(From a ‘Jumping Jack’ to the ‘Best Bariatric Surgeon’)
Knowing is not enough; we must apply, Willing is not enough; we must do! Johann Wolfgang von Goethe
Another lockdown OPD
It was another weekend lockdown with an empty OPD waiting hall. Around noon, there was a welcome intrusion by a friend from the neighbouring department.
“I want you to see a patient for me.” He came into my chamber talking. SB was one of the the youngest professors in this college, while I was one of the oldest.
“Sure, what is the problem?” I pointed him to a chair kept across the table at an appropriate distance.
SB hesitated for a moment, “He seems to have a liver problem. Is it okay if he comes on Monday? He has consulted elsewhere, but he wants a second opinion. He will come with all his papers and you evaluate him as a fresh case.”
It was a reasonable statement, but I wanted him to stay for some time. “Sure, Monday is fine. Is he related to you?”
“No, not related. He was a year senior to us, but his wife was my classmate from MBBS days. He is a famous surgeon himself.”
“A good friend then?” I asked.
“We were never very close. In fact, our whole group disliked him. He took away the most beautiful girl of our batch,” SB said casually.
“Was he very brilliant?” I just wanted a little more time with SB.
“He was brilliant alright! But not in studies. He was a great sportsman. We called him ‘jumping jack’ in college. He could never sit still. He was our ace basketball player and was even selected for the state team. Tall, dark and handsome, with an exceptionally agile body. All the boys envied him and the girls were mad after him.”
“Ooh, sportsmen are great people! I exclaimed.
SB had by now switched on, “He did MS surgery after his MBBS. He initially wanted to do sports medicine, but this subject had no degrees in India back then. As an Assistant Professor in our alma mater, he was very popular among the higher ups and within 2 years of joining, he secured a fellowship abroad.”
SB continued, “He worked under a bariatric surgeon in the UK and picked up the tricks of the trade. He came back to India after 5 years with an FRCS. At the age of 35, he developed an excellent ‘Bariatric Surgery’ centre at our institution and was promoted as the head of this new department within a few years. Just 3 years after that promotion, he resigned and joined a famous chain of private hospitals in Delhi as their chief Bariatric Surgeon.”
“I know many sportsmen who have made excellent surgeons.” I chipped in.
SB continued, “ From here his life changed. His surgical results as well as bedside manners were superb. And soon he became very popular. Patients were referred to him from all over the country. Several central and regional ministers got operated by him.”
“Are you talking about CK?”
SB nodded, “Yes, how do you know him?”
“I have heard of his fame. What happened then?” I asked.
SB said, “He developed his team of support staff, including counsellors, dieticians, physicians and junior surgeons. He was among the first surgeons to have started using a robotic arm for his bariatric surgery in India. But still, he had to put in 18 hours a day. His famous quote is-Reaching the top is easy, but one needs to work really hard to stay at the top.”
“Yes, He has been on the top in his field! What happened to him?”
“You will see on Monday. I don’t want to prejudice you!”
And then we talked of other things.
At 10 AM, on Monday , I saw a familiar face walking into my OPD. He was familiar because his hospital used him as a poster boy and frequently plastered his confident looking picture in full-page newspaper advertisements. Now, he looked much older than those pictures, and one would not call his habitus as athletic now.
Tall, dark, but not so handsome.
He was tall alright, but the arms coming out of a half-sleeve shirt were thin. And he also had a paunch as big as mine. SB had accompanied him but left soon after escorting him to my chamber.
I greeted CK and told him that I knew how great a surgeon he was. He beamed.
“I have come here under duress! My wife forced me to seek a second opinion.” He started on a jovial note.
“I thought your friend SB had arranged this visit!” I remarked.
“Naah! SB is my wife’s classmate. All her classmates use to move around her like puppies in college. And she knows how to manipulate them even now!” A big grin flashed on his face.
“So, what brings you to Odisha?” I asked.
“I had come to visit my brother-in-law who lives nearby. He had been asking me to come for several years. My wife forced me to come. She said a visit to Sri Jagannath Temple at Puri may cure me.” he sheepishly said.
It turned out that for some time he had known that he had chronic liver disease. He had consulted a hepatologist in his hospital at Delhi. The diagnosis was Compensated Cirrhosis. He was detected to have hepatitis C virus infection in 2016. He was prescribed the newly marketed wonder drugs and had achieved sustained viral response (cure). That was over five years back.
I saw his old papers. The treatment was as per latest guidelines. The present problem? His last ultrasound had shown a suspicious nodule in the liver and his doctor suspected malignancy.
The further course of action, in my mind, was clear. He needed a few more tests to confirm or refute the diagnosis. He had talked about his ultrasound report with his hepatologist too and the latter had also advised him the same.
But there was something I needed to do more than what his doctor did.
“Do you miss your sports?” I asked.
“Of course I do. It was my life till I went to the UK. My mentor, there, was the best bariatric surgeon in Europe then. He kept me tied to work for nearly five years. When I came back, there was so much to be done here in India. That pushed basketball in the background.”
“And you know that exercise is not only good for our body, but a basic necessity?” he looked surprised at my question.
He smiled and said.“You are asking a bariatric surgeon! It is a routine part of my counselling for my patients. I can rattle out the benefits of exercise to you now!” He then took out his mobile and showed me a picture indicating the benefits of exercise (Figure-1) placed next to that of bariatric surgery in obese in form of a slide.
I commented, “You must be emphasising the role of exercise in weight loss in obese people! Diet and exercise are the first-line treatment for weight loss.”
CK said, “Of course! I din it into my obese patients. The importance of diet control and exercise as the first-line treatment cannot be overstated. We consider surgery only if this treatment and other treatments fail.”
Focus on exercise
“Yes, that is what I thought. But I am not talking about obese people now! For example, you are not obese. Has anyone ever advised you about exercise?” I asked.
“AC sir, I am a sportsman! I have enjoyed the exercise. Why would anyone want to advice exercise to an athelete?” He appeared irritated.
I said, “For example, when your hepatologist advised you on treatment for hepatitis C in 2016? Did he talk about lifestyle modification? I have seen his sole prescription that you have and it says –advised lifestyle measures!”
CK thought for some time.,”Yes, he did say ‘avoid alcohol’, ‘avoid smoking’ and ‘lose some weight.’ Well, I have stayed away from alcohol and smoking. But my weight has been more or less constant. I was 78 Kg in college and I am 80 Kg now. With my height of 183 cm, my BMI falls in the normal range. I did not feel the need to lose weight!”
It was here that I chose to I drop the bomb, “That false perception may be the cause of your present problem!”
He was now angry, “You are talking to a bariatric surgeon. I know everything about obesity and I know I am not obese. Even if you take the Asian definition,3 I may just be a fraction above the definition for normal.”
I said, “So you know about Asian definition of obesity. But do you know why Asian’s have a different definition for obesity?
There was no smile now on his face, “Yes, I think it has something to do with ‘thrifty genes’!”4
I continued,”CK, What I am going to say is no reflection on your knowledge. For example, I know nothing much about bariatric surgery. But I would like to talk about 3 important issues that have a direct bearing on your health. Would you like me to go on?”
He just nodded.
And so, I carried on, “There was a paper in Lancet in 2004, which described the Y-Y paradox.5 First Y is a close friend of mine.”
He seemed interested. “Who is the first Y?”
“Dr C. S. Yajnik from Pune.”I explained. “This paper compared two authors of this paper, an Indian, Dr Yajnik and a Britisher Dr Yudkin. Both had a BMI of 22.3. But when they measured body fat on DEXA, it was noticed that Yajnik had 21.2% fat, while Yudkin had only 9.2%. Europeons are mostly muscular, while we Indians have more fat in our body.
“Interesting” There was now a gleam in his eyes.
I explained further, “This was to emphasise the TOFI phenotype. Thin Outside but Fat Inside! This paper was a follow-up publication from their earlier paper 7 that compared newborn babies born in Pune with those born in London! In comparison, Indian babies had significantly lower birth weight but had higher body fat, central adiposity and hyperinsulinemia. We Indians, by birth, are prone to visceral adiposity and insulin resistance.“
“Why are you telling me this?” He was getting impatient.
I continued, “The second point is that BMI is not an ideal way to diagnose obesity. Very muscular men like the Bollywood actor Salman Khan or Sonu Sood may have a BMI in the overweight or obese range because of the weight of their cultivated muscles. When you were young, you also must have had very well developed muscles accounting for most of your weight.”
He agreed, “I guess that would be correct.”
We are our losing muscles everyday!
I said further,” Now the third point. As we age above 20s, we tend to lose 1% of our muscles every year till 70 years and then, about 1.5% every year.8 The rate of muscle loss is double if one has a liver disease like cirrhosis. Maybe more if one does not exercise. Most of the muscle-bulk is gradually replaced by fat! So even if your weight has been constant, inside you, a major proportion of your muscles have gradually been replaced by fat.”
He nodded as if he understood.”Maybe you are right, my strength is not the same as what it used to be. I switched to robotics as I was getting tremors at the end of a long surgery”
I nodded and went on further, “I am just trying to give you some facts. When you were diagnosed with Hepatitis C in 2016, you had, in fact, two diseases! Both diseases cause cirrhosis. One was hepatitis C, and the other one was fatty liver or Non-alcoholic Fatty Liver disease(NAFLD). Both have a lot of common presentations. Both are associated with insulin resistance and liver fibrosis.”
He asked, “I know, NAFLD is a disease of obese people. But I am not obese!”
Disease of oxymorons
He interjected, “My fatty liver may have been due to hepatitis C!”
I replied, “It is possible that hepatitis C may have contributed, but even if you did not have hepatitis C, you would be having NAFLD in all likelihood.”
“Why do you say that?” He was still not convinced.
“Because you have all indications of metabolic syndrome, which is the main cause of NAFLD! Your triglycerides are high, your HDL is low, your blood pressure and blood sugar is marginally high and you have a paunch as big as mine!”
He looked at his paunch and then mine. “That makes it NAFLD?”
I said,”Yes.You were treated for Hepatitis C by the pills you were given, and you ignored treatment for the other disease i.e. NAFLD.”
Lifestyle is the key
He frowned, “You mean his lifestyle advice was for NAFLD?”
I replied, “You ignored it because there were no pills prescribed for it. Isn’t it?”
He commented, “But he never explained everything to me!” and after a pause added, “Maybe I did not spend enough time with him.”
I thought for some time and asked him, “Have you gone to his chamber with all your reports for follow up?”
He looked at the ceiling,”Come to think of it, mostly the follow up was on the phone. He asked me to get the HCV-RNA PCR test done a couple of times and I read out the report to him on the phone. And he said it was a sustained viral response.”
“You are a busy surgeon. Probably, number one in the country. Not finding time for yourself is an occupational hazard. But I will still say that you have been casual with your own health.”
I allowed that to sink in and then said, “The bitter truth is that you have not only given up your strength i.e. sports, but also taken your health for granted, just because you were a sportsperson once.”
He was finding it difficult to accept what I said, “But I am working the whole day! My day also has only 24 hours.”
I carried on, “There are studies to show that sitting in a chair may be as harmful as smoking! Every additional hour of sitting as in television viewing, increases the risk of liver disease significantly.11,12,13 Your robotic arm may have benefited the patients, but may have harmed you!”
“What is the bare minimum exercise required to be healthy?” He was still trying to punch holes in my theory.
I replied, “General recommendation is 150–300 minutes of ‘moderate-intensity’ exercise (3–6 metabolic equivalents) or 75–150 minutes of ‘vigorous-intensity’ exercise (more than 6 metabolic equivalents) per week. 14 As a rough guide, exercise intensity must begin at a level easily tolerated by the patient as per his current fitness, and gradually increased as per his tolerance over a period of time. Benefits increase as the volume and intensity of exercise increase.”15
He took a few moments to assimilate the facts given by me. Then, like a true sportsman, he asked, “Will exercise help me now that I have developed cirrhosis?” After losing one game, he wanted to prepare for the next.
Muscle and liver: close buddies
I emphatically said, “It definitely will.16 Muscles as an organ is a close friend of the liver. Exercise reduces fat, improves insulin sensitivity and helps in NAFLD at all stages of the disease. Exercise will help even if you do not lose weight.”17
He said in a low voice,”I got so involved in my work that I had no time to exercise! Over the years, I have often thought that I should play basketball sometimes, but I could never do!”
I replied,”You must have heard the usual excuses for avoiding exercise from your patients. My backache does not allow me to exercise; I have no time; My knees are bad; my heart is weak. We all justify our inability to exercise by blaming something other than ourselves. If one starts seeing exercise as a treatment, one can surmount all these barriers.”
He chirped, “Yes, I know that. We have often discussed this with obese people. (Figure-3) Chronic hip and knee pain affects all domains of people’s lives. As a gut reaction, patients avoid activity for fear of causing harm. Chochrane reviews have shown that participation in exercise programmes may improve physical function, depression and pain. I have always insisted that our counsellors provide reassurance and clear advice about the value of exercise in controlling symptoms. They should encourage participation in exercise programmes that people regard as enjoyable and relevant. It brings a range of health benefits to everyone.”18 He spoke like a parrot who remembered his lesson.”
Woodcutter with a blunt saw
I asked, “I am sure your obese patients also must be saying that they have no time?”
He sheepishly said, “Yes, I often tell them the story about the woodcutter, who would not sharpen his saw because he was too busy cutting his daily quota of trees. The story used by Stefen Covey to drill into people the importance of 7th principle – sharpen the saw!.”20
I said, “So there!”
He was now charged, “I also tell them that cardio exercises are as good as isometric exercises. We advise them to use hand springs, weight lifting etc if they can not walk or run. But spend at least one hour exercising.”
I remarked, “How come we forget all this when it comes to ourselves!”
Knowing is not enough, we must do!
He remained quiet for some time, staring at me. He slowly started again.
“Yes. You are right. I have read somewhere – Knowing is not enough; we must apply. Willing is not enough; we must do.”
I nodded, “Can’t agree with you more.”
It was here that he turned the tables on me. “ AC sir, how come you also have a paunch as big as mine.”
I wasn’t prepared for it. But it was no use hiding from him now.
“I guess I am in the same boat as you. As a physician, I am cursed to sit in a chair the whole day, more so now with COVID-19 pandemic and lockdowns.”
He asked, “But you do exercise! Don’t you?”
I answered, “Yes, a bare minimum of 30 minutes in the morning. But nowhere as much as I should be doing. All that is negated by sitting in a chair the whole day. I sincerely wish someone would invent a pill that can mimic exercise.”21
“So, for all the lecture you gave me, you too are a lazy-bum!” He remarked and grinned.
I too smiled, “Not really. I am actually a gym-junkie who has been forced to learn extraordinary energy saving skills.”
[Note: As always, the names of the characters are fictitious but issues are real. It has been written to remind all my friends that the silent pandemic of fatty liver is upon us, as is the pandemic of obesity. 22 It has been written for 10 Jun 2021, which is being observed as International NASH Day. To some extent, the motive is also to remind myself to exercise more.]
|↑1||Pictures from Hallsworth K, Adams LA. Lifestyle modification in NAFLD/NASH: Facts and figures. JHEP Reports 2019; 1: 468–479|
|↑2||Brethauer SA, Chand B, Schauer PR. Risks and benefits of bariatric surgery: current evidence. Cleve Clin J Med. 2006 Nov;73(11):993-1007. doi: 10.3949/ccjm.73.11.993. PMID: 17128540.|
|↑3||WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004 Jan 10;363(9403):157-63. doi: 10.1016/S0140-6736(03)15268-3. Erratum in: Lancet. 2004 Mar 13;363(9412):902. PMID: 14726171.|
|↑5||Yajnik CS, Yudkin JS. The Y-Y paradox. The Lancet 2004; January 10: 163|
|↑6||Picture from Yajnik CS, Yudkin JS. The Y-Y paradox. The Lancet 2004; January 10: 163|
|↑7||Yajnik CS, Lubree HG, Rege SS, Naik SS, Deshpande JA, Deshpande SS, Joglekar CV, Yudkin JS. Adiposity and hyperinsulinemia in Indians are present at birth. J Clin Endocrinol Metab. 2002 Dec;87(12):5575-80. doi: 10.1210/jc.2002-020434. PMID: 12466355.|
|↑8||Montano-Loza AJ, and Ebadi M. Definition and Diagnosis of Sarcopenia in the Research and Clinical Settings. In Frailty and Sarcopenia in Cirrhosis: The Basics, the Challenges, and the Future. Tandon, Puneeta, Montano-Loza, Aldo J. (Eds.). Frailty and Sarcopenia in Cirrhosis. Springer Nature 2020. pp3-12.|
|↑9||Ding C, Chan ZL, Magkos F. Lean, but not healthy: the “metabolically obese, normal-weight’ phenotype. Current Opinion in Clinical Nutrition and Metabolic Care 2016;19:408-417.|
|↑10||Bondini S, Younossi ZM. Non-alcoholic fatty liver disease and hepatitis C infection. Minerva Gastroenterol Dietol. 2006 Jun;52(2):135-43. PMID: 16557185.|
|↑11||Grontved A, Hu FB. Television viewing and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a meta-analysis. JAMA 2011;305:2448–2455.|
|↑12||Dunstan D, Salmon J, Owen N, Armstrong T, Zimmet P, Welborn T, et al. Associations of TV viewing and physical activity with the metabolic syndrome in Australian adults. Diabetologia 2005; 48: 2254–2261|
|↑13||Bowden Davies KA, Sprung VS, Norman JA, Thompson A, Mitchell KL, Harrold JOA, et al. Physical Activity and Sedentary Time: Association with Metabolic Health and Liver Fat. Med Sci Sports Exerc 2019; 51: 1169–1177.|
|↑14||Hashida R, Kawaguchi T, Bekki M, et al. Aerobic vs. resistance exercise in non-alcoholic fatty liver disease: a systematic review. J Hepatol 2017;66:142–152.|
|↑15||Bowden Davies KA, Sprung VS, Norman JA, Thompson A, Mitchell KL, Harrold JOA, et al. Physical Activity and Sedentary Time: Association with Metabolic Health and Liver Fat. Med Sci Sports Exerc 2019; 51: 1169–1177|
|↑16||Chalasani N, Younossi Z, Lavine JE, Charlton M, Cusi K, Rinella M, et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology 2018;67:328–357.|
|↑17||Anand AC. Nutrition and Muscle in Cirrhosis. J Clin Exp Hepatol. 2017 Dec;7(4):340-357. doi: 10.1016/j.jceh.2017.11.001. Epub 2017 Nov 8. PMID: 29234200; PMCID: PMC5719462.|
|↑18||Hurley M, Dickson K, Hallett R, Grant R, Hauari H, Walsh N, Stansfield C, Oliver S. Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review. Cochrane Database Syst Rev. 2018 Apr 17;4(4):CD010842. doi: 10.1002/14651858.CD010842.pub2. PMID: 29664187; PMCID: PMC6494515.|
|↑19||Picture from Hallsworth K, Adams LA. Lifestyle modification in NAFLD/NASH: Facts and figures. JHEP Reports 2019; 1: 468–479|
|↑20||Covey, Stephen R. The 7 Habits of Highly Effective People.® Published by Simon & Schuster.|
|↑21||Hawley JA, Joyner MJ, Green DJ. Mimicking exercise: what matters most and where to next? J Physiol. 2021 Feb;599(3):791-802. doi: 10.1113/JP278761. Epub 2020 Jan 14. PMID: 31749163; PMCID: PMC7891316.|
|↑22||Meldrum DR, Morris MA, Gambone JC. Obesity pandemic: causes, consequences, and solutions-but do we have the will? Fertil Steril. 2017 Apr;107(4):833-839. doi: 10.1016/j.fertnstert.2017.02.104. Epub 2017 Mar 11. PMID: 28292617.|