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One of the most pervasive, chronic diseases; Obesity is in dire need of new and updated strategies of medical treatments and prevention. Being a leading cause of mortality, morbidity, disability, healthcare utilization and healthcare costs around the world obesity’s high prevalence has always continued to strain the world healthcare system.
According to medical science obesity has been defined as excess of adipose tissue. There are different methods that exist to determine the excess fat tissue; the most common one of them is Body Mass Index which is also called BMI. An endocrine cell is a fat cell and an endocrine organ adipose tissue. A number of products are secreted by an adipose tissue like metabolites, cytokines, lipids, and coagulation factors. Increased levels of circulating fatty acids and inflammation are caused by significant, excess adiposity or obesity. This leads to an insulin resistance, which can lead to type 2 diabetes.
The biology of the food we eat is very complex, it involves smell, taste, texture, temperature, cognitive, emotional responses and metabolic and autonomic information. Which help in signaling the brain to either initiate or cease eating. Several substances act on the brain signaling the need for an increase in intake of food. Same way, there are other substances as well that signal the brain to decrease its food intake. Obesity affects more than one-third of the world’s adult population around 278.6 000. The number of people with obesity has increased over the years. Today, 69 percent of the adults around the world have been categorized as obesity or having excess weight.
According to a report, there are 114,000 excess deaths every year associated with obesity. Obesity includes risk for around more than 30 chronic health conditions. These include:
· type 2 diabetes
· high cholesterol
· heart disease
· fatty liver disease
· sleep apnea
· stress incontinence
· heart failure
· degenerative joint disease
· birth defects
The healthcare costs of adults around the world with obesity is approximately $200 billion every year. People with obesity are discriminated and are made fun of around the world.
Obesity has been increasing around the whole world. High body mass index has started to now rank with major health problems globally like childhood under-nutrition, high blood pressure, high cholesterol, unsafe sex, iron deficiency, smoking, alcohol and unsafe water.
For people who are obsessed, weight loss means lifestyle changes that would be difficult to achieve and would be even more challenging to be able to maintain.
Obesity occurs when a person’s body consumes more calories than it should be burning. Although overeating and under-exercising, resulting from a lack of will power and self-control are significant contributing factors, but according to doctors obesity is a complicated medical problem that has genetic, environmental, behavioural, and social factors involved as well.
Research has shown that in certain cases, certain genetic factors might be responsible for causing the appetite changes and fat metabolism that is responsible for causing obesity. For a person who has been genetically prone to weight gain and for a person who has been leading an inactive and unhealthy lifestyle has a high risk of being obsessed.
Although a person's genetic makeup might be responsible for obesity, it isn’t the primary cause. Consumption of excess calories from foods with high levels of fat and doing little or no physical activity daily over a long period of time would lead to gain in weight. Psychological factors are also responsible for obesity. There are certain medical conditions like binge eating disorder, like cushing’s disease or polycystic ovary syndrome would lead to gain in weight and obesity. Binge eating disorder is a disorder where a person would be having recurrent episodes of binge eating. In binge eating disorder, a person goes on eating a large amount of food very fastly and would still feel a lack of control over his eating.
Defining Body Mass Index
Body Mass Index is defined as a mathematical calculation that involves height and weight, irrespective of the person’s family history, his gender, his age or his race. Body Mass Index is derived either by dividing the person's body weight in kilograms by their height in meters squares or by using the conversion with pounds and inches squared. This is frequently used to study population because of it is easy to determination and because of it’s well-supported association with mortality and health effects. But, there are other measures as well for excess adipose tissue, like waist circumference and waist-to-hip ratio.
Indian Medical Council in case of Obesity describes two main approaches that weight loss surgery should be taking to achieve change:
· Restrictive procedures that would lead to decrease in food intake.
· And procedures that would alter digestion, therefore cause the food to be poorly digested and incompletely absorbed so that it is able to be eliminated in the stool.
1. Sleeve Gastrectomy
This is a minimally invasive procedure that helps in reducing the size of the stomach, which reduces the amount of food a person can eat.
During this surgery, a surgeon creates a thin vertical sleeve of stomach which is the same as the size and the shape of a banana. It has a stapling instrument with it in order to be able to permanently reduce the size of the stomach. This is not reversible because the remaining portion of the stomach has been removed. This is a simple surgery because there is no rerouting or reconnecting the intestines.
· Sleeve Gastrectomy reduces the amount of food that a person can eat in one single sitting.
· Because there is nothing that has been rerouted therefore it is still possible that vitamins and nutrients would still be absorbed by the body.
· Because there is no artificial device that has been implanted therefore there are no adjustments that need to be done after the surgery.
· Around more than 55 percent of the excess weight is lost.
Just like any other surgery, there are risks with this surgery as well. Some of them are:
· Tissue getting separated t stapling site
· Problems related to indigestion like bloating, gas, and pain which is called dyspepsia
Combined Restrictive & Malabsorptive Surgery
Understanding clinical procedures in a better way has led to combining of restrictive and malabsorptive approaches and increase in the choices of weight loss surgeries that have become effective for thousands of patients. Adding malabsorption, delays the mixing with bile and pancreatic juices which help in the absorption of nutrients. This results in a feeling of fulfillment, along with this there is a sense of satisfaction as well which reduces the desire to eat more.
According to Bariatric Surgeons, Roux-en-Y gastric bypass is currently the go-to procedure for weight loss surgery. It is considered as one of the most often performed weight loss surgeries around the world. In this surgery, stapling is responsible for creating a small stomach pouch. The remaining stomach is not removed though, but is completely stapled shut and divided from the stomach pouch. The outlet protruding out from this pouch which has been newly formed is directly emptied into the lower portion of the jejunum, therefore bypassing absorption of calorie. This is done so that when the small intestine is divided just beyond the duodenum a connection with the newly formed stomach pouch can brought up and constructed. Into the side of the Roux limb of the intestine the other end is connected creating the "Y" shape. It is possible to increase the length of either segment of the intestine in order to produce different of malabsorption; higher or lower level they might be.
Advantages of Combined Restrictive & Malabsorptive Surgery
· The average excess weight that a person is able to lose after the procedure is done is usually higher in a patient than with purely procedures that are restrictive.
· One year after surgery, weight loss is able to average 77 percent of body weight that is excess.
Laparoscopic Adjustable Gastric Band
The Laparoscopic Adjustable Gastric Band System is a silicone elastomer ring that has been designed to be specially placed around the upper part of a person’s stomach. On the inner surface it is filled with saline. This helps in creating a new small stomach pouch that leaves the larger part of the stomach much below the band so the food storage area in the stomach can be reduced, whereas the pouch that is above the band is able to hold only very small amount of food. The band is also responsible for controlling the stomach outlet between the stomach’s two parts. To regulate the flow of the food from the upper to the lower part of the stomach the size of the stoma is responsible. A person feels full sooner and has a feeling of satiety if the stoma is smaller. So that the person is not hungry between meals. The band is connected by connecting a tube to an access port that has to be placed beneath the skin during the time of the surgery. Later on, the stoma size can be changed by the surgeon through the access port either by adding or by subtracting saline inside the inner balloon. The rate of weight loss is driven by the adjustment process. Like for example if the band is too loose and weight loss is too inadequate, then by adding more saline the size of the stoma can be reduced in order to further restrict the amount of food that is able to move through it. In case if the band it too tight, then the surgeon would have to remove some saline in order to loosen then band and would have to reduce the amount of restriction.
· The restrictive procedure can help in reducing the amount of well-chewed solid food that enters and passes through the digestive tract in the usual order. That allows the nutrients and vitamins (as well as the calories) to be fully absorbed into the body.
· There is no need to cut or staple the stomach or bypass the intestines therefore eliminating an operative risks related to the bypass surgery.
Biliopancreatic Diversion helps in removing around half of the stomach in order to produce restrictions both on food intake and reduction of acid output. It leaves upper stomach that much enough to maintain a proper nutrition. Then the small intestine is divided attached with one end to the stomach pouch in order to create an alimentary limb. This helps to let all the food move through this segment; but a lot of the food is not absorbed though. The bile and pancreatic juices then move through the biliopancreatic limb, which has been connected close to the end to the side of the intestine. This helps in supplying digestive juices in the section of the intestine that is called the common limb. The surgeon can vary the length of the common limb in order to regulate protein, fat and fat-soluble vitamins’ amount of absorption of.
Extended Gastric Bypass
This is a small gastric pouch that leaves the remainder of the stomach in place. A long limb of the small intestine has to be attached to the stomach so that the bile and pancreatic juices can be diverted. Gastric pouch size and the length of the bypassed intestine are responsible for determining the ulcers, malnutrition risks.
This procedure is restricted only to the outer margin. It leaves a sleeve of stomach with the pylorus and the beginning of the duodenum at its end. The first portion of the small intestine is the duodenum. The duodenum is divided in such a way that that pancreatic and bile drainage are both able to be bypassed much easily. Then after that to the duodenum’s beginning the alimentary limb is attached, whereas the common limb is created in the same way.
Advantages of Biliopancreatic Diversion
1. The major advantage of Biliopancreatic Diversion is that the degree the patient feels highly satisfied because of the reason that he is able to have larger meals when compared with other procedures like purely restrictive or gastric bypass procedure.
2. It can helping in the production of high amount of losing excess amount of weight because it is able to provide the highest levels of malabsorption.
3. Maintenance of excess body weight loss in long term can be successful if the patient is able to adapt and adhere to a strict diet, supplements, exercise and a behavioral regimen.
Risks of Biliopancreatic Diversion
1. There is a period of intestinal adaptation for all malabsorption procedures when bowel movements are very liquid and frequent. Over the time this condition might lessen, but might be a permanent lifelong occurrence.
2. There are chances of abdominal bloating and malodorous stool or gas occurring.
3. Changes to the intestinal structure might result in the increasing the risk in the formation of gallstone and might even lead to the need to remove the gallbladder.
4. Intestinal irritation and ulcers can be caused by Re-routing of bile, pancreatic and other digestive juices beyond the stomach.
Orbera Gastric Balloon
Orbera Gastric Balloon is a procedure which is short termed. In this a spherical saline filled silicone balloon has to be placed in the stomach by endoscopy. It has been designed in such a way that it occupies a portion of stomach which helps to reduce gastric volume and to delay gastric emptying. This procedure reduces the amount of food that is required in order to feel full therefore assisting in reduction of calories. People who undergo Orbera Gastric Balloon and are successful tell by their experience that they have lost around 20% of their total body weight. This whole system though remains in place only for 6 months so weight loss can be jumpstarted and then must be removed.
Laparoscopic or Minimally Invasive Surgery
During a laparoscopic operation, in the abdomen a small video camera is inserted. And on a separate video monitor the surgeon views the surgery .
Through small incisions made in the abdominal wall, camera and surgical instruments are inserted. This approach is less invasive because of the reason to open the abdomen that it is able to replace the need for one long incision. After surgery patients who’ve had laparoscopic weight loss surgery experience less pain which results and helps to breathe easily. It also improves lung function and higher overall oxygen levels. Other realized advantages of laparoscopic surgery are that there are fewer wound complications like infection and hernia.
Obesity in India
India, still a developing nation that is struggling with poverty, malnutrition, and disease, now has the second highest number of obese children in the world, at 14,00, 000. A recent study spanning 195 countries and territories from 1980 through 2017, published in India Journal of Medicine ascertained that 2 billion children and adults all over India, were struggling with obesity. Of the 600 000 adults grappling with obesity, Delhi topped the list with 79 000 obesity-afflicted people, followed by Mumbai with 57 000 people. However, in the case of the nearly 108 000 children, Bangalore leads with 15 000 obese children, shadowed closely by India at 14 000.
Obesity in India differs from the rest of the world. Indian obesity is marked by the ‘Thin-Fat Indian Phenotype’. This essentially refers to a markedly higher proportion of body fat, abdominal obesity, and visceral fat in the Indian population, as compared to our Chinese and American counterparts. Hence, world obesity generally reported in terms of waist circumference, and a BMI beyond 30, significantly underestimates the prevalence of obesity in India. Therefore, Indian obesity must be estimated according to a lower threshold of BMI 25. Additionally, even a normal BMI of up to 23, might show higher instances of isolated abdominal obesity.
Data released by the World Obesity Federation, a community of organizations dedicated to solving the problem of obesity, shows that the percentage of Indian adults living with obesity is set to jump to around 5% by 2025, from 3.7% in 2018. Our genetic predisposition for high lipoprotein(a) levels predisposes us to a higher risk of developing diabetes mellitus, cardiovascular diseases, and death, particularly at a younger age than the rest of the world. With India still struggling against rural malnutrition, the rising threat of urban obesity serves as a double-edged sword.
What are the causal factors?
The main culprits of the obesity epidemic are an inactive lifestyle and unhealthy diet. But, genetic factors also play a significant role. This is supported by the ‘Thrifty Gene Hypothesis’ put forth by Neil Gupta, which suggests that periods of famines in human evolutionary history resulted in a favoured selection of a thrifty genotype which led to highly efficient fat storage during periods of abundance.
Additionally, the traditional diet of India is rich in carbohydrates, with large quantities of rice in the coastal regions, chappatis in the interiors, and heavy consumption of bread all over. The widespread availability of fried and unhealthy fast food, adds empty calories to the diet. With Indians caught between these two carbohydrate-rich diets, it is no wonder that obesity is on the rise in the country.
Moreover, it has been observed that the higher people belong on the social ladder, the lesser physical work they perform. However, this is best perceived amongst the middle class who still view a ‘healthy’ body structure as a reflection of prosperity. The upper class, with an increased disposable income, are far more conscious of their health and maintain an active lifestyle. It has become imperative for people to bring their weight under control before they hit age 40. As the years pass, a person’s metabolism slows down, leading to accumulation of fat, making it increasingly difficult to achieve any sustained weight loss.