Frequently Asked Questions
Medications
Many Americans with obesity have severe health problems such as diabetes, high blood pressure, elevated cholesterol, and coronary heart disease. Patients who undergo bariatric surgery and successfully lose weight see these health conditions improve, and they may be able to stop some medications with their doctor’s advice.
Taking fewer prescription medications doesn’t always mean “no more pills,” though. Many people take more pills, as they follow vitamin and mineral plans, and have a better awareness of benefits. Good health is the goal, not the fewest pills.
Prescription or over-the-counter drugs may be absorbed differently after surgery, depending on the procedure type. Your medication therapy may be affected by this change. In the early period right after surgery, larger tablets or capsules may not be recommended by your surgeon so that pills do not become stuck. Because of this, your surgeon may recommend that you take medications in different forms, such as crushed, liquid, suspension, chewable, sublingual, or injectable. Some long-acting medications and “enteric coated” medication may not be crushable. While others may be crushed and administered with food.
Sleeve gastrectomy and adjustable gastric banding tend to have little to no change in the absorption of medications. Roux-en-Y gastric bypass and duodenal switch can have more significant changes in how drugs are absorbed. Check with your surgeon and pharmacist about how you should take each of your medications. Some patients need a higher dose of anti-depressants to have the same effect. This is not a complication, but you need to be aware of how you feel, and speak up with all your caregivers
Maybe. Some doses may change (see the previous question). Some medication doses may decrease as the obesity-related health conditions improve. For example, diabetic patients often require less insulin or other diabetes medications after surgery because glucose control can improve quickly. Patients who take high blood pressure and cholesterol medication can see their doses lowered if these disease states improve. Your doctor should oversee any changes in prescription medication; this is not something that you should do yourself.
Your surgeon or bariatric physician can offer guidance on this topic. One clear class of medications to avoid after Roux-en-Y gastric bypass is the “Non-steroidal anti-inflammatory drugs” (NSAIDs), causing ulcers or stomach irritation. They are especially linked to a kind of ulcer called “marginal ulcer” after gastric bypass. Marginal ulcers can bleed or perforate. Usually, they are not fatal, but they can cause many months or years of misery, and are a common cause of re-operation, and even (rarely) reversal of gastric bypass.
Dr. Mailapur also asks his patients to avoid the use of NSAIDs after sleeve gastrectomy and adjustable gastric banding as well. Corticosteroids (such as prednisone) can also cause ulcers and poor healing but may be necessary for some situations. Some long-acting, extended-release or enteric coated medications may not be absorbed after bariatric surgery. You must work with your surgeon and primary care physician to monitor how well your medications are working. Your doctor may choose an immediate-release medication in some cases if the concern is severe enough. Finally, few prescription medications can be associated with weight gain, so you and your doctor can weigh the weight gain’s risk versus that medication’s benefit. There may be alternative medications in some cases with less weight gain as a side effect.
Dr. Ravindra Mailapur asks to take a proton pump inhibitor like Prilosec, Nexium, or Protonix for three months after surgery. You need to open the capsule and mix it with diet jello for the first two weeks and swallow the capsule or table after that.
Not all medications are crushable. It’s dependant on the drug formulation, whether the medication can be crushed. In general, non-coated, immediate-release tablets can be crushed. It is important that you are VERY careful with medications. Please always check with your surgeon, primary physician, or pharmacist before making medication decisions. An online list of non-crushable medications is available at http://www.ismp.org/tools/donotcrush.pdf
Fitness
Physical activity is essential for long-term weight management. Different patients may have different needs and abilities. As you progress in your fitness program, your body becomes more efficient at the same activity, which means you tend to burn fewer calories. As you lose weight, the number of calories burned per hour tends to decrease as well. And so, throughout time, it is necessary to increase the intensity or length of your fitness activities gradually. Your surgeon or fitness instructor may have specific recommendations for you in this regard.
Current recommendations for activity are 150 minutes of moderate activity each week, such as brisk walking, jogging, Zumba, swimming, or using exercise machines. Please note that the ability to tolerate exercise safely differs from person to person. Please make sure that you can safely handle your chosen activity and amount.
That depends on the type of exercise. You should begin walking while still in the hospital unless instructed otherwise. As you heal, begin to increase your exercise time and intensity. Your doctor will release you to increase your activity based on your progress. After surgery, exercises such as weights, sit-ups, pull-ups, or any abdominal straining should wait until you get the go-ahead from your doctor.
Include aerobic (“cardio”), resistance (strength) and flexibility exercise into your routine for best results. Try different exercise programs to find what is right for you. Learn what is available in your community through your bariatric program, local fitness centers, and fellow patients. Warm water exercise (such as lap swimming or water aerobics) is excellent for those with joint pain. Home exercise videos are another option if you do not have access to a nearby gym.
Smoking
In order to lower the risk of complications, it’s highly recommended that you quit smoking or using chewing tobacco before your weight-loss surgery. Hopefully, this can be an opportunity for you to kick the habit for good.
Smoking or chewing tobacco leads to the decreased blood supply to your body’s tissues and delays healing. Smoking harms every organ in the body and has been linked to:
- Blood clots (the largest cause of death after bariatric surgery)
- Marginal ulcers after gastric bypass
- Heart disease
- Stroke
- Chronic obstructive pulmonary (lung) disease
- Increased risk for hip fracture
- Cataracts
- Cancer of the mouth, throat, esophagus, larynx (voice box), stomach, pancreas, bladder, cervix, and kidney
Eight weeks is needed to reduce the risk of fatal blood clots and pneumonia. Stopping just a week or two before can make some risks worse; this is not unique to bariatric surgery. Your surgeon will have specific guidelines on how long you must be tobacco-free before surgery, and many will reschedule surgery until you are “clean.” There are blood tests that can show if you have been smoking, even if you are on a nicotine patch or gum, so don’t cheat!
Talk to your primary care practitioner; they would be glad to help! You can also call 1-877-44U-QUIT (1-877-448-7848) or 1-800-QUIT-NOW (1-800-784-8669), or log on to http://www.smokefree.gov.
Drinking Alcohol
Alcohol is not recommended after bariatric surgery. Alcohol contains calories but minimal nutrition and will work against your weight loss goal. For example, wine has twice the calories per ounce than regular soda does. The absorption of alcohol changes with gastric bypass and gastric sleeve because an enzyme in the stomach usually begins to digest alcohol is absent or greatly reduced.
Alcohol may also be absorbed more quickly into the body after gastric bypass or gastric sleeve. Absorbed alcohol will be more potent. Studies have demonstrated that obesity surgery patients reach a higher alcohol level and maintain the higher levels for a more extended period than others. In some patients, alcohol use can increase and lead to alcohol dependence. For all of these reasons, it is recommended to avoid alcohol after bariatric surgery.
Pregnancy After Bariatric Surgery
It is recommended you avoid getting pregnant for 18 months after surgery. This allows you to have maximum weight loss and reach a stable weight. You will also be very limited in your nutrient intake for quite some time after surgery.
You can experience a boost in fertility quite soon after surgery, so it is important to use a barrier method of birth control such as IUD, or condoms and spermicide to ensure you do not become pregnant. Birth control pills are much less effective patients with obesity and in the phase of rapid weight loss. If you do become pregnant, please contact your bariatric surgeon and your obstetrician to monitor your progress. You will need to closely monitor your nutrient intake and be evaluated for vitamin deficiencies.
Overall, pregnancy after weight loss surgery can be done safely, by taking steps to minimize risks to your body and the developing fetus. Studies demonstrate a decreased risk of pregnancy-induced hypertension (high blood pressure) and a reduced risk for gestational diabetes. For best outcomes, discuss your options with your surgeon and obstetrician.
Other
Multivitamin, calcium with vitamin D, and in some cases, an iron or vitamin B12 supplement. Sometimes Vitamin A is added to the regimen depending on the operation’s degree of malabsorption. A chewable form is recommended, at least initially, after surgery. Be sure you are using a vitamin appropriate for adults, not a children’s multivitamin.
Vitamin supplements will be a lifelong requirement.
Most patients get 60-80 grams daily, but some may require more depending on their response to surgery or their operation type. Your dietitian can provide more detailed information.
Protein should be taken in multiple doses, across multiple meals or healthy snacks. The body cannot absorb more than approximately 30 grams at once. Also, protein is a nutrient that helps us feel fuller, longer. If we try to include proteins in each meal or healthy snacks, we’re less likely to feel hungry when it’s not time to eat.
There are many options, even for those with special dietary needs or preferences. Your dietitian can provide additional information on protein sources. Meats, eggs, dairy products, and beans are common protein sources in everyday foods. Protein extracts made from soy, brown rice, and whey are commonly sold in stores. Protein shakes or bars may offer additional ways to meet your protein needs. You may find it helpful to calculate your daily protein intake to ensure you’re not falling short. As you can tolerate more regular foods, you get a higher portion of the regular meals, and supplements become less necessary.
The body needs additional protein during the period of rapid weight loss to maintain your muscle mass. Protein is also required for regular metabolism to occur. If you don’t provide enough protein in your diet, the body will take its protein from your muscles. You will lose muscle mass, and you can become frail.
Caffeine fluids have been proven to be as good as any others for keeping you hydrated. Still, it is a good idea to avoid caffeine for at least the first thirty days after surgery while your stomach is extra sensitive. After that point, you can ask your surgeon or dietitian about resuming caffeine. Remember that caffeine often comes paired with sugary, high-calorie drinks, so be sure you’re making wise beverage choices.
Dehydration is the most common reason for readmission to the hospital. Dehydration occurs when your body does not get enough fluid to keep it functioning at its best. Your body also requires fluid to burn its stored fat calories for energy. Carry a bottle of water with you all day, even when you are away from home; remind yourself to drink even if you don’t feel thirsty. Drinking 64 ounces of fluid is a good daily goal. You can tell if you’re getting enough fluid is if you’re making clear, light-colored urine 5-10 times per day. Dehydration signs can be thirst, headache, hard stools, or dizziness upon sitting or standing up. You should contact your surgeon’s office if you are unable to drink enough fluid to stay hydrated.
Each person’s case is different. But the operation usually lasts about two hours. After surgery, you will remain in the recovery room until your anesthesiologist clears you to be moved to your hospital room, usually about two to three hours after surgery.
You will remain in the hospital until the surgeon has decided that you are stable enough to return home, usually one day. Adjustable gastric band patients may go home the same day.
The time that you take off from work depends on what type of work you do. After a laparoscopic approach most patients return to work in one or two weeks. You will have low energy for a while after surgery and may need to have some half days, or work every other day for your first week back. Your 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.
If you still have your gallbladder and it is causing you symptoms, the surgeon may request an ultrasound of your gallbladder to examine it better before your surgery, to determine whether removing it is necessary.
Numerous metabolic changes occur after weight loss surgery. The number of calories your body is accustomed to consuming is drastically reduced. Hair loss is often minimal and the hair usually grows back. Consuming adequate amounts of protein and taking your multivitamins will reduce the amount of hair that may be lost.
Your surgeon will be in the room and is the person in charge of all aspects of the operation. In most cases Dr. Mailapur will have another surgeon to assist him in performing the surgery, but he may be the only one. A resident and operating room nurses are often in the room to help with the surgery.
Many 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. You will not feel well if you do too much.
The Roux-en-Y gastric bypass changes your gastrointestinal tract. Because nothing is removed during this bypass, it can be reversed. However, this operation should be viewed as a permanent change. If you are not ready for that type of commitment, bariatric surgery may not be the best option for you at this point.
Many 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. You will not feel well if you do too much.
It is not recommended to drink carbonated beverages after undergoing bariatric surgery.
There is no reliable way to predict the amount of excess skin you may have. Younger patients will have fewer problems with excess skin after weight loss but most patients will have excess skin that may require surgery for removal.
Ages 15-65 are good years for weight loss surgery.
Your energy level may be low immediately following surgery. You will need about one to two weeks after laparoscopic surgery before going back to work.
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). Participate instead of competing at least for the first month. Build slowly over several weeks. If you swim, your wounds 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 surgeon may ask to see the operative report from complicated or unusual procedures, especially those on the esophagus, stomach, or bowels.
Most groups recommend waiting 12-18 months after surgery before getting pregnant.Most women are much more fertile after surgery, even with moderate pre-op weight loss. Birth control pills do NOT work as well in heavy patients. 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!
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’s 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 heavy women 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.
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. You can view the OAC guide on their website.
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.
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 6-18 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”). 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 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.
