Frequently Asked Questions (FAQs)

Frequently asked questions are answered here

Is obesity a problem?
Why surgery?
Why treat obesity?
Are you a candidate for surgery?
What is the body mass index (BMI)?
Who should be performing the operation?
How much weight am I going to lose?
What are comorbidities?
Will my medical problems improve after bariatric surgery?
What about my Quality of life?
What are the main differences all of the weight loss procedures?
With all of these options, how do I choose the right one?
I have failed at so many other diet methods. Am I going to fail at this?
Will I enjoy eating?
Will this operation cure my diabetes?
What about my gallbladder?
If I get pregnant will I be able to get enough nutrition for my baby?
What medications will be prescribed after the procedure?
Do patients need to be controlled by multiple dietary restrictions and rules?
Is exercise important?
Will I need plastic (body contouring) surgery after my surgical weight loss procedure?
Will health insurance cover my weight loss operation?
Are there other Web sites that can help me learn about weight loss surgery?
What about the use of diet pills for weight loss?
What about dietary supplements for weight loss?
 

Is obesity a problem?

The term "overweight" is used for anyone with more body fat than is considered to be healthy. From a medical point of view, people tend to develop more diseases as they increase their excess body fat. This means that many diseases, such as diabetes, occur in many individuals simply as a result of excess weight, or excess body fat content. Also, a person is increasingly more likely to die early as their weight increases. Diseases that occur due to being overweight are called weight related co-morbidities. A person's risk for medical problems increases significantly with their weight. By decreasing a person's excess weight, we can improve or even cure weight-related diseases, increase life expectancy and dramatically improve quality of life. At The N.E.W. Program at Community Hospital of Long Beach, the effective treatment of obesity is our number one priority.

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Why surgery?

There is an epidemic of obesity occurring in America. Unfortunately, complex medication regimens, dietary supplements, special diets and medical weight loss programs are rarely successful in severely obese patients. To date, the only reasonable and scientifically proven method of achieving long-term weight control in morbidly obese patients is Bariatric Surgery.

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Why treat obesity?

Weight-related health problems result in a tendency to die younger. In fact, one scientific study demonstrated a twelve-fold increase in mortality (annual death rate) for obese men between the ages of 25 and 34. Many other studies have also shown increased mortality in obese patients for both genders, and of all ages.

In one well-performed study, diabetic, morbidly obese patients had a mortality of 28% over a 7-year period, while similarly matched patients who underwent a gastric bypass had a mortality 4.5 times lower. Most of the reduction in mortality was probably due to a lower death rate from heart disease. Obesity is life-threatening and recent studies suggest that procedures to cure obesity will significantly increase a person's lifespan.

* Improve, Prevent and Cure Serious Medical Illness
* Increase Life Expectancy
* Improve Quality of Life

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Are you a candidate for surgery?

Are you more than 80 to 100 pounds overweight? Have you tried losing weight with a doctor's assistance in the past, only to regain it? Do you also suffer from diabetes, heart disease, or sleep apnea?

If you answered yes to most of these questions, you may need to consider laparoscopic bariatric surgery as a possible measure to control weight.

The following guidelines for selecting patients for obesity surgery was established by the National Institutes of Health:

1. You must have a BMI of greater than 35 with a significant medical problem associated with your weight, or a BMI of greater than 40 with or without any medical problems.
2. You should have an objectively measurable complication (physical, psychological, social, or economic) that might benefit from weight reduction.
3. You should be intelligent enough to understand the full importance of the proposed surgical procedure, including all known and unknown risks.
4. You should be willing to be observed for a prolonged period.
5. You should have attempted weight reduction using conservative treatment modalities without success.
6. Age limitations: Patients that are still under the care of their parents (teenagers) require special counseling before proceeding to bariatric surgery. Any teenager above the age of 15 who has undergone detailed family counseling at The N.E.W. Program may be a candidate. We will consider offering bariatric procedures to patients up to the age of 74.
7. NO active drug or alcohol abuse!!! Any major psychiatric disorders should be medically under control.

What is the body mass index?

Body Mass Index (BMI) This is a reasonable measurement of how much fat someone has. It is calculated by dividing your weight in kilograms by your height in meters, squared.

20-25 Normal
25-30 Overweight
30-34 Obese
35-39 Morbid Obesity
40-50 Severe morbid obesity
>50 Super Morbid Obesity


For patients whose BMI is between 30-35, you may be a candidate for our Low BMI study protocol using the LAP-BAND® System or Realize Personalized Banding System. At The N.E.W. Program, we were involved in the early trials of the LAP-BAND® System. Our experience with the LAP-BAND® has encouraged us to start offering the gastric banding procedure to patients whose BMI is between 30-35.

The laparoscopic adjustable gastric band (LAGB) is a device that was approved by the Federal Drug Administration (FDA) for the use on the treatment of morbid obesity. The use of this device has been approved in those patients whose body mass index (BMI) is greater than 40, or who have a BMI greater than or equal to 35 with a severe obesity-related medical conditions. The use of this device in patients whose BMI is less than 35 has not been approved by the FDA.

However, there are individuals who are medically obese, i.e. have a BMI between 30 and 35, and who have weight-related comorbidities. These individuals can also experience repeated failure with long-term weight control, despite multiple attempts. For this reason, The N.E.W. Program has developed an experimental protocol using gastric banding to achieve healthier weight control in these people. This is a clinical trial being studied by The N.E.W. Program of Orange County at this time. This study will help determine if obese people who do not qualify for bariatric surgery under the current NIH guidelines will benefit from the gastric banding procedure.

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Who should be performing the operation?

Only trained bariatric surgeons should perform these operations. Very few surgeons can perform this operation laparoscopically. Even the open procedures should only be done in centers that specialize in the care of the overweight patient. Make sure your surgeon has performed hundreds of these operations laparoscopically. How do you know if your surgeon is an expert?

1. Has your surgeon performed at least 100 cases? (Most studies have documented that at least 100 cases are necessary to become proficient. It probably takes 250 laparoscopic cases to become an expert.)
   
   
2. What kind of training your surgeon had?
   - A weekend or one-week course? - NOT ENOUGH
   - Rigorous training in laparoscopy and bariatric surgery during residency?
   - Fellowship training in laparoscopy? Bariatric surgery? Both?
   
   
3. Does your surgeon place tight restrictions on who is a candidate for laparoscopic surgery? This is often a sign of lack of expertise. Examples:
   - Size limits
   - Eliminating patients due to previous operations
   
   
4. How long does your surgeon take to do the procedure? Long operating room times are often a sign that the surgeon has not developed efficient skills yet. Most expert surgeons perform a gastric bypass in less than 2 hours (and sometimes in 1 hour).
   
   
5. Age. If your surgeon is older, or has been performing open bariatric surgery for years- beware. Many older surgeons were never taught how to perform laparoscopic surgery in their training and had to "pick it up" on the way.
   
   
6. Ask your surgeon how he/she learned laparoscopic bariatric surgery. Was it after a one-week course, was it by trial and error, or did they receive dedicated training in residency or during a one-year fellowship (generally the best).

How much weight am I going to lose?

Weight loss varies between the different procedures as well as between people. Bariatric surgeons use specific terminology to discuss expected weight loss. Excess body weight is defined as a person's current weight minus their ideal body weight. Success after bariatric surgery is defined as losing 50% of your excess body weight. On average, after a gastric bypass, our patient lose 70-80% of excess weight. After a gastric band, patients lose an average 50% of their excess weight.


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What are comorbidities?

Co-morbidities are diseases that are caused by obesity. Most co-morbidities of obesity are cured or significantly improve with weight loss.

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Will my medical problems improve after bariatric surgery?

So, your chances of losing significant weight and improving your medical illnesses is very high.

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What about my quality of life?

A person's quality of life is significantly improved after weight loss. Aside from the medical consequences of obesity, the social consequences are obvious to anyone who is obese. Difficulty sitting in seats on airplanes, in movie theaters and on buses is prevalent. Difficulties with simple acts such as tying shoes, and difficulties with basic personal hygiene, are also common. The most serious is the social stigmatization and prejudice against obesity that is ubiquitous throughout almost every society in the world. These consequences of obesity result in difficulties in personal relationships and at work.

In one well-done study it was demonstrated that the quality of life of patients who are severely obese is equal to a person undergoing chemotherapy for cancer! Further, after weight loss, those patients' quality of life improved to the level of the general population. Quality of life just three months after weight loss surgery returns to normal!

Click on the image below to enlarge.



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What are the main differences between the LAP-BAND® System and the gastric bypass?

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With all of these options, how do I choose the right one?

After educating yourself on all the aspects of these operations you can decide with your surgeon which is the best operation. These operations can be performed laparoscopically in almost everyone.

The Gastric Band requires significant post-operative manipulation, has a re-operative rate that is high, but is the simplest procedure to perform. The Gastric Band probably has the lowest average weight loss and is a much slower weight loss than the other operations. The operative mortality is the lowest of all the procedures. There are occasional patients who do not lose significant weight after this operation.

The Gastric Bypass is the most studied of all the bariatric operations. It is generally a safe and effective operation. The early complication rate is higher than with the Gastric Band. 

NOTES: In Our Hands:

The incisions are exactly the same in all the procedures.

The Gastric Band can be performed on an outpatient basis.

The recovery and the return to work are nearly identical with all the procedures.

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I have failed at so many other diet methods, am I going to fail at this?

Although we cannot make guarantees, unlike dieting where it has been proven that 95% of people will regain any weight lost, bariatric surgery has a long track record of success. The average weight loss after a BPD-DS is 80% of excess weight. That means a woman who weighs 420lbs and has an ideal body weight of 120lbs would be expected on average to lose 240lbs. Certainly some patients will lose more. Others may only reach a weight loss of 150lb (50% of excess). The Gastric Bypass achieves a similar weight loss of about 70-80 percent of excess weight. The Gastric Band has slightly less overall weight loss at 50 percent, further, this weight loss occurs over a slower period than with the gastric bypass. However, the Gastric Band is a more simple operation with less initial operative risks. There are rare patients who do not achieve successful weight loss.

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Will I enjoy eating?

No. Patients who follow these few guidelines to eating after weight control surgery will become people who eat food for quality and flavor, not for volume. These people, and many of our patients, enjoy food more after surgery than they did before surgery. They pay more attention to what they are eating, are often pickier eaters, and don't feel guilty about eating food.

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Will this operation cure my diabetes?

Probably. Most patients lose enough weight that they no longer require any treatment for diabetes. Often patients who were taking more than 100 units of insulin a day are discharged home without needing any. The effects of the operation in control of diabetes are very rapid - even before significant weight loss! People most likely to be completely free of insulin are those who have been diabetics for less than five years. There is a 95% chance of diabetes being cured after a gastric bypass if you have been diagnosed within the last 5 years. If your diagnosis of diabetes was more than 10 years ago, your chance of being cured after a gastric bypass is 54% with the remaining patients having marked improvement. On average, after a gastric bypass, diabetic patients will have normal fasting blood glucose and normal HbA1C with a very significant reduction, if not elimination of their medications.

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What about my gallbladder?

We take out patient's gallbladder only when we feel the risk of complications for gallbladder removal is lower that the chance of developing significant symptoms from gallstones. For people who have gallstones and no symptoms, it has been shown that there is a one percent per year risk of developing problems related to the gallstones. There is almost a one percent chance of injuring your bile duct during removal of the gallbladder. After significant weight loss, patients who did not have pre-operative gallstones have a 30 percent chance of developing stones. If you take Actigall for six months, your risk for gallstones is only three percent.

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If I get pregnant will I be able to get enough nutrition for my baby?

Many patients have gotten pregnant after both gastric bypass and the LAP-BAND® procedure. In fact, several studies have demonstrated that significant weight loss can improve fertility and one recent, excellent study from Australia showed that weight loss after the LAP-BAND® improves fertility in morbidly obese women. There is also a syndrome called Polycystic Ovary Syndrome (PCOS) which can lead to infertility. This syndrome involves excessive hair growth and hormonal changes that generally resolve with dramatic weight loss after bariatric surgery. As far as getting enough appropriate nutrition to have a safe pregnancy, this has not been a demonstrated problem with either the LAP-BAND® or the gastric bypass. However, you are recommended to consult with your bariatric program nutritionist to be safe if you do get pregnant.

In fact, all bariatric operations often cured obesity-related infertility. Pregnancy is one of our most common "side-effects." We strongly discourage all women NOT to get pregnant in the first year after the operation. This may cause significant fetal problems as your body may not have enough vitamins and proteins stored for the both of you. After the majority of weight is lost and you are nutritionally stable, pregnancy has been shown to be very safe. Overall, there is no difference in fetal outcome after having bariatric surgery when compared to the general population; however, follow-up with us is very important to ensure your nutritional status is acceptable to have a child.

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What medications will be prescribed after the procedure?

Patients are generally placed on an antacid medication for 6 months after their procedure to minimize the chance of developing an ulcer. Patients who take non-steroidal medications (Advil®, Aleve®, aspirin, Motrin®, Naproxen®, etc...) for more than a week at a time will be required to take an antacid medication to protect the stomach. Patients who have a gallbladder will have to take Actigall 300mg twice a day for six months in order to minimize the chance of developing gallstones. A multivitamin, iron, B12 and Calcium supplement is recommended for most patients.

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Do patients need to be controlled by multiple dietary restrictions and rules in order to stop regaining weight?

No. We've found that, despite our strong interest in our patient's success, our patients want to be successful with their weight control even more than we want them to be successful. This has resulted in our philosophy of forming a partnership with our patients, through education and good patient support, which will help our patients achieve their weight control goal. We are not a diet program - there is no rigid diet to adhere to after surgery. We just teach you how to use your new tool for the best results.

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Is exercise important?

Being physically active, more than "exercise", is important for maintaining the lost weight. Regular exercise is, of course, helpful in losing weight and improving your health. Becoming more active as the weight is lost will help you realize the benefits of a healthier weight and increase your long-term success. Look at increased activity as one of the rewards for being successful with weight control. Being able to walk upstairs without your knees and back hurting, and without getting severely short of breath, is a great thing-enjoy it.

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Will I need plastic (body contouring) surgery after my surgical weight loss procedure?

Patients who lose significant weight often will require excess skin to be removed. There is not much a patient can do to prevent this excess skin from becoming a cosmetic problem. Depending on how much weight is lost, this can amount to 20 or more pounds!! We usually recommend waiting 18-24 months after surgery to have this performed, if desired. We can recommend plastic surgeons that are specialized in taking care of our patients.

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Will health insurance cover my weight loss operation?

The answer to this is very complex. Many insurance plans do offer some level of coverage for bariatric surgery.  Other insurers do not want to cover weight loss surgery because of the significant costs involved.

Some insurance plans have established a number of criteria patients must meet in order to be approved for surgery, such as nutrition consults and psychological consultations. Many insurance companies are now starting to require 6 months of a documented "physician-supervised" diet. This is a very big obstacle for some patients, however, documenting all previous diet programs is essential in obtaining insurance coverage.  The NEW Program offers a 6-month medically supervised diet program to help patients meet this criteria. The only way to know for sure whether your insurance company covers your bariatric procedure is for one of our insurance specialists to check for coverage.

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Are there other Web sites that can help me learn about weight loss surgery?

Here are some other selected websites the may of of interest in your research:

Obesity Help
American Society of Bariatric Surgery
International Federation for Surgery of Obesity
American Society of Bariatric Physicians
The North American Association for the Study of Obesity 

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What about the use of diet pills for weight loss?

Amphetamine-like and other stimulant drugs have been used for a long time to suppress appetite and facilitate weight loss. However, significant sustained weight loss has not been achieved with these drugs, and rapid weight gain usually occurs when these drugs are discontinued. There are many side-effects and health risks associated with use of weight-loss drugs and there is also some potential for these types of drugs to be abused.

Phentermine and Fenfluramine have been available for about 25 years. In the absence of a reduced-calorie diet and regular exercise, these pills are ineffective. The combined use of these two drugs has never been approved by the FDA.

Fenfluramine (Pondimin®) and dexfenfluramine (Redux®) are considered hazardous. People who used these drugs needed to engage in regular physical activity in order to develop sustained weight loss. Weight regain occurs once these drugs are stopped; in other words "yo-yo" dieting is common with these drugs. In high doses both have caused brain cell damage in experimental trials with animals. Some people developed primary pulmonary hypertension while taking these drugs and this was related to damage to heart valves. In 1997, both drugs were removed from the market by the FDA because serious damage to heart valves was discovered in many users.

Phentermine has not been associated with heart-valve damage. However, it can raise blood pressure and is dangerous if used by anyone who is hypertensive or taking blood pressure medicine.

Any patient who is considering bariatric surgery for weight loss, and who has taken these medications in the past, should discuss the need for an ultrasound of the heart, an Echocardiogram, prior to surgery to ensure that the heart function was not damaged by these drugs.

Orlistat (Xenical®) works in the intestine by blocking the absorption of dietary fat. This drug is generally taken three times per day with meals. A low-fat diet is necessary for Xenical® to work! If you eat high fat food, you will usually develop severe intestinal symptoms, diarrhea or very foul smelling flatus (gas). These symptoms can be prevented by strict adherence to a very low-fat diet. The amount of weight lost with this drug is usually small, and weight regain will occur when the drug is discontinued. Studies may be developed where this drug is used in combination with the LAP-BAND®® for improved long-term weight loss.

Sibutramine (Meridia®) is an appetite suppressant that seems to have minimal effectiveness in most people. This drug may increase heart rate and blood pressure, or cause insomnia, headache, constipation, and dry mouth. Life-threatening interactions with certain antidepressants and migraine medications may occur. It should be avoided by pregnant women and by nursing mothers.

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What about dietary supplements for weight loss?

Some dietary supplements are labeled as "natural" and promoted as "fat burners." There is nothing "natural" about taking huge quantities of concentrated chemicals that occur in nature only in very small concentrations. The "fat burning" properties are generally due to the fact that these compounds are often stimulants that are not currently regulated by the FDA. The FDA will likely begin regulating these "natural" compounds in the interest of public safety. Typically, there are no reliable scientific studies testing the efficacy or safety of these drugs. These "supplements" have been used unsuccessfully at one time or another by the majority of patients who come into the offices of bariatric surgeons looking for help with weight control. Unfortunately, these products can have dangerous chemicals in them which can increase risk for heart disease or other illnesses, especially if taken in large quantities. Some of these are simply diuretics that result in total body dehydration; or are laxatives that may result in laxative dependence or abuse.

Examples include:

• St. John's wort - mimics fenfluramine
  
• Ma huang (ephedra) - amphetamine-like (mimics phentermine)
  
• Kola nut or guarana - caffeine
  

• White willow - salicin
  
  Any patient who is considering bariatric surgery for weight loss, and who has taken these medications in the past, should discuss the need for an ultrasound of the heart, an Echocardiogram, prior to surgery to ensure that the heart function was not damaged by these drugs.