Obesity and diets are thought to be interlinked. Different types of diets exist, each one claiming benefits over the other, often confusing the reader about which is the best diet for him or for her. We attempt to offer a comprehensive summary about how you can choose the best diet for yourself. Diets have a better role in prevention of obesity as well as maintenance of weight loss, however dietary therapy alone for weight loss has not offered the best results for long term “weight loss maintenance”.
Rachel Freire has published a great summary in his review article published in ‘Nutrition’ Journal which included a study of different types of diets like intermittent fasting, keto diet, calorie restricted diet, Very low calorie diet, low carbohydrate diet (most commonly adopted diets) , and concluded as follows:

1. The creation of new diets will continue to follow popular trends. However, the belief that these diets promote weight loss has emerged more from personal impressions and reports published in books, rather than from rigorously controlled research.
2. Over several decades, efforts have been concentrated on clinical trials to determine the best diet for the treatment of obesity. Unfortunately, the evidence remains inconclusive and contested, and the trials present important limitations.
3. In the “short term” diet promote different degrees of success, but in the “long term”, the small difference does not instill confidence for prescribing one diet over another.https://pubmed.ncbi.nlm.nih.gov/31525701/

Despite the above conclusion, people do experience different types of response or success in losing weight.However, the response remains unpredictable and grossly variable among people .This clearly suggests that there are some factors in the human body which modulate or govern the response to a therapy .These could be the genetic tendency, epigenetic expression ,intestinal bacteria/gut microbiota ,environmental and socio economic factors ,sleep cycle , stress, associated medical conditions , nutritional status ,etc., which have an impact on the body’s tendency to store a certain percentage of fat also known as ‘the set point of obesity’ in that individual. Eventually, the hormonal response generated in the body by all the factors mentioned above may induce an imbalance in the metabolism resulting in the disease of obesity in an individual. Hence the treatment of the disease of obesity should be based on evidence based scientific protocol just like the treatment of any other chronic disease e.g., Hypertension, cancers, etc.

Unfortunately, patients with obesity are blamed for unhealthy eating habits and /or lifestyle. This is more commonly seen as a bias especially when viewed by a normal weight or a lean individual or clinician or any therapist. This is simply because of a tendency to compare one’s own habits and response and an attempt to apply the same to others. I would like to state here that many scientific organizations in the world like AMA,American Medical Association, OSSI,Obesity Surgery Society of India declared “Obesity as a disease’’and‘not just a lifestyle disorder’.Even bariatric surgery started being called metabolic surgery after better understanding of the altered metabolism in people with obesity. Bariatric surgery got included in the insurance cover, which clearly explains that obesity is accepted as a disease.

I would like to discuss some important and common myths about Obesity.

Myth 1 : OBESITY IS CAUSED ONLY BECAUSE OF WRONG DIETS
We often see people who eat freely and still maintain their weight and also those who try to eat less but still remain in the category of overweight or obesity. Some are thought to be blessed with a metabolism to remain thin or normal weight ever.At the same time those who are not blessed with such metabolism are blamed. Prof. Lee Kaplan et al published the explanation for this after a multigenerational multicentered study known as “MARS”. I strongly recommend all those who feel that” those who cannot lose weight do not have willpower “to read the Myth published in “MARS”. https://jnjinstitute.com/en-

The study clearly states a myth which even doctors and clinicians find difficult to believe. The MARS study clearly concluded that “weight cannot be reliably controlled by voluntarily adjusting energy balance through diet and exercise “. The converse is also true for very lean and thin who try to gain weight by increasing calories and still don’t succeed .

Myth 2 : ANY GRADE OF OBESITY CAN BE TREATED WITH DIET INTERVENTION AND EXERCISE.

As mentioned earlier, obesity is a disease and needs to be treated like all other diseases. Treatment of any disease is based on grade, severity, and stage of the disease. Forexample, the treatment for cancer varies depending on the type and grade of disease and it is well known that the best results are seen only in those who are diagnosed early and treated in time as per the best available evidence-based therapy of that cancer. Needless to say that the same thing holds true for the treatment of obesity at various stages.

Evidence based/BMI (Body Mass Index) based algorithm for obesity.
Note : Even though BMI has its limitations , the algorithm can be generally applicable to all , with some exceptions.

The algorithm shows that diet and exercise are present in all the approaches for the treatment of obesity but this algorithm also indicates that diet and lifestyle change cannot be a single line of treatment when you cross a certain grade of obesity and it should always be accompanied by other complimentary therapies.

In conclusion, diet for weight loss can be adopted a jumpstart. Caution is required for each diet and hence it should be the diet supervised by a qualified nutritionist. Maintenance of weight loss may require supervision from qualified obesity experts. Failure of therapy should not be considered as failure on part of the patient. Start a dietary change which has “no expiry date”.

Diets most often fail to work in patients with morbid obesity. Metabolic and bariatric surgery is the only proven long-term treatment for morbid obesity till further research would invent medications which can mimic the metabolic and hormonal change after bariatric surgery.

Hypertension or high blood pressure is the force with which the blood pushing against the artery wall is too high. Any blood pressure above a mark of 140/90 is called blood pressure and above 180/120 is called severe. The significant rise in obesity is found to have a direct correlation to risk of high blood pressure. Obesity and hypertension together can give rise to an array of health issues and challenges there by affecting health, quality of life and life expectancy. Apart from just weight and obesity the fat distribution is also an important factor that plays a major role. Abdominal Obesity or central obesity around the waist circumference is the influencing factor for developing hypertension.

Hypertension and Obesity have a major impact on both the following systems.

• 1. Cardiovascular Diseases: When a person is over-weight or obese, the body requires pumping more effort thereby working harder to pump blood through the body. This puts more strain on the arteries and when this strain is resisted it causes the blood pressure to rise. Thus, obesity and hypertension together are one of the top reasons forcardiovascular diseases.
• 2. Kidney Dysfunction: When a person is overweight or obese and has high blood pressure, this excess pressure damages the vessels in the kidneys by thickening them thereby affecting the blood flow. This affects the kidneys main function of removing the waste and fluids.

Obesity, Hypertension and Obstructive Sleep Apnoea

Snoring is the most common sign of Obstructive Sleep Apnoea (OSA). In people who are overweight or obese snoring and eventually sleep apnoea is one of the most common co-occurring problem. In obese people the fat deposits in the chest and waist circumference or central obesity causes the lungs to get compressed thereby restricting the airflow thereby dropping the oxygen saturation. People who have chronic sleep apnoea experience sudden drop in their oxygen levels thereby increasing the blood flow and putting a pressure on the blood vessels which increases the blood pressure. This kind of a situation can be a silent killer as they could lead to serious complications like stroke or heart attack.

Is there a solution that can treat all these problems?

Bariatric Surgery can be a treatment for all these health problems all in one go. Bariatric surgery brings about a significant and long-term change in the weight and also brings about a significant drop in the blood pressure levels. As the person starts losing weight, the pressure on the heart to work hard and to pump more blood reduces, thereby reducing the strain on the arteries which in turn reduces the blood pressure. Once there is reduction in the blood pressure, the pressure on the small vessels going to the kidneys will reduce and will enhance the functioning of the kidneys.

Similarly, with the significant reduction in weight, waist circumference and reduction of fat deposits in the neck and chest region would open up the lungs that are compressed, improve the oxygen saturation and reduce the blood pressure caused due to the drop in oxygen saturation.

Thus one treatment can break the vicious cycle, improve health and quality of life.

Currently India has the third highest number of obese patients in the world after USA and China. Also, India has the second highest number of patients with diabetes after China. With this staggering growth in the number of obese as well as diabetics in the India both these health problems have become a major and ever lasting impact on the economy and health status.

Is there a correlation between Obesity and Diabetes?

It is estimated that about 60-90% patients with Type II Diabetes are also obese with a BMI more than 30kg/m2 in India. In Indians the fat percentage is much higher than the muscle mass. With more of central or visceral obesity ie, around the waist and abdomen patients with a BMI of as low as 23kg/m2 Indiansare also prone to developing diabetes. It is this high fat percentage and low muscle mass in the body that makes the person more prone to developing hyperinsulinemia thereby increasing their risk for type II Diabetes and also progressively leading to failure of the pancreatic cells. In obese patients these free fat cells around the muscles, abdomen and liver lead to a cytokine storm thereby leading to insulin-resistance and excess inflammation.

How can it be treated?

Lifelong and sustained weight loss through lifestyle modifications is the appropriate treatment for obesity and diabetes. But in patients who are overweight or obese (BMI >28kg/m2) with diabetes, the metabolism of the person is affected in such a way that following a diet and exercising and maintaining that weight becomes impossible. In such patients a treatment that will only help with the weight loss but also treat their diabetes is the most appropriate form of treatment.

So then, is there a cure?

Bariatric Surgery

Metabolic or Bariatric surgery for Type II Diabetes is now a treatment approved by the American Diabetes Association (ADA) as a scientific treatment for remission or cure of Type II Diabetes.

Who can undergo this surgery?

In Indians and Asians since the fat percentage is much higher than their western counterparts, anyone who is above a BMI of more than 28kg/m2 along with Type II Diabetes is an ideal patient to undergo bariatric and metabolic surgery. In patients with Obesity and Diabetes it is a dual burden.

How does surgery work?

Almost all patients who undergo bariatric surgery show a significant improvement in their diabetic status. The dual benefit of bariatric surgery is such that it induces weight loss thereby treating obesity but along with that there is a significant change in hormones and metabolism of the blood glucose which is independent of the weight loss.

Surgery has shown to improve diabetic status in almost 90% patients by reducing their blood sugar levels, reducing the medicine dose that they required as well as improving the health problems arising out of diabetes. In 78% of the patients there is improvement in blood sugar levels along with elimination of all anti diabetic medications.

In a study titled ‘Gastric Bypass vs. Medical/Lifestyle Care for Type 2 Diabetes in South Asians’ Dr Shashank Shah was the first surgeon to be awarded the Vivian Fonseca Award by the American Diabetes Association for surgical treatment of Type II Diabetes. In the study two group of patients, one undergoing surgical treatment and the other on medical and lifestyle management alone were compared way back in 2006 and it was found the efficacy of bariatric surgery much more as patients with uncontrolled diabetes who underwent surgery achieved total disease remission compared to the medical arm which continued to be on medicines.