Table of Contents:
- Bariatric Surgery Gets a Bad Rap
- What is the Point of Bariatric Surgery?
- Bariatric Surgery Benefits
- What Exactly is Bariatric Surgery?
- Which Procedure is Best?
- Your New Diet
- The Emotional Rollercoaster
- Does Insurance Cover Bariatric Surgery?
- How Do I Get Started?
Bariatric Surgery Gets a Bad Rap
Bariatric surgery gets a bad rap. And it makes sense.
Tell your friends or family members that you are considering bariatric surgery and you usually get a response like this; ‘You don’t need surgery. You’re not that fat. You can do it the natural way.’
Your friends and family members care about you. But they are scared, misinformed and sometimes even a tad bit jealous. They aren’t trying to make you feel bad. But they’ve heard stories.
Here’s the thing about stories; stories are only as good as the details. ‘Ann had bariatric surgery and lost 150 pounds. She completely got off all her meds and she no longer has diabetes.’ That’s a true but very boring story.
This story is much more interesting and something you might even share with a friend; ‘Jane tried to lose weight the ‘easy way.’ Yep, she had that Lap Band thing. Well she almost died on the operating table. For an entire year, she could only drink water and eat baby food. Then she gained it all back! I just saw her drinking a coke and eating a donut. Man, people just want the easy way out.’
It’s stories like these that give all of bariatric surgery a bad rap. And while some of those scary stories are true, most of them are embellished, changed, and outright gossip.
Some patients do regain weight years after bariatric surgery. It’s typically not the surgery that failed, but instead the patient or bariatric program that failed. Failure (inadequate weight loss) typically happens for two reasons:
- Lack of pre and post-operative education and support (the bariatric program’s fault if these weren’t offered) or…
- Lack of implementation (the patient never changed their lifestyle by not taking advantage of the education and support offered).
The scary bariatric surgery stories that you hear are shared because they’re ‘share-worthy.’ And while some stories may be true or have a kernel of truth, the data (the clinical studies) tells us that those are the exceptions.
Lap Band Success Rate
Gastric Sleeve Success Rate
Gastric Bypass Success Rate
Duodenal Switch Success Rate
The line graphs above show patients who have lost more than 50% of their excess weight and managed to keep it off for more than 5 years. The popularity of the Lap Band has dropped significantly due to the long-term complication rate and low success rate.
Bariatric surgery is a life changing procedure that is the opposite of easy. It is hard, it is abrupt, and it is major surgery. And, as pointed out, if you don’t change your lifestyle, there is a chance you will fail (inadequate weight loss).
What is the Point of Bariatric Surgery?
So what then, is the point of surgery if you have to change your lifestyle anyway? Couldn’t you do that without surgery?
- Bariatric surgery forces a reduction in calories or minimizes the absorption of calories or both (depending on the type of surgery).
- Procedures that are restrictive in nature (your stomach size is reduced) allow patients to feel full after a small amount of food. This forces patients to eat less.
- Procedures that are malapsortive create a smaller intestinal tract for the body to absorb calories. This forces lower calorie absorption.
- And in some procedures, ghrelin production (the ‘hunger hormone’) is reduced leading to a reduction of hunger.
- Most bariatric procedures also create a feeling of nausea after consuming foods high in carbohydrates or sugar. This ‘helps’ many patients choose nutrient dense foods that are low in sugar and low in simple carbohydrates.
- Bariatric surgery forces patients to re-learn how to eat. It forces patients to choose better foods. It forces patients to think about how much and when they eat.
- Bariatric surgery patients are able to lose a lot of weight in a short amount of time.
Then How Do Some People Gain Weight Back?
If bariatric surgery forces you into a new diet, and it forces you to eat less, and it forces you to not eat unhealthy foods, then how do people regain the weight?
People are smart. And, as with any bad habit, our minds can rationalize a little bit of something because a little bit is ‘ok.’ And then a little bit more the following day. And a week later, that Sugar Free Caramel Frappuccino that was just a one-time thing now has whip on it and your buying it every day on the way to work.
And life is tough. For many bariatric surgery patients, food was a shoulder to lean on. Food was a support system and food made those bad days a little bit better.
And slowly but surely, as you snack more and your meals get a little bit larger and more simple carbohydrates find their way to your plate, your body adjusts and allows the gradual introduction of bad foods.
A single slice of pizza doesn’t make you feel sick anymore. A small piece of cake is ok. And you found those sweet potato chips that don’t seem to upset your new stomach so you eat a bag a day at your desk.
Slowly but surely, the weight comes back. Habits are hard to break.
Again, what is the point of bariatric surgery?
You are probably saying to yourself, well I still have to change my lifestyle. I can do that without bariatric surgery. Why go through the hassle of surgery?
You have tried the ‘natural’ way. You have likely tried to lose weight for most of your adult life. You are here because, for you, nothing else has worked. And the data shows that, for most people, nothing else will work.
Bariatric surgery forces you to lose weight while you learn how to eat healthy. And a successful bariatric patient will know how to recognize when they have fallen off the wagon. Because you will. Everyone does.
The key is recognition. Successful bariatric patients recognize bad habit creep and quickly address the issue. This can be done by food journaling, by attending regular support groups, by getting friends and family to support your journey.
Every patient has different triggers and different emotional ties with food. Understanding your relationship with food during the pre-operative psychological counseling, the pre-operative physician supervised weight loss program, the post-operative dietitian consults and monthly support group meetings will better prepare you for bad habit creep.
And as the weight comes off, it becomes easier to exercise. Medication is often reduced. Cholesterol and sleep apnea are better controlled. More energy and a visible physical change can be powerful motivators.
Bariatric surgery creates such a drastic physical change that the weight loss itself becomes a strong motivator to continue to lose more and keep it off.
So why choose bariatric surgery?
Because the drastic weight loss will motivate you to continue your journey to better health while your pre and post-operative education helps you implement healthy habits that last.
Bariatric Surgery Benefits: What You Can Expect
Now that we’ve explained why it works and quelled some of the common misconceptions with bariatric surgery, let’s take a look at what you can expect.
On top of decreasing medications and losing weight, bariatric surgery has other benefits as well.
- Reduced risk of cancer – SOARD: Bariatric surgery reduces cancer risk in morbidly obese patients
- Improved self-esteem and quality of life – International Journal of Obesity: Does obesity surgery improve psychosocial functioning? A systematic review
- Improvement in fertility and complications during pregnancy – Human Reproduction Update: Reproductive outcome after bariatric surgery: a critical review
- Longer life – The New England Journal of Medicine: Long-term Mortality After Gastric Bypass
Below is a list of common comorbidities that are often improved with bariatric surgery.
- Sleep Apnea
- High Blood Pressure
- High Cholesterol
- Type 2 Diabetes
- Venous Stasis Disease (Collection of Blood in the Lower Limbs)
- Soft Tissue Infections
Type 2 Diabetes is extremely common in morbidly obese patients. Data shows that laparoscopic gastric bypass, lap gastric banding and gastric sleeve surgery can reduce your dependence on medication and often completely resolve the condition.
Less frequent comorbidities that are occasionally accepted by insurance include:
- Congestive Heart Failure
- Fatty Liver Syndrome
- Gall Bladder Disease
- Stroke or Stroke Risk
- Inability to Carry Out Daily Activities
- Psychosocial Stress Resulting From Obesity
- GERD (Acid Reflux Disease)
- Knee and back pain
Bariatric surgery is not a cosmetic procedure. While you will lose weight and may look better, the success of bariatric surgery should be based on a reduction of co-morbidities, improved longevity, and an improved quality of life, not numbers on a scale. Are you happier, healthier and going to live longer?
Let’s take a look at some non-scale victories.
- When you don’t need the extender belt on an airplane.
- When you can shave your legs without a struggle or mirror.
- When you make it up the stairs without breaking a sweat.
- When you are not embarrassed to take a picture.
- When you get to wear that dress that you’ve had in your closet for years.
- When you can cross your legs.
- When you aren’t always the biggest person in the room.
- When you fit comfortably in a seat.
- When you can wrap a standard bath towel around your body.
- When you don’t have to shop at plus size stores.
- When you can get in and out of booths easily at restaurants.
- When your joints don’t hurt at the end of the day.
- When you are not the ‘fat’ member of your group of friends.
The list can go on and on and will be different for everyone. Losing weight does so much more than just improving medical conditions and lowering the number on your scale.
Celebrate your non-scale victories. Make a list of the things you want to do that your weight has prevented you from doing and reward yourself when you reach those goals. Don’t reward yourself with food. A manicure, tickets to a concert or sporting event, a night out with the friends are great rewards.
What Exactly is Bariatric Surgery?
Commonly referred to as weight loss surgery, bariatric surgery is one of the few weight loss treatments that has a history of proven results. The term bariatric surgery refers to any surgical procedure on the stomach or intestines to induce weight loss.
Bariatric surgery is a term that encompasses a number of procedures. The most common procedure in the United States is gastric sleeve surgery (sleeve gastrectomy). Gastric bypass is the second most often performed and Lap Band surgery is the third most popular procedure in the United States. Duodenal Switch is another very effective, although less often performed, procedure.
Newly FDA approved procedures such as gastric balloons fall under the bariatric surgery umbrella as well.
A Brief History of Bariatric Surgery
In the 1950s, weight loss surgery began with the intestinal bypass. This surgical procedure shortened the length of the small intestine. The intestines absorb calories and macronutrients. And if this area was shortened then there would be less absorption of calories and macronutrients as the food worked its way out of the patient’s body.
A large portion of the intestines had to be bypassed to create significant weight loss. Unfortunately, bypassing a large portion of the intestines led to malnutrition and in some cases, death.
In 1966, Chikashi Ito and Dr. Edward E. Mason developed gastric bypass surgery. In this procedure the stomach was resected and a smaller portion of intestines were bypassed. With a smaller stomach patients found it harder to eat large meals and the bypassed intestines led to less calorie absorption. The result? Weight loss.
Because of these groundbreaking developments, Mason is now commonly referred to as being the “father of obesity surgery.”
Most bariatric surgery procedures are now done laparoscopically. This is also called “minimally invasive surgery.” 3 to 6 smaller incisions are made and small instruments and a camera are inserted into the patient’s body. Recovery is quicker and patients experience less pain.
So Which Procedure is Best?
Looking at the timeline above, you’d think that gastric balloon surgery is the latest and greatest procedure for weight loss. Or you may think that the Lap Band is the best because you’ve heard so much about it.
Everyone has a different relationship with food, different medical histories, and different lifestyles. One procedure does not fit all.
Open and honest conversations with your bariatric surgeon will help you choose the procedure that best fits your personality, level of risk aversion, and lifestyle.
Feel free to take our Bariatric Surgery Selector Test, but again, open and honest conversations with your bariatric surgeon will lead to the best procedure for you.
- Not all bariatric surgeons perform every procedure.
- There could be a strong bias towards gastric banding if your surgeon only performs the Lap Band procedure.
- Ask your bariatric surgeon which procedures he or she performs and if he/she doesn’t perform a procedure, ask why.
- The support and education from the bariatric program and your desire/ability to utilize the offered support is probably more important than the type of procedure you choose.
- Gastric bypass surgery has been proven to be clinically effective for long-term weight loss. However, without the proper guidance before and after surgery, you may still fail.
Restrictive Vs. Malapsorptive
Weight loss surgery works because of restriction and/or malabsorption. Some surgical procedures involve only restrictive elements, while others involve a combination of both.
Malabsorptive procedures alter the digestive tract so that a certain amount of the small intestine is bypassed. This allows for food to pass through the intestines quicker and less calories are absorbed.
Although there are some procedures that are purely malabsorptive, none of these types of surgeries are performed anymore.
Restrictive procedures reduce the size of the stomach so a patient feels full quicker. This is typically done with staples and the stapled stomach is either removed or bypassed depending on the procedure.
Reducing the size of the stomach may also reduce ghrelin production and reduce hunger.
Restrictive procedures can be restrictive only or combined with a malabsorptive aspect.
For each procedure we will give you the key benefits and risks and then provide you with a link for more information about that procedure if you want to learn more. As always, check with your doctor for his/her experience with each procedure and have an open an honest discussion about your lifestyle medical condition to determine the best procedure for you.
Gastric Bypass Surgery
Average Excess Weight Loss: 60% to 80%
Serious Complication Rate: 1.25%
Average 30 Day Mortality Rate (Death Rate): 0.14%
Procedure Type: Restrictive and Malapsorptive
- Long history of success and clinical studies to validate its effectiveness.
- Average of 60% to 80% excess weight loss.
- May reduce hunger.
- Excellent rate of diabetes cessation after surgery.
- May relieve heartburn and acid reflux.
- It is a technically challenging procedure and typically requires a bit more time under anesthesia compared to other popular bariatric surgeries.
- Vitamins and minerals are required daily or you’ll risk log-term nutritional deficiencies.
- If you are prone to ulcers, discuss this with your doctor.
Gastric bypass restricts the amount you can eat and slightly reduces the amount of calorie absorption by re-routing your intestines. Some believe the re-routing of your intestines may produce a favorable change in gut hormones that increases satiety and reduces hunger.
Learn more about gastric bypass surgery.
Gastric Sleeve Surgery
Average Excess Weight Loss: 57% to 70%
Serious Complication Rate: 0.96%
Average 30 Day Mortality Rate (Death Rate): .08%
Type of Procedure: Restrictive
- Average hospital stay of 2 nights but in some cases it is an outpatient procedure.
- Average of 60% to 70% excess weight loss.
- May reduce hunger.
- No foreign objects like Lap Bands.
- No re-routing of the intestines like gastric bypass.
- Straightforward procedure that is relatively easy to replicate.
- Vitamins and minerals are required for life. However, the risk of vitamin and mineral deficiencies is lower than duodenal switch and gastric bypass.
- Does not improve heartburn or acid reflux and in some cases may worsen it.
- Less long-term data compared to gastric bypass.
Re-routing your intestines is only a benefit if you prefer the least amount of anatomical change. Hunger reduction can be significant for some and not improve at all for others.
Duodenal Switch Surgery
Average Excess Weight Loss: 80% to 90%
Serious Complication Rate: 2% to 3%
Average Mortality Rate (Death Rate): 0.29% to 2.7%
Procedure Type: Restrictive and Malapsorptive
- The best weight loss profile, up to 85% excess weight loss.
- The best long-term weight loss success rate (better than 50% excess weight loss) of 95%.
- Best rate of comorbidity reduction.
- Highest risk for malnutrition.
- Strictest dietary guidelines.
- The longest and most complex procedure of the 3 primary bariatric procedures (bypass, sleeve and duodenal switch).
- Highest 30 day serious complication rate.
- Strict adherence to vitamins and minerals and post-operative diet are required for success and to prevent malnurtition.
Duodenal Switch surgery has been around for a while but because of it’s complexity and risk for malnutrition many surgeons have shied away from the procedure. With better surgical tools, better support and patient education teams, more clinical studies showing excellent success and reduction of comorbidities, and refinements to the procedure (i.e. SIPS – Stomach Intestinal Pylorus Sparing), the duodenal switch procedure is gaining in popularity.
It’s important to discuss this procedure with your surgeon. Your surgeon’s experience and his/her patient’s outcomes should be evaluated as well as their support program.
Learn more about duodenal switch surgery.
Your New Diet
Every bariatric program has slightly different diet guidelines. Different procedures may have different guidelines as well.
The information below is not meant to replace your doctor’s or dietitian’s diet guidelines. It is however, meant to give you an idea of what to expect with your new diet.
The Before Surgery Diet
Most bariatric programs recommend a one or two-week pre-op diet. The purpose of this diet is to reduce the size of your liver prior to surgery.
Many obese individuals have a fatty liver. Fat cells grow between liver cells and make the liver large, function poorly, and hard for your surgeon to move out of the way during surgery.
The pre-op diet is typically very low in carbohydrates and high in protein. This forces your body to use your fat cells as energy. Your liver shrinks quickly and surgery becomes safer and easier.
Low carb and high protein is typically recommended before surgery.
The After Surgery Diet
The typical post-operative bariatric surgery diet consists of four or five stages. Stages 3 and 4 are occasionally combined.
- Stage 1 – Clear Liquid Diet – For one or two weeks after surgery.
- Stage 2 – Full Liquid Diet – For one to two weeks after stage one.
- Stage 3 – Pureed Food – For one to four weeks after stage two.
- Stage 4 – Soft Foods – For one to two weeks after stage three.
- Stage 5 – Regular Diet – For the remainder of the patient’s life after stage three (starts typically 8 to 12 weeks after surgery).
Stage One – Clear Liquids
During the first stage, the patient’s diet will consist of water, broth, Jell-O, sugar-free popsicles, sugar-free crystal light. These substances should not contain any sugar or fat and should be consumed slowly.
You should avoid:
- Carbonated beverages
Try your best to get 64 ounces of water. Dehydration is very common after bariatric surgery. Sip, sip, sip all day long.
The clear liquids let your stomach heal and prevents you from getting sick which can also put undue pressure on your new stomach.
Stage Two – Full Liquid Diet With Protein
Stage two typically focuses on liquids and protein. Below are common foods for stage two.
- Non-fat Greek Yogurt
- Protein powder mixed with a sugar free non-carbonated clear liquid.
- Protein powder mixed with Greek Yogurt.
- Protein shake in 4 ounce increments throughout the day.
- Sugar free pudding.
- Soup with soft noodles.
- Non-fat yogurt.
- Carnation instant breakfast. Look for the sugar free option.
- Very thin creamed soups. No chunks.
- Sugar free sorbet.
- Very watery hot oatmeal. Check the sugar content.
- Sugar free, nonfat ice cream
- Thinned applesauce. Check sugar content.
Staying hydrated is extremely important. Get your fluids in throughout the day by drinking 4 to 6 ounces every hour.
Stage Three – Pureed Foods
Stage three typically focuses on introducing foods with a thin consistency. Below are some common foods for stage three.
- 1 protein shake per day.
- Almond milk or coconut milk makes a great protein shake.
- Cottage cheese (low fat)
- Soft cereals – Let your cereal sit in the non-fat milk until it’s soft.
- Soft vegetables – steam or boil them until they are soft.
- Soft cheeses – limit these, they are typically high in fat.
- Ground chicken or beef. Add some beef or chicken stock to keep the meat soft.
- Scrambled eggs – these are a great source of protein.
- Soft (steamed) fish. Remember to chew well.
- Canned tuna and salmon (you can add low fat mayo). Great source of protein.
- Mashed fruit. Bananas, avocados, and canned fruit (watch sugar content).
You should avoid the following foods:
- While smoothies are ok, limit their sugar content. Most smoothies have a lot of sugar.
- Starchy foods like pasta, rice and bread.
- Fibrous vegetables like celery, broccoli, asparagus, raw leafy green
500 calories is common at Stage 3. Remember to track with the Baritastic app!
Stage Four – Soft Foods
By this point, patients are typically excited to get back to more ‘normal’ foods. However, most programs still recommend choosing soft foods to prevent undue stress on your new stomach. Remember to follow your bariatric programs diet guidelines! Now is not the time to cheat.
- All foods from previous stages.
- Continue your daily protein shakes.
- Any type of fish.
- Chicken and other tender meats are typically allowed.
- Make sure you chew thoroughly and take small bites.
- Vegetables (it’s still recommended that you cook these to soften them a bit).
- Sweet Potatoes
- Healthy cereals
You should avoid the following foods in week four:
- Fried foods
- Fibrous vegetables (i.e. celery and asparagus)
- Sugary drinks
- Pastas and other high carbohydrate, low nutrient foods (pizza).
- Whole milk and other whole milk dairy foods.
Stage 5 – Regular Diet
Its time to start your new life.
Admittedly, the hardest part and the most important factor in your long-term success is your ability to implement a healthy, sustainable lifestyle. Does this mean you will never have a cookie again? Possibly, but probably not. It simply means you will choose healthy foods over unhealthy foods. You will shop healthy and your body will receive it’s energy from nutrient dense foods that keep you satiated.
You should choose healthy foods and have a good understanding of what is not healthy. For meals, protein is typically consumed first, followed by vegetables and finally by a small amount of healthy complex carbohydrates. Most programs recommend (recommendations vary based on target weight, height, and sex) the following macronutrient goals:
- ~1200 calories per day (this varies depending on the patient’s target weight and height)
- 65 to 85 grams of protein
- 40 to 80 grams of carbohydrates (ideally vegetables)
- Very little refined sugar
- Most programs don’t have patients monitor their fat intake as long as they are getting regular blood work. But choose lean meats whenever possible.
Knowing Your Obese Self
From the nutritionist consults, from tracking your food on Baritastic, from your psychological counseling, you should know your triggers. You should know why you were obese. You should be able to recognize when you fall off the wagon and be able to get back up. You quickly shake off that bad day and get back on track.
Knowledge of healthy foods, an understanding of your body’s signals, its cravings, and how your body feels after eating certain foods and different amounts of those foods is paramount to your success.
For some people, chips in the pantry might not be a risk. Others can have a small dessert on special occasions. And still others should not indulge in dessert or keep carbohydrate-filled foods nearby.
Setting up your ‘regular diet’ should be a combination of discussions with your dietitian and putting to use what you have learned about you.
The Emotional Roller Coaster
Bariatric surgery produces drastic weight loss. As patients lose weight, hormones change. Obesity increases estrogen production in men and women (Reduced-Calorie Dietary Weight Loss, Exercise, and Sex Hormones in Postmenopausal Women: Randomized Controlled Trial). Rapid reduction of weight reduces estrogen. While losing weight at a fast rate in the months after surgery, patients often struggle to manage their emotions. The new restricted diet along with the re-balancing of hormones can produce irritability and emotional instability. For some patients this is a minor inconvenience, others do not notice any emotional changes. But for some patients the months after surgery can be difficult.
Self-perception, self-worth, and inter-personal relationships can change.
Acknowledging the potential for an emotional struggle and preparing for it can be helpful. The Emotional First Aid Kit is one of our top recommendations and worth a read for patients before or after bariatric surgery.
Does Insurance Cover Bariatric Surgery?
Insurance often covers bariatric surgery. While most of the major insurance carriers offer coverage for bariatric surgery, not all policies include coverage. To find out if your insurance policy includes coverage, we recommend three steps:
- Call your insurance carrier and ask if your policy covers sleeve gastrectomy surgery. Tell them to check CPT Code: 43775. Also ask if they cover CPT Code: 43644 (gastric bypass).
- It doesn’t matter which procedure you end up having. This is your first check to see if your policy includes coverage for bariatric surgery procedures.
- Call a local bariatric surgeon or bariatric program and ask if they’ll check if you have coverage.
- Most bariatric programs are happy to check and often have someone on staff that does this on a regular basis.
- Use our bariatric program finder to find a bariatric program in your area.
- Familiarize yourself with your insurance companies requirements for coverage.
- Check your insurance company requirements for coverage here.
How Do I Get Started?
If you’re just getting started and choosing to use insurance to cover the cost of bariatric surgery, it’s important to note that it takes about 6 months on average to get to surgery. Yep, it’s a long process. There are some benefits to this:
- Bariatric surgery is a tool to lose weight. If you don’t implement the necessary lifestyle changes, you risk weight regain and the benefits of the surgery won’t be fully realized.
- The 6 months leading up to surgery help prepare you for life after surgery.
- During the 6 months leading to surgery, you will likely be required to undergo a psychological evaluation, a physician supervised weight loss program, and possibly be required to lose weight.
- Fully engage in the process leading up to surgery and make sure you complete everything required by your insurance carrier.
The first step to get started is to find a bariatric program in your area and attend a seminar. Seminars, sometimes online, are a great way to learn more about the risks and benefits of bariatric surgery. I recommend attending an in-person seminar so you can meet the surgeon and or bariatric team. You may want to attend multiple seminars with different programs until you find a surgeon that you feel comfortable with.
The second step is your initial consult with the surgeon. This is typically a one-on-one meeting with the surgeon where you’ll review your surgical options, discuss your lifestyle and answer any questions you may have. You will likely leave with a piece of paper that outlines the necessary steps for approval. Many of these steps will be done outside of your surgeons office. Make sure you stay on track and set-up the needed appointments to get approval. Keep your surgeons office aware of your progress as you move through the checklist. We recommend using the checklist feature in the Baritastic app for this. Search the major app stores for Baritastic from your Smartphone (it’s free!).
Bariatric surgery is a life-changing process. The surgery is a tool to help you lose weight. Once the weight comes off, it’s up to you to implement lifestyle changes that last. As you lose weight exercise becomes easier. The knowledge you’ve gained during your nutrition consults becomes invaluable. The friends you’ve made at support groups and the team of professionals at your bariatric program become indispensable.
Use your tool to take the hardest first few steps for you. Implement what you’ve learned, lean on the resources that you’ve gained. The next steps are up to you.