• Choose a primary care physician if you don't have one already, and establish a relationship with him or her. Work with your physician to ensure that your routine health maintenance testing is current. For example, women may have a Pap smear, and if older than 40 years of age, a mammogram. For men, this may include a Prostate Specific Antigen test (PSA). Results of diagnostic and routine screening for co-morbid conditions such as type 2 diabetes and high cholesterol can be necessary for documentation of medical necessity.
• Make a list of all the diets you have tried (a diet history) and take it to your doctor.
• Take any relevant medical data to your appointment with the bariatric surgeon, including reports of special tests (echocardiogram, sleep study, etc.), or a hospital discharge summary if you have been in the hospital for weight-related health problems.
• Take a list of your medications, including dosage and schedule.
• Quit smoking. Surgical patients who use tobacco products are at a greater surgical risk. Talk to a doctor for help with this.
• Gather all of the information (diet records, medical records, medical tests) your insurance company may require. This reduces the chance of being turned down because you failed to provide necessary information. Letters from your personal physician and professionals supporting the medical necessity of treatment are particularly valuable. When several physicians report the same findings, it may confirm a medical necessity for surgery.
• When you send your letter, call your insurance carrier regularly to ask about the status of your request. Your employer or human relations office also may be able to help you work through any issues. Be sure to write down dates and the names of people you speak with and keep notes about the conversations. When possible, get them to fax you copies of the policies they are quoting.
• Make sure your primary care physician is documenting your weight loss efforts and your weight in your medical records at every visit.

Since every insurance policy is unique, it's important that you thoroughly understand your certificate of coverage to know exactly what is and isn't covered through your plan.

To qualify for insurance coverage, many insurers require patients to have a history of medically supervised weight loss efforts.

Keep track of every visit you make to a healthcare professional for obesity-related issues or visits to supervised weight loss programs. Make note of other weight loss attempts made through diet centers and fitness club memberships. Keep good records, including receipts.

If your bariatric surgeon recommends bariatric surgery, he or she will prepare a letter to obtain preauthorization from your insurance company. The goal of this letter is to establish the medical necessity of bariatric surgery and gain approval for the procedure. The following information is generally included in the preauthorization letter:

• Your height, weight, and Body Mass Index, and any documentation you might have as to how long you have been overweight.
• Simply describing your condition as morbid obesity is not enough. A full description of all your obesity-related health conditions, including records of treatment, a history of medications taken, and documentation of how these conditions affect your everyday life, is necessary.
• A detailed report of how your excess weight affects daily activities, such as walking, tying your shoes, or maintaining personal hygiene.
• A detailed history of the results of your dieting efforts, including medically and nonmedically supervised programs, medical records, and records you may have kept of payments to and meetings you’ve attended with commercial weight loss programs.
• A history of exercise programs, including receipts for gym memberships.
• Ask your doctor to include clinical information about how effective bariatric surgery can be, particularly the control or loss of obesity-related health conditions.

Normally, your insurance provider will respond to your request within 30 days. You should schedule a follow-up if you have not heard from your insurance company in that amount of time.

If your insurance company denies your request, you can make an appeal. At this point, consider hiring an insurance lawyer or insurance advocate, both of whom can be very helpful. The insurance lawyer or advocate should have an in-depth understanding of the appeals process, as well as any laws that apply, and how to go about responding to the insurance company. With some insurance carriers, the number of appeals that you can make is limited. So be sure to learn as much as possible about the appeals process ahead of time.
 
At the end of this stage, with the help of a bariatric surgeon, you will know if you qualify for surgery.

Most bariatric programs require that patients participate in support groups before surgery. This group setting is helpful for patients before surgery, as they discuss their concerns and hear from other patients who have gone through bariatric surgery.

Selecting a Procedure
After you have completed the presurgery medical, nutritional, and psychological evaluations and have adequate metabolic control, your bariatric surgeon will discuss the benefits and risks of the different surgical procedures, and together you will choose the most appropriate surgery for you. Once you and your surgeon have agreed upon a procedure, your next step will be to set a date.
 
What Can I Do to Prepare?
Bariatric surgery is like other major surgeries. You can best prepare by knowing the benefits and risks of surgery and by closely following your doctor's instructions.

To mentally prepare yourself:

• Understand the surgical process and what to expect afterward.
• Keep in mind that you’ll never be able to eat the way you did before, and that you’ll have to watch the way you eat for the rest of your life.
• Talk to people who have had bariatric surgery.
• Write a letter to yourself and your surgeon explaining your reasons for having bariatric surgery and outlining your plans to maintain your weight loss after surgery.
• Start a journal. Record how you feel now, the challenges you face, and the things you hope to be able to do after bariatric surgery.
• Get a letter of support from your family. It helps to know you have people behind you, waiting to help.

To prepare yourself physically, follow the guidelines that your doctor will give you. The guidelines will be based upon your procedure, your personal profile, and other factors. You want to ensure your best outcome, and the guidelines will help you accomplish that.

For many gastric bypass surgery patients, the long-anticipated day of surgery is an exciting end to a long wait. It’s often referred to by postsurgical patients as their “birthday,” because of the life-changing transformation of health they’ve achieved.

Preparing for the day of gastric bypass surgery is like preparing for many other surgeries: Your surgeon will have specific instructions for you to follow. A few of the more frequently given instructions include:

• Do not drink or eat anything prior to surgery, beginning the evening before the day of surgery.
• Most medicines can be taken the day of surgery, just with small sips of water (however, your doctor will have instructions regarding specific medications).
• Bring all of your medications with you.
• Bring your CPAP machine, if you have one, for use in the hospital.
• Arrive early; some hospitals and surgery centers require patients to be up to two hours early.

Again, your surgeon will give you specific instructions, especially regarding your medications, to prepare you for surgery.

When you arrive, you will undergo a few preoperative steps. You will change out of your clothes. You will see your nurses, and often, you will see your surgeon as well as your anesthesiologist. An IV line will be started to keep you hydrated and to administer medications such as antibiotics. The preoperative experience is often a short one, after which you will be taken to the operating room.

If you are not already under anesthesia before you get to the operating room, you will be once there. Then, you will be intubated and your surgeon will perform the operation. Gastric bypass procedures, whether they are minimally invasive or open, are fairly short… about 75 to 90 minutes.

After surgery, your healthcare team will make sure your vital signs are acceptable and arrange for you to be taken to a recovery room.

Bariatric surgery is not a quick fix. It’s an ongoing journey toward weight loss through lifestyle changes. After surgery, the difference in your body makes it physically easier to adjust your eating and lifestyle habits. Fortunately, you will not have to go through the process alone. A team of professionals will be there to support your efforts. Positive changes in your body, your weight, and your health will occur, but you will need to be patient through the recovery process.  

Voices of Experience
Hear patients and healthcare professionals, including a dietician, speak from experience about the realities of bariatric surgery.

Waking Up in the Recovery Room
In the early days after surgery, you may not feel much different. Even though you’ve taken a big step, you may find yourself asking what has changed. In the recovery room, you can expect to have some discomfort and feel the effects of the surgery (this can last for several days). Unfortunately, you may feel worse before you feel better.  

Some doctors will provide a Patient Controlled Analgesia (PCA), or a self-administered pain management system, to help control pain. Other doctors prefer to use an infusion pump that provides a local anesthetic directly to the surgical site to control pain without the side effects of narcotics.
 
Short-term Risks
All abdominal operations carry the risks of bleeding, infection in the incision, blood clots, lung problems (pneumonia, pulmonary embolisms), strokes or heart attacks, anesthetic complications, and blockage or obstruction of the intestines. These risks are greater in patients suffering from morbid obesity. You should be aware that some surgical side effects, such as a blood clot, can be life-threatening. According to the 2004 consensus statement from the ASBS, the risk of death during bariatric surgery is less than 1 percent.
 
Postsurgery Diet
The changes made to your gastrointestinal tract will require permanent changes in your eating habits that must be followed for successful weight loss. Postsurgery dietary guidelines will vary by bariatric surgeon. You may hear about postsurgery guidelines different from the ones you receive. It is important to remember that these guidelines will be different depending on the surgeon and type of procedure. What is most important is that you follow your surgeon's guidelines. The following are some of the generally accepted dietary guidelines:

When you start eating solid food, it is important to chew your food thoroughly and eat very slowly. It is important to wait two to three minutes after swallowing before putting the next bite of food in your mouth. You will not be able to digest 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 eaten enough food. Fluids consumed with meals can cause vomiting and dumping syndrome, and can lead to feeling hungry sooner after a meal.
• Don’t eat desserts and other items with sugar if they have more than 3 to 5 grams per serving size.
• Avoid carbonated drinks, high-calorie nutritional supplements, milk shakes, foods high in fat, and foods that have no nutritional value.
• Avoid alcohol.
• Limit snacking between meals.

How much food will I be able to eat following surgery? How often will I be able to eat?
Most patients are instructed to eat 1/4 cup, or 2 ounces, of food. As time goes on, you can eat more (as instructed by your medical team). Most people can eat approximately 1 cup of food after a year or more postsurgery.  

What could happen if I don’t follow one or more of the dietary guidelines?
The guidelines are designed to improve the chance of long-term success in weight loss. If you don’t follow the guidelines, you may not lose or maintain the loss of the estimated 70 to 90 percent of excess weight. You may experience complications such as vomiting, diarrhea, or malnutrition after surgery.
 
How soon will I be able to walk?
Soon after surgery, doctors will require you to get up and move around. Patients are asked to walk or stand at the bedside the night of surgery and take several walks the next day and soon after. Upon leaving the hospital, you may be able to care for all your personal needs, but you will need help with shopping and lifting, and with transportation.

How soon can I drive?
You should not drive until you have stopped taking medications (associated with surgery) and can move quickly and alertly. Usually, this takes seven to 14 days after surgery.

When can I go back to my normal activity level?
Your ability to resume presurgery levels of activity depends on your physical condition, the nature of the activity, and the type of bariatric surgery you had. Many patients return to normal levels of activity within six weeks of surgery.
 
Should I use birth control?
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 bariatric surgery.

Recovering from Bariatric Surgery

Recovery takes effort. The diet is strict. Your body is trying to heal. Your weight is beginning to adjust. The recovery stage of the process becomes easier once you start to see positive changes. The timing varies by patient. Some patients begin to lose pounds within days of their surgery. For others, a couple of months go by before they see noticeable weight loss. With courage and a circle of support, you can make it through recovery.

Maintaining Excess Weight Loss

Bariatric surgery is meant to help you keep off excess body weight for life. Maintaining weight loss means a dedicated lifestyle—finding new ways to deal with food, get exercise, and even relate to other people.

Bariatric surgery is not an immediate fix. It’s a positive, ongoing process of change. Following surgery, your body will give you signals to stop eating before you take in extra calories that would return your excess body weight. It’s what you do with these signals that counts. When you take on new habits and truly stick to them, you can achieve lasting weight loss without dangerous weight loss/weight gain cycles. At least two-thirds of patients who have gastric bypass surgery are able to keep off at least 50 percent of their excess weight for 10 years or longer.⁷

Your surgeon, nutritionist, and psychologist are each involved in providing you with ongoing support. Also, surgical centers will help you locate and take part in a support group with other patients, where you can share experiences, insights, and concerns. The goal is to adopt lifestyle changes, lose fat, gain muscle, and keep off the weight for good.

Why is exercise so important?
When you have bariatric surgery, you lose weight as the amount of food energy (calories) you can eat becomes much less than your body needs. Your body has to make up the difference by burning unused fat or muscle tissue. Your body will tend to burn any unused muscle before it begins to burn the fat it has saved up. Without daily exercise, your body will burn unused muscle, and you will lose muscle mass and strength. Daily aerobic exercise for 20 minutes will tell your body to use your muscles and force it to burn the fat.

How much exercise is needed after bariatric surgery?
Exercise is an important part of success after surgery. Exercise actually begins on the afternoon of bariatric surgery––the patient must be out of bed and walking. The goal is to walk further every day after that, including the first few weeks at home. You may be encouraged to begin exercising, limited only by discomfort, about two weeks after surgery. The type of exercise depends on your overall condition. Some patients who have severe knee problems can't walk well, but may be able to swim or bicycle. Many patients begin with low-stress forms of exercise and move on to more demanding activity when they are able.

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

What is dumping syndrome?
Eating simple sugars (such as sugar, honey, and corn syrup), high-fat foods, or other small-particle foods can cause dumping syndrome in patients who have had gastric bypass surgery. This occurs when these products, which have a small particle size, are “dumped” from the stomach into the intestine at a rapid rate. Water then is pulled into the intestine from the bloodstream to dilute the sugar load. This flush of water causes symptoms that can include diarrhea, rapid heart rate, hot flashes or sweating and clammy skin, dizziness, or the feeling of needing to lie down. Some individuals experience some or all of these symptoms after eating more than 3 to 5 grams of sugar, alcohol sugar, or greasy foods, while others can handle greater amounts.  

Though the symptoms are unpleasant, dumping syndrome can be a helpful condition. Some patients will avoid sugar because of the very unpleasant symptoms it can cause. Dumping syndrome generally occurs 10 to 30 minutes after eating, and the symptoms can last for 30 minutes to two hours.

The best treatment is prevention by avoiding foods that cause dumping syndrome. If you have dumping syndrome, lie down for a short while to lessen the symptoms. Dumping syndrome is a positive side effect of the surgery; it helps you learn to eat healthy!

Do I meet with a nutritionist after surgery?
Personal nutrition counseling after surgery is available as needed or as required by your physician.

What is the long-term follow-up schedule?
Although the short-term effects of bariatric surgery are well-understood, there are still questions about the long-term effects on nutrition and body systems. Over time, you will need regular checks for anemia (low red blood cell count) and vitamin B12, folate, and iron levels.

To ensure success, it is recommended that you make several visits to your bariatric surgeon within the first year and then a yearly visit for life.

How can I find a support group?
Support groups give patients an excellent chance to talk about personal and professional issues. Most patients learn, for example, that bariatric surgery will not fix existing emotional issues right away or heal the years of damage that morbid obesity might have caused to their emotional well-being. Surgeons found through the Find a Surgeon tool have support groups in place to assist you with short-term and long-term questions and needs. Most bariatric surgeons who frequently perform bariatric surgery will tell you that ongoing support after surgery helps to achieve the greatest level of success for their patients.