PREGNANCY AND WEIGHT LOSS SURGERY

Gastric Bypass & Band Surgery (Lap Band & Realize Band) Increases Fertility

One of the first questions many of my female patients in their twenties and thirties ask me when contemplating gastric bypass or lap band surgery is how the procedures will affect their ability to get pregnant. Many have tried to conceive in the past, and have been unsuccessful. The good news is that in addition to improving ones overall health, both procedures can have a positive effect on fertility. While they can’t overcome serious fertility issues, research shows both gastric bypass and lap band surgery can improve many factors related to infertility for those who are obese.

Obesity’s Toll on Fertility and Pregnancy
Obesity takes a toll on the body, as many people know it’s often the cause of diabetes, heart disease, high blood pressure and sleep apnea. What many don’t realize is the toll carries over to fertility too. Being seriously overweight causes an increase in the level of two key hormones related to fertility – estrogen and testosterone. While an increase in these two hormones result in excess body hair and risk in breast and uterine cancer, it’s also directly related to infertility, causing irregular or heavy periods. Weight loss after gastric bypass or lap band surgery results in normalization of estrogen and testosterone, and a return to normal menstrual cycle and improved fertility.
For those who are able to conceive, obesity also takes a toll on the pregnancy increasing the risk for gestational diabetes, hypertension and spontaneous abortions. There is also an increased rate of cesarean sections due to large weight fetus that results from gestational diabetes. Weight loss surgery prior to pregnancy can help resolve the pregnancy-related medical conditions obese woman are at risk for, often resulting in a safe and healthier birth.

Pregnancy after Gastric Bypass or Lap Band Surgery
After patients learn about the benefits to weight loss on fertility, they quickly ask how gastric bypass or lap band surgery will affect pregnancy. Is pregnancy safe after surgery? Will I be able to take in enough nutrients for both me and the baby? Multiple studies show that pregnancy is safe after bariatric surgery provided you follow a couple of key guidelines. To start, for your safety and the safety of the baby it’s very important to avoid becoming pregnant for one year after gastric bypass surgery as this is the time where one’s weight loss will be most significant. Contraception is a must for the first year after both procedures, and for gastric bypass in particular oral contraceptives (OCP) might not be adequately absorbed after the procedure so it’s important to use an additional form of contraception.
With lap band surgery, one can safely conceive six months after the procedure but might not have lost enough weight yet to avoid pregnancy related health conditions.
As with any patients who have had weight loss surgery, nutritional supplements need to be taken religiously before, during and after pregnancy. This is because gastric bypass surgery is both a restrictive and mal-absorptive procedure. It results not only in a decreased intake of food – four to six ounces of food per meal - but it also decreases the absorption of calories and nutrients you have consumed.
Lap band and the new Realize band surgery is a restrictive procedure, resulting in only decreased amount of solid food one can consume at one setting. The decrease in calories, means a decrease of nutrients you take in, so it’s important to add nutritional supplements to your diet.

Key supplements to increase include iron to form new red blood cells, calcium for mineralization of fetal skeleton, folic acid to prevent birth defects, vitamin B1 (thiamine), vitamin B12 and vitamin A. Women should also take protein supplements in the form of protein shakes (Table1) or protein bars as one cannot take the recommended daily allowance of 60 grams of proteins per day from foods. I recommend taking at least half or 30 grams in supplements and the rest from foods rich in proteins. (Table 2)

For women who have undergone gastric bypass or lap band procedure pregnancy can be safe for them and even healthier for the baby with regular follow-up visits to your bariatric surgeon and obstetrician. Below are ten guidelines to help you along the way.

Ten Guidelines to follow for a safe pregnancy:
1. Avoid pregnancy for one year after weight loss surgery
2. Take multivitamins (Vitamin A, B1, B12, Iron, Folic Acid)
3. Make regular appointments with your bariatric surgeon and obstetrician
4. Obtain regular blood test to check for vitamin deficiency
5. Eat multiple small meals a day (at least four meals per day) and spend 30
minutes to eat each meal
6. Eat high-protein, low-carbohydrates and a low fat diet
7. Take 30 grams of proteins in supplements
8. Drink plenty of water (40 – 60 ounces per day)
9. Continue regular low impact exercise for both body and mind
10. For lap band or realize band patients, one can remove the restriction by an
adjustment if patients develop pregnancy related nausea.

Table 1 High-protein and low-carbohydrates shakes
Protein supplement shakes are best mixed with skim milk or lactaid milk as lactose intolerances can occur after surgery. Another option is to mix in the blender the protein powder with sugar-free yogurt or sugar-free beverages. You may split your protein shake into 2 or 3 servings, as long as you take 30 -40 grams of protein in 100-150 calories. Suggested supplements include:
• Designer Protein (90kcal/17.5g pro per scoop)
• Isopure (210kcal/50g pro per 2 scoops)
• Pro-stat 64 (15g proteins and 1g Carbohydrate per2 tablespoon)
• ISS Whey Protein (96kcal/17g pro per scoop)
• Twinlabs Triple Whey Fuel (100kcal/21g pro per scoop)


Table 2 Foods Rich in Protein
Our bodies need the amino acids and other nutrients found in protein-rich foods. Protein builds and repairs muscle, and is the fuel that gives our body energy. Patients should attempt to get at least 60 grams of protein a day. Good sources of protein include:
• Turkey, chicken, or beef - purchase 97% lean meat
• Baked, broiled, or BBQ skinless chicken, white turkey meat, or fish
• Ground or chopped chicken or turkey (white meat) for salads (use nonfat, non- dairy based dressing)
• Water packed tuna (1/4 cup = 1 oz meat)
• Egg whites or egg substitute. (Yolk has all the cholesterol and fat, whites
are pure protein)
• Nonfat yogurt
• Cereals: oatmeal or cream of wheat with nonfat milk
• Kidney beans, navy beans, lima beans, pinto beans
• Baked potato
• Nonfat cottage cheese (great on a baked potato)
• Cereals (read labels for those high in protein and fat free or low fat)
• Fish baked or broiled

Choosing a Procedure

Lap Band vs. Gastric Bypass: Choosing the Right Procedure

Patients considering weight loss surgery often ask “which procedure is right for me?” At the New Jersey Bariatric Center both surgical weight loss procedures -- gastric bypass or lap band -- result in successful weight loss. The best way to make the decision regarding which procedure is best for you is to consider several factors: loss of pounds, reversibility, diet requirements and risk, and compare the pros and cons of them against your personal goals. 


Weight loss:

Initial weight loss with the gastric bypass is approximately 3lbs to 5lbs per week for the first three to six months. Over 18 months the gastric bypass procedure results in approximately 60 to 70 percent excess weight loss. However, gastric bypass is both a restrictive (restricts the intake of food) and mal-absorptive (less absorption of calories you take in) procedure resulting in weight loss from both decreased food intake and decrease calorie absorption. 

With the lap band procedure weight loss is slower, about 1lbs to 2lbs a week. Over an18 months it will approximately result in a 50-60% excess weight loss. Since the Lap Band is only restrictive, and not mal-absorptive, it requires much more personal will power to avoid high calories and snacking. In addition, Lap Band requires significant and consistent follow up for the first year to adjust the band.

Keep in mind, that a slower weight loss does not necessarily mean less ‘hanging skin,’ nor does faster weight loss result in more ‘hanging skin’ problems. These issues are a factor of the amount of weight loss and your age, not the amount of time it takes to lose the weight. 



Reversible:

Unlike the gastric bypass, the lap band procedure is reversible. At any time, you can choose to have the band removed. Keep in mind, patients who typically have the band removed often gain the weight back over a short time period. 


Diet:

Regardless of the procedure, patients are required to eat healthy and exercise to maintain the weight loss. However, when comparing the procedures, the gastric bypass requires less dietary compliance as it combines both the restrictive and mal-absorptive components. With the bypass you simply can’t intake the same amount of food, high caloric food or eat to quickly without getting physically ill (dumping syndrome). However, due to the mal-absorption component of the bypass, patients must take protein and vitamin supplements for life. 
Dumping syndrome can occur after gastric bypass surgery resulting in dizziness and heart palpitations. It occurs 15 to 30 minutes after a high carbohydrate meal, especially one that's rich in sugars such as sucrose (table sugar) or fructose (fruit sugar). Some people also experience low blood sugar (hypoglycemia), related to excessive levels of insulin delivered to the bloodstream as part of the syndrome. Insulin influences your tissues to take up the sugar present in your bloodstream. 



Risk:
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To date, at the New Jersey Bariatric Center we have no mortality and below average complications for both procedures. However, when comparing the two procedures and looking at the national statistics the lap band has a significantly lower risk of death than the gastric bypass procedure since it is less invasive.



Making the decision:

Ultimately, the decision to have the procedure is entirely up to you. After reviewing all the information and attending one of the free educational seminars at New Jersey Bariatric Center, you must decide if the benefits outweigh the side effects and potential complications. This surgery is only a tool. Your ultimate success depends on strict adherence to the recommended dietary, exercise and lifestyle changes.

While most patients enjoy an improvement in obesity-related health conditions (such as diabetes, heart disease, mobility, self-image and self-esteem) after the successful results of weight loss surgery, these results should not be the overriding motivation for having the procedure. The goal is to live better, healthier and longer. 
The key is not to be pressured to pick a procedure by anyone, including your medical doctor, your family or a friend. Do the research yourself and learn the pros and cons of both the procedures. In the end, the decision is yours, it’s your life and you will need to be comfortable with what you choose.

Finding Your Inner Athlete

Weight loss surgery is a wonderful tool in leading a healthy lifestyle, helping people to control portion size and food choices and enabling a successful weight loss journey. It’s not the only tool, however, and following a regular exercise plan is another necessary component for a successful lifestyle change. Whether you’re new to an exercise plan or looking to energize your current plan, the tips in this issue will help you to find your inner athlete, that person who loves exercise. 

Starting Out with the Right Environment: We all have different exercise styles: Some of us prefer to work out at home, while others enjoy the energy and camaraderie of a gym environment. If you prefer to work out alone and want to stay in the privacy of your own home, make sure you designate a space and set it up with the right equipment. You’re unlikely to use that elliptical if you have to move a couch or a stack of books to get to it, so make exercise a priority in the home. This could be as simple as finding a good comfy exercise mat, a jump rope, and a set of resistance bands. If you like the motivation of working out with others, a gym might be a better solution. Keep in mind that different gyms have very different atmospheres. Some are more family- oriented with lots of classes, others cater to the individual exerciser. All can be intimidating to a novice so ask around for recommendations, read the online reviews, and go visit. When you visit, ask any of the questions that might be holding you back—are there weight limits on the cardio machines? When are the least crowded times of day? Can a trainer teach you how to use the machines? Choosing the right gym for you can make a huge difference in your motivation to work out— so don’t just settle for the first one you visit! 

Getting Help From the Experts: Don’t be reluctant to ask for help, whether from the staff at the gym, a friend whose fitness plan you admire, or by hiring a personal trainer or exercise physiologist to devise a plan for your specific needs. An expert can help you to refine your fitness goals, make your workouts more effective, and help to motivate you to achieve. We work closely with Stephen Kelly, MPT to help you develop an exercise program that is right for you.

Setting Goals and Measuring Success: Keeping track of your pounds lost is only one way of measuring the success of your exercise plan. Start to notice other ways in which exercise can enhance your life: by improving energy and mood, creating flattering shape and definition in your physical appearance, keeping your heart healthy and strong, and improving your sense of achievement. One great way to see your success and increase your motivation is to set attainable and written goals. For example, if you start with an initial goal of working out three or four times per week, and write down in a calendar or notebook each time you complete a workout, at the end of a month you will be able to see your progress and feel incredibly proud of making exercise a habit in your life. Depending on what exercises you prefer, you might set goals such as a particular distance or amount of time walking or running.

Thinking Outside the Treadmill: More advanced exercisers know that once you get set in the routine of an exercise plan, you can start to feel that your results slow and you become less excited about the same old routine. For these reason, it’s important to “think outside the treadmill” and find activities that you enjoy and that also help you to move your body. At any level, incorporating different exercises and activities ensures that you vary your exercise from day to day so that your body doesn’t become too accustomed to one thing. Maybe there’s an activity that you’ve always wanted to try—perhaps salsa dancing or kayaking or tennis. Now’s the time to take up that new activity! 

Think outside the treadmill

Q: How can I “think outside the treadmill”? Outside of a regular workout, what activities should I try?

A: Yoga is excellent for both mind and body.  It is intimidating to start a class, especially if you are inflexible.  But once you start doing it, the activity is truly enjoyable.  Pilates is another good activity to strengthen the core muscles of the pelvis and abdominal region.  Any of the activities that you can do in a group or that are scheduled at a certain time are great.  They make you put it in your schedule and it eventually becomes part of a routine.  Attending activities with other people just makes the activity more social and enjoyable. 

What can I do when I need to energize my routine or break a plateau?

Q: I already have a regular exercise routine, but sometimes I get bored or my weight loss stalls. What can I do when I need to energize my routine or break a plateau?   

A: Completely alter your routine maybe every 12 weeks. Your muscles get used to the work; they almost "get bored” themselves.  So alter the activities you are doing and change your routine relatively frequently.  For example, for one month, you might run on a treadmill for 15 minutes, stretch, perform some upper body strength training, and finish.  After 12 weeks, start possibly biking for 15 minutes, then a yoga class three times weekly.  Then walk/run on your off days for 20-30 minutes. 

 

I hate exercise. Is there a way for me to find my inner athlete?

Q: I’m a beginning exerciser and I’m a bit overwhelmed with starting an exercise program.  What should I do?  

A: Start slowly.  Do not perform more than 3 sessions of exercise per week to avoid muscle soreness.  Don't try to do too much all at once, because you won't stick with everything.  Stick with one thing (like walking) and make it a habit.  Once it has become habitual, you can introduce a new activity.   Also, try to get a friend or co-worker to begin with you so that you have another person. Start with walking, even pool walking for the summertime. These are easy activities that are low- impact activities.  Whatever activity you start, try to do it at a pace where you can tolerate up to 20 minutes of continuous activity. 

How to prevent from emotional eating?

 

The most important thing is first to recognize your 
weaknesses when it comes to food - are you an 
emotional eater, compulsive eater, a binge eater or 
just love to eat?  If you are unclear what is the 
problem, monitor your eating by keeping a food log 
for one week, including time of day, how you felt 
before and after eating, and how long it took you to 
eat the meal. Just because you underwent surgery, 
your “emotional” reasons for eating do not 
disappear. If you still have trouble identifying the 
problem ask a loved one if they have noticed a 
pattern in your eating  
 
Once you have identified your weakness, the best 
way to control it is by planning.  Pay attention to 
difficult places, people, or foods. Before letting 
yourself get out of control, make a plan.  Plan out a strategy so you do not 
overindulge (plan to clean up, organize a game with 
the kids, take a walk after eating, be the first one to 
volunteer for a chore that is not by the food).  
 


 

Distraction is a great way to keep away from food, 
positive coping strategies are a great way to soothe 
and comfort you in bad times, and re-education on healthy choices is a perfect way to take back 
control. Remember: You are in control of what you 
eat, how much you eat, and how you eat it. Once 
you have learned this, you will be able to be more 
active in prevention. You have come a long way 
since your surgery and there will always be work to 
do. 
 
 
 
 
 

Avoiding the Appeal Process: Guidelines for Lap Band or Gastric Bypass Surgery Insurance Approval

Due to the growing popularity of weight loss surgery – gastric bypass and lap band surgeries - insurance companies across the United States are making the approval process more difficult, therefore causing appeals to become more and more common.  Insurance providers are no longer looking for reasons to approve these surgeries; instead they’re looking for any and every reason to deny them.  They view weight loss procedures as cosmetic, rather than as a medical necessity and the serious procedures that they are.  Establishing medical necessity becomes the key to getting an insurance company to authorize a surgery, but it’s a long, detail-intensive process that requires diligence, patience and partnership from both the patient and the insurance coordinator to make it happen.  Though each insurance policy is different, and should be verified individually for more specific details, the majority of them require similar information to help determine medical necessity and avoid the appeal process.                        

The presence of morbid obesity, a BMI (Body Mass Index) of 40 or higher, or a BMI of 35-39 in conjunction with significant co-morbid conditions – heart disease, high blood pressure, diabetes and sleep apnea - for at least five years is the primary determinant for insurance companies.  Most commonly office notes containing records of your weight from previous visits to primary care physicians, specialists for obesity related conditions, and nutritionists are used to fill this requirement. This information is essential in the process; it is what the insurance companies use to ensure that weight loss surgery is reserved only for those who have been unsuccessful in significant weight loss efforts.  An authorization is unlikely without this documentation, so to facilitate submission of your case it is beneficial to contact your doctors for all of your medical records and have them forwarded to the office.  
            
Participation in a medically supervised weight loss management program is a crucial detail in the approval process and is required by most insurance companies.  For example, Horizon BCBS of New Jersey recently updated their Bariatric Medical Coverage Policy Number 22 in June 2007 to limit access to bariatric surgery by adding the need for 6 month medically supervised program and five year weight loss history.  These programs generally entail monthly appointments with the office to document weight and manage the progress of each patient, nutritional counseling for adequate eating habits, psychological counseling for behavioral modification, as well as participation in an exercise regimen. The duration of the program will vary with each insurance company, but is usually between three to six months.  Although a six month weight loss management program might prepare a patient to better understand weight loss surgery, there is ample medical literature that demonstrates preoperative medically supervised weight loss program is an ineffective treatment for morbid obesity and in fact has no measurable beneficial effect prior to bariatric surgery. (1, 2)  Note that this is not required for Medicare patients and these guidelines are not consistent with the National Institute of Health. (3)

Documentation is needed every step of the way.  Insurance companies will ask for documentation from each office visit, so it is important that you keep all scheduled appoints and visit the office at least once a month for as long as your insurance company requires.  A missed appointment can ultimately result in a denial from the insurance company.  In addition, supporting letters from a nutritionist, psychologist, and exercise professional are required, so those appointments are just as important to keep.      
                                               
An authorization may take as long as four weeks or as little as one week depending on the content of the submitted information.  All of the above documentation is required, but information overload is the key.  Providing your insurance coordinator with information such as documentation of any previously tried weight loss medications, previous nutritional counseling, or any other attempts at weight loss will help the approval process along.  YOU CAN NEVER SEND IN TOO MUCH INFORMATION.  The more information the insurance company has to review the higher the chance of a fast approval. We recommend you keep a detailed log of your appointments.  During the course of your weight loss management program you will be extremely busy keeping up with all of your appointments and insurance companies are counting on you missing something, and a log of your hard work to date will help you stay one step ahead.  Remember that all of the above requirements need to be completed before we submit a request for authorization as insurance companies look for these specific documents before even reviewing the information, and should any of these items be missing it will result in an immediate denial.

In the event of a denial, we will work with you to help overturn this decision. As a patient, and a paying customer of your insurance company, your voice will have the most significant impact in the appeals process.  Let your voice and dissatisfaction be heard loud and clear regarding the limitations brought on by your insurance companies.  First, speak to your insurance company directly and appeal your case to the medical director, both verbally and in a letter documenting your efforts.  Next, contact Ms. Heather Howard, the New Jersey Commissioner of Health to share your thoughts on the limitations imposed by your insurance provider.  Finally, contact the New Jersey Department of Banking & Insurance (DOBI); it can also help with unfair practices of insurance companies.

Tackling the insurance process can be emotionally draining, but to keep your spirits up and your perseverance strong remember what you’re fighting for – the opportunity to live healthier life.  For more information on the insurance process you can contact the office at (908) 378-1779.

1. Jamal MK, DeMaria EJ, Johnson JM, Carmody BJ, Wolfe LG, Kellum JM, Meador JG. Insurance-mandated preoperative dietary counseling does not improve outcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity.
Surg Obes Relat Dis. 2006 Mar-Apr;2(2):122-7.

2. Presutti RJ, Gorman RS, Swain JM.
Primary care perspective on bariatric surgery.
Mayo Clin Proc. 2004 Sep;79(9):1158-66; quiz 1166. Review.

3. National Institute of Health. Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Int Med 1991;115:956-961

COMMONLY ASKED QUESTIONS:

How many visits are required with the Nutritionist and Psychologist for clearance?  
Generally one visit with each should suffice, unless otherwise recommended by your surgeon. 
For the best chance of approval, be sure to visit with a nutritionist and psychologist who have experience with weight loss surgery patients as they’re familiar with the specific details insurance companies look for when reviewing submissions. 

How many visits are required for the exercise regimen?
Our office works with Ivy Rehab, an exercise center located near both offices.  They offer a program that can be completed in three sessions.  Ivy Rehab accepts most insurances, but again benefits should be verified prior to your visit.

What co-morbid conditions are used to determine morbid obesity if my BMI is between 35-39?    
Though there are numerous conditions directly related to being overweight, however insurance companies only view some of them as being life-threatening in conjunction with Morbid Obesity.  Those conditions include Hypertension, Diabetes, Coronary Artery Disease, and Sleep Apnea with the use of a C-Pap machine. It is important to contact your insurance company for this information as many plans may require more specific details related to these conditions.

Do all insurance companies cover Weight Loss Surgery?  Most plans do allow coverage for weight loss surgery, however there are sometimes exclusions on services related to Morbid Obesity.  To avoid any misconceptions, contact the office for further details on your policy.

WHAT YOU CAN DO TO HELP THE APPROVAL PROCESS:

1. Begin gathering a five year weight loss history.
2. Obtain all records relating to your weight or weight loss efforts.
3. Meet with Nutritionist and Psychologist as soon as possible
4. Keep all office appointments.  Should you need to cancel contact the office to reschedule your appointment in that same month.
5. Get involved! Call your insurance company and your insurance to send you the guidelines.  Take the name of the person you speak to.

FOR HELP WITH INSURANCE VERIFICATION YOU CAN FAX YOUR INSURANCE CARD TO THE OFFICE AT (908) 688-8861 ATTENTION ROBIN.  PLEASE INCLUDE THE FOLLOWING INFORMATION WITH YOUR FAX:

• Front and back copies of your insurance card
• Your date of birth
• Your social security number
• A contact phone number to receive a call back on benefit information