1. Weight Loss Surgery at East Carolina University An Introduction to Our Program: Before, During, and After!

2. Goals and Objectives Describe obesity and health effects of obesity Describe weight loss programs offered by East Carolina University (ECU) Describe pre-operative work-up and post- operative care related to weight loss surgery

3. Our Informational Materials This is not intended to persuade you to have surgery and should NOT be considered medical advice Only you, your family, your medical doctor, and your surgeon know if bariatric surgery is right for you If you are interested in exploring weight loss surgical options further, you will need to talk with a bariatric surgeon

4. Why have your surgery with ECU? Our surgeons are highly qualified experts We are involved in research We have an array of services aimed at providing care to morbidly obese clients and their families We genuinely want to help you reach your goals

5. Choosing a Surgeon You or your doctor may choose a specific surgeon from our practice to see. The surgeon that you select may require additional personal or medical information in order to schedule an appointment. Once you have established a relationship with our surgeons, you should then follow only their advice and educational materials

6. What is Morbid Obesity?  Being 100 pounds over “ideal weight” (your ideal body weight will be calculated during your first visit with your surgeon)  Using the Body Mass Index (BMI) Morbid Obesity is defined as a person: -BMI of 40 or higher OR -BMI of 35 or higher with co-morbidities related to morbid obesity

7. Sizing Up Your Level of Body Fat Using the Body Mass Index (BMI) –Used to determine if you qualify for surgery –Measures obesity based on weight and height

8. Changing Perceptions of the Seriously Overweight In the Past: Obesity was seen as a weakness or failure of individual Diet and exercise were prescribed treatments Weight loss surgery was viewed as dangerous and extreme Now in the Present: Obesity is considered a disease and the cause of many serious health conditions Surgery has gained acceptance as the only proven method to treat this disease

9. What are the impacts of Obesity?? Social Implications –Unfortunately, still an acceptable form of social discrimination Economic Implications –Personal cost = $15,568 per year (diets, food, prescriptions) –National cost = $200 billion $93 billion in medical bills $33 billion on weight-loss products/services Medical and Health Implications –With BMI > 30 70% increase in coronary artery disease 75% increase in stroke 400% increase in diabetes 55% increase in mortality

10. Health Conditions Associated with Morbid Obesity (Co-morbidities) High Blood PressureHeart Disease Congestive Heart FailureSwelling (legs, feet) DiabetesSleep Apnea Degenerative Joint DiseaseDVT (Blood Clots) Shortness of BreathAcid Reflux Stress IncontinenceDepression Irregular Menstrual Cycles Gallbladder Disease

11. What are your options?? 1. Diets, exercise, and behavioral change –Up to 10% loss of excess body weight –Ineffective long-term: less than 5% sustain any significant weight loss 2. Weight Loss Drugs –Minimal sustained weight loss –Side effects prevent long term use 3. Weight Loss Surgery –Average 55-75% loss of excess body weight Source: Adkinson, Am J. Clinical Nutrition, 1994

12. Who Qualifies for Weight-Loss Surgery? Clinical Terms Used to Describe Various Levels of Body Fat Norm a l Weight (BMI 18.5 to 24.9) Overweight (BMI 25 to 29.9) Obese (BMI 30 to 34.9) Severely Obese (BMI 35 to 39.9 ) Morbidly Obese (BMI 40 or more) BMI 18.5-24.9 BMI 25-29.9BMI 30-34.9BMI 35-39.9 BMI>40

13. Characteristics of Potential Candidates 100 pounds above your Ideal Body Weight Body Mass Index: -40 or greater with no co-morbidities -35 or greater with co-morbidities Age of 18 to 65+ (assessed on individual basis) Failed attempts at weight loss Health complications related to obesity No psychological contraindications Understanding of the surgery/risks Compliance with diet/exercise requirements

14. Most Common Surgical Options Restrictive and malabsorptive Roux-en-Y BypassLAP BAND Restrictive

15. Gastric Bypass Advantages Rapid initial weight loss Laparoscopic approach is possible Longer experience in USA Takes 1-2 hours Disadvantages Stomach cutting, stapling and intestinal re-routing required Portion of digestive tract is bypassed, resulting in nutritional deficiencies “Dumping syndrome” can occur Non-adjustable Extremely difficult to reverse

16. Dumping Syndrome -Stomach contents move too rapidly through the small intestines following surgery -Does not happen with the band. -Avoid by following prescribed diet -Symptoms: -Rapid heart beat-Headache -Sweating -Nausea -Dizziness -Diarrhea -Lightheadedness -Stomach cramping -Sleepiness

17. The LAP-BAND System Advantages Lowest mortality and complication rate Least invasive surgical approach No stapling, cutting, or intestinal re-routing Adjustable Reversible Low malnutrition risk Takes 1 hour/ outpatient surgery Disadvantages Slower initial weight loss than Gastric Bypass Regular follow-up critical for optimal results: Need adjustments Requires implanted medical device

18. What Surgery is Right for Me? REMEMBER….. All surgery has risks Not all patients are candidates for surgery Discuss your options with your surgeon

19. Possible Risks and Complications Remember: there are risks associated with any surgery Your surgeon will discuss specific details regarding each surgical option at your first new patient appointment.

20. Comparing Weight-Loss Results Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and Bariatric Surgery, ANZ J Surg, 2004; 74: 200-204. Gastric Bypass LAP-BAND

21. Your Appointments With the Surgeon and the Surgery Practice You will have three visits with your surgeon before your surgery. Your first visit is called your “New Patient Visit”. At this visit, you will do the following: - Talk with the surgeon about the procedure - Explore financial and insurance requirements - Have a brief physical exam - Determine preoperative evaluations you may need - We will remind you to STOP SMOKING!!! You must be smoke-free for 3 months prior to surgery and should not smoke after surgery as well! - Have an opportunity to complete a few tests before going home.

22. After the “New Patient” Visit You will receive a letter a few weeks later with appointments you must keep before your second visit. These will include: Psychological evaluation Nutrition evaluation Upper Gastric Exam Blood testing (lab work) Anesthesia Consult Also, if not done at your “new patient” visit: Chest X-Ray EKG ABG

23. Possible Pre-Operative Evaluations (you may need these additional tests before your second visit if your surgeon feels it is necessary) Other Lab Work Colonoscopy Sleep Study Upper gastric endoscopy Consult with cardiologist Consult with pulmonologist Consult with vascular doctor Ultrasound of the abdomen

24. 6 Month Program Depending on your insurance company, you may have to complete a six month diet and exercise program. Please refer to the example progress note in your introductory handout. When you contact our office, we will inform you if this is your insurance requirement. If you do require a program, you will need to complete 4 months prior to being scheduled for your first visit with the surgeon.

25. Scheduling your appointments Please do not miss your appointments!! Remember: rescheduling may mean prolonging your process. If you repeatedly miss an appointment or fail to show up for an appointment without notice, you may be dismissed from the program. This surgery is a lifestyle change, and we want you to be successful in your weight loss journey!

26. Making The Decision Once your consults and tests are completed, you will have your second visit, called the “Decision Visit” - You will be seen in the clinic by your surgeon -Tests results are reviewed -All questions about the surgery are answered -The risks and benefits of the surgery are reviewed with you -Research opportunities will be discussed with you -You will receive a prescription for a diet that we will instruct you to begin 2-3 weeks before surgery.

27. Prescription Diet Before Surgery  We will give you the prescription for Optifast, which will be in the form of shakes (and the choice of one soup if you like) in place of meals.  This prescription is not usually covered by insurance. It is approximately 71$ per week.  This diet will allow you to jumpstart your weight loss journey.  At your first appointment, we will go into further detail regarding your pre-operative diet.

28. Insurance Approval Process After your “Decision Visit”, our office will begin the approval process if you are an adequate candidate for surgery. We will mail or fax your evaluations, diet and exercise history, letters of clearance, and personal letter from our office to your specific insurance company. This approval process may take as long as 6- 8 weeks.

29. Insurance Coverage Approved When we receive insurance approval, we will contact you with your third appointment and surgery date! Your third appointment is the “History and Physical”.

30. History and Physical Appointment Includes the following:  Brief physical exam  Discussion of surgery, risks and benefits  Consent forms signed  Update lab work and tests if necessary  Must have support person present or your surgery may be cancelled!!

31. Insurance Tips to Remember -You MUST meet the requirements of all the insurances that you have prior to submitting for approval -Depending on your insurance company, the approval process may be lengthy (6-8 weeks) -You must check your SPECIFIC policy (or policies) to make sure weight loss surgery is a covered benefit!!! -If your insurance company denies your request for surgery, the appeal process may be started. This can be quite lengthy and involved, so it is important to know from the beginning your specific insurance company’s criteria. We will help you to the best of our ability to meet these requirements, but it is ultimately your responsibility to be familiar with your individual insurance policy.

32. Helpful Hints Prior to Surgery -This is a weight-loss program! Any weight gain could result in prolonging, rescheduling, or cancelling your surgery. -You must quit smoking! We may require a nicotine test prior to having surgery in order to ensure you have stopped. -Multiple cancellations, skipped appointments, or just not showing up for appointments can result in prolonging the pre-operative process and possibly dismissal from the program.

33. Day of Surgery (you have been approved and completed your third visit which is your History & Physical) -You will be admitted to our Ambulatory Surgery Unit (ASU) -An IV will be started -You will be given an antibiotic and additional teaching by the nurse -After you have been prepared for surgery, you will go to the operating holding area -Your family may wait in the family waiting area and will be contacted after the operation

34. Recovery Hospital Stay: Open surgery (3 to 4 days) Laparoscopic (2 to 3 days) Lap Band (1-2days) Out of Work: Open surgery (4 to 6 weeks) Laparoscopic (2 to 4 weeks) Lap Band (1 to 2 weeks) -No driving for 1-2 weeks following surgery -No heavy lifting anything over 10 pounds for one month after surgery

35. Gastric Obesity Procedure (GOP) Diet Following Surgery GOP Level I Diet: - This starts after surgery and lasts for 2 weeks -Two ounces (1/4 of a cup) of Optisource in place of meals -Between “meals” you may have two ounces of non-sweetened, non-carbonated beverages. - You MUST SIP WATER all day long -No carbonated beverages

36. Home Diet Following Surgery We will give you specific details about your diet following weight loss surgery. Generally this consist of: Drastically limiting volume Limiting the consistency of food Limiting the types of food

37. Tips for Eating After Weight Loss Surgery -Do not drink liquids with meals, either drink 30 minutes before or 30 minutes after -Chew food well -Take small bites of food -Eat meals over a 30 to 45 minute time span -Eat meals on small plate, use baby spoon

38. Eating after LAP BAND Small volumes 2-3 oz. of healthy foods Similar restrictions as the gastric bypass When you are not “filling up” than adjustment needs to be done. Band may need to be adjusted 3-4 times in first year. Diet modified after each adjustment

39. How Much Weight Can a Patient Expect to Lose Following Surgery? Depends on the surgery and the follow-up 75% of excess weight -with Gastric bypass at the end of one year 45% of excess weight with Band but increases to 65% at 2-3 year follow up with adjustments Amount of weight loss varies from person to person Must be compliant with follow-up!!!!!

40. Plastic Surgery Consult Following Surgery -There may be excess skin on the chest, abdomen and arms and legs -We can refer you to a plastic surgeon when the following criteria is met: -After you Have Maintained a Stable Weight (this may be 12-18 months or longer) - Your nutritional status is adequate - Your surgeon will ultimately decide when this referral is appropriate -Insurance rarely covers these procedures. Document issues with your primary care now and after surgery.

41. Vitamins and Medications after Surgery (REQUIRED for LIFE) Gastric Bypass -2 chewable multivitamins daily (ex: Flinstones) -Calcium Citrate or Tums 1000 mg daily -Vitamin D 800 iu daily -Vitamin B 12 250 mcg daily -Ferrous Sulfate elixir 325 mg daily (menstruating women only) Band -2 chewable multivitamins daily (ex: Flinstones) In addition, women take: -Calcium Citrate or Tums 1000 mg daily -Vitamin D 800 iu daily

42. Vitamins and Medications Tips to Remember! -After surgery, all vitamins and medications need to be one of the following: CRUSHED CHEWABLE LIQUID FORM - Please speak with your primary care doctor and pharmacist to help adjust these medications. Some drugs are NOT safe to crush.

43. -Females should not become pregnant for at least 12 to 18 months following Gastric Bypass. Pregnancy prior to this could result in fetal demise or neural tube defects - After the band surgery, it is best you maintain a stable weight loss and plateau prior to becoming pregnant. - You must follow what your surgeon tells you is best, and please inform them if you plan on having children in the future after weight loss surgery. Pregnancy following Surgery

44. Follow-Up After Surgery Gastric Bypass Lifelong commitment Every 2 weeks for first month after surgery Every 3 months for the first year after surgery Yearly for a lifetime Lab work is checked at every visit Lap Band Life long commitment 2 weeks and 6 weeks after surgery At 6 weeks, you may have your first adjustment Monthly for first year After first year, surgeon will decide how often to see you Lab work checked every 3 months

45. Support Groups We encourage you to join a support group prior to surgery and maintain participation with the support group after surgery. Ideally, you should attend the support group offered by your surgical practice. Our Support Group is the 3 rd Tuesday of each month at 6pm. Enter through the Brody Outpatient Center Lobby and follow the signs!

46. Exercise - Exercise is an important part of your weight loss journey. Remember, surgery is a tool to help you reach your goals. You must do your part as well! - You will work up to doing exercise daily for 30 to 45 minutes per day - Exercise options can include: -Walking with hand weights -Bike riding-Weight Training -Aerobics-Jogging -Swimming -Water aerobics

47. Making An Appointment The next step in pursuing weight loss surgery is a visit with a qualified bariatric surgeon. If you already have an appointment with a weight loss surgeon, please keep the appointment, or if you are no longer interested, please contact their office to cancel your appointment.

48. Conclusion Thank you for reviewing our informational material! We look forward to working with you in the future, and we are available to answer any questions you may have. Please type in the following web address in your internet browser to receive your certificate, http://www.ecu.edu/weightlosssurgery/certificate.cfm Please print out the following certificate and sign. This certificate is proof that you have completed our online orientation. Please write down any questions you may have on the space provided. You must bring this form with you to your first appointment with the surgeon, as this is a requirement for our program. We look forward to seeing you soon!