At her daughter’s birthday party last year, Shivani Shah*, 44, was pleased that she looked slim. Early in 2015, she was obese at 96 kg, but lost about 40 kg following a bariatric surgery at a Mumbai Hospital. But her happiness was undermined by her alarm about her appearance.

“It looked like I was wearing dentures with those sunken cheeks,” said Shah. The sudden dramatic weight loss and the low food intake had robbed Shah’s body of nutrients and vitamins that had previously made her look healthy.

“I felt sick all the time,” she added.

In April 2015, Shah had undergone a sleeve gastrectomy, a surgery where the size of her stomach had been reduced, limiting food intake. Shah had high cholesterol but did not suffer any other medical conditions linked to obesity. She decided to have bariatric surgery because her size and weight were restricting her movement.

Sleeve gastrectomies and other bariatric surgeries are based on the principle that restricting the stomach’s size also reduces the production of hormones responsible for hunger, which aids loss of weight. An estimated 12,000 to 15,000 bariatric surgeries are performed in India annually, according to the Obesity and Metabolic Surgery Society of India, and many of these are performed on patients from outside the country.

The first 30 days following the surgery were daunting for Shah. She felt weak and tired all the time. Then came a phase where she would vomit food that her smaller body now deemed extra. “If I ate more than half an idli, I had to go and vomit,” she said. At a wedding about three months after her surgery, Shah spent most of her time in the washroom, throwing up the food she had eaten.

Despite the trauma of the side-effects, Shah does not regret the surgery. “I would not take my child to class because I was too lazy to get up and didn’t have the confidence to go out,” she recalled about her days at 96 kg.

She now feels that the weight loss has helped her to be a more involved parent.

Living with side-effects

Patients like Shah often choose to suffer the side-effects of bariatric surgery rather than live with diabetes and hypertension that are commonly associated with obesity. In medical terms, they are called co-morbidities of obesity because obese people have higher chances of developing these conditions. Obese people may also suffer from sleep apnea – interrupted breathing while sleeping, which can compromise the supply of oxygen to the brain and other parts of the body.

“Some patients will have loose skin following the surgery but the focus is that we get rid of co-morbidities,” said Dr Vina Mathur, bariatric surgeon from Mohak Bariatrics and Robotics facility in Indore which claims to have performed the highest number bariatric surgeries in India.

Unhealthy appearance, low food intake and weakness are expected side effects of every bariatric surgery. These are different from complications that sometimes occur, but ideally should not, like bleeding at the site of surgery, deep vein thrombosis and pulmonary embolism.

Mathur said that only 1% to 2% of the patients who underwent bariatric surgery at her hospital developed complications following surgery. “The chances of complications in a bariatric surgery are less compared to knee replacement surgery,” she claimed. Other bariatric surgeons say that the rate of complications is less than one per cent. An overview of bariatric surgery published by doctors from the All India Institute of Medical Sciences in Delhi finds that “the incidence of leaks which is one of the most serious complications is 1%-2%”.

Complications in bariatric surgery, as in any surgery, can be fatal. In March 2014 an obese man who underwent a bariatric procedure died after supposedly developing lung complications during the surgery, the Times of India reported.

Life after bariatric surgery is no walk in the park. Many patients’ bodies, like Shah’s, reject all but the minimum amount of food. Most patients have to stick to strict diets to prevent gaining weight again. “If they consume alcohol, eat fried food then there is a problem,” said bariatric surgeon Dr Ramen Goel. “They will gain weight.”

From overweight to malnourished

Nutritionist Ratna Thar from Mumbai once had a case of a 50-year-old woman who turned anaemic after a bariatric surgery. She shrunk to 38 kg from 90 kg. “She was admitted to the hospital to gain weight,” said Thar. “It was financially and emotionally distressing for the family and the patient.”

According to Thar, the patient had protein-energy malnutrition owing to the restricted diet she was put on following the weight-loss surgery. A surgery that reduces the size of the stomach and also alters the intestinal tract to reduces food intake impacts the process of food absorption in the body.

“The body is getting less food and it is unable to absorb enough,” said Eileen Canday, head of nutrition and dietetics department at Sir HN Reliance Foundation hospital in Mumbai. “Naturally, there will be deficiency of vitamins, minerals and other nutrients responsible for various metabolic functions.”

Canday has consulted patients who have developed osteoarthritis following weight-loss surgery. “Here, I would not blame the patient for not maintaining the diet regimen they are asked to follow,” she said. “The centre offering the surgery should ensure a life-long follow up to these patients.”

Thar said many of her clients start losing hair after bariatric surgery. “It may sound trivial but there is so much emotional distress,” she explained. Hair loss is common in patients who undergo bariatric surgery because of a sudden deficiency of micro nutrients.

“Hair, skin and nails are damaged if the body does not have enough micronutrients,” said Canday.

Punam Jain before the weight-loss surgery.

Punam Jain rues the loss of her hair after her bariatric surgery and is on supplements to stop her hair from falling and to strengthen it.

Thirty three-year-old Jain, mother to an 11-year-old boy, underwent bariatric surgery because her weight was giving her back aches. “I had no disease but my back pain was aggravated because of my weight,” said Jain. “I could never continue exercise or yoga. I tried every thing but could not lose weight.”

She weighed 80 kg in October 2015 before her surgery and weighs 54 kg today.

Jain tried several diets before the surgery but could not maintain them. “I would lose weight and gain it back,” said Jain.

Punam Jain, a year after weight-loss surgery.

Who gets bariatric surgery?

Both Jain and Shah opted for bariatric surgeries after reading about the procedure on the internet. Shah visited several doctors. Jain spoke to at least ten other people who had already had the surgery. “No diet and exercise was helping me,” she reiterated. “After trying everything, I opted for the surgery.”

“It [bariatric surgery] is marketed very loosely,” said Dr Gaurav Mehta, hepatologist from Kokilaben Dhirubhai Ambani Hospital. “There are grey areas.”

A surgical intervention is offered for weight-loss when a person fails to lose weight despite lifestyle interventions. But, weight-loss clinics routinely promote bariatric surgeries online, sometimes even with discounts attached, which raises the question of whether such surgeries are only performed when absolutely necessary.

Dr A Bhandarwar, head of surgery department at Sir JJ Hospital and Grant Medical College in Mumbai said that patients should be selected judiciously for the surgery. “A patient has to be counseled by a psychologist and nutritionist before the surgery,” he said. “If they are not committed to following diet and exercise after the surgery, there is no point in operating.”

Since 2013, Bhandawar’s department has offered the surgery to more than 250 middle- and low-middle-income patients. In a medical college there is no monetary motivation for offering the surgery and only a deserving candidate will get bariatric surgery, said Bhandarwar.

Both Goel and Mathur said that even in private facilities, patients are counseled before they opt for the surgery which can cost anywhere between Rs 3 lakhs to Rs 10 lakhs, depending on the surgeon and the hospital.

Former president of the Obesity and Metabolic Surgery Society of India Dr Shashank Shah said that the society does not have any role to regulate the marketing and promotion of such surgeries. Shah said that such practices fall under the ambit of the regulatory authority like the Medical Council of India.

In selecting a patient for a bariatric surgery, doctors ideally have to adhere to guidelines instituted by several professional medical bodies. The society’s website says that a person’s Body Mass Index should be more than 40 units to qualify for a sleeve gastrectomy procedure.

“If the person has a co-morbid condition but a BMI lower than 40, he will also qualify to undergo the surgery,” said Shah. “These guidelines are based on guidelines issued by international bodies.”

The guidelines however vary from country to country because types of obesity and age of onset of diseases differs in different population.

Booming industry

In India, about 220 surgeons offer bariatric surgery. Any person who is a qualified surgeon can practice bariatric surgery. “Any surgeon who is trained and confident can perform bariatrics,” said Goel who is also a founding member of the Obesity Surgery Society of India. The society and other professional bodies are devising short courses to train surgeons in bariatrics.

“We are devising guidelines to improve the medical outcomes of bariatric surgery,” said Shah.

Outcomes of such operations have been improving because of advancement in technology and improvement in skill of doctors, according to Goel. “I discharge 95% of my patients within 48 hours of the surgery,” he said.

Monitoring surgeries for complications is not difficult, said Shah, because 90% of bariatric operations are performed by about 20 surgeons right now. However, a report by Statistics Market Research Consulting, the global bariatric surgery devices market is was worth $1.35 billion in 2015 and is expected to grow to $2.96 billion by 2022. Industry experts say that India has a major role to play in this growth.

Despite the demand for bariatric surgery in India, there is little reporting on outcomes. The Obesity Surgery Society of India has instituted an Indian registry. “Doctors will have to report their numbers,” said Goel. If the registry is made public, prospective patients can know the complications, risk and side-effects associated with the surgery. The society is still unclear if the data will be shared in the public domain.

Shah is adamant that Indian surgeons do not offer bariatric surgery to anyone unnecessarily. “It is a perception,” he said.

As bariatric surgeons gear up to deal with more patients and more demand, Shivani Shah is slowly getting used to her new weight and getting her life back to normal. “At one point, I looked like a cardboard after the surgery but the weight is stabilising,” she said.

*Name of the patient changed to protect identity.