Mufaffazal Lakdawala, Vice President, Obesity Surgery Society of India
Harry Frydenberg, President, International Federation for Surgery of Obesity and Metabolic disorders, Australia
Seigo Kitano, President, Japanese Laparoscopy and Endoscopy Surgery society, Japan
Anton Cheng, Unit Chief, Singapore General Hospital
Chih-Kun Huang, Chief, Bariatric and metabolic surgery centre, Taiwan
The problems associated with obesity are as much emotional as they are physical. Unfortunately, our fixation with our bodies makes us completely ignorant of the role our mind plays in physical issues. So we decided to source some top experts to throw light on the emotional aspects. Coincidently, top experts across Asia and Australia had visited India last month to discuss guidelines governing the assessment of a patient as a candidate for bariatric surgery. Here’s what they have to say.
What emotional problems do obese people face?
Dr Lakdawala: Most of these people avoid being social because of a negative self-image. The more they do this, the more they get depressed and lonely. Their job and relationships also get affected. They go deeper and deeper into their shell of loneliness. They then insult their body by eating more. [It is easy to insult your body with food as it never retaliates]. These psychological imbalances cause them to eat the wrong foods, which in turn causes them to gain weight. It is a vicious cycle.
Dr Frydenberg: Most obese people face undermining psychological and stress-related problems. They feel outcast and do not have many friends. Because of their dissatisfaction about their bodies, they do not go out or socialise and this leads to loneliness and depression.
Depression causes them to eat in excess. Unfortunately, they also don’t have a set point in the body that tells them to stop. Despite not being hungry, they keep eating to feel better—their way of compensating for the bad feeling they are experiencing.
And most often than not, the food they eat is of the wrong kind—chocolates, high-fat food and goodies. So it’s the combination—type of food and the amount.
I’d like to mention here that people erroneously believe that obesity remains a problem because of their genetic make-up. However, the genetic risk in morbid obesity is less than five per cent as there are a lot of genetic back ups in the body. A low-emotional state is what really escalates the problem.
Dr Kitano: Obese individuals feel unsuccessful all the time because of their weight. They feel alone and separated from the society. They do not socialise and become depressed, which makes living with the condition more difficult.
Dr Cheng: Depression is the number one emotional problem obese people face. Hence, while deciding the treatment too, it becomes important for us to consider their emotional state.
Dr Huang: Obese people suffer from depression, anxiety and lack of confidence. They feel rejected by the general population and do not mix much. They eat to control these negative emotions and in turn become obese—it’s like a vicious cycle. So these psychological problems need to be treated first before opting for surgery.
What role does the person’s mindset play in the success of a surgery?
Dr Lakdawala: Having a positive mindset is important when preparing for surgery. Hence, psychiatric counselling is the most important part of the process. We need more than 100 per cent cooperation from the patients—we do not go ahead with the surgery if the person is not even 50 per cent ready. Before the surgery, we encourage them to talk to people who have had successful surgeries. We form support groups and help them get the confidence that it is not the end of life and there is a second chance at life. These groups help us to bring them out of depression.
Dr Frydenberg: Since they are depressed, they usually have to be given anti-depressants or mood elevators before the treatment. Motivation is the next most important factor in surgery. For instance, I always tell my patients that there is no miracle cure and surgery is just a tool in managing the condition.
The surgery involves a multi-disciplinary approach involving a surgeon, dietician, physical therapists, and a psychological expert. It is important to make the patients feel cared for.
Dr Kitano: The mindset of the person is important. If the person is not ready mentally, it affects his recovery. Generally, post surgery, most patients feel happier—their face becomes much brighter.
Dr Cheng: I tell my patients that the surgery is a very small part of what they have to do. Surgery will just help them adjust their lifestyles. However, the real hard work starts after the surgery. We start by first counselling the patient about the entire journey before we decide to operate. This plays a crucial role in the success of the surgery. If they are not ready, no one can guarantee a successful surgery. Hence, it is important to prepare the patient. In some cases, they can also opt for psychological counselling.
In fact, some people even discontinue treatment after realising the hard work they have to do. So we tell them that if you are not willing, you should not opt for the surgery. I believe that success of the surgery is a collective effort. Surgery is done last.
I feel that the surgeon is the least important person; all others truly lay the foundation. It is important for the person to be mentally ready for it. She needs to be open, positive and willing. It is not easy for all people to become mentally so strong.
Dr Huang: It is important to prepare the person for the surgery to control her anxiety and depression. Hence, psychiatry is crucial. We need 100 per cent cooperation from the patient. My message to them is: Change your mind to change your body.
Can there be a relapse after surgery?
Dr Lakdawala: If the right surgery is done on the right person, there is no chance of relapse. Once this is ensured, our multi-disciplinary approach to surgery does the rest. The nutritionist is the most important fulcrum and regular monitoring and follow ups helps patients to maintain their new weight. Regular follow-ups is key to success. Since there is no single cure for obesity and it is a life long condition, monitoring is extremely important.
Dr Frydenberg: It’s a matter of keeping themselves motivated. If post surgery, they do not follow proper eating patterns they can relapse. Most surgeries are based on the principle of restriction—but you still have to eat the right kind of foods. Even in less quantity, if you eat foods full of calories, then there is no point in doing it. It is essential for them to be conscious of what they are eating. They have to be continuously monitored especially by the dietician. So, I would say that the success is actually a joint effort and depends on the patient and her expert.
Dr Kitano: In case of obesity surgery, which is a multi-disciplinary approach, it is important to educate the patients to improve their dieting habits. This helps them to cooperate in the post surgery rehabilitation to maintain their weight.
Dr Cheng: Some of them do go back to their old eating habits and create problems for themselves. Hence, they need to be continuously monitored. Once they realise the effects that weight has on their life, they become more serious.
Dr Huang: Relapse depends on regular monitoring. We try and help them break the cycle by doing regular counselling. It is not just about the surgery, it is about the lifestyle and behaviour of the person.
Obesity damages other parts of the person’s body. Is the damage permanent?
Dr Lakdawala: No, the damage is not permanent in most diseases. Conditions like sleep apnoea, type-2 diabetes, blood pressure, gastric reflux disease, varicose veins, leg ulcers, high cholesterol and joint pain can all be reversed. Only in cases where the patient has late diabetic nephropathy or osteoarthritis, can the damage not be completely reversed.
Dr Frydenberg: This depends on age, elasticity of their body and how much weight they have lost. The younger the person, the better is their response. As you grow older, it becomes little difficult as the body does not cooperate much. The surgery prevents certain future problems. In many cases, post surgery, people no longer need an orthopaedic surgery. Their blood pressure and heart disease also get managed—and all this is because of the reduction in weight.
Dr Kitano: Damage can be minimised and diseases of the heart and blood pressure can be managed. Surgery can save their life as excess weight has severe effects on the body.
Dr Cheng: Surgery not just brings down weight, but also minimises related problems. Patients are better able to manage the problems—hypertension, heart disease and bone problems come under control.
Dr Huang: By losing weight, about 70 per cent of co-morbid diseases like cardio myopathy, high blood pressure and even sleep apnoea can be reversed. However, if the patient has the disease for over 10 years, it might not go away. Though, it will definitely reduce. The surgery maintains the homeostasis of the body.
In order to collate, present, discuss and debate to adopt mutually formulated clinical guidelines, CODS spearheaded the convening of ACMOMS [Asian Consensus Meeting on Metabolic Surgery]—the first-of-its-kind gathering of the best laparoscopic surgeons and endocrinologists across Asia.
The third annual conference of ACMOMS resulted in the formulation of guidelines specific to the Asian genotype as opposed to the guidelines established by the National Institutes of Health [NIH] in the US that had relevance for the Caucasian body type but little applicability to the Asian body type. These guidelines that were published in the reputed Obesity Journal in addition to numerous other scientific journals have gained accolades globally. This has resulted in the creation of the Asian Diabetes Taskforce, which had its first meeting last year in Taipei.
On this occasion, Dr Muffazal Lakdawala, founder of CODS, demonstrated the Single Incision Laparoscopic Sleeve [SILS] gastrectomy, which he has pioneered in Asia. This surgery is an evolution of the laparoscopic procedure involving multiple small incisions performed through the navel leading to shorter hospital stays, quicker recovery time, less pain and trauma and no visible scars.
This was first published in the September 2010 issue of Complete Wellbeing.