FAQ

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What can I do to reduce?

Depending on which class of obesity you fit into and whether or not you have associated co-morbid conditions, the options available are: Diet, Exercise, Medicines, and Surgery.

Why do I not lose Weight in-spite of dieting?

The rate of metabolism is different for every person. People whose metabolic rate low tends to develop obesity. Only dieting will not achieve substantial weight loss. Once you go on a low calories diet, you lose weight initially after which a plateau is reached. Further weight loss is either slow or no more. Frustration sets in, followed by discontinuation of the diet. Now you will gain more weight than before. This is also called the yo-yo Phenomenon.

What about medicines?

Medicines have come into the market to reduce appetite and increase satiety, but could not sustain existence in the market due to serious side effects like mood swings, suicidal tendencies, and fluctuations in blood pressure etc. those medicines have been banned from the market and are no longer available. Now available is a medicine, which prevents absorption of a percentage of the fat from the meal you eat, thus protects you from putting on weight to some extent. This medicine also is not devoid of side effects if taken for a long-term. Moreover rebound weight regain is known after stopping it.

There are few medicines that can help reduce weight, but they are not without side effects. It is observed that 95% of patients resume their original weight within 2 years after stopping medicines.

What is Bariatric surgery?

Bariatric surgery is a group of surgeries, which are performed to induce long-term weight loss along with curing most of the medical problems like diabetes, blood pressure, arthritis etc.

How does it differ from Liposuction?

Bariatric surgery is often confused with liposuction. Liposuction is a cosmetic surgery where few kilograms of fat is removed by suction through tiny incisions This surgery is mainly used for body contouring or shaping the body where there are few extra kilos of fat like the waistline, ARMS, SADDLE BAGS or thighs.

Thus it helps in getting the body into proportion and this can be maintained only if the person is normal weight or a few kilograms overweight and take an effort to lose those extra kilograms with diet and exercise. But if the person undergoing liposuction is obese, for one these liposuction changes may not be very visible or then there are very high chances of getting back to normal in no time. Thus liposuction is not a weight loss surgery for the obese and is purely a contouring surgery. Furthermore, this cosmetic surgery is not of any help for morbidly obese patients in resolving their associated medical problems like diabetes, hypertension, sleep apnea etc.

How is it done?

Bariatric surgeries are done by the laparoscopic approach. It is done through small incisions. Hence it has the advantage of being associated with less pain, faster recovery, and fewer wound complications.

How effective is weight loss surgery?

Depending on the type of surgery anywhere from 70 to 90% of your excess body weight (EBW) CAN BE LOST AFTER BARIATRIC SURGERY. Clinical studies show that the following surgery most patients lose weight rapidly IN THE FIRST FEW MONTHS and continue TO LOSE WEIGHT UNTIL 12 to 18 months post surgery. However, you will not wake up from the surgery with any weight loss, MEANING THAT THERE IS NO INSTANTANEOUS WEIGHT LOSS POST SURGERY.

Patients may lose 30 to 50% of their excess weight in the first 6 months, and ~77% TO 90% as early as 12 months after surgery. Another study showed that patients could maintain 50-60% loss of excess weight 10-14 years after surgery.

How safe is surgery?

Surgery is safe in expert hands and in hospitals with a good infrastructure and equipment. In a surgery of over 10,000 patients, the mortality rate for weight loss surgery was 0.3%.

Do I qualify for the surgery?

If you are morbidly obese, (BMI > 37.5 or BMI > 32.5 with associated co-morbid medical conditions) and you have failed to lose weight significantly by other methods, and if you are motivated and committed for a lifelong change in lifestyle, then you qualify for the surgery. Also, it is important to make sure that you do not have any metabolic or endocrine disorders causing obesity, have any major psychiatric problem or any severe medical problems, which can make surgery dangerous. For women, it is also necessary to make sure pregnancy is avoided in the near future.

Which Procedure is right for you?

If you are morbidly obese, (BMI > 37.5 or BMI > 32.5 with associated co-morbid medical conditions) and you have failed to lose weight significantly by other methods, and if you are motivated and committed for a life long change in lifestyle, then you qualify for the surgery. Also it is important to make sure that you do not have any metabolic or endocrine disorders causing obesity, have any major psychiatric problem or any severe medical problems, which can make surgery dangerous. For women, it is also necessary to make sure pregnancy is avoided in the near future.

Which Procedure is right for you?

The most important step in selecting a weight loss surgery is getting all the information you need about the various surgical options. Ultimately your surgeon and other physicians are your best sources for that information. After evaluating you, they can give their best recommendations. The three most common procedures performed are:
Roux-en-Y Gastric Bypass Procedure
Stapling is used to create a smaller, upper stomach pouch, which restricts the amount of food able to be consumed.
A portion of small bowel is bypassed thus delaying food from mixing with digestive juices to avoid complete calorie absorption.

Sleeve Gastrectomy-
The stomach is converted into a long thin tube by stapling along its longitudinal axis.The excluded part of the redundant stomach is removed through a small incision.

Laparoscopic Adjustable Gastric Banding
A band is placed around the upper most part of the stomach separating the stomach into one small and one large portion.Band can be adjusted to increase or decrease restriction.

What is the expected hospital stay for the surgery?

Most patients stay in the hospital approximately 4 to 5 days after an open procedure and 2 to 3 days after a laparoscopic procedure.

You will be discharged when you are able to

1.Take enough liquids and nutrients by mouth to prevent dehydration
2.Have no fever
3.Have adequate pain control with ORAL medications.

How long will I need to recover?

If the surgery is done open then it may take bout six weeks, but if it is done laparoscopicallyabout 10 days to two weeks. At which time some patients have returned to a desk job. It may take a litter longer if you do heavy manual labor.

What are the benefits of Bariatric surgery?

Besides significant and sustained weight loss, there are several benefits including freedom from co-morbid conditions:

Blood sugar levels for patients with type II diabetes that improves almost immediately and become completely normal within a year after surgery.
Blood pressure and cholesterol lower.
There is relief of sleep apnea, asthama and acid reflux.
Arthritis pain decreases and there is improved mobility.
There is improvement in the mood and self esteem.
The cosmetic benefits follow after some time when there is significant Weight-loss

What are the risks of Gastric Bypass Surgery?

Although the operation is considered safe, complications may occur as with any major surgery. However, the risk of remaining obese will eventually outweigh the risks involved with the surgery. Gastric bypass surgery may be associated with loosening of the staple line or anastamotic leak, pulmonary embolism, vomiting due to decreased side of the stomach, wounded infections, blood clots in the legs, scar problems including hernia, developments of gall stones, dumping syndrome leading to loose motions and vitamin deficiencies.

When can I have children after the surgery?

The surgeons are advising the female patients to wait at least ONE YEAR after surgery to avoid the stress of a pregnancy during the period of rapid weight loss and allow her weight to stabilize. Please be careful to use birth control methods in the first TWELVE months.

Will the problems due to my obesity GO away after the surgery?
Yes some of the complications will resolve and some will improve dramatically, like sleep apnea, asthma, hypertension and high cholesterol. In fact the Type II Diabetes will respond with ~ 85-90% resolution and obesity surgery is now considered the best treatment for TYPE II diabetes.

When can I have children after the surgery?

The surgeons are advising the female patients to wait at least ONE YEAR after surgery to avoid the stress of a pregnancy during the period of rapid weight loss and allow her weight to stabilize. Please be careful to use birth control methods in the first TWELVE months.

Will the problems due to my obesity GO away after the surgery?

Yes some of the complications will resolve and some will improve dramatically, like sleep apnea, asthma, hypertension and high cholesterol. In fact the Type II Diabetes will respond with ~ 85-90% resolution and obesity surgery is now considered the best treatment for TYPE II diabetes.

Is this procedure considered cosmetic?

No, it is considered a medically indicated procedure.

Did you know that?
Most people get their diabetes cured before they leave the hospital loosing one Kilo of weight reduces blood pressure by 1mm of mercury gaining one kilo of weight reduces your life by 4.

What are the different types of Diabetes that we encounter?

Type I :Complete or near total insulin deficiency.
Type II: Insulin resistance, impaired insulin secretion,Increased glucose production, abnormal fat metabolism.
Type III: Drugs, Endocrinopathies, Infections, etc.
Type IV: Gestational Diabetes.

Which type of diabetes can be benefitted from metabolic surgery?

Type II diabetes can be resolved after bariatric surgery.

Does the duration of diabetes alter the effect of the surgery?

Yes, the duration of diabetes has a very vital role to play because as the duration of diabetes progresses, it deteriorates the pancreatic function. Residual pancreatic function is very important for the success of metabolic surgery. This can be found out by special lab blood investigations like fasting and stimulated Cpeptide function and also fasting and stimulated insulin levels.

Does the age of onset of diabetes have any significance?
The onset of diabetes below the age of 30 years signals the necessity to confirm that the diabetes is of the Type II variety and not the LADA ( latent autoimmune diabetes of the adult)variety which initially presents as Type III but later on goes on to be Type I diabetes. This can be done by doing some special lab blood tests like GAD antibody test, insulin and islet cell antibody tests.

What is the lowest BMI for which a diabetic can be operated upon?

A diabetic having a BMI of 30 and above can be considered for metabolic surgery. Metabolic surgery involves some amount of weight loss and hence BMI is to be considered

What happens when a patient has type II diabetes?

1. Insulin resistance:Low response to insulin mediated glucose uptake in skeletal muscles and peripheral tissues.
Increased hepatic glucose output
2. Impaired beta cell function : Inadequacy of beta cells to provide sufficient insulin. The beta cells are unable to adapt to higher glucose load which in turn leads to beta cell failure.
Beta cell death (apoptosis) leads to decrease in beta cell mass which is a point of no return.
3. Defect in alpha cells: Increased glucagon secretion(Hyperglucagonemia)

OR

Failure of beta cells to secrete adequate amounts of insulin to compensate.
Insulin resistance in peripheral tissues.
Increased endogenous glucose production.
Accelerated lipolysis in the adipocyte.
Defeciency or in cretin resistance in the gastrointestinal tract.
Hyperglucagonemia in the Alfa cells.
Glucose reabsorption in the kidneys.
Insulin resistance in the brain.

How does the Roux en Y gastric bypass help in resolution of type to diabetes?

Decrease in ghrelin levels: Ghrelin is a hormone that stimulates insulin counter regulatory hormones,suppresses insulin sensitising hormone- adipose tin, blocks hepatic insulin signalling and decreases insulin secretion. After surgery ghrelin levels decrease drastically and hence help resolution of Type II diabetes.

Foregut theory: When food bolus passes through the duodenum, there is release of duodenal factor having anti- cretin effect. Exclusion of the duodenum leads to exclusion of the duodenal factor and thus avoids the anti- cretin effect helping in resolving type II diabetes.
Hindgut theory: Early entry of undigested food in the distal ileum leads to early and increased release of GLP I / PYY from L cells (three times) of the small bowel leading to resolution of type II diabetes.
GLP I : Increases insulin secretion in response to glucose intake( incretin effect)
Decreases insulin resistance
Decreases gastric emptying leading to decrease in appetite and increased satiety
Decreases glucagon secretion.
After the gastric bypass, GLP I is seen to increase beta cell proliferation, increase pancreatic islet cell mass and increase beta cell stimulation.
PYY: Increases GI motility, decreases gastric pancreatic and intestinal secretions, increases satiety and decreases food intake, increases insulin dependant glucose disposal.

What is the science behind getting diabetes under control after metabolic surgery?

Hair loss is inevitable when large amount of weight loss is considered. This weight loss could be following weight loss due to long term illness, diet and exercise or following weight loss surgery. This Can be minimised or avoided by again being high on protein in the diet, regular supplements specefic hair loss containing calcium pantheon ate, nicotiana idle, biotin, Vit C, inositol, frolic acid, Vit B6,zinc, iron, copper, silica, selenium, amino acids like lysine,methionine and cysteine. These supplements are available as a single tablet to be taken once or twice a day. Also if you are suffering from hypothyroidism, continue to take medication for the same. Liquids mainly water should be consumed in good quantities.

What is the incretin effect?

When hypertonic nutrients enter the small bowel, there is a release of GI hormones, which lead to pancreatic stimulation, which in turn leads to insulin secretion. Oral glucose has a higher insulin release than I.V glucose due to incretin effect.

What is the metabolic syndrome?

Triglycerides > 150mg%
HDL< 40 (males), < 50 (females) FBS> 110mg%
BPD > 130/85
Waist circumference> 50″ (males), 40″ (females)
A person having any three of these is said to have Metabolic Syndrome.

Will I never regain weight after I undergo bariatric surgery?
If you maintain changes in lifestyle, just you have a very high chance of maintaining your weight.

Why do i regain weight after bariatric surgery?

Once a person loses weight and reaches ideal body weight, then he/ she has a tendency to become complacent. They start straying away from the lifestyle changes they had incorporated in their daily regime. They get back to binging on fast foods, calorie dense foods, high calories liquids, and frequent alcohol intake. They even turn away from daily walks or daily exercises.

Another major reason for weight regain after bariatric surgery is when a person does not attain adequate weight loss or does not reach ideal boy weight.

What should I do so that I can maintain my weight after bariatric surgery for years?

It is not difficult at all. Just need to adhere to the lifestyle changes advised by your doctor. This does not mean that you will never be able to eat tasty food and food you like all your life. This also does not mean that you need to wear your joints by exercising all day long. What is required of you is very simple DISCIPLINE. You can binge on fast food or foods you like once or max twice a week. Other days have a regular balanced meal. Just half an hour of a brisk walk or some sort of exercise as advised by your doctor will help you maintain weight over years and also remain healthy.

Why do I not reach ideal body weight even though I have undergone weight loss surgery?

Many reasons. Firstly, one feels that once weight loss surgery is done, he/ she got a neither lifetime ticket for nor gaining weight. Secondly, when a person starts to lose weight at quick pace during the first few months, they decide for themselves that this weight loss is rapid and if this continues, there is every chance that they might disappear. Hence they force themselves to eat calorie dense foods like ice creams, milk shakes tectonic slow down the weight loss process. Thirdly, they do not follow the instruction given by the doctor before surgery of which monthly visits plays a vital role. If you are regular with your visits, your doctor can detect the problem for you not losing weight at the desired rate and take adequate steps to enhance the weight loss process. Fourthly, one feels that once bariatric or metabolic surgery is done and he /she gets off the medication taken for diabetes and hypertension, he/ she can also give up the medication they used to take for hypothyroidism(if they are suffering from hypothyroidism). This they do at their own will and cannot be corrected, as they do not go for their regular visits as every thing is going on well till the time they realise that they have stopped losing weight and infant started regaining weight. If they come back to their doctor for regular vists the reason can be found out, medication restarted and with finer adjustments in diet and exercise, weight loss can be achieved. Fifthly, one should have realistic expectation- as we age, skin elasticity decreases and with excess weight loss of any manner( dieting, Workouts …….) some sort of sagging will be there depending on the age and the severity of obesity. What actually happens is relatives and friends comments play a vital role in motivating the patients during their weight loss journey which is actually done for getting them back to health. If they pass comments like you are looking much more that you age, patients get demotivated and stray away fro their doctors instruction and end up having inadequate weight loss.

How can I reduce or avoid sagging after weight loss by any means, diet and exercise or weight loss surgery?

Sagging what a common man perceives is skin sagging, but sagging in the actual sense involves sag in the skin and muscle too. Skin when over stretched due to obesity tends to get loose as you lose weight. When you put on weight, fat also gets deposited within the muscle fibers. As you lose weight, the fat between the muscle fibres disappears and your muscles tend to loosen and start sagging. This means that when you lose weight, you need to be high on protein in your diet as well as take protein supplements. You also need to exercise, do stretches to tone up your muscles and skin. Lightweights should be used to tone up different parts with exercises specific to those areas. Supplements need to be taken regularly. These exercise and high protein diet should start from the start of weight loss process and continue much beyond achievement of desired weight loss.

What about hair loss?

When hypertonic nutrients enter the small bowel, there is a release of GI hormones, which lead to pancreatic stimulation, which in turn leads to insulin secretion. Oral glucose has a higher insulin release than I.V glucose due to incretin effect.

ow long does it take for one to get out of type II diabetes after metabolic surgery?

This varies from patient to patient and there are many points which influence the outcome. Duration of diabetes, residual pancreatic function, Severity of diabetes, rate of progression of diabetes, duration since patient is on insulin, whether insulin needed to be started within 5 years of onset of diabetes, family history of diabetes, whether complications from diabetes have set in.
The resolution of diabetes can be as early as the next day after surgery to Six months post surgery. A very rare case could take about a year.

What are the improvements that a diabetic patient experiences after metabolic surgery?

What are the improvements that a diabetic patient experiences after metabolic surgery?
1.Resolution of diabetes meaning no necessity to take insulin or medication to keep sugar under control.
2.Nephropathy: In those having microalbuminuria, there is a graded reduction and in many disappearance of microalbuminuria.
Serum and urinary creatinine levels also have been seen to improve to very great extent.
3.Neuropathy: Burning and tingling of the feet and legs are also seen to decrease.
4. Retinopathy: slowing down and then stop in progression of retinopathy has been observed in patients who have had diabetic retinopathy.
5. Cardio———-

What about stretch marks after weight loss?
Stretch marks do not disappear once a person undergoes weight loss surgery, but there are methods by which these marks can be made visibly lighter.

References
Roux en Y gastric bypass provides a solution for diabetes mellitus?