"Excess weight is not a lack of discipline, but a disease"

"Excess weight is not a lack of discipline, but a disease"

In 2016, a man weighing 236 kilograms approached Doctor of Medical Sciences Shuhrat Hoshimov. Bariatric surgery — that is, surgical intervention to reduce weight — could not even be considered immediately: the operating table in the clinic could not support a load of more than 200 kilograms.

The patient turned out to be a very sincere and open-hearted person. He would give flowers to the nurses and joke constantly: "Girls, I am actually very handsome, it's just that fat is hiding all my beauty." Meanwhile, he could barely get out of bed in the mornings.

To bring his weight down to the permitted 200 kilograms, a temporary silicone balloon was placed in the patient's stomach, which occupied a large part of the stomach volume. The man began to feel full even with very small portions. Within a few months, his weight decreased by 36 kilograms. After that, the balloon was removed, and preparation of the patient for surgery began.

According to the World Health Organization, Uzbekistan leads Central Asia in the prevalence of excess weight among adults with a figure of 63.7 percent. In Turkmenistan and Tajikistan, this figure reaches 58 percent, in Kazakhstan — 56.5 percent, and in Kyrgyzstan — 56.2 percent. There are many reasons for this. One of them is the national cuisine.

Pilaf, manti, hot somsa — these are part of our cultural code. Only, the calories of such dishes were "calculated" to match the heavy physical labor of our ancestors. To "burn off" a plate of pilaf, one needs to work in the field all day. In the 21st century, however, a person eats fatty food to their heart's content, gets into a car to go to the office, and sits in front of a computer until evening, says doctor Shuhrat Hoshimov.

In addition to high-calorie foods and a sedentary lifestyle, addiction to gadgets also worsens the situation. Young people stare at smartphones until midnight, as a result of which sleep duration is shortened. Not getting enough sleep affects the hormones that control appetite and can increase the risk of obesity.

Realization of the problem happens individually for everyone, but in any case, it begins from the moment the body stops obeying.

Before getting married, Mahmuda's weight was 42 kilograms. With a height of 156 centimeters, this woman looked compact, almost fragile. Now she is 41 years old. She works as a nurse's aide and is raising three children. Her whole life consists of a monotonous cycle between hospital wards, home, and the market.

An entire lifetime lies between that compact Mahmuda and the Mahmuda of today: over time, the woman's body gradually stopped obeying her.

It all started at the age of 38 with a severe emotional shock — she lost her child. Then the pandemic began, and Mahmuda ended up in the Zangiota infectious diseases complex. She had a severe case of Covid. The woman took high doses of a hormonal drug recommended by the WHO for severe cases. The disease was defeated, but the body showed a different calculation: her weight, which had previously remained around 74 kilograms, rose sharply to 94.

The path that led another Tashkent resident, Shuhrat Y., to the critical point was different. Until his body weight reached 165 kilograms, he loved to travel and would walk for hours in unfamiliar cities. After the age of 40, kilograms began to add up one after another, and gradually the circle of his life shrank to the distance between the house door and the car door.

The 2020 pandemic was a turning point for this man as well. Car traffic was stopped, the streets became empty, and on one of those quiet days, his elderly father called Shuhrat and said: "Shuhrat, come, cook pilaf for me."

Shuhrat is 57 years old. He cooks dishes very well. Only, the path to his father's house is ten bus stops and a five-meter slope near a traffic light. For a person weighing 165 kilograms, this is not just an obstacle, but an ordeal: with every 10-15 meters walked, the body punishes him with heavy, suffocating shortness of breath.

"Relatives told my father: 'How will he come? He is obese. He won't even make it halfway.' But I set off. My father is calling, how can I not go? There are no cars, everything is quiet. I am walking, slowly, gradually, step by step... I am walking and thinking: on one hand, I must fulfill my father's wish, but on the other hand, how hard it is, I am suffocating, there is not enough air," Shuhrat recalls.

That day he reached his father. But it was on that very path that a bitter thought burned his heart, making him realize how narrow and limited his world had become.

The main misconception in society that doctors fight against is the blind belief in "willpower."

"Advice about 'eating less and exercising' is nonsensical in most cases," explains surgeon Shuhrat Hoshimov. "At this stage, excess weight is not a lack of discipline, but a full-fledged disease."

Along with the physical pressure of one's own body, social pressure also enters a person's life.

The changes in Mahmuda's appearance did not go unnoticed either at home or at work. First, her husband took her aside: "You are gaining weight, do something." Her sisters also joined in: "Look at yourself, you are getting fat." Her colleagues at the hospital also spoke openly: "Why are you gaining so much weight? You are short, you are starting to look like Kolobok (Bo‘g‘irsoq)."

Illustrative photo: Joachim Schnurle / Unsplash

At such times, Mahmuda would suffer inside and feel bitter.

"I would get very nervous because I couldn't find clothes that fit me. Because of my short height, I couldn't choose anything from the market. It was painful to have to buy ugly-cut clothes designed for elderly women. My husband would reprimand me: 'What did you put on? It doesn't suit you, look for clothes designed for larger people,'" says Mahmuda.

Before accepting the fact of the disease, Mahmuda and Shuhrat went through a dead end of attempts to solve the problem independently.

With the help of various diets, slimming teas and coffees, and fat-burning supplements, she managed to lose 10 kilograms (from 94 to 84), after which the scale needle stopped completely.

Shuhrat also tried to "pull himself together": he reduced the amount of food, bought two treadmills for his home and work to walk in his spare time. During Ramadan, he would manage to lose 10-12 kilograms, but then the weight would return "with interest": 120, 150, 165 kg...

Neither Mahmuda nor Shuhrat tried to lose weight using popular drugs like Ozempic or Mounjaro, but such cases are common in doctors' practice.

Surgeon Shuhrat Hoshimov does not criticize these drugs, but calls them a temporary crutch.

"I have had patients who took such drugs. While you are taking them, you don't want to eat, you lose weight.

Once you stop taking them, your weight returns, and what's more, with an addition, which breaks a person mentally.

Such drugs are needed for something else. For example, a patient comes with high sugar levels, and due to the risk of complications, they cannot be operated on immediately. Then, together with endocrinologists, we lower the sugar level to a permitted level, including with the help of such injections, to perform the surgery safely," the doctor explains.

Obesity is viewed in medical protocols as a multi-factor disease. It leads to a number of dangerous diagnoses such as diabetes, cardiovascular diseases, joint and spine damage, hypertension, and oncological diseases. In women, excess weight can cause infertility, and in men, impotence.

Mahmuda's gallbladder was the first to give out; during the examination before its removal, doctors diagnosed her with diabetes. The woman argued with the doctors with tears in her eyes: "I don't have any diabetes!" Her grandmother had once died of this disease, so she did not want to believe the diagnosis. However, diabetes was already showing itself: unbearable itching and irritation appeared, her heart beat fast with tachycardia, and heavy lethargy overcame her. Her nervous system also broke down — Mahmuda would snap at her loved ones, argue at work, and could cry over the slightest thing.

Photo: Yevgeniy Sorochin / Gazeta

Medicines and injections did not help, sugar levels jumped from 10 to 25 mmol/l, and when the figure reached 30 mmol/l, Mahmuda was hospitalized in a pre-coma state.

There, lying under IV drips, she finally "heard" the doctors' words: "You cannot live with such sugar levels — you will simply fall into a coma."

To reduce weight and achieve diabetes remission, Mahmuda decided to undergo bariatric surgery. She had many fears: "What if you give the money, go under the knife, and the diabetes remains? What if the weight doesn't go away either?"

The family reacted sharply to this decision, but by then Mahmuda did not care about others' opinions. Years of reproaches and constant fear of diabetic coma helped her make the decision: "I am doing this for myself and my health."

Surgeon Shuhrat Hoshimov admits that he regularly has to lecture husbands who stubbornly insist that their wives "just restrain their appetite and eat less." For such cases, a special presentation is prepared on the doctor's computer.

"I am always on the patient's side. I sit such a husband in front of the monitor and show him graphs, statistics, and research data. I tell him: 'Understand, obesity is a disease. Tomorrow, severe concomitant diseases will develop on this background. Think about it, without surgery, your wife will live 10–12 years less. After all, your children need a mother, and you need a healthy, active, and happy wife,'" he relates.

Convincing husbands is important because in 70 percent of cases, they are the ones who pay for the surgery. However, Shuhrat Khurshidovich often sees the opposite picture as well: during the consultation, the husband tells his wife, "I am with you, by your side, I support you." Such a man is ready for any expense so that his beloved woman can undergo the surgery easily and recover faster.

According to the doctor, everything depends on the relationship between the spouses.

Photo: Yevgeniy Sorochin / Gazeta

Fear of death brought Shuhrat to the operating table — overweight people around him began to pass away one after another.

"A close friend of mine died in Kyrgyzstan, he was only 42 years old. His heart stopped as a result of obesity. A driver who worked for me for many years, transporting goods, died in Kazakhstan. He passed away right on the road, during a trip. He took the cargo to Ust-Kamenogorsk, they called from there — he ended up in the hospital, and that was it, we lost him. The doctor said the cause of death was excess weight. I had a 35-year-old young doctor acquaintance in Shymkent. He used to say: 'Shuhrat, we both need to solve the weight issue! I just don't have time, I have to go into surgery every day.' Well, he didn't make it in time," the man says.

The way out was shown to him by an acquaintance who previously weighed around 180 kilograms and then lost weight drastically with the help of surgery. "He was a Kolobok, and turned into a handsome guy," Shuhrat describes him.

The first bariatric surgeries in Uzbekistan were performed about 40 years ago, but almost everything has changed since then. In 2015, after completing advanced training in Russia, China, South Korea, Turkey, and the UAE, Shuhrat Hoshimov, together with his colleagues, performed laparoscopic gastric sleeve resection in the country for the first time.

"Previously, bariatric surgeries were performed in an open way, through an abdominal incision. In large people, the incision is also large; there is no other way due to the thickness of the subcutaneous fat layer," — during the conversation, Shuhrat Khurshidovich rarely uses the medical term "obesity," preferring to call patients "large people." "Accordingly, wounds healed with difficulty, with complications and purulent processes.

Today, we work without incisions, through small punctures.

This allows for minimal trauma and rapid recovery. Patients get on their feet in 2–3 days, not 7–10 days as before."

Photo: Yevgeniy Sorochin / Gazeta

The modern technology is as follows: a laparoscopic telescope is inserted into the abdominal cavity through small punctures, which transmits the image of internal organs to a monitor. Then an endoscopic stapler — a special medical instrument — comes into play, which cuts off a part of the stomach and simultaneously clamps and "sews" the tissue. The cut-off piece, deflated like an empty balloon, is carefully pulled out through one of the punctures, slightly widening it to one and a half to two centimeters.

Bariatrics is not plastic or cosmetic surgery, so patients are placed on the operating table in strict accordance with medical protocols.

According to world standards, an indication for surgery is a body mass index (BMI) above 40, or above 35 if a person has concomitant diseases: diabetes, hypertension, joint destruction, and others.

Most often, patients are referred to bariatric surgeons by doctors of other specialties — endocrinologists, traumatologists, gynecologists. Excess weight sometimes prevents becoming a mother, and Shuhrat Khurshidovich is very happy when his former patients send him photos with babies in their arms. Sometimes a person's joints are so destroyed that they need to be replaced with artificial joints, but the prosthesis cannot support the body weight. Then the traumatologist recommends getting rid of excess weight first with the help of bariatric surgery.

The motivation of men and women coming for consultation is different.

"70 percent of my patients are women. Although there is nothing shameful about this, they almost never admit that they are going for surgery solely for appearance. They are afraid of looking selfish. They say, 'For my husband, for my children.' In such cases, I say: 'Do it for yourself. If you are happy and healthy, your family will be happy too,'" says the doctor.

According to him, the main demands in men are health or career.

"An overweight person is ashamed of himself, and in men, this insecurity is further strengthened due to problems with potency. After losing weight, they become more active, regain self-confidence, and are often promoted. In addition, there are areas where a career directly depends on physical condition — the military, law enforcement. I have had such patients too," Hoshimov specifies.

Photo: Yevgeniy Sorochin / Gazeta

There is another category of patients in Uzbekistan, whom the doctor calls "brides and grooms." They are brought to the doctor by their parents, because in many families with a traditional lifestyle, it is the parents who decide marriage issues.

They perceive excess weight not as a health problem, but as an obstacle to starting a family.

"Parents bring a 20-year-old guy for a consultation. He weighs 150 kilograms, sits at the computer at night, eats pizza, and drinks sweet carbonated drinks. His parents are upset: 'No one is marrying my son, help us.' Or they bring their daughters with the desire to marry them off and have grandchildren. That is, excess weight and deterioration of life quality are not always sufficient motivation to seek medical help and pay for surgery, but the marriage factor becomes a trigger. Perhaps, if there were no marriage issue, some of these patients would not have turned to a specialist," says the surgeon.

During Doctor Hoshimov's 11 years of bariatric practice, only about 15 people have ended up on the operating table again. The stomach is a muscular organ; if it is constantly "strained" with food, it will inevitably stretch again.

In the first month after the surgery, patient Shuhrat ate almost nothing. Unable to eat even a single chicken egg, he switched to quail eggs. Two or three spoons of soup and a bowl of liquid porridge — that was his entire food. Every day he excitedly watched the scale showing minus 0.5 kg. After some time, his weight stopped at 105 kg — he lost 60 kilograms from his highest figure. His blood pressure normalized, exhausting heartburn and swelling disappeared. Another unique thing happened — the body stopped sending hunger impulses.

"Previously, my stomach and head would shout: 'Come on, let's eat!' Now it's not like that. I have to make sure I don't forget to eat, I try to eat by the clock. If I feel I am losing strength and my head is getting heavy, it means calories have decreased, I need to have a snack. I carry some nuts, raisins, or high-quality chocolate in my bag. But now I eat like Europeans. I have been to Europe and seen: they bring a large plate, there are two spoons of food on it, and they don't even finish that! Previously, I could eat a whole platter of pilaf by myself, but now I am like them," the man says.

Photo: Yevgeniy Sorochin / Gazeta

Shuhrat does not disclose the details of the surgery to most of his acquaintances.

"People are different," he sighs. "Some understand correctly, while others just start saying that I should have eaten less. One day I was visiting, and as usual, I ate my portion and stopped. A man started mocking me: 'What, did you have your stomach cut, and now you are afraid to eat?' It was very unpleasant.

I answered him: 'Look, friend, I am ready for anything to live normally, and you are ready for anything to eat a lot. Do you see the difference?'

He felt embarrassed, fell silent, and left the table."

However, if he sees a person struggling to breathe and move, he does not pass by indifferently. For him, this is an unbroken chain of help. Shuhrat shares his experience and does not spare time to explain.

"When my condition became very difficult due to my weight, I prayed, and the Creator sent me a person who told me about the surgery, and then good doctors," he relates.

After bariatric surgery, Mahmuda and Shuhrat's lives changed radically. Shuhrat says he is traveling again and walking for hours through his favorite cities — there is no trace of shortness of breath.

"In the summer, I went on a business trip to Astana — to a major international exhibition. For four days in a row, from morning till night, I walked kilometers in the pavilions. An overweight person could not do that!", — the returned lightness gives him sincere, almost childish joy.

Mahmuda is also pleased. In the very first month after the surgery, she lost 20 kilograms. Along with the excess weight, painful itching and skin inflammations also went away, and her blood sugar level returned to normal. Today her weight is 57 kilograms. She says she does her nurse's aide work as before — without extra effort, climbs stairs easily, and can wear the clothes she likes. In one of the recent photos, the woman is seen wearing a fuchsia-colored dress with luxurious rose-shaped sleeves.

"Excess weight makes a person 'half,'" Mahmuda says as she says goodbye. "You cannot live fully, you cannot dress as you want. To become a whole person again, one must return the weight to normal."

International protocols for the treatment of obesity were developed based on many years of research conducted in the USA, Canada, and Europe. That is, the norms are set based on the "average European."

"Although the standards are universal, we are different," explains Shuhrat Hoshimov. "The world medical community is now actively discussing the concept of the racial factor. Representatives of the Negroid race can live with a high BMI and remain metabolically healthy. In Asians, on the contrary, complications — diabetes, heart and vascular damage — begin to develop at much lower figures. If today a BMI of 35 is recognized as the threshold of second-degree obesity, as the evidence base accumulates, differentiation by race may occur. For example, 37 for the Negroid race and 33 for the Asian race."

It is for this reason that Doctor Hoshimov's team, in cooperation with the Republican Scientific and Practical Center of Sports Medicine under the National Olympic Committee, started a scientific project on genetic research of metabolism in Uzbekistan.

A grant was allocated for this work by the Ministry of Higher Education, Science and Innovation.

"Now wealthy people all over the world have started studying their genomes. A personal test can provide information about many things: what diseases there is a predisposition to, what tests need to be taken, what diet should be followed, what sport gives the best result for the body. What if we apply this approach to the scale of the whole country?

A genetic profile can be the basis for state decisions.

Understanding the characteristics of the population's metabolism, it is possible to change the diet in kindergartens and schools at the national level, or determine which sports should be developed and subsidized so that people do not reach the surgical table," says the doctor.

Anyone diagnosed with obesity can try to become a participant in the study.

For patients, this is also an opportunity to reduce the cost of bariatric surgery, because part of the consumables is purchased within the framework of the grant. The preferential price of the surgery is 15-16 million soums instead of the usual 19-20 million soums. It is difficult to state the exact sum in advance. It depends on the duration of the hospital stay, the presence of concomitant diseases, and other factors.

At the same time, Shuhrat Khurshidovich does not accept everyone who wishes. In addition to BMI, he also evaluates the patient's motivation and readiness to follow post-operative recommendations.

"A person must have a personal, conscious desire. The option 'involve me in the study, and I will continue to sit on the couch and eat chips' will not work.

For us, it is important not just to collect statistics, but to understand how to change the situation.

Participants are monitored in dynamics: a genetic analysis is performed, surgery is done, and then metabolism is monitored after two, three months, and half a year. This allows gradually transitioning a person from the phase of active weight loss to stabilization and, ultimately, to healthy eating," the surgeon emphasizes.

Based on the results of the two-year large-scale study, Shuhrat Hoshimov plans to develop new algorithms for the treatment of obesity and test them in medical institutions of Uzbekistan.