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Dr. R. Padmakumar
Dr. D. Madhukara Pai
Dr. Farish Shamsudeen

The post Handbook on Bariatric Procedures appeared first on Dr. R. Padmakumar.

Bariatric deals with Obesity. “Baros” is a Greek word which means heavy or large. Bariatric surgery is also referred to as “weight loss surgery” and is performed on people who suffer from obesity. It includes a variety of procedures like Intragastric Balloon Placement, Laparoscopic Sleeve Gastrectomy, various gastric bypass surgeries, and Sleeve with Hybrid Ileal Interposition. These procedures have proven to be effective in long-term weight reduction, resolution of diabetes, improvement in cardiovascular risk factors and obstructive sleep apnea, etc.

BMI = Weight (kg) / Height (m)2

WHO guidelines 2019 for adults over 20 years old

Pediatric BMI Criteria

For children BMI is calculated and compared with Z score for age.

Children: Other than Indian (Click to view)

https://www.who.int/tools/growth-reference-data-for-5to19-years/indicators/bmi-for-age

Boys – Indian

5-18 years: IAP Boys Body Mass Index Charts (Click Link Below)

https://iapindia.org/iap-growth-charts/

Girls – Indian

5-18 years: IAP Girls Body Mass Index Charts (Click Link Below)

https://iapindia.org/iap-growth-charts/

Z score more than 1.64 or BMI more than +2 SD is considered as obese.
Z score more than 1.04 or BMI more than +1 SD is considered as
Overweight.
Thinness is less than -2 SD.

Asian BMI criteria:

Asian BMI Cut-off points :
More than 25 BMI – Clinical obesity
More than 27.5 BMI – Metabolic Surgery can be performed
(2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and
International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO)
Indications for Metabolic and Bariatric Surgery
Dan Eisenberg, Scott A. et.al. iObesity Surgery volume 33, pages3–14 (2023))

Causes of obesity and overweight

It is due to an imbalance between energy in and energy out. An increased intake of energy-rich foods that are high in fat and sugars and a reduction in physical activity due to the sedentary nature of work make the body switch over to energy saving mode. Genetic factors also play a role in causation of obesity. Excess production of Ghrelin also is a contributing factor.

METABOLIC SYNDROME

Metabolic syndrome is a clustering of at least three of the following five medical conditions: abdominal obesity, high blood pressure, high blood sugar, high serum triglycerides, and low serum high-density lipoprotein (HDL).

Metabolic syndrome is associated with the risk of developing cardiovascular disease and type 2 diabetes. In the U.S., about 25% of the adult population has metabolic syndrome, a proportion increasing with age, particularly among racial and ethnic minorities.

Insulin resistance, metabolic syndrome, and prediabetes are closely related to one another and have overlapping aspects. The syndrome is thought to be caused by an underlying disorder of energy utilization and storage.

Each Propels the Other

Diagnostic Criteria of Metabolic Syndrome

Patient has at least three of the five conditions

• Fasting glucose ≥ 100 mg/dL (or receiving drug therapy for hyperglycemia)
• Blood pressure ≥ 130/85 mmHg (or receiving drug therapy for hypertension)
• Triglycerides ≥ 150 mg/dL (or receiving drug therapy for hypertriglyceridemia)
• HDL-C < 40 mg/dL in men or < 50 mg/dL in women (or receiving drug therapy for reduced HDL-C)
• Waist circumference ≥ 90 cm (35 in) in men or ≥ 80 cm (32 in) in women
  

Minor Components

• Sleep apnea
• NASH
• PCOD
• Hirsutism
• Acanthosis nigricans
• Xanthelasmas

Image showing Acanthosis nigricans

Causes:

1) Insulin resistance with fatty acid influx.
2) Low grade chronic inflammation and oxidative stress.

Deleterious effects of Diabetes Mellitus

Vascular damage:

• micro-vascular (retinopathy; nephropathy and neuropathy)
• macro-vascular (premature and more extensive cardio- , cerebro- and peripheral vascular disease)

Premature mortality and morbidity in diabetes result from such complications.

The Dangerous Cluster of Metabolic Syndrome

• It varies between 7.1 to 42.6 % across counties, 26.1 to 29.8 % in South Asia
• 3 times likely to have MI and stroke
• Five fold risk of developing type 2 diabetes mellitus

Reference – https://doi.org/10.1016/j.cegh.2020.03.018

Health consequences of overweight and obesity

Obesity increases the risk of many diseases like

1. Type 2 diabetes, hypertension, dyslipidemia;
2. Cardiovascular diseases and stroke, which were the leading cause of death in 2012;
3. Musculoskeletal disorders (osteoarthritis);
4. Cancers (endometrial, breast, ovarian, and colon).
5. Liver and gallbladder disease
6. Obstructive Sleep Apnea
7. Infertility
8. Psycho-social disorders

Childhood obesity is a growing concern as these children have an increased risk of insulin resistance, hypertension, breathing difficulties, fractures, and psycho-social problems as well as later in adulthood, have a higher chance of obesity and even premature death.

Treatment for Obesity

The first-line treatments for obesity and overweight include diet, exercise, behaviour therapy, and anti-obesity drugs. But for severe obesity this has limited success and success for long term is very poor. Whenever a patient approaches for weight loss, the screening form is filled and investigations are carried out. Procedure is planned based on BMI, comorbidities, and the investigation results.

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