon. Interventions involve dietary regulation, exercise, behavioural modification, pharmacotherapy and surgery.

"A patient must importantly have been unsuccessfully put though the conventional interventions before the surgical option is considered," said M. Muralidharan, Department of Bariatric Surgery and Surgical Weight Loss unit at Apollo Hospitals.

"Surgery is at best only a tool and it is vital that the patient is motivated to stay fit," he said.

Management options depending on clinical status include drugs such as Orlistat which reduce the amount of fat metabolism but only bring down 5 per cent weight loss, restrictive surgery which reduces the size of the stomach and malabsorptive surgery in which surgeons surgically reduce the length of the intestinal track where food interacts with the digestive juices.

The Lap Band technique (Laparoscopic Obesity Surgery), a form of restrictive surgery which is the in-thing in the U.S. and the U.K., involves putting a band around the upper stomach. This procedure achieves a weight loss of 30 per cent.

Yo-yo effect

Some of these procedures are associated with loss of vitamins, minerals and iron. History also points to a high dropout phenomena resulting in a backlash, or the yo-yo effect, where patients go back to food bingeing and regain weight. The Lap Band technique's strength and weakness is its flexibility and though there is no mineral loss involved, the procedure has been proven ineffective on sweet eaters.

The middle path, which combines the best of both the restrictive and the malabsorptive procedures, is the gastric bypass and this effects as much as 70 per cent weight loss.

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