About Obesity

What is Obesity?
How is Obesity Measured?
What is Morbid Obesity
What Causes Morbid Obesity
Health Risks and Related Conditions
Treatment Options
BMI Calculator
Height/Weight Chart
FAQ's

What is Obesity?
Though we all use the terms "fat" and "obese" casually in conversation, there is a medical definition of the condition and yes, obesity is considered a health "condition."

"Obesity" specifically refers to an excessive amount of body fat. "Overweight" refers to an excessive amount of body weight that includes muscle, bone, fat, and water. As a rule, women have more body fat than men. Most health care professionals agree that men with more than 25 percent body fat and women with more than 30 percent body fat are obese. These numbers should not be confused with the body mass index (BMI), however, which is more commonly used by health care professionals to determine the effect of body weight on the risk for some diseases.

How is Obesity Measured
Measuring the exact amount of a person's body fat is not easy. The most accurate measures are to weigh a person underwater or in a chamber that uses air displacement to measure body volume, or to use an X-ray test called Dual Energy X-ray Absorptiometry, also known as DEXA. These methods are not practical for the average person, and are done only in research centers with special equipment.

There are simpler methods to estimate body fat. One is to measure the thickness of the layer of fat just under the skin in several parts of the body. Another involves sending a harmless amount of electricity through a person's body. Results from these methods, however, can be inaccurate if done by an inexperienced person or on someone with extreme obesity.

Because measuring a person's body fat is difficult, health care professionals often rely on other means to diagnose obesity. Weight-for-height tables, used for decades, have a range of acceptable weights for a person of a given height. One problem with these tables is that there are many versions, all with different weight ranges. Another problem is that they do not distinguish between excess fat and muscle. According to the tables, a very muscular person may be classified obese when he or she is not. The BMI is less likely to misidentify a person's appropriate weight-for-height range.

What is Morbid Obesity
According to the National Institutes of Health (NIH), a person is considered "obese" when he or she weighs 20 percent or more than his or her ideal body weight. At that point, the person's weight poses a real health risk. Obesity becomes "morbid" when it significantly increases the risk of one or more obesity-related health conditions or serious diseases (also known as co-morbidities).

Morbid obesity sometimes called "clinically severe obesity" is defined as being 100 lbs. or more over ideal body weight or having a Body Mass Index (BMI) of 40 or higher.

According to the NIH Consensus Report, morbid obesity is a serious chronic disease, meaning that its symptoms build slowly over an extended period of time. Today 97 million Americans, more than one-third of the adult population, are overweight or obese. An estimated 5-10 million of those are considered morbidly obese.

What Causes Morbid Obesity
Obesity occurs when a person consumes more calories from food than he or she burns. Our bodies need calories to sustain life and be physically active, but to maintain weight we need to balance the energy we eat with the energy we use. When a person eats more calories than he or she burns, the energy balance is tipped toward weight gain and obesity. This imbalance between calories-in and calories-out may differ from one person to another. Genetic, environmental, and other factors may all play a part.

Genetic Factors

Obesity tends to run in families, suggesting a genetic cause. However, families also share diet and lifestyle habits that may contribute to obesity. Separating genetic from other influences on obesity is often difficult. Even so, science does show a link between obesity and heredity.

Environmental and Social Factors

Environment strongly influences obesity. Consider that most people in the United States alive today were also alive in 1980, when obesity rates were lower. Since this time, our genetic make-up has not changed, but our environment has. Environment includes lifestyle behaviors such as what a person eats and his or her level of physical activity. Too often Americans eat out, consume large meals and high-fat foods, and put taste and convenience ahead of nutrition. Also, most people in the United States do not get enough physical activity.

Environment also includes the world around us—our access to places to walk and healthy foods, for example. Today, more people drive long distances to work instead of walking, live in neighborhoods without sidewalks, tend to eat out or get “take out” instead of cooking, or have vending machines with high-calorie, high-fat snacks at their workplace. Our environment often does not support healthy habits.

In addition, social factors including poverty and a lower level of education have been linked to obesity. One reason for this may be that high-calorie processed foods cost less and are easier to find and prepare than healthier foods, such as fresh vegetables and fruits. Other reasons may include inadequate access to safe recreation places or the cost of gym memberships, limiting opportunities for physical activity. However, the link between low socio-economic status and obesity has not been conclusively established, and recent research shows that obesity is also increasing among high-income groups.

Although you cannot change your genetic makeup, you can work on changing your eating habits, levels of physical activity, and other environmental factors.  Try these ideas:

·  Learn to choose sensible portions of nutritious meals that are lower in fat.

·  Learn to recognize and control environmental cues (like inviting smells or a package of cookies on the counter) that make you want to eat when you are not hungry.

· Engage in at least 30 minutes of moderate-intensity physical activity (like brisk walking) on most, preferably all, days of the week.

·  Take a walk instead of watching television.

· Eat meals and snacks at a table, not in front of the TV.

· Keep records of your food intake and physical activity.

Other Causes of Obesity

Some illnesses may lead to or are associated with weight gain or obesity:

·  Hypothyroidism, a condition in which the thyroid gland fails to produce enough thyroid hormone. It often results in lowered metabolic rate and loss of vigor.

· Cushing's syndrome, a hormonal disorder caused by prolonged exposure of the body's A doctor can tell whether there are underlying medical conditions that are causing weight gain or making weight loss difficult.

·  Lack of sleep may also contribute to obesity. Recent studies suggest that people with sleep problems may gain weight over time. On the other hand, obesity may contribute to sleep problems due to medical conditions such as sleep apnea, where a person briefly stops breathing at multiple times during the night.

· Certain drugs such as steroids, some antidepressants, and some medications for psychiatric conditions or seizure disorders may cause weight gain. These drugs may slow the rate at which the body burns calories, stimulate appetite, or cause the body to hold on to extra water. Be sure your doctor knows all the medications you are taking (including over-the-counter medications and dietary supplements). He or she may recommend a different medication that has less effect on weight gain. tissues to high levels of the hormone cortisol.  Symptoms vary, but most people have upper body obesity, rounded face, increased fat around the neck, and thinning arms and legs.

· Polycystic ovary syndrome, a condition characterized by high levels of androgens (male hormone), irregular or missed menstrual cycles, and in some cases, multiple small cysts in the ovaries. Cysts are fluid-filled sacs.

Health Risks and Related Conditions
Obesity is more than a cosmetic problem. Many serious medical conditions have been linked to obesity, including type 2 diabetes, heart disease, high blood pressure, and stroke. Obesity is also linked to higher rates of certain types of cancer. Men who are obese are more likely than non-obese men to develop cancer of the colon, rectum, or prostate. Women who are obese are more likely than non-obese women to develop cancer of the gallbladder, uterus, cervix, or ovaries. Esophageal cancer has also been associated with obesity.

Other diseases and health problems linked to obesity include:

• Type 2 Diabetes
• High blood pressure/Heart disease
• Dyslipidemia/High Cholesterol
• Osteoarthritis of weight-bearing joints
• Depression
• Sleep apnea/Respiratory problems
• Gastroesophageal reflux/Heartburn
• Infertility
• Urinary stress incontinence
• Menstrual irregularities
• Lymphedema

Health care providers generally agree that the more obese a person is, the more likely he or she is to develop health problems.

Psychological and Social Effects

Emotional suffering may be one of the most painful parts of obesity. American society emphasizes physical appearance and often equates attractiveness with slimness, especially for women. Such messages make overweight people feel unattractive.

Many people think that individuals with obesity are gluttonous, lazy, or both. This is not true. As a result, people who are obese often face prejudice or discrimination in the job market, at school, and in social situations. Feelings of rejection, shame, or depression may occur.

Who should lose weight?
Health care providers generally agree that people who have a BMI of 30 or greater can improve their health through weight loss. This is especially true for people with a BMI of 40 or greater, who are considered extremely obese.

Preventing additional weight gain is recommended if you have a BMI between 25 and 29.9, unless you have other risk factors for obesity-related diseases. Obesity experts recommend you try to lose weight if you have two or more of the following:

• Family history of certain chronic diseases. If you have close relatives who have had heart disease or diabetes, you are more likely to develop these problems if you are obese.
• Preexisting medical conditions.High blood pressure, high LDL cholesterol levels, low HDL cholesterol levels, high triglycerides, and high blood glucose are all warning signs of some obesity-associated diseases.
• Large waist circumference. Men who have waist circumferences greater than 40 inches, and women who have waist circumferences greater than 35 inches, are at higher risk of diabetes, dyslipidemia (abnormal amounts of fat in the blood), high blood pressure, and heart disease.

Fortunately, a weight loss of 5 to 10 percent of your initial body weight can do much to improve health by lowering blood pressure and other risk factors for obesity-related diseases. In addition, research shows that a 5- to 7-percent weight loss brought about by moderate diet and exercise can delay or possibly prevent type 2 diabetes in people at high risk for the disease.

In a recent study, participants who were overweight and had pre-diabetes—a condition in which a person’s blood glucose level is higher than normal, but not high enough to be classified as diabetes—were able to delay or prevent the onset of type 2 diabetes by adopting a low-fat, low-calorie diet and exercising for 30 minutes a day, 5 days a week.

Treatment Options
Normally, as food moves along the digestive tract, digestive juices and enzymes digest and absorb calories and nutrients.  After we chew and swallow our food, it moves down the esophagus to the stomach, where a strong acid continues the digestive process.

The stomach can hold about 3 pints of food at one time. When the stomach contents move to the duodenum, the first segment of the small intestine, bile and pancreatic juice speed up digestion. Most of the iron and calcium in the foods we eat is absorbed in the duodenum. The jejunum and ileum, the remaining two segments of the nearly 20 feet of small intestine, complete the absorption of almost all calories and nutrients. The food particles that cannot be digested in the small intestine are stored in the large intestine until eliminated.

Surgical Weight Loss Programs

Bariatric surgery, or weight loss surgery, is a method of weight loss for the severely obese who are unable to lose weight by any other means.  As people learn more about the many health risks of being obese, greater numbers seek what may seem like a drastic solution: surgery.

Bariatric surgery includes a spectrum of procedures from restrictive to malabsorptive to those combining the two. Restrictive procedures such as Adjustable Gastric Banding (LapBand®) and Vertical Banded Gastroplasty (VBG) reduce the size of the stomach, and malabsorptive and combined procedures such as Roux-en-Y Gastric Bypass (RGB),Biliopancreatic Diversion, Fobi Pouch and Duodenal Switch (DS) reduce the body's ability to absorb calories and nutrients from food.

Two Methods of Weight Loss Surgery
Surgical approaches include laparoscopic procedures, in which surgery is performed through small abdominal openings. Such minimal-access surgery offers a faster, less painful recovery. But not everyone qualifies for less-invasive surgery. It depends on medical history, surgical difficulty, and body shape.

Traditional open weight loss surgery

Once the only method used for surgical procedures, traditional open surgery involves making a 10- to 12-inch incision to access the stomach and intestines. Depending on surgeon expertise incision size can vary on the open surgeries.

Minimally invasive, or laparoscopic, weight loss surgery

In minimally invasive, or laparoscopic, surgery, the surgeon uses five or six small incisions (each 1/4 and 1/2 inch long) to gain access to the stomach and intestines. The laparoscope is a telescope attached to a video camera.

The surgeon inserts the laparoscope through the incisions and gets a magnified view of the patient’s organs on a television monitor. The entire operation is performed inside the abdomen after gas has been inserted to expand the abdomen.  Minimally invasive surgery techniques have reduced hospital and recovery times for many operations. The incidences of complications have also been reduced.

Both approaches have excellent long-term results, allowing patients to lose 80-90% of their excess weight in 10-24 months, with most patients maintaining 48-74% of their initial weight loss after five years. However, there are risks involved. This option, therefore, is usually restricted to patients who cannot lose weight on one of the dietary programs discussed in Non-Surgical Weight Loss.

BMI Calculator
The BMI is a tool used to assess overweight and obesity and monitor changes in body weight. Like the weight-for-height tables, BMI has its limitations because it does not measure body fat or muscle directly. It is calculated by dividing a person's weight in pounds by height in inches squared and multiplied by 703.

Two people can have the same BMI but different body fat percentages. A bodybuilder with a large muscle mass and low percentage of body fat may have the same BMI as a person who has more body fat. However, a BMI of 30 or higher usually indicates excess body fat.

The BMI table below provides a useful guideline to check your BMI. First, find your weight on the bottom of the graph. Go straight up from that point until you come to the line that matches your height. A BMI of 25 to 29.9 indicates a person is overweight. A person with a BMI of 30 or higher is considered obese. Please review your findings with your health care provider if your BMI is outside of the normal range.


 

Height/Weight Chart
Health care providers are concerned not only with how much fat a person has, but also where the fat is located on the body. Women typically collect fat in their hips and buttocks, giving them a "pear" shape. Men usually build up fat around their bellies, giving them more of an "apple" shape. Of course some men are pear-shaped and some women become apple-shaped, especially after menopause.

Excess abdominal fat is an important, independent risk factor for disease. Research has shown that waist circumference is directly associated with abdominal fat and can be used in the assessment of the risks associated with obesity or overweight. If you carry fat mainly around your waist, you are more likely to develop obesity-related health problems.

Women with a waist measurement of more than 35 inches and men with a waist measurement of more than 40 inches may have more health risks than people with lower waist measurements because of their body fat distribution.

Cost of Obesity
Research proves that people could live longer and healthier at an ideal body weight. The average American has gained around 8 pounds in the past 10 years. LSU researchers estimate that .the direct costs of obesity in the United States is now at 39.3 billion dollars a year. That is more than 5% of all medical costs..

Market Data Enterprises says, .Americans spend another $38 billion a year trying to lose weight..

Other researchers report that after a four and a half year study .the costs of long-term weight loss on one popular very-low-calorie diet program was $286.36 per pound.!! Long-term weight loss is not only expensive, but very hard to attain.

Obesity is not just a concern of a morbidly obese person. The problems affect society as a whole since obesity contributes to the incidence of chronic disease. According to the Surgeon General .Obesity, with its rank among the top ten diseases, may be America's number-one contributor to health care costs..

FAQ's - Frequently Asked Questions

Preparation for WLS

· What are the routine tests before wls?
· What are the purposes of all these tests?
· Why do I have to have a GU Evaluation?
· Why do I have a Sleep Study?
· Why do I have a Psychiatric Evaluation?
· What impact do my medical problems have on the decision for wls, and how do the medical problems affect risk?
· If I want to undergo a gastric bypass, how long do I have to wait?
· What can I do before the appointment to speed up the process of getting ready for weight loss surgery

Insurance Issues

· Why does it take so long to get insurance approval?
· How can they deny insurance payment for a life-threatening disease?
· What can I do to help the process?

Laparoscopic Bariatric Surgery

· Does Laparoscopic Surgery decrease the risk?
· Will I have a lot of pain?
· How long do I have to stay in the hospital?
· Will the doctor leave a drain in after laparoscopic surgery?
· If I have laparoscopic bariatric surgery, what can I expect when I wake up in the recovery room?
· How soon will I be able to walk?
· How soon can I drive?

The Hospital Stay

· What is done to minimize the risk of deep vein thrombosis/pulmonary embolism or DVT/PE?
· What should I bring with me to the hospital?

Life After Weight Loss Surgery

· What do I need to do to be successful after surgery?
· What's so important about exercise?
· What is the right amount of exercise after weight loss surgery?
· Can I get pregnant after weight loss surgery?
· What happens to the lower part of the stomach that is bypassed?
· How big will my stomach pouch really be in the long run?
· What will the staples do inside my abdomen? Is it okay in the future to have an MRI test? Will I set off metal detectors in airports?
· What if I'm not hungry after weight loss surgery?
· Is there any difficulty in taking medications?
· Will I be able to take oral contraception after surgery?
· Is sexual activity restricted?
· Is there a difference in the outcome of weight loss surgery between men and women?
· Will I be asked to stop smoking?
· If I continue to smoke, what happens?
· How can I know that I won't just keep losing weight until I waste away to nothing?
· What can I do to prevent lots of excess hanging skin?
· Will exercise help with excess hanging skin?
· Will I be miserably hungry after weight loss surgery since I'm not eating much?
· What if I am really hungry?
· Will I have to change my medications?
· What is a hernia and what is the probability of an abdominal hernia after surgery?
· Is blood transfusion required?
· What is phlebitis and is it preventable?
· Will I lose hair after weight loss surgery? How can I prevent it?
· What are adhesions and do they form after this surgery?
· What is the "Candida Syndrome?"
· What causes it to appear?
· Can it be cured?
· What is sleep apnea (SA)?

Diet

· How long will I be off of solid foods after weight loss surgery?
· What are the best choices of protein?
· Why drink so much water?
· What is Dumping Syndrome?
· Is there a problem with consuming milk products?
· Why can't I snack between meals?
· Why can't I eat red meat after surgery?
· How can I be sure I am eating enough protein?
· Is there any restriction of salt intake?
· Will I be able to eat "spicy" foods or seasoned foods?
· Will I be allowed to drink alcohol?
· Will I need supplemental vitamins?
· What vitamins will I need to take after surgery?
· Is it important to take calcium, iron, trace elements or female hormone replacements?
· Do I meet with a nutritionist before and after surgery?
· Will I get a copy of suggested eating patterns and food choices after surgery?

General

· What is the youngest age for which weight loss surgery is recommended?
· What is the oldest patient for who weight loss surgery is recommended?
· Can Weight Loss Surgery prolong my life?
· Can weight loss surgery help other physical conditions?

FAQ Answers

Preparation for Surgery

What are the routine tests before surgery?
Certain basic tests are done prior to surgery: a Complete Blood Count (CBC), Urinalysis, and a Chemistry Panel, which gives a readout of about 20 blood chemistry values. Often a Glucose Tolerance Test is done to evaluate for diabetes, which is very common in overweight persons.

All patients but the very young get a chest X-ray and an electrocardiogram. Women may have a vaginal ultrasound to look for abnormalities of the ovaries or uterus. Many surgeons ask for a gallbladder ultrasound to look for gallstones. Other tests, such as pulmonary function testing, echocardiogram, sleep studies, GI evaluation, cardiology evaluation, or psychiatric evaluation, may be requested when indicated.

What is the purpose of all these tests?
An accurate assessment of your health is needed before surgery. The best way to avoid complications is to never have them in the first place. It is important to know if your thyroid function is adequate since hypothyroidism can lead to sudden death post-operatively. If you are diabetic, special steps must be taken to control your blood sugar. Because surgery increases cardiac stress, your heart will be thoroughly evaluated. These tests will determine if you have liver malfunction, breathing difficulties, excess fluid in the tissues, abnormalities of the salts or minerals in body fluids, or abnormal blood fat levels.

Why do I have to have a GI Evaluation?
Patients who have significant gastrointestinal symptoms such as upper abdominal pain, heartburn, belching sour fluid, etc., may have underlying problems such as a hiatal hernia, gastroesophageal reflux or peptic ulcer. For example, many patients have symptoms of reflux. Up to 15% of these patients may show early changes in the lining of the esophagus, which could predispose them to cancer of the esophagus. It is important to identify these changes so a suitable surveillance or treatment program can be planned.

Why do I have to have a Sleep Study?
The sleep study detects a tendency for abnormal stopping of breathing, usually associated with airway blockage when the muscles relax during sleep. This condition is associated with a high mortality rate. After surgery, you will be sedated and will receive narcotics for pain, which further depress normal breathing and reflexes. Airway blockage becomes more dangerous at this time. It is important to have a clear picture of what to expect and how to handle it.

Why do I have to have a Psychiatric Evaluation?
The most common reason a psychiatric evaluation is ordered is that your insurance company may require it. Most psychiatrists will evaluate your understanding and knowledge of the risks and complications associated with weight loss surgery and your ability to follow the basic recovery plan.

What impact do my medical problems have on the decision for surgery, and how do the medical problems affect risk?
Medical problems, such as serious heart or lung problems, can increase the risk of any surgery. On the other hand, if they are problems that are related to the patient's weight, they also increase the need for surgery. Severe medical problems may not dissuade the surgeon from recommending gastric bypass surgery if it is otherwise appropriate, but those conditions will make a patient's risk higher than average.

If I want to undergo a gastric bypass, how long do I have to wait?
New evaluation appointments are usually booked 4-8 months in advance. Once a patient is seen, if the surgeon and patient agree it is appropriate, the operation can usually be scheduled within 8 weeks.

Why so long?
There is more need for weight loss surgery than there are qualified bariatric surgeons.

What can I do before the appointment to speed up the process of getting ready for surgery?
Select a primary care physician if you don't already have one, and establish a relationship with him or her. Work with your physician to ensure that your routine health maintenance testing is current. For example, women may have a pap smear, and if over 40 years of age, a breast exam. And for men, this may include a prostate specific antigen test (PSA).

Make a list of all the diets you have tried (a diet history) and bring it to your doctor.

Bring any pertinent medical data to your appointment with the surgeon - this would include reports of special tests (echocardiogram, sleep study, etc.) or hospital discharge summary if you have been in the hospital.

Bring a list of your medications with dose and schedule.

Stop smoking. Surgical patients who use tobacco products are at a higher surgical risk.

Insurance Issues

Why does it take so long to get insurance approval?
After your telephone interview consultation is completed, it usually takes your doctor 1-2 days to send a letter to your insurance carrier to start the approval process. The time it takes to get an answer can vary from about 3-4 weeks or longer if you are not persistent in your follow-up. Most treatment centers have insurance analysts who will follow up regularly on approval requests. It may be helpful for you to call the claims service of your insurance company about a week after your letter is submitted and ask about the status of your request.

How can they deny insurance payment for a life-threatening disease?
Payment may be denied because there may be a specific exclusion in your policy for obesity surgery or "treatment of obesity." Such an exclusion can often be appealed when the surgical treatment is recommended by your surgeon or referring physician as the best therapy to relieve life-threatening obesity-related health conditions, which usually are covered.

Insurance payment may also be denied for lack of "medical necessity." A therapy is deemed to be medically necessary when it is needed to treat a serious or life-threatening condition. In the case of morbid obesity, alternative treatments - such as dieting, exercise, behavior modification, and some medications - are considered to be available. Medical necessity denials usually hinge on the insurance company's request for some form of documentation, such as 1 to 5 years of physician-supervised dieting or a psychiatric evaluation, illustrating that you have tried unsuccessfully to lose weight by other methods.

What can I do to help the process?
Gather all the information (diet records, medical records, medical tests) your insurance company may require. This reduces the likelihood of a denial for failure to provide "necessary" information. Letters from your personal physician and consultants attesting to the "medical necessity" of treatment are particularly valuable. When several physicians report the same findings, it may confirm a medical necessity for surgery.

When the letter is submitted, call your carrier regularly to ask about the status of your request. Your employer or human relations/personnel office may also be able to help you work through unreasonable delays.

Surgery

Does Laparoscopic Surgery decrease the risk?
No. Laparoscopic operations carry the same risk as the procedure performed as an open operation. The benefits of laparoscopy are typically less discomfort, shorter hospital stay, earlier return to work and reduced scarring.

Will I have a lot of pain?
Every attempt is made to control pain after surgery to make it possible for you to move about quickly and become active. This helps avoid problems and speeds recovery. Often several drugs are used together to help manage your post-surgery pain. While you are still in the hospital, a Patient Controlled Analgesia (PCA), which allows you to give yourself a dose of pain medicine on demand, may be used by your physician. Various methods of pain control, depending on your type of surgical procedure, are available. Ask your surgeon about other pain management options.

How long do I have to stay in the hospital?
As long as it takes to be self-sufficient. Although it can vary, the hospital stay (including the day of surgery) can be 1-2 days for a laparoscopic band, 2-3 days for a laparoscopic gastric bypass, and 5-7 days for an open gastric bypass.

Will the doctor leave a drain in after surgery?
Most patients will have a small tube to allow drainage of any accumulated fluids from the abdomen. This is a safety measure, and it is usually removed a few days after the surgery. Generally, it produces no more than minor discomfort.

If I have surgery, what can I expect when I wake up in the recovery room?
Some doctors will provide a Patient Controlled Analgesia (PCA) or a self-administered pain management system, to help control pain. Others prefer to use an infusion pump that provides a local anesthetic in the surgical site to control pain without the side effects of narcotics. As with any major surgery, you are in danger of death from a blood clot or other surgical side effects. Statistically, the risk of death during these procedures is less than 1 percent. Your doctors will have assessed you for risks and prepared accordingly.

All abdominal operations carry the risks of bleeding, infection in the incision, thrombophlebitis of legs (blood clots), lung problems (pneumonia, pulmonary embolisms), strokes or heart attacks, anesthetic complications, and blockage or obstruction of the intestine. These risks are greater in morbidly obese patients.

How soon will I be able to walk?
Almost immediately after surgery doctors will require you to get up and move about. Patients are asked to walk or stand at the bedside on the night of surgery, take several walks the next day and thereafter. On leaving the hospital, you may be able to care for all your personal needs, but will need help with shopping, lifting and with transportation.

How soon can I drive?
For your own safety, you should not drive until you have stopped taking narcotic medications and can move quickly and alertly to stop your car, especially in an emergency. Usually this takes 7-14 days after surgery.

The Hospital Stay

What is done to minimize the risk of deep vein thrombosis/pulmonary embolism or DVT/PE?
Because a DVT originates on the operating table, therapy begins before a patient goes to the operating room. Generally, patients are treated with sequential leg compression stockings and given a blood thinner prior to surgery. Both of these therapies continue throughout your hospitalization. The third major preventive measure involves getting the patient moving and out of bed as soon as possible after the operation to restore normal blood flow in the legs.

What should I bring with me to the hospital?
Basic toiletries (comb, toothbrush, etc.) and clothing may be provided by the hospital, but most people prefer to bring their own. Choose clothes for your stay that are easy to put on and take off. Because of your incision, your clothes may become stained by blood or other body fluids. Other ideas:

• reading and writing materials
• crossword and other puzzles
• personal toiletries
• bathrobe
• chapstick
• slippers
• A pillow for the ride home
• earplugs
• cell phone and charger

Life After Surgery

What do I need to do to be successful after surgery?
The basic rules are simple and easy to follow:

Immediately after surgery, your doctor will provide you with special dietary guidelines. You will need to follow these guidelines closely. Many surgeons begin patients with liquid diets, moving to semi-solid foods and later, sometimes weeks or months later, solid foods can be tolerated without risk to the surgical procedure performed. Allowing time for proper healing of your new stomach pouch is necessary and important.

When able to eat solids, eat 2-3 meals per day, no more. Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources should be eaten first. These should comprise at least half the volume of the meal eaten. Foods should be cooked without fat and seasoned to taste. Avoid sauces, gravies, butter, margarine, mayonnaise and junk foods.

Never eat between meals. Do not drink flavored beverages, even diet soda, between meals.

Drink 2-3 quarts or more of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operation.

Exercise aerobically every day for at least 20 minutes (one-mile brisk walk, bike riding, stair climbing, etc.). Weight/resistance exercise can be added 3-4 days per week, as instructed by your doctor.

What's so important about exercise?
When you have a weight loss surgery procedure, you lose weight because the amount of food energy (calories) you are able to eat is much less than your body needs to operate. It has to make up the difference by burning reserves or unused tissues. Your body will tend to burn any unused muscle before it begins to burn the fat it has saved up. If you do not exercise daily, your body will consume your unused muscle, and you will lose muscle mass and strength. Daily aerobic exercise for 20 minutes will communicate to your body that you want to use your muscles and force it to burn the fat instead.

What is the right amount of exercise after weight loss surgery?
Many patients are hesitant about exercising after surgery, but exercise is an essential component of success after surgery. Exercise actually begins on the afternoon of surgery - the patient must be out of bed and walking. The goal is to walk further on the next day, and progressively further every day after that, including the first few weeks at home. Patients are often released from medical restrictions and encouraged to begin exercising about two weeks after surgery, limited only by the level of wound discomfort. The type of exercise is dictated by the patient's overall condition. Some patients who have severe knee problems can't walk well, but may be able to swim or bicycle. Many patients begin with low stress forms of exercise and are encouraged to progress to more vigorous activity when they are able.

Can I get pregnant after weight loss surgery?
It is strongly recommended that women wait at least one year after the surgery before a pregnancy. Approximately one year post-operatively, your body will be fairly stable (from a weight and nutrition standpoint) and you should be able to carry a normally nourished fetus. You should consult your surgeon as you plan for pregnancy.

What if I have had a previous weight loss surgical procedure and I'm now having problems?
Contact your original surgeon - he or she is most familiar with your medical history and can make recommendations based on knowledge of your surgical procedure and body.

What happens to the lower part of the stomach that is bypassed?
In some surgical procedures, the stomach is left in place with intact blood supply. In some cases it may shrink a bit and its lining (the mucosa) may atrophy, but for the most part it remains unchanged. The lower stomach still contributes to the function of the intestines even though it does not receive or process food - it makes intrinsic factor, necessary to absorb Vitamin B12 and contributes to hormone balance and motility of the intestines in ways that are not entirely known. In the BPD procedures, some portion of the stomach is completely removed.

How big will my stomach pouch really be in the long run?
This can vary by surgical procedure and surgeon. In the Roux-en-Y gastric bypass, the stomach pouch is created at one ounce or less in size (15-20cc). In the first few months it is rather stiff due to natural surgical inflammation. About 6-12 months after surgery, the stomach pouch can expand and will become more expandable as swelling subsides. Many patients end up with a meal capacity of 3-7 ounces.

What will the staples do inside my abdomen? Is it okay in the future to have an MRI test? Will I set off metal detectors in airports?
The staples used on the stomach and the intestines are very tiny in comparison to the staples you will have in your skin or staples you use in the office. Each staple is a tiny piece of stainless steel or titanium so small it is hard to see other than as a tiny bright spot. Because the metals used (titanium or stainless steel) are inert in the body, most people are not allergic to staples and they usually do not cause any problems in the long run. The staple materials are also non-magnetic, which means that they will not be affected by MRI. The staples will not set off airport metal detectors.

What if I'm not hungry after surgery?
It's normal not to have an appetite for the first month or two after weight loss surgery. If you are able to consume liquids reasonably well, there is a level of confidence that your appetite will increase with time.

Is there any difficulty in taking medications?
Most pills or capsules are small enough to pass through the new stomach pouch. Initially, your doctor may suggest that medications be taken in liquid form or crushed.

Will I be able to take oral contraception after surgery?
Most patients have no difficulty in swallowing these pills.

Is sexual activity restricted?
Patients can return to normal sexual intimacy when wound healing and discomfort permit. Many patients experience a drop in desire for about 6 weeks.

Is there a difference in the outcome of surgery between men and women?
Both men and women generally respond well to this surgery. In general, men lose weight slightly faster than women do.

Will I be asked to stop smoking?
Patients are encouraged to stop smoking at least one month before surgery.

If I continue to smoke, what happens?
Smoking increases the risk of lung problems after surgery, can reduce the rate of healing, increases the rates of infection, and interferes with blood supply to the healing tissues.

How can I know that I won't just keep losing weight until I waste away to nothing?
Patients may begin to wonder about this early after the surgery when they are losing 20-40 pounds per month, or maybe when they've lost more than 100 pounds and they're still losing weight. Two things happen to allow weight to stabilize. First, a patient's ongoing metabolic needs (calories burned) decrease as the body sheds excess pounds. Second, there is a natural progressive increase in calorie and nutrient intake over the months following weight loss surgery. The stomach pouch and attached small intestine learn to work together better, and there is some expansion in pouch size over a period of months. The bottom line is that, in the absence of a surgical complication, patients are very unlikely to lose weight to the point of malnutrition.

What can I do to prevent lots of excess hanging skin?
Many people heavy enough to meet the surgical criteria for weight loss surgery have stretched their skin beyond the point from which it can "snap back." Some patients will choose to have plastic surgery to remove loose or excess skin after they have lost their excess weight. Insurance generally does not pay for this type of surgery (often seen as elective surgery). However, some do pay for certain types of surgery to remove excess skin when complications arise from these excess skin folds. Ask your surgeon about your need for a skin removal procedure.

Will exercise help with excess hanging skin?
Exercise is good in so many other ways that a regular exercise program is recommended. Unfortunately, most patients may still be left with large flaps of loose skin.

Will I be miserably hungry after weight loss surgery since I'm not eating much?
Most patients say no. In fact, for the first 4-6 weeks patients have almost no appetite. Over the next several months the appetite returns, but it tends not to be a ravenous "eat everything in the cupboard" type of hunger.

What if I am really hungry?
This is usually caused by the types of food you may be consuming, especially starches (rice, pasta, potatoes). Be absolutely sure not to drink liquid with food since liquid washes food out of the pouch.

Will I have to change my medications?
Your doctor will determine whether medications for blood pressure, diabetes, etc., can be stopped when the conditions for which they are taken improve or resolve after weight loss surgery. For meds that need to be continued, the vast majority can be swallowed, absorbed and work the same as before weight loss surgery. Usually no change in dose is required. Two classes of medications that should be used only in consultation with your surgeon are diuretics (fluid pills) and NSAIDs (most over-the-counter pain medicines). NSAIDs (ibuprofen, naproxen, etc.) may create ulcers in the small pouch or the attached bowel. Most diuretic medicines make the kidneys lose potassium. With the dramatically reduced intake experienced by most weight loss surgery patients, they are not able to take in enough potassium from food to compensate. When potassium levels get too low, it can lead to fatal heart problems.

What is a hernia and what is the probability of an abdominal hernia after surgery?
A hernia is a weakness in the muscle wall through which an organ (usually small bowel) can advance. Approximately 20% of patients develop a hernia. Most of these patients require a repair of the herniated tissue. The use of a reinforcing mesh to support the repair is common.

Is blood transfusion required?
Infrequently: If needed, it is usually given after surgery to promote healing.

What is phlebitis and is it preventable?
Undesired blood clotting in veins, especially of the calf and pelvis. It is not completely preventable, but preventive measures will be taken, including:

• Early ambulation
• Special stockings
• Blood thinners
• Pulsatile boots

Will I lose hair after surgery? How can I prevent it?
Many patients experience some hair loss or thinning after surgery. This usually occurs between the fourth and the eighth month after surgery. Consistent intake of protein at mealtime is the most important prevention method. Also recommended are a daily zinc supplement and a good daily volume of fluid intake.

What are adhesions and do they form after this surgery?
Adhesions are scar tissues formed inside the abdomen after surgery or injury. Adhesions can form with any surgery in the abdomen. For most patients, these are not extensive enough to cause problems.

What is the "Candida Syndrome?"
Some patients have a type of yeast present on the surface of their skin, intestine or vagina at the time of surgery. This leads to overgrowth in certain circumstances. A whitish coating may occur on the tongue or throat. This syndrome is associated with a frothy mucous, nausea, difficulty swallowing, sore throat, loss of taste and appetite, and occasionally abdominal bloating and diarrhea.

What causes it to appear?
It is promoted by the use of most antibiotics and some other medications, by stress, by reduced immune response, and by diabetes.

Can it be cured?
There are several effective medications now available for treating the overgrowth of Candida.

What is sleep apnea (SA)?
It is the interruption of the normal sleep pattern associated with repeated delays in breathing. Sleep apnea often shows rapid improvement after surgery. In most patients, there is a complete resolution of symptoms by six months following surgery.

Diet

How long will I be off of solid foods after surgery?
Most surgeons recommend a period of four weeks or more without solid foods after surgery. A liquid diet, followed by semi-solid foods or pureed foods, may be recommended for a period of time until adequate healing has occurred. Your surgeon will provide you with specific dietary guidelines for the best post-surgical outcome.

What are the best choices of protein?
Eggs, low-fat cheese, low-fat cottage cheese, tofu, fish, other seafood, chicken (dark meat), turkey (dark meat).

Why drink so much water?
When you are losing weight, there are many waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you and helps your body to rid itself of waste products efficiently, promoting better weight loss. Water also fills your stomach and helps to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it may be because you did not drink enough water in the hour before.

What is Dumping Syndrome?
Eating sugars or other foods containing many small particles when you have an empty stomach can cause dumping syndrome in patients who have had a gastric bypass or BPD where the stomach pylorus is removed. Your body handles these small particles by diluting them with water, which reduces blood volume and causes a shock-like state. Sugar may also induce insulin shock due to the altered physiology of your intestinal tract. The result is a very unpleasant feeling: you break out in a cold clammy sweat, turn pale, feel "butterflies" in your stomach, and have a pounding pulse. Cramps and diarrhea may follow. This state can last for 30-60 minutes and can be quite uncomfortable - you may have to lie down until it goes away. This syndrome can be avoided by not eating the foods that cause it, especially on an empty stomach. A small amount of sweets, such as fruit, can sometimes be well tolerated at the end of a meal.

Is there a problem with consuming milk products?
Milk contains lactose (milk sugar), which is not well digested. This sugar passes through undigested until bacteria in the lower bowel act on it, producing irritating byproducts as well as gas. Depending on individual tolerance, some persons find even the smallest amount of milk can cause cramps, gas and diarrhea.

Why can't I snack between meals?
Snacking, nibbling or grazing on foods, usually high-calorie and high-fat foods, can add hundreds of calories a day to your intake, defeating the restrictive effect of your operation. Snacking will slow down your weight loss and can lead to regain of weight.

Why can't I eat red meat after surgery?
You can, but you will need to be very careful, and we recommend that you avoid it for the first several months. Red meats contain a high level of meat fibers (gristle) which hold the piece of meat together, preventing you from separating it into small parts when you chew. The gristle can plug the outlet of your stomach pouch and prevent anything from passing through, a condition that is very uncomfortable.

How can I be sure I am eating enough protein?
40 to 65 grams a day are generally sufficient. Check with your surgeon to determine the right amount for your type of surgery.

Is there any restriction of salt intake?
No, your salt intake will be unchanged unless otherwise instructed by your primary care physician.

Will I be able to eat "spicy" foods or seasoned foods?
Most patients are able to enjoy spices after the initial 6 months following surgery.

Will I be allowed to drink alcohol?
You will find that even small amounts of alcohol will affect you quickly. It is suggested that you drink no alcohol for the first year. Thereafter, with your physician's approval, you may have a glass of wine or a small cocktail.

Will I need supplemental vitamins?
B12 injections are sometimes suggested once a month for the first year and every six months thereafter. B12 may also be taken orally or sublingually (under the tongue) by many patients.

What vitamins will I need to take after surgery?
Most surgeons recommend a daily multivitamin for the rest of your life.

Is it important to take calcium, iron, trace elements or female hormone replacements?
Some patients require these supplements, but your need for these can be determined by your surgeon.

Do I meet with a nutritionist before and after surgery?
Most surgeons require patients to consult with a nutritionist before surgery. Counseling after surgery is available on an individual basis as needed or required by your physician.

Will I get a copy of suggested eating patterns and food choices after surgery?
Surgeons provide patients with materials that clearly outline their expectations regarding diet and compliance to guidelines for the best outcome based on your surgical procedure. After surgery, health and weight loss are highly dependent on patient compliance with these guidelines. You must do your part by restricting high-calorie foods, by avoiding sugar, snacks and fats, and by strictly following the guidelines set by your surgeon

General

What is the youngest age for which weight loss surgery is recommended?
Generally accepted guidelines from the American Society for Bariatric Surgery and the National Institutes of Health indicate surgery only for those 18 years of age and older. Surgery has been performed on patients 16 and younger. There is a real concern that young patients may not have reached full developmental or emotional maturity to make this type of decision. It is important that young weight loss surgery patients have a full understanding of the lifelong commitment to the altered eating and lifestyle changes necessary for success.

What is the oldest patient for whom weight loss surgery is recommended?
Patients over 65 require very strong indications for surgery and must also meet stringent Medicare criteria. The risk of surgery in this age group is increased, and the benefits, in terms of reduced risk of mortality, are reduced.

Can Weight Loss Surgery prolong my life?
There is good evidence from scientific research that if you have Type 2 diabetes (or other serious obesity-related health conditions), are at least 100 lbs. over ideal body weight, and are able to comply with lifestyle changes (daily exercise and low-fat diet), then weight loss surgery may significantly prolong your life.

Can weight loss surgery help other physical conditions?
According to current research, weight loss surgery can improve or resolve associated health conditions.

Condition Percentage found in preoperative individuals Percentage cured 2 years after surgery Diabetes or insulin resistance 34%  85% High blood pressure 26% 85% High triglycerides 40% 66% Sleep apnea 22% in males, 1% in females  40%