New avatars in endocrine practice: The bariatric physician.

Overweight and obesity are rapidly increasing in India, with prevalence of 17% reported from studies in Chennai.[1] The adverse effects and the public health impact of obesity is well-known to the readers of this journal. The management of obesity is multidisciplinary, with involvement of different interventions such as dietary, life-style related, psychological, medical and surgical.[2] Pharmacotherapy of obesity is based upon a few drugs with the effectiveness limited to modest loss of weight.[34] Orlistat is the only approved drug currently available for use in India. Because of this, there is a need to explore other means of obesity management.

Over the last 10 years, bariatric surgery has emerged as an important procedure to help patients with obesity get over their fat. Analysis has found the procedure to be cost-effective in patients with high obesity related health costs like diabetes.[5] Estimates suggest that the number of bariatric procedures performed in the United States increased from 13,365 in 1998 to nearly 150,000 in 2005[6] and to approximately 200,000 procedures in 2007, according to the American Society for Metabolic and Bariatric Surgery. In 1998 in the United States, there were approximately 250 bariatric surgeons, which increased to approximately 700 in 2001 and expanded to nearly 1,100 by 2003.[78] The projected number of bariatric surgeries in the world for 2013 is more than 500,000.[9] Although similar published data from India is scarce, there is a substantial increase in number of bariatric surgeries performed in India.

The American Association of Clinical Endocrinologists (AACE), The Obesity Society, and the American Society for Metabolic and Bariatric Surgery 2008 clinical practice guidelines recommend that bariatric surgeon, bariatric coordinator (advanced practice nurse or well-educated registered nurse), internist with nutrition or bariatric medicine experience and registered dietician are essential members of the bariatric team with other specialists like endocrinologist, cardiologist, psychologist, cardiologist, gastroenterologist, physiatrist, physician nutrition specialist and sleep medicine specialist as consultants to be utilized.[10] The multidisciplinary team is important for patient selection and to ensure that nutritional and post-operative outcomes are optimal. The endocrinologist is an essential component of the bariatric surgery team. He is involved in patient care, pre-operative assessment, nutritional assessment and post-surgical follow-up for nutritional complications.[11] Further, most of these eligible patients, especially those with diabetes are primarily referred from endocrine practices.

Bariatric surgery trends show that the largest number of procedures performed is Roux-en-Y gastric bypass followed by lap banding.[91012] Roux-en-Y gastric bypass is associated with nutritional problems in a significant proportion of cases and will require expert nutritional management.[1011] The shortage of specialists in nutritional medicine is an accepted fact in Western literature.[13] In India, the shortage is much more serious. Endocrinologists, with their knowledge in metabolism and nutrition are theoretically are the best suited to deal with nutritional issues.[14] However in India, with most endocrinologists remaining busy in handling uncontrolled hyperglycemia and its complications, there is a limited time to devote to nutritional medicine, leave alone bariatric surgery. The current curriculum of endocrine training in India has limited emphasis on nutritional management of obesity and bariatric surgery. Even in internal medicine post-graduate courses, clinical nutrition is a neglected topic.

Though bariatric surgery is reaching smaller towns and cities, the bariatric care teams may not have an endocrinologist on board, and may depend upon non-specialist physicians to offer post-operative metabolic advice. This brings in the new avatars of “bariatric physicians” or obesity medicine physicians. This is the contemporary equivalent of an earlier phase when everyone with any interest in diabetes (academic or otherwise) named themselves as diabetologist. Just like diabetes, bariatric science and science of nutrition is primarily the realm of endocrinology. However, just like diabetes, the current work force of endocrinologists would find it virtually impossible to manage the swarming pandemic of obesity. AACE in its position paper on obesity and obesity medicine has recognized the shortage of qualified professionals to treat obesity and has suggested avenues for obesity medicine training and certification.[15] American Board of Obesity Medicine is an organization for certifying obesity physicians.[15] The AACE acknowledges the fact that highly trained and qualified endocrinologists can provide clinical leadership and mentoring in this area.[15]

In a country like India, if endocrinology des not face up to the (challenging) situation, the specialty of obesity will be dominated by non-medical professionals, alternative medicine practitioners and quick fix solutions. It is time for endocrinology, and endocrinologists, to recognize and improve this developing specialty. “Endocrine bariatrics” should be developed and nurtured by endocrinologists. A multipronged approach, involving training of existing endocrinologists and physicians, improving curriculum of obesity and nutrition management in post-graduate and subspecialty training, and providing certifications, is needed. To give optimum care to patients in this new scenario, we endocrinologists have to learn the new trade.