Baylor Scott & White Center for Bariatric Surgery Waxahachie

After bariatric surgery, most patients return to work in one or two weeks. You will have low energy for a while after bariatric surgery and may need to have some half days or work every other day for your first week back. Your weight loss surgeon will give you clear instructions. Most jobs want you back in the workplace as soon as possible, even if you can’t perform ALL duties right away. Your safety and the safety of others are extremely important – low energy can be dangerous in some jobs. Some patients are worried about getting hernias at incisions. That is almost never a problem from work or lifting. Hernias are more often the result of infection. However, you will not feel well if you do too much.

Right away! You will take gentle, short walks even while you are in the hospital. The key is to start slow. Listen to your body and your surgeon. If you lift weights or do sports, stay “low impact” for the first month (avoid competition, think participation). Build slowly over several weeks. If you swim, your wounds from weight loss surgery need to be healed over before you get back in the water.

The general answer to this is yes. Make sure to tell your surgeon and anesthesiologist about all prior operations, especially those on your abdomen and pelvis. Many of us forget childhood operations. It is best to avoid surprises! Sometimes your bariatric surgeon may ask to see the operative report from complicated or unusual procedures, especially those on the esophagus, stomach or bowels.

It can. Be sure to follow any instructions from your surgeon about managing your diabetes around the time of surgery. Almost everyone with type 2 diabetes sees big improvement or even complete remission after surgery. Some studies have even reported improvement of type 1 diabetes after bariatric procedures.

Yes, but you may need medical clearance from your cardiologist. Bariatric surgery leads to improvement in most problems related to heart disease including:

• Alta presion sanguinea
• Colesterol
• Lipid problems
• Heart enlargement (dilated heart or abnormal thickening)
• Vascular (artery and vein) and coronary (heart artery) disease

During the screening process, be sure to let your surgeon or nurse know about any heart conditions you have. Even those with atrial fibrillation, heart valve replacement or previous stents or heart bypass, weight loss surgery usually does very well. If you are on blood thinners of any type, expect special instructions just before and after surgery.

Most women are much more fertile after surgery, even with moderate pre-op weight loss. Birth control pills do NOT work as well in patients who are overweight. Birth control pills are not very reliable during the time your weight is changing. For this reason, having an IUD or using condoms and spermicide with ALL intercourse is needed. Menstrual periods can be very irregular, and you can get pregnant when you least expect it!
Most groups recommend waiting 12-18 months after surgery before getting pregnant.
Many women who become pregnant after surgery are several years older than their friends were when having kids. Being older when pregnant does mean possible increased risks of certain problems. Down syndrome and spinal deformities are two examples. The good news is that, after surgery, there is much less risk of experiencing problems during pregnancy (gestational diabetes, eclampsia, macrosomia) and during childbirth. There are also fewer miscarriages and stillbirths than in women with obesity who have not had surgery and weight loss.
Kids born after mom’s surgery are LESS at risk of being affected by obesity later, due to activation of certain genes during fetal growth (look up “epigenetics” – for more information). There is also less risk of needing a C section.

Most patients have some loose or sagging skin, but it is often more temporary than expected. You will have a lot of change between 6 and 18 months after surgery. Your individual appearance depends upon several things, including how much weight you lose, your age, your genetics and whether or not you exercise or smoke. Generally, loose skin is well-hidden by clothing. Many patients wear compression garments, which can be found online, to help with appearance.
Some patients will choose to have plastic surgery to remove excess skin. Most surgeons recommend waiting at least 18 months, but you can be evaluated before that. Plastic surgery for removal of excess abdominal and breast skin is often covered by insurance for reasons of moisture, hygiene and rash issues.
Arms and other areas may not be covered if they are considered “purely” cosmetic by your insurer. Some of these “less invasive” operations can be done in the clinic, however – so they can be much more affordable!

Some hair loss is common between three and six months following surgery. The reasons for this are not totally understood. Even if you take all recommended supplements, hair loss will be noticed until the follicles come back. Hair loss is almost always temporary. Adequate intake of protein, vitamins and minerals will help to ensure hair re-growth, and avoid longer term thinning.

You will need to take a multivitamin for life. You may need higher doses of certain vitamins or minerals, especially iron, calcium and vitamin D. You will also need to have at least yearly lab checks. Insurance almost never pays for vitamin and mineral supplements but usually does pay for labs. You can pay for supplements out of a flex medical account.

There are loan programs available to cover the cost of health expenses such as metabolic and bariatric surgery. Appeals to insurance companies or directly to your employer may reverse a denial of coverage. Metabolic and bariatric surgery is a health expense that you can deduct from your income tax.
If you are not able to qualify for a loan, the Obesity Action Coalition (OAC) produces a helpful guide titled “Working with Your Insurance Provider – A Guide to Seeking Weight-loss Surgery.” This guide can help you work with your provider and advocate for your surgery to be covered.

This is an advance directive that applies only to decisions about mental health treatments in the event the patient's illness leaves him or her incapable of exercising choice at a later date. The declarations apply only if the person making the declaration is declared to be incompetent by a court. Further information on mental health declarations is available from the social work office.

Complications are often reported under a separate medical billing code. The insurance company may not cover these costs. Appeal is often very helpful, and direct contact with your hospital can make a big difference for final costs. Many surgeons also offer a special insurance policy to cover unexpected additional costs.

Yes. Most bariatric surgeons put their patients on a special pre-operative diet, usually two or three weeks just before surgery. The reason for the pre-operative diet is to shrink the liver and reduce fat in the abdomen. This helps during the bariatric surgery procedure and makes it safer.
Some insurance companies require a physician-monitored diet three to six months prior to surgery as part of their coverage requirement. These diets are very different from the short-term diets, and they usually are more about food education and showing a willingness to complete appointments and to learn.

On rare occasions, there may be ethical uncertainties or disagreements about your medical treatment, including advance directives, the level of treatment appropriate to your condition, or the authority of your healthcare decision maker. All Baylor Scott & White Health institutions have access to ethics committees and ethics consultants who may offer counsel and assist in resolving ethical issues that might arise. You, your family, healthcare decision maker, physician or any member of your healthcare team may request guidance from the Ethics Committee. This service is provided without cost to you or your insurance plan.

No and Yes.
Most people think of a “diet” as a plan that leaves you hungry. That is not the way people feel after surgery. Eventually, most patients get some form of appetite back six to 18 months after surgery. Your appetite is much weaker and easier to satisfy than before.
This does not mean that you can eat whatever and whenever you want. Healthier food choices are important to best results, but most patients still enjoy tasty food and even “treats.”
Most patients also think of exercise as something that must be intense and painful (like “boot camp”). However, regular, modest activity is far more useful in the long term. Even elite athletes can’t stay at a “peak” every week of the year. Sometimes exercise is work, but if it becomes a punishing, never-ending battle, you will not keep going. Instead, work with your bariatric surgeon’s program to find a variety of activities that can work for you. There is no “one-size-fits-all” plan. Expect to learn and change as you go!
For many patients (and normal weight people, too) exercise is more important for regular stress control and for appetite control than simply burning off calories. As we age, inactivity can lead to being frail or fragile, which is quite dangerous to overall health. Healthy bones and avoiding muscle loss partly depends on doing weekly weight bearing (including walking) or muscle resistance (weights or similar) exercise.

Almost everyone is able to find some activity to “count” as moderate exercise, even those who are partially paralyzed or who have arthritis or joint replacement or spine pain. Special therapists may be needed to help find what works for you.

Some insurance requires this type of letter from either your surgeon or primary care provider before final approval for surgery. Many will just accept your surgeon’s consultation summary note. It is best to ask your insurer directly. Most companies want information pertaining to current weight, height, body mass index, the medical problems related to obesity, your past diet attempt history and why the physician feels it is medically necessary for you to have bariatric surgery. Your bariatric surgeon will often have a sample letter of necessity for you to take to your primary care physician.

As you lose weight, you may be able to reduce or eliminate the need for many of the medications you take for high blood pressure, heart disease, arthritis, cholesterol and diabetes. If you have a gastric bypass, sleeve gastrectomy or a duodenal switch, you may even be able to reduce the dosage or discontinue the use of your diabetes medications soon after your procedure.

As many as 50% of patients may regain a small amount of weight (approximately 5%) two years or more following their surgery. However, longitudinal studies find that most bariatric surgery patients maintain successful weight loss long-term. "Successful" weight loss is arbitrarily defined as weight loss equal to or greater than 50% of excess body weight. Often, successful results are determined by the patient by their perceived improvement in quality of life. In such cases, the total retained weight loss may be more or less than this arbitrary definition. Such massive and sustained weight reduction with surgery is in sharp contrast to the experience most patients have previously had with non-surgical therapies.

As your body size increases, longevity decreases. Individuals with severe obesity have a number of life-threatening conditions that greatly increase their risk of dying, such as type 2 diabetes, hypertension and more. Data involving nearly 60,000 bariatric patients from ASMBS Bariatric Centers of Excellence database show that the risk of death within the 30 days following bariatric surgery averages 0.13%, or approximately one out of 1,000 patients. This rate is considerably less than most other operations, including gallbladder and hip replacement surgery. Therefore, in spite of the poor health status of bariatric patients prior to surgery, the chance of dying from the operation is exceptionally low. Large studies find that the risk of death from any cause is considerably less for bariatric patients throughout time than for individuals affected by severe obesity who have never had the surgery. In fact, the data show up to an 89% reduction in mortality, as well as highly significant decreases in mortality rates due to specific diseases. Cancer mortality, for instance, is reduced by 60% for bariatric patients. Death in association with diabetes is reduced by more than 90% and that from heart disease by more than 50%. Also, there are numerous studies that have found improvement or resolution of life-threatening obesity-related diseases following bariatric surgery. The benefits of bariatric surgery, with regard to mortality, far outweigh the risks. It is important to note that as with any serious surgical operation, the decision to have bariatric surgery should be discussed with your surgeon, family members and loved ones.

Individuals affected by severe obesity are resistant to long-term weight loss by diet and exercise. The National Institutes of Health Experts Panel recognize that "long-term" weight-loss, or in other words, the ability to "maintain" weight loss, is nearly impossible for those affected by severe obesity by any means other than metabolic and bariatric surgery. Bariatric surgeries are effective in maintaining long-term weight loss, in part, because these procedures offset certain conditions caused by dieting that are responsible for rapid and efficient weight regain following dieting. When a person loses weight, energy expenditure (the amount of calories the body burns) is reduced. With diet, energy expenditure at rest and with activity is reduced to a greater extent than can be explained by changes in body size or composition (amount of lean and fat tissue). At the same time, appetite regulation is altered following a diet increasing hunger and the desire to eat. Therefore, there are significant biological differences between someone who has lost weight by diet and someone of the same size and body composition to that of an individual who has never lost weight. For example, the body of the individual who reduces their weight from 200 to 170 pounds burns fewer calories than the body of someone weighing 170 pounds and has never been on a diet. This means that, in order to maintain weight loss, the person who has been on a diet will have to eat fewer calories than someone who naturally weighs the same. In contrast to diet, weight-loss following bariatric surgery does not reduce energy expenditure or the amount of calories the body burns to levels greater than predicted by changes in body weight and composition. In fact, some studies even find that certain operations even may increase energy expenditure. In addition, some bariatric procedures, unlike diet, also causes biological changes that help reduce energy intake (food and beverage). A decrease in energy intake with surgery results, in part, from anatomical changes to the stomach or gut that restrict food intake or cause malabsorption of nutrients. In addition, bariatric surgery increases the production of certain gut hormones that interact with the brain to reduce hunger, decrease appetite, and enhance satiety (feelings of fullness). In these ways, bariatric and metabolic surgery, unlike dieting, produces long-term weight loss.

Actually, only a small percentage of bariatric patients claim to have problems with alcohol after surgery. Most (but not all) who abuse alcohol after surgery had problems with alcohol abuse at some period of time prior to surgery. Alcohol sensitivity (particularly if alcohol is consumed during the rapid weight-loss period) is increased after bariatric surgery so that the effects of alcohol are felt with fewer drinks than before surgery. Studies also find with certain bariatric procedures (such as the gastric bypass or sleeve gastrectomy) that drinking an alcoholic beverage increases blood alcohol to levels that are considerably higher than before surgery or in comparison to the alcohol levels of individuals who have not had a bariatric procedure. For all of these reasons, bariatric patients are advised to take certain precautions regarding alcohol:

• Avoid alcoholic beverages during the rapid weight loss period
• Be aware that even small amounts of alcohol can cause intoxication
• Avoid driving or operating heavy equipment after drinking any alcohol
• Seek help if drinking becomes a problem

If you feel the consumption of alcohol may be an issue for you after surgery, please contact your primary care physician or bariatric surgeon and discuss this further. They will be able to help you identify resources available to address any alcohol-related issues.

Individuals affected by severe obesity who are seeking bariatric and metabolic surgery are more likely to suffer from depression or anxiety and to have lower self-esteem and overall quality of life than someone who is normal weight. Bariatric surgery results in highly significant improvement in psychosocial well-being for the majority of patients. However, there remain a few patients with undiagnosed preexisting psychological disorders and still others with overwhelming life stressors who commit suicide after bariatric surgery. Two large studies have found a small but significant increase in suicide occurrence following bariatric surgery. For this reason, comprehensive bariatric programs require psychological evaluations prior to surgery and many have behavioral therapists available for patient consultations after surgery.

Bariatric operations can lead to deficiencies in vitamins and minerals by reducing nutrient intake or by causing reduced absorption from the intestine. Bariatric operations vary in the extent of malabsorption they may cause and vary in which nutrients may be affected. The more malabsorptive bariatric procedures also increase the risk for protein deficiency. Deficiencies in micronutrients (vitamin and minerals) and protein can adversely affect health, causing fatigue, anemia, bone and muscle loss, impaired night vision, low immunity, loss of appropriate nerve function and even cognitive defects. Fortunately, nutrient deficiencies following surgery can be avoided with appropriate diet and the use of dietary supplements, i.e. vitamins, minerals, and, in some cases, protein supplements. Nutrient guidelines for different types of bariatric surgery procedures have been established by the ASMBS Nutritional Experts Committee and published in the journal Surgery for Obesity and Other Related Disorders. Before and after surgery, patients are advised of their dietary and supplement needs and followed by a nutritionist with bariatric expertise. Most bariatric programs also require patients to have their vitamins and minerals checked on a regular basis following surgery. Nutrient deficiencies and any associated health issues are preventable with patient monitoring and patient compliance in following dietary and supplement (vitamin and mineral) recommendations. Health problems due to deficiencies usually occur in patients who do not regularly follow-up with their surgeon to establish healthy nutrient levels.

Although there is a very small percentage of individuals affected by obesity who have eating disorders, such as binge eating disorder syndrome, that may result in the intake of excess food (calories), for the vast majority of individuals affected by obesity, obesity is a complex disease caused by many factors. When treating addiction, such as alcohol and drugs, one of the first steps is abstaining from the drugs or alcohol. This approach does not work with obesity as we need to eat to live. Additionally, there may be other issues affecting an individual’s weight, such as psychological issues. Weight gain generally occurs when there is an energy imbalance or, in other words, the amount of food (energy) consumed is greater than the number of calories burned (energy expended) by the body in the performance of biological functions, daily activities and exercise. Energy imbalance may be caused by overeating or by not getting enough physical activity and exercise. There are other conditions, however, that affect energy balance and/or fat metabolism that do not involve excessive eating or sedentary behavior, including:

• Chronic sleep loss
• Consumption of foods that, independent of caloric content, cause metabolic/hormonal changes that may increase body fat (sugar, high fructose corn syrup, trans fat, processed meats and processed grains)
• Low intake of fat-fighting foods (fruits, vegetables, legumes, nuts, seeds, quality protein)
• Stress and psychological distress
• Many types of medications
• Pollutants

Obesity also "begets" obesity, which is one of the reasons why the disease is considered ”progressive.” Weight gain causes a number of hormonal, metabolic and molecular changes in the body that increase the risk for even greater fat accumulation and obesity. Such obesity-associated changes reduce fat utilization, increase the conversion of sugar to fat, and enhance the body’s capacity to store fat by increasing fat cells size and numbers and by reducing fat breakdown. Such defects in fat metabolism mean that more of the calories consumed are stored as fat. To make matters worse, obesity affects certain regulators of appetite and hunger in a manner that can cause an increase in the amount of food eaten at any given meal and the desire to eat more often. There are many causes for obesity and that the disease of obesity is far more than just an "addiction" toward food. The treatment of obesity solely as an addiction may be beneficial for a very small percentage of individuals whose only underlying cause for obesity is excessive and addictive eating, but it would be unlikely to benefit the multitudes, particularly those individuals affected by severe obesity.