Bariatric Surgery: Everything You Need to Know (Including What Your Doctor Might Not Be Telling You)

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Why Do People End Up Morbidly Obese

Well-meaning acquaintances, friends, and relatives may suggest that you’re “taking the easy way out” by pursuing bariatric surgery. They can make you feel guilty for even considering this as a last resort. Why can’t you just lose the weight on your own?

Genetic predisposition. Some are genetically predisposed to gain weight, even when they exercise, even when they try to diet. Certain hormone imbalances and disorders can also make it hard to stay at a healthy weight.

Emotional eating. The barrier that keeps most morbidly obese people from losing weight is that our eating is connected with our emotions. Early on, many of us learned to use food as a way to cope. Food for us is not just fuel; it’s the way we deal with life’s problems and blows.

Regardless of the particular cause, some of us have been on one diet or another all our lives. We have lost the same 50, 70, or 100 pounds over and over. In fact, our attempts to lose weight have made us worse off. Along with the health effects of too much weight, we carry the shame of failure and frustration.

Weight and Your Wellbeing

The physical health problems associated with obesity are many and serious: high cholesterol, high blood pressure, acid reflux, gall bladder disease, congestive heart failure. Type two diabetes, hypoglycemia, asthma, sleep apnea and other sleep problems, fertility problems, arthritis, lack of energy. Knee and back pain, gout, migraines, psychosocial stress. Even scarier: liver disease, increased risk of cancer, risk of stroke, and earlier death.

Associated emotional problems that stem from these conditions can also make it harder to overcome them. For example, you may be struggling with depression, anxiety, and guilt. Sometimes, the biggest problem we have to face is the low self-esteem that goes along with being the biggest person in the room.

What Is Bariatric Surgery?

Bariatric surgery is not a cosmetic procedure. We may hope to look better after losing weight, but the best reasons for undergoing this major surgery are to extend and improve our lives.

The common term for bariatric surgery is “weight-loss surgery.” It means any surgical procedure on the stomach or intestines that aims at weight loss. Doctors have been performing these surgeries since the 1950s, with a good success rate.

The most common procedures are lap band, with a success rate of 47%; gastric sleeve, with a success rate of 80%; and gastric bypass, which has an 85% success rate. Another procedure, duodenal switch, has a success rate of 95%, but is more complicated and less common in the U.S.

These procedures support weight loss while requiring lifestyle changes. Drastic weight loss can motivate you to keep on the road to better health.

Whichever procedure you choose, pre- and post-operative education is key to developing lasting, healthy habits.

Getting Ready for Surgery

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Mentally and Emotionally Preparing

Convincing others — and yourself — this is the best solution

Your first job is to conquer your own hesitance about weight-loss surgery. Even asking about it takes courage. Then, when you’ve reached the point of seriously considering it, you need to be prepared for a long haul.

You will need to get lots of people on board with your decision. First, your family — maybe not extended family, but certainly the people you live with day to day.

Next, you need your doctor to approve your decision. No matter how much you hate to get weighed, you will need a referral from your primary physician. And, you need to convince your insurance carrier that bariatric surgery is necessary for your health and to prolong your life.

Navigating Relief and Fear

You will probably feel a profound sense of relief just to know there’s a solution to obesity- related health problems. But along with that relief comes worry. It’s major surgery. Things could go very wrong. You might even die. Will having surgery be worth it?

What if you can’t get the weight off during those post-surgery months? What if you can’t keep it off and all this trouble and pain is for nothing? After all, you’ve tried and tried to lose weight and it hasn’t worked — or only worked for a short time.

Then there’s having to consult with medical personnel and, even worse, insurance representatives, to advocate for yourself. You’ll have to talk about your weight, which means confronting the shame that goes with it.

You may worry that people will think you’re weak — that you’re taking the easy way out. How do you overcome that prejudice? Especially since part of you still shares it.

Overcoming Resistance

And what about all those hoops you have to jump through? You have to have at least six months of records showing your weight on a regular basis and detailing your attempts to lose it. When you can’t bear the sight of your own body, much less the weight on the scale, how are you going to face that challenge?

Your research, from articles to videos, shows people who’ve had bariatric surgery eating impossibly small portions. You hear about all the restrictions ahead: first, a liquid diet; then mashed food; then, even when you get back to “normal,” ongoing restrictions, such as not drinking with meals. How will you ever be able to eat normally again — how will you ever be able to eat out?

These are mental challenges it won’t be easy to meet. But if you want to be well again, if you want a long, productive life, it is possible to work through them.

Advocating for Yourself

I was fortunate that my primary care physician was willing to support my bariatric surgery decision from the beginning. But you may have to work to convince your medical advisor that this route is good for you. Advocating for yourself isn’t easy, especially if, like most of us who suffer from morbid obesity, you don’t like calling attention to yourself and your weight.

To succeed, you must learn how to speak up for yourself. Here are some suggestions.

• Decide what you want. Believe in yourself!
• Know the facts. Educate yourself about bariatric surgery and potential issues.
• Plan. You need a strategy for recovery and ongoing lifestyle changes.
• Gather support. It’s helpful to have family, friends, and people who have similar issues on your side.
• Target your efforts. Find the best medical practitioner. Find the right person at your insurance company to plead your case to.
• Express yourself clearly. Tell doctors and insurance agents that you are interested in surgery and why you feel you need it. Stick to the point, and don’t give up if they say “no.” It may help to role play scenarios with a friend or family member who supports your decision.
• Assert yourself, but don’t lose your temper. Respect the rights of others, but ask for what you need, and then listen.
• Finally, don’t give up. Be firm and persistent. Follow through on what you promise. (Those six months of weight-loss records, for example.)

After Surgery Is Approved

You’ve made the decision to have bariatric surgery. You’re both excited and scared about taking this serious step toward improving your health and your life, but you’re going to do it. Now you need to build your support system. Nobody goes through such a major life change, such a serious physical challenge, without help.

Find Your Team

Choosing the right people to support you on your journey is one of the most important decisions you have to make. You will need to depend on family, friends, acquaintances, and even strangers who have gone through this experience before you. The most important quality to look for in your team is respect and support for your decision.

You will need help with ordinary tasks and responsibilities while you are undergoing and recovering from surgery. A few needs:

• Someone to care for your children and pets while you’re in the hospital and perhaps during recovery at home
• Help cooking meals and cleaning the house
• Someone to accompany you to the hospital and be your advocate when you can’t do that yourself
• Help dealing with the inevitable emotions and stresses of major surgery and a major lifestyle change

First, you have to overcome your reluctance to ask for help. Then, you have to reach out. Share your needs with family and friends who are sympathetic to your goals. If they’re not on board, you don’t have time for them right now.

If it feels right to you, you can use social media to reach out. Contact your church, work friends, fellow hobbyists, and people you’ve come to know in other ways. Trust that there will be someone who can help.

Be Informed and Follow Your Doctor’s Advice

Use the resources available through your medical advisors. Seek out a sympathetic nurse.

A therapist can help you deal with the emotional consequences of surgery and also the issues that led to your obesity in the first place. If you don’t have a therapist, maybe it’s time to make that connection. Find a good therapy group.

And above all, follow your doctor’s advice! Learn as much as you can about what will be happening to your body and mind, but trust the experts.

Plan for an Extended Recovery

Your time in the hospital may be only three to four days, but it will take longer for you to feel “recovered.” The period (about nine months) when you are relearning how to eat and coming to terms with the smaller size of your stomach is crucial to your long-term success. There will be lots of ups and downs. Be ready for a long road to full recovery.

Having support from friends and family is important, but this is the time to get involved with a support group. Being with others going through the same experience can give you the perspective you need to keep going.

Even if your physical recovery is swift and relatively painless, you will have to learn how to deal with the changes in your life. If, as with many, food has been the way you deal with past trauma, uncomfortable feelings, your need for independence, or any other of life’s problems, you no longer can depend on that comfort. If food has been your addiction, you now have to kick the addictive response to it. There will be setbacks. You need to be prepared to bounce back from them.

Lose Weight Before Surgery

Your bariatric surgeon is likely to require you follow a weight-loss plan for a number of months (six is common) before surgery. The reasons: to make sure you really are committed to your goal of losing the excess weight, and to help you be as healthy as possible going into surgery.

This can be a frustrating time. You’ve tried so many diets and exercise programs before, and none have worked. You hate thinking about your weight, and your program requires you weigh yourself daily and keep records of your weight, food intake, and exercise. You’ve made a major decision and are anxious to get it over with. But again, following your doctor’s advice is the shortest and best way to reach your goal, no matter how frustrating it feels.

Confront Your Fears

To make this transformative decision, you’ve already had to overcome lots of fears. Some of your fears involve others’ opinions. “What will people think?” Some arise from self-doubt. “Am I being selfish?” These are not frivolous concerns. Believe in yourself and face them. Your decision to take care of your health so that you can be there for your loved ones is a good one. Trust in yourself.

Another very real fear is the fear that anyone feels when they are about to undergo major surgery. You could die. This is not a frivolous thing. It’s serious. But the vast majority of people who have surgery don’t die from it. So, face your fear realistically.

At last, the big day is here. Your surgery is performed. You wake up in the hospital. Are you a different person? Is it all over now? Not yet. The journey of recovery has begun, and it will take resilience.

Immediately After Surgery

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In the Hospital

If you have built your support team, you will have fewer worries going in. Your family and home responsibilities are covered, and you have people to support you in the hospital and after you return home. But that doesn’t mean there won’t be challenges.

During the initial stages of recovery, hospital staff will be checking your blood pressure, oxygen levels, and more. You may feel as though you are always being poked and prodded at, with little privacy. Thankfully, this stage doesn’t last forever,

Your doctors will advise you about the physical challenges that may follow bariatric surgery: constipation, dumping syndrome (nausea, vomiting, and weakness caused by eating high sugar meals, sodas, and fruit juices), possible infection of the wound, and possible leaks in the new connections. But medical advice may not give you the information you need about the emotional side effects.

One consequence of the surgery I noticed immediately: I no longer felt like eating. My hunger hormones were gone for a period of time. I had to force myself to eat, and I felt weak. Others report that they felt hungry during the post-op period while on a liquid diet.

Hungry or not, a liquid diet can be a source of emotional stress. Be aware that different people react in different ways. The important thing is to keep following your medical and nutritional advice and trust that, in time, you’ll be feeling more normal.

Another potential problem is “food grief.” Food has a special meaning for people who suffer from morbid obesity, and “mourning for lost foods is a natural step in the re-birth process after weight loss surgery.” For a long time, maybe all our lives, food was our friend. We turned to it in celebration, in sadness, for comfort, for reward. Now, we can no longer turn to food. We have to find other ways to fill the void food once filled for us.

Along with the pain associated with surgery comes the challenge of managing it. The pain medication you are given in the hospital may not work for you. Keep advocating for yourself until you find one that does. It may also take time to know exactly how much medication you need. Trust your doctor, but don’t be afraid to ask for a higher dose if you are in pain, or a lower dose if you are experiencing other unpleasant side effects.

It’s worth reiterating here, I am not a nutritionist or medical practitioner. And, I am certainly not advocating for you to ignore your doctor’s advice. Rather, by telling your doctor how you feel when you’re on pain medication, he or she may be able to transition you to a more effective medicine or dosage in a safe, supervised way.

Other challenges: meeting the medical requirements for discharge from the hospital and meeting your own fears and expectations. Will you be ready to be sent home? How will you manage after you get there?

Your First Few Days at Home

Your first major challenge will be dealing with pain and managing your pain medication. If you’re like me, you will want to get off medication as soon as possible. But follow your doctor’s advice. Pain meds usually require tapering off. Quitting “cold turkey” is likely to cause withdrawal symptoms, such as feelings of anxiety or depression, trouble sleeping, headaches, night sweats, nausea, vomiting, and diarrhea. I made the mistake of not tapering off my pain meds and lived to regret it.

You — and members of your family — might be appalled at how little you eat. You might worry about not getting enough of the right nutrition — protein, for example. The combination of pain, medication, and lack of hunger hormones can mean almost total loss of appetite.

Feeling responsible for things at home may make you push yourself too hard, especially if loved ones need you. Preplanning for getting help during this early recovery period is important. You will need to have both physical and emotional support in place. Recognize that even though they care, some people won’t be able to help. But don’t be afraid to ask.

Take baby steps. Your recovery has many facets: overcoming pain and regaining your physical strength are just the beginning. Emotional adjustment to the new circumstances of this life-changing step is major and ongoing.

Therapist Lynne Routsong-Wiechers, herself a successful bariatric surgery patient, lists “Seven Steps to Improving Emotional Adjustments Post-Surgery” in her article, “Baby Steps — Emotional Adjustments to Weight-Loss Surgery.”

• Follow your doctor’s orders. Ask questions when you have them and express concerns, but trust your doctor’s recommendations and prioritize your physical health.
• Keep a journal. You can use this to keep track of the foods you eat, as well as whether or not you are emotionally eating, but you might also choose to express what you’re thinking and feeling. This will be a private record, just for you. Remember, you are more than your diet and weight.
• Write down realistic goals and expectations. Celebrate when you meet them!
• Reflect on the past. Remember why you decided to make this change, and honor how far you’ve come.
• Take plenty of photos and keep your old clothes. This will help you physically see your immense transformation.
• Call on that support team you’ve created.
• Look forward to living life to the fullest!

Ongoing Recovery

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Physical Issues

Even after you’ve conquered the first few days after surgery, the challenges go on. This early recovery stage can last from one to six weeks. The specifics vary with the particular procedure, but here’s a general outline of your physical recovery:

Develop strategies to deal with these attacks: exercise, journaling, and deep breathing are a few suggestions. Seek help if your attacks are severe.

Focus on One Part of Your Body

You might find yourself focusing on one body part. For me, it was my double chin. I had lost inches from my waistline and was making good progress, but when I looked in the mirror and saw that same double chin, I felt like I was making no progress at all.

This kind of body image distortion, if it becomes obsessive, can lead to Body Dysmorphic Disorder (BDD), a mental health disorder. People with BDD can spend hours a day obsessing about their appearance. These obsessions and the low self-esteem that results can make them avoid social situations, have problems at work or school, or even lead to suicidal thoughts or suicide attempts.

It’s important to seek help and support if you feel yourself becoming fixated. Remember that no body is perfect, and people are much more like to think about their own “flaws” than notice yours. Practice positive self-talk and try to replace thoughts about your body with something else, such as a new hobby or activity. Now that you’ve lost weight, a whole new world is open to you!

Health Problems

It’s not uncommon for patients to regain some weight after surgery, although it’s a myth that many patients regain all their lost weight.

Regaining Weight

Regaining even a small amount of weight can feed your fear. What if you stretch the pouch and end up gaining weight back or stalling your weight-loss? What if you have to go back to the hospital for something and you gain weight because of the treatment?

About half of all bariatric surgery patients regain weight after two years. But the average regain is about 8% after reaching the lowest point, and total ten-year excess weight loss is still over 50%. The main reasons for regaining weight are: how much excess weight you carried before surgery, alcohol or drug abuse, lack of a support system, or having a psychological problem or food “addiction.”

Realize that even if you regain some weight, you are still healthier than you were before surgery. Take steps to avoid the main reasons for weight gain. Be aware of the dangers of a substitute addiction to alcohol or drugs. Get yourself a support system and use it. Get treatment if you suspect you are overeating because of food addiction.

Plateauing

Don’t lose hope if you stop losing weight for a few days. These things happen. You can overcome the weight loss plateau.

Your metabolism may have slowed because you couldn’t exercise after surgery. You can start losing weight again. Focus on getting the right amount and intensity of exercise. Track your heart rate. You should be exercising at 60 to 85% of your maximum heart rate (220 minus your age). Vary your exercise routine to keep yourself challenged. Be sure to drink enough water, and continue eating right.

Complications

I worried that something would get stuck in the very small connection between my stomach pouch and small intestine. Would I have to go to the emergency room? Could something else happen to me?

As with all surgeries, there can be complications with bariatric surgery. But this surgery is very safe (99.8% survival rate). And less than 10% of patients have a complication. Though the list of complications is fairly long, most are not life-threatening (e.g., indigestion, diarrhea or constipation, nausea and vomiting, dumping syndrome). Some can be prevented by self-care.

Stick to your bariatric diet, follow your doctor’s instructions, inform yourself about what to look for, and share your worries with your doctor.

Sutures

I had difficulty with sutures coming out before they were supposed to. Others have had infections at the wound site. Monitor the site of your surgery and consult your doctor if things aren’t going right.

Hypoglycemia

Hypoglycemia (low blood sugar) happens when after eating, a rise in blood sugar makes your body produce more insulin, which then lowers blood sugar. Unless it’s extreme, this can be managed by changes in your diet.

Nutritional Deficiencies

Common vitamin and mineral deficiencies among bariatric surgery patients are Vitamin B12, Folate and Zinc, iron, copper, Calcium, and Vitamin D. Potassium deficiency can also be a problem, causing nausea, cramping, and dry skin. Supplements may help. Consult your doctor and dietician.

Dehydration

The recommended daily intake of water — 64 ounces — may be hard to get down, particularly right after surgery. Eight cups sounds like a lot, but if you break it down to one-fourth cup every 15 minutes for eight of the twelve or so hours you are awake, it is manageable. There’s an app for reminding you when to drink at GetHYApp.com.

Clothing

Especially in the early weeks and months after surgery, when you are dropping weight fast, you may find you can’t find anything to wear. This may sound like a minor problem, but you might be caught off guard by how much you spend on new clothes as you lose weight rapidly. While you are changing sizes every week or two, you may want to find some ways to save money:

• Borrow clothes or shop at thrift stores.
• Shop your closet. Now’s the time to wear those too small items you just couldn’t part with when you were heavier.
• Don’t buy too much. Get exactly what you need until the next size change.
• Buy just a few practical basics and splurge on accessories.
• Don’t buy for the future. Clothes that fit and flatter now are better for your confidence.
• Alter. If you can’t alter your own clothes, find someone who can and get items altered as you lose weight. Most things can be taken in.
• Exchange Clothing. If you’re in a support group, consider swapping clothes with other group members.

Relationships

Social Life

Your new body may allow you to make new decisions: to start dating or to go to the beach. But because your body image may not have caught up with the reality of your new body, you may still have the self-doubts you had before.

Part of your mind still thinks the way you did before surgery. You may feel unattractive, even invisible. Inside, you still feel fat. Negative self-talk may still be your go-to response to interacting socially with other people.

Counseling, a support group, and self-affirmations can help. Most importantly, give yourself credit for all you have accomplished. You’ve come a long way.

Different Reactions

Sad, but true. Not all of your friends and family will react positively to the new you. Old friends, even family members, may envy or resent your new look.

Family, friends, and even strangers may have a range of reactions to the changes in you. Your children may support you, but carry a lot of anxiety, fearing that you may die. Some may become diet police, worried that you’ll regain the weight and ill health of your days of obesity. Some will trust you to know your own needs.

Know that others’ reactions don’t mean anything about you. You are taking care of yourself, and that’s a good thing.

Getting More Attention

Now that you have lost weight, you are probably getting more attention. This may make you uncomfortable. Obesity goes with isolation. In fact, some people use their weight to keep from being in the spotlight. Being noticed may be flattering, but it can also be stressful.

Jealousy

If you’re married or in a relationship your significant other may be jealous of all the attention you’re getting from other people. Your spouse might fear that the new you might leave the relationship and so may try to sabotage your efforts to maintain your weight loss.

Your overweight friends might be jealous in a different way. If monthly dinners out with your “foodie” friends were the main thing that kept you together, or if these friends are not sympathetic to your weight loss efforts, they may, consciously or unconsciously, sabotage you.

Remember to surround yourself with people who support you. Don’t judge others who may be struggling, but don’t sacrifice your progress to please them.

Guarding Against Judgment

The different way strangers and acquaintances perceive you now may make you feel flattered, but also confused and even resentful. You may wonder — do these people like you for yourself, or are they just attracted to your new appearance? Would they have liked you before?

People you don’t see every day may not recognize you. Others may make you feel that you’re being judged for your decision to have the surgery. You may be re-introducing yourself to one person and defending yourself to another.

It’s understandable that you may be struggling with your sense of self. But, remember, you are worthy of kindness at any weight. Be your own best support.

Honoring Your Accomplishment

You can’t control the beliefs and behavior of other people, but you can be true to your goals and to yourself. Keep honoring your decision, your hard work, your determination, and your truly astonishing accomplishments. Whatever others say or imply, you are a brave and magnificent person, and you deserve a magnificent life.

Embrace Your Future

Bariatric surgery is a last-resort choice for losing weight that is killing you. Deciding to go ahead with it and working through all the barriers and difficulties is not for the faint of heart. But for those who choose to go forward, it can be life-saving in many ways.

By arming yourself with information about what to expect, you can feel prepared to navigate the weight loss surgery process with greater confidence and ease. Keep coming back to this guide and check in with yourself at every step along the way.

Before, immediately after, and long after surgery, remember these key points:

• Create a support system
• Take care of your body
• Believe in yourself

No matter where you are in your surgery journey, you deserve the new life you have given yourself. Enjoy.

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