Taking control of uncontrolled diabetes

India is home to approximately 77 million diabetics in the 20–79 age group and an estimated 53% of them are undiagnosed. In terms of the number of adults with diabetes, the country is second only to China (with 140 million cases). By 2045, the number of people in India living with this chronic health condition is expected to touch 125 million.

The most common form of diabetes — Type-2 — affects more than 90–95%. Type-1 diabetes (5–10% of all cases) is a condition where the body produces little to no insulin, the hormone that carries “instructions” to the cells to let sugar from the blood (glucose) into the cells, to release energy. Insulin also “messages” the liver to store glucose and release it as and when the body is in need of energy. The result is a steep rise in the level of sugar in the bloodstream. This means the patient needs an insulin dosage every single day (approx. 171 cases per 1000 people).
Type-2 diabetes occurs when the beta cells of the pancreas don’t produce enough insulin. The body cells fail to effectively respond to insulin (insulin resistance) and cannot utilise the blood sugar for energy.

Uncontrolled diabetes and its consequences High blood sugar levels (hyperglycemia) of 130 milligram per deciliter [mg/dl] (after not eating or drinking for at least 8 hours) and 180 mg/dl (2 hours after a meal) are associated with several health risks over time. For comparison, a person without diabetes normally has a fasting blood sugar level of 70–99 mg/dl and less than 140 mg/dl (after a meal). Left untreated, hyperglycemia might result in life-threatening conditions like damage to the heart, kidney and eye diseases, fatty liver, nerve damage, strokes, diabetic coma, and depression. Importantly, people with both type 1 and type 2 diabetes are at risk of hyperglycemia.

Exercise, weight loss, stress reduction, good sleep, medication, and insulin therapy can help reverse blood sugar levels and keep health risks at bay. Weight loss is particularly recommended as an effective means to improve blood sugar levels. Even so, there are many scenarios where despite dietary changes, exercise, and other non-surgical methods, the patient’s BMI is still a concern.

Bariatric procedures for diabetes
A BMI of 25–30 indicates the person is in the overweight range. People with elevated BMI in the range of 35–40 plus (i.e., obesity/extreme obesity) often need to battle various health-related medical problems. Such patients are frequently advised weight-loss surgeries — known under the umbrella term — bariatric (metabolic). These procedures work by limiting the size of the stomach to reduce the amount of food it can hold, restoring the normal hormonal balance, especially Ghrelin, GLP-1, GLP-II, GIP, and curbing the digestive system’s ability to absorb chemical compounds contained in food.
Here are some of the most common bariatric procedures: -
Gastric Bypass or Roux-en-Y Gastric Bypass (RYGB)
A small pouch, roughly the size of an egg, created from the stomach connects to the upper third of the small intestine (jejunum) bypassing large parts of the stomach and the top portion of the intestine. Thus, the RYGB procedure limits the calories absorbed by the digestive system and significantly restrains appetite. People who typically opt for RYGB have BMI in the range of 35 to 40-plus, along with chronic weight-related issues.

Gastric Sleeve Surgery/ Vertical Sleeve Gastrectomy (VSG)
This is a surgical weight-loss procedure wherein 75–80% of the stomach is removed. What is left behind is a tubular sleeve nearly the size of a banana with limited food capacity. The surgery is laparoscopic and, therefore, minimally invasive, i.e., skin and tissues are not cut, as in open surgery. Furthermore, VSG prompts hormonal changes to reduce appetite. Much like RYGB, this is suggested for patients whose BMI is in the 35–40 plus range and who also face severe weight-related disorders.

Biliopancreatic Diversion with duodenal switch (BPD/DS)
Though not as common as the previous two, BPD/DS is considered an effective weight-loss procedure (not usually done in India) and is carried out in two steps:

1 — The stomach is reduced to a fifth of its normal size like in VSG where the (pyloric) valve connecting the stomach to the small intestine stays, as also the first part of the small intestine, namely, the duodenum.
2 — The duodenum connects to the end of the intestine, which drastically reduces the small intestinal length, that is available for absorption of food.
So, BPD/DS reduces the stomach’s size and intestinal length, significantly limiting the body’s capacity to absorb nutrients. It is ideal for people with BMI in excess of 50, and voracious meat eaters.

Adjustable gastric banding
It involves very little surgical intervention and people with a BMI of 30–35 with weight-related disorders, can avail this. A soft silicone pouch is placed around the upper part of the stomach to limit its capacity. But unlike surgeries, banding is completely reversible and the pouch can be inflated or deflated to tighten or relax it. This is done using an access port embedded in the patient’s skin. Food fills up the small pouch quickly, stretches the gastric wall and stays there longer than usual, causing the patient to feel fuller much faster than before, and reducing level of the “hunger” hormone. The food, then, makes slow progress through a narrow opening in the pouch into the lower stomach, where it is digested normally. Patients reportedly experience a weight loss of 40–60%, but 3 of 5 might need reoperations,in the long term.

Gastric Plication
This is a minimally invasive procedure in which the stomach is folded in and stitched to reduce food intake. The resulting weight loss is estimated to be in the range of 15–20%. Gastric plication is generally risk-free and patients can return home the same day, after the procedure. Candidates for gastric plication should have a minimum BMI of 30.

Swallowable intragastric balloon
This is neither a pill nor a surgical procedure. Here, the patient swallows a capsule containing a deflated burst-proof balloon and a thin tube attached to it, all the while guided by a specialist. Once the capsule reaches the stomach, the balloon is filled with 550 ml of fluid via the attached tube, which is then gently withdrawn. Since the balloon occupies some space in the belly, the patient feels full even with less food. The balloon is timed to deflate at the end of 16–24 weeks and pass through the gastrointestinal tract. No endoscopic tools or anesthesia is required and patients are known to lose on average 13–15 kilos (average of 15% weight loss). Those with a BMI score of 27 plus qualify for this. Bariatric procedures present a definitive solution, not just for uncontrolled diabetes but also for other critical conditions like heart disease, high cholesterol, triglycerides, and blood pressure, and fatty liver. The positive effect of this surgery on obesity is now common knowledge. What is probably less known is that these procedures can also lead to significant improvements in people with PCOD, infertility, respiratory problems, urinary stress incontinence, osteoarthritis, and serious sleep disorders (e.g., sleep apnea). The Metabolic Surgery Clinic for Diabetes at P. D. Hinduja Hospital & Medical Research Centre, Khar, Mumbai provides customised bariatric procedures that are mapped to the needs of each patient. Our team includes internationally acclaimed surgeons as well as specialist physicians, dieticians, endocrinologists, psychiatrists, psychologists, and specially trained nurses. What’s more, surgeons at our Metabolic Surgery Clinic for Diabetes have been credited with performing India’s first-ever Ileal interposition procedure for type 2 diabetes, since 2008.

Our clinic provides a mix and match of various bariatric procedures including:

• Gastric Bypass or Roux-en-Y Gastric Bypass (RYGB)- Surgery / Duodenal Switch with Biliopancreatic Diversion
• Mini Gastric Bypass (MGB or OAGB) - Banded Bariatric Procedures
• Ileal Interposition* + BMI-adjusted sleeve (especially for slim or normal weight diabetics) — Laparoscopic Adjustable Gastric Band

• Sleeve Gastrectomy — Gastric Plication
• Sleeve + Transit or Illeal Loop Bipartisan (SASI) — Sleeve + Loop Duodenal Switch (SADI-S /SIPS)
• Sleeve + Sleeve Jejunal Bypass — Endoscopic or Swallowable Intragastric Balloon
• Sleeve + DJB or Loop DJB — Banded Bariatric Procedures, Revisional Bariatric Surgery (where the weight loss from a previous procedure has been less than optimal

(*1st in India to perform Ileal Interposition!)

Connect with us for an appointment or further details at 022–4510 8989 / 6154 8989