A dilemma for patients as well as clinicians!

Let us consider both the cases:

1. Knee replacement before weight loss surgery

Observations:

a) The knee pain would be resolved, and the patient will be able to walk without pain.

b) The benefits of walking as an exercise may be added, but post-operative physiotherapy is so difficult because of the huge excess weight at times.

c) There would be higher risks during anaesthesia due to the comorbidities, surgery may be more difficult due to the excess fat deposition around the knees and thighs. Special care may be needed to minimize wound infection or delayed healing since fat has poor healing properties.

d) The associated conditions in these patients like diabetes, blood pressure, breathing difficulty add to the difficulties before and after the joint replacement.

2. Weight loss surgery or bariatric surgery before the joint and knee replacement

Observations

a) Weight loss surgery adds distinct benefits like weight loss, reversal or control of diabetes, blood pressure and breathlessness.

b) Patient’s pain also reduces significantly because of the weight loss and less pressure on joints. In many patients, the pain totally disappears, and knee replacement can be deferred.

c) Post knee and joint surgery their movements on recommended physiotherapy exercises also turns easy

However, if a joint replacement is performed after the bariatric and obesity surgery, the surgery is easier and diabetes control reduces the chances of infection.

There has been a known association between genes and obesity.

There are over 50 genes studied which are strongly associated with obesity and there are many more which would be known after further studies. Certain genes are protective and ones with these genes maintain a near-normal weight. On the other hand, certain genes may make someone more prone to obesity. However, there is no need to be helpless. Genes can only predispose to obesity. The other environmental factors like lifestyle, dietary pattern, and choices, activity grade, etc. can add fuel to the genetic tendency and induce obesity.

It is known that there are some genetic syndromes that can lead to obesity due to the defect or absence of certain hormones. These are purely genetic forms of obesity and fortunately rare.

One example of a boy I witnessed had leptin deficiency. Those with leptin deficiency by birth have uncontrolled hunger because of the lack of the hormone and the child continues to demand food all the time and eventually succumbs to obesity. What can be learned from this is, if you have excess/ uncontrolled hunger, it could be because of the imbalance of certain hormones, known or unknown. Such a person should seek an opinion from a bariatric physician.

Those who have a history of obesity in families have a higher incidence of severe obesity as well as associated disorders like diabetes, heart disease, etc. Even though genes do play a role in this, they are not the primary or the only reason for this type of obesity. Fortunately, bariatric surgery and certain medications work well in such forms of obesity with strong family tendency.

There are some who cannot gain weight and some who cannot lose weight. It is all thought to be due to metabolism

What is metabolism is always a mystery to many? Metabolism can control the total fat stored in the body and controls the utilization of energy in the body through various sources

The body needs energy for daily activities like breathing, thinking, beating of heart, cell movements, and actions, etc. Such energy, when spent, is called the resting energy expenditure or some people relate it to Basal Metabolic Rate or BMR. This BMR and energy spent as resting energy can vary from person to person. Some medications, hormonal imbalance, or even obesity can slow down this energy expenditure and can become a cause for more energy saved and stored in the body.

When an obese person tries to lose weight, the body may take it as an insult and try to correct it. This is called homeostasis and depends on various hormones like thyroid hormones, testosterone, female hormones, leptin, insulin, hunger hormones, etc. Many of such hormones are also secreted or affected by the fat cells. The stomach, intestines, and the digestive system play a major role in secreting these hormones and controlling one’s hunger, satiety, energy expenditure, and eventually the weight.

Various studies have evaluated the changes in the body when a person tries to lose weight and they state that your body will try to regain the lost weight by changing its physiology and hormones for weight regain. That is why people find a lack of control over eating when they try to diet. This happens due to the compensatory increase in the hunger hormone, known as ghrelin. Unfortunately, it is wrongly interpreted as a lack of willpower.

Those with morbid obesity have a lowered metabolic rate. Excess weight can induce pressure on the joints giving rise to pain and reduced mobility. Breathlessness on walking due to the weight further adds to weight gain and this slowly becomes a vicious cycle. These patients have a typical history of multiple attempts of weight loss followed by weight regain. Such patients with slower metabolism can be treated by a procedure which can normalize their metabolism. Bariatric and metabolic surgeries are keyhole and daycare procedures that can correct the metabolism as well as hormones and induce weight loss which can be reasonably maintained for many years. It resolves all the weight-related diseases and makes life healthier and more enjoyable. Many patients start believing in this mechanism of metabolism once they witness it and some repent for not getting bariatric surgery earlier!