FAT CHANCE OF CURE

As the diabesity epidemic in India gobbles up the population at a rocket rate, MEENAKSHI RAO looks at the efficacy of surgical interventions that are being coined as the best instruments of cure

Indians, by tradition, consider surgical options as the last resort to treating any ailment. They view surgeons as that merciless breed of medics ready to cut into them at the drop of a prescription.

But it is people like an obese Jaya (name changed) who came all the way from small-town Jhansi to Delhi and aggressively argued that she needed to be put to knife, who are changing perception.

“She was 110 kg at a 5 feet height and not medically literate. But she just took three days to decide that she needed to undergo bariatric surgery. First day, she had lots of enquiries, the second day her tests and third day the operation. Today, she is 60 kg and cured of her diabesity,” Dr Anoop Misra, chairman, Fortis-CDOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, New Delhi, tells you.

Dr Misra, who sits on a mine of published and unpublished diabesity data from India, correctly points out that he is no surgeon and doesn’t need to propel the cause of surgery. But being in the midst of wholesome diabesity management and cure research, he insists that “diabesity surgery should be a part of diabetes management from the start and not the last resort which blurs chances of total remission.” He calls it a remarkable and magical cure.

Dr Misra has a point. Global and Indian data suggests that diabesity surgery, which Dr Pradeep Chowbey explains is nothing but a tweaked form of bariatric surgery in which a particular part of the stomach and intestine is bypassed and stapled, garners the best results when the patient has had an early onset of diabesity.

Dr Chowbey, who is chairman, Surgeries and Allied Surgical Specialities at Max Hospital, and more importantly, one of the best known laproscopic interventionists of the stomach with over 70,000 scopic operations under his belt, says that diabesity (diabetes + obesity) is prevalent in 60 per cent of diabetic patients in India, out of which around 25-30 per cent have a  high BMI index of more than 30.

“But if they undergo this surgery within five years of the onset of diabesity, there is a 90 to 95 per cent chance of them getting cured of both diabetes and obesity,” he asserts. And miraculously some other ailments like renal failure too, something that Dr Atul Peters, one of the few dedicated bariatric surgeons in India, was shocked to see in one of his patients.

The man, from Chandigarh, was just 31 and suffering from uncontrolled diabetes despite a high dosage of insulin. He was on dialysis three days a week and dying under the weight of his own flab.

“When we conducted the surgery on him, I saw a miracle take place. On the first post-operative day, his kidney which had stopped producing any urine without dialysis, gave an output of 500 ml! I was shocked. By the third week of his surgery, not only was his weight going down steadily but also his dialysis sessions reduced from thrice a week to once in three weeks. Of course, he will still require a kidney transplant but the surgery surprisingly revived his failed kidney to an extent,” he tells you.

This shows that the jury is still out on the varied impact of metabolic surgery. In India, most surgeons like Dr Rajesh Khullar agree that super specialisation in bariatrics is still at its nascent stage with not more than 15 dedicated bariatric centres nationwide which have the certification of the US-based global monitor, Surgical Review Corporation.

Dr Khullar is the president of the Obesity and Metabolic Surgery Society of India which, he says, is slowly garnering members. “There are around 250 members now and the breed is growing,” he tells you, pointing towards the awareness happening at all levels, mostly by word of mouth and the results seen in other patients.

The concept of bariatric surgery came into India initially as a perceived cosmetic surgical indulgence for the rich, much looked down upon. Medical PRs were back then desperately propelling the concept as a disease alleviator and not a lifestyle intervention for deep pockets.

Today, it is a life-saving surgery as per the WHO classification and the scenario stands changed. Earlier, out of say 28 surgeries a month, 24 were of foreign patients and only four of Indians. There’s been a complete reversal now with 90 per cent Indians agreeing for surgery. “Out of 28 today, 26 are Indians, among them some well-known faces from political and other fields” Dr Peters asserts.

Dr Chowbey whose most recent patient was Finance Minister Arun Jaitley, and earlier the Pakistani singer Adnan Sami’s family and Sahara chief Subroto Roy and some other members of his family, says that all have benefitted immensely from the surgery. Jaitley who was unsuccessfully fighting uncontrolled diabetes is today on minimal medication, has much lower weight parameters and high energy levels. The same goes for BJP MPs Nitin Gadkari and Venkaiah Naidu and some Congressmen.

India, as we all know, has nearly 65.1 million cases of diabetes and occupies the second position, next to China, in the global list of countries with the highest number of persons with diabetes. Doctors are alarmed at the rate at which the epidemic is growing and being neglected by policy and initiatives which are more focussed on immediate mortality epidemics like malaria, dengue etc.

Both Dr Chowbey and Dr Misra agree that India needs to look at its food policies minutely and see what’s going into its population which already has a fat friendly and thrifty gene to take care of. “Sixty minutes of brisk walk goes a long way in warding off diabetes but it has to go with a fibre intense diet and low stress,” Dr Misra says. But he adds that, with growing insulin resistance in our fat happy liver and pancreas (sometimes even non-obese patients suffer from liver and pancreas fat), it is crucial that Governmental, legal, corporate and individual intervention is gainfully employed to shoo away insulin resistance.

“Everyone wears a seat belt which means legal provisions work. Same goes for junk busters too. I have an Indian study which shows increased taxes on soft drink beverages can plateau diabesity. We should not only excessively tax SSBs (sugar sweetened beverages) but sugar itself if we want to cut into the epidemic”.

According to the model, if SSB sales continue to increase at current rate, compared to no tax, a 20% SSB tax would reduce obesity across India by 3% and the incidence of Type 2 Diabetes by 1.6% between 2014–2023. In absolute figures, this would avert 11.2 million cases of obesity and 4,00,000 cases of Type 2 Diabetes. Notably, if SSB sales increase more steeply as predicted by drinks industry marketing models, the tax would avert 15.8 million cases of obesity and 6,00,000 cases of diabetes.

Dr Chowbey’s teammate Dr Vikas Ahluwalia, who is director of Bariatric and Metabolic Medicine, points out that a study in Delhi’s schools returned with alarmingly high incidence of obesity and schools like DPS RK Puram which banned junk on its premises, cut its obese population by at least 15-20 per cent.

Dr Misra wants a downstream process in which the intervention against junk food, highly processed non-fibre eats and aerated beverages goes down to the grassroots, i.e. children.

Diabetes due to obesity has alarmingly been growing younger and younger. Dr Peters, for example, operated upon a nine-year-old boy who had morbid obesity. “We followed this boy’s medical history for two years before doing the surgery and curing him,” he tells you.

However, the metabolic surgery does not come without inherent risks like internal bleeding, leaks in new intestinal joints and DVT (deep vein thrombosis) which basically means harmful blood clots, which Dr Chowbey says are rare and low, as low as things going wrong in a gall bladder operation. Dr Peters puts the risk in the same category as a hysterectomy operation the fatality rate of which is 0.02 per cent.

Having said this, it is also true that India still does not have specific rules to monitor expertise in this field and there is still no super specialised course in metabolic surgeries. Moreover, a chunk of Indian diabetologists remain queasy about the surgical intervention and would like to go with tradition measures like insulin jabs coupled with diet and exercise. This has kept the number of metabolic surgeons low. Dr Peters admits that Delhi has not more than 6 or 7 dedicated bariatric surgeons but over 20 are performing such surgeries, putting patients at grave risk.

Dr Khullar says that in the absence of individual certification by the ICMR, an informal US monitoring system is being followed in India which means that a laproscopic surgeon can be deemed fit for bariatric surgeries only after he performs more than 20 such surgeries without faltering.

But awareness is growing at a brisk pace despite the high cost of the surgery which ranges between Rs2.3 to Rs3 lakh with a one to two-hour operation and three to four days of hospitalisation. Till now there is only one private health insurer — Star — which provides a cover for bariatric surgery. The big thing, says Dr Chowbey who had been in discussions with the Ministry since 2008, is that the Central Government Health Scheme (CGHS) after much prodding and explaining, gave insurance cover to bariatric surgery on December 18, 2013,  and private players will soon follow.

In the face of the sky rocketing median expenditure on diabetes care by Indian patients, the metabolic surgery, if done with expertise and reason, looks like a viable option, what with an average Indian spending Rs10,000 a year in urban areas, Rs 6,260 in rural areas, and the low-income group spending nearly 25–35% of its annual income on diabetes care.

India’s pioneering bariatric & metabolic surgeon DR PRADEEP CHOWBEY answers some FAQs

Is bariatric surgery the same as metabolic surgery?

Largely yes, but in metabolic surgery, which is a cure for diabesity, the length and portion of the intestine bypassed is different from a weight reduction procedure.

Can metabolic surgery cure Type 2 Diabetic patients who are not obese?

Hectic research has gone into this ground-breaking project and by 2016, a breakthrough is expected. Right now, it is into clinical trials with 150 non-obese T2D patients having globally undergone the procedure. This breakthrough will be the biggest step ever in tackling diabetes. It is also called Low BMI Metabolic Surgery or Distal Interposition.

Is BMI the barometer for this surgery?

A 32-plus BMI is considered good to go for weight reduction surgery. However in Asians, including Indians, it goes down to 30 BMI for morbid obesity as they are straddled with this fat conserving, thrifty gene.

But many endocrinologists are still queasy about the surgical option...

The idea is still growing in India and we need to have an awareness campaign. Though diabetes medication has evolved over the years, medicines can control, not cure, diabetes. Metabolic surgery cures over 90 per cent patients in the first five years of onset. Besides, it is humanly impossible to be on a lifetime crash diet. Metabolic surgery is a permanent, quick and safe way to beating the epidemic.

But surgeries are going wrong...

Sometimes, when we operate these patients, they are already suffering from a condition of the liver known as non-alcoholic steotatic hepatitis (NASH) caused by fatty liver. If not treated, it causes cirrhosis. So the pre-op assessment should me meticulous. And post op, the patient has to take care not to insult his liver and other organs.   

You call it the only comprehensive surgery in the world...

Just think about it. Once you are cured of diabetes, you are cured of spending, and related complications. This helps the person's psyche, it increases marital harmony, increases fertility, gives him or her more job opportunities and in the long run, also boosts the productivity of the individual and the country. So, it impacts both physical and emotional wellness. Rest of the surgeries are like localised plumbing, but this one is comprehensive.

Every 10 kg of excess weight reduces life by three years

• Annual direct and indirect cost of diabetes care: Rs1541.4 billion ($31.9 billion) in 2010 for India. Because of the high economic burden on patients and families, people neglect health care, causing severe morbidities and early mortality.
• Between 1989 and 2005, prevalence of diabetes increased significantly from 8.3% to 18.6% in the urban population and from 2.2% to 9.2% in the rural population in South India.
• Indian diet is predominantly starchy, consisting of over 60% or more carbohydrates. High intake of carbohydrates can lead to hyperinsulinaemia, high serum triglycerides and low HDL cholesterol levels associated with insulin resistance.
• Although dietary guidelines in other countries remain to be formulated, those from India recommend 3-5 servings of fruit and vegetables. There is evidence, from a short-term study that supplementation of Vitamin D improves insulin sensitivity in Asian Indians.
• In the physical activity guidelines for Asian Indians, daily physical activity of 60 minutes duration, including 10-15 minutes of resistance exercise and work-related activity is recommended.

Source: Sunday Pioneer, October 11, 2015