|Year : 2015 | Volume
| Issue : 1 | Page : 22-29
Obesity and surgical management in indians: A literature review
Anish Desai, Reshmi Pillai, Sandeep Sewlikar, Nilesh Mahajan
Medical Affair and Clinical Operations, Johnson and Johnson Medical India,Mumbai, Maharashtra, India
|Date of Web Publication||6-Jan-2015|
Director - Medical Affairs and Clinical Operations, Johnson and Johnson Medical India, Arena Space, Off JVLR, Behind Majas Depot, Jogeshwari East, Mumbai - 400 060, Maharashtra
Source of Support: None, Conflict of Interest: None
The prevalence of obesity and related co morbid conditions are on an exponential growth globally as well as in developing countries like India encompassing children to elderly population with disregard to socioeconomic status. This review is an attempt to evaluate the published work on obesity and bariatric/metabolic surgery in Indian obese patients to identify gaps in evidences. Based on the current literature research, it can be concluded that there is a need for updated information on the prevalence of obesity in Indian sub-continent. The latest National Family Health Survey is of 2007/2008 and WHO data is of 2010. The increasing prevalence of obesity and metabolic syndrome and perception of disease emphasizes that there is a need for effective communication and education to mothers to bring awareness and reduce the burden in India. Effective outcome with respect to weight loss was observed with Roux-en-Y Gastric Bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), like adjustable gastric banding and also mini-gastric bypass. This weight loss was stable over long follow-up for majority of patients with a reduction of body mass index ranging from 10 to 14 kg/m 2 3 years after bariatric surgery (BS). With respect to treating type 2 diabetes mellitus (T2DM) RYGB and LSG are the two most published metabolic procedure in Indians for surgical treatment of T2DM. No mortality has been recorded so far in published literatures for any types of procedures. BS offers economic benefit to patients in the long run however further studies are warranted.
Keywords: Bariatric surgery, diabetes remission, Indian, obesity
|How to cite this article:|
Desai A, Pillai R, Sewlikar S, Mahajan N. Obesity and surgical management in indians: A literature review. J Obes Metab Res 2015;2:22-9
| India growing: In Obesity|| |
More than 50% of the 671 million obese individuals in the world live in following 10 countries in descending order: USA, China, India, Russia, Brazil, Mexico, Egypt, Germany, Pakistan, and Indonesia.  In current Indian scenario, even with growing awareness about health and fitness, more than 3 crores of the Indian population is obese. , Prevalence of overweight and obesity is observed to be high among urban men and women among all age groups compared with the rural population.  Occurrence of overweight/obesity is similarly on the rise in rural and slum areas of India. For instance obesity incidence in Kerala was (42%), and in urban slum areas of northern India it was 40%. As per latest National Family Health Survey-3 (NFHS 3) obesity (body mass index [BMI] 30 kg/m 2 ) is highest in Punjab (9%) followed by Delhi (8%) and Tamil Nadu. Goa also has a high prevalence of overweight and obesity (>20%) [Figure 1].  Prevalence of abdominal obesity has been consistently higher in women than in men.  In women overweight and obesity increased with age, education, and parity.  Prevalence of obesity in women was found to be more profound in the age between 40 and 49 years (23.7%), those residing in cities (23.5%), having high qualification (23.8%), and belonging to Sikh community (31.6%) and households in the highest wealth quintile (30.5%). Although obesity prevalence increased over time India had low rates of obesity in 2013 with 3.7% (3.3-4.1) of men and 4.2% (3.8-4.8) of women obese in India.  The latest NFHS is of 2007/2008 and WHO data is 2010. Thus, there is a requirement for an epidemiological survey and update in Indian population regarding the ever increasing epidemic of obesity.
|FIGURE. 1. Top 10 states of India in order of percentage of overweight or obese people, based on data from 2007 National Family Health Survey|
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| Obese Young India: In Adolescent and Children|| |
Rate of overweight among Indian adolescents is between 10% and 30% and the percentage of abnormalities because of it increases by 85% in overweight children. ,,,, The mean prevalence of overweight/obesity among the children was 19.2% for males and 18.1% for females with incidence high in age group of 9-13.5 years [Figure 2].  MARG study, the largest study on secular trends of childhood obesity in India showed a significant rise in the prevalence of obesity from 9.8% in 2006 to 11.7% in 2009. ,,,, In India, adolescents from parts of Punjab, Maharashtra, Delhi, and South India are overweight and obese (11-29%). ,,,, High percentages of mothers in India are unaware of link between diet and chronic diseases, which may be the reason for such increasing occurrence, thereby highlighting need for effective education and communication of mothers. 
|FIGURE. 2. Percentage prevalence of overweight/obese children within each group|
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| Perception of Obesity in India|| |
People in India neither accept obesity as a disease nor understand the consequences of diseases associated with obesity. It is observed that 61% of morbidly obese people do not categorize themselves into the bracket of "extremely/morbidly obese" but cast them in the "overweight/obese category."  A large number of studies indicate that feeling of body dissatisfaction is less among Asian women when compared to other ethnic groups.  Research reflects that majority of the people are comfortable the way they are or few feel the need to reduce weight or practice weight loss measures. , These disconnect between actual weight and perceived weight plays an important role when it comes to self-identifying one as an obese individual. Thus appropriate overall, perception of weight status is essentially associated with the decision to lose weight.
| Obesity and related Comorbidities|| |
The rising prevalence of overweight and obesity in India directly correlates to the increasing incidences of comorbidities like metabolic syndrome (hypertension, type 2 diabetes mellitus [T2DM], dyslipidemia, and cardiovascular diseases).  Studies highlight that the prevalence of T2DM, risk factors for cardiovascular system and incidence of breast cancer are high in obese Indians and rate of recurrence of T2DM and hypertension is directly proportion to increasing weight. ,,,,,, One-fourth to one-third of urban population in India has metabolic syndrome and overall prevalence varies from 9% to 50%, with women at increased risk. 
In children and adolescents multiple sclerosis occurs in the age group of 8-19 years. , Nearly 65% of normal weight Indian urban children and adolescents (12-19 years) were found to have at least one cardiometabolic risk factor such as blood pressure, insulin resistance or triglycerides and the percentage of abnormalities in overweight children increases to 85%.  People clearly lack awareness and fail to link obesity with related co-morbid conditions, thus increasing disease burden. 
| Management of Overweight/Obesity in India|| |
As per Asian consensus guidelines for the management of overweight/obesity, it is significant to consider Waist Circumference along with BMI before initiating medical or surgical management. One should consider antiobesity drugs only in combination with diet and lifestyle modifications and monitor on an ongoing basis for efficacy as well as safety. Metformin and exenatide may be used as add-on drugs in certain clinical cases. 
Surgical management of obesity known as bariatric surgery (BS) has developed over last two decades. BS principally modifies the digestive system through restrictive method (by decreasing the gastric volume) or causing malabsorption (by altering the path of the food bolus). These methods help change an individual's eating behavior and modifies lifestyle to lose weight. Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians and Recommendations for Physical Activity, Medical and Surgical Management by Misra et al. 2009, indicate that BS is ideal for Asian Indians with BMI above 32.5 kg/m 2 with co-morbidity, and BMI above 37.5 kg/m 2 without co-morbidity.
The surgical options for weight loss surgery can be restrictive procedures like adjustable gastric banding (LAGB) and sleeve gastrectomy (SG). Malabsorptive procedures like Bilio-pancreatic diversions and combined procedures like Roux-en-Y Gastric Bypass (RYGB). Experimental procedures such as ileal interposition and duodeno-jejunal bypass are also prevalent. In Asia especially in India mini-gastric bypass (MGB) procedure is also performed. IFSO-APC 2013 saw many poster presentations from India on this procedure. Each surgical procedure has its advantages and disadvantages about to weight loss, resolution of co-morbidities, perioperative morbidity and mortality and long-term efficacy. Surgical treatment is not for everyone; hence appropriate patient selection is equally important as procedure selection.
| Bariatric Surgery Awareness and Acceptance|| |
As per Google trends India ranked second highest for volume of information searches on "BS"  and the number of patients undergoing BS is also on the rise. The Obesity Surgery Society of India stated that the number of people undergoing BS increased from 2200 in 2010 to more than 5000 in 2011.
In India, laparoscopic sleeve gastrectomy (LSG) and RYGB are the two most performed bariatric procedures. Occurrence of LSG has increased and the second most popular bariatric operation in the world with 36% of international volume.  There is a vast difference in the numbers of bariatric cases and metabolic/bariatric surgeons as a percentage of the total national population in India, highlighting the need for more trained surgeons to address the growing epidemic [Figure 3] and [Figure 4].
|FIGURE. 3. As per email questionnaire sent to the leadership of the 50 nations or national groupings in International Federation of Surgery for Obesity 2011, metabolic/bariatric surgery procedure in India|
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|FIGURE. 4. Number of Bariatric cases and Bariatric Surgeons w.r.t total population in India, Total National Population, 2011 data from the World Bank|
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| Indian Clinical Evidence for Bariatric Surgery|| |
Approximately, >119 randomized clinical trials were published in last decade for BS worldwide  and a total of 19 randomized control trials (RCTs) compared surgical/nonsurgical interventions with medical care. All RCTs including a Cochrane review (2009) observed a significant difference between the interventional and medical care groups. , Clinical evidences show that BS is effective in improving and/or resolution of comorbidities and help reduce overall cause-specific mortality.  Literature search yielded 12 studies with respect to bariatric procedures performed on the Indian population (few more discussed in metabolic surgery section) [Table 1]. ,,,,,,,,,,,, represents study characteristics, which includes RCTs, retrospective noncomparable studies and retrospective comparable studies in total 2143 patients. Over 30% of excess weight loss (EWL) was noted as early as 3 months following the procedures and increased gradually over a period, reaching 59-80% after 12 months of follow-up. , It would be appropriate to conclude that the favorable effect of BS on excessive body weight was stable over time in Indian patients. At 1-year follow-up, all three procedures showed similar body weight reduction (70%). Three years following surgery, it was observed that EWL dropped to 60% in patients undergoing LSG, and at the same time reached 44% among individuals, who underwent LAGB.
Raj et al. 2010 in their comparative study [Figure 5] demonstrated that in over 3 years follow-up; the laparoscopic RYGB (LRYGB) procedure was the most effective procedure with respect to EWL, followed by LSG and LAGB. 1,054 patients who underwent laparoscopic MGB at an Indian center showed the % EWL at 1-year was 85% and was maintained at a follow-up at 6 years [Figure 6] indicating equal efficacy of the procedure.  Clinical studies addressing patients with BMI <35 are discussed in detail in metabolic surgery section. EWL with RYGB, LSG, LAGB and also MGB  was stable over long follow-up for majority of patients with reduction of BMI ranging from 10 to 14 kg/m 2 3 years after BS as reported by Prasad et al. 2012  and Todkar et al. 2010.
|FIGURE. 6. Body mass index evolution and % excess weight loss after mini-gastric bypass|
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| Diabesity: Bariatric Surgery more than Weight Loss Surgery|| |
In India, approximately 85% of people with diabetes are type 2, and of these, 90% are obese or overweight.  Risk for diabetes in association with increasing BMI was studied by Snehalata et al. in 2003 and the results showed a significant association of diabetes at a BMI >23 kg/m 2 . Compared to diet, lifestyle interventions and antidiabetic medications BS achieved greater and more sustained short term T2DM remission BS when performed to resolve obesity-related co-morbidities such as metabolic syndrome (obesity, T2DM, hypertension, and dyslipidemia) is known as metabolic surgery.  Metabolic surgery not only brings about EWL but also has an effect on incretins and proves beneficial in the management of diabetes.
The procedures now accepted as standard metabolic surgery include: Lap banding, LSG, lap RYGB and lap-modified duodenal switch.  The International Diabetes Federation 2011, recommends metabolic surgery for patients with T2DM and obesity who do not meet targets with medical treatment with major comorbid illness. IFSO-APC consensus statements in 2011 stated that bariatric/metabolic surgery could be considered in Asian with BMI >30 kg/m 2 as a treatment of T2DM/metabolic syndrome that are inadequately controlled by lifestyle interventions or medical treatment; however, it is a secondary alternative for individuals with BMI >27.5 kg/m 2 . It should be noted that any surgery performed on patients with a BMI <27.5 kg/m 2 should be strictly performed only under clinical study protocols with the informed consent of the patient and prior approval from an ethics committee. 
In a poster presented at IFSO-APC 2013, it was shown that with nearly 50% of type 2 diabetics being obese, BS may be cost effective for their treatment as the initial high cost of the surgical procedure is offset over a period of 2-4 years eliminating medical costs to resolve co-morbidities. 
| Metabolic Surgery Clinical Evidence|| |
Recent BS studies showed successful results in patients with T2DM and patients were off medication after surgery [Table 2].  Represents metabolic surgery studies in Indian patients suggesting T2DM resolution in 81-100% of patients 1-year after LRYGB, 81-98% of patients (1-year) and 75-86% of patients (2 years) following LSG.
|Table 2: Resolution of diabetes mellitus after bariatric surgery in Indian patients|
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In a prospective observational study of 52 Indian patients with uncontrolled T2DM (BMI 30-35 kg/m 2 ) who elected to undergo LRYGB, median percentage of EWLs was 72.2% (1-year) and 67.8% (5 years). After 1-year, it was observed that 84.6% of patients achieved euglycemia without medication; using American Diabetes Association criteria 73.1% achieved complete remission and 23.1% achieved partial remission. After 5 years, no hyperglycemia recurred despite weight gain in eight patients; rates of complete and partial remission decreased to 57.7% and 38.5%, respectively, but overall improvement rate in metabolic status was maintained at 96.2%. With the increase in EWL % there was a corresponding increase in T2DM remission in RYGB patients. Patients with the best %EWL had the best chance of complete remission such as patients with >75% EWL had statistically significant greater remission rates than those with %EWL <50%. 
Another prospective cohort study (n = 15) with T2DM (BMI 22-35 kg/m 2 ) who underwent RYGB reported significant improvement in BMI, fasting plasma glucose (FPG), A1C, systolic blood pressure, total cholesterol, and high-density lipoprotein from baseline. One month after surgery, 80% of patients discontinued all antidiabetic medications and 93% had FPG levels within normal range; by 3 months, 100% were euglycemic. At 9 months, hypertension resolved in 67% of previously hypertensive patients and dyslipidemia resolved in 100% of previously dyslipidemic patients. 10-year coronary heart disease (CHD) risk, risk of fatal CHD, risk of stroke, and risk of fatal stroke significantly decreased after surgery.  An Abstract presented at IFSO 2013 showed similar results as shown in [Figure 7]. Retrospective analysis of 214 patients who underwent LSG, reports that 48/98 diabetics had remission, 33 required less medications and rest remained stable. 98/104 patients who were hypertensive came off medication or required less drugs. Thus, LSG is an effective metabolic surgery. Another study by Dasgupta et al. Also reinforces that antidiabetes medication use decreased from 88.57% to 11.4% in obese Indians after SG surgery. 
|FIGURE. 7. A prospectively controlled trial of n = 50 type 2 diabetes mellitus patients subjected to subjected to one of the four surgeries|
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Results of a retrospective study in 69 patients with BMI >35 who underwent either of the two procedures (LYRGB or LSG) showed that both procedures are comparable whereas another study in 59 patients showed that LRYGB is associated with significant improvement in diabetes control with discontinuation or marked reduction of antidiabetic medications in the majority of morbidly obese Indian patients. , Shah et al. prospectively evaluated the role of LSG on gastric emptying half-time and small bowel transit time and effect of these on weight loss, satiety, and improvement in morbidly obese T2DM patients with >1-year of T2DM. These results have shown that the procedure is effective in patients with longstanding T2DM (mean: 5.38 years) and is thus capable of reversing established pathogenetic mechanisms mediating the progress of T2DM.
Kular et al. 2013, study shows that T2DM remission of 93.2% at 6 years with the improvement of over 98% was observed after MGB. Likewise, the improvement was also seen in hyperlipidemia, sleep apnea, and fatty liver [Figure 8]. MGB is hence considered as an option specifically in Asia for metabolic surgery. 
The efficacy of ileal transposition with sleeve gastrectomy (SGIT) surgery in diabetic patients (BMI 23-35) was studied by Goel et al. in 5 patients with disease duration of >10 years.  The study target (HbA1c <7) was achieved in 60% of patients within 1-month and in 100% of patients within 6 months. Requirement of medications reduced significantly within 6 months, and their HbA1c levels reduced from 9.65% to 6.22%. Laparoscopic ileal interposition with diverted SG for treatment of T2DM reported in 17 Indian patients by Kota et al. addressed both foregut and hindgut theories and brought about remissions in T2DM patients with reasonable safety. ,,
So far, RYGB and LSG are the two most published metabolic procedure in Indians for surgical treatment of T2DM.
| Impact of Obesity and Metabolic Syndrome on Economic|| |
An IFSO 2014 abstract highlighted that the average monthly expenditure of an obese individual including medications to treat co-morbidities was 500 USD (30,000 INR). 50% of these patients spent approximately 80-300 USD/monthly (5000-20000 INR). 4% spent more than 1600 USD/monthly (>100,000 INR) incl. surgeries due to complications of diabetes and excessive weight. The basic average cost of BS at a center of excellence in India is approximately 7000 USD (583 USD/monthly), which is lesser than the monthly expenditure of the obese individual.  Diabetes is an expensive disease, the chronic nature of the disease and associated complications increase the cost of treatment. A recent study in India showed that total annual expenditure by patients on diabetes care on average was 10,000 INR (US $227) in urban areas and 6,260 INR (US $142) in rural areas. Treatment costs increased with duration of diabetes, presence of complications, hospitalization, surgery, insulin therapy and urban setting. Thus, expenditure proportionately increased with the number of complications and treatment cost of complications varied significantly between the populations.  The shift of BS from a weight loss surgery to metabolic surgery on the basis of proven clinical evidence in management of diabetes is helping solve this dilemma of "diabesity."
However one of the major causes that most Indians avoid or delay BS is that it lacks insurance cover and compels patients to cover the cost on their own. Health insurers are now considering BS as a lifesaving intervention for obese patients fighting with medical conditions either caused by or related to obesity. It is now no longer a cosmetic procedure, but a metabolic operation to control or cure T2DM. In December 2013, the Central Government Health scheme has declared that it would fund bariatric surgeries for current and former government employees. Many insurance firms need to take a cue from this initiative. 
| Complications after Bariatric Surgery|| |
Like all surgical procedures, complications can occur after BS. Overall literature published on BS in Indians did not ascertain any mortality. Reoperation to treat the delayed leak from the gastroesophageal junction after LSG was reported after 21 days of surgery whereas with, LRYGB it was after 3 days of surgery in a study conducted by Lakdawala et al. The incidence of leaks, which is one of the most serious complications is 1-2%. Commonly observed complication during the literature review was port wound infection in both LSG and RYGB procedure. Pulmonary embolism after LRYGB and internal herniation through the retro colic window 1-month postoperative was also observed. Thus the chances of complications are low. However complications due to nutritional deficiencies have been reported and should be widely cared in postoperative program.
| Conclusion|| |
Review of published literature indicates a need for updated data on prevalence and management of obesity in India. BS for weight loss management and metabolic surgery in obese T2DM Indians requires long-term follow-up data. LSG and RYGB are the two most performed bariatric procedures in India. With nearly 50% of T2DM being obese,  bariatric/metabolic surgery may be cost effective, however long-term follow-up data and economic evaluation in Indian scenario is further warranted to help health insurance to include BS.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]