Tag: bariatric surgery

Bariatric Surgery in Delhi

There is a dramatic increase in prevalence of obesity. The traditional approaches like dietary and lifestyle modification, physical activity and pharmacotherapy fail to facilitate weight loss and treats obesity. So, bariatric surgery is the most sustainable treatment option. Bariatric surgery also promises improvement in obesity related comorbidities like type 2 diabetes, hypertension, dyslipidemia, arthritis etc. so, the term bariatric surgery is now replaced with bariatric and metabolic surgery. These days metabolic surgery for diabetes has emerged as a proven tool for resolution or control of type 2 diabetes. This weight loss treatment in Delhi is being done only at specialized centers, by adequately trained and expert surgeons. Thus it gives a permanent cure to this traditionally regarded as a progressive, unrelenting disease called type 2 diabetes.

In last few years there has been an increase in weight loss treatment in Delhi. Many centers are currently performing bariatric surgery. Patients from every corner of India prefer to come to Delhi for bariatric surgery owing to the availability of best medical facilities, trained and experienced bariatric surgeons and specialized paramedic staff. Even International patients prefer Delhi, India for bariatric surgery.
Sleeve gastrectomy and roux-en-Y gastric bypass are the most commonly performed weight loss procedures. Metabolic surgery for type 2 diabetes targets patients with uncontrolled diabetes who are currently on oral drugs and insulin. Scientific literature reports that bariatric and metabolic surgery results in weight loss, improvement/ normalization of blood sugar levels, reduction/ withdrawal of diabetes medications and decrease in cardiovascular disease risk factors. It is a simple procedure and the patients may be able to leave the hospital in one day or even the same day in selected cases.

In patients with reflux disease and type 2 diabetes the results of sleeve gastrectomy may be inferior to the roux-en-Y gastric bypass but the excess weight loss of both the procedures may be comparable in a select subgroup of patients.

Nutritional deficiencies are present in obese patients as consumption of high energy diet compromises on protein, vitamin and mineral intake. As Sleeve gastrectomy and roux-en-Y gastric bypass involves removal or bypassing of some parts of stomach and /or small intestine, so, macronutrient (protein) and micronutrient deficiencies (calcium, iron, B12, vitamin D, folate etc.) are very likely to occur post- operatively in the patients. Nutritional assessment remains the key component pre-operatively and post-operatively to identify, prevent and treat nutritional deficiencies at an early stage. Nutritional assessment involves taking physical measurements of body (height, weight etc.), analyzing blood and urine samples, identifying deficiency signs and symptoms and performing a comprehensive dietary assessment.

Consuming a well- balanced energy restricted diet with vitamin and mineral supplements and timely follow up with the bariatric team promises success of the surgery.

Management of Diabetes After Bariatric Surgery

Obesity has become the principal cause of Type 2 Diabetes Mellitus these days.

Excessive fat deposition leads to insulin resistance, which results in metabolic syndrome. There are various ways to treat type 2 diabetes including lifestyle modification, weight reduction and drugs including insulin. All these conventional methods have proved to be inefficient in achieving long-term results.

Surgery has evolved as the most efficient alternative to the conventional treatment and results in sustained weight loss as well as remission or resolution of type 2 Diabetes.

Bariatric and metabolic surgery changes the anatomy of the gastrointestinal tract in a beneficial way, this alteration increases good hormones. After bariatric surgery there is an augmented release of hormones like GLP-1 and PYY from small intestine that leads to improvement in the high blood sugar levels.

Since bariatric surgery is a highly efficient tool to reduce the blood sugar levels in an obese diabetic patient, there is a need for adjustment of anti-diabetes medicines in these patients post surgery.

Moreover, there is decreased calorie intake after bariatric surgery for which dose adjustments of the anti-diabetes medicines are needed.

The post-operative diet schedule includes:

  1. Phase 1 and 2 is of clear liquids to full liquid diet for 2 weeks. At this stage the calorie intake is about 600 to 800 kcal/day.
  2. Phase 3 is of pureed diet.
  3. Phase 4 consists of soft to normal diet and the calorie intake is about 1200 to 1500 kcal/day.

Before surgery, patients are usually switched over on intravenous insulin and blood glucose is monitored at regular intervals.

Similarly in the post-operative period, blood sugar is again maintained on intravenous insulin. On discharge, patient is shifted to tablets along with long acting insulin in most of the cases for initial few days.

Patient is taught to measure and chart blood sugar twice daily or in few cases thrice daily and the doses are adjusted accordingly. Subsequently as patients lose weight, there is further decrease in the requirement of drugs. Most of the time, almost all of the drugs are withdrawn to avoid any hypoglycemic episode. It is advised to maintain a blood sugar level between 120 to 150mg%. Remission of diabetes is seen in close to 80% of patients who do not need any treatment. There is a continuous need for follow-up with at least 3 monthly HbA1c levels.

In patients with poorly controlled diabetes mellitus, withdrawal of drugs may precipitate ketoacidosis in early post operative period. These patients are monitored carefully for symptoms and signs of diabetic ketoacidosis.

General guidelines:

To Monitor blood glucose at least twice a day with the aim to maintain it between 110-180mg/dl.

Tab Metformin is started on day 1 of surgery. The long acting insulin doses are reduced by 50%.

  • Signs and symptoms of stress hyperglycemia which include frequent urination, increased thirst, blurred vision, fatigue, headache or ketoacidosis which includes fruity-smelling breath, nausea and vomiting, shortness of breath, dry mouth, weakness, confusion, coma, abdominal pain must be addressed carefully and must be monitored by watching blood gases as well as urinary ketones.
  • Patients must be educated about signs and symptoms arising from hypoglycemic episodes (Blood sugar less than 70 mg%) like shakiness, dizziness, sweating, hunger, irritability or moodiness, anxiety or nervousness, headache.
  • During such episodes, patient must take 15-200 ml of fruit juice or milk if on liquid diet; if on solids any sweet candy. Similarly patient can take curd or yoghurt if on pureed diet.
  • Such people must take adequate protein to avoid episodes of hyper or hypoglycemia.

How Does Bariatric Surgery Reverse Diabetes?

Obesity is the root cause of diverse diseases such as Asthma, sleep apnea, cardiovascular problems, Type 2 Diabetes Mellitus, joint pains and most important some forms of cancers.

Obesity increases insulin resistance in the body leading to Type 2 Diabetes Mellitus, and also results in Metabolic Syndrome.

There are various ways to deal with these problems which include changes in the lifestyle and modification in the eating habits and use of certain drugs. But almost all of the studies conducted have come to the conclusion that these therapies are not effective in providing a sustained weight loss. Bariatric surgery has been the most effective treatment option till date which results in effective and sustained weight loss along with resolution of the other problems associated with obesity.

There are various bariatric and metabolic surgical procedures available which can be done by Laparoscopic Techniques as well as with Robotic assistance. They include Sleeve gastrectomy, Roux-en-Y gastric bypass, Mini Gastric Bypass, Ileal Interposition, Duodeno-Jejunal Bypass and so on.

Mechanism of resolution of Diabetes Mellitus:
Intestine is now considered as a metabolic organ and this new insight can be utilized for the treatment of Diabetes. Bariatric and metabolic surgery leads to changes in the anatomy of the gastrointestinal tract resulting in the treatment of obesity and diabetes mellitus. The quick lowering of blood sugar after bariatric surgery is due to hormonal changes after re-routing of the small intestine and not purely do the restriction of the calorie intake. It has been proposed and proved that after bariatric surgery there is an augmented release of certain hormones like GLP-1 and PYY from small intestine that leads to improvement in the high blood sugar levels.

These hormones not only decrease the cellular resistance to insulin, they also increase the efficiency of insulin. There is also decreased production of glucose from the liver due to their effects.

After surgery, long term follow up for the best results is a must. It’s a complete life style change. One must follow instruction carefully for optimum results.
There are absolute guidelines decided by international diabetes federation for selection of the patients who can be benefitted from surgery.

These surgeries must be done at the best bariatric and metabolic surgical centers doing these surgeries routinely and under expert care and experienced hands. Although hospital stay remains from 2 to 3 days, a strict and regular follow up is a must.

Obesity and Cancer

For us the word cancer evokes panic and fear of imminent death, whenever some one close is diagnosed with cancer we are shocked. All cancers though are not same; a great majority can be cured when caught early. And then there are types associated with predisposing medical conditions. We normally picture cancer patients as thin, worn out, barely able to eat, in pain, and in a state of constant dread. This may be true to a large extent. But many recently diagnosed cancer patients are in fact overweight and even obese. You will be surprised to know that obesity is a major risk factor for many cancers, so much so that it is considered to be second only to smoking, the most common one. Here are a few well known facts, for example obesity in women increases risk of Breast cancer fourfold, the uterine and ovarian cancer 5 fold, obese men and women are much more prone to cancers of esophagus, colon, gall bladder and thyroid, and many more.

Not only Cancer occurs more in obese, it is also more difficult to diagnose early. A lump may remain hidden in fat for a long time. The imaging and tests are less reliable in bulky and are less sensitive making it difficult to pick even a moderate size tumor. Severely obese even cannot be accommodated in a standard size CT scanner. Secondly it is diagnosed a t a more advanced stage, so is difficult to treat, the surgery becomes riskier and limited in scope in serious obesity. Radiation and chemotherapy likewise are needed in larger doses resulting in more side effects and morbidity.

So it is all the more important to keep weight in-check and treat serious obesity early. Bariatric surgery with its long long-lasting and superior results is the best way to lose weight in suitably selected patients. Bariatric surgery`s benefits compound with time and are consistent with lifelong health and happiness.

Home Care After Bariatric Surgery

Now you have been discharged from the hospital and have reached home and are feeling relieved but apprehensive too, because you think stitches could break, or you are afraid of pain at home, or how much to walk, whether or not to take bath and so on. These are some helpful points for your guidance

Wound Care

  • Change the dressings every day, if your doctor tells you to do so. Be sure to change your dressing always whenever it gets dirty or wet.
  • You may have bruising around your wound or redness around the incisions, do not  panic, this is normal.
  • Avoid wearing tight clothing to prevent rubbing against your incisions.
  • Stitches or staples are usually removed within 7 to 10 days after surgery. some stitches dissolve on their own. Your doctor will tell you if you have them.
  • You can have shower when advised by your doctor, let water run over your incision, do not scrub over the incisions.

Personal hygiene

  • Take shower daily.do not rub the wounds. let only water run on your incisions
  • You can oil massage and wash your hairs daily to feel fresh and active
  • Change your clothes daily
  • Clean your skin folds well with soap and water once a day and keep them dry specially during the rainy season

Activity

  • Walk as much as you can, move around and use stairs at home
  • Do not lift things heavier than 5 to 7 kgs in the initial months
  • Increase your exercise slowly
  • Take short walks
  • Get up and move around if you some pain in your belly, it may help
  • Do not join gym until recommended by your doctor.

Follow-up

  • To help recover from surgery and changes in your lifestyle ,see your surgeon regularly and other health care providers.
  • The dietitian will teach you to eat correctly with your small stomach.
  • The psychologist can help you deal with the feelings or concerns you may have after surgery.
  • Blood tests are important as recommended by your surgeon, get them done timely to prevent vitamins and mineral deficiencies.

When to Call the Doctor

  • Temperature is above 100°F .
  • You have redness, pain, swelling or bleeding around your incision
  • You have pain that your pain medicine is not helping
  • You have breathing difficulty
  • You cannot eat or drink
  • You are vomiting after eating

These simple precautions will help you tide over the initial difficult time at home after your bariatric surgery. Bariatric surgery is the best way to lose weight and regain health.

Infertility in Women and Bariatric Surgery

The relationship between PCOS, obesity and infertility has been documented for many years. Anovulation, miscarriage, impairment in follicle formation and altered activity are the known effects of these. These women also face difficulty in managing diabetes, pre-eclampsia, growth disorders, higher rates of caesarean delivery, higher maternal mortality, and increase their children’s risks for metabolic disease in the future.

A considerable weight loss can increases the chances of spontaneous ovulation, which is why the solution – bariatric surgery. This surgery is known to improve both fertility and pregnancy in women with reproductive concerns, polycystic ovarian syndrome (PCOS), along with metabolic syndrome (MS).

Bariatric surgery’s positive effect on women

Bariatric surgery in reproductive age women has been shown to decrease menstrual irregularities. Women suffering from hormonal imbalance show considerable improvement post operatively, and chances of conceiving increases after this surgery. Sensitivity to leptin levels increases post-surgery, reflecting improved reproductive metabolic status. Many women (about 10%-25%) with subclinical hypothyroidism, haven also shown a significant improvement following surgical weight loss.

Women already take pregnancy into consideration when electing for bariatric surgery. Nowadays women undergoing surgery are aware of their own reproductive risks and a significant number of these women are thinking ahead.

Studies on infertility in women and bariatric surgery

Bariatric surgery has attracted interest of many scholars with more individuals showing improved fertility post weight loss treatment. An older study, implied that a BMI drop greater than 5 kg/m2 was a significant predictor of fertility within 2.5 years of follow up after surgery. There was also a trend to a reduced need for fertility treatment in women conceiving within 3 years of weight loss surgery compared to their need for fertility treatment prior to surgery. Reports also show previously anovulatory women conceiving post-operatively without ovulation induction agents.

A study comparing pregnancy outcomes in women before and after weight loss surgery showed improvements in pregnancy related hypertension and diabetes mellitus, and a significant drop in caesarean delivery rate too. Moreover, bariatric surgery did not result in increase rates of post-partum haemorrhage, infection, shoulder dystocia or foetal demise.

The benefits of bariatric surgery in women suffering from PCOS with metabolic syndrome are discussed extensively on various platforms, leading in favour of surgery in such cases. Nutritional and vitamin deficiencies in these women during that time frame of rapid weight loss can be dealt with supervised supplementation, regular follow-ups with the surgeon and obstetrician. There were no differences in maternal complications, foetal outcomes or delivery complications, making bariatric surgery a highly recommended solution and one of the best way to lose weight in morbidly obese people.

The Gulf Obesity Crisis

Obesity is now the biggest healthcare challenge world wide, approximately one in three is either obese or overweight. It has overtaken malnutrition and infectious diseases as the worlds no.1 heath problem. The problem is even bigger in middle east. According to one study, 51 million people in the Gulf are classed as obese. An epidemic indeed. In the same study, Qatar is reported to have the highest incidence of obese men (44 per cent) in the Middle East and North Africa region, followed by Kuwait (43 per cent) and Bahrain (31 per cent), while the prevalence of obesity among women exceeded 50 per cent in three Middle Eastern countries; Kuwait (59 per cent), Libya (57 per cent) and Qatar (55 per cent).

Not only does obesity carry serious consequences for people’s health, it  also carries a global cost of $2 trillion, consuming 2.8 per cent of global Gross Domestic Product and demanding approximately 15 per cent from the healthcare budgets of developed countries, according to the authors of the McKinsey report.

Researchers have produced the startling forecast that if current obesity rates continue, almost half of the world’s adult population will be overweight or obese by 2030.

The demand for bariatric surgery is increasing by 20 per cent annually in Gulf countries, however in many cases it is out of necessity rather than choice. Bariatric surgery is proven to reduce the risk of serious health complications associated with obesity such as cardiovascular disease, sleep apnea, certain cancers and perhaps most pressing for the region, type 2 diabetes. According to experts, we must not believe that obesity is not self-inflicted or a lifestyle choice, rather than a critical health issue.

It is these damaging perceptions which have led to widespread criticism of bariatric surgery, which can cost between $8,000 and $15,000, as many claim that the procedure is becoming a substitute for a lifestyle overhaul. It is from this viewpoint that a serious stigma has emerged.

An increase in bariatric procedures could also realize financial savings for governments and healthcare systems alike, as patients who have undergone surgery, are more likely to avoid life-threatening and costly conditions such as heart disease and diabetes, which currently affects approximately one in ten adults in the Middle East and North Africa region

More young patients end up undergoing bariatric surgery in UAE

Doctors advise weight-loss procedures if children have high BMI and other health issues

Abu Dhabi: With obesity cases rising in the UAE, more and more younger patients are being recommended for weight-loss surgeries, experts have said.

The surgeries are a last resort in the fight against obesity and its related complications. They are often a better choice than letting children’s health get progressively worse.

Statistics compiled by regulator Health Authority Abu Dhabi (Haad), indicate that nearly 30 per cent of school going children in Abu Dhabi are overweight or obese and the proportion rises to 40 per cent among teenagers. Worldwide obesity has nearly doubled since 1980 and in 2011 more than 40 million children under the age of five were overweight (WHO).

Unless we take some drastic and wide ranging measures, the obesity will soon become worlds biggest and most expensive health issue ever.

A food for thought,shall we say.

The curse of Overfeeding

Mohammed is an 18 year boy from Afghanistan, he is shy, simple, has a easy smile, and is full of life. As a toddler he grew up active and playful, he was 15 kgs when he was 4. Then he steadily started gaining weight. Slowly but relentlessly, he over-grew. At 15 years he was 115 kgs at 5 feet 6. Very very obese indeed. When he came to us 3 years later, he could barely walk, sleep only sitting, sweat all day, and couldn’t speak without losing breath. He had become a giant, he weighed a huge 185 kgs at a BMI of 71.

His tests for genetic or hormonal problem came out normal. We looked into his life history, didn’t have much clue about he being so obese. On further questioning we found that Mohammed was born after eight sisters but he was born normal, a precious male child. Hence he was fed too much with food, love and affection by his doting mother and sisters. We have this gender issue in this part of world,a male child is the preferred one, he is the natural heir, is supposed to look after parents in old age, and fetch dowry. Hence he was pampered. Initially he must have resisted but later on yielded to pressure and temptations of calorie rich sumptuous food. As it happens, his sense of satiety slowly got blunted and he could eat all day without feeling full, a condition known as hyperphagia. He was suffering from what I call the curse of over-feeding.

Mohammed underwent a difficult Bariatric surgery, he was kept on ventilator support for next three days, before he could breath on his own. he made a slow recovery. Our psychologists and nutritionists mean while gave counselling sessions to Mohammed and his mother regarding his feeding and after-care.
Two weeks later they returned home.

Mohammed did well, 2 months later he had lost 21 kgs ,now he could walk without help,and sleep undisturbed.
Five months later he had joined back his elementary school which he had left years ago owing to his crippling obesity. He was well on his way to return to a normal life. Then we lost contact with them.we hope and pray the parents haven’t gone back to their old ways.

This story of Bariatric surgery is unique, so many times our misplaced love can ruin our children’s life. Our myths and false beliefs, force us to overfeed them. An over weight child is likely to become obese adult, will suffer from premature ageing diabetes hypertension, heart diseases and more.

Now how much is good enough for our children, is a contentious issue, but here are some simple rules of thumb. If we follow them we are going do well.

There is a natural tendency to overfeed children. We are always worried if we are feeding them enough, so if in doubt stop.

Toddlers by and large have a well developed sense of feeling full, stop as soon as they lose interest in their meal.
Feed on demand is the ideal way, like all ideals difficult to follow. But worth pursuing.
Pre-school children are at risk of obesity more than ever before. they get bored easily. Do not feed to appease, reward or pacify your children with snacks. it creates an unhealthy craving for snacks.

Give them sweets and chocolate strictly only “once a week”.

Don’t push the food around on their plates and don’t force them to finish what you give them. Don’t overfill their plates and ask them to finish every time, instead serve a smaller portion and refill.

What you can hold in your palm is a good enough portion to star with.

If your child is gaining weight steadily, her clothes are getting short instead of tight at the waste, bravo !! You have done well.

Ramadan after Bariatric Surgery

We are into the middle of the holy month of Ramadan, and the Eid is around the corner, Delhi and the walled city in particular are celebrating Ramadan with full fervor and gaiety. The day begins well before sunlight with Sahrei the morning prayer and a succulent meal of Nihaari a special meat dish cooked in overnight slow fire; and then the Roza or day-long fast ,without food and water begins. Many relax at home and take a siesta, but most continue with their daily grind. It is summer in Delhi at its peak with relentless sultry heat; there is hardly any breeze though occasionally a dust storm Luu brings welcome relief. The lanes are sleepy. Occasionally one encounters a rickshaw puller in a white cap silently trudging along, his face dry and flushed, his Lips parched with almost no sweat on the brow.

All this makes fasting even more arduous. Faithful offer their ritual after- noon namaz and patiently wait for the evening. At last the Sun goes down and here comes the welcome Iftar hour. The city wakes-up from its deep slumber, the shops open in tandem and the streets in Ballimairan, Hauz Kazi and Chandni Chowk come alive with decorations, lights and flowers. Slowly the scent of Ittar and of freshly made kababs, jalebis and naans from numerous stalls wafts all over in the welcome breeze.

Presently you see waves of men in white thronging to Jama Masjid for their evening namaaz. Often you see a few tired faces with gleam in their eyes and a sense of accomp//ishment, reminding me of our bariatric surgery patients who visit us after two weeks of liquid diet with same calm and serene face and the same sense of pride; they too are waiting for their puree diet.

This brings me to the question many of my patients ask, whether they can observe religious fasts. My advice to them is clear

  • Visit your physician; take a fitness check before you have a go at it
  • It is best to wait for one year till you are settled with your normal diet.
  • If you are observing fast do not go out in the sun for long hours, don’t undertake strenuous work.
  • Keep a watch on your hydration; you should pass urine at least two or three times during the daytime. It should be clear or light yellow.
  • Drink at least two liters of fluids in the Night, to make up the deficit
  • Open your fast with fruits like apples and water-melon
  • Take high protein food; avoid oil rich curries, fries and pastries to prevent dumping
  • Eat slowly, chew well otherwise you tend to vomit and your dehydration will worsen
  • If you are suffering from severe Kidney disease, better not do it.
  • Diabetics should take special care to avoid hypoglycemia, or keto- acidosis. Check your sugar levels twice a day and urine for ketones. Your insulin and medicine requirements will change.
  • Better still consult your physician before you begin with your fasts.

Enjoy your fasts and feast this Ramadan and Eid and take care.