Bariatric surgery is a major event in a patient’s weight-loss journey, but the event is best seen as a new beginning. Obesity is a lifelong disease and there is no operation, diet or medication that can by itself offer a permanent cure. Surgery with good aftercare and moderate lifestyle changes can give wonderful long-term results for health and weight.
Nutrition (food and supplements) and Fluids
In the weeks after surgery, your dietitian will have a nutrition plan for you to follow.. This may include a liquid diet for a period of time followed by a progression to soft or pureed foods, and eventually more regular-textured food. While you are healing in the first few months, it is extra hard to get enough fluid. Most patients receive a goal of 64oz or more of fluids daily to avoid dehydration, constipation, and kidney stones. You will also need a lifelong habit with daily supplements, usually including:
- Vitamin D
- Vitamin B12
The American Society for Metabolic and Bariatric Surgery (ASMBS) has specific recommendations on the recommended doses, but be sure that you follow your dietitian’s advice. (Mechanick, 2013)
Healthy lifestyle choices give the best results for health and quality of life after surgery. Protein-rich foods are important, with recommendations ranging from 60-100g of protein daily, depending on your medical conditions, type of operation and activity level. Limiting foods high in added sugar such as (cookies, cakes, candy, juice or other sweets) and refined carbohydrates (white breads, pastas, crackers, refined cereals) can improve your weight loss results.
Q: Which vitamin and mineral supplements should I expect to take after weight-loss surgery?
A: Multivitamin, calcium with vitamin D, and in some cases, additional iron and/or vitamin B12 supplement. Sometimes additional fat-soluble vitamins (A, D, E, and K)are added to the regimen depending on the operation’s degree of vitamin malabsorption. A chewable form is recommended, at least initially after surgery.
Q: How long will I need to take vitamin supplements?
A: Vitamin and mineral supplements will be a lifelong requirement.
Q: How much protein do I need daily?
A: Most patients get 60-80 grams daily, but some may require more depending on their response to surgery or their type of operation. Your dietitian can provide more detailed information.
Q: Can I take all of the protein in one dose?
A: Protein should be eaten at every meal and snack throughout the day. It is not known if there are additional benefits to having more than 30 grams of protein at once. Protein is a nutrient that helps you feel fuller for longer. If you try to include proteins in each meals or snacks, you’re less likely to feel hungry when it’s not time to eat.
Q: How should I get my protein? With shakes? Bars? What if I’m a vegetarian?
A: There are many options even for those with special dietary needs or preferences. Your dietitian can provide additional information on protein sources. Meats, eggs, dairy products, tofu, beans, and lentils are common protein sources in everyday foods. Protein supplements made from whey and soy are commonly sold in stores and can help you meet your protein needs. You may find it helpful to calculate your daily protein intake to be sure you’re not falling short. As you are able to tolerate more regular foods, you get a higher portion of the required food sources and supplements become less necessary.
Q: What happens if I don’t take in enough protein?
A: The body needs additional protein during the period of rapid weight loss to maintain your muscle mass. Protein is also required to have a healthy metabolism. If you don’t provide enough protein in your diet, the body will take its protein from your muscles and you can become weak.
Q: Do I need to avoid caffeine after bariatric surgery?
A: Caffeine fluids have been shown to be as good as any others for keeping you hydrated. Still, it is a good idea to avoid caffeine for at least the first thirty days after surgery while your stomach is extra sensitive. After that point, you can ask your surgeon or dietitian about resuming caffeine. Remember that caffeine often comes paired with sugary, high-calorie drinks, so be sure you’re making wise beverage choices.
Q: Why is fluid intake important?
A: Dehydration is the most common reason for readmission to the hospital. Dehydration occurs when your body does not get enough fluid to keep it functioning at its best. Your body also requires fluid to burn its stored fat calories for energy. Carry a bottle of water with you all day, especially when you are away from home. Remind yourself to drink even if you don’t feel thirsty. Drinking 64 ounces of fluid is a good daily goal. You can tell if you’re getting enough fluid is if you’re making clear, light-colored urine 5-10 times per day. Signs of dehydration can be thirst, headache, hard stools or dizziness upon sitting or standing up. You should contact your surgeon’s office if you are unable to drink enough fluid to stay hydrated.
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Many Americans with obesity have severe health problems such as diabetes, high blood pressure, elevated cholesterol and coronary heart disease. Patients who undergo bariatric surgery and successfully lose weight see these health conditions improve, and they may be able to stop some medications with their doctor’s advice.
Taking fewer prescription medications doesn’t always mean “no more pills,” though. Good health is the goal, not fewest pills. Many people actually take more pills, as they follow vitamin and mineral plans, and have better awareness of benefits.
Common Questions about Medications and Weight Loss Surgery
Q: What effect does weight loss surgery have on my medications?
A: Prescription or over-the-counter drugs may be absorbed differently after surgery, depending on the type of procedure. Your medication therapy may be affected by this change. In the early period right after surgery, larger tablets or capsules may not be recommended by your surgeon so that pills do not become stuck. Because of this, your surgeon may recommend that you take medications different forms, such as crushed, liquid, suspension, chewable, sublingual or injectable. Some long-acting medications and “enteric coated” medication may not be crushable. Some medication may be crushed and administered with food.
Sleeve gastrectomy and adjustable gastric banding tend to have little to no change in the absorption of medications. Roux-en-Y gastric bypass and duodenal switch can have more significant changes in how medications are absorbed. Check with your surgeon and pharmacist about how you should take each of your medications. Some patients need a higher dose of anti-depressants to have the same effect. This is not a complication, but you need to be aware of how you feel, and speak up with all your caregivers.
Q: Will my medications change after bariatric surgery?
A: Maybe. Some doses may change (see the previous question). Some medication doses may decrease as the obesity-related health conditions improve. For example, diabetic patients often require less insulin or other diabetes medications after surgery because glucose control can improve quickly. Patients who take high blood pressure and cholesterol medication can see their doses lowered if these disease states improve. Any changes in prescription medication should be overseen by your doctor; this is not something that you should do yourself.
Q: Which medications should I avoid after weight loss surgery?
A: Your surgeon or bariatric physician can offer guidance on this topic. One clear class of medications to avoid after Roux-en-Y gastric bypass is the “Non-steroidal anti-inflammatory drugs” (NSAIDs), which can cause ulcers or stomach irritation in anyone but are especially linked to a kind of ulcer called “marginal ulcer” after gastric bypass. Marginal ulcers can bleed or perforate. Usually they are not fatal, but they can cause a lot of months or years of misery, and are a common cause of re-operation, and even (rarely) reversal of gastric bypass.
Some surgeons advise limiting the use of NSAIDs after sleeve gastrectomy and adjustable gastric banding as well. Corticosteroids (such as prednisone) can also cause ulcers and poor healing but may be necessary in some situations. Some long-acting, extended-release, or enteric coated medications may not be absorbed as well after bariatric surgery, so it is important that you work with your surgeon and primary care physician to monitor how well your medications are working. Your doctor may choose an immediate-release medication in some cases if the concern is high enough. Finally, some prescription medications can be associated with weight gain, so you and your doctor can weigh the risk of weight gain versus the benefit of that medication. There may be alternative medications in some cases with less weight gain as a side effect.
Q: Are there any additional prescription medications I will have to take after bariatric surgery?
A: Some patients may require anti-acid medications, either temporarily or indefinitely. Some surgeons prescribe a temporary medication for gallstone prevention if you still have a gallbladder. Ask your surgeon if these will be needed.
Q: Are all medications crushable?
A: Not all medications are crushable. Whether or not a medication can be crushed would depend on the drug formulation. In general, non-coated, immediate release tablets may be crushed. It is important that you are VERY careful with medications, so please always check with your surgeon, primary physician, or pharmacist prior to making medication decisions. An online list of non-crushable medications is available at http://www.ismp.org/tools/donotcrush.pdf.
Fitness and Weight Loss Surgery
Physical activity is very important for long-term weight management. Different patients may have different needs and abilities. As you progress in your fitness program, your body becomes more efficient at the same activity, which means that you tend to burn fewer calories. As you lose weight, the number of calories burned per hour tends to decrease as well. And so, throughout time, it is necessary to gradually increase the intensity or length of your fitness activities. Your surgeon or fitness instructor may have specific recommendations for you in this regard.
Q: How much exercise should I get?
A: Current recommendations for activity are 150 minutes of moderate activity each week such as brisk walking, jogging, Zumba, swimming, or using exercise machines. Please note that the ability to safely tolerate exercise differs from person to person. Please make sure that your chosen exercise and amount will be safely tolerated by you.
Q: How soon after surgery can I exercise?
A: That depends on the type of exercise. You should begin walking while still in the hospital, unless instructed otherwise. As you heal, begin to increase your exercise time and intensity. Your doctor will release you to increase your activity based on your progress. After surgery, exercises such as weights, sit-ups, pull-ups, or any abdominal straining should wait until you get the go-ahead from your doctor.
Q: What type of exercise should I do?
A: Include aerobic (“cardio”), resistance (strength) and flexibility exercise into your routine for best results. Try different exercise programs to find what is right for you. Learn what is available in your community through your bariatric program, local fitness centers, and fellow patients. Warm water exercise (such as lap swimming or water aerobics) is excellent for those with joint pain. Home exercise videos are another option if you do not have access to a nearby gym.
Learn more: cdc.gov/physicalactivity
Not surprisingly, when a person goes through major lifestyle and body changes after surgery, major adjustments occur in how we think about ourselves and how others think of us. Some patients gain much more confidence as they successfully change their lifestyle and manage their weight. Others struggle with continuing to see themselves as affected by obesity. Marriages and relationships can be strained with the adjustments that occur. Strong relationships can become stronger as those involved communicate and work through these changes. Weak relationships can fracture and suffer as a result of these changes. Your workplace dynamics can change; some of your teammates at work may support and cheer you on, while others may be less supportive.
For all of these reasons, access to an experienced mental health professional can be an important part of postoperative recovery. Above all, each patient should be prepared for “bumps in the road” along the journey, whether it’s interpersonal conflict, marriage stress, a surgical complication, or a plateau in weight-loss. (Lehman Center Weight Loss Surgery Expert Panel. Commonwealth of Massachusetts., 2007)
Eating habits are frequently affected by emotions, stress, boredom, mindless eating, or even eating disorders. These are very common but not always obvious. If you find yourself eating to relieve stress or eating when you are full or not hungry, you should seek additional help from your surgeon, qualified psychologists, or behavioral therapists. These issues can be successfully treated to get patients back on track if identified.
Once you have had surgery, your life will be forever different. Your body has now been modified to give you a better chance to overcome the underlying genetic, metabolic, environmental and lifestyle-induced state of obesity. These are powerful forces that created an unhealthy “weight set point” where your body has likely been stuck or hovering around, almost like a thermostat that is set too high. Your body is very effective at trying to maintain that weight and preventing change. As you lose weight, it is important to know that your body will try to establish a new set point. This leads to periodic plateaus in weight. This is normal and expected. Do not allow yourself to be discouraged when you reach a plateau, as these are normal and necessary parts of the weight-loss journey.
Sleep and Stress
A healthy sleep pattern (called “sleep hygiene”) is another key to successful weight management. Setting a regular bedtime is not just for kids! Even adults benefit from regular sleep times, and from setting aside enough time to sleep. Inadequate sleep has been identified as one contributing factor in weight gain. As you seek to improve your sleep habits, there are techniques that can help: avoiding evening caffeine, exercising earlier in the day (not in the few hours before bed), and creating a peaceful bedroom environment that is quiet, not too bright, and comfortable. Also, many patients have sleep apnea before bariatric surgery. While sleep apnea can improve with weight loss, it is important to continue your treatment for sleep apnea. You should discuss the appropriateness of changing sleep apnea treatment with your doctor before you make any modifications.
Successful stress management is another pillar of post-operative success. We know that unmanaged stress can lead to poor choices which can derail your weight-loss attempts. Stress can stifle your success if it is not acknowledged and managed. Even before surgery, it is important to cultivate habits and relationships that relieve stress. Strong relationships with open communication, regular exercise, , and calming habits such as meditation or yoga are all ways to deal with stress. Support groups are readily available in many weight-loss programs. These provide a venue to interact with your healthcare providers and with other patients to share stories, lend support, and to continually be educated with the latest developments in the rapidly evolving field of obesity medicine.
To have a lower risk of complications with weight-loss surgery, almost every bariatric surgery program will recommend that you quit smoking or using chewing tobacco prior to your surgery. Hopefully, this can be an opportunity for you to kick the habit for good.
Q: Why do I have to quit smoking or using tobacco before surgery?
A: Smoking or chewing tobacco leads to decreased blood supply to your body’s tissues and delays healing. (Haskins & Amdur, 2014). Smoking harms every organ in the body and is been linked to:
- Blood clots (the largest cause of death after bariatric surgery)
- Marginal ulcers after gastric bypass
- Heart disease
- Chronic obstructive pulmonary (lung) disease
- Increased risk for hip fracture
- Cancer of the mouth, throat, esophagus, larynx (voice box), stomach, pancreas, bladder, cervix, and kidney
Q: How soon do I have to quit smoking before surgery?
A: Six weeks is needed to reduce the risk of fatal blood clots and pneumonia. Stopping just a week or two before can even make some risks worse; this is not unique to bariatric surgery. Your surgeon will have specific guidelines on how long you must be tobacco-free before surgery, and many will reschedule surgery until you are “clean.” There are blood tests that can show if you have been smoking, even if you are on a nicotine patch or gum, so don’t cheat!
Q: Where can I get help to help me quit?
A: Talk to your primary care practitioner; they would be glad to help! You can also call 1-877-44U-QUIT (1-877-448-7848) or 1-800-QUIT-NOW (1-800-784-8669), or log on to http://www.smokefree.gov.
Q: Can I drink alcohol after surgery?
A: Alcohol is not recommended after bariatric surgery. Alcohol contains calories but minimal nutrition and will work against your weight loss goal. For example, wine contains twice the calories per ounce that regular soda does. The absorption of alcohol changes with gastric bypass and gastric sleeve because an enzyme in the stomach which usually begins to digest alcohol is absent or greatly reduced.
Alcohol may also be absorbed more quickly into the body after gastric bypass or gastric sleeve. The absorbed alcohol will be more potent, and studies have demonstrated that obesity surgery patients reach a higher alcohol level and maintain the higher levels for a longer period than others. In some patients, alcohol use can increase and lead to alcohol dependence. For all of these reasons, it is recommended to avoid alcohol after bariatric surgery. (American College of Surgeons, 2011)
Pregnancy after Bariatric Surgery
Q: Is it safe to get pregnant after I have bariatric surgery?
A: It is recommended you avoid getting pregnant for 12-18 months after surgery. This allows you to have maximum weight loss and reach a stable weight. You will also be very limited in your nutrient intake for quite some time after surgery. (Abodeely, 2008).
Q: I’ve never been able to get pregnant anyway, so I won’t need to worry about avoiding pregnancy after surgery, will I?
A: You can experience a boost in fertility quite soon after surgery, so it is important to use a barrier method of birth control such as IUD, or condoms and spermicide to ensure you do not become pregnant. Birth control pills are much less effective patients with obesity and in the phase of rapid weight loss. If you do become pregnant, please contact your bariatric surgeon and your obstetrician to monitor your progress. You will need to closely monitor your nutrient intake and be evaluated for vitamin deficiencies.
Overall, pregnancy after weight loss surgery can be done safely, by taking steps to minimize risks to your body and to the developing fetus. Studies demonstrate a decreased risk of pregnancy-induced hypertension (high blood pressure) and a decreased risk for gestational diabetes. For best outcomes, discuss your options with your surgeon and obstetrician.
Many studies show that we’re all more likely to engage in better habits when we know that someone will be regularly checking in with us. For this reason, most bariatric surgery programs plan for long-term follow-up visits with a healthcare provider experienced with obesity management. These follow-up visits may be the surgeon, a physician assistant or nurse practitioner, dietitian, mental health professional, exercise specialist, or a medical weight-loss specialist (bariatrician). The most important thing is that you find a bariatric surgery program that provides for this long-term care, so that any problems or concerns that develop over time can be addressed by an experienced team. Medical professionals are not replaceable, but joining with others on the journey can be just as important. Support groups can be a great way to learn, and to share in a safe setting.
Most programs are very sensitive to the fact that patients feel vulnerable to criticism and bias. You need to be able to feel safe to share your challenges and struggles, so that you can get help when you need it most! Your caregivers understand and expect that ups and downs happen, and that life changes and the body adapts over time. “Tune-ups” are possible, and useful.
Congratulations on taking such an important step toward a healthier life! Life after bariatric surgery is not all easy, but strong planning, appropriate education, and determination can help as you make this journey.
Contributed by members of the American Society for Metabolic and Bariatric Surgery (ASMBS) Patient Safety Committee and Public Education Committee
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