In India, where one-in-six people are undernourished, an unlikely business is booming: obesity surgery.
As economic growth averaging more than 7 percent a year helped shrink the number of chronically hungry, the population of overweight and obese Indians has climbed. In cities such as New Delhi and Mumbai, adult women are more likely to be too fat than too thin, studies show. The result is an epidemic of life-shortening diseases such as hypertension and diabetes, which is estimated to afflict 63 million Indians.
To counter the trend, about 400 surgeons operating in 250 hospitals are offering stomach-shrinking procedures. That’s made India one of the fastest-growing centers in the $1.2 billion global market for bariatric devices. Covidien Plc, which competes with Johnson & Johnson in supplying titanium stomach staples, predicts obesity operations in India will double to 10,000 this year, with as many as 2 million Indians as suitable candidates.
“These companies are doing very well -- well beyond their targets in India,” said Ramen Goel, a surgeon at Nova Specialty Surgery, a private hospital in Mumbai, who was one of the first to offer the treatment in India in 2000. “Diabetes is now surgically controllable. Not everybody can exercise to make themselves healthy, it’s just not possible.”
$2.3 Billion Market
The global market for the staples, staple-guns and other devices used in bariatric surgery is expanding about 9.7 percent a year and will reach $2.3 billion by 2018 driven, according to GlobalData, a London-based market research firm.
Most of the operations are done in the U.S., where two-thirds of adults are overweight or obese. The American Society for Metabolic & Bariatric Surgery counted about 220,000 of the procedures in 2009.
The weight-loss operations are gaining popularity as evidence of their efficacy in helping to fight diabetes, cardiovascular disease and other obesity-linked conditions builds. Gastric surgery helps people lose weight by shrinking the size of the stomach, restricting calorie uptake. The operations may also aid weight loss by changing the composition of helpful bacteria that live in the gut, Harvard University researchers said in a study published in March.
Demand is also increasing in developing countries. Low- and middle-income nations are facing what the World Health Organization describes as a “double burden,” in which the traditional threats of infectious disease and undernourishment are overlaid with risk factors, such as obesity, that are associated with modernization and affluence.
“We have essentially a double whammy,” said Nikhil Tandon, a professor of endocrinology and metabolism at the All India Institute of Medical Sciences in New Delhi. “In the original industrialized nations, that happened over centuries. In India, it’s happened in 20 years.”
The past two decades has brought a “dramatic increase” in obesity in India, said Aarti Shetty, an industry analyst at Frost & Sullivan in Mountain View, California. “This, coupled with increased interest to enhance external personal appearance, drives growth in the obesity surgery market,” she said.
In 2011, Ethicon Endo-Surgery Inc., a unit of Johnson & Johnson, had a 24 percent share in the global bariatric surgery devices market, according to the report from GlobalData. Covidien followed with a 21 percent share and then Allergan Inc., with a 16 percent market share.
Covidien is benefiting from “strong” demand for products that support bariatric surgery, especially in India, said Mark Rooney, head of the Dublin, Ireland-based company’s Indian Subcontinent business, in a telephone interview from New Delhi. The company has recently set up an R&D facility in the southern Indian city of Hyderabad to develop products that can be adopted in emerging markets, he said.
In India, where more than two-thirds of the population lives on less than $2 a day, bariatric surgery can address the underlying cause of some metabolic diseases, enabling patients to avoid the cost of medications, blood-sugar monitoring and complications such as foot ulcers, according to Rooney.
“We know we’ve got a good treatment that’s the most cost-effective and most accessible to Indians,” he said.
Two major challenges to tackling obesity in many developing nations are a shortage of well-trained physicians and a lack of awareness about the disease and solutions for it, said Sushobhan Dasgupta, managing director of Johnson & Johnson Medical India.
J&J trains about 8,000 surgeons annually in India in the latest surgical products, advanced procedures and techniques, including minimally invasive bariatric surgery, through three institutes of surgical education, Dasgupta said.
“India is witnessing a dramatic rise in obesity and Johnson & Johnson India is working to address this challenge and help patients live healthier lives,” he said. “Many of our products are used during bariatric surgery, which we believe is a good option for obese patients.”
There are numerous approaches to obesity surgery. Most achieve weight loss by restricting the size of the stomach. These include gastric banding that is adjustable and reversible, the type of procedure that New Jersey Governor Chris Christie underwent in February. In another technique, sleeve gastrectomy, the outer part of the stomach is removed and reshaped to resemble a narrow tube. Surgeon Goel said he prefers the Roux-en-Y gastric bypass operation in which the stomach is bypassed so that food enters a small gastric pouch before passing into a loop of the small bowl.
Gastric banding is less popular in India, where foods such as curry are often served seeped in calorie-laden liquids, making the procedure less effective, he said.
The intragastric balloon, a surgical option not yet approved in the U.S., is available in India, showing there is demand for new procedures in the South Asian nation, Frost & Sullivan’s Shetty said.
Too much focus on bariatric surgery risks ignoring the underlying causes of obesity, which need to be tackled during childhood, said Tandon, the endocrinology professor at the All India Institute of Medical Sciences. About a quarter of school children from “middle class-to-affluent” families in urban India are either overweight or obese, Tandon said, citing a 2007 survey.
‘Chopping Them Up’
“Why allow these kids to grow into a situation where they need bariatric surgery later on?” he said. “There are obviously simpler ways of preventing people from getting overweight than to allow them to first become overweight and then chopping them up.”
About a quarter of affluent Indians are obese with early development of Type 2 diabetes, according to the WHO. The United Nations agency predicts that 31 percent of adult men in India will be overweight by 2015 from 22 percent a decade earlier, while the prevalence of overweight women will increase to 29 percent from 21 percent over the same period.
Obesity is increasing in India’s slums as well. A 2009 survey of women living in an urban slum in the southern city of Chennai found three overweight for every two who were underweight.
The results reflect increasing barriers to a healthy diet and lifestyle in built-up areas. Gym membership, fresh fruits and vegetables are unaffordable for many in India, ranked 136th of 186 nations in the UN’s Human Development Index, a gauge of well-being and life chances. A lack of safe sidewalks, overcrowding and pollution hinder outdoor exercise.
Indians are especially vulnerable to diabetes because of a tendency to have a higher ratio of fat to lean-muscle mass than other Caucasians, and to deposit more body fat around the abdomen, where it interferes with insulin and increases blood-sugar levels, causing an earlier onset of diabetes, said Reenita Das, a partner at Frost & Sullivan in Mountain View, California.
“In Mexico, China, Brazil and India, where the economies have improved, people are getting richer and they are getting fatter and sicker,” she said, and that India and China are home to more than half the world’s total number of diabetics.
Surgery is a reasonable remedy for many obese middle-class patients, according to Ajay Bhandarwar, who offers the treatment at a public clinic in Mumbai’s Sir J.J. Hospital.
“Exercise, diet -- they don’t work in the majority of them,” said Bhandarwar, who is also a professor of surgery at Grant Medical College. “They will lose 5 to 10 kilograms, but they can’t maintain it because of lifestyle or commitments.”
Even when the surgery is successful, it’s no guarantee of a longer life.
One of Bhandarwar’s patients, a 44-year-old policeman, weighed 330 pounds (150 kilograms) when he underwent bariatric surgery in January, a decision he made after watching a program about it on the Discovery Channel.
Twenty years of munching on vada pav, a popular street snack made of white bread and deep-fried potato, and drinking five cups a day of sweet tea, known as chai, to stay alert during his shift, added about 200 pounds to his 5 foot-5 inch (1.68 meters) frame and contributed to him developing diabetes and hypertension in his 30s, the policeman said in an interview in March.
He said he felt fitter and healthier after losing 62 pounds in 85 days. Last week, he died of a heart attack, Bhandarwar said.
Bhandarwar’s government-run hospital mostly caters to Mumbai’s poor, though he said his clientele also includes a politician’s wife and elected patriarchs from surrounding villages. He performs bariatric surgeries for as little as 160,000 rupees ($2,950), charging patients only the cost of equipment and drugs, Bhandarwar said.
“The number of surgeries is going up day by day,” said Bhandarwar, who has performed 40 obesity surgeries since starting 13 months ago. “The future is bright as far as this disease goes.”