Obesity. A word that was once thrown around nonchalantly has now become a predicament to be reckoned with. Over the years, obesity has transformed from being a debilitating health affliction to an epidemic that has plagued scores of individuals across the globe. A case study into the gravity of the disease unveiled traumatizing data. Worldwide obesity has been on an upward trajectory since the 80s with numerous stakeholders suggesting that it has nearly doubled in cases. For example, in 2008, 9.8 per cent of men and 13.8 per cent of women in the world were obese, compared with 4.8 per cent for men and 7.9 per cent for women in 1980. Basically, the number of obese people has nearly quadrupled from 250 million to 904 million between 1980 and 2008. What this means for the world’s soaring healthcare costs needs little explanation: “On current trends, globally, we will see a huge increase in the number of people suffering certain types of cancer, diabetes, strokes and heart attacks, putting an enormous burden on public healthcare systems.” according to the co-author of the Future Diets report .This speaks volumes about how a fast-paced life and extremely unhealthy dietary habits have adversely affected the general well-being of people all around the world and this only seems to worsen. This aforementioned statistic is particularly disturbing because obesity is a disease that has some serious long-term health implications. Not only does obesity drastically reduce the quality of one’s life by crippling so many of its aspects but it also markedly cuts down on his average life expectancy. This condition is especially dire in Pakistan, which unfortunately packs disturbing figures under its belt. Obesity in Pakistan is an evolving issue that has attracted concern only in the recent few years. Urbanization and an unhealthy, energy-dense diet owing to the excess of oil and fats in Pakistani cooking, as well as changing lifestyles are among the root causes contributing to obesity in the country. According to a list of the world’s “fattest countries” published by Forbes, Pakistan ranked 165 (out of 194 countries) in terms of its overweight population, with 22.2% of individuals over the age of 15 crossing the threshold of obesity. This ratio roughly corresponds with other studies, which state one-in-four Pakistani adults as being overweight. But the picture is not so bleak as the medical profession offers us a myriad of options to tackle this goliath of a problem with obesity surgeries leading the array of options.
Before delving deeper into the numerous kinds of obesity surgeries, it would be prudent to note that the medical term for them are bariatric surgeries. Breaking it down to rudiments, bariatric surgeries are weight-loss procedures performed on obese patients who do not respond to non-surgical treatment. Since they are so varied in both scope and complexity, it is advisable to tackle their different types systematically. Obesity surgeries have a clear dichotomy between mal-absorptive and restrictive weight loss surgeries, the former involves reducing the amounts of fats and calories the body can absorb from food while the latter is concerned with cutting out portions of the stomach. Banding and intra gastric balloon were previously employed, but these techniques have now fallen out of favor as they are more tiring and time consuming and offer decreased patient compliance on top.
The duodenal switch is one of the earliest surgical procedures to artificially assist weight loss in cases of morbid obesity. The duodenal switch surgery combines a sleeve gastrectomy and an intestinal bypass. This procedure got its name because the duodenum, the first part of the intestine, is divided and attached to the lower section of the small intestine. The pylorus, the outlet muscle that controls the emptying of the stomach, is preserved during this surgery; this often results in dumping syndrome. During this procedure, approximately 60 to 70 per cent of the stomach is removed; this results in the stomach forming into the shape of a tube. After that, two thirds or more of the intestine is bypassed, which leaves only a few feet inside the intestine where digestive enzymes and food can meet which this causes malabsorption. After the surgery, the body will be unable to absorb a majority of the calories and nutrients that are eaten, so very high weight loss often occurs. Most patients lose between 60 and 80 per cent of their excess body weight over a 2-year period. Ten years after surgery, most patients have shown to still have a total weight loss of approximately 70 percent. The average recovery time for patients is between 3 to 4 weeks and the procedure is not without its pinch of salt. After a duodenal switch surgery, patients often experience decreased absorption, which causes more frequent and looser bowel movements and increased flatulence. Patients should also be closely monitored for vitamin, mineral, and protein deficiencies due to the marked decrease in the absorption of nutrients. If not cared for meticulously, the patient could end up suffering from various deficiency diseases. This surgery has been shown to result in the most reliable and longest lasting results of all weight loss procedures.
Another successful variation of bariatric surgery that is practiced in Pakistan is the Roux-en-Y gastric bypass. In Roux-en-Y gastric bypass, the surgeon creates a small pouch at the top of the stomach. The pouch is the only part of the stomach that receives food. This greatly limits the amount that you can comfortably eat and drink at one time. The small intestine is then cut a short distance below the main stomach and connected to the new pouch. Food flows directly from the pouch into this part of the intestine. The main part of the stomach, however, continues to make digestive juices. The portion of the intestine still attached to the main stomach is reattached further down. This allows the digestive juices to flow to the small intestine. Because the food now bypasses a portion of the small intestine, fewer nutrients and calories are absorbed. The eventual goal of a gastric bypass is to minimize the absorption of calories in the body. It achieves this by creating a new smaller stomach pouch that facilitates smaller meals which in turn reduces the number of calories absorbed from meals. A gastric bypass has the added advantage of providing significant long term weight loss, around 60 to 80 percent, and it may also lead to conditions that are conducive for energy expenditure. Gastric bypass surgeries are of two main types: open and laparoscopic. With open surgery, the surgeon makes a large surgical cut to open the patient’s stomach and the bypass is done by working on his stomach, small intestine, and other organs. The other way to do this surgery is to use a tiny camera, called a laparoscope. This camera is placed inside the patient’s stomach and allows the surgeon to examine the insides. This surgery is called laparoscopy. Gastric bypass surgeries require 2 to 4 hours at most and are highly effective.
But the restrictive procedure that has gained the most popularity in the past ten years is Laparoscopic Vertical Sleeve Gastrectomy (LSG). A sleeve gastrectomy is typically performed laparoscopically. During this procedure, approximately 80 percent of the stomach is removed. The stomach then becomes more of a tube shape, similar in shape to a banana. The surgeon will make small incisions in the upper abdomen and then insert small instruments through those incisions to complete the procedure. Since the stomach becomes much smaller, the amount of food that a person can consume after this procedure is much more limited. This surgery also prompts hormonal changes, which frequently cause weight loss as well. The hormonal changes can also help with certain weight-related health conditions, such as high blood pressure and heart diseases. The individuals who have this surgery may lose up to 60 percent of their total body weight, sometimes even more, and that within just two years. The certitude of success to a great extent depends on the person’s adherence to lifestyle changes and eating habits since surgical procedures can only do so much. The recovery is pretty simple for this procedure. For the first week after the procedure, the patient is only allowed to consume sugar-free, noncarbonated liquids. The next three weeks will consist of only pureed foods. After that, patients are typically able to resume a normal diet. Over the first few months after surgery, patients will need to have frequent checkups to ensure that everything is going smoothly. However, the procedure is not without a few drawbacks as patients often experience body aches, tiredness, feeling cold, dry skin, hair thinning and loss, and mood changes for up to 6 months after the surgery.
In the March of 2015, the first laparoscopic bariatric surgery at Pakistan Institute of Medical Sciences was performed on a patient weighing over 200 kilograms. The obese patients who have diabetes and hypertension secondary to obesity experience complete remission. On an average, 40 to 60% of excess weight loss is seen in 6 months, and 80 to 100% at 1 to 2 years after surgery. Obese patients are more predisposed to diseases like diabetes mellitus, hypertension, and heart attacks than normal weight population. In addition, they also encounter respiratory problems, joint degeneration, infertility, psychosocial impairments, and above all, lower life expectancy and poor quality of life as compared to normal weight people. And since obesity is the mother of all diseases in overweight people, this procedure could have life-saving implications for many in Pakistan.
When it comes to weight-loss surgeries, it’s important to note that there’s a difference between liposuction and the aforementioned bariatric procedures. Liposuction is a cosmetic procedure intended to remove existing fat, but does not address the issues causing the patient’s weight gain. While you may initially lose weight or inches with liposuction, it is not a permanent weight loss solution in any shape or form. Liposuction is more commonly recommended for individuals who are not struggling with obesity, but rather have areas of stubborn fat that just won’t melt away with diet and exercise. However, the bariatric procedures like Roux-en-Y gastric bypass, duodenal switch and Laparoscopic Vertical Sleeve Gastrectomy, are not aimed to improve cosmetics but are rather intended to address the cause of excess fat, rather than simply removing fat for the sake of aesthetics. These bariatric surgeries can achieve long-term weight loss and are the go-to solution for patients with a BMI of 40 or over.
It would not be completely outlandish to say that these surgeries can single-handedly change the lifestyle of an individual, in ways that are nearly innumerable. Most of the patients that avail this option usually go into it immobile and incapable of performing daily tasks. The patients are usually bed ridden and physically crippled to the point that even the most basic of activities cannot be performed without external assistance. Getting these surgeries done are literal weights off their shoulders that enable them to live a life that they deserve. One of freedom and independence. One that promises a better and more hopeful future.
Although traditionally, obesity is being treated with dietary changes, exercise, and weight loss medicines, remarkable weight loss is seen in patients who add surgery to the above-mentioned interventions. A lamentable factor here is that since Pakistan is a developing country, the level of awareness and the medical techniques available here are very limited. However, major healthcare institutions like Aga Khan and SHIFA have made significant strides in this direction and offer top of the line bariatric surgical procedures to those willing to spend big bucks. Moreover, the laparoscopic surgeons at PIMS aim to establish a state of the art Laparoscopic Surgery Centre there which would facilitate these bariatric surgeries. The only note-worthy obstacle in this regard is the cost of building such a centre which would easily require the investment of millions of rupees. Undoubtedly, in a country like Pakistan, such procedures are direly required since obesity is rampant if anything but the extant impediments don’t let a completely rosy picture be painted. Nonetheless, the tireless endeavours and the constant research advancements have a lot to add to this cause and in the not so distant future, we are looking at a healthier and better medically equipped Pakistan.