Obesity is probably unique amongst grave medical diseases that it fights with “cosmetic” disorders for attention of public, patients, policy makers, and medical fraternity. Though it is now officially recognized by American Medical Association as a disease, perceptions on the ground remain unchanged and many other national societies are lagging behind. At a time, when world is going through an obesity pandemic, patients suffering with this disease are not recognized as such, do not have a dedicated group of medical specialists looking after them, and find it difficult to get funding for their treatment from both public sector as well as the insurance mechanisms. The response of professional and patient groups, insurance companies, and governments can at best be described as patchy so far. This article makes a case for obesity to be formally recognized in India as a disease and the need for healthcare practitioners in India to develop the specialty of bariatric physicians to look after patients with this disease.

1.
The
e disease
of obesit
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ty and the
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e need forr bariatricc

2. Review Article
The disease of obesity and the need for bariatric
physicians
Kamal K. Mahawar a,b,
*
a
Senior Consultant, Bariatric and Metabolic Surgery, Indraprastha Apollo Hospital, New Delhi, India
b
Honorary Consultant Surgeon, Sunderland Royal Hospital, Sunderland SR4 7TP, United Kingdom
a r t i c l e i n f o
Article history:
Received 21 April 2014
Accepted 2 May 2014
Available online 27 May 2014
Keywords:
Obesity
Obesity surgery
Obesity in India
Bariatric physician
a b s t r a c t
Obesity is probably unique amongst grave medical diseases that it fights with “cosmetic”
disorders for attention of public, patients, policy makers, and medical fraternity. Though it
is now officially recognized by American Medical Association as a disease, perceptions on
the ground remain unchanged and many other national societies are lagging behind. At a
time, when world is going through an obesity pandemic, patients suffering with this dis-
ease are not recognized as such, do not have a dedicated group of medical specialists
looking after them, and find it difficult to get funding for their treatment from both public
sector as well as the insurance mechanisms. The response of professional and patient
groups, insurance companies, and governments can at best be described as patchy so far.
This article makes a case for obesity to be formally recognized in India as a disease and the
need for healthcare practitioners in India to develop the specialty of bariatric physicians to
look after patients with this disease.
Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
We are living through a pandemic of obesity.1,2
Worldwide,
the prevalence of obesity has nearly doubled since 1980 and in
2008, more than 1.4 billion adults, 20 years and older, were
overweight. Of these over 200 million men and nearly 300
million women were obese. It is estimated that 65% of the
world’s population live in countries, where being overweight
and obesity kill more people than being underweight.3
It is
undoubtedly the most significant public health issue of this
century globally. In some Western countries, more than a
third of the population is obese4
and up to 80% of population is
either overweight or obese, leaving the “normal” weight peo-
ple behind in minority. Modern living with its impact on
calorie balance has not spared developing countries like India
either.5e8
A recent study of 5 major cities in India9
found that
the prevalence of obesity was 6.8% and 33.5% people were
overweight. The problem was worse amongst women. In
some part of India, authors found that 11%e29% of adoles-
cents were either overweight or obese. Authors concluded
that, “Obesity, overweight, central obesity and sedentary
behavior coexist with under-nutrition, and have become a
public health problem in cities of India”. Another recent
study10
of 12e18-year-old girls in an urban English medium
school found that 28.5% of the girls were overweight and 4.2%
were obese. Overweight and obesity are rapidly becoming a
major healthcare challenge for the middle and upper classes
in urban India.11
* Sunderland Royal Hospital, Sunderland SR4 7TP, United Kingdom.
E-mail address: kamal_mahawar@hotmail.com.
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 0 3 e1 0 9
http://dx.doi.org/10.1016/j.apme.2014.05.006
0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

3. American Medical Association has now recognized that
obesity is not simply a lifestyle condition, it is a disease12
and
living with it has consequences.2,13
At least 2.8 million people
die every year globally as a result of being overweight or obese
and an estimated 35.8 million DALY (Disability Adjusted Life
Year) are lost of being overweight or obese.14
Childhood
obesity is a particularly worrying problem.10,11,15,16
Rates of
childhood obesity have increased more than threefold in the
last 30 years. More than 40 million children under the age of
five were overweight in 2011 globally.3
Given the scale of problem, it is indeed surprising that
obesity struggles to be recognized as disease, has no dedi-
cated medical specialty to look after the patients, govern-
ments have largely turned a blind eye to it, and the most
effective treatment for some obese patients (bariatric sur-
gery) has to fight for the attention of wider medical frater-
nity, policy makers and insurance industry. This article
reviews how obesity is fighting for attention as a disease and
the need to introduce and develop a new specialty of obesity
special bariatric physicians in India to look after obese pa-
tients who have some very complex needs. We also examine
the skill set that such bariatric physicians will need to
possess.
2. Obesity: a disease?
2.1. Obesity: not a cosmetic or lifestyle condition
For many patients, the serious adverse health consequences
of obesity will appear later in life, but the adverse cosmetic
effects are present then and there. It is hardly then a surprise
that this is the aspect, which worries many patients more
than the ill effects of obesity on their health. Apart from its
obvious impact on quality and quantity of life, obesity also
leads to psychological and social issues, sexual and marital
problems, loss of confidence, work place stigma, unemploy-
ment, and economic difficulty. The causes of this disease, like
many other diseases known to us, may lie in personal lifestyle
choices that an individual makes but this cannot be an excuse
to not treat these patients. For example, medical fraternity
does not think twice before treating patients with diseases
that result from other lifestyle choices like smoking, alco-
holism, traveling, and sexual choices. T2DM and coronary
artery disease, which result from a lifestyle similar to obesity,
can also come in the category of so-called lifestyle diseases.
But when it comes to obesity, a large number of medical
practitioners are happy not addressing the problem and lett-
ing patients live with its adverse health consequences. It
would have been acceptable, if there were no effective treat-
ment available. That is fortunately not the case with obesity
and there are good treatments available for patients across
the spectrum of this disease.
2.2. Definition of a disease and where obesity stands
Before we examine whether or not to call obesity a disease, we
must first understand what do we actually mean by “disease”.
World Health Organization has defined “health” as, “a state of
complete physical, social, and mental wellbeing and not
merely an absence of disease or infirmity.” It has, however,
not defined disease in such clear terms. That is because it is
not easy to define disease.17
History is replete with examples
where conditions seen as part of normal living (like osteopo-
rosis) are now recognized as disease and conditions treated as
diseases in past (like homosexuality) are now accepted as a
normal way of living.17
It will not be important to talk about
such labeling, if our views and notions did not develop around
these labeling. Recognizing an adverse health condition as a
disease means that sufferers are recognized, treated, and
financially reimbursed for their ill health. It has some very
serious implications for these people. It portrays them as the
victim of the disease, rather than perpetrators.
American Medical Association has defined disease as an
impairment of the normal functioning of some aspect of the
body. Dictionary definition of “disease” is “a disordered or
incorrectly functioning organ, part, structure, or system of the
body resulting from the effect of genetic or developmental
errors, infection, poisons, nutritional deficiency or imbalance,
toxicity, or unfavorable environmental factors; illness; sick-
ness; ailment”.18
Another dictionary19
has defined it as “A
disorder of structure or function in a human, animal, or plant,
especially one that produces specific symptoms or that affects
a specific location and is not simply a direct result of physical
injury”. Yet another popular dictionary defines it as “a con-
dition of the living animal or plant body or of one of its parts
that impairs normal functioning and is typically manifested
by distinguishing signs and symptoms”.
Let us try and examine “obesity” against these definitions.
It definitely does not result from injury. Accumulation of
excess fat impairs functioning of a number of organ systems
in human body, like liver, pancreas, kidney, etc. Though
obesity can be asymptomatic in early stages (just like hyper-
tension and T2DM), most patients will eventually develop a
number of complications in due course and die pre-
maturely.19e21
In terms of clinical signs, this is one of those
very few diseases where signs of the disease are obvious to
anyone who can look at the patients and confirmed by a
simple scale.
According to the Centers for Disease Control and Preven-
tion in United States of America, health consequences of
obesity include coronary heart disease, T2DM, hypertension,
cancers (endometrial, breast, and colon), dyslipidemia, stroke,
liver and gallbladder disease, sleep apnea and respiratory
problems, osteoarthritis, and gynecological problems
(abnormal menses, infertility). Cost of looking after obesity
and its associated problems runs into hundreds of billions of
dollars globally.22
It is also the commonest cause of metabolic
syndrome and conditions like benign intracranial hyperten-
sion, acid reflux etc. However, the important fact to note is
that in early stages, many of these adverse health conse-
quences can be controlled and even reversed, if obesity is
managed successfully. In late stages, when end-organ damage
has already taken place, changes may be irreversible and it
will shorten the life of the sufferer by a period ranging from
years to decades.20,21
Childhood obesity is another worrying
aspect of this pandemic. It is associated with a higher chance
of obesity, premature death and disability in adulthood. Obese
children experience poor self-esteem and adverse psycho-
logical effects, breathing difficulties, sleep apnea, increased
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 0 3 e1 0 9104

4. risks of fractures, hypertension, early markers of cardiovas-
cular disease, and insulin resistance.3
By not formally recognizing obesity as a disease, we are
simply living in denial. It is the biggest healthcare challenge of
this century and denying its existence will not make it
disappear!
2.3. Obesity: similarity with Type 2 Diabetes Mellitus
It is clear from the preceding paragraphs that obesity is truly a
disease. In fact, it is a multi-system disease. The closest
analogy one can think of in this context would be Type 2
Diabetes Mellitus (T2DM), of which obesity is also the com-
monest cause. Like T2DM, diet has a major role to play in its
causation and management. Like T2DM, uncontrolled obesity
results in a number of complications. Like T2DM, obesity
management needs close dietetic support. Like T2DM, patient
suffering with advanced obesity needs a number of specialists
for management. Like T2DM, it is a significant burden on
healthcare resources. Like T2DM, there is currently no “cure”
available for it. And finally, like T2DM, surgery is the most
effective of all the currently available treatments in inducing
prolonged remission. However sadly, unlike T2DM, we don’t
have any dedicated physicians looking after these patients.
Unlike T2DM, awareness amongst public and healthcare
professionals regarding disastrous health consequences of
obesity is very low. Unlike T2DM, it does not struggle to be
called a disease and unlike T2DM, many healthcare pro-
fessionals are happy to let their patients live with it.
2.4. Obesity: bariatric physicians
Currently, bariatric surgery is the only dedicated medical
specialty that caters specifically to obese patients. It is neither
feasible, nor desirable, that bariatric surgeons should deal
with the obesity pandemic on their own. Majority of over-
weight and obese patients do not qualify for surgery and
should be managed by somebody else. Currently, no single
health practitioner possesses all the skills and knowledge
required to look after patients with this very complex disease.
It is hence hardly surprising that patients are not looked after
properly and usually allowed to live with their disease and its
consequences. There is an enormous need to develop
specialist obesity physicians globally and clarify the re-
sponsibilities of such a role.23e27
Even though this idea has
been going around for a while and gets sporadic mention in
scientific literature, there has been little progress in this field
and the wider medical community has been rather slow to
address this need. United Kingdom has taken lead in this di-
rection with Royal College of Physicians now recommending
such obesity champions in each and every hospital.28
Table 1
summarizes the recommendations from the Royal College
regarding such obesity specialists. Progress in India, under-
standably, has been rather slow, as obesity is only now
beginning to rear its ugly head here. Endocrinologists are best
suited for this role,23,28
but it not likely that they will be able to
cope with the demand on their own. In Indian context, many
general practitioners already manage less complicated dia-
betes patients on their own, with support from endocrinology
colleagues. There is no reason why the willing ones could not
also take on the role of specialist obesity physicians or bar-
iatric physicians.
2.5. Obesity: roles and responsibilities of a bariatric
physician
Becoming a specialist in obesity management or “Bariatric
Physician” is a unique, complex role with challenging needs.
Training in this area has been inadequate in the past and there
will be need to develop training courses for clinicians wishing
to develop this role. A dedicated bariatric physician will need
following skills.
2.6. Bariatric physician: able to diagnose obesity and its
complications
It is obvious that a bariatric physician will need to be able to
diagnose obesity. Though there is some debate amongst pro-
fessionals regarding the best indicator of an individual’s
adiposity and severity of obesity, BMI (Body Mass Index) is by
and large the most commonly used indicator for this purpose.
Table 2 gives widely accepted World Health Organization and
South Asian BMI cut-offs for diagnosis of obesity. Waist
Circumference and Waist:Hip Ratio are other useful in-
dicators. Men, whose waist circumference is greater than or
equal to 94 cm (90 cm for Indians) and women with a waist
circumference of greater than or equal to 80 cm, have a higher
risk of metabolic complications. Risk is substantially
increased for men with a waist circumference of more than
102 cm and women with a waist circumference of more than
88 cm. A Waist Hip Ratio (WHR) of >0.9 in men and >0.85 in
women is indicative of significant abdominal fat accumula-
tion and substantially increases the risk of metabolic com-
plications. Finally, a new system of classifying obesity
“Edmonton Obesity Staging System” has been developed
(Table 3) to classify patients according to the severity of their
disease.29
Bariatric physicians should be able to identify secondary
causes of obesity and treat them accordingly. Since obesity is a
multi-system disease, bariatric physicians should keep a close
Table 1 e Guidance from Royal College of Physicians (UK) on specialist obesity physicians.
1. There is a need to establish a subspecialty of obesity medicine for physicians. The terms ‘bariatric medicine’ and ‘bariatric physician’
are proposed.
2. The subspecialty should be within the umbrella of diabetes and endocrinology, although this does not preclude physicians with other
primary specialties from developing subspecialty recognition in bariatric medicine.
3. A core curriculum and relevant experience for accreditation in this specialty is needed.
4. Physicians specialized in bariatric medicine will provide local leadership in the planning, provision, and delivery of obesity treatments,
within secondary care, and in collaboration and partnership with primary care.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 0 3 e1 0 9 105

5. eye on their patients for a number of complications affecting
various organ systems that are associated with this disease.
Focus should be on diagnosing them early and managing
them appropriately. Optimum management of some of these
complications may need help from other specialists.
2.7. Bariatric physician: aware of management options
Not only do many healthcare professionals not realize that it
is dangerous to live with obesity, they also feel that sufferer
can easily correct the situation if they had sufficient “will
power”. Placing responsibility solely on individuals in this
way, when we have a pandemic at our hands is extremely
unfair and also ineffective. There is little doubt that diet, ex-
ercise, health education, and behavioral counseling play pri-
mary role in the prevention and management of obesity.
A bariatric physician should have an in-depth knowledge
of nutrition and the role of diet and exercise in weight loss. A
bariatric physician should know general principles of healthy
eating and what constitutes a “good balanced diet”. It is not
rocket science to know that one should i) control overall cal-
orie intake; ii) limit energy intake from fat, simple sugars, fried
snacks, sweets, and liquids (juices, soft drinks, and milk); iii)
increase consumption of water, fruit and vegetables, legumes,
whole grains, egg white, and lean meat; and iv) engage in
regular physical activity (at least 60 min a day for children and
150 min per week for adults) to correct calorie imbalance.
Bariatric physician must set “realistic” targets with these in-
terventions to avoid discouraging patients. A target of
0.5e1.0 kg weight loss on a weekly basis is widely considered
acceptable. It should also be appreciated that developing a
healthy lifestyle has a much bigger role in prevention of
obesity than its treatment.
A number of medical and surgical interventions are available
to help obese individuals, who have failed to lose and maintain
sufficient weight on conservative management with diet, exer-
cise, and behavioral counseling alone. Bariatric physician
should be fully aware of the indications, advantages, disad-
vantages, complications, and expected results of pharmaco-
logical, endoscopic, and surgical interventions available for
treatment of obesity. Amongst currently available treatments,
pancreatic lipaseinhibitor“Orlistat”isthe onlypharmacological
agent and “Gastric Balloon” is the only endoscopic device
available for routine use. Gastric Balloon is only licensed to be
usedfor a singletreatmentperiod of6 months. Patients typically
achieve a weight loss of approximately 15 kg during this
period,30
some of which is maintained even up to 5 years later.31
It is, however, not uncommon for patients to remain unsuc-
cessful despite optimum conservative, pharmacological, and
endoscopic management. For such patients, options are either
to undergo surgery or live with their obesity and its conse-
quences. It is not always realized that for patients who meet
guidelines for surgery,32,33
surgery is not only the cheaper
option34e36
butalsomuchsaferandhealthier.37e39
Risksofliving
with obesity, for these patients, are much higher and the cost of
surgery is recovered as early as within 2e3 years after surgery.
There is a deep-rooted misconception that risks of this
surgery are higher than living with obesity. Healthcare pro-
fessionals don’t think twice before recommending coronary
artery bypass surgery for patients with coronary artery dis-
ease, which is probably riskier than obesity and metabolic
surgery and probably less beneficial, but when it comes to
bariatric and metabolic surgery, many patients and health-
care professionals consider the risks to be prohibitive. It is not
commonly realized that major complication rates and mor-
tality with obesity surgery is probably lower than other
commonly performed like laparoscopic cholecystectomy, in
the hands of high volume dedicated bariatric surgeons.40e45
Perioperative mortality with bariatric surgery is fortunately a
very rare event and the benefits in terms of weight loss, co-
morbidity resolution, and improvement in quality of life, of
bariatric surgery are now firmly established in scientific
medical literature.
2.8. Bariatric physician: knows good bariatric surgeons
in area
Bariatric physicians should be aware of local33
and interna-
tional32
guidelines for bariatric surgery (Table 4). For eligible
patients, bariatric surgery is the most effective treatment and
a bariatric physician should refer these patients to a “good”
bariatric surgeon in their area. It should be realized that
Table 2 e Diagnosing obesity.
International Classification of Obesity
BMI 25.0e29.9 (Pre-Obese or Overweight)
BMI 30.0e34.9 (Obese Class I)
BMI 35.0e39.9 (Obese Class II)
BMI 40.0 (Obese Class III)
Classification of Obesity for Indians/South Asians
BMI 23.0e27.5 (Pre-Obese or Overweight)
BMI 27.5e32.5 (Obese Class 1)
BMI 32.5e37.5 (Obese Class II)
BMI 37.5 (Obese Class III)
Table 3 e The Edmonton obesity strategy system.
Stage 0 No apparent obesity-related risk factors (e.g. blood pressure, serum lipids, fasting glucose, etc. within normal range), no physical
symptoms, no psychopathology, no functional limitations, and/or impairment of wellbeing
Stage 1 Presence of obesity-related subclinical risk factors (e.g. borderline hypertension, impaired fasting glucose, elevated liver enzymes,
etc.), mild physical symptoms (e.g. dyspnea on moderate exertion, occasional aches and pains, fatigue, etc.), mild psychopathology,
mild functional limitations, and/or mild impairment of wellbeing
Stage 2 Presence of established obesity-related chronic disease (e.g. hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease,
polycystic ovary syndrome, anxiety disorder, etc.), moderate limitations in activities of daily living and/or wellbeing
Stage 3 Established end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis,
significant psychopathology, significant functional limitations, and/or impairment of wellbeing
Stage 4 Severe (potentially end-stage) disabilities from obesity-related chronic diseases, severe disabling psychopathology, severe functional
limitations, and/or severe impairment of wellbeing
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 0 3 e1 0 9106

6. results of this surgery, like many other interventions, are best
in the hands of dedicated, high volume surgeons in high vol-
ume centers. Table 5 lists characteristics of what one would
describe as a “good” bariatric surgeon.
2.9. Bariatric physician: perioperative care of patients
undergoing surgery
A bariatric physician will need to work very closely with his/
her surgeon to provide optimum perioperative care to their
patients. Looking after a bariatric surgery patients before and
after surgery involves careful consideration of a number of
things and the bariatric physician should be aware of these
aspects of care.
1. They should make an effort to know preoperative, in
hospital care, and postoperative protocols of their
preferred bariatric surgery center.
2. They should understand the risks, benefits, and com-
mon complications of surgical procedures offered by
their preferred bariatric surgery centre. They should
look out for early symptoms and signs of complications
and refer patients back to their surgeon at the earliest
opportunity.
3. Patients are prescribed proton pump inhibitors for a
variable period after bariatric surgery and Non-steroidal
Anti-inflammatory Drugs are usually contraindicated
after bariatric surgery (especially gastric bypass).
4. Some surgeons recommend Ursodeoxycholic acid for
prophylaxis of gallstones during the early postoperative
phase for a variable period.
5. Some patients will need routine mineral and vitamin
supplements depending on their surgeon’s protocol.
Need is higher with procedures that have malabsorptive
component, like gastric bypass and duodenal switch.
Table 4 e Local (IFSO-APC) and International (NICE) criteria for obesity surgery.
Salient points from IFSO-APC consensus statement 2011
1. Bariatric surgery should be considered for the treatment of obesity for acceptable Asian candidates with BMI 35 with or without co-
morbidities.
2. Bariatric/GI metabolic surgery should be considered for the treatment of T2DM or metabolic syndrome for patients who are inadequately
controlled by lifestyle alterations and medical treatment for acceptable Asian candidates with BMI 30.
3. The surgical approach may be considered as a non-primary alternative to treat inadequately controlled T2DM, or metabolic syndrome, for
suitable Asian candidates, with BMI 27.5.
4. Bariatric/GI metabolic surgery is generally recommended for patients within the ages of 18 and 65.
5. All surgeons who perform bariatric/GI metabolic surgery are properly credentialed and provide a quality bariatric surgical service in
accordance with both the required level of skill and experience and the capability of the health service.
6. Surgical treatment of obesity and metabolic disorder need a multidisciplinary approach with a team, which includes surgeons, physicians,
psychiatrists, dieticians, counselors, and others as needed.
Salient points from United Kingdom’s Nice Guidelines for bariatric surgery
1. Bariatric surgery is recommended as a treatment option for people with obesity if all of the following criteria are fulfilled:
They have a BMI of 40 kg/m2
or more, or between 35 kg/m2
and 40 kg/m2
and other significant disease (for example, type 2 diabetes or high
blood pressure) that could be improved if they lost weight.
All appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for
at least 6 months.
The person has been receiving or will receive intensive management in a specialist obesity service.
The person is generally fit for anaesthesia and surgery.
The person commits to the need for long-term follow-up.
2. Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more
than 50 kg/m2
in whom surgical intervention is considered appropriate.
3. Surgery for obesity should be undertaken only by a multidisciplinary team that can provide:
preoperative assessment, including a riskebenefit analysis that includes preventing complications of obesity, and specialist assessment
for eating disorder(s)
information on the different procedures, including potential weight loss, and associated risks
regular postoperative assessment, including specialist dietetic and surgical follow-up
management of co-morbidities
psychological support before and after surgery
information on, or access to, plastic surgery (such as apronectomy) where appropriate
access to suitable equipment, including scales, theater tables, Zimmer frames, commodes, hoists, bed frames, pressure-relieving
mattresses, and seating suitable for patients undergoing bariatric surgery, and staff trained to use them.
4. Surgery should be undertaken only after a comprehensive preoperative assessment of any psychological or clinical factors that may affect
adherence to postoperative care requirements, such as changes to diet.
Table 5 e Characteristics of a good bariatric surgeon.
Adequately trained.
Perform a range of bariatric and metabolic procedures.
Team based practice, supported by dietitians.
Has a low mortality and complication rate. Transparently
and honestly share data with you.
Maintains reasonable volume.
Practices evidence based surgery.
Only carries out surgery when indicated. Informs patients
clearly, if indication is not approved by national guideline/
controversial.
Gives patients clear postoperative instructions.
Prepared to offer life-long support and follow up to patients.
Approachable and works closely with you.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 0 3 e1 0 9 107

7. 6. They should keep an eye on the medication usage for
other health conditions. Usually, with improvement in
co-morbidities need for medications such as anti-
diabetic drugs, anti-hypertensives, anti-hyper-
lipidaemic, drugs, antacids, painkillers for arthritis, etc.
decline
7. Bariatric surgery may variably influence absorption of
drugs. For drugs with narrow therapeutic window, pa-
tients should undergo careful drug level monitoring in
the early phase to titrate the dosage of the drug.
8. Bariatric physician should be prepared to offer regular
postoperative follow up to their patients. Follow-up
appointments should be alternated in such a way that
patient see either the surgeon or the physician at reg-
ular intervals.
9. Women in childbearing age should be advised to use
regular non-pharmacological contraception to avoid
pregnancy for at least 18 months after surgery.
10. Patients should be counseled to avoid smoking as that
increases the risk of postoperative complications like
marginal ulceration.
3. Conclusion
Obesity is a complex multi-system disease with very serious
implications for the patients. Currently, the management of
these patients is unsatisfactory, as most general practitioners
lack the knowledge and resources to treat these patients
effectively. There is a vast need to develop and train specialist
obesity physicians or bariatric physicians to take care of this
unmet need. In this article, we have attempted to define the
skill set and role of such a specialist bariatric physician.
Conflicts of interest
The author has none to declare.
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