How Bariatric Surgery is the most effective method to combat both
Morbid obesity has become an epidemic creating a problem not only for the health of individuals but also affecting the healthcare budget of governments across the world. The world has become more obese of people today than ever in the past. More than 1/3 of the population of the United States is obese. When it comes to the number of obese in its population, today India is behind only the United States and China. The World Health Organization estimates that by 2022, the number of obese children will outnumber severely undernourished ones, globally. The incidence of diabetes mellitus (especially type II) has risen commensurately with the incidence of obesity that along with hypertension and dyslipidemia lead to a rise in Metabolic syndrome.
A host of other diseases linked directly to obesity include not limited to T2 Diabetes Mellitus, Sleep Apnea, Osteoarthritis, GERD, Gallstones, Gout, Infertility, Cancers etc. Type II Diabetes Mellitus is a disorder of insulin resistance due to excess of fat, which is secreted in excess quantity and lack of insulin sensitivity in the liver.
Over a period of time, sugar levels in the blood increase because of diabetes that can result into numerous problems such as heart diseases, blindness, kidney disease, foot gangrene etc. This occurs due to hardening and blockade of the smaller blood vessels pumping blood in and out of the various organ systems in the body.
Hypercholesterolemia and Hypertension! Can obesity be blamed?
The Guyton hypothesis indicates that obesity route to a change in the usual salt balance mechanism at normal blood pressures. Usually, salt balance in the normal body is maintained by the kidney which increases salt and water retention, while it reduces the same at advanced blood pressures. In obesity, there is excess salt and water retention and lower excretion through the kidneys even when the blood pressure is normal.
Obesity also leads to sympathetic stimulation and alteration in the leptin (a hormone produced by fat) pathway, thus an increase in blood pressure.
The role of leptin is to signal the mind ‘that you are full and encourages one to stop eating’. Leptin usually compels energy intake and upsurges energy expenditure, by causing activation of the sympathetic nervous system, which causes increased production of body heat by raising the heart rate, blood pressure etc.
However, in leptin resistant individuals, higher leptin levels cause sympathetic activation, without the anti-obesity benefits. Persistent sympathetic activation due to high leptin levels leads to an increase in blood pressure, secondary to obesity. This can easily be controlled by medications, but the only cure to this problem is sustaining weight loss!
Obesity is a severe life-long, life threatening disease with few options available for sustained weight loss with health benefits in the long term. Diet alone or in conjunction with exercise seems to fail in more than 98% of people with morbid obesity. Drugs like Orlistat flop to achieve substantial weight loss. Whereas, the FDA approved drugs namely Liraglutide, Phentermine, Topiramate, Phentermine are either too costly or often not available in India and cause restricted weight loss in a few chosen patients. In such scenarios the Metabolic Surgery is left to be the only medically approved choice for constant weight loss.
Bariatric/metabolic surgery leading to resolution of co-morbidities such as diabetes mellitus, hypertension etc. along with weight loss
It largely depends upon the number of surgeries. A lot of bariatric surgeries are done with confine caloric consumption. This cuts down the insulin resistance from fat cell mass and rises the sensitivity of every organ to insulin. However, insulin can excellently use carbs and bring down fat if required by the body resulting to reduce the amount of body excess fat content.
Evading the foregut in gastric bypass surgeries, also has the additional benefit of reducing the transit of food through the duodenum and proximal jejunum (small intestine). This prevents the release of a putative signal which may be responsible for lack of insulin sensitivity and diabetes mellitus.
Can this be continued in the long-term?
Short and transitional term results are inspiring. Short-term resolution of diabetes mellitus sums up to 80-95% of all patients. Intermediate term remission of diabetes varies from 60-75% of patients. Repeated diabetes is less severe and has lesser side effects on end organs such as kidney, heart, eye, legs etc. Due to poor devotion to nutritional supplementation, insufficient physical activity and poor diet control post-surgery, leads to 20-45% patients regain some weight in the long term.
To conclude, obesity is a harsh reality of this century. Coupled with Type II Diabetes Mellitus, it is the most severe life threatening and costly epidemic. Non-surgical approaches have a few limited possibilities. Metabolic surgery/ Bariatric surgery remains the sole hope for a healthier future of those with diabetes and obesity.
About the Author
Dr. Muffazal Lakdawala
Founder & Chief Surgeon – Digestive Health Institute