It has always been a given for generations that ‘once a diabetic, always a diabetic’. Absolutely like the truism for high blood pressure, asthma and hypothyroidism. You know that if you are unlucky enough to get these labels stuck on you, you are going to take pills or injections all your life and suffer the disease as it progresses into making each organ weaker than ever before. No more.

Riya, a plump 50-year-old diabetic who was taking insulin injections for many years, was fed up of her lifestyle and the fact that she was developing complications of diabetes and high blood pressure. Being highly educated, she searched the Internet for newer options. Every website she visited mentioned high cure rates after gastric bypass surgery. She came to us at Belle Vue Clinic, where we did the same surgery on her (keyhole method). Riya’s blood sugar, always in the high 300s, normalized immediately after her surgery. Discharged after a couple of days, she joined back her school in a week, no longer worried about her blood sugar. Her colleagues are now asking her about her secret – how did her weight and blood sugar get under control so quickly?

In 1994, an American doctor called Walter Pories published a scientific paper provocatively titled, “Who would have thought it? An operation is the cure for Type II Diabetes Mellitus!” This paper showed the astonishing results that an operation called gastric bypass led to patients getting cured of diabetes in nearly 90 percent of cases. Blood sugar levels stay normal even several years after the operation.

Since then, this kind of operation, called ‘Metabolic Surgery’ or ‘Bariatric Surgery’ has become a standard across the globe.

What is done in the gastric Bypass?

We staple the stomach to form a very small pouch. When swallowed food comes from the food-pipe   into this pouch, it meets a dead end. So we need to create a way for the food to go down. To do this, we take the small intestine up and create a channel between it and the stomach pouch. So, now the food goes into the small gut, bypassing most of the stomach and upper small bowel.

How Does This Work?

This works by reducing the stomach’s capacity to take in food, leading to satiety upon consuming a small portion of around an ounce of fluid. There is reduced spike in blood glucose after food (less volume + less absorption= low nutrient absorption).

The net effect of this operation is that undigested food reaches the small bowel, leading to the release of some hormones called incretins. These incretins (a group of around 200 chemicals) act to bring down the blood sugar levels and also halt the deterioration of pancreatic hormonal function that is the hallmark of Type II Diabetes Mellitus.

It is now clear that the alarming rise in cases of diabetes is linked to the widespread obesity in towns and cities. Indeed, 80 percent of new diabetics are fat to varying degrees. So far, doctors have been advising diabetics to lose weight by diet control and exercise, and to take medicines for diabetes. To a large extent, this is a hit-and-miss method of treatment, as there is no sure and predictable response in patients, largely because everyone differs in how strictly they follow their dietary discipline. Most people cheat on their diet, don’t exercise beyond the irregular morning walks and keep getting new complications of diabetes every year.

Most of these patients who undergo the gastric bypass procedure are also very obese. Says Dr. Arindam Ghosh, a bariatric surgeon based in Ludhiana’s Apollo Hospital, “Many of my diabetic patients are obese Punjabis weighing up to 200 kgs. Some of them live in the US and Canada, where the obesity levels are far greater than in India.”

Even though increasing numbers of our patients are searching the Internet daily for information, awareness levels are still abysmal. Patients think surgery involves physical removal of fat from their body. The younger generation is taking the lead. Yogesh Sharma, a 19 year old student who weighed 168 kgs, came to me for surgery to reduce his weight and cure his diabetes after convincing his parents that his decision was the correct one. To their credit, the Sharmas saw merit in the scientific approach. Most people are, however, very scared of the very word ‘surgery’ and would rather see their lives slowly but surely getting spoiled by disease.

Many people like Ruchita Doshi, a 57-year-old lady who has undergone spine surgery, regret their decision, “I wish I had undergone bariatric surgery before. My obesity led to arthritis and spine disease for which I needed to spend rupees three lakhs on treatment. Now they say I cannot be operated as I am undergoing dialysis because of diabetic nephropathy (end stage kidney disease).” Ruchita shares the opinion of many doctors that surgery for diabetes cure would have offset the costs of the complications of the primary disease. What are you doing about your obesity and diabetes?

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1. Zurlo F, Lillioja S, Esposito-Del Puente A, Nyomba BL, Raz I, Saad MF, Swinburn BA, Knowler WC, Bogardus C, Ravussin E. Low ratio of fat to carbohydrate oxidation as predictor of weight gain: study of 24-h RQ. Am J Physiol. 1990; 259:E650–657.
2. Jequier E. Alcohol intake and body weight: a paradox. Am J Clin Nutr. 1999;69:173–174.
3. Breslow RA, Smothers BA. Drinking patterns and body mass index in never smokers: National Health Interview Survey, 1997–2001. Am J Epidemiol. 2005;161:368–376.
4. Ahmed A Arif and James E Rohrer. Patterns of alcohol drinking and its association with obesity: data from the third national health and nutrition examination survey, 1988–1994. BMC Public Health. 2005; 5: 126.

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(pic: bmj.com)

Many companies have clearly shared that fantasy or vision. Billions of dollars are at stake to be the one to discover the ultimate pill. The Ultimate Pill™ will have the following characteristics:

1. Help burn fat

2. Allow you to eat normally without putting on fat

3. Have no side effects

4. Be cheap and easily available

5. Reverse obesity-related changes (this is perhaps taking things too far)

Obviously, we are nearly talking science fiction here.

The various drugs that have been used in the past are now mere footnotes in the history of obesity medicine. Heard of fenfluramine? A few years back, rimonabant was said to be the wonder drug, working through some mysterious cannabinoid receptors in the brain (how exotic it sounds!). That fell through, because people were getting depressed enough to commit suicide.

Sibutramine and Orlistat have been heavily prescribed by physicians around the world to effect weight loss short of bariatric surgery. Sibutramine causes appetite suppression, while orlistat affects fat absorption and allows unhealthy eating without the fear of weight gain. So they said.

We have said it before that orlistat can cause liver problems, and is a candidate for withdrawal. Now the world is told that sibutramine has been withdrawn in the US, Canada and Europe because of heart attacks (the SCOUT study).

The BMJ says:

The therapeutic cupboard containing antiobesity drugs has never been well stocked. The European Medicines Agency (EMA) recently decided that sibutramine must follow the example of rimonabant, withdrawn last year because of safety concerns. This leaves just one drug—orlistat—to face the rising tide of obesity across the continent. The demise of sibutramine carries both irony and wider messages for the management of obesity.

Sibutramine fell at the crucial hurdle of cardiovascular risk. Arterial disease—which leads ultimately to myocardial ischaemia, heart failure, and stroke—affects most obese people to some degree and is their major cause of death. Much evidence suggests that weight loss decreases morbidity and mortality associated with cardiovascular disease,3 and this is an important justification for all antiobesity measures, including drugs. Unfortunately for sibutramine, an interim analysis of the SCOUT (Sibutramine Cardiovascular Outcome Trial) study found that the drug increased morbidity from cardiovascular disease. The odds were always stacked against sibutramine, because cardiovascular risk is embedded in its mechanism of action. Sibutramine acts centrally to reduce food intake; it inhibits the presynaptic reuptake and degradation of serotonin and noradrenaline, thus enhancing the appetite suppressing actions of both neurotransmitters.

Why drugs have not yet worked for weight loss in obese patients may be due to the fact that obesity is a heterogeneous disease with multiple factors, whereas the drug tends to be focal in its mechanism of action.

So, sadly, another drug has failed. The role of bariatric surgery is as crucial as ever. It is now the only scientifically proven method of weight loss. What is more, it is safe and effective. As study after study keeps showing us. But will the naysayers hear the truth?

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(even men go crazy over hair loss!) Pic credit: here.

But who is man enough to tell a lady that her hair loss is not serious?

Though it is not possible to discuss the physiology of hair loss in any kind of detail in this platform, we should have a working knowledge of how and why this happens.

Hair follicles are the living part of hair, the latter being keratin strands without inherent blood and nerve supply. When hair follicles get less nutrition or blood supply, the hair falls off. The important things to understand here are that:

1. The hair follicle itself is capable of recovering fully and regenerating hairs, and

2. The hair loss that the patient notices is a reflection of the insult suffered by the hair follicle several weeks beforehand.

So, in practice, what happens is that a patient notices clumps of hair coming off in the bathroom or during sleep, three or more months after the gastric bypass. A panic appointment is made, and we take time to assuage the panic. Usually, women being women (please forgive the unintended sexism), the reassurance wears thin, as the hair loss continues. In the meantime, the visible scalp areas elicit comments in the patient’s family and circle (“OMG! What is wrong with you? My aunt had something like this, and they later said it was cancer!!” is one of the comments you may hear), and the panic washes up once too often (“But, doctor, you never told me about this!”).

True, as surgeons, while we dwell at length about leaks, thromboembolism, weight loss plateaus and other such major issues, we may not harp much on the hair loss thing. One of the reasons is that this is a reversible phenomenon. Once the weight loss is achieved and the patient’s nutritional intake comes to near normal, the hair loss stops and the regrowth is established.

Anecdotal reports of benefits exist for various supplements, including biotin, primrose oil and flaxseed oil and horsetail extract, among others. It is all up to you to experiment and find out which one would work magically for you!

One thing we do strongly advise is not to go for hair transplants and other major interventions like this. After all, there is such a thing called common sense: why over-think something that is self-correcting?

For a nice overview of nutritional and metabolic complications after bariatric surgery, read this article in Diabetes Care.

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We have all heard of this saying, and all of us agree. A skilled laparoscopic surgeon plots to take out huge tumors and cysts through the keyhole method, while the dinosaur surgeon tends to think of employing his hands to remove organs (like the appendix) that may have been better left alone.

Let me tell you a small story about myself. Not too long ago, at a Bariatric Surgery conference three or some years back, I had a chat with a renowned endocrinologist who was known for his work in obesity and diabetes. At that time, I was 86 kgs heavy, and most of it was fat. A hard-working surgeon, I was in the peak of physical un-fitness and a heart attack waiting to happen. My resting heart rate was always around 100 and my blood glucose was similarly poised over the century mark. I asked this gentleman how I could improve my markers and lose my fat. I also didn’t want to become a diabetic, I said.

He told me what anyone in his position would have: take a metformin pill, and do some walking. If your sugar levels go up, we will add another drug, he said.

I thought long and hard over what he said. I embarked on a new journey in life: a life of health and fitness. I trained hard and started IF (Intermittent Fasting). After an year of blundering along, I found my groove and results came in: resting heart rate down to 6o, blood glucose and lipid levels normal, and body fat well down (BW now 75 kgs).

To come back to the point, the doctor I asked hit my problem with the drug hammer he was holding by default. I did the smart thing by trying something different. I now firmly believe that everyone should try healthy eating and exercise in order to improve health and reduce body fat. As bariatric surgeons, we should not use the surgery hammer to hit every obese patient. When there is clear burden of disease (diabetes, hypertension, sleep apnea, gallstone disease, etc.) and the level of obesity is such that it is statistically unlikely to come off with lifestyle regulation, we recommend bariatric surgery. Not otherwise.

In other words, as specialists dealing with obesity and related diseases, we should have a broad perspective. We are always in danger of using a narrow knife-wielder’s perspective and eyeing every patient as a potential victim. We must be very careful. At BMI, we never stop telling each other this.

In clinical practice, the psyche of the patient is very important. But a more important factor (and an often unrecognized one) is the psyche of the doctor.

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