Rev Mar 2013 Rev July 2016 - uchospitals.edu Mar 2013 Rev July 2016 . ... ¨ Attend evaluation appointment with Surgeon, Registered Dietitian, and Psychologist

Rev Mar 2013

Rev July 2016

Center for the Surgical Treatment of Obesity

2

Bariatric Surgery Contacts

Appointment Scheduling Office

(773) 834-3524 Intake Coordinator

Laura Kujawa [email protected] (773) 834-2161

Project Assistant

Lachelle Curry [email protected] (773) 702-1618

Fax Number for Insurance Documents and Medical Records

(773) 834-0201 or (773) 834-3204 [email protected]

Nurse Practitioners

Angela Willis, RN, APN [email protected] Alisha Wilson, BSN, RN [email protected]

Registered Dietitians Jessica Schultz, RD [email protected] Kristyn Clark, RD [email protected] Bariatric Surgery Website

http://www.uchospitals.edu/specialties/general-surgery/obesity/ DCAM 6A Clinic Phone Number (773) 834-3536


3

Welcome! We are glad that you have chosen the University of Chicago Medicine and the Center for the Surgical Treatment of Obesity as your partner to better health and wellness. Obesity surgery is a powerful tool, but not a cure, for obesity. When used properly, obesity surgery is the most effective way to achieve sustained weight loss in severely obese people. On average, people lose 50-80% of their excess body weight as compared to 10% with a medically-supervised program. Landmark studies have shown that obesity surgery can lead to significant improvement and often resolution of diabetes, high blood pressure, elevated cholesterol, sleep apnea, and acid reflux, as well as significantly improve many other medical conditions related to obesity. This partnership includes dietary and lifestyle changes, and the use of nutritional supplements, as recommended. Lifestyle changes include regular exercise that includes both aerobic and resistance components to maximize functional outcomes. Following the recommended vitamin supplementation, adequate protein and nutritional intake is important to enhance long-term outcomes and minimize the risk of developing a nutritional deficiency. It is also important to maintain long-term follow-up so as to identify and treat any issues or concerns before they become more severe and difficult to manage. This continued and important partnership with us is the key for success.

§ Obesity surgery is safe — as safe as having your gallbladder removed. Most patients go home the second day after surgery.

§ Obesity surgery is covered by many insurance payers, both public and private.

Surgery might be the tool you need to help end your struggle with obesity

Best Wishes, University of Chicago Medicine



4

What is Obesity? Obesity is determined by body mass index, which estimates the amount of body fat based on height and weight.

Body Mass Index (BMI) Status 18.5 – 24.9 Healthy BMI 25 – 29.9 Overweight 30+ Obese

You can assess your BMI at http://www.cdc.gov/healthyweight/index.html. Obesity is an epidemic, increasing at an alarming rate and affecting more than ⅓ of adults in the U.S. Obesity can be caused by a variety of genetic, behavioral and environmental factors. Regardless of the cause, obesity can have devastating consequences to your health. Obese individuals face a much higher risk of developing the following conditions:

§ Type 2 diabetes § High blood pressure § Heart disease

§ Stroke § Cancer § Death

The conventional method of preventing and treating obesity is generally diet, exercise and lifestyle modification. Unfortunately, these strategies often don’t work for severely obese individuals. Bariatric surgery is a viable solution for those who struggle with obesity and associated medical conditions. Is Weight Loss Surgery for Me? Weight loss surgery could be an option for you if:

§ Your body mass index (BMI) is 40 or higher § Your BMI is 35 to 39.9 and you have a medical condition linked to obesity, such

as : o Acid reflux/heartburn o Cancer o Diabetes o Fatty liver disease o Gout o Heart disease o High cholesterol

o Hypertension (high blood pressure) o Hypothyroidism o Obstructive sleep apnea o Osteoarthritis o Polycystic ovarian syndrome o Pseudotumor cerebri o Urinary stress incontinence

Generally, candidates for bariatric surgery must also have participated in a medically supervised weight loss program. A medically supervised weight loss program is prescribed by a licensed practitioner, who monitors your progress over several months. If not, don't worry. We have the resources to get you started in this process. Last but not least, candidates must be fully committed to changing their life through bariatric surgery.


5

Types of Weight Loss Surgery The University of Chicago Medicine is the only program in the Midwest that offers four surgical weight loss procedures:

All of our surgeons perform all of these surgeries laparoscopically or minimally invasively. This means surgery is performed with small cameras and tools through several small openings across the belly. Patients prefer this approach because of its many benefits. Those benefits include fewer complications, quicker recovery, less pain, and better cosmetic results. Adjustable Gastric Band

• An inflatable silicone band is surgically inserted and wrapped around the top portion of the stomach.

• The band is designed to restrict food you consume by making you feel full faster.

• The band can be tightened or loosened by injecting or withdrawing a safe solution in the office after surgery.

• You can lose about 40-50% of your excess body weight. • Banding is the least complex surgery to perform. • Weight loss is less predictable with the band.

Sleeve Gastrectomy

• Surgeons remove ¾ of your stomach. • This procedure will make you feel full faster and with smaller

meals. • You can expect to lose approximately 60% of your excess

weight. • There is more consistent weight loss with the sleeve than the

gastric band. • There is also no intestinal rearrangement and are fewer

potential nutritional side effects. • This surgery is irreversible.


6

Roux-en-Y Gastric Bypass

• The gastric bypass is the most common bariatric surgery. • A golf ball-sized portion of the stomach is divided and

reattached to a lower section of the small intestine. • You will feel less hungry and absorb fewer calories and

nutrients. • You could lose 60-75% of your excess body weight. • There is a greater chance of improving or getting rid of your

medical problems, like diabetes and high blood pressure.

Duodenal Switch

• Surgeons will remove three-fourths of the stomach and then rearrange the small intestine and reattach the new stomach.

• Food will bypass about half of your intestines, and your body will absorb less fat and fewer carbohydrates.

• This procedure is occasionally done in two stages for safety. • This complex procedure is generally for our most obese

patients (BMI > 50) or those with very severe diabetes. • Patients could lose about 80% of excess body weight. • Nearly all patients can see their diabetes go away.


7

Risks of Weight Loss Surgery Even though our surgeons can confidently and safely perform these complex procedures, it is important to note the risks of each procedure and choose the bariatric procedure that is right for you. Take the time to discuss the risks and rewards, or pros and cons, of each surgery with your surgeon and how they relate to your circumstance. Adjustable Gastric Band

• Gastric band erosion • Gastric band slippage • Gastritis • Infection in the port • Throwing up from eating more than your new stomach can

hold or from foods that have a tougher or chewier consistency • Inconsistent or inadequate weight loss after gastric banding.

Sleeve Gastrectomy

• Reflux • Leaking from poor healing of staple lines where the stomach

has been stapled together • Throwing up • Narrowing of stomach

Roux-en-Y Gastric Bypass

• Leakage from poor healing of staple lines • Bowel obstruction • Ulcers and gallstones • Dumping (Ill feeling after eating sugary food) • Nutritional deficiencies

o These conditions can often be prevented with bile salt supplements, vitamins and mineral intakes.

Duodenal Switch

• Risks associated with the duodenal switch are similar to the gastric bypass but are a little more frequent since the surgery is more complex.

• Vitamin and mineral supplementation is important for all the procedures.

• Frequent and malodorous bowel movements o This can be controlled with diet choices, including reduced

intake of dietary fats.


8

Program Checklist

This checklist is provided as a tool for you to direct your next steps. Our staff will be in touch with you throughout the process to help with navigating the steps, coordinating insurance approval, and connecting you with other providers to manage your care. ¨ Attend information session/webinar ¨ Contact your insurance company to confirm coverage ¨ Attend evaluation appointment with Surgeon, Registered Dietitian, and Psychologist

o Contact your insurance company to verify that these appointments are covered under your policy

o Arrive to your appointment 15 minutes early and bring: government issued photo ID, insurance card, one week of completed food logs

¨ Receive surgical staff team meeting decision, including eligibility for surgery, recommended surgical procedure, and list of pre-surgical requirements and recommendations, if applicable

¨ Receive insurance pre-approval o While you are working on your requirements, we will notify your insurance

company by letter that you are requesting pre-approval for bariatric surgery ¨ Letter from primary care doctor

o If accepted, we will send your primary care physician (PCP) a letter outlining any testing and pre-surgical requirements needed before we can schedule your operation

¨ Complete all pre-surgical requirements ¨ Attend PREP group ¨ Schedule surgery ¨ Attend pre-operative consent and teaching day (approximately 1-3 weeks before

your surgery date) ¨ Surgery ¨ Attend post-operative appointments


9

Insurance Planning Worksheet How can I help to make sure I am approved by my insurance company? This worksheet is intended to help you review your health insurance policy coverage and benefits for weight loss surgery. By initiating contact with your insurance company as soon as possible and following the steps below you can help speed up the approval process. If your insurance does not cover surgery, we offer a self-pay option. Have the following information available from your health insurance card when you contact your insurance company:

§ Patient name § Patient date of birth § Insurance name § Insurance ID number § Insurance Group number § Subscriber name § Subscriber date of birth § Subscriber employer

Call the customer/member services phone number listed on the front or back of your insurance card. Tell the representative that you would like to “check your policy benefits” and ask the following: 1. Is weight loss surgery for morbid obesity a “covered benefit” of my policy? Listed

below are the operative codes and diagnosis code.

Operative procedure codes: § CPT 43770 (Laparoscopic Adjustable Gastric Band) § CPT 43775 (Laparoscopic Vertical Sleeve Gastrectomy) § CPT 43644 (Laparoscopic Roux-en-Y gastric bypass) § CPT 43659 [or 43775+44238] (Laparoscopic Duodenal Switch)

Diagnosis code (ICD-10) for morbid obesity: E66.01 2. Does this benefit require a medically supervised weight loss program? If yes,

what is the program length? 3. Is a referral from my primary care doctor required?


10

Other questions that may help you with your insurance § Are there any exclusions? § What is the calendar year renewal date? § What is my deductible per calendar year? § How much have I met towards my deductible? § What is my maximum out-of-pocket cost per calendar year? § How much have I met towards my maximum out-of-pocket? § Is the deductible applied to my maximum out-of-pocket? § What is my inpatient surgical co-pay to the doctor? § What is my inpatient surgical co-pay to the hospital? § What is my outpatient surgical co-pay to the hospital? § What is my co-pay for a specialist office visit? § What are the phone and fax numbers for the bariatric pre-determination department?

Helpful Tips § Keep a detailed record of all your communications, including doctors’ offices,

nutritionist, weight loss program, and insurance representatives. § Contact your primary care doctor and request one clinic record per year for the last 5

years. This will help with documenting your obesity and co-morbidity condition(s). § If you have been on a supervised diet through the doctor’s office or a commercial

program, request a copy of your records containing this information.

11

Financial Planning for Bariatric Surgery In addition to surgery, there may be other costs that your insurance does not cover. This financial planning worksheet is intended to help you review these costs and make a financial plan, if needed. Lovenox/ Enoxaprin (generic) Coverage/Co-Pay: You will need two doses per day for 14 days for a total of 28 doses. Please call your pharmacy or pharmacy benefit provider. $ _______ 40 mg $ _______ 60 mg $ _______ 80 mg $ _______ 100 mg

Nexium Coverage: If not covered, you will be required to buy an over-the-counter alternative. We will provide dosing instructions at the time of hospital discharge. Protein shakes: You will need 28 shakes during the 10 days before surgery and first 2 weeks after surgery for laparoscopic banding procedure. $2-4 per shake ($56-112 total) Daily Vitamins $3-30/month Multi-vitamin $3-8/month Vitamin B complex 50 $11-16/month Calcium citrate 600 mg – twice a day $3-7/month Dry vitamin D 10,000IU (for gastric bypass and duodenal switch) $2-3/month Dry vitamin A 10,000IU (for duodenal switch only)

When selecting your vitamin and minerals, we strongly recommend supplements containing the USP Verified Mark (noted above). For more information on the USP Verified Mark please visit: http://www.usp.org/usp-verification-services/usp-verified-dietary-supplements/usp-verified-mark. Transportation and Parking: Please anticipate 7 visits to the medical center for routine appointments in the first year after surgery. Information about parking rates is available at http://www.uchospitals.edu/visitor/directions/parking.html.


12

What to Expect After Surgery Nutrition After surgery, the size of your stomach will be reduced. Those patients who undergo the Roux-en-Y Gastric Bypass or the Duodenal Switch procedures will experience nutrient malabsorption, as well; because of this, you will need to make several important dietary and lifestyle changes. This handout highlights the dietary changes needed after surgery.

Dietary Recommendations for Laparoscopic Banding Procedure

Weeks 0-2

•  Liquids only

Weeks 2-4

•  Pureed/ blended foods

Weeks 4-8

•  Soft, low fiber, easily digested foods

Week 8+

•  Regular diet

• Only 3 meals per day o 2 oz (¼ cup) of food per meal during first few weeks o No snacks o You must eat enough protein every day to heal your wounds,

stay healthy, and lose weight. Consume at least 65 grams of protein daily.

• Do not eat and drink together o Consume liquids 30 minutes before or after meals o No carbonated beverages o Drink 6-8 glasses of low-calorie fluids daily

• To prevent nausea and vomiting, do not eat or drink too much. o Excessive vomiting can cause the band to slip, and

overeating may cause the pouch to stretch, which cancels the effect of the surgery.

• An active lifestyle after surgery is essential to your weight loss success

o Within 2 months of having surgery, 30 minutes of daily exercise is recommended

• Take vitamins daily, as recommended • It is typical to go back to a liquid diet after every band adjustment


13

Dietary Recommendations for Roux-en-Y Gastric Bypass and Vertical Sleeve Gastrectomy

Weeks 0-2

• Pureed/ blended foods

Weeks 2-6

• Soft, low fiber, easily digested foods

Week 6+

• Regular diet

• 4-6 meals per day o 2-4 oz (¼-½ cup) of food per meal during first few weeks o Spend 30-45 minutes eating each meal o You must eat enough protein every day to heal your wounds,

stay healthy, and lose weight. Consume at least 65-85 grams of protein daily.

• Fluids are important to prevent dehydration o No carbonated beverages o Drink at least 48-64 oz of fluid daily between meals



• Take vitamins daily, as recommended


14

Dietary Recommendations for Duodenal Switch

Weeks 0-2

• Pureed/ blended foods

Weeks 2-6

• Soft, low fiber, easily digested foods

Week 6+

• Regular diet

• 4-6 small meals per day o 2-4 oz (¼-½ cup) of food per meal during first few weeks o Spend 30-45 minutes eating each meal o You must eat enough protein every day to heal your wounds,

stay healthy, and lose weight. Consume at least 85 to 100 grams of protein daily.

• Fluids are important to prevent dehydration o Do not eat and drink together o Consume liquids 30 minutes before or after meals o No carbonated beverages o Drink at least 48-64 oz of fluid daily between meals



• Take vitamins daily, as recommended o


15

Dietary Recommendations

Amounts of Protein in Common Foods (grams per serving)

Food item Grams of protein

Serving size

Pureed Poultry/Beef/Fish/Pork 7 1 oz (cooked) Plain Scrambled Egg 6 1 egg Melted Cheese 4-8 1 oz (1 slice) Milk (2%, 1% or nonfat) 8 8 oz (1 cup) Cottage Cheese (small curd) 8 ¼ cup Yogurt (Without seeds or skins) 8 8 oz (1 cup) Greek Yogurt (plain) 24 8 oz (1 cup) Peanut Butter 8 2 tablespoons Cashew Butter 6 2 tablespoons Milk Kefir (plain) 11 8 oz (1 cup) PB2 (powered peanut butter) 5 2 tablespoons Fairlife Milk (lactose free) 13 8 oz (1 cup) Nonfat powdered milk 8 2½ tablespoons Refried Beans (low fat) 6 ½ cup (cooked) Tofu 5 ¼ cup Pureed Vegetables 2 ½ cup (cooked) Pureed Fruit/Fruit Juice 0 ½ to ¾ cup juice Cream Soup 3 ½ cup Tomato Soup 2 ½ cup Pudding 3 ½ cup Farina 2.5 ¾ cup Grits 3.5 1 cup Oatmeal 3 ½ cup


16

Tips to Increase Your Protein Intake Everyone will need to take some sort of protein shake after surgery. Look for high protein/low calorie drinks. There are many flavors and formulations available. If you don’t like the first one you try, don’t worry. You’ll find one that suits your needs. § Double-strengthen your milk (add 2½-3 tablespoons of non-fat powdered milk per 1

cup milk). § If you have lactose intolerance, try Lactaid ®, Dairy Ease ®, or Fairlife Milk ® which

contains enzymes to help digest your milk. You may also try soy or hemp milk. § Add PB2, non-fat powdered milk or a protein supplement of your choice to any liquid

or pureed food (cottage cheese, soup, yogurt, hot cereal § Sip on a protein drink between meals.

Recommended Beverages Carbonated beverages are not acceptable, as they may stretch the pouch, cause feelings of over-fullness, and may lead to vomiting. § Water § Low-fat Milk or 2% Milk or Fairlife Milk ® § Crystal Light ®, or iced tea sweetened with Stevia in the Raw ® or Monk fruit in the

Raw ® or other sugar substitute § Hot tea or coffee unsweetened or natural sweetened with a sugar substitute § Vitamin Water Zero or Powerade Zero Once you’re in the maintenance phase, it is very important you maintain a healthy diet. Your everyday diet should be high in quality protein and vegetables, moderate in complex carbohydrates and healthy fats, and low in simple carbohydrates, unhealthy fats and processed foods. Remember, you will also need vitamin supplements to compensate for the loss of nutrients, especially after the duodenal switch and gastric bypass. Exercise Within six weeks of surgery, you should exercise for at least 30 minutes every day. You should do aerobic or cardio workouts, which are any workout that increases your heart rate like brisk walking, jogging or swimming. You should also begin strength and resistance training, like body weight exercises and stretching. It is important to find activities that you enjoy and that allow you to see your progress and improvement.


17

Supportive Resources

PREP Group: The Preoperative Readiness Education Program (PREP) group is a one-time skills group. The purpose of this group is to discuss ways to successfully maintain long-term weight loss. A combination of activities and lecture will be given in this 3-hour group. Additional registration information will be provided to you after your evaluation in our program.

Support Group: The support group meets the first Tuesday of the month in the Center for Care and Discovery, 5700 S. Maryland Avenue, 7th floor, Room 7750 from 5:00 to 6:30 p.m. This group is for both pre-surgical surgery candidates and post-surgical patients. There is no registration for this group. We look forward to seeing you there! Note: Please contact Christine Daemicke at [email protected] or 773-702-1351 for additional information about these programs.


18

What Makes A Good Support Person?

§ Someone who is willing to make the commitment and be available. § Someone who listens, but doesn’t judge you. § Someone who is present before, during, and after surgery. § Someone with whom you feel comfortable communicating your needs and

feelings. § Someone with whom you will not feel embarrassed to help you with your care. § Someone who is positive about the surgery. § Someone who will be a motivator. § Someone who can make your meals and encourage you to eat properly. § Someone who is available to attend the meetings. § Someone who is knowledgeable about the surgery. § Someone who facilitates change and accepts the changes in you.

Information for Support Providers

Agreeing to serve as a support person for someone undergoing bariatric surgery is a substantial and important commitment. Support providers serve as motivators, cheerleaders, and friends for patients. Your role is to be an advocate for the patient’s health. Sometimes this may mean sitting with the patient and being a good listener. Sometimes this may mean encouraging the patient to walk when she or he doesn’t feel like it. Be supportive, positive, and understanding. Assisting the patient in the following treatment guidelines:

§ Encourage the patient to eat at regular intervals even when the patient isn’t hungry. This is necessary to promote healing post-surgery. This may be difficult to do since the patient has a loss of appetite following surgery.

§ Help puree meals or ensure that acceptable food is available. § Assist the patient in consuming 60 to 80 grams of protein a day. § Encourage the patient to walk and move around. Even though patients may feel

discomfort after surgery, physical activity is necessary in order to avoid post-surgery complications, to promote healing and weight loss.

§ Aid in getting the patient to attend all follow-up appointments. Provide emotional support and be a positive influence on the patient:

§ After surgery, recovery can be difficult. Validate the patient’s experience. § Accept that after surgery, there may be a time when the patient is grieving for

losing the ability to eat their pre-surgery diet. This is common and most people move out of this stage soon. Listen and empathize with the patient.

§ Learning how to follow the diet post-surgery takes time. Support the patient’s efforts to make changes and encourage ongoing improvement.

§ Be available when the patient needs assistance or emotional support.


19

Other Resources

BMI Calculators and Healthy Weight Information http://www.cdc.gov/healthyweight/index.html http://nhlbisupport.com/bmi/ www.BMI-calculator.net Weight Loss Forums, Chats, Support Groups, Blogs www.obesityaction.org www.obesityhelp.com www.exchanges.webmd.com/bariatric-surgery-exchange www.wlslifestyles.com http://theworldaccordingtoeggface.blogspot.com http://bariatricfoodie.blogspot.com Follow us on Instagram @ uchicagoweightloss Physical Activity http://www.cdc.gov/healthyweight/physical_activity/index.html http://www.heart.org/HEARTORG Nutrition, Dietary, Vitamin Resources Bariatricadvantage.com BariatricFusion.com BariLife.com Celebratevitamins.com Unjury.com Naturemade.com Berimelts.com Online Food Diary, Tracking websites, Smartphone Apps Spark People My Fitness Pal Get-2-Goal Workouts


20

Name: ____________________________ Date: _____________

Food Diary Time of snack/meal Food Item Amount cup/oz How was it

prepared?

10:00 am Bagel with peanut butter Orange juice

1 item (3oz) 20 oz bottle

Deli-type, blueberry

1:30 pm Turkey Sandwich Chips (Doritos) Mt. Dew

2 sl bread, 2 oz turkey 2 oz bag 12 oz can

1 T mayo, 1 t mustard

Breakfast _____am/pm

- - -

- - -

Snack _____am/pm

- - -

- - -

Lunch _____am/pm

- - -

- - -

Snack _____am/pm

- - -

- - -

Dinner _____am/pm

- - -

- - -

Snack _____am/pm

- - -

- - -

Beverages Consumed: (cups/ounces) _____Water _____Iced tea/hot tea/coffee _____Milk _____Pop/Soda _____Juice _____Other


21

Notes: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________