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Alarm over quick-solution weight surgery

New Delhi, Oct. 7: A week after her 27th birthday, after a decade of eating in abundance and few thoughts about gaining weight, Alisha opted for surgery to fight obesity, a procedure involving her stomach that would make her eat less.

She recalls her typical diet before the operation — six buttered parathas or eight puris for breakfast, a large sandwich or four vadas at about 11am, a large plate of rice and curries for lunch, three bread pakoras or two full packets of orange-cream biscuits at teatime, then rice, chapatis, more curries and vegetables for dinner, chicken thrice a week.

She also had vanilla ice cream and sweets — jalebis, barfees or laddus — four or five times a week.

“Food had become my hobby,” said Alisha, a health care sector professional in the capital, who requested that her name be changed for this report. “Now, the cravings for food are gone — now I feel full after only half a chapati or three spoons of rice.”

Bariatric surgery — the procedure that Alisha underwent — has gained popularity in India, with surgeons estimating that between 10,000 and 12,000 patients opted for the procedure in 2013, compared with fewer than 100 patients a decade ago.

The rise in numbers, doctors say, seems to be driven by a combination of factors — growing medical evidence that bariatric surgery can help tackle obesity as well as provide relief from uncontrolled diabetes, patient-to-patient recommendations, and high-profile patients. Union ministers Nitin Gadkari, Venkaiah Naidu and Arun Jaitley are among patients who have undergone bariatric surgery.

Medical studies have indicated that bariatric surgery is an effective and durable treatment for type-2 diabetes in obese patients, and enable all such patients to become free of insulin dependence and many to become free of other diabetic medications three to five years after surgery.

“It’s a last-resort option for patients for whom diet and exercise don’t work, but should be an early option for patients with morbid obesity and uncontrolled diabetes,” said Anoop Misra, the chairman of the Fortis-Centre for Diabetes Obesity and Cholesterol, New Delhi.

In a typical bariatric procedure, surgeons create something called a Roux-en-Y gastric bypass that restricts food intake to a small pouch, and sends the food directly from the pouch into the small intestine. This also decreases how food is absorbed.

Before her surgery, Alisha, although otherwise healthy, weighed 120kg and had a body mass index (BMI) — weight in kilograms divided by height in metres squared —above 44. Two months after surgery, her weight has dropped to 101kg and, she has been told, with a well-maintained diet, it could drop over the next year to 70kg.

“Extreme obesity can be a life-threatening condition,” said Pradeep Chowbey, a bariatric surgeon and executive vice-chairman at Max Healthcare, New Delhi. “It can harm the liver, threaten the heart, cause joint problems, or diabetes and thereby damage the kidneys.”

Medical guidelines prescribe bariatric surgery to Indians with a BMI of above 32.5 if they have other associated illnesses such as diabetes or high blood pressure, and above 37.5 even when they have no illnesses.

“At times, the BMI alone is not a good indicator as many Indians have diabetes even with relatively lower BMI values,” said Muffazal Lakdawala, a bariatric surgeon at the Centre for Obesity and Diabetes Surgery, Mumbai.

While doctors encourage overweight and obese patients to shed weight through diet and exercise, many patients find it hard to sustain weight loss over long periods of time.

“Achieving weight loss through diet and exercise alone becomes particularly difficult when patients are above 100kg or 110kg,” said Arun Prasad, a senior consultant surgeon at the Apollo Indraprastha Hospital, New Delhi. “Many patients try, but how many can maintain the regimen through a lifetime. Any deviations, and the weight rebounds back. Some patients may also have mobility issues, they just cannot exercise adequately enough.”

But sections of medical professionals aren’t comfortable with the steep rise in numbers.

“In some patients, it could indeed be a life-saving surgery, but it has also become a quick solution to people who don’t want to take the trouble of going on diet and doing adequate exercise long enough,” said Deepika Aggarwal, a senior consultant nutritionist in the capital.

Patients who undergo bariatric surgery, she said, in any case need to maintain a strict diet after surgery. “With the right levels of determination, obese patients can lose up to 40kg through diet and exercise alone,” she said.

Some physicians also argue that the long-term effectiveness of bariatric surgery has not been adequately established yet. “There is an urgent need for well-designed randomised controlled trials to assess the long-term usefulness of this procedure,” Jagjit Singh, an assistant professor at the Government Medical College, Chandigarh, wrote in a letter to the British Medical Journal last year. “Or else, it may turn out to be yet another ‘cure worse than disease’ situation.”

But surgeons assert that a bariatric procedure is prescribed only when required. “This is not cosmetic surgery. Through the control of obesity and diabetes, this procedure can improve the quality of life and increase the life expectancy of patients,” said Prasad.