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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 53  |  Issue : 4  |  Page : 135-139

Obesity and surgical intervention: How acquainted are we?


Department of General Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Submission18-Mar-2020
Date of Decision21-Apr-2020
Date of Acceptance05-Jun-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
M V Ramya
Bangalore Medical College and Research Institute, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_29_20

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  Abstract 


Background: Obesity is one of the leading causes of worry due to the vital role it plays in pathophysiology of many metabolic diseases. Even though there are various approaches taken to treat obesity, bariatric surgery has been shown to be effective. There is still hesitancy among the medical fraternity to accept bariatric surgery. We aim, in this study, to evaluate the perceptions and awareness about obesity and bariatric surgery among the medical fraternity.
Materials and Methods: A survey consisting of an anonymous questionnaire was conducted which included undergraduate students, house surgeons, postgraduate residents, and consultants from various specialties in various institutes across Karnataka as participants. The study was conducted in September 2019. The research tool was designed using www.surveymonkey.com, which consisted of questions regarding obesity and its surgical management and was circulated among medical colleagues through social networking websites such as WhatsApp and Facebook, Inc. The survey was made available for 10 days. Questions were framed using skip logic, wherein each set of participants had a selected set of questions. A total of 28 questions were circulated for each participant.
Results: Six hundred and seventy-one participants took part in the survey, among which 53.57% were undergraduate students, 28.18% were postgraduate residents, and 18.25% were consultants. About 88.03% believe that obesity is a disease and has a high prevalence in India. Nearly 96.87% of them are of the opinion that obesity affects only the educated, high socioeconomic status, and urban population, and 25.3% of them believe that obesity is not seen in the rural, low socioeconomic status population. Only 7.12% of them are aware of the fact that obesity is a causative factor for cancer. About 46.3% of them opine that obese patients are discriminated in the health sector. However, 61.57% of them would not like to undergo the surgery in case they ever fall into the obese category nor would they recommend it to their relatives.
Conclusion: By making simple models and flow charts to educate the healthcare professionals regarding obesity, pathophysiology and the treatment might reduce the stigmatizing attitudes and reduce the discriminatory attitude towards obese patients and would help in the efficient management of obesity and its associated comorbidities.

Keywords: Bariatric surgery, graduates, medical students, metabolic surgery, obesity


How to cite this article:
Manangi M, Hegde B, Shivashankar S, Anandan P, Venkatappa S, Ramya M V. Obesity and surgical intervention: How acquainted are we?. Formos J Surg 2020;53:135-9

How to cite this URL:
Manangi M, Hegde B, Shivashankar S, Anandan P, Venkatappa S, Ramya M V. Obesity and surgical intervention: How acquainted are we?. Formos J Surg [serial online] 2020 [cited 2020 Oct 23];53:135-9. Available from: https://www.e-fjs.org/text.asp?2020/53/4/135/292726




  Introduction Top


Obesity is a major public health and economic problem of global significance. The prevalence rates are increasing all over the world, both high-income country and lower middle-income country. Obesity and related problems are now so common that they are replacing the more traditional public health concerns such as undernutrition and infectious disease.[1]

India is a developing country which is in a transitional state of undernutrition due to poverty and obesity because of rapid urbanization.[2]

In India, more than 135 million individuals are affected by obesity. The prevalence of obesity in India varies among age, gender, geographical environment, socioeconomic status, etc. According to the ICMR-INDIAB study 2015, the prevalence rates of obesity and central obesity are 11.8%–31.3% and 16.9%–36.3%, respectively.[2]

Among men, the prevalence is generally similar at all income levels, with a tendency to be slightly higher at higher income levels. However, among women, obesity prevalence increases as income decreases, with higher income women less likely to be obese compared to lower income women.[3]

Obesity plays a key role in the pathophysiology of many metabolic diseases such as Type 2 diabetes, hypertension, dyslipidemia, osteoarthritis, sleep apnea, cardiovascular disorders, and cerebrovascular accidents. Excess weight is also known to have been associated with certain cancers such as colon and prostate in men and breast, uterine, and ovarian in women.[4]

Obese individuals are not only vulnerable to metabolic disorders but also subjected to negative societal attitudes, stigma, and prejudice. Weight bias has been documented in multiple settings including places of employment, health-care facilities, educational institutions, mass media, and close interpersonal relationships with friends and family members.[3]

Many measures have been taken to tackle the burden of obesity, such as diet and lifestyle modification and also drug therapies. However, none of them have shown to curb obesity effectively.

Bariatric surgery has shown promising results in many studies[5],[6],[7] and is gaining popularity off late. Bariatric surgery has been implicated in not only weight loss but also improving glycemic control,[8],[9],[10] hypertension,[11] obstructive sleep apnea,[12] arthritis, infertility,[13],[14] hypothyroidism,[15],[16] and depression.[17]

Furthermore, bariatric surgery causes a reduction in the costs of the health service by reducing the costs of treating comorbidities, whose conservative treatment absorbs medical resources over the long term and is often ineffective.[4]

Despite the growing evidence, there exists a preformed notion that bariatric surgery is only to enhance physical appearances or that it is only for the affluent society. Albeit, the abundant literature and concrete evidence suggesting favorable outcomes of bariatric surgery on obesity, there still persists hesitancy among the medical fraternity about the acceptance of it. There is a need to educate health-care providers about obesity and its surgical management. We aim, in this study, to explore the perceptions and awareness about obesity and bariatric surgery among medical fraternity.


  Methods Top


A survey consisting of an anonymous questionnaire was conducted which included undergraduate students, house surgeons, postgraduate residents, and consultants from various specialties in various institutes across Karnataka as participants. The study was conducted in September 2019. This retrospective study is exempted by the ethical committee.

The research tool was designed using www.surveymonkey.com, which consisted of questions regarding obesity and its surgical management and was circulated among medical colleagues through social networking websites such as WhatsApp and Facebook, Inc. The survey was made available for 10 days.

Questions were framed using skip logic, wherein each set of participants had a selected set of questions. A total of 28 questions were circulated for each participant.

Questions were framed to address the following aspects:

  1. Obesity as a disease or burden?
  2. Obesity and its effects on health
  3. Obesity and its effects on social well-being
  4. Treatment modalities for obesity
  5. Bariatric surgery as a treatment for obesity
  6. Myths on bariatric surgery
  7. Awareness about costs and availability of the services provided in their institute
  8. Attitudes and perceptions regarding bariatric surgery.



  Results Top


The responses were collected and analyzed in the website www.surveymonkey.com. Six hundred and seventy-one participants took part in the survey, among which 53.57% were undergraduate students, 28.18% were postgraduate residents, and 18.25% were consultants [Table 1].
Table 1: Demography of the respondents

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Obesity – As a disease

About 82.03% of the total participants consider obesity as a disease. If all the participated consultants consider obesity as a disease, only 52.45% of postgraduates and 29.58% of undergraduates consider obesity as a disease. Majority of the participants (92.31%) correctly answered that the abbreviation of BMI is body mass index.

Only 12.07% of consultants, 8.45% of postgraduates, and 4.78% undergraduates believe that obesity is also seen in the rural, low socioeconomic status population.

Majority of the participants answered the question correctly regarding the metabolic syndrome that it consists of insulin resistance (95.44%), obesity (92.02%), and hypertension (77.21%). When asked to enumerate the disorders associated with obesity, only 34% of the participants quoted cancer.

Obesity – Effects on various aspects of life

About 76.35% of the participants believe that obesity affects societal relationships, and 98.58% of the participants believe that it affects physical and mental health.

When asked regarding which aspect of life is affected by obesity, 63.15% of the consultants, 7.95% of postgraduates, and only 3.26% of the undergraduates responded that it affects professional life.

Regarding the discrimination of obese individuals with respect to various aspects of life such as professional, societal, interpersonal relationships, health, and psychological factors, the responses are as shown in the graph [Figure 1].
Figure 1: Aspects of life affected by obesity

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About 44.83% of the participants agree that discrimination against obese individuals is present in health-care facilities.

About 50.14% of the participants answered that they were not happy dating an obese person.

Obesity and bariatric surgery

When asked regarding what was really meant by “surgical treatment of obesity,” only 45.31% of the participants opined correctly that it is reduction of the intake of food or it is digestion and absorption through operations on the stomach and intestines. About 10.63% of the participants assume that it is excision of the excess intra-abdominal fat; 9.38% of the participants think that it is the excision of excess subcutaneous fat. However, 34.69% of the participants believed that the answer was all of the above [Figure 2].
Figure 2: Surgical treatment of obesity

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When questioned if the participants were aware of the availability of bariatric surgery in their institution, if all the consultants were aware of the facility, only 27.89% of the undergraduate students and 67.02% of the postgraduate students were acquainted about it.

When questioned regarding the probable cost of undergoing a bariatric surgery, only 21.56% of the participants responded that the cost is < US$ 699.31. About 49.06%, 18.44%, and 10.94% of the participants responded that the cost is US$ 1398.62–4195.86, US$ 4195.86–6993.10, and US$ >6993.10, respectively [Figure 3].
Figure 3: Cost to undergo bariatric surgery

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More than half of the participants, i.e., 53% of the participants (56.04% of consultants, 54.51% of postgraduates, and 51.87% of undergraduates) do not think it is justifiable to go under the knife for obesity.

A striking 51.11% of the participants replied that they would not recommend bariatric surgery to their near and dear ones.

When asked if the participants would undergo bariatric surgery, if they ever fall within the obese category, 60.57% of the participants (consultants (74), postgraduates (115), and undergraduates (219) disagreed to this.

Regarding the knowledge about obesity and bariatric surgery, 42 of them felt that it is not needed in their practice; surprisingly, 26 of them felt that it is not relevant/needed to know.


  Discussion Top


Obesity is associated with numerous negative health outcomes and also limits treatment success in certain conditions.[18] Despite the frequency with which doctors encounter obesity, there is a paucity of data regarding their knowledge and attitude toward obesity and bariatric surgery.

It is possible that doctors' hesitation to treat obesity is caused by their negative attitudes about this disorder, often stereotyping obese patients as weak willed, lack self-control, and lazy. These attitudes likely lead to avoiding interactions with obese patients regarding weight management and discussion about its complications.[19] There is a reluctance among health-care professionals to accept obesity as a disease.

According to Sikorski et al., 56.8% of the professionals felt that they get biased while treating obese patients.[20] Similarly, in our study, 44.83% of the participants felt that obese patients get discriminated in the health-care sector.

Although medical professionals are aware about various metabolic disorders related to obesity, association with cancer is not looked upon seriously. The World Cancer Research Fund reports showed that common cancers in obese people are predominantly endometrial, esophageal adenocarcinoma, colorectal, postmenopausal breast, prostate, and renal; in our study, only 34% of the respondents were aware of the fact that obesity is a risk factor for cancer.

In a study conducted by Giaro et al., 7.7% of the doctors felt that they need not improve their knowledge regarding bariatric surgery,[4] whereas in our study, only 1.90% felt the same way.

In a study conducted by Ponstein, 6.7% of the medical fraternity surveyed did not support bariatric surgery,[21] whereas in our study, 51.11% of the respondents did not support bariatric surgery for their near and dear ones.

Zacharoulis et al. found that in their study, a minority of doctors (24.7%) knew of the existence of a nearby bariatric center in their area,[22] whereas majority of consultants (70.31%), 7.89% of the undergraduate students, and 67.02% of the postgraduate students in our study were acquainted about it.

As per a study conducted by Doble et al., the mean total procedural cost for bariatric surgery in the US hospitals was US$14,389,[23] and in another study conducted by Beebe et al., in India, the approximate cost was US$ 8000.[24] However, in our institution, run by the State Government of Karnataka, it is being done for approximately US$ 562.01.

When asked to select the appropriate treatment for a patient who failed to lose weight with diet and exercise, majority of the participants, in the study by Zacharoulis et al., stated that they would insist on the bariatric procedures.[22] However, in our study, 53% of the respondents do not think that it is justifiable to go under the knife for obesity.

Despite being aware of obesity and its adverse effects on different aspects of life, medical professionals seem hesitant to accept bariatric surgery as a treatment modality for obesity. There exists a lack of proper education about obesity and bariatric surgery among medical students. A multidisciplinary approach to bariatric patients will promote better outcomes and quality of life. By making simple models and flow charts to educate the health-care professionals regarding obesity, pathophysiology and the treatment aspect might reduce the stigmatizing attitudes toward obese patients. Communication between disciplines is essential. Additional studies are needed to establish which educational programs will best serve in the medical and surgical care of the morbidly obese.


  Conclusion Top


Various continuing medical education programs on obesity and its surgical treatment would educate medical professionals. It is also advisable to introduce content on obesity and metabolic surgery into the curriculum taught at medical schools and would seem appropriate to include topics on obesity and its prevention in the syllabus of preventive and social medicine to highlight the primordial type of prevention. Educating medical professionals regarding obesity may reduce the discriminatory attitude toward obese patients and would help in the efficient management of obesity and its associated comorbidities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Ahirwar R, Mondal PR. Prevalence of obesity in India: A systematic review. Diabetes Metab Syndr 2019;13:318-21.  Back to cited text no. 2
    
3.
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Giaro M, Wyleżoł MS, Lipski P, Truszczyński O. An evaluation of the knowledge of the surgical treatment of obesity among surgeons. Wideochir Inne Tech Maloinwazyjne 2014;9:6-12.  Back to cited text no. 4
    
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Oppert JM, Bellicha A, Roda C, Bouillot JL, Torcivia A, Clement K, et al. Resistance training and protein supplementation increase strength after bariatric surgery: A randomized controlled trial. Obesity (Silver Spring) 2018;26:1709-20.  Back to cited text no. 5
    
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Courcoulas AP, Yanovski SZ, Bonds D, Eggerman TL, Horlick M, Staten MA, et al. Long-term outcomes of bariatric surgery: A National Institutes of Health symposium. JAMA Surg 2014;149:1323-9.  Back to cited text no. 7
    
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Genser L, Barrat C. Bariatric surgery versus intensive medical therapy for diabetes -5- year outcomes. Obésité 2017;12:65-7.  Back to cited text no. 8
    
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Tang Q, Sun Z, Zhang N, Xu G, Song P, Xu L, et al. Cost-effectiveness of bariatric surgery for type 2 diabetes mellitus: A randomized controlled trial in China. Medicine (Baltimore) 2016;95:e3522.  Back to cited text no. 9
    
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Cummings DE, Cohen RV. Bariatric/metabolic surgery to treat type 2 diabetes in patients with a BMI <35 kg/m2. Diabetes Care 2016;39:924-33.  Back to cited text no. 10
    
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Banerjee S, Garrison LP Jr., Flum DR, Arterburn DE. Cost and health care utilization implications of bariatric surgery versus intensive lifestyle and medical intervention for type 2 diabetes. Obesity (Silver Spring) 2017;25:1499-508.  Back to cited text no. 11
    
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Sillo TO, Lloyd-Owen S, White E, Abolghasemi-Malekabadi K, Lock-Pullan P, Ali M, et al. The impact of bariatric surgery on the resolution of obstructive sleep apnoea. BMC Res Notes 2018;11:385.  Back to cited text no. 12
    
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Moran LJ, Norman RJ. The effect of bariatric surgery on female reproductive function. J Clin Endocrinol Metab 2012;97:4352-4.  Back to cited text no. 13
    
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Scholtz S, Le Roux C, Balen AH. The role of bariatric surgery in the management of female fertility. Hum Fertil (Camb) 2010;13:67-71.  Back to cited text no. 14
    
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Rudnicki Y, Slavin M, Keidar A, Kent I, Berkovich L, Tiomkin V, et al. The effect of bariatric surgery on hypothyroidism: Sleeve gastrectomy versus gastric bypass. Surg Obes Relat Dis 2018;14:1297-303.  Back to cited text no. 15
    
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Zendel A, Abu-Ghanem Y, Dux J, Mor E, Zippel D, Goitein D. The impact of bariatric surgery on thyroid function and medication use in patients with hypothyroidism. Obes Surg 2017;27:2000-4.  Back to cited text no. 16
    
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Hjelmesæth J, Rosenvinge JH, Gade H, Friborg O. Effects of cognitive behavioral therapy on eating behaviors, affective symptoms, and weight loss after bariatric surgery: A randomized clinical trial. Obes Surg 2019;29:61-9.  Back to cited text no. 17
    
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Ferrante JM, Piasecki AK, Ohman-Strickland PA, Crabtree BF. Family physicians' practices and attitudes regarding care of extremely obese patients. Obesity (Silver Spring) 2009;17:1710-6.  Back to cited text no. 18
    
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20.
Sikorski C, Luppa M, Glaesmer H, Brähler E, König HH, Riedel-Heller SG. Attitudes of health care professionals towards female obese patients. Obes Facts 2013;6:512-22.  Back to cited text no. 20
    
21.
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22.
Zacharoulis D, Bakalis V, Zachari E, Sioka E, Tsimpida D, Magouliotis D, et al. Current knowledge and perception of bariatric surgery among Greek doctors living in Thessaly. Asian J Endosc Surg 2018;11:138-45.  Back to cited text no. 22
    
23.
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24.
Beebe DS, Goel S, Lakdawala M, Olejniczak MJ, Jochman J, Singh H, et al. Surgery for obesity: India versus USA – A snapshot perioperative care comparison at two centers. J Anaesthesiol Clin Pharmacol 2010;26:157-61.  Back to cited text no. 24
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