Obesity and its comorbid disorders are leading causes of morbidity and premature mortality around the world. Obese persons are also vulnerable to low self-esteem and depression because of the psychological and social stigmata that can be associated with obesity. Obesity is recognized as a chronic condition resulting from an interaction between environmental influences and an individual's genetic predisposition to weight gain.
Who is Obese? Any person who’s BMI is above 30 is considered Obese.
Normal Body mass index is between 18 & 25
Overweight: BMI 25 - 30
Obese: BMI >30
Severe Obese: BMI >35
Super Obese: BMI>50
What is BMI?
BMI or Body Mass index is weight of a person (in Kg) divided by Height (in metre) squared. This is much more accurate measurement than just the weight for ones height.
Why does obese person need to loose weight?
Obesity results in a lot of complications – respiratory problems resulting in feeling sleepy and lethargic; Sleep Apnoea where you cant sleep lying down and may stop breathing; asthma; heart problems like angina, heart attack, High blood pressure; strokes/paralysis; Diabetes; Gall stones; Joint problems/Arthritis because of severe wear and tear causing severe back, knee and ankle pains, cancers of breast, ovary, endometrium, prostrate, DVT/pulmonary embolism etc. The obese people are likely to die early compared to non-obese. This is in addition to the Low morale and lack of confidence that results from the psychological aspects of obesity.
Do my problems get better if I loose weight?
Yes. Majority of the problems get reversed or are easy to control. Sometimes you may develop gallstones as you lose weight. You may not alter the problems like arthritis etc that have set in.
Is the obesity alone the problem in an obese person?
Not so. It is the lack of motivation and lack of exercises that bring you down.
Why can’t I lose weight?
The problem with majority of the obese is they eat more than they require. One feels hungry all the time and doesn’t feel full at all. Obese person is basically a ‘compulsive eater’ and has no control. There is a problem with the Satiety centre in the brain. Various genes have been implicated. In the majority surgery is needed to help one to reduce the weight. ‘Eat less and do exercise’ are the two key ingredients needed to reduce weight. The first one doesn’t have control and the second is difficult to practise before one loses weight because of joint pains etc.
Are there any methods other than surgery to help lose weight?
Yes. Dieting, Drugs and exercises. You would have tried dieting already and might have been unsuccessful. You might have tried various diets. Sibutramine and Orlistat are the commonly used drugs.
1. SIBUTRAMINE is a selective inhibitor of the reuptake of both serotonin and norepinephrine and is used more widely since the discontinuation of fenfluramine and dexfenfluramine. It induces both decreased food intake and increased thermogenesis. It acts centrally to reduce energy intake by inducing a feeling of satiety after eating, and it also limits the decline in metabolic rate that typically accompanies weight loss.
A meta-analysis demonstrated that sibutramine-treated patients are 3 times more likely to achieve between 5% and 10% weight loss than placebo-treated patients who received the same diet and exercise advice. The Sibutramine Trial of Obesity Reduction and Maintenance study showed that approximately 43% of the obese patients treated with sibutramine, diet, and exercise maintained 80% or more of their initial weight loss(in 6 months) at 2 years compared with 16% following diet and exercise regimens alone.
2. ORLISTAT, an inhibitor of pancreatic lipase, decreases fat absorption in the intestine. Orlistat blocks digestion of approximately 30% of ingested dietary Triglycerides and has been shown to achieve a weight loss of approximately 10% (compared with approximately 5% in the control group). Since the induction of fat malabsorption is its basis of action, however, steatorrhea (oil leak, incontinence, smelly fatty stools) is a common adverse effect if enough fat is ingested during a meal.. Orlistat use has been associated with reductions in fat-soluble vitamin levels (vitamin D and E); vitamin supplementation is recommended.
Orlistat has been found to enhance weight loss in a primary care setting and long-term maintenance of weight loss. Data indicate that orlistat plus diet promote significantly greater weight loss than diet alone in obese patients with type 2 diabetes treated with Metformin, and that weight loss achieved with diet plus Orlistat improved glycaemic control and other cardiovascular factors.
When is Surgery needed?
NICE (National Institute of Clinical Excellence) suggests Obesity Surgery is beneficial to people with
BMI >40 or BMI >35 with comorbid factors eg. Diabetis, hypertension, joint problems, breathing problems
How is surgery going to help?
There are 2 types of procedures: A. Restrictive and B. Restrictive & Malabsorptive (Bypass):
A. Restrictive Procedure:
Restrictive procedures restrict the food intake. It is going to help only if you are going to comply with the advice of the doctor. You have to take small meals and do a lot of exercises. You feel full because the size of the stomach is reduced to less than a fist size and the food lodged in stomach doesn’t move because of the size of the stomach pouch; food stretches the stomach and sends the signals to the brain that stomach is full and you don’t need any more food. Gastric Stimulator works with a principle of causing satiety.
B. Combined Restrictive & Malabsorption Procedures:
Here food intake gets restricted to an extent because of the small size of the stomach but the main way it works is food goes straight from stomach to the small bowel without any delay and without being digested for a long distance; this causes malabsorption if one tries to eat too much or take fatty foods or sweets. This results in metabolic disturbances if you are not careful and therefore you need to be constantly monitored by a physician/surgeon to correct any electrolyte and vitamin deficiencies especially calcium, iron and Zinc and B1, B12, A, D and K. This type of operations are usually reserved for people whose BMI is beyond 40, ‘sweet eater’, ‘binge eater’, compulsive eater or on patient’s choice. These types of operations could be still performed if the restrictive procedures are not successful. These are now used more and more again because of the sustained good weight loss.
What Restrictive procedure can I have?
1. Generally Laparoscopic Adjustable Gastric Banding is performed because it is adjustable, reversible and simple to perform. 5 small holes are made in the abdomen. A silicone Band is applied around the stomach laparoscopically (key hole method) and locked into place. This divides the stomach into 2 parts – one very small pouch of 20cc (less than a fist), which leads through the narrowing caused by the band into the second large part of the stomach. The band has a sleeve underneath which is connected by a tubing to a port. This port is kept underneath the skin over left lower ribs. 2. Laparoscopic Sleeve Gastrectomy, where ¾ of your stomach on the greater curve side is removed making your stomach very narrow and restrictive. Increasingly surgeons are performing this as no foreign body is used and there areno problems once stomach heals. This is done on its own or as first stage of Duodenal Switch
How does the gastric band work?
Food gets settled in the small part of the stomach after passing through oesophagus (gullet) and doesn’t go easily into the large part of the stomach. If this goes easily then the band can be tightened by inflating the sleeve inside the band, which is connected by tubing into a port that is kept underneath the skin. The food lodged in the small part of the stomach gives the feeling of fullness as it stretches the small part of the stomach: this signal goes to the brain satiety center and the brain tells you that you don’t have to eat any more as you no longer feel hungry.
What Malabsorption Procedures can I have?
There are mainly two procedures:
Laparoscopic Gastric Bypass (RNY): The stomach is divided into two parts and the small stomach pouch available for food is joined to the small bowel, bypassing the rest of the stomach and the duodenum. The bile and pancreatic juices are not allowed to contact the food until low down in the small bowel. This way the food is restricted and also malabsorbed if one wants to eat more or take the stuffs they shouldn’t.
Laparoscopic Duodenal Switch: Here 70% of the stomach is removed (Sleeve Gastrectomy) but the continuity of the gut is preserved until a few centimetres of Duodenum which is divided and connected to the Small bowel; the biliary/pancreatic diversion is done about 125 cm from the large bowel (caecum). This is a modification of the old Biliary Pancreatic Diversion (BPD) without its problems of stomach ulceration, severe dietary deficiencies and severe dumping because of the preservation of the alimentary route of stomach, pyloric sphincter (valve) and part of Duodenum.
How much weight do I lose?
Restrictive Procedures: You lose about 45- 55% of your excess weight over 3 years. You will maintain that weight after that. Say your normal weight should be 60kgs but you weigh 120kgs. The excess weight is 60kg. Half of it is 40 kg. You should weigh about 90 kg after operation. There is about 25% failure rate i.e losing less than 25% of excess weight.
Malabsorption Procedure: you lose about 70-80% of your excess weight over 3 years. You lose your weight rapidly compared to the restrictive procedures.
What are the advantages of the Key Hole (Laparoscopic) Surgery compared to the conventional Open surgery?
In Open Surgery, the large cut made over the front of the abdomen (tummy) to approach the stomach causes a lot of pain. The recovery is slow. Many times you may have to be ventilated for a day or two if you don’t breathe well after the operation. There is risk of the stitches giving way causing the bowels to come out (abdomen bursts) or the wound gives way slowly over a period of time resulting in a large hernia (Incisional hernia). As you lie in the bed for a longer period you are prone to DVT (developing a clot in the leg veins as one can develop in long flights if they sit and don’t move) and pulmonary embolism (clot going into lungs), which can be fatal.
In the Key Hole (Laparoscopic) obesity surgery, one gets up quickly within a couple of hours and moves about, as there is very little pain because of 5/6 small holes made in the abdomen. One can go home in a couple of days after gastric banding and 3-5 days after Bypass surgeries. The complication rate is much smaller for the gastric banding but slightly more for the Bypass surgeries. Conversion to an open surgery is resorted to only for complications that cannot be sorted out laparoscopically
What do I have to do after the operation?
1st Month: You will be on a liquid diet (almost water thin) of about 800 Calories for a month after the operation.
A. Gastric Band: This is to prevent any vomiting, which may result in disruption of the stitches that keep the band in position That results in the stomach slipping through the band and causing a pouch; this results in continuous vomiting and you cannot keep anything down until the band is removed or unlocked by surgery again.
B. Gastric Bypass (RNY), Sleeve Gastrectomy & Duodenal Switch: This is to prevent disruption of stitches resulting in anastamotic leak which is a very serious complication.
The liquid diet (that you take in a day) consists of fat low fat yogurts (as much as possible), skimmed milk (dairy and vegetable), and lots of soups with a little oil, pureed and liquidized fruits and boiled vegetables. Avoid fizzy drinks. Avoid bread in the first couple of months.
2nd month: You start with soft diet. Avoid bread all together for another month as it sticks and doesn’t move. Slowly introduce solid diet. Take small amounts: a fist size only at any time. You don’t drink any water or any fluids along with food. You wait for half an hour before you drink any liquid. You should not force food. You feel full with a small amount of food and you don’t feel hungry after that. You have to eat only 3 times a day at this rate. Do not eat snacks in between meals. Eat slowly and chew well. You should drink at least 2 - 3 litres of fluid a day. You should stick to low fat high protein diet. You should stop taking any chocolates or any concentrated sweets, rich cakes, pastries, pies and chips (In bypass and Duodenal Switch they cause diarrhoeas; so you are forced to consume less of this type of food). Avoid high calory soft drinks and beers (these have a lot of calories). Your day’s food should consist of Fruits, vegetables, salads, a slither of butter/cheese at the most, skimmed milk/low fat yogurts (1/2 a litre), meat or fish, a lot of fluids (2 litres of water, tea, coffee etc. with very little sugar). Chew your food well. Avoid bread until you feel food goes down easily.
How long do I have to stay in the Hospital?
Usually 1 nights after Lap Gastric Banding and 3 - 5 days after RNY, Sleeve Gastrectomy and Duodenal Switch.
When do I go back to work?
Usually after 2 weeks. But you could walk by 2nd day and do brisk walks by 2nd week.
Exercises: You should build up exercise activity until you can do these exercises comfortably. Exercise for at least half an hour a day. This should keep you fit and keep your weight steady. Exercises are crucial to prevent osteoporosis and tone up your muscles. It gives you a feeling of well being.
When should the band be tightened?
If you feel that the food you are eating is going easily without any problem and you are able to eat more food, then the band should be tightened.
What are the long-term problems of having the band?
1.Pouch formation, 2.wound/Port infection, 3. twisting/snapping of port and 4. Erosion of the band into the stomach. All of these need surgical intervention to correct the problem.
Do I need ‘follow up’?
As stated earlier you need a constant supervision by your own doctor, metabolic physician, surgeon or a combination of the three to prevent nutritional problems. It is a life long commitment.
Do I need plastic surgery?
You may or may not, depending on how much you lose weight. The abdominal (tummy) skin may become very lose and may need ‘tummy tuck’ i.e. removing the excess flabby abdominal skin. Some may need ‘thigh tuck’ to remove the excess flabby thigh
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