wls education

WHERE TO BEGIN
This library is a good place to start. Talking to your primary care physician, physician specialist or family physician is a good next step. Remember, there is much misinformation about weight loss surgery that you may encounter from unqualified sources. Talking to others who have taken the path you are now considering may help. Specific information regarding you and a surgery decision should be made by you in conjunction with a bariatric surgeon.

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WHAT IS OBESITY?

Obesity results from the excessive accumulation of fat that exceeds the body's skeletal and physical standards. According to the National Institutes of Health (NIH), an increase in 20 percent or more above your ideal body weight is the point at which excess weight becomes a health risk.¹ Today 97 million Americans, more than one-third of the adult population, are overweight or obese.² An estimated 5 to 10 million of those are considered morbidly obese.³

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WHAT IS MORBID OBESITY?

Obesity becomes "morbid" when it reaches the point of significantly increasing the risk of one or more obesity-related health conditions or serious diseases (also known as co-morbidities) that result either in significant physical disability or even death.⁴ As you read about morbid obesity you may also see the term "clinically severe obesity" used. Both are descriptions of the same condition and can be used interchangeably. Morbid obesity is typically defined as being 100 lbs. or more over ideal body weight or having a Body Mass Index of 40 or higher. ⁵According to the National Institutes of Health Consensus Report, morbid obesity is a serious disease and must be treated as such.⁶ It is a chronic disease, meaning that its symptoms build slowly over an extended period of time.

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CAUSES OF MORBID OBESITY
The reasons for obesity are multiple and complex. Despite conventional wisdom, it is not simply a result of overeating. Research has shown that in many cases a significant, underlying cause of morbid obesity is genetic.⁷ Studies have demonstrated that once the problem is established, efforts such as dieting and exercise programs have a limited ability to provide effective long-term relief.

Science continues to search for answers. But until the disease is better understood, the control of excess weight is something patients must work at for their entire lives. That is why it is very important to understand that all current medical interventions, including weight loss surgery, should not be considered medical cures. Rather they are attempts to reduce the effects of excessive weight and alleviate the serious physical, emotional and social consequences of the disease.

• Contributing Factors
• Genetic Factors
• The Pima Paradox
• Environmental Factors
• Metabolism
• Eating Disorders & Medical Conditions

Contributing Factors
The underlying causes of severe obesity are not known. There are many factors that contribute to the development of obesity including genetic, hereditary, environmental, metabolic and eating disorders. There are also certain medical conditions that may result in obesity like intake of steroids and hypothyroidism.

Genetic Factors
Numerous scientific studies have established that your genes play an important role in your tendency to gain excess weight.

The body weight of adopted children shows no correlation with the body weight of their adoptive parents, who feed them and teach them how to eat. Their weight does have an 80 percent correlation with their genetic parents, whom they have never met.
Identical twins, with the same genes, show a much higher similarity of body weights than do fraternal twins, who have different genes.

Certain groups of people, such as the Pima Indian tribe in Arizona, have a very high incidence of severe obesity. They also have significantly higher rates of diabetes and heart disease than other ethnic groups.

We probably have a number of genes directly related to weight. Just as some genes determine eye color or height, others affect our appetite, our ability to feel full or satisfied, our metabolism, our fat-storing ability, and even our natural activity levels.

The Pima Paradox

The Pima Indians are known in scientific circles as one of the heaviest groups of people in the world. In fact, National Institutes of Health researchers have been studying them for more than 35 years. Some adults weigh more than 500 pounds, and many obese teenagers are suffering from diabetes, the disease most frequently associated with obesity.

But here's a really interesting fact - a group of Pima Indians living in Sierra Madre, Mexico, does not have a problem with obesity and its related diseases. Why not?

The leading theory states that after many generations of living in the desert, often confronting famine, the most successful Pima were those with genes that helped them store as much fat as possible during times when food was available. Now those fat-storing genes work against them.

Though both populations consume a similar number of calories each day, the Mexican Pima still live much like their ancestors did. They put in 23 hours of physical labor each week and eat a traditional diet that's very low in fat. The Arizona Pima live like most other modern Americans, eating a diet consisting of around 40 percent fat and engaging in physical activity for only two hours a week.

The Pima apparently have a genetic predisposition to gain weight. And the environment in which they live - the environment in which most of us live - makes it nearly impossible for the Arizona Pima to maintain a normal, healthy body weight.

Environmental Factors

Environmental and genetic factors are obviously closely intertwined. If you have a genetic predisposition toward obesity, then the modern American lifestyle and environment may make controlling weight more difficult.

Fast food, long days sitting at a desk, and suburban neighborhoods that require cars all magnify hereditary factors such as metabolism and efficient fat storage.

For those suffering from morbid obesity, anything less than a total change in environment usually results in failure to reach and maintain a healthy body weight.

Metabolism

We used to think of weight gain or loss as only a function of calories ingested and then burned. Take in more calories than you burn, gain weight; burn more calories than you ingest, lose weight. But now we know the equation isn't that simple.

Obesity researchers now talk about a theory called the "set point," a sort of thermostat in the brain that makes people resistant to either weight gain or loss. If you try to override the set point by drastically cutting your calorie intake, your brain responds by lowering metabolism and slowing activity. You then gain back any weight you lost.

Eating Disorders and Medical Conditions

Weight loss surgery is not a cure for eating disorders. And there are medical conditions, such as hypothyroidism, that can also cause weight gain. That's why it's important that you work with your doctor to make sure you do not have a condition that should be treated with medication and counseling.

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HEALTH THREATS OF MORBID OBESITY

Morbid obesity brings with it an increased risk for a shorter life expectancy. For individuals whose weight exceeds twice their ideal body weight (that's about 2-6% of the U.S. population),⁸ the risk of an early death is doubled compared to non-obese individuals.⁹ The risk of death from diabetes or heart attack is five to seven times greater.¹⁰ Even beyond the issue of obesity-related health conditions, weight gain alone can lead to a condition known as "end-stage" obesity where, for the most part, no treatment options are available.¹¹ Yet an early death is not the only potential consequence. Social, psychological and economic effects of morbid obesity, however unfair, are real and can be especially devastating. ¹²

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OBESITY RELATED HEALTH CONDITIONS ¹³

Obesity-related health conditions are health conditions that, whether alone or in combination, can significantly reduce your life expectancy. A partial list of some of the more common conditions follows. Your doctor can provide you with a more detailed and complete list:
Type 2 Diabetes. Obese individuals develop a resistance to insulin, which regulates blood sugar levels. Over time, the resulting high blood sugar can cause serious damage to the body.

High blood pressure/Heart disease. Excess body weight strains the ability of the heart to function properly. The resulting hypertension (high blood pressure) can result in strokes, as well as inflict significant heart and kidney damage.

Osteoarthritis of weight-bearing joints. The additional weight placed on joints, particularly knees and hips, results in rapid wear and tear, along with pain caused by inflammation. Similarly, bones and muscles of the back are constantly strained, resulting in disk problems, pain and decreased mobility.

Sleep apnea/Respiratory problems. Fat deposits in the tongue and neck can cause intermittent obstruction of the air passage. Because the obstruction is increased when sleeping on your back, you may find yourself waking frequently to reposition yourself. The resulting loss of sleep often results in daytime drowsiness and headaches.

Gastroesophageal reflux/Heartburn. Acid belongs in the stomach and seldom causes any problem when it stays there. When acid escapes into the esophagus through a weak or overloaded valve at the top of the stomach, the result is called gastroesophageal reflux, and "heartburn" and acid indigestion are common symptoms. Approximately 10-15% of patients with even mild sporadic symptoms of heartburn will develop a condition called Barrett's esophagus, which is a pre-malignant change in the lining membrane of the esophagus, a cause of esophageal cancer. For more information on Heartburn, its causes and possible cures, visit www.heartburnhelp.com.

Depression. Seriously overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, sneers and remarks from strangers. They often experience discrimination at work, cannot fit comfortably in theatre seats, or ride in a bus or plane.

Infertility. The inability or diminished ability to produce offspring.

Urinary stress incontinence. A large, heavy abdomen and relaxation of the pelvic muscles, especially associated with the effects of childbirth, may cause the valve on the urinary bladder to be weakened, leading to leakage of urine with coughing, sneezing, or laughing.

Menstrual irregularities. Morbidly obese individuals often experience disruptions of the menstrual cycle, including interruption of the menstrual cycle, abnormal menstrual flow and increased pain associated with the menstrual cycle.

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OPTIONS FOR TREATMENT

For anyone who has considered a weight loss program, there is certainly no shortage of choices. In fact, to qualify for insurance coverage of weight loss surgery, many insurers require patients to first undergo medically supervised weight loss efforts.

Most non-surgical weight loss programs are based on some combination of diet/behavior modification and regular exercise. Unfortunately, even the most effective interventions have proven to be effective for only a small percentage of patients. It is estimated that less than 5% of individuals who participate in non-surgical weight loss programs will lose a significant amount of weight and maintain that loss for a long period of time.14

According to the National Institutes of Health, more than 90% of all people in these programs regain their weight within one year.15 Sustained weight loss for patients who are morbidly obese is even harder to achieve. Serious health risks have been identified for people who move from diet to diet, subjecting their bodies to a severe and continuing cycle of weight loss and gain known as "yo-yo dieting."

The fact remains that morbid obesity is a complex, multifactorial chronic disease.

For many patients, the risk of death from not having the surgery is greater than the risks from the possible complications of having the procedure.

That is the key reason that in 2000, approximately 40,000 weight loss surgical procedures were performed and why the American Society for Bariatric Surgery estimates that 63,000 weight loss surgical procedures were performed in 2001. Patients who have had the procedure and are benefiting from its results report improvements in their quality of life, social interactions, psychological well-being, employment opportunities and economic condition.

In clinical studies, candidates for the procedure who had multiple obesity-related health conditions questioned whether they could safely have the surgery. These studies show that selection of surgical candidates is based on very strict criteria and surgery is an option for the majority of patients.

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HOW EFFECTIVE IS SURGERY

The actual weight a patient will lose after the procedure is dependent on several factors. These include:

Patient's age
Weight before surgery
Overall condition of patient's health
Surgical procedure
Ability to exercise
Commitment to maintaining dietary guidelines and other follow-up care
Motivation of patient and cooperation of their family, friends and associates

In general, weight loss surgery success is defined as achieving loss of 50% or more of excess body weight and maintaining that level for at least five years.¹⁸ Clinical data will vary for each of the different procedures mentioned on this site. Results may also vary by surgeon. Ask your doctor for the clinical data stating their results of the procedure they are recommending.

Clinical studies show that, following surgery, most patients lose weight rapidly and continue to do so until 18 to 24 months after the procedure. ¹⁹ Patients may lose 30 to 50% of their excess weight in the first six months and 77% of excess weight as early as 12 months after surgery.²⁰ Another study showed that patients can maintain a 50-60% loss of excess weight 10-14 years after surgery.²¹ Patients with higher initial BMIs tend to lose more total weight. Patients with lower initial BMIs will lose a greater percentage of their excess weight and will more likely come closer to their ideal body weight.

Patients with Type 2 Diabetes tend to show less overall excess weight loss than patients without Type 2 Diabetes. The surgery has been found to be effective in improving and controlling many obesity-related health conditions. A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.²² For example, many patients with Type 2 Diabetes, while showing less overall excess weight loss, have demonstrated excellent resolution of their diabetic condition, to the point of having little or no need for continuing medication.²³

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UNDERSTANDING THE GASTROINTESTINAL TRACT²⁴

To better understand how weight loss surgery works, it is important to understand how your gastrointestinal tract functions. As the food you consume moves through the tract, various digestive juices and enzymes are introduced at specific stages that allow absorption of nutrients. Food material that is not absorbed is then prepared for elimination. A simplified description of the gastrointestinal tract appears below. Your doctor can provide a more detailed description to help you better understand how weight loss surgery works.

1. The esophagus is a long muscular tube, which moves food from the mouth to the stomach.
2. The abdomen contains all of the digestive organs.
3. The stomach, situated at the top of the abdomen, normally holds just over 3 pints (about 1500 ml) of food from a single meal. Here the food is mixed with an acid that is produced to assist in digestion. In the stomach, acid and other digestive juices are added to the ingested food to facilitate breakdown of complex proteins, fats and carbohydrates into small, more absorbable units.
4. A valve at the entrance to the stomach from the esophagus allows the food to enter while keeping the acid-laden food from "refluxing" back into the esophagus, causing damage and pain.
5. The pylorus is a small round muscle located at the outlet of the stomach and the entrance to the duodenum (the first section of the small intestine). It closes the stomach outlet while food is being digested into a smaller, more easily absorbed form. When food is properly digested, the pylorus opens and allows the contents of the stomach into the duodenum.
6. The small intestine is about 15 to 20 feet long (4.5 to 6 meters) and is where the majority of the absorption of the nutrients from food takes place. The small intestine is made up of three sections: the duodenum, the jejunum and the ileum.
7. The duodenum is the first section of the small intestine and is where the food is mixed with bile produced by the liver and with other juices from the pancreas. This is where much of the iron and calcium is absorbed.
8. The jejunum is the middle part of the small intestine extending from the duodenum to the ileum; it is responsible for digestion.
9. The last segment of the intestine, the ileum, is where the absorption of fat-soluble vitamins A, D, E and K and other nutrients are absorbed.
10. Another valve separates the small and large intestines to keep bacteria-laden colon contents from coming back into the small intestine.
11. In the large intestines, excess fluids are absorbed and a firm stool is formed. The colon may absorb protein, when necessary.

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HOW WEIGHT LOSS SURGERY WORKS

Surgeons first began to recognize the potential for surgical weight loss while performing operations that required the removal of large segments of a patient's stomach and intestine. After the surgery, doctors noticed that in many cases patients were unable to maintain their pre-surgical weight. With further study, surgeons were able to recommend similar modifications that could be safely used to produce weight loss in morbidly obese patients. Over the last decade these procedures have been continually refined in order to improve results and minimize risks. Today's bariatric surgeons have access to a substantial body of clinical data to help them determine which surgeries should be used and why.
Today, the American Society for Bariatric Surgery describes two basic approaches that weight loss surgery takes to achieve change:²⁵

1. Restrictive procedures that decrease food intake.
2. Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.

Restrictive Procedures
The theory is simple. When you feel full, you are more likely to have reduced feelings of hunger and will no longer feel deprived. The result is that you are likely to eat less. Restrictive weight loss surgery works by reducing the amount of food consumed at one time. It does not, however, interfere with the normal absorption (digestion) of food. In a restrictive procedure, the surgeon creates a smaller upper stomach pouch. The pouch connects to the rest of the stomach through an outlet known as a "stoma." In a cooperative and compliant patient, the reduced stomach capacity, along with behavioral changes, can result in consistently lower caloric intake and consistent weight loss.

During recovery, patients must adhere to the strict specific dietary guidelines and restrictions their surgeon prescribes. While these guidelines may vary from one surgeon to the next, it is important for each patient to follow the surgeon's guidelines. When the time comes to resume eating "regular" food, the patient must learn to adapt to a new way of eating. At each meal, they are restricted to consuming approximately 1/2 to a full cup of food before feeling uncomfortably full. Patients who see the best results from a restrictive procedure are those who learn to eat slowly, eat less, and avoid drinking too many fluids, particularly carbonated beverages. If the patient fails to follow these guidelines, they can stretch the stomach pouch and/or the stoma outlet and defeat the purpose of the surgery. The effectiveness of a restrictive procedure is reduced by constant snacking or by drinking high-calorie, high-fat liquids. Failure to achieve the expected level of weight loss is usually the result of a patient failing to comply with the recommended dietary and behavior modifications, such as increased exercise and regular support group attendance.

Malabsorptive Procedures that Alter Digestion
It can be said that some of the restrictive approaches discussed above have not always achieved the excess weight loss surgeons and patients anticipated. For this reason, procedures that alter digestion, known as malabsorptive procedures, were developed to work in conjunction with restrictive approaches. Some of these techniques involve a bypass of the small intestine, thus limiting the absorption of calories. On balance, malabsorptive or malabsorptive/restrictive procedures have resulted in an overall increase in the loss of excess weight. The risk of complications and side effects generally increases with the lengthening of the small intestine bypass. You and your surgeon must determine the risks and benefits over your lifetime with the type of weight loss surgery you choose.

Basically, weight loss operations fall into three categories:

• Restrictive procedures make the stomach smaller to limit the amount of food intake.
• Malabsorptive techniques reduce the amount of intestine that comes in contact with food so that the body absorbs fewer calories.
• Combination operations take advantage of both restriction and malabsorption.

1. Thomas, Paul, ed. Weighing the Options: Criteria for Evaluating Weight Management Programs. Washington, D.C.: National Academy Press, 1995.
2. National Institutes of Health. "Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults." [Online] June 1998.
3. American Society for Bariatric Surgery.Surgery for Morbid Obesity: What Patients Should Know. Toronto: FD-Communications Inc.,2000.
4. National Institutes of Health. "Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement." [Online] 25-27 March 1991.
5. American College of Surgeons. Recommendations for facilities performing bariatric surgery. Bull Am Coll of Surg Sept 2000; 85(9) 20-3.
6. National Institutes of Health. "Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement." [Online] 25-27 March 1991.
7. American Society for Bariatric Surgery. "Rationale for the Surgical Treatment of Morbid Obesity." [Online] 8 April 1998.
8. Balsiger BM, Kennedy FP, Abu-Lebdeh HS, et al. Prospective evaluation of roux-en-y gastric bypass as primary operation for medically complicated obesity. Mayo Clinic Proc 2000 July; 75 (7): 673-80.
9. American Society for Bariatric Surgery. "Rationale for the Surgical Treatment of Morbid Obesity." [Online] 8 April 1998.
10. National Institutes of Health. "Gastric Surgery for Severe Obesity." [Online] 20 February 1998.
11. American Society for Bariatric Surgery.Surgery for Morbid Obesity: What Patients Should Know. Toronto: FD-Communications Inc.,2000.
12. American Society for Bariatric Surgery. "Rationale for the Surgical Treatment of Morbid Obesity." [Online] 8 April 1998.
13. American Society for Bariatric Surgery.Surgery for Morbid Obesity: What Patients Should Know. Toronto: FD-Communications Inc.,2000.
14. National Institutes of Health. "Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement." [Online] 25-27 March 1991.
15. National Institutes of Health. "Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults." [Online] June 1998.
16. National Institutes of Health. "Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults." [Online] June 1998.
17. Wittgrove AC, Clark GW. Laparoscopic gastric bypass roux-en-y--500 patients: technique and results with 3-60 month follow-up. Obes Surg 2000 Jun; 10(3): 233-9.
18. National Institutes of Health. "Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement." [Online] 25-27 March 1991.
19. American Society for Bariatric Surgery. "Rationale for the Surgical Treatment of Morbid Obesity." [Online] 8 April 1998.
20. Wittgrove AC, Clark GW. Laparoscopic gastric bypass roux-en-y--500 patients: technique and results with 3-60 month follow-up. Obes Surg 2000 Jun; 10(3): 233-9.
21. Pories WJ, Swanson MS, MacDonald KG et al. Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus. Ann of Surg 1995; 222(3): 339-53.
22. Wittgrove AC, Clark GW. Laparoscopic gastric bypass roux-en-y--500 patients: technique and results with 3-60 month follow-up. Obes Surg 2000 Jun; 10(3): 233-9.
23. Pories WJ, Swanson MS, MacDonald KG et al. Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus. Ann of Surg 1995; 222(3): 339-53.
24. American Society for Bariatric Surgery.Surgery for Morbid Obesity: What Patients Should Know. Toronto: FD-Communications Inc.,2000.

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RISKS OF SURGERY

Surgery should not be considered until you and your doctor have evaluated all other options. As with all surgeries, there are risks associated with this procedure. If complications occur during the operation, your doctor may choose to perform open surgery. Your doctor must determine if you are an appropriate surgical candidate.

Indication
Weight loss surgery is typically reserved for those individuals 100 pounds or more overweight (Body Mass Index [BMI] of 40 or higher) who have not responded to other less invasive therapies such as diet, exercise, medications, etc.

In certain circumstances, less morbidly obese patients (with BMIs between 35 and 40) may be considered for surgery (patients with high-risk co-morbid conditions and obesity-induced physical problems that are interfering with quality of life).

Important Considerations
Surgery should not be considered until you and your doctor have evaluated all other options. The proper approach to weight-loss surgery requires discussion and careful consideration of the following with your doctor:

1. These procedures are in no way to be considered as cosmetic surgery.
2. The surgery does not involve the removal of adipose tissue (fat) by suction or excision.
3. A decision to elect surgical treatment requires an assessment of the risk and benefit to the patient and the meticulous performance of the appropriate surgical procedure.
4. These weight loss surgical procedures (approved in the United States) are not reversible.
5. The success of weight loss surgery is dependent upon long-term lifestyle changes in diet and exercise.
6. Problems may arise after surgery that may require reoperations.

Success of surgical treatment must begin with realistic goals and progress through the best possible use of well-designed and tested operations.

Complications and Risks
As with any surgery, there are operative and long-term complications and risks associated with weight loss surgical procedures that should be discussed with your doctor. Possible risks include, but are not limited to:

QUESTIONS FOR YOUR SURGEON

Being a well-informed patient is good for you and good for your doctor. Here are some of the questions you should ask before deciding on a bariatric surgeon:

What types of weight loss surgery procedures have you performed?
How many of each procedure have you performed?
Can this surgery be performed using minimally invasive techniques?
Can I be considered a candidate for surgery even though I have one or more associated health conditions related to my obesity?
Which procedure is best for me? Why? What are the risks involved?
How long will I be in surgery?
What is the length of my anticipated hospital stay?
How long will it be before I can return to pre-surgery levels of activity?
How will my eating habits change?
Do you have information about surgery costs and payment options?
What is the typical excess weight loss and improvement of associated health conditions for your other patients?
Do you have patients who are willing to share their experiences, both positive and negative?
What information can you give me to help family and friends better understand this surgery?
What type of long-term, after-care services (such as support groups and counseling) can you provide for me?
What do you expect from me if I decide to choose a surgical solution?
For more examples of questions to ask your surgeon, visit the American Society for Bariatric Surgery Web site at www.asbs.org.

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MAKING YOUR DECISION

Weight loss surgery is major surgery. Although most patients enjoy an improvement in obesity-related health conditions (such as mobility, self-image and self-esteem) after the successful results of weight loss surgery, these results should not be the overriding motivation for having the procedure. The goal is to live better, healthier and longer.

That is why you should make the decision to have weight loss surgery only after careful consideration and consultation with an experienced bariatric surgeon or a knowledgeable family physician. A qualified surgeon should answer your questions clearly and explain the exact details of the procedure, the extent of the recovery period and the reality of the follow-up care that will be required. They may, as part of routine evaluation for weight loss surgery, require that you consult with a dietician/nutritionist and a psychiatrist/therapist. This is to help establish a clear understanding of the post-operative changes in behavior that are essential for long-term success.

It is important to remember that there are no ironclad guarantees in any kind of medicine or surgery. There can be unexpected outcomes in even the simplest procedures. What can be said, however, is that weight loss surgery will only succeed when the patient makes a lifelong commitment. Some of the challenges facing a person after weight loss surgery can be unexpected. Lifestyle changes can strain relationships within families and between married couples. To help patients achieve their goals and deal with the changes surgery and weight loss can bring, most bariatric surgeons offer follow-up care that includes support groups, dieticians and other forms of continuing education.

Ultimately, the decision to have the procedure is entirely up to you. After having heard all the information, you must decide if the benefits outweigh the side effects and potential complications. This surgery is only a tool. Your ultimate success depends on strict adherence to the recommended dietary, exercise and lifestyle changes.

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LIFE AFTER SURGERY

• Diet
• Going Back to Work
• Birth Control and Pregnancy
• Long-Term Follow-Up
• Support Groups

Diet

The modifications made to your gastrointestinal tract will require permanent changes in your eating habits that must be adhered to for successful weight loss. Post-surgery dietary guidelines will vary by surgeon. You may hear of other patients who are given different guidelines following their weight loss surgery. It is important to remember that every surgeon does not perform the exact same weight loss surgery procedure and that the dietary guidelines will be different for each surgeon and each type of procedure. What is most important is that you adhere strictly to your surgeon's recommended guidelines. The following are some of the generally accepted dietary guidelines a weight loss surgery patient may encounter:

• When you start eating solid food it is essential that you chew thoroughly. You will not be able to eat steaks or other chunks of meat if they are not ground or chewed thoroughly.
• Don't drink fluids while eating. They will make you feel full before you have consumed enough food.
• Omit desserts and other items with sugar listed as one of the first three ingredients.
• Omit carbonated drinks, high-calorie nutritional supplements, milk shakes, high-fat foods and foods with high fiber content.
• Avoid alcohol.
• Limit snacking between meals.

Going Back to Work

Your ability to resume pre-surgery levels of activity will vary according to your physical condition, the nature of the activity and the type of weight loss surgery you had. Many patients return to full pre-surgery levels of activity within six weeks of their procedure. Patients who have had a minimally invasive laparoscopic procedure may be able to return to these activities within a few weeks.

Birth Control & Pregnancy
It is strongly advised that women of childbearing age use the most effective forms of birth control during the first 16 to 24 months after weight loss surgery. The added demands pregnancy places on your body and the potential for fetal damage make this a most important requirement.

Long-Term Follow-Up
Although the short-term effects of weight loss surgery are well understood, there are still questions to be answered about the long-term effects on nutrition and body systems. Nutritional deficiencies that occur over the course of many years will need to be studied. Over time, you will need periodic checks for anemia (low red blood cell count) and Vitamin B12, folate and iron levels. Follow-up tests will initially be conducted every three to six months or as needed, and then every one to two years WHICH IS WHY IT IS SO IMPORTANT TO HAVE YOUR PRIMARY CARE PHYSICIAN INVOLVED IN YOUR DECISION TO HAVE SURGERY.

Support Groups
The widespread use of support groups has provided weight loss surgery patients an excellent opportunity to discuss their various personal and professional issues. Most learn, for example, that weight loss surgery will not immediately resolve existing emotional issues or heal the years of damage that morbid obesity might have inflicted on their emotional well-being. Most surgeons have support groups in place to assist you with short-term and long-term questions and needs. Most bariatric surgeons who frequently perform weight loss surgery will tell you that ongoing post-surgical support helps produce the greatest level of success for their patients.

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INSURANCE OPTIONS

At some point, after you have spent a considerable amount of time exploring the option of weight loss surgery, you will need to determine how to pay for the procedure. A growing number of states have passed legislation that requires insurance companies to provide benefits for weight loss surgery for patients that meet the National Institutes of Health surgical criteria. And while insurance coverage for weight loss surgery is widespread, it often requires a lengthy and complicated approval process.

Here are some of the key steps you should take to obtain insurance coverage for weight loss surgery:

• Read and understand the "certificate of coverage" that your insurance company is required by law to give you. If you do not have one, consult your company's benefits administrator or ask your insurance company directly.
• Your primary care physician may be the only one you can ask for a referral to a qualified bariatric surgeon. Even if you are not required to get a referral, the support of your primary care physician is essential.
• Organize your medical records, including your history of dieting efforts, visits to a healthcare professional for obesity-related issues or visits to supervised weight loss programs. Document "other" weight loss attempts made through diet centers and fitness club memberships.
• If your surgeon recommends weight loss surgery, he or she will prepare a letter to obtain pre-authorization from your insurance company.

The Appeals Process
If your initial request for pre-authorization is not approved, insurers provide an appeal process that allows you to address specific reasons for denying your request. It is important that you reply quickly. It is also recommended that you enlist the help of an experienced insurance advocate.

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OBESITY MAP

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DIABETES

The number of Americans with diabetes has reached 17 million - a jump of more than a million in two years - and health officials Wednesday urged physicians to start treating the debilitating disease earlier.

Officials of federal health agencies and the American Diabetes Association recommended guidelines that advise routine diabetes screening for men and women age 45 and older, especially if they are overweight.

Those who have levels of blood sugar that are higher than normal but fall short of full-blown diabetes will be considered to have "prediabetes," a new term for what used to be called impaired glucose tolerance, or impaired fasting glucose, experts say.

An estimated 90% to 95% of diabetics have type 2 diabetes, which generally occurs during middle age and is associated with obesity and inactivity, both of which impair the body's ability to produce or efficiently use insulin. Type 1 is caused by an inability to produce insulin and generally is diagnosed in adolescence or the early 20s.

"People who develop regular type 2 diabetes don't go from normal sugars to type 2," says Frank Vinicor, director of the diabetes program for the Centers for Disease Control and Prevention. "They almost all go through this phase, called impaired glucose tolerance."

Fortunately, he says, studies in Europe and the USA have determined that if patients in the prediabetic stage make lifestyle changes - exercising regularly and losing 5% to 7% of their body weight - they can decrease their chance of developing diabetes by 58%.

Diabetes is on the rise in all age groups, but what causes most alarm among doctors is that they are finding type 2 diabetes in teenagers and young adults, particularly among racial and ethnic minorities.

"The main concern is that you're going to see more people with a longer duration of diabetes," Vinicor says. "It used to be one rarely saw type 2 diabetes except in people over 40, so maybe they had 30 years of high blood sugar and high blood pressure and the associated complications. Now, if someone is only 15 and gets it, you're likely to see 50 to 60 years of type 2 diabetes."

What was once "a disease of our grandparents is now a disease of young adults and teenagers," says Francine Kaufman, a pediatric endocrinologist at Children's Hospital in Los Angeles. "And it's pretty much all due to the life we all live."

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OBESITY STATS

Over a Third of the Adult U.S. Population is Obese

As Americans are gaining weight in record amounts, they are shunning dieting and becoming increasingly sedentary. And the results are very disturbing: according to government statistics, unhealthy weight has increased at record levels since 1980, with upsurges occurring in both men and women, all racial groups, and across the age levels. For this reason, today over a third of the adult U.S. population -- 32 million women and 26 million men -- are classified as overweight or obese. Further, government surveys show that more Americans are getting fatter with each ten-year increment up until age 60.

X-FACTOR Survey

The X-FACTOR survey was conducted by Louis Harris and Associates, using a nationally representative sample of 2000 overweight Americans who were interviewed by telephone between February 21 and March 6, 1997. In this poll of overweight adults, 69 percent were classified as having a BMI in the 25-29 range; 21 percent had a BMI of 30-34, and 10 percent had a BMI of 35 and above. Of the total number of respondents, 57 percent were men and 43 percent were women. More on the results of this survey follow:

Most overweight Americans are not currently "dieting".

—Three-quarters of overweight and obese American adults (78 percent) are not currently on a diet to lose weight.
— This anti-diet sentiment reflects a lack of understanding about the relationship between obesity and poor health. Accordingly, almost half (46 percent) of the very high risk respondents reported being in "fair or poor health."
—Even among very high risk individuals, only 37 percent said they were dieting to lose weight. While one in four (28 percent) high risk adults are on a diet, less than one in five (18 percent) people with a moderate risk are taking any action.
—Overweight and obese women (30 percent) are twice as likely as overweight and obese men (13 percent) to be dieting currently.

Most overweight Americans understand that they should reduce dietary fat, even if they don't know how to put this recommendation into practice.

— Two-thirds of overweight adults (67 percent) recognize the causal relationship between limiting fat intake and good health.
—Among the 22 percent of respondents who said they were currently dieting, the practice of limiting fat intake is favored even more than limiting calories. Of this group, 89 percent reported trying to limit the fat in their diets while only 71 percent said they were trying to restrict calories.
—Fat consciousness persists even after people have stopped dieting. Among the former dieters in the study, 67 percent reported continuing to limit fat intake while only 38 percent continued to control their calories.

In contrast, very few overweight Americans recognize that controlling calories is a fundamental health enhancing strategy.

— Less than half of overweight and obese adults (42 percent) try to limit their intake of calories, although this is an essential element in weight management.
—This situation exists across the board among overweight individuals, regardless of educational attainment. While 40 percent of those with less than a high school education are counting calories, 42 percent of high school graduates, 41 percent of those who had some college education, and 43 percent of college graduates practice this weight control technique.

A strikingly high number of overweight adults with a poor or fair health status are trying to control their fat intake.

— Limiting fat intake has been correctly identified as a health enhancing strategy, and overweight adults with health problems are actively trying to embrace this strategy. According to the survey, seven in 10 (69 percent) overweight adults with a fair or poor health status limit their fat intake. In contrast, only 45 percent of these individuals are trying to control calories because the excess calorie/health link is much less understood.

Overweight and obese adults are not encouraged to lose weight by their doctors -- though women are more likely than men to receive such counsel.

—Only three in ten overweight and obese adults (30 percent) report that a doctor has encouraged them to diet for health reasons; seven in ten (70 percent) have not received such counsel.
—Overweight and obese women (39 percent) are considerably more likely than overweight and obese men (23 percent) to indicate that a physician advised them to lose weight.

Obesity levels rise as education levels drop It is well known that as income increases, obesity rates drop but the XFACTOR Survey is one of the few studies which links education levels with obesity. The relationship between these factors is evidenced by these new findings:

—Overweight Americans with less education are the most likely to report themselves as being in "fair" or "poor" health. While 39 percent of respondents with less than a high school education put themselves into the poor or fair health category, the amount drops to 29 percent among high school graduates, 22 percent for those with some college education, and to 17 percent among college graduates.
—The least educated are also the ones most likely to be told by their doctors to lose weight for health reasons. One in three (36 percent) of overweight adults who did not complete high school got this recommendation compared to 28 percent of high school graduates and 29 percent of college grads.
— The least educated are also the least likely to enroll in a weight loss plan. Only about one in ten (13 percent) high school drop outs will take this step compared with almost one in four (23 percent) college grads.

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SURGICAL PROCEDURES

The Laparoscopic Approach for Severe Obesity

Roux-en-Y Gastric Bypass (RNY)

Morbid obesity is a complex, medical disease, which affects more than nine million people in the United States. It is not a moral problem due to a lack of will power. Studies have shown that diets, medications, behavioral modification or exercise programs have a 95% failure rate in this population, due to underlying physiologic, chemical and genetic factors.

Morbidly obese patients have a very high risk of associated health problems and early death. The National Institutes of Health (NIH) has endorsed Roux-en-Y and Gastric Bypass (RNY) as an acceptable choice for weight loss surgery. Depending on the circumstances, RNY can be accomplished by an open or laparoscopic technique.

Surgery is an aid to dieting and assists individuals alter their eating habits by restricting food intake or limiting absorption of ingested food.

The surgical procedure for weight loss we offer is Roux-en-Y Gastric Bypass (RNY). This procedure assists a patient in reducing food and caloric intake. All weight loss procedures are associated with medical risks and vary in the anticipated chance of success in losing weight.

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THE LAPAROSCOPIC APPROACH FOR SEVERE OBESITY
Laparoscopic operations are performed through several small incisions with the aide of a fiberoptic video camera and special instruments which can reduce the trauma and discomfort associated with a long open incision. Hospitalization, post-op pain, and recovery time is usually reduced compared to traditional surgery. Laparoscopic obesity operations have only been performed since 1993. Therefore the American Society of Bariatric Surgeons recommends choosing a surgeon who is experienced in both laparoscopic and open bariatric operations, and who understands the complexities of surgical treatment of obesity.

This is a general overview of our approach to laparoscopic management of severe obesity. A personal consultation can be arranged to determine if you are a candidate. More specific descriptions of each surgery follow:

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Roux-en-Y Gastric Bypass (RNY)
Roux-en-Y Gastric Bypass (RNY) is a more complex operation. The small upper pouch (1-2 ounce) is completely separated from the distal stomach which is left in place. A "Y" shaped segment of small bowel is attached to the pouch with a narrow opening. This delays the mixing of food and digestive juices from the distal stomach resulting in poorer absorption of calories and nutrients. This both restricts food intake and interferes with absorption resulting in more consistent weight loss, but has a higher risk of complications or side effects. 80% of patients lose at least half their excess weight with the RNY procedure.

The RNY averages a 3-day hospitalization with a return to full activity in 7-10 days. A liquid protein and soft diet is suggested for 3 weeks post op.

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QUESTIONS FOR YOUR DOCTOR

You should work with your doctor to document your weight loss attempts, including all previous weight loss programs or efforts in which you have participated. You should also carefully record any obesity-related health conditions you suffer from and if they are getting worse. Are you continuing to sleep poorly? Are you having more and more trouble walking? How high is your blood pressure compared to two or three years ago?

These records will help you decide if weight loss surgery is an option for you. They will also help provide the health history for your physician and as required by your insurance company.

Other questions to ask your doctor:

How would I benefit from weight loss?
What are my best options now?
Am I a candidate for weight loss surgery?
What are the next steps I should take?
Can you refer me to a bariatric surgeon?
What should I look for in a bariatric surgeon?

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THE HISTORY OF SURGICAL TREATMENT FOR OBESITY

The concept for bariatric surgery, or the surgical treatment of obesity, came about somewhat serendipitously. In the course of removing large portions of the stomach or small intestine in patients with cancer or severe ulcers, surgeons noticed an interesting trend. The patients tended to lose weight.

Over the past 50 years, numerous world-class surgeons have taken part in exploring this concept. As with anything, there was a learning curve. But the mistakes and shared global data have helped other innovators to improve upon the techniques and bring bariatric surgery into the modern age.

The procedures available today have either stood the test of time or drawn from the lessons learned by the early pioneers. As a result, the surgical treatment for obesity has never been as safe or as effective.

The Jejuno-Ileal Bypass (JIB)

According to the American Society of Bariatric Surgery, the first report of a procedure designed to induce weight loss was published in 1954.1 Two surgeons by the name of Kremen and Linner described a procedure which involved connecting the upper part of the small intestine to the lower part of the small intestine. Essentially, this meant that food would "bypass" a large amount of the small intestine, including sections called the jejunum and the ileum. Patients could eat as much as they wanted, but only a small amount of the calories and nutrients would be absorbed by the body. The jejuno-ileal bypass (JIB), as it was called, pioneered the concept of malabsorption. Shortening the nutrient absorptive circuit remains the most powerful bariatric technique used today.

Unfortunately, the JIB can also be blamed for the negative or fearful attitude some people still have towards weight loss surgery. By the late 1960s and early 1970s, the procedure had become quite popular in the United States due to the dramatic and sustained weight loss it produced. But after long-term data accumulated, physicians discovered that it carried several distressing and even life-threatening complications. Patients regularly experienced diarrhea, electrolyte imbalances, anemia, vitamin deficiencies, malnutrition, gallstones, and a number of other adverse effects. But more frighteningly, some patients developed severe kidney and liver failure, leading to a number of deaths. As a result of its high risk, the JIB procedure was abandoned in favor of safer techniques. The procedure is no longer performed in the United States.

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The Biliopancreatic Diversion (BPD)

By the late 1970s, surgeons had learned from the JIB experience and gained an idea of what not to do. The next major bariatric procedure to emerge came out of Italy in 1976. Dr. Nicola Scopinaro of the University of Genoa revised the JIB procedure so that most of the small intestine remained intact, thus reducing the chances of liver or kidney problems.

To achieve maximum weight loss, Scopinaro's procedure used two components instead of one. First, approximately 2/3 of the stomach was removed to moderately restrict the amount of food that can be consumed at one time. Then the outlet to the stomach was connected to the final segment of the small intestine. By diverting food through this new "limb," the nutrients were effectively separated from the bile and pancreatic enzymes that would break them down. As a result, BPD greatly reduced nutrient absorption and caloric intake.

The first to combine the restriction of food intake and malabsorption, BPD is also the first procedure to remain in usage (albeit limited) more than two decades after its advent. In 1996, Scopinaro reported that after 18 years of follow-up, his patients maintained an excess weight loss of 72%.2 According to the American Society of Bariatric Surgery, BPD has yielded the best long-term results published to date.1

The BPD is also unique because it is the only current procedure that allows you to eat normal quantities of food and still achieve excellent weight loss. But there's a catch. The procedure still carries some of the malabsorptive complications of JIB, including loose stools, malodorous gas, and serious deficiencies in protein and minerals such as calcium. BPD patients must take vitamin supplements for the rest of their lives to avoid malnutrition and bone demineralization.

In 1993, a group of Canadian doctors published the first results of a modification of the BPD procedure known as the biliopancreatic diversion with duodenal switch (BPDDS).3 The BPDDS preserves the pyloric valve that connects the stomach to the beginning portion of the small intestine. In addition, physicians increase the length of the small intestine left intact. As a result of these adjustments, this variant reportedly carries fewer complications but with comparable or greater weight loss.

Nonetheless, BPD is the still the most complicated and extreme bariatric procedure in use. While it produces profound weight loss, it also carries a high risk of nutritional and metabolic problems. This led researchers to continue searching for an even safer approach. Presently, the BPD remains in use, especially in Europe, but is less popular in than some of the newer procedures available in the United States.

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Gastroplasty

The science of "stapling" surgeries originated in World War II. To provide a rapid method of dealing with injuries sustained on the battlefield, the Russians developed surgical instruments which could staple body tissue together. Later, these instruments were refined into what's used today.

Gastroplasty, or "stomach stapling," represented the next wave of weight loss surgery in the early 1980s. Surgeons could now reduce the volume of the stomach without removing any portion of it. Instead, a staple line would hold the stomach tissue together to create a new wall. Three staples would be removed from the center of the line, however, to allow for a narrow passageway into the lower stomach.

As a result, patients became full after eating only small amounts of food, due to the reduced stomach size and slower passage of food through the new, narrow stomach outlet, or stoma. Those who had early gastroplasty—called horizontal gastroplasty—lost weight over the first few months, but at a certain point, doctors observed that they stopped losing weight or even regained weight. Doctors quickly determined that the stoma was stretching out over time in many patients.

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Gastric Bypass (aka Roux-en-Y)

While restrictive procedures could reduce stomach capacity temporarily, they couldn't always prevent the stoma from stretching out over time. The question for researchers became: how do we help patients maintain the weight loss?

Surgeons returned to the concept of malabsorption. As the BPD had proven, restricting the absorption of nutrients and calories provided lasting weight control, despite stomach pouch expansion. But many doctors and patients hesitated about BPD, given the potential for serious nutritional complications. The perfect middle-ground seemed to be another hybrid procedure combining restriction and malabsorption called the gastric bypass, developed by Dr. Edward Mason all the way back in 1966.

It's an interesting sidebar to note that Dr. Mason is the only surgeon to devise two different and well-received procedures for the treatment of obesity. Considered the "Father of Bariatric Surgery," he also founded the American Society for Bariatric Surgery (ASBS) in 1976.

An important step in the growth of gastric bypass surgery came in 1993, when private practitioners Dr. Alan Wittgrove and Dr. Wesley Clark of San Diego, California, co-developed a less-invasive, laparoscopic method of performing the procedure. Instead of making one large incision in the abdomen, they made several small incisions and operated remotely using long, slender instruments and a narrow-shafted camera to visualize the operative field. Patients experienced less pain and scarring, and the overall hospital stay and recovery time were shortened. Today, about half of all patients meet the criteria for the laparoscopic approach.

In the search for permanent, profound weight loss, the recent data on gastric bypass has placed it at the forefront. In 2000, Drs. Wittgrove and Clark reported their results with laparoscopic gastric bypass in 500 patients.9 After one year, the average excess body weight lost was 77%. This loss persisted over time, as 62% of patients maintained a weight loss of 75% or more of excess body weight. In addition, co-morbidities such as diabetes, hypertension, and sleep apnea were reduced overall by 96%.

Although the procedure now reflects decades of refinement, numerous variations of gastric bypass still exist. There is no international standardization yet for the size of the stoma, the volume of the stomach pouch, the length of the Y-shaped limb, or the attachment sites of the Y-shaped limb. In this sense, gastric bypass procedure has room for even further improvements. Surgeons with the best techniques and modifications will obviously return the best results, but it takes some time for that information to reach and influence other medical institutions around the globe.

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Adjustable Gastric Banding

In the early 1990s, bariatric surgeons in Europe and Scandinavia were in the early stages of investigating another procedure that would eventually become the least invasive and traumatic bariatric surgery to date. For the first time, surgeons explored the idea of implanting a restrictive device instead of cutting or stapling the stomach to reduce its capacity.

The first device of this kind was the Swedish Adjustable Gastric Band (SAGB), patented in 1985 by Obtech Medical in Sweden. Essentially, a silicone band was placed around the upper stomach to create a tiny stomach pouch. The procedure restricted food intake by producing an earlier feeling of fullness. The new stomach outlet wasn't as susceptible to stretching, and the patient could have the band removed (thus reversing the procedure) if desired.

The earliest versions of the SAGB required open surgery and carried some problems. In addition, the weight loss results were not as good as the prevalent restrictive procedure. But the gastric banding concept soon regained momentum thanks to a modified version that surfaced in 1990 and included an inflatable balloon on the inner surface of the band. Tubing connected the balloon to a reservoir of liquid positioned beneath the skin. Using a needle, physicians could add or withdraw liquid to adjust the size of the band and, consequently, the rate of weight loss.

With the unique attributes of reversibility and adjustability, the gastric banding concept garnered even more interest. An American company, INAMED Health (Santa Barbara, CA), with 25 years of silicone manufacturing expertise, designed a next-generation version called the BioEnterics® LAP-BAND® Adjustable Gastric Banding System that could be implanted laparoscopically. The new design included multiple sized bands and accessories. As a result, the procedure became more accessible and patient-friendly due to its minimal invasiveness and shortened recovery. Patients could potentially stay just one night in the hospital and be home the following day.

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In Summary

Bariatric patients have more choices than ever. Studies indicate that operative mortality for most contemporary weight loss surgeries has fallen to less than 1% while permanent and significant weight loss has been achieved according to multiple published reports. For the growing population of morbidly obese Americans, bariatric surgery is the most effective, long-term weight loss treatment available.

References

1. MacGregor, Alex, Ed. The Story of Surgery for Obesity. American Society of Bariatric Surgeons (ASBS). 2002 Amendment. Accessed June 20, 2002.
2. Scopinaro N et al. Biliopancreatic diversion for obesity at eighteen years. Surgery 1996 Mar;119(3):261-8.
3. Mason EE. Vertical banded gastroplasty for obesity. Arch Surg 1982 May;117(5):701-6.
4. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am 1967 Dec;47(6):1345-51.
5. Mason EE et al. Gastric bypass for obesity after ten years experience. Int J Obes 1978;2(2):197-206.
6. Mason EE. Why the Operation I Prefer is Vertical Banded Gastroplasty 5.0. Obes Surg 1991 Jun;1(2):181-183.
7. Wittgrove AC, Clark GW. Laparoscopic Gastric Bypass, Roux-en-Y-500 patients. Technique and results with 3-60 month follow-up. Obes Surg 10, 2000: 233-239.
8. O'Brien PE et al. Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity. Br J Surg 1999 Jan; 86(1): 113-8.
9. Dargent J. Laparoscopic adjustable gastric banding: lessons from the first 500 patients in a single institution. Obes Surg 1999 Oct; 9 (5): 446-52.
10. Rubenstein R. Laparoscopic adjustable gastric banding at a U.S. center with up to 3-year follow-up. Obes Surg 2002, 12, 380-384.

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NON-OPERATIVE TREATMENT

Published scientific reports document that non-operative methods alone have not been effective in achieving a medically significant long term weight loss in severely obese adults. It has been shown that the majority of patients regain all the weight lost over the next five years.[45, 46] The average medical weight reduction trial is a 10-12 week study with average weight loss of 2.5 kg [47] The use of anorectic medications has recently been advocated as a long term therapeutic modality in management of what is clearly a chronic disease. In a nearly four year study, utilizing a two drug regimen of Phentermine and Fenfluramine, behavior modification, diet and exercise, the initial optimistic results have not been sustained, with a one third drop out rate and a final average weight loss of only three pounds in those who were followed for the four years of the study.[48] This drug combination appears to have an unacceptably high association with cardiac valvular disease and has been withdrawn from therapeutic use because of these potentially life threatening sequelae. Dietary weight loss attempts often cause depression, anxiety, irritability, weakness and preoccupation with food [49]. The treatment goal for morbid obesity should be an improvement in health achieved by a durable weight loss that reduces life threatening risk factors and improves performance of activities of daily living. Temporary fluctuations of body weight from calorie restricted diets should be avoided.

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PREPARATION FOR SURGERY
Weight loss surgery is like other major surgeries. The best preparation is to understand the risks and potential benefits and to closely follow your doctor's instructions.

To mentally prepare yourself:

• Understand the surgical process and what to expect afterwards.
• Talk to people who have had weight loss surgery.
• Write a letter to yourself and your surgeon explaining your reasons for having the surgery and outlining your plans to maintain your weight loss after surgery.
• Start a journal about your experience. Record how you feel now, the obstacles you encounter, the things you hope to be able to do after surgery.
• Get a letter of support from your family. It helps to know you have people behind you, waiting to help.

To physically prepare yourself, strictly follow your doctor's guidelines. These usually include, but are not limited to:

• Restricting yourself to a clear liquid diet 12-24 hours before surgery.
• Stop smoking for at least a month before surgery.
• Be certain to follow your surgeon's instructions regarding any medications you may be taking to control other health conditions.
• Arrive on time, with supplies from home for a three- to four-day hospital stay. If you use special equipment for sleep apnea, you should bring your machine to the hospital.

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GLOSSARY

Absorption—Process by which digested food is absorbed by the lower part of the small intestine into the bloodstream.

Adipose—Fatty; pertaining to fat

Anastomosis—Surgical connection between two structures

Bariatric—Pertaining to Weight or weight reduction

BMI—Body Mass Index—Method of calculating degree of excess weight. Based on weight and body surface area.

Cardiovascular—Pertaining to heart and blood vessels

Clinically Severe Obesity—Body Mass Index of 40 or more, which is roughly equivalent to 100 pounds or more over ideal body weight; a weight level that is life risking. Also known as Morbid Obesity.

Co-Morbid—Associated illness (i.e., arthritis, hypertension) disabling conditions associated with clinically severe obesity or obesity-related health conditions.

Colon—Large intestine beginning at the end of the small intestine and ending at the rectum.

Contraindications—Any symptom or circumstance indicating the inappropriateness of an otherwise advisable treatment (i.e., alcoholism; drug dependency; severe depression; sociopathic (antisocial) personality disorder)

Criteria—Defines potential candidate for surgery

Digestion—Process by which food is broken down by stomach and upper small intestine into absorbable forms

Dilation—Process of enlarging a passage or anastomosis

Disease—Process injurious to health and/or longevity

Divided Gastric Bypass—Operation providing a tool for management of clinically severe obesity.

Dumping Syndrome—Uncomfortable feeling of nausea, lightheadedness, upset stomach, diarrhea, associated with ingestion of sweets, high-calorie liquids or dairy products.

Duodenum—First 12" of small intestine immediately below stomach. Bile and pancreatic fluids flow into the duodenum through ducts from liver and pancreas respectively.

Gastric—Pertaining to stomach.

Gastric Bypass—Operation designed to make non-functional a portion of the stomach.

Gastrointestinal—Pertaining to stomach or intestine

Gastrojejunostomy anastomosis—Upper connection of the Gastric Bypass operation

Gastroplasty—Operation for morbid obesity which reshapes the stomach

Genetic—Pertains to transmitted hereditary characteristics

Hernia—A weakness in the abdominal wall resulting in a detectable bulge

Herniation—Process in which a hernia is formed

Hyperosmolality—Presence of highly concentrated substances capable of producing dumping syndrome

Hypertension—High Blood Pressure

Lleum—Ten feet of small intestine, responsible for absorption

Jejunum—Ten feet of small intestine; the part responsible for digestion

Kilogram—Measure of weight equal to 2.2 pounds

Laparoscopy—Method of visualizing and treating intra-abdominal problems with long fiber-optic instruments

Morbid—Pertaining to disease, illness, increased risk of death

Morbid Obesity—Body Mass Index of 40 or more, which is roughly equivalent to 100 pounds or more over ideal body weight; a weight level that is life risking

Mortality—Pertaining to death

Multi-disciplinary—Team approach to evaluation and treatment of clinically severe obesity; includes surgical, internal medicine, nutrition, psychiatric, and exercise physiology assessment and treatment

NIH—National Institutes of Health

NIH Consensus Report—Summaries of meetings regarding clinically severe obesity and assessment and treatment of obesity; issued periodically by NIH.

Obesity—Pertaining to excessive weight or adipose tissue

Obstructions—Narrowing of an anastomosis or segment of gastrointestinal tract which retards normal passage of food or waste materials

Psychotherapy—Evaluation and treatment of mentally related disorders

Pulmonary—Pertains to the lungs

Roux-en-Y Gastric Bypass—A surgical method of reconnecting the stomach and upper small intestines in roughly a Y shape.

Staples—Surgically sterile devices for connecting tissue; usually permanent and made of stainless steel or titanium

Strictures—Narrowing of anastomosis or section of intestine; often related to scarring or ulcers

Therapy—Treatment

Type 2 Diabetes—A disorder of glucose and insulin metabolism

back to the glossary

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