This debate has divided the Indian medical fraternity barely two months after international medical associations of surgeons said Asians with a BMI (body mass index) of over 27.5 and uncontrolled diabetes could consider surgery as a treatment option. The current Indian guidelines, prepared jointly by endocrinologists and bariatric (weight-loss) surgeons in 2009, state that only morbidly obese people (with a BMI of 32.5) with uncontrolled diabetes can be offered surgery.
On one side are endocrinologists who treat diabetes with medicines, on the other side bariatric surgeons who claim there is enough evidence to show that leaner people can undergo surgery for diabetes control. There is no consensus on the nomenclature — diabetes or metabolic or bariatric — either.
“We now have recognition from international medical associations in this matter yet an educational video we put out in this regard is being labelled a hoax,’’ said bariatric surgeon Dr Ramen Goel of Wockhardt Hospital, Mumbai Central. He said local medical associations from small towns had held meetings to criticise the video.
At a press conference on Wednesday, he spoke about a clinical trial he had conducted almost a decade ago in which leaner patients with uncontrolled diabetes underwent surgery.
“Our seven-year follow-up shows that 70% of those patients still enjoy the surgery’s positive effects,” he said. About 32% of those patients were still in complete remission, another 23% had partial remission, and 13% needed small doses of medicine to keep their diabetes under control.
“For a patient who had uncontrolled diabetes despite taking insulin, the stage of needing a pill or two daily is good progress,” he added.
Dr Shashank Shaha bariatric surgeon from Lilavati Hospital, Bandrasaid patient selection is important for diabetes surgery to work. “The new international guidelines, spelt out in December 2022, say patients over 27.5 BMI with significant central obesity and uncontrolled diabetes despite multiple medications can be considered for metabolic surgery,” he said, adding that “surgery shouldn’t be seen as a permanent cure”.
Endocrinologists such as Dr Shashank Joshi are categorical that surgery is still an experimental option for diabetics. “It is at best the last resort for a patient with uncontrolled diabetes, after every other option has failed,” he said. Moreover, there are new “compelling” medicines that not only help in remission of diabetes but also in weight control. “In fact, the new medical agents that cause remission also protect the heart and kidneys,” said Dr Joshi.
Dr Anoop Misraa senior endocrinologist from Delhi, said there is no doubt that bariatric surgery helps control diabetes in morbidly obese patients. “The numbers for bariatric surgery are rising in India as a result, but the main discussion right now is on whether it can be offered to leaner patients with diabetes,” he said.
Dr Misra said the fraternity is still resolving the issue. “We should have new guidelines within a couple of months,” he said.