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Surgery not a magic cure for obesity Adherence to recommended diet, physical activity program equally important

It is alarming, but obesity has reached epidemic proportions in Kuwait. Oil has not only brought great wealth to the Gulf, but a huge change in lifestyle and food habits. Fast food, fast cars and everything else that money can buy has led to the rise of obesity so much so that today at least 88 percent of Kuwaitis are considered overweight. In fact, according to a study published by the London School of Hygiene and Tropical Medicine, based on data from the World Health Organization, Kuwait is the second most obese nation in the world, after the US. Some may dismiss it lightly as a story that has been blown out of proportion, but there is no doubt that this is one of biggest health stories, and a severe public health crisis.

It is a proven fact that obesity can lead to several diseases including cancer, heart disease and diabetes and the cost of these illnesses apart from their toll on health can be astronomical. Among the many recourses available to fight the obesity epidemic is bariatric surgery. Overweight and obese people are increasingly seeking bariatric surgery because of the failure or inability to shed excess weight through diet and exercise.

Dr Salman Al Sabah, Director of Surgical Research and Academic program in the Department of Surgery, and Consultant Surgeon at Al Amiri Hospital and Royal Hayat Hospital blames this growing rate of obesity on lifestyle changes combined with a genetic predisposition among the locals to gain weight. “In 2012, at least 6,000 people in Kuwait underwent bariatric surgery and a paper published on Obesity Surgery in 2013 reported that Kuwait has the highest numbers of operations performed as a percentage of the national population,” he observes.

A founding member of Gulf Obesity and Metabolic Surgery Society (GOSS), an association actively involved in  fighting this disquieting increase in obesity, he has also served as the Director of the First and Second Kuwait Bariatric and Metabolic Surgery Conference. According to him, this surge in bariatric surgery in Kuwait is due to an alarming increase in obesity “The increase in bariatric procedures is not just limited to Kuwait; the whole region is facing a dramatic rise in the number of operations. Since 2012, over 25,000 bariatric procedures have been performed in the Middle East.” In Insight today, Dr Salman Al Sabah discusses the problem of obesity in Kuwait, the reasons people are resorting to surgical means to lose weight and the need to implement innovative techniques and promote research to reduce the burden of obesity on society.

Question: Is it true that the incidence of obesity in Kuwait is second highest in the world - that one out of three Kuwaiti is obese - what is the reason?
Answer: It is true that according to the World Health Organization Kuwait is ranked as one of the highest countries in the world for obesity. In my opinion, the reasons for this are multi-factorial. I believe it is a combination of lifestyle through affluence that has over time resulted in significant changes in dietary and physical activity patterns. Additionally, there is also a genetic component that attributes to obesity.

Q: What do you mean by genetic components?
A: Some people with certain genetic profiles might have a higher susceptibility to obesity, once exposed to certain environmental factors which include poor nutrition and low physical activity with higher caloric intakes.

 Q: So if you have those genes you are more prone to obesity?
A: There are still studies being conducted in this area regarding the obesity genes however genes can be affected by their environment. Recent studies indicate that genes can also change according to lifestyle habits of a person.

Q: I happened to read somewhere that obesity is one of the health fall outs of the Iraqi invasion. Is that right?
A: The Gulf war did play a role in increasing obesity in Kuwait. This was because, after the liberation of Kuwait, many fast food franchises opened here and from there a trend emerged that shifted the tastes nationally from the traditional to contemporary cuisines same as in other countries worldwide. As you are aware, obesity is a global burden. One reason for this is the ease of access to fast food with minimal physical activity. Here in Kuwait you can get food delivered to your door with the click of a button. Currently, in Kuwait there is a growing awareness about healthy eating and exercise. In recent times, many companies have been promoting healthy living, including gyms, spas nutritional centers and educational conferences. At present, different organizations have been doing many outreach awareness campaigns to promote healthy living, in malls, universities and schools.

Q: Does the weather have a role to play as well in the obesity problem of Kuwait?
A: The weather in Kuwait does contribute to obesity and other conditions. Here in Kuwait, the temperature for most of the year is very high to be engaged in any physical activity outdoors. However as easy as it is to blame the weather, there are many indoor air-conditioned options available that promote physical activity such as the many gyms and spas. Also, there are many indoor alternative ways of exercising. Malls, for example, do not only need to be only about food and shopping. People can walk comfortably indoors. In fact, it is recommended that people should exercise at least 30 minutes a day.

Q: Why do people go in for bariatric surgery? Is this the only option for people suffering from morbid obesity?
A: People are referred to bariatric surgery for the treatment of obesity and related health conditions such as diabetes and hypertension. Bariatric surgery is a proven treatment option for the morbidly obese. There are both medical and surgical treatments available for the treatment of obesity that includes lifestyle modification through diet and exercise and surgery if recommended.

Q: What are the risks involved with this surgery?
A: There are risks involved in all surgeries and treatments; however with bariatric surgery the risks are relative and dependent on individual patient health. In the suitable patients, the health risks from obesity far outweigh the risks associated with bariatric surgery. In patient’s that have other pre-existing conditions other than obesity like diabetes, hypertension or any cardiovascular conditions the risks may be increased.

Q: What are the effects of this type of surgery?
A: The primary intended effect of bariatric surgery is weight loss. However, there are many other benefits for patients who suffer from other conditions. These include resolution or remission of diabetes mellitus, improvement of cardiovascular risk factors and hypertension. Additionally, most patients also show improved quality of life, resolution of depression in some cases and many other benefits. See attached image.

Q: How much weight does a patient generally lose after surgery?
A: Weight loss after surgery depends on many factors. One of them includes the patient’s body mass index (BMI), follow up, the extent to which the patient adheres to the recommended diet and physical activity program. Patients should understand that surgery is yet another way to manage obesity in addition to nutrition and exercise. It is not a magic cure. Patients should also understand that if they are not committed to changing their lifestyle, they can even regain the weight after bariatric surgery. One way of measuring the success of the surgery is by the patient losing 50% of their excess weight over a period of one year and also the resolution/improvement of other health conditions like diabetes, hypertension and dyslipidemia (cholesterol).

Q: What is the success rate of this surgery?
A: There are many types of bariatric surgery for the treatment of obesity, such as Laparoscopic sleeve gastrectomy, Gastric Bypass, Gastric Band, Intragastric Balloon to name a few. They differ in technique based on the patient’s characteristics and other health conditions. All these surgeries have different rates of success that is dependent also on the extent to which patients comply with medical advice both before and after the surgery. Based on the procedure they have different timelines and success rates.

Q: How different is gastric bypass and sleeve gastrectomy from bariatric surgery?
A: They are various procedures under bariatric surgery. In fact, bariatric surgery has gained popularity over the last five years in the Arabian Gulf region for the treatment of morbid obesity. Recently, according to the American Diabetes Association, it has also gained popularity as a proven treatment for the remission and in certain cases remission of type 2 diabetes which as you know is very high here in Kuwait and in the gulf region. Among the types of bariatric surgeries, the procedure Sleeve Gastrectomy commonly known here as stomach stapling has become the most common procedure performed in the region.

Also, patients feel that sleeve gastrectomy is an easier procedure with comparatively fewer risks of complications and many surgeons in the region also agree. In 2012, at least 6,000 people in Kuwait underwent bariatric surgery and a paper published on Obesity Surgery in 2013 reported that Kuwait has the highest numbers of operations performed as a percentage of the national population. The reason for this is that Kuwait ranks high in obesity, in the world. The increase in bariatric procedures is not just limited to Kuwait; the whole region is facing a dramatic rise in the number of operations. Since 2012, over 25,000 bariatric procedures have been performed in the Middle East.

Q: I came across another procedure I wanted to ask you about. It is a procedure called POSE. Is stomach stapling and POSE the same thing?
A: In bariatric procedure, each method has its own name. In Sleeve gastronomy, we do use staples and perhaps that is why it is called stomach stapling. POSE (Primary Obesity Surgery, Endoluminal) is yet another procedure. It is regarded as a minimally invasive procedure, because we do not make any holes in the abdomen. It is not a surgery. Basically, we do everything through the gastroscopy, but with special equipment. We use special sutures and anchors to make the stomach smaller in size. The whole idea behind this is that it stimulates the brain to eat less, but with more satiety.

Q: Ok you feel full?
A: Yes. You tend to feel full. You do not overeat.

Q: Is ‘POSE’ a risk free procedure?
A: All surgeries and procedures do have their risks. However, this procedure is relatively minimally invasive. One of the very rare complications of this procedure is internal bleeding which can be treated with early diagnosis.

Q: So why should one anyone go for something major like bariatric surgery and not opt for a procedure that is minimally invasive as POSE?
A: All types of bariatric surgery have their success rate however all these procedures are based on the eligibility of the patient. The doctor is both qualified and responsible to recommend the best individualized treatment option for their patient based on intended weight loss targets.
For instance, POSE is good for people who have a BMI between 30 and 40 and they want to lose 50 to 60 % of their excess weight. But keep in mind, it is a new procedure. It has been around for a short time. We still don’t know the long-term outcomes of POSE. And even now when we do it, we do it under a research protocol.

Q: What qualifies people for bariatric surgery in the governmental hospitals? In which government hospital is this available? Is it also available in private hospitals?
A: In Kuwait, bariatric surgery is performed in both the governmental and private hospitals. In 2013, Kuwait approved the National Bariatric Surgery Guidelines in keeping with the international best practice standards. Eligibility for the surgery depends on the patient characteristics. If they are morbidly obese (BMI > 40 kg/m2 or Ž35 kg/m2 with co-morbidities), have failed attempts at diet and exercise, are motivated and well informed, and are free of significant psychological disease, they are eligible for this surgery. In addition, the expected benefits of the operation must outweigh the risks. The decision to use surgery requires assessing the risk-benefit ratio in each case. Those patients whose BMI exceeds 40 kg/m2 are potential candidates for surgery if they strongly desire substantial weight loss, because obesity severely impairs the quality of their lives. In certain instances, less severely obese patients (with BMI’s between 35 kg/m2 and 40 kg/m2) also may be considered for surgery.

Patients who are included in this category are high-risk comorbid conditions such as life-threatening cardiopulmonary problems (e.g., severe sleep apnea, and obesity-related cardiomyopathy) or severe diabetes mellitus. Other possible indications for patients with BMI’s between 35 kg/m2 and 40 kg/m2 include obesity-induced physical problems that interfere with lifestyle (e.g., joint disease treatable, but for the obesity, or body size problems precluding or severely interfering with employment, family function, and ambulation). The Asian guidelines for the treatment of metabolic syndrome (diabetes, hypertension and dyslipidemia) also started to include BMIs of 30 kg/m2 - 35 kg/m2.
Besides many private hospitals, these procedures are also performed in all governmental hospitals in Kuwait. I work in Al-Amiri Hospital and Royale Hayat Hospital with a multidisciplinary team that fights obesity with both surgical and non-surgical interventions. Since lifestyle modification plays a huge role, patient adherence is also a part of the success of these procedures.

 Q: Is it true people tend to confuse bariatric surgery with cosmetic surgery?
A: It is true people do tend to confuse bariatric surgery with cosmetic surgery. However, it is the role of the doctor or surgeon to recommend bariatric surgery for people who require it based on the national guidelines.
The reason why people perceive “stomach stapling” as the norm in Kuwait is due to the high prevalence of both obesity and diabetes in Kuwait. Kuwait does have the highest numbers of operations performed as a percentage of the national population according to the International Federation for the Surgery of Obesity and Metabolic Disorders in a worldwide study of 42 countries in 2011.

Q: Is it also true that this form of surgery was suspended for a brief period last year? What was the reason ?
A: Yes, the surgery was suspended for a brief period of time last year to evaluate the safety and efficacy of the surgery and to establish national guidelines. After which it was decided that bariatric surgery is a proven and recommended option for the treatment of morbid obesity.

Q: Where does GOSS come into the picture? Is it a new association? And is it limited to the Middle East?
A: In May 2013, the Gulf Obesity Surgery Society (GOSS) was established with an executive board of 18 members to include three members from each Gulf country including the Kingdom of Saudi Arabia, United Arab Emirates, Kuwait, Oman, Qatar, and Bahrain. The First Annual Gulf Obesity Surgery Society (GOSS) meeting was held in Kuwait City between Dec 11-14, 2013. This meeting was co-chaired by Dr. Abdulrahman Nimeri from UAE and myself representing the State of Kuwait. The First Annual GOSS meeting featured the fifth Annual Sheikh Khalifa Medical City (SKMC)-Cleveland Clinic Obesity Symposium and the Second Kuwait Society of Metabolic Surgery meeting. This annual meeting will continue to take place on a rotation basis among all six Gulf countries.

Q: What made you interested in this branch of medicine?
A: With the current rise in obesity and other related conditions like diabetes here in Kuwait and in the region, I believe there is a real need for bariatric surgery as a treatment of obesity. I am trained in general surgery and I have specialized in gastrointestinal surgery and minimally invasive surgery. In order to be a bariatric surgeon one needs certain skills including good laparoscopic skills, and I already possessed and practiced those skills as a gastrointestinal surgeon. At the end of the day, we are doctors and we want to help as many patients as we can. Since we know that the rate of obesity is alarming here in Kuwait, this is one way to help people and give back to the community.

Q: What got you involved with GOSS?
A: In November 2011, after our First Kuwait Obesity and Metabolic Surgery meeting, awareness was raised about the high frequency of surgeries along with the high prevalence of obesity. After many other regional and international conferences, I was approached for help in establishing the Gulf Obesity Surgery Society.

Q: How hopeful are you about the future?
A: My vision for the future is to establish a national bariatric surgery registry. I would like to implement innovative techniques and promote research to reduce the burden of obesity, diabetes and other related diseases here in the state of Kuwait. I believe that in working in collaboration with both international and national universities, hospitals and institutes we can promote research from a genetic, academic and medical perspective in order to discover novel and less invasive treatment options for obesity, diabetes and other related diseases. 


Dr Salman Al Sabah MBBS, MBA, FRCSC, graduated from Kuwait Medical School. He completed his residency in General Surgery and Master of Management and Health Leadership degree at McGill University, Canada. He also completed his Fellowship in Minimal Invasive and Bariatric Surgery at McGill University. At present he is the Director of Surgical Research and Academic Program in the Department of Surgery, and a Consultant Surgeon at Al Amiri hospital, Kuwait. His principle clinical foci are Metabolic/Bariatric Surgery, Minimally Invasive Surgery, Advanced Endoscopy and research. He has contributed several international presentations as a speaker, moderator and publications to the field of Minimally Invasive and Bariatric Surgery.

Dr Al-Sabah is also the Director of the First and Second Kuwait Bariatric & Metabolic Surgery Conference and the First Gulf Obesity and Metabolic Surgery Society Meeting. He is a member of many international and national surgical and medical societies including Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), American College of Surgeons (ACS), Endoscopic & Laparoscopic Surgeons of Asia (ELSA), Gulf Obesity and Metabolic Surgery Society, Kuwait Obesity Surgery Association and Kuwait Medical Association.

Dr Al-Sabah represents Kuwait internationally and is a Board Member to the International Federation for the Surgery of Obesity and Metabolic Disorders: Asia Pacific Chapter and Endoscopic & Laparoscopic Surgeons of Asia. He is a Fellow of the Canadian Royal College of Surgeons. He is the founder of the Gulf Obesity and Metabolic Surgery Society in the Gulf and the Kuwait Obesity Surgery Association in Kuwait.

By Chaitali B. Roy
Special to the Arab Times

By: Dr Salman Al Sabah

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