Diabetes & Obesity is a lethal COMBO

Dr. Mufazzal Lakdawala is a world renowned Baritric surgeon who has changed the life of famous politicians and Bollywood personalities after operating upon them. He is founder & President of ACMOMS ( Asian Consensus Meeting on Metabolic Surgeries) and also President of IFSO, International Federation for Surgery of Obesity. He talks about diabetes, Kashmir and people in a candid interview

Why is diabetes becoming the most discussed disease?

Diabetes is a growing concern worldwide. In 2009- 10, UN passed a resolution about non- communicable diseases of which diabetes was a part. It was discussed that metabolic syndrome including diabetes, hypertension etc., would be a major killer. It is the biggest health concern across the world and all the governments need to stand up and take a call, including J& K. Type 2 diabetes, now called Adult Onset Diabetes, constitutes 90% of the diabetics world over. It used to be blamed on genes but that is not the case entirely.

We had forgotten that when we are in our 20s and 30s we don’t have expanding waistlines. It is when the waistlines expand, all the problems start to appear and that is exactly when diabetes shoots its ugly head up. India ranks second to China in terms of number of diabetics. The unfortunate part is that 50 percent of diabetics are undiagnosed. By the time one is diagnosed with diabetes, half of the time span is already over. The remaining period is therefore an accelerated time resulting in kidneys shutting down, eyes failing to see, slippers and shoes fall off when you don’t even know. Today we have a realistic solution for obese diabetics that would mean 80 percent of the diabetics. It is a preventable disease but not genetic per se. The only role of genes is that they would make us predisposed to conserve what we eat. It is popularly called ‘ Thrifty Gene Hypothesis’. It was a survival tactic but today we are not faced with periods of famine but have a lot more to eat than what is needed. The same genes are becoming detrimental therefore. Earlier it was thought that diabetes is a disease of pancreas now it is quite clear that it has a lot to do with the gut instead.

Is Kashmir diabetes scenario any different?

There is not much of a difference.
But diet is an issue. People of Kashmir eat rice primarily, as a staple. And that is not good at all. One more thing that appears to be a staple of people of Kashmir is red meat, which again is bad, very bad. The combo of red meat and rice on the journey to weight loss is a tough bet. It is difficult to make people give up on either rice or red meat because this is something that they have eaten since childhood. It is my advice to the people of Kashmir to cut down on red meat and rice, whether or not one is diabetic. But I don’t know how many out there would take this advice! But we also have to look at the fact that over the past people have eaten this food without going through the problems that we are bereft of now. It is because of the lifestyle changes that have redefined how the food we eat treats us.

The key word therefore is moderation in the amount of food and being physically active, at least for an hour daily. And remember, once you are older, or your trousers start getting tight round the waist, reduce your rice intake by half. Our metabolic rates slow down with age. Post- menopausal women also need to be aware of what they are eating.

How can obesity be addressed in schools, as you say, when all that school canteens serve is the food that is called ‘ junk’?
Authorities around the world have already started taxing the junk foods heavily. But India still has not recognised obesity as a disease. Until the government does not do that, junk food will continue to be on the plate of children.

We talk about midday meals to kids, because we are still talking about undernutrition. I feel under- nutrition has already been tackled in India except a few pockets that we all know about. But we are bereft with malnutrition that results in kwashiorkor and rickets. Today hypoproteinemia and Vitamin- D deficiency needs to be tackled rather than mere adding of calories to the diet of kids. Obese people are also malnourished.

The whole proposition of not recognising obesity as a disease is misplaced, misleading. The most productive section of the society, people in their thirties and above are getting afflicted with diabetes. That makes it all the more important to tackle it before it happens.

There are a myriad of offers touted as ‘ diabetes solutions’ out there. How do you see that affecting people’s health?

Allopathy is the only branch of the medicine that is ‘ accountable’ today. The success and the failure of these medicines are quantified. It is not the case with other branches of medicine. Like for example, Ayurveda; one does not even know the ingredients, there are variations of dosage recommendations and then if something goes wrong, what is the antidote for that? There are no research trials going on any of these drugs, Homeopathy is better but we are still away from perfection.

Diabetes, for decades has been tackled with pills and shots. In terms of which drug is better, when and how to use insulin and other questions like that much still needs to be discussed. It has been told and re- told that there is no cure for diabetes.

It is radical to think today that there is a cure for diabetes and that cure is bariatric surgery. It is almost unbelievable and that is why there is so much debate.

It will take time to make people believe that a cure for diabetes is possible but it surely is happening. People who have undergone the metabolic surgery have seen the benefits and it will percolate from there. The associations such as American Diabetes Association ( ADA) and others have accepted bariatric surgery as a solution for obese diabetics. 99.9 percent of diabetics are managed through pills and shots, imagine when we will be able to get even 2 percent diabetics out of this net of drugs! The surgery can prevent them from the unavoidable dialysis, amputations, eye- surgeries.

Some would argue that surgeons are being over- zealous and want to cut everybody but till we get surgery in a pill, this is the only real solution for diabetes.

Who is the ‘ right’ candidate for bariatric surgery?
International Diabetic Federation guidelines that were formulated by five surgeons, thirteen endocrinologists, epidemiologists and researchers have defined it well. The white paper has a complete chart that says I was one of the authors, say Patients with BMI above 37.5 if you are an Asian and having diabetes that is not getting controlled are to be prioritized for surgery. Patients with BMI above 27.5 and having diabetes that is not getting controlled are to be given an option of surgery, made aware of it. Insulin bites that hand that feeds it, makes one put on weight. We take insulin without realising that it might be making us put on weight, and you will have to take more and more of it. Some of the newer drugs that may be without this effect are very expensive for most people. Some of these drugs have come up because of Bariatric surgery because it was being done of obese people and for a long time it was not realised that it works well on diabetes. Most drugs for obesity, and there are about 500 of these in the pipeline have been banned with 2- 3 years. They have side- effects such as high suicidal tendency. Orlistat is perhaps the only drug that is an option and is right now available only for the US patients.

How well is J&K equipped to do Bariatric surgeries?

It is not well prepared. There are shortcomings of equipment and trained surgeons. Remember, this is a lifestyle surgery. It is not like cancer where you operate upon a patient and if something goes wrong, you say, alright, the patient anyways had limited chance. A diabesity surgery where you are challenging the very thought process that says, ‘ oh, he is fat but he is fine’, is tricky. You have to make people believe that this is a better chance for a better lifestyle. And in this case, if things go wrong, no one is going to forgive you. Media is the first one to jump on us. That gives us all the more reason to realise that if we are not prepared, let us prepare ourselves. Therefore Kashmir needs to use next six months to a year to get prepared – get equipment, send surgeons from here for trainings, spend some time with us for example, surgeons who do high volume of such cases. Then, slowly take baby steps and start on your own. Right now, doing bariatric surgery here is a little dicey.

There are a lot of people who would need and want a Bariatric surgery but are not in a financial position to get it done, what are the options for them?

It is a problem, more so because the equipments come on a high price, there are high taxes on these as these have to be imported. The day it is it is seen and accepted as a life- saving surgery by the governments, the cost will come drastically down. It is an ultra- modern surgery. We will also need to get the insurance companies to play their role and cover this type of surgery in the plans.

Governments need to put its foot down and say that this is the kind of food that we prescribe to be kept available for kids. There need to be warnings on food packets about their calorific significance, like the ones we have on packets of cigarettes. Warnings need to be there on cola drinks too. It might not happen suddenly, but it needs to start. Today, what are the foods that we get in schools, pizzas, burgers, potato chips?! You have every film star endorsing a cola drink or a wafer.

You taught a lot during your visit to Kashmir; did you learn something in return?

Yes, I learnt to curtail myself. We had eight surgeries slated up. We did seven surgeries and the in the eighth case, there was an urge to got out, operate and save someone’s life. This case was a high risk case, he had a shunt placed, he was more than 200 kgs. Everybody said, let us do it. But I realised that we did not have the kind of backup that would be ideal for this case. So I said, I am not doing this case. I asked him to come to Mumbai, where I promised to it free of cost. I had promised to try save his life, but I will do it with conditions that I feel are optimum, where chances of saving him are better. A workshop is not the ideal most place to test the doctors skill sets. My motto is to try and save all the lives one can, many people disagree on that. I learnt to re- look at my motto too.

How do you see Kashmir coming up as a Corporate Tourism Destination?

After meeting Chief Minister Mufti Mohammad Sayeed, I feel, if ‘ pushed’, he would be able to make a lot of things happen here.

Infrastructure is something that needs to be worked on to promote Kashmir as a corporate destination. If one wants Kashmir to come up for this kind of tourism, then one has to look at Delhi as a model. Airports are lavish, there are outlets for everything, the roads are amazing. Hospitals are abundant, well- equipped, well connected. This place can be a beautiful place for Medical Tourism, especially for lifestyle diseases. We can health spas and other avenues like that. Somewhere political stability needs to come in and people need to be made realise that it is absolutely safe to some here. Sometimes media portrays an image that is absolutely contrary to what we see when we come here. I wish media would portray how people from over 35 countries came here, did surgeries here and had a beautiful time here.

The biggest barrier is in the minds of people. Over here too, people need to realise that there is a huge potential in Kashmir but they will have to harness it themselves. Nobody else is going to come and do it for them. I always say, become so good that people want you.

The key word therefore is moderation in the amount of food and being physically active, at least for an hour daily. And remember, once you are older, or your trousers start getting tight round the waist, reduce your rice intake by half.

Dr. Mufazzal Lakdawala at the inaugral session of VIII ACMOMS Conference held in Srinagar.