Mumbai Gets First Center For Adolescent Bariatric Surgery

Publication: Times of India

Obesity quickfix for teens, but docs sound caution.

Now, obese teens can go for surgery in city

Bariatric surgery, a controversial procedure to treat obesity, will now be offered to teenagers in the city. It is believed that at least 30% of adolescents in metros are obese. Most of them are from the affluent class. The surgery could cost between Rs 2.5 and Rs 4 lakh.

Bariatric surgery one of the most globally debated approaches to treat obesity will now be offered to adolescents at a dedicated center in Chembur. Experts offering the method feel bariatric surgery which still remains a 'grey area' for the insurance sector could be the only solution for morbidly obese children to lead a healthy and disease-free life. With the obesity epidemic now affecting adolescents as much adults, it is believed that at least 3000 of adolescents in metros are obese. The phenomenon is more pronounced among children from the higher socio-economic strata. In fact a handful of bariatric surgeons in the city have been operating on adolescents for a few years, though the cases are rarely spoken of and data is scarce. About 10,000 bariatric surgeries are estimated to be performed in the country every year of which less than 60 are adolescents or from the Paediatric age-group. Obesity surgeon Dr. Ramen Goel, who will head the Nova Teen facility at Chembur's Nova Specialty Hospitals Center, said bariatric surgery has emerged as the most ideal way to tackle issues of psycho-social development and low self-esteem that obese children usually grow up with. However he added, not every obese child needs surgery "Only those with a BMI of more than 40, or only 4% of the extremely obese will qualify" he said. Goel insisted that the selection of patients will be the key. He said the surgery will be offered to those young adults who have co-morbid conditions that can't be tackled by medication or diet and who have reached adequate skeletal growth. The surgery which will not be offered to the paediatric age-group immediately could cost Rs 2.54 lakh. Skeptics point out that in the absence of guidelines for these surgeries in the country there is a huge risk of it becoming a choice of treatment for obesity in children. A Union health ministry official told TOT that the demand for such surgeries has increased 20%-40% in the metros. "Many doctors offer this surgery for adolescents, but very few reveal details about it. There has to be more transparency if it is such a safe and life-saving procedure," the official added. Goel however added that data from the center will be compiled so that India-specific guidelines can be developed. Bariatric surgeon Dr. Srihari Dhorepatil said it is a complicated surgery "It has life-long ramifications and kids may be too young to understand. So unless there are life-threatening implications, a child should not be made to undergo it. Also, the child has to undergo major lifestyle changes. If the family fails to cooperate, the child may be miserable," he said.

Surgical Procedures

Gastric Band: Here, a band is wrapped around the upper part of the stomach to create a small stomach that is filled up by small quantity of food. Narrow opening of the modified stomach delays the passage of food into the intestine making the person feel full for a long while. It is a reversible procedure.

Sleeve Gastrectomy: The stomach is reduced to about 25-30% of its original size, by removing a large part of it. The edges are then attached using surgical staples as well as glue. The irreversible procedure controls hunger pangs to a great extent as the hormones stimulating hunger are removed.

Gastric Bypass: In this surgery, the size of the stomach is made smaller and the food is made to bypass parts of the small intestine. Besides reducing food intake, bypassing the intestine curtails the absorption of nutrients and food leading to loss of weight. It is considered to be tougher than the other surgical forms.

Bariatric Surgery for Adolescents

Favorable Factors:

  • 90% severely obese adolescents become extremely obese adults
  • Studies show 93% obese teens have abnormal insulin, 67% from sleep apnea, 36% hypertension, 13% have type-II diabetes
  • Girls often have polycystic ovary syndrome, menstrual problems, steroid hormone imbalance, etc.
  • Studies show 33% of morbidly obese adolescents have 3 or more cardiovascular risk factors like abnormal HDL, LDL, raised insulin
  • About 95% of obese teens have two or more co-morbidities
  • Adolescent extreme obesity is associated with more sever quality of life impairment Drawbacks:
  • Even if minimal, surgery involves risk of bleeding or infection
  • Leaks from intestinal incision and blood clots in lower legs have been recorded in some cases outside India
  • Complications such as malnutrition and hernias, though rare, have also been documented
  • Life-long follow up visits to the hospital or doctor even if there is no problem post-surgery
  • Drastic change in lifestyle and food habits and cent percent dedication to stick to them
  • Chances of failure if the patients fails to monitor lifestyle, change eating habits

Few guidelines, data on surgery for weight-loss

Mumbai: Obesity may be reaching alarming proportions in the adolescent age-group but the medical fraternity is divided on using a surgical approach to tackle the urban epidemic. In the absence of clear scientific data, doctors strongly resist suggesting bariatric surgery to those below 18. Till date, few randomized controlled trials have been carried out in India or abroad to judge the long-term efficacy of the surgery in severely obese young adults. Globally mortality has also been associated with the surgery. Last November, when Zoya Khan underwent bariatric surgery at Mumbai's Breach Candy hospital, it created a controversy as she was just 11 months old. While Zoya had a genetic disorder that made her gain weight abnormally many blamed the lack of guidelines for allowing doctors to 'try' the procedure on patients. Head of endocrinology at REM Hospital, Dr. Nalini Shah, supports 'judicious' use of the surgery in morbidly obese adolescents. "The world is still studying the implications of the surgery. Its safety is still an open-ended question," she said adding it may be a solution to some genetic problems. "The selection of patients is of extreme importance," she added. Echoing the view, bariatric surgeon Dr. Srihari Dhorepatil insisted the surgery should be only for those 'physically handicapped' by their weight. "Children who have co-morbid conditions like diabetes, hypertension and weigh more than 100kg can be candidates. Surgery should be considered only if weight becomes a life-threatening issue," he said. "The surgery brings major metabolic changes in the body Teens have high nutritional demand, the surgery should not mess with it," he said. Bariatric surgeon Dr. Ramen Goel added it is imperative that doctors carry out a detailed body composition analysis. "Endocrine or metabolic disorders, if any, should be ruled out before selecting a young adult for the surgery" he said. He also strongly advocated the use of natural weight-loss methods before opting for the surgery. A surgeon from JJ Hospital, however, said follow-ups remain a problem. "When patients have to pay from their pocket, they are reluctant to keep visiting the specialist," the surgeon said. A patient of bariatric surgery needs to pay frequent visits to his/her doctors. "The visits have to be more frequent for an adolescent patient," said Goel. Laparoscopic and bariatric surgery consultant from Seven Hills Hospital, Dr. Ushast Dhir, emphasized that only established institutions should offer the surgery. "Now even general surgeons perform bariatric surgery. We need stringent guidelines to check that," he added.

NUMBER CRUNCHING: A recent study among 24,000 school children in south India showed that the proportion of overweight children increased from 4.94% in 2003 to 6.57% in 2005. Similar study from northern India reported a childhood obesity prevalence of 5.59% in the higher socio-economic strata, compared to 0.42% among the lower socio-economic strata. Unlike developing countries, about 30% children in the upper socio-economic strata are likely to be obese Indian obesity surgeons say about 4% of these children would qualify for bariatric surgery.

'I regained my confidence'

Mumbai: Pedder Road resident Urmila Rao (18) vividly remembers life before last year's bariatric surgery in a south Mumbai hospital. "I weighed around 115 kg. I had difficulty with even basic activities like breathing and walking," she said. Following an allergy in school and subsequent treatment with steroids, Urmila's weight rapidly multiplied in school and college. "With obesity health problems and emotional issues like depression, low self-confidence started affecting me," she said. Urmila also had irregular periods and was diagnosed with polycystic ovary syndrome, a hormonal imbalance that can create fertility issues. After innumerable gym enrolments and countless visits to dieticians, Urmila was told about surgery. "We debated and discussed it for days and finally decided to go for it," she said, adding that a year after the surgery she is 35 kg lighter. "My friends do not know about this. I told them I am on a special diet," she said.

Urmila insists the surgery requires lot of commitment and stringent adherence. "For a few months after surgery I was on liquid food, then soft food and only now have I started eating normal," she said. "I have learnt to control my cravings and my food portions. I now fit in normal clothes and have regained my confidence to a great extent," she said. Urmila however, says this surgery is not for those who cannot bring about drastic changes in their lifestyle. (Name changed on request).

WHO QUALIFIES?

  • Severely obese adolescent teens with BMI above 40
  • Adolescents who have attained skeletal maturity
  • Girls usually reach skeletal maturity at or before 13 years of age and boys at 15 years
  • Adolescents who have co-morbidities related to obesity that might be cured or managed with weight loss
  • More severe BMI elevation (more than 50) may indicate surgical treatment even if co-morbidities are less severe

By Sumitra Deb Roy

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