By- Dr. Aparna Govil Bhasker I am a Mumbai girl and nothing defines Mumbai better than its local trains. Over the last few months, I have gradually shifted to using local trains a lot more than my car, which to be honest is more of […]
Dr. Aparna Govil Bhasker
Bariatric and Laparoscopic GI Surgeon,
Global Hospital, Parel; Apollo group of hospitals, Currae hospital, Thane; Namaha and Suchak Hospitals, Kandivali and Malad
It is widely believed that the cohort of children born in the year 2000 in the USA, may live sicker or may not outlive their parents. With 19.3% of Indian children being either overweight or obese, we too are staring into an epidemic of childhood obesity.
In the Indian context a “chubby” child not only signifies good health but also good parenting. While it is true that genetics load the gun, it is the environment that pulls the trigger. In the vast majority of obese children, the cause for weight gain is polygenic and environmental. Monogenic obesity such as that caused by leptin deficiency is extremely rare and is seen in less than 1% of obese children.
Obese children tend to suffer from various health consequences like type 2 diabetes, obstructive sleep apnea, hypertension, dyslipidemia, fatty liver and so on. Till 30 years ago it was rare to see type 2 diabetes in children, but today children as young as 8 years are turning diabetic. Unfortunately, the changes these chronic diseases bring are irreversible and even if these children go ahead and lose weight as adults it leads to permanent damage to their blood vessels and other organs like kidneys, liver and heart. Apart from the physical changes, they also have serious self-esteem issues and tend to get isolated from their peers.
Treatment options for childhood obesity largely include diet and lifestyle modification and pharmacotherapy in some instances. Success of bariatric surgery for treatment of adult obesity has led to a gradual surge in bariatric surgery cases being performed on obese children over the last few years. Bariatric surgery includes a variety of surgical procedures like gastric banding, sleeve gastrectomy, Roux-en y gastric bypass and duodenal switch. These are performed laparoscopic or by open method.
A couple of years back the International Journal of Surgery published a case report about a two years old toddler becoming one of the youngest patients to undergo weight loss surgery at a hospital in Riyadh, Saudi Arabia. This toddler underwent a laparoscopic sleeve gastrectomy surgery, wherein two thirds of the stomach was surgically removed. The report was published 2 years after the surgery was conducted and the child had lost about 10 kg in 24 months (an average of 0.4 kg per month).
This report was widely publicized in tabloids across the world and had generated a lot of media frenzy. Although most cases of bariatric surgery on children and toddlers are presumably performed as life-saving procedures; the overzealous media hype around them is worrisome. This overenthusiastic excitement borders on unreasonably coercing bariatric surgery as being a standard of care for obese toddlers and children, even in the absence of any hard evidence. These cases raise a lot of pertinent questions, not only about the future medical and psychosocial outcomes in these children, but also about medical ethics and moral accountability.
Most bariatric procedures lead to a significant reduction in the levels of “Ghrelin” hormone. It has been proven that ‘Ghrelin’ plays a significant role in secretion of the growth hormone and is an important link connecting growth and body composition with metabolism. This reduction in Ghrelin levels can have unknown repercussions on the growth.
Bariatric surgery is also known to cause bone loss and osteoporosis in children. Nutritional deficiencies are known to occur after surgery, and to expect lifelong commitment in terms of nutritional supplementation from a toddler may be too much to ask for. The implications on future reproductive health and pregnancy outcomes are also unknown.
Direct extrapolation of adult results to pediatric population has not worked in the past and may not work in these case too. Moreover, an average weight loss of half a kg per month, can possibly be also achieved by implementation of a strict medically supervised lifestyle modification. These children are too immature to understand the gravity of the surgery being performed on them. For many years to come, they will not be able to apprehend the demands and exigencies of a bariatric procedure. It may be overzealous to perform this on children, who may be at risk of experiencing unanticipated negative consequences several years into the future. It is also not justifiable to surgically modify healthy organs of an innocent toddler in absence of any clear evidence regarding safety and future outcomes.
Another question that arises here is, ‘Who exactly are we treating?’
We would expect that parents would act in the best interest of their children, and usually, they are the ones who would take the decision and give consent for surgery. Poor parental food choices are a significant contributing factor leading to a rise in childhood obesity. More often than not, in such cases, we are probably actually treating the parental guilt rather than the health of the children in question. Surgery may be just a convenient solution to what may be perceived as parental failure.
As parents and doctors, we have a huge responsibility when it comes to the future of our children. Extreme caution is warranted while treating such cases. Prevention is certainly better than cure. Childhood obesity must be taken very seriously. We need to cultivate healthy eating habits in children and there must be regular health campaigns focused at prevention of obesity. Some of these severely obese children may be suffering from a genetic cause for obesity and must be evaluated and treated accordingly.
Cutting into a child’s healthy organ as a quick-fix must be avoided at all cost; and doctors and hospitals must refrain from generating unwarranted media hype around these cases. It is high time that the right perspective is brought to the forefront. Bariatric surgery must not be confused as being a standard of care for treatment of severely obese children. Even in cases where there is no other choice, a multidisciplinary team must look into all aspects before reaching to a decision and surgery must be performed with extreme caution. Bariatric surgery in children must be reserved only as a last resort when all other options have been exhausted and the choice is between life and death.
©Dr. Aparna Govil Bhasker Come December and its the season of weddings. Be it DeepVeer, Nickyanka or the Ambani extravaganza, this year it seems to be unending. Social media has gone into a frantic frenzy with hundreds of shared images of exquisite wedding locales, star […]
©Dr. Aparna Govil Bhasker As the year comes to an end, we finally wrapped up writing, editing, rediting and re-re- editing our book on doctor- patient relationships. Oh no…dont get me wrong! This is not a promotional post! Those will come later :), closer to […]
Dr. Aparna Govil Bhasker
Bariatric and advanced laparoscopic surgeon, Mumbai
Obesity is defined as a condition where a patient has accumulated so much body fat that it may have a negative impact on their health. A person is considered to be obese if their body mass index (BMI) is greater than 27.5 kg/m2. Bariatric surgery is a treatment option for patients suffering from clinically severe obesity and currently this is the only modality for sustained weight loss in this group of patients. Anyone with a BMI more than 37.5 kg/m2 qualifies for bariatric surgery. patients with BMI more than 32.5 kg/m2 with two obesity related diseases like type 2 diabetes, heart disease, high blood pressure, high cholesterol, obstructive sleep apnoea, joint pains, gout, PCOD or infertility etc also qualify for surgery.
Unfortunately, today there are many myths about bariatric surgery in India and this article attempts to clear those myths and present the facts in a lucid manner.
|Bariatric surgery is a cosmetic procedure done for making the patient look better||Bariatric surgery is performed for the treatment of clinically severe obesity. It is not a cosmetic procedure. Not only does it lead to massive weight loss but it also leads to improvement in obesity related diseases such as type 2 diabetes, high blood pressure, heart disease, sleep apnoea, high cholesterol, gout, joint pains, PCOD, infertility etc.|
|Bariatric surgery is the same as liposuction or tummy tuck||Liposuction and tummy tucks are superficial and localized cosmetic procedures, primarily performed to improve the appearance of the patient. After these procedures patients lose only about 5 to 10 kg of their weight and do not experience any kind of improvement in the above-mentioned diseases related to obesity. Patients also tend to regain the lost weight early on.
Bariatric surgery, on the other hand is a gastro-intestinal surgery with a central action. Patients lose up to 70% of their excess body weight after this surgery. They also experience a significant improvement in other diseases. Weight loss is sustained for a much longer period of time after bariatric surgery.
|Bariatric surgery leads to extreme weakness||Bariatric surgery in India is performed by the key hole method- laparoscopically. Recovery is much faster and patients are usually discharged one day later. Most patients get back to work within one week after surgery. As the food intake is restricted, patients need to be on nutritional supplements like multi-vitamins, calcium, iron and protein. Supplementation protocols depend on the type of surgery you have undergone. Compliance to nutritional supplementation and adequate hydration is a must and prevents weakness after surgery. Patients are also advised to do their investigations at regular intervals to avoid any kind of nutritional deficiencies. Regular follow up is a must after any kind of bariatric surgery and is the key to success.|
|One cannot eat anything after bariatric surgery||All bariatric procedures lead to restriction of food intake. In the first 3 to 6 months, restriction is higher. It is advisable to have small frequent meals to keep up the nutritional intake. As time goes by, food intake increases gradually and patients are able to eat better quantities. It is also important to pay attention to quality of food being consumed after surgery.|
|Patients can regain all the lost weight in a few years||Bariatric surgery in Mumbai leads to massive weight loss in the first 2 years. Most patients lose up to 70% of their excess during this time. However, like in the management of any other chronic disease, lifestyle modification is an important part of management of obesity. Patients who embrace lifestyle modification get better weight loss results in the long term. Not all patients regain weight.|
|Bariatric surgery has a high complication rate||Bariatric surgery is safe. The complication rate of bariatric surgery is much lesser than many other surgeries done for cancer or heart. The risk of complications is the same as that in knee replacement surgery or gall bladder surgery. The mortality rate after bariatric surgery is less than 0.5%|
Author- Mariam Lakdawala, Registered Dietician The most common observation made among diabetic patients is that they generally grab on sugar or sugary beverages when they get hypoglycaemic (a drop in the blood sugar levels). But are these sugar shots really helpful? Temporarily – yes, but […]
Mariam Lakdawala, Bariatric nutritionist; Dr. Aparna Govil Bhasker, Bariatric Surgeon
Honeymoon period is basically the golden period in the first year post bariatric surgery wherein the patient experiences drastic weight loss. Obesity surgery leads to weight loss through a combination of various mechanisms such as restriction of food intake, a decrease in hunger sensation, mal-absorption of calories, action of gut microbes and hormonal activity in the gut.
An interesting fact about the “post-bariatric surgery honeymoon phase” is that it is relatively longer than the “post-marriage honeymoon phase”. However, like the other one, this too is a temporary phase which sadly comes to an end after 6-9 months of surgery. After about 6 months or so, weight loss starts slowing down, but continues to happen until 1 year-18 months. Most patients reach the nadir of weight loss between 18 to 24 months.
By the end of 12 to 18 months, there is a considerable increase in food intake and hunger. Bariatric surgery is a tool that must be used for pushing one into a lifestyle change. Patients who embrace a healthy diet and an exercise regime, tend to do better in the long term. Varying degrees of weight regain is seen after obesity surgery in the long term. Regular follow up is the key to maintenance of weight loss in the long term.
In the first 6 to 9 months after the surgery, the main focus must be on conditioning the mind to, adopt a low calorie well balanced diet:
- Your diet is important not only during the honeymoon phase but is even more important after 12 to 18 months to prevent weight from coming back
- Restricting outside eating & intake of fried food, ice-cream, chocolates, processed foods, sugary foods etc.
- Fat gives double the amount of energy as compared to carbohydrates and proteins, hence it should be restricted in the diet.
- The body spends more energy to digest protein; thus, a high protein diet is very important for weight loss and maintenance. It is wise to distribute protein rich foods in all the meals in order to ensure better absorption.
- Avoid keeping long gaps between meals, eat every 3-4 hours to prevent overeating in the subsequent meal
- Maintaining a food diary is the best method to be aware of the food choices you make.
- Grazing which is a repetitive eating behaviour, in an unplanned manner not associated with hunger or satiety sensations, could develop post the surgery. It might lead to poor weight loss if not corrected. A simple way to deal with it is to eat the entire meal at a go and keep a decided gap consciously between the meals.
The story doesn’t end on what to eat, how to eat? how much to eat? When to eat? Is equally important. Given below is the cycle of mindful eating created to make you more mindful about your eating habits.
Mindful eating basically involves the practise of eating food slowly, in a relaxed environment by limiting other distractions so that you can focus well on your meals. As a result, you will be more conscious of portions and food intake.
Make exercise a way of life – Engage in any form of physical activity daily for at least 40-45 minutes. Make exercising fun by engaging in the activities you like so that you don’t leave it in between.
In addition to a focused exercise, increase the nonspecific exercise activities like usinga stairs instead of taking elevators or escalators, park your vehicle a little away from the intended destination, avoid using vehicle for short distances, etc
Stay away from lifestyle stressors like alcohol, smoking, erratic sleeping, sedentary lifestyle, work stress, etc.
Engage in meditation/ yoga/ breathing techniques or spend 30-40 minutes of your time daily in any activity that keeps you away from negative thoughts.
Dr. Aparna Govil Bhasker is one of the best bariatric surgeons in India and is associated as a consultant bariatric surgeon in Mumbai with many renowned hospitals.
Author: Mariam Lakdawala RD Bariatric nutritionist and diabetic educator Hair loss is one of the most important concerns that patients have after weight-loss/bariatric surgery. In the first 6 months, more than normal amount of hair fall may be experienced depending upon the age, gender, genetic […]