Posts in Bariatric Surgery

gratitude

GRATITUDE

Bariatric Surgery

©️Dr. Aparna Govil Bhasker

I love sitting around in the surgical lounge for a bit after the surgery is over. It is usually here that we end up meeting our colleagues and have some light banter. We talk about this and that and then get on with our day.

This morning, in one of the hospitals I visit, I met the hospital owner in the OT lounge. My anesthetist friend and I, complimented him for creating a superb facility and delivering high quality healthcare to people in that part of the city. To our surprise, he was taken aback totally and said that most people only call him up to complain and raise issues, rarely does he receive compliments. This set me thinking.

It has been 25 years since I entered the field of medicine. In these 25 years, I have collected immense amount of career capital and achieved many professional milestones. But that is not all. More importantly I have made hundreds of friends and forged many beautiful relationships. Some are conventional and some very unconventional.

For instance, the friendly watchman outside one of the hospitals, who always greets me with a great smile. (And primes me about how many patients are waiting already)

A kind driver of another consultant who helps me park my car for last so many years! (Reflects on my parking skills too ?)

The mausi who ensures to serve my coffee without sugar. (Just the way I like it)

The wardboy who volunteers to do the daily dressing of my patient with a chronic wound and doesn’t give up until it heals. (Loved to see the glint of happiness in his eyes when the wound healed)

The nurse who continues to care for others even after tragedy struck her own family. (I wish I can be as strong as her)

The boy in the hospital canteen who serves me food everyday. (Given his way, I would put on 2 kgs every month)

The manager who always hears me out patiently everytime I call to complain about a million issues. (His patience is enviable)

The fellow surgeons who always support when stress comes calling. (No questions asked, no judgement ever)

The list is endless. But there is a special connection with each of them. We share a common universe, a common purpose, we are there for each other and whether we know it or not, we rely on each other in many ways. Every morning when I walk into the hospital, I feel reassured to see familiar faces. We have our differences at times, but these bonds are unbreakable. We share our lives together.

On the face of it, it may appear that the world is turning more and more bitter, but if we look around us, in our immediate universe we will find a lot of sweetness in small things and kind gestures. It’s high time we appreciate our blessings and express our gratitude.

It’s time to say “thank you” to every one of these special people for being a part of my life and making me who I am.

©️Dr. Aparna Govil Bhasker

Learn to just be

Bariatric Surgery

LEARN TO JUST BE

Dr. Aparna Govil Bhasker

It fills me with wonder when I look at the sky,
Its a beautiful blue as far as I can see with my eye,
Rays of the glowing sun peep through the clouds with silver lining,
And pretty birds soar as high as they can fly in the sky,

The sun, the clouds and the birds, the sky is in love with them all.

I envy you O’ sky because you are so everloving and hopeful that you can….. just be.

It fills me with wonder as I look at the tall mountain,
Who lets the river flow through it and give the gift of life,
To the seed that will grow eventually into a beautiful tree.
The mountain is effortless as it gives space to the river to flow and the tree to grow.

I envy you O’ mountain because you are so magnanimous….you can…. just be……

It fills me with wonder as I look at the tiny flower,
That dares to grow in the bed of grass,
A bright yellow in all its beauty,
Not afraid of being trampled along and crushed by this world,

I envy you O’ flower because you couldn’t care less and you can dare to …..just be…..

It fills me with wonder sometimes when I look at me,
Hope and love are what I want to be,
The gift of life is precious, but sometimes I falter,
And run in this race to get ahead of the unknown.
Life is short, and I need to make an effort to get away from the cacophony and get above the noise,
To find some peace, and learn to ….. just be.

Dr. Aparna Govil Bhasker

MY REFLECTIONS ON THE SEASIDE

Bariatric Surgery

Endearing is the innocence of childhood that believes in the pure joy of creating castles of sand. Children don’t get demotivated when these castles are washed away by the waves of the sea. It is inspiring to see their enthusiasm about making another one the next day and another one and another one….

I wonder when did adulthood swallow the joys of childhood.

Its pure joy to see the youth playing beach football. Oblivious of the world around them, they exhalt in the moment. There is no need for a fancy ground, nor branded shoes or a trophy coach.They don’t play to win, they play for friendship and fun.

I envy their carefree moments.

Its beautiful to see a group of friends celebrating a birthday on the seaside. There is lovely music playing on one of their phones, a cake is waiting to be cut and selfies ready to be taken. Its only friends who can make one feel so special!

I miss my friends.

Its lovely to see a young couple and another old couple content in each other’s company. The young ones have a whole life ahead of them and older ones have already lived a lifetime. Both realize that its a privilege to have someone special to go back to at the end of the day!

I count my blessings.

There is a lot more… the sun sets to rise again, the moon starts shining far away, the waves calm down, the birds go back home. Its the end of the day and it’s reassuring to see that despite all that is happening around us, life goes on, undithered, lovingly…enthusiastically.

There is a lot to be thankful for.

Dr. Aparna Govil Bhasker

Obesity and Metabolic Surgery Society of India (OSSI) Recommendations for Bariatric and Metabolic Surgery Practice During the COVID-19 Pandemic

Bariatric Surgery Blog

Very proud to be a part of this committee of experienced bariatric surgeons in India to help in formulating these important guidelines for resumption of #bariatricsurgery during the ongoing COVID 19 pandemic.

#Obesity has emerged as one of the most serious risk factors affecting the severity and prognosis of COVID 19 infection. Till date, Bariatric surgery remains the only effective option for sustained weight loss in patients suffering from clinically severe obesity. These guidelines will help surgeons to prepare for possible recommencement of bariatric surgery in a safe manner for patients suffering from obesity.

Kudos to the leadership of our President OSSI- Dr. Manish Khaitan for guiding us and ofcourse to Dr. Sandeep Aggarwal for threading this extremely important document together.

Let’s hope that this pandemic settles soon and in the meantime we do right by our patients as we resume bariatric surgery across the country.

Please click on the link to read the guidelines-

https://rdcu.be/b6pTh

E-Upsurge July 2020

A Dose of Realistic Optimism for Surgeons

Bariatric Surgery Blog

“Action, heroism, certainty and optimism”, are some of the key tenets of surgical culture all across the world. However, in today’s times surgeons have been compelled to cope up with, “inaction, fearfulness, uncertainty and some degree of pessimism”. To say that COVID-19 pandemic has disrupted the very foundation of healthcare would probably be an understatement. 

These are uncertain times and “fear” is the dominant emotion, ruling the minds of people across the world. In the absence of a precedent and adequate data to rely on, decision making is one of the most challenging tasks today. Most governments across the world chose to freeze, as did most of the big businesses. However, the only profession, where decisions cannot be deferred is medicine. As doctors we do not have the luxury to defer and have to take split second decisions all the time. Decision making during Covid 19 pandemic is probably one of the biggest tests that all of us have had to face. 

At the beginning of the pandemic, surgical associations across the world were quick to act. Guidelines were drawn and circulated at a lightening pace. However, at the ground level, each of us have had to grapple with taking decisions on a daily basis and it has been a lonely exercise. Along with clinical dilemmas we have also had to deal with moral and ethical dilemmas. Should we be focusing on what could go wrong or refocus on what could go right? Would it be smarter to be pessimistic at this time than being optimistic? Could being optimistic be a liability at this time? How should we think about the future? What are the implications for patients and for surgeons? I have personally struggled with many of these questions over the last few months.

Taking a decision to get a surgery done is not an easy one. Patients and their families derive a lot of clues from the surgeon’s demeanour and body language which helps them to take these decisions. As I mentioned earlier, even the smallest of surgical procedures can lead to grave complications and rarely can even lead to mortality. As the complexity of the operation increases, so does the chance of having complications. Most patients and their families suffer from optimism bias and despite being informed about complications during a consultation, they tend to filter the information related to bad news. Hence the onus is on the surgeon to drive the point home. In an increasingly litigious environment, surgeons have to tread carefully on the fine line between being optimistic and being brutally honest.   

Well, the solution to this conundrum may probably be found in realistic optimism. I have always believed that surgery is a very humbling branch. While surgeons may be vested with the power to cure many diseases, all of us are well aware that however skilled and experienced we may be, we can never get to a hundred percent. We all know that failure can strike us at anytime. Sometimes it could be because of an unintentional mistake and at other times we just lose to the forces of nature. Law of averages eventually catches up with all of us some day. Despite this awareness, most of us choose to go on. We take all risks into account and perform new operations every day. Should we attribute this to heroism? I guess our non-surgical colleagues may agree to that. However, being a Bariatric Surgeon myself, I know that what drives us is not heroism, but optimism. Not just optimism, I would say that it is actually realistic optimism that drives most surgeons.

So, what is realistic optimism and how do we apply it to the surgical practice? How is it even more relevant in today’s times?

Optimism is a necessity. However, unrealistic optimism can sometimes be misconstrued as having a non challant and uncaring attitude. In worst case scenarios, unrealistic optimists may be treading on waters of denial. When it comes to surgery or taking surgical decisions this would translate into ignoring possible risks and complications and focusing only on the positives. In a scenario where things may not go our way, it comes as a shock to the patient and their family. Despite the good intent of the doctor/surgeon, this forms for a perfect setting for a litigation. During the Covid-19 pandemic not taking the added risk into account would border onto sheer foolhardiness.

On the other end of the spectrum is unrealistic pessimism. Unrealistic pessimists would go on to highlight the negatives much more than the positives. They would downplay the possible benefits of a particular procedure and focus a lot more on the side effects and complications. While it is important to keep our patients informed, it is also necessary to have some perspective. Treatments and surgical operations only come into common practice when their benefits are significantly more than the risks. No doctor deliberately wants to harm their patients but sometimes in trying to be honest we may tip over the scales to being too pessimistic. An over defensive doctor may unknowingly take away hope and push the patient into denying treatment. I would not shy away from saying that during this pandemic many of us have veered into the realm of unrealistic pessimism which may have unknowingly affected the disease outcomes for our patients. Only time will tell whether this was for good or bad.

This finally brings me to the middle ground and we all have to ultimately choose between being realistically pessimistic and realistically optimistic. Being realistically pessimistic is considered as a safe zone for certain professions and surgery is one of them. It is said to prepare patients and their families better for any eventuality. It also takes the onus of liability away from the doctor/surgeon. As surgeons we are an integral part of the tragedies of our patients and their families. Being realistically pessimistic helps us to maintain a certain degree of detachment which is necessary for our own survival. It prevents over involvement and protects surgeons as they venture into the unfamiliar territory of taking high stake decisions. Realistic pessimism is the sentiment which is ruling through the Covid-19 pandemic across all surgical specialties. There can be no arguments against it and in the present times, it is probably the most sensible way to proceed.

All said and done, doctors are human too. What ails the world today, ails us too. However, we also have to move forward and rise to the occasion to do right by our patients. We have to take the risks into account but ultimately, we have to move towards resilience. As we do this, we have to take our patients and their families along with us on the road to realistic optimism. While personal impact of negative outcomes can never be compared to statistics of complications, as doctors/surgeons we cannot take away hope from millions of patients. Just as patients must be made aware of all possible negative outcomes, they must also be made aware of the tangible benefits of the treatment being offered. Risk taking is a part of the journey towards a better life. As surgeons we become a part of this journey alongwith our patients. We have to help them to be able to objectively weigh the pros and cons and reach to a decision taken mutually for their betterment. Being realistically optimistic helps to ease the tension for a patient and their family and clear a partially cloudy disposition. At times carefully chosen words of optimism may be just the ice-breaker that was needed in order to reach to a life-saving decision.

Covid-19 pandemic is being considered as the Black Swan of 2020. Healthcare is at the forefront in this battle. As we wade through these troubled waters the need of the hour is to move away from panic and paranoia. We have to approach this challenge with increasing resilience and realistic optimism. We have no option but to become comfortable with ambiguity. None of us will be a hundred percent right or wrong in our decisions but ultimately whatever happens, in our hearts we must know that whatever we are doing is in the best interest of the people that we are serving.

Author: Dr. Aparna Govil Bhasker; MBBS, MS

Bariatric and laparoscopic surgeon, Mumbai

Email: draparnagovil@gmail.com

Mobile: +919819566618

A guest article contributed for Upsurge- Association of Surgeons, Nagpur.

HAPPY NURSE’S WEEK

Bariatric Surgery

As a young and inexperienced intern, my first surgical knot was taught to me by an OR nurse.

After I joined surgery, my first breathless day in minor OT was supervised by a senior nurse who could do the excisions and sutures seamlessly and took pride and interest in teaching the young ones in surgery (believe me no one even looked at us at that time).

As the only female PG in the whole surgery department, they were my best buddies, and after a long day in OR when no canteens would be open, I always knew where to look for food and always found it there without fail.

As I became a surgeon, their watchful eyes and insights during surgery helped prevent many a complications and I will always be grateful for that.

Always more systematic and always more dedicated, our nurses work silently day in and day out with the just one goal in mind and see to it that, “every patient on their watch gets the care that they deserve”.

Here’s to the innumerable cups of coffee, the shared tiffins and all the little and sometimes big favours that you have done to us!

Wish you all a very Happy Nurses Day!! We love you all! 

Metabolic surgery for treatment of Diabesity- A reality

Bariatric Surgery Blog Metabolic surgery Obesity Surgery Weight loss surgery

 

Dr. Aparna Govil Bhasker

Bariatric Surgeon, Mumbai

 

“A picture speaks a thousand words”.

diabetes care book

In February 2016, the cover page of Diabetes Care, one of the best international journals in the field of diabetes, carried a picture of a surgery being performed in the military hospital in the first world war. This was not only the first time, surgeons featured on the cover of a medical journal, but this entire issue was a special article collection dedicated to “metabolic surgery and the changing landscape of diabetes care”.

Quintessentially, diabetes has been a medical disease, traditionally treated with pills and injections. Metabolic surgery in mumbai for the treatment of type 2 diabetes is a novel concept that has come to fore in the recent years. In 1978, Dr. Henry Buchwald from Minnesota, USA defined metabolic surgery as the operative manipulation of a normal organ or organ system to achieve a biological result for potential health gain [1]. Today, the term metabolic surgery is typically used to describe surgical procedures to treat type 2 diabetes and other components of metabolic syndrome.

Though the concept is not very new and has been around for about 30 years now, medical community has been very slow to warm up to the idea of metabolic surgery. Way back in 1995, Sir Walter Porries from USA, published a provocative paper – “Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes” [2]. In the same year-“metformin”, the wonder drug of diabetes treatment was discovered. While metformin went on to be the most commonly used drug in the diabetes spectrum, metabolic surgery still remains one of the most underutilized treatment option. 

Lack of proper evidence has been cited as one of the reasons for the slow uptake of metabolic surgery. In addition to all the other evidence, in the recent years we have level 1 evidence in the form of eleven randomized controlled trials that have compared metabolic surgery with best medical management in overweight and obese patients. One hundred percent of these studies have shown that when it comes to over weight and obese patients, metabolic surgery is far superior in achieving glycaemic control [3]. In 2015, an Italian researcher compiled results of metabolic surgery in more than ninety thousand diabetic patients. In this study more than 71% diabetic patients achieved remission after metabolic surgery [4]. By remission, I mean that these patients had normal fasting blood glucose and HbA1c levels despite no medications for at least one year. Metabolic surgery has also been shown to lead to a significant improvement in high blood pressure and patients are six times more likely to reduce ≥ 30% of their blood pressure medications after surgery [5]. It is needless to say that metabolic surgery leads to an improvement in metabolic and inflammatory profile and decreases the long-term cardio-vascular risk in this patient population. With data and results available for almost one hundred thousand obese diabetic patients, I think it is time that we put the argument about lack of evidence to rest.

In 2015, a landmark meeting was held in London where 48 international scholars came together and formulated guidelines for metabolic surgery. It is important to note that out of 48, 75% of the voting delegates were non-surgeons. The voting panel mainly consisted of diabetologists, endocrinologists and physicians along with a few academic surgeons. These guidelines have been endorsed by 54 international societies across the world, many of which are diabetes societies. Diabetes India is one of them [6]. In 2017, the American Diabetes Association (ADA) accepted these guidelines as an integral part of management of type 2 diabetes [7].

The ADA guidelines for metabolic surgery are as under:

  • Metabolic surgery should be recommended to treat type 2 diabetes in appropriate surgical candidates with BMI ≥ 40 kg/m2 (BMI ≥ 37.5 kg/m2 in Asian Americans), regardless of the level of glycemic control or complexity of glucose-lowering regimens, and in adults with BMI 35.0– 39.9 kg/m2 (32.5–37.4 kg/m2 in Asian Americans) when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy.
  • Metabolic surgery should be considered for adults with type 2 diabetes and BMI ≥ 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans) if hyperglycemia is inadequately controlled despite optimal medical control by either oral or injectable medications (including insulin).

The ADA also acknowledged that obesity management delays the progression of pre-diabetes to diabetes and is also beneficial in treatment of type 2 diabetes. They also said that modest weight loss reduces the need for glucose lowering agents.

Despite great results, presence of evidence and guidelines from the ADA, metabolic surgery is not even being performed for 1% of the eligible patient population who stand to benefit from this. I believe that the biggest reason for this is lack of awareness. People are still not aware about the potential benefits of this therapy. I agree that surgery comes with a risk of anaemia, calcium and vitamin deficiencies but these are preventable with a good follow up and team approach. The advent of laparoscopy has reduced the mortality rate by ten folds as compared to open surgery and the overall complication rate after a Roux-en y gastric bypass is about 3.4% which is about the same as that of a gall bladder or a knee surgery. It is up to us to choose the trade off between preventable nutritional deficiencies and a low complication rate after surgery with potential complications of remaining obese and diabetic in the long term. Given a choice I would rather have my patients on multi-vitamin, iron and calcium supplementation rather than being on insulin or in worse cases kidney transplants, angioplasties, amputations etc.

There is also a contention that even after metabolic surgery, the weight along with diabetes comes back after a few years. Approximately one-third of the patients do experience a relapse or recurrence after a median 8.3 years. I would say that this is not bad at all. 8.3 years of disease-free interval has the potential to yield significant long-term cardiovascular benefits. Metabolic surgery is not an absolute “cure” but it does buy the patient almost a decade of good quality of life and has the potential to push back the expected complications of diabetes.

In conclusion, metabolic bariatric surgery in mumbai is a powerful tool for the treatment of obese diabetics. There is a substantial body of evidence that is showing that surgery on the GI tract yields better glycemic control in this patient population as compared to medical management alone. The role of gut in diabetes is being studied and is a hot topic across the world. Hopefully we shall have some tangible answers in the near future to explain the mechanisms behind diabetes remission after surgery. In the meanwhile, the medical community needs to break down walls and start building bridges so that the best possible therapy is advised to the patients. It is important to be cognizant of the burden that this burgeoning epidemic of diabesity is adding to our healthcare system. Diabetes and obesity are a deadly combination and although we cannot guarantee a cure, we can atleast endeavour towards getting a better glycemic control and quality of life. Metabolic surgeons and diabetologists/endocrinologists need to work in conjunction to provide the best treatment options to their patients.

Although it is true that ultimately it is He who heals, we as doctors must give our best to our patients.

 

References:

  1. Buchwald H. Metabolic surgery: a brief history and perspective. Surg Obes Relat Dis.2010 Mar 4;6(2):221-2.
  2. W J Pories, M S Swanson, K G MacDonald, S B Long, P G Morris, B M Brown, H A Barakat, R A deRamon, G Israel, J M Dolezal. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995 Sep; 222(3): 339–352.
  1. Viktoria L Gloy et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f5934
  2. Panunzi S, De Gaetano A, Carnicelli A, Mingrone G (2015). Predictors of remission of diabetes mellitus in severely obese individuals undergoing bariatric surgery: do BMI or procedure choice matter? A meta-analysis. Ann Surg 261:459–467
  1. Schiavon CA, Bersch-Ferreira AC, Santucci EV et al. Effects of Bariatric Surgery in Obese Patients With Hypertension: The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension). 2018 Mar 13;137(11):1132-1142.
  2. Rubino F, Nathan DM, Eckel RH et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care.2016 Jun;39(6):861-77.
  3. American Diabetes Association (2017) Obesity management for the treatment of type 2 diabetes. Diabetes Care 40:S57–S63

 

DR. APARNA GOVIL BHASKER- BEST BARIATRIC SURGEON IN MUMBAI, INDIAAbout Dr. Aparna Govil Bhasker

Dr. Aparna Govil Bhasker is an accomplished and renowned Bariatric Surgeon in Mumbai and Laparoscopic Surgeon.

Read more about Dr. Aparna Govil Bhasker- https://www.bestbariatricsurgeon.org/dr-aparna-govil-bhasker/  

Please write in to info@bestbariatricsurgeon.org or draparnagovil@gmail.com & Call/Text/WhatsApp: +919819566618 or +919930922761

Dr. Aparna’s website is- https://www.bestbariatricsurgeon.org

You can read her lovely blogs on- https://www.aparnagovilbhasker.com

Dr. Aparna Govil Bhasker is a visiting consultant at the following hospitals:

  • Gleneagles Global Hospital, Parel, Mumbai
  • Surya Hospital, Santacruz West, Mumbai
  • Hinduja Healthcare Surgical, Khar West, Mumbai
  • Apollo Hospital, CBD Belapur, Navi Mumbai
  • Suchak Hospital, Malad, Mumbai
  • Namaha Hospital Kandivali, Mumbai
  • Currae Specialty Hospital, Thane
  • MGM Hospital, Vashi, Navi Mumbai
  • Apollo Spectra Hospital, Tardeo and Chembur, Mumbai
  • Saifee Hospital, Mumbai

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Using bariatric surgery to fight obesity

Using bariatric surgery to fight obesity

Bariatric Surgery Blog Obesity Surgery Weight loss surgery

Dr. Aparna Govil Bhasker
Bariatric and Laparoscopic Surgeon

In the last week amongst the other patients I saw, there was one with a history of a stroke a few days back, one with a history of stroke, 2 years ago and a young lady with a condition called intracranial hypertension.

The one common factor between all three patients was, that all of them suffered from morbid obesity or clinically severe obesity, as it is called now.

The thing about obesity is that it is wrongly perceived as a sign of good health and a well to do economic status, atleast in India. However once people crossover from the overweight to the obese category, which is somewhere around a BMI of 29 to 30 or so, they tend to put on weight faster.

As the BMI continues to increase, obesity gradually starts affecting each and every part of the human body. Diabetes, high blood pressure and dyslipidemia are the big three that alongwith obesity form the metabolic syndrome. Eventually these together increase the risk of having cardiovascular events. Stroke is one of them.

Coming to the treatment part. Bariatric surgery is recommended for patients suffering from clinically severe obesity if their BMI is greater than 35. It can also be considered as a treatment option for patients with a BMI more than 32.5 with two or more associated diseases. As of now it is the only valid treatment option that leads to sustained weight loss in this patient population.

As a bariatric surgeon, I see many such patients on a daily basis. I also usually see that these patients and their families are very scared of getting the surgery done. There are many myths and many detractors who prevent these patients from getting treated on time.

Now here is the thing about treatment of any disease. Firstly, one needs to recognize that he or she is suffering from a disease. Secondly, get one or may be two expert opinions from qualified professionals and specialists about the best way forward. Thirdly, plan the entire process, prepare well and get it done. Last but not the least, dont delay the treatment. Every treatment works best in the early stages of a disease. Every single day that you delay, you are allowing the disease, time to grow and decreasing the chances of curing it.

Problems like stroke, heart related issues, embolism etc are life threatening complications of obesity. Dont let it grow to this extent.

Getting timely treatment can save your life and also improve your quality of life. Consult the right doctor at the earliest. Please dont miss the bus.

Dr. Aparna Govil Bhasker
Bariatric and Laparoscopic Surgeon

BARIATRIC SURGERY – Should Children Have It

BARIATRIC SURGERY – Should Children Have It

Bariatric Surgery Blog

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.

weightloss diet in mumbai, india

Quality versus Quantity Nutrition

Bariatric Surgery Blog Diet Obesity Surgery Weight loss surgery

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.

weight loss diet in mumbai, india

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.

Hypoglycemia

How to manage Reactive Hypoglycemia?

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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 after 2-3 hours there are higher chances of experiencing another episode of Hypoglycemia. This kind of meal or rather simple sugar induced Hypoglycemia is known as Reactive Hypoglycemia. After the ingestion of sugar/ sugary beverages there is a rapid increase in the insulin secretion. Insulin causes a rapid digestion and absorption of sugars and still remains in the blood eventually causing low blood sugar levels.

The symptoms include dizziness, fatigue, light headedness, sweating, irritability, confusion, blurred vision, heart palpitations, etc.

Here are some dietary tips to prevent and manage reactive hypoglycaemia,

  1. Avoid consumption of sugar, honey, jaggery, processed foods, bakery products (bread/ biscuits/ cookies/ toast/ khaari/ butter, etc).
  2. Add fiber rich foods like vegetables, pulses, sprouts, fruits to every meal in order to improve the quality of carbohydrates.
  3. Do not keep long gap between the meals. Eat a small snack in between the main meals.
  4. Ensure every meal is balanced with good quality proteins from milk, curds, paneer, soy and its products, egg, fish, poultry, meat, etc.

Reactive hypoglycaemia could be because of multiple other reasons (Eg. Post gastric bypass surgery) and can be managed with the same dietary modifications. In case it doesn’t resolve with the diet, you can check with your doctor for further medical management.