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 surgery 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 […]
Author- Mariam Lakdawala (Registered Dietician)
Common questions I generally get from my patients suffering from obesity,
“I don’t eat much, still why am I gaining weight?”
“I eat less than one of my friend, but why is she so thin and I am not?”
My answer to such questions is simple, “Don’t only see how much is on your plate, but also see ‘what’ is on your plate”.
The basic rule of weight loss is to restrict the overall quantity of food and increase the calorie burning capacity of the body. However, this rule has been outdated as only quantity restriction in the absence of food quality management, will not result in positive weight loss outcomes. Also a good quality diet which consists of good quantities of proteins and fiber keeps you full for longer and delays the intake of subsequent meal.
Though factors like genetics and heredity play a major role in adding those kilograms, ‘food’ can also be a major factor for tipping the scales towards obesity. If the quality of the diet is poor, food becomes the major cause of obesity. Your food plate determines the quality of your meals. An ideal food plate must have all the major (macro) nutrients i.e. carbohydrates (also includes fiber), proteins and fats in correct proportions.
In India, our diet is rich in carbohydrates with very less quantities of vegetables and proteins. This has an adverse impact on our metabolism and exposes us to various metabolic diseases, including obesity. In metropolitan cities the dependence on ready to eat processed foods like biscuits, breads, noodles, sausages/ nuggets etc is much higher in order to save time. These processed foods are generally high in sugars, salt and fat which makes them less nutritious and dense with empty calories. Poor quality diet coupled with lack of physical activity just makes it worse and has played a big role in increasing obesity levels.
The quality and quantity of food are two sides of the same coin. Both the aspects are equally important not only for weight loss but also for maintaining good health and must not be ignored.
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 […]
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 factors, etc. This hair loss however, is not permanent and it can be decreased with dietary modifications and adequate supplementation.
Why does hair-fall happen after bariatric/weight-loss surgery:
Hair follicles have two phases of growth namely:
Anagen – Active growth phase
Telogen – Inactive phase
Hair follicles start with anagen phase wherein the growth occurs and then move on to the telogen phase which lasts for 100-120 days. Then the hair falls out. This process, if accelerated, is called Telogen Effluvium and is the cause of hair loss in bariatric patients.
Telogen effluvium could occur due to:
- Rapid weight loss
- Increased stress
- Chronic disease such as liver disease or any chronic debilitating disease
- Hormonal imbalance such as hypothyroidism
- Poor compliance with supplementation resulting in micronutrient deficiencies especially, iron deficiency
- Decreased absorption in case of a mal absorptive surgery, as most of the iron absorption occurs in the Duodenum
- Less Hydrochloric acid (HCL) to convert iron into its most bioavailable form, as 3/4th of the stomach containing HCL is bypassed.
- Food intolerances resulting in overall very less food intake
- Low protein intake- There is decreased absorption of proteins post a mal-absorptive surgery
- Decreased tolerance to protein rich foods
To decrease hair fall, make sure that the following nutrients are included in your diet
- Proteins: Insufficient protein intake can cause thinning of hair, affect the normal process of hair growth and causes diffuse alopecia. Thus, a protein intake of 1.5 g/ kg of ideal body weight is very important post the surgery with more emphasis on essential amino acids. Among all the essential amino acids, L-Lysine has shown to improve hair growth after the period of decline and also can improve the levels of iron in the body. L-lysine supplementation of 1.5-2 g is recommended (Faria. S, et. al, 2010). Its bioavailable forms are found in fish, meat and eggs. The vegetarian sources include, soy products, lentils, quinoa, black beans, pistachios, pumpkin seeds, etc.
Protein deficiency can be identified by serum albumin levels, loss of muscle mass, hair fall and weakness.
- Iron: Iron supplementation can help to decrease hair fall induced by iron deficiency. In case of GI related disturbances or if the haemoglobin levels are very low, intra-venous iron can be prescribed. Iron deficiency can be identified by serum iron studies and a complete blood count.
- Biotin: It plays a vital role in the development of hair follicles.
Supplementation of 1-2 mg of Biotin may be helpful to decrease hair fall (Faria. S, et. al, 2010).
- Zinc: It is an important factor for the growth and development of hair. In case of hair loss 15 mg/d of zinc chelate is recommended (Faria. S, et. al, 2010).
- Essential fatty acids: Biotin if complimented with essential fatty acids, can decrease hair loss. Foods rich in essential fatty acids include fatty fishes, flaxseeds, flaxseed oil, extra virgin olive oil, etc
- Vitamin B12: Deficiency of B12 may alter the pigmentation of hair. However, this alteration can be reversed by B12 supplementation.
Take a look at few suggestions to help you deal better with fear of hair loss post weight loss surgery
- Relax and don’t worry, you will lose 5-15% of your hair due to the stress of surgery and weight loss. It rarely lasts more than 6 months and grows back.
- If it lasts for more than 6 months visit your primary care doctor to be evaluated for any illness or non-nutritional reason for hair loss
- Be regular with follow-ups so that any nutritional deficiency causing hair loss can be timely identified and taken care of
Surgical & Prosthetics
Interventions like hair transplant, hair restoration therapy like QR678, may be considered if hair-loss persists even after 18 to 24 months of bariatric/weight-loss surgery.
Wigs, weaves, etc can be used as a temporary measure to tackle with hair loss if required.
Last but not the least, hair-fall after bariatric/weight-loss surgery is a transient phenomenon and is self-limiting. However if it has become a cause of stress, do visit us so that we can evaluate and help you out.
Faria, S., Pereira Faria, O., Diniz Lins, R., & Rodrigues de Gouvea, H. (2010). Hair Loss Among Bariatric Surgery Patients. Bariatric Times, 7(11), 18-20.
Author: Mariam Lakdawala, RD Bariatric nutritionist and diabetic educator My last blog emphasized on the importance of protein supplementation post weight loss/bariatric surgery. It is extremely important to meet the protein requirements (especially for vegetarians) to prevent or decrease the consequences of possible protein insufficiency after […]