| Dr Ramen Goel |
Economic well being of nation has its own down sides, which are not even discussed in economic forums/ legislative assemblies. Improved food availability, motorised transport, screen based education and sports have led to increased obesity amongst population. Children are the most vulnerable segment affected by ‘obesity epidemic’. Over 30 per cent children amongst affluent society are overweight or obese. The quality of life for these children is comparatively lower than those of normal weight kids. 50 per cent – 77 per cent of these are likely to carry their obesity into adulthood, increasing risks of often life-threatening conditions. Usual conditions associated with obesity include premature death, heart disease, obstructive sleep apnea, hypertension, dyslipidemia, and type 2 diabetes mellitus.
Type 2 diabetes or pre-diabetes incidence in children has increased from 9 per cent in 1999 to 23 per cent in 2008, i.e. 1 in 4 children are either diabetic or pre-diabetic. This is scary because of the consequent health problems for the entire generation of children. Imagine a 13-year-old developing diabetes and suffering from its complications and consequences on job, family and finances at the age of 25-30.
This is especially hard on young diabetic/pre-diabetic girls, who are likely to conceive in next 15-20 years. Associated high BP and abnormal cholesterol are likely to result in infertility, complicated pregnancy and unhealthy baby. The cost of associated psychological stress and marital issues in a conservative Indian society are hard to calculate.
These children are looking at a prospect of 70-80 years of strict diet control, regular medicine intake and exercises with possible frequent hospitalisations for their indiscretions, side effects of medicines and diabetes complications. This is hard on them because of their age, social milieu and peer pressures.
Though pharmaceutical research has made rapid strides in diabetes management, not a single agent is able to help achieve remission/resolution of diabetes. In fact, most of the diabetic medicines themselves lead to weight gain, the primary reason for diabetes in these kids.
No single factor has been identified, which can be held responsible for this sudden obesity and diabetes epidemic. Genes, lifestyle, environment and biological factors are blamed for this tsunami of diabetes. Reversing this trend requires multi-faceted approach which may include eating healthy, being physically active, living in unpolluted environment, sleeping adequately etc. However, all the aspects of this multi-faceted approach have to be implemented together, otherwise how can one explain increasing diabesity in unpolluted cities of Europe and US with sports facilities, walking and cycling trails and high health awareness.
In our country, it seems to be a utopian dream – something which may not happen in our lifetime. Till that time, physicians and medical services will have to manage large numbers of young patients with serious complications.
For severely overweight adolescents who have failed organised attempts to lose weight and/or to maintain weight loss through conventional non-operative approaches and who have serious or life-threatening conditions, bariatric surgery may provide the only practical alternative for achieving a healthy weight and for escaping the devastating physical and psychologic effects of associated diabetes.
As the need for a surgical weight loss option for younger patients becomes evident, physicians are faced with the task of delineating clear, realistic, and restrictive guidelines for using this aggressive approach. Though in adults, bariatric surgery is commonly performed for adults with BMI values of =32.5 with co-morbidities and for adults with BMI values of =37.5 without comorbidities, simple adoption of these guidelines for use in younger age groups would overlook the developmental and psychological needs of adolescents. Besides, behavioural therapy approaches to weight management have been demonstrated to be more effective for children and adolescents than adults. Also a proportion (20–30 per cent) of obese adolescents may not become obese adults. For these reasons, surgery is usually reserved for very severely obese adolescents with co-morbidities.
However, a child in whom surgery is indicated considering age, weight, attainment of linear growth and associated co-morbidities, surgery should not be deferred / denied as studies have shown that 71 per cent – 95 per cent teenagers will maintain diabetes resolution even 2 years after surgery. In other studies, while 9/10 diabetic children who were on medicines, only 1/10 required medicines after surgery. Long term diabetes remission is well known in adults after surgery, but in my opinion, its impact in children in avoiding/delaying diabetes complications like heart attacks, kidney failure or brain strokes are worth the cost and possible risk associated with any surgery of this magnitude.
Though exciting and effective, surgery for diabetes in children is a comparatively new specialisation and should be undertaken in dedicated centers with trained and experienced team. The implications for the child’s well-being and psychological impact should be carefully weighed and communicated to family. Multiple counselling sessions for understanding of post op requirements should be made clear to patient and documented. A new vista of disease cure/remission is opened with surgery, which was hitherto unknown with any kind of medical management or lifestyle adjustments.