Frequently Asked Questions and Weight Loss Surgery

Research shows that behaviour is not the sole determinant of obesity, which explains why lifestyle changes, including diet and exercise, can be ineffective.

It is commonly accepted that when energy intake exceeds energy expenditure, body fat increases.

This theory, however, does not take into consideration the complex factors underlying excessive weight gain.

With the incidence of obesity rising world wide, despite increased public awareness, it is evident that weight gain is not merely a problem of self-control or a sign of personal weakness.

• Genetics: The metabolic processes underlying weight gain have a strong inherited component. Obesity is a feature of at least 24 genetic disorders and studies in large populations have identified variants in genes that predispose someone to obesity.
• Appetite and Energy Intake: Appetite is very hard to control. The biochemical pathways regulating appetite are powerful. A person’s feedback control system carries complex messages regarding the body’s nutrient state from the gastrointestinal tract to a part of the brain called the hypothalamus, which regulates appetite. It is believed that people with obesity have a defective feedback control system – the appetite-regulation part of the brain does not function properly, and instead, continues to stimulate hunger and food-seeking behaviour, despite adequate energy reserves.
• Calorie Absorption: It has been shown that those prone to obesity absorb more calories from their diet. This is affected by factors such as a person’s gut flora (the micro-organisms found in the gut) and their hormone response to food.
• Energy Expenditure: Activity and exercise account for approximately 20 per cent of the energy a person expends. Around 70 per cent of energy is expended through metabolic processes and another 10 per cent through the processing of food. Energy expenditure varies between people. There is a strong relationship between resting energy expenditure and fat-free mass, which makes weight loss increasingly difficult for people with higher fat reserves.

Life Events: People can become overweight any time, however there are certain life events that can trigger weight gain. These include pregnancy, menopause, periods of sleep deprivation, giving up smoking, transitioning from an active adolescent to a more sedentary lifestyle, and when beginning or changing medications. There are a number of medications that can cause weight gain including oral hypoglycemics, hormonal therapy, steroids, antidepressants, antihistamines, anti-hypertensives and anti-epileptic medications.

Obesity is self-perpetuating. Excess fat reduces energy levels, making it more difficult to exercise. Intense or lengthier exercise causes the body to release the stress hormone cortisol, which not only contributes to hunger, but also promotes fat storage independently of calorie intake.

For men, extra belly fat also raises oestrogen levels and lowers testosterone, making it even harder to gain muscle and lose fat. Reduced muscle mass means a lower base rate of metabolism, increasing the ease of weight gain.

Few people with obesity experience long-term weight loss by lifestyle changes alone. Surgery puts people with obesity back on an even playing field and allows their efforts toward weight management to be effectual and sustainable.

Obesity is a medical condition that adversely affects every system in the body. It has recently surpassed tobacco smoking as the leading cause of preventable death in Australia.

At any age, obesity shortens your lifespan. People aged between 25 and 35 who have severe obesity are 12 times more likely to die early than those without obesity. Adults who have obesity at 40 years of age die on average seven years sooner than adults whose BMI is within the healthy range. The impact of years of life lost is greater for men than for women. It has been estimated that the steady rise in life expectancy over the last 200 years may come to an end due to the increasing prevalence of obesity.

The medical problems associated with obesity are referred to as co-morbidities. Eight out of 10 people who suffer from obesity will develop one of the following co-morbidities; six out of 10 will develop at least three:

• Type 2 diabetes
• Heart disease
• Stroke
• High blood cholesterol and abnormal blood lipids
• High blood pressure
• Chronic kidney disease
• Respiratory disease
• Sleep apnoea
• Polycystic ovarian syndrome
• Infertility
• Osteoarthritis
• Fatty liver disease and liver failure
• Heartburn and reflux
• Cancer – breast, bowel, liver, kidney, prostate, endometrial
• Depression
• Blood clots
• Gall stones
• Abdominal hernias

Fortunately, obesity can be treated and weight loss reverses most of the damage.

For example, weight loss surgery resolves type 2 diabetes in 80 per cent of people with obesity once the excess weight is lost.

Bariatric surgery truly is a marvel of modern medicine and it can provide patients with staggering results, but like many other procedures, not everyone is a suitable candidate. It is also important for you to remember that despite the excellent success rate of weight loss surgery, they do not substitute your need to eat healthily and can only help you to work within the framework of your diet. Operating on a caloric defecit can severely derail your diet successfully and there a lot variables to consider. Every patient’s needs and goals are different so success becomes a term relative to you but if you want to live a better, longer life, then you should consider it.

As much as we would like for weight loss or bariatric surgery to be available to all patients, this is simply not the case and when you come in for your first consultation we will determine whether or not this is the case for you. Traditionally, patients who are 50kg or more overweight and have exhausted all other avenues for weight loss including diet, exercise and behavioural changes, are eligible candidates for weight loss surgery. BMI or body mass index is also a consideration for patients that elect for weight loss surgery and a BMI of 40 or higher is usually the minimum or 35 if you have other obesity-related conditions like diabetes, high cholesterol and sleep apnoea.

There is no age limit. Obesity surgery limits your food intake. Some surgeries also restrict the amount of food you can digest.
This surgery is for people who have tried everything to lose weight to no avail. Studies show that this kind of surgery can reduce death rates for the obese.

As is always mentioned, electing for weight loss surgery is a big decision to take and therefore there are a number of things to take into consideration when making yours. Should you suffer from mental health issues or conditions such as depression, bipolar disorder and/schizophrenia, then we would highly encourage you to see a psychiatrist before you begin your surgery. This is because these conditions can be worsened by the changes in your body when you experience significant weight loss. Of course, there are some medical conditions that may preclude you from having weight loss surgery, but we will discuss these with you at length during your consultation.

At the Surgical Weight Loss Centre, we specialise in four surgical options for weight loss. These are: sleeve gastrectomy; gastric bypass; gastric banding; and SADI-S. In terms of technique, we perform minimally invasive laparoscopic surgery, also known as ‘keyhole’ surgery, on the stomach, duodenum, small bowel, gallbladder, adrenal glands, and pancreas.

Once you come in to see us, we will give you a thorough examination and begin to determine the correct course of action as regards your treatment. The more we know about your unique situation, the better we can come up with a treatment plan that we believe will be in your best interests at all times. Our team is highly experienced and we are determined to help you along on your weight loss surgery journey and to acheive your weight loss goals. We will discuss all treatments with you at length and find out exactly what your expectations are for weight loss surgery before present you with some options.

We have a team of experienced specialists, each of whom plays a role in providing treatment for long-term, healthy and sustained weight loss. The team is headed by Dr Jordaan, who is a specialist upper gastrointestinal surgeon with over 25 years of surgical experience. Our team also includes anaesthetists, bariatric nurses, dieticians, and a clinical psychologist. All of the members of our team work together to put together a customised treatment plan for each of our patients, from the initial consultation and the surgery to dietary management and ongoing care following surgery.

Step One: Contact Us

The first step of your surgical weight loss journey is to contact us. We will arrange an appointment for you to see our surgeon, Dr Jordaan, and our team of bariatric nurses and allied health professionals.

To ensure you receive the Medicare rebates for your appointment with Dr Jordaan, you will need a referral from your GP or specialist. At your initial consultation, you will have the opportunity to discuss whether weight loss surgery is suitable for you, what your surgical options are and which procedure would best suit your individual needs.

If you would like more information before you book your initial consultation, please come along to one of our patient information seminars

Step Two: Pre-Operative Care

Our aim is to ensure your surgical weight loss journey is safe, smooth and successful.

Should you decide to enter our program, our bariatric nurses will assist you every step of the way including:

• Organising a tentative date and hospital for surgery. This date is usually around four weeks after your initial appointment. Dr Jordaan operates at both Pindara Private Hospital and the Gold Coast Private Hospital so please let the nurse know if you have a preference.
• Coordinating your referrals and appointments with:
  • Our dietetic team
  • Our clinical psychologist
  • Other specialist physicians as required
  • Other investigations as required
  • The gastroenterologists to arrange a pre-operative gastroscopy
  • QML Pathology request form for comprehensive pre-operative blood tests
  • Providing prescriptions for pre-operative medication.

Our administrative team is also here to help you navigate through the sometimes confusing processes of the private health system.

Step Three: Preparing For Surgery

There are a number of tasks that need to be completed to ensure you are prepared for surgery and the subsequent weight loss journey.

Blood Tests: You will need to visit a QML Pathology collection centre for your blood test. The purpose of this test is to see what your base line nutrition and vitamin levels are, so you need to fast (not eat or drink) for the blood test for at least four hours. You do not need to make an appointment – simply turn up at your convenience. We have arranged for your tests to be bulk-billed so you will not have any out-of-pocket expenses for blood tests at QML.

Specialist Physician Assessment: People with obesity are considered to have a higher risk of operative complications than those of a healthy weight. Dr Jordaan is proactive at rigorously identifying, assessing and managing peri-operative risk factors to ensure your surgery is as safe as possible. This may include an assessment by a specialist physician.

Nutritional Assessment and Advice: You will have a one-on-one appointment with one of our specialised dietitians to identify factors that may impact on your nutrition before and after surgery. These include dietary beliefs and behaviours, cultural background, psychosocial issues (such as eating motivations) economic factors and goal setting.  You will need to undertake a two week ‘induction diet’ to prepare your body for surgery and ensure the safety of your operation. Our dietitians will adjust the pre-operative diet to suit your individual protein and nutrient requirements. After your procedure, our dietitians will develop a personalised eating plan and guide you through each phase of your weight loss journey with written instructions and follow-up appointments to support you through each dietary change.

Psychological Preparation and Support: The interaction between mind and body is crucial to successful long-term weight loss. Our clinical psychologist, Lorraine Langsford, will assist you to identify barriers and behaviours that have previously held you back from achieving your weight loss goals. She will introduce you to the ‘mindful eating’ program as a tool to overcome the stumbling blocks you may encounter through the weight loss process. For some, continued care with Lorraine will form an invaluable part of their journey.

Multidisciplinary Team Meeting: Our multidisciplinary team will meet to discuss how we can best support you before surgery, during your recovery and in the months and years afterward to become a healthier, happier you.

Final Appointment: You may need a final pre-operative consultation with Dr Jordaan to clarify any remaining questions and to finalise arrangements for the day of the operation. Our rooms will also contact you a few days prior to your date of surgery to confirm fasting and admission times.

Step Four: The Day of Surgery

Today’s the day! You will meet Dr Jordaan again in theatre to start the next step of your journey. It is important not to eat or drink in the six hours prior to your operation. You will be given pain medication and meet your anaesthetist before you go into theatre. Should any specific anaesthetic issues be identified during your pre-operative assessment with Dr Jordaan, an appointment will be arranged for you to meet with your anaesthetist prior to the day of your surgery.

In Hospital Recovery

Dr Jordaan’s advanced laparoscopic surgical skills and our comprehensive pain management program, which includes pain medication prior to, during and post-surgery, means you will experience minimal pain. We will encourage you to be actively walking around 10 to 12 hours after surgery. This is for a number of reasons including minimising the risk of developing deep vein thrombosis and pneumonia.

In hospital, you will be given intravenous fluids for one to two days to maintain hydration. You will undertake a scan the day after surgery to visualise your new anatomy before commencing oral fluids. Typically, people who have a gastric band stay one night in hospital while patients who have a gastric sleeve or bypass stay two to three nights.

Dr Jordaan and his team will visit you once or twice a day to check on your progress while you’re in hospital. Our dietitian will visit you in the days following surgery to explain the recovery phase diet in detail, answer your questions and provide you with written instructions on how to protect your new anatomy. Prior to discharge, you will be given information on wound care and the use of pain medication.

Step Five: Post-Operative Phase

Post-Discharge Recovery

After any weight loss procedure, your stomach will need time to settle to allow the swelling to subside. During this time, it is likely you won’t feel very hungry. Your diet will be based on high protein fluids. You will be provided with detailed information about your post-operative diet, including meal plans and food suggestions for each phase.

In the first two weeks after surgery, you will have a follow-up appointment with our bariatric nurses and one of our dietitians to ensure your recovery is on track.

Weight Loss

For all procedures: You will have an appointment with our bariatric nurses one to two weeks after your procedure, to check your wounds and ensure your recovery is well on track. Typically, our patients recover well and easily. If the nurse has any concerns about your recovery they will arrange for you to be reviewed by Dr Jordaan.

Dr Jordaan sees all patients 3 months after surgery to review progress and ensure you are on track to reach your long-term weight loss goals.

You will have another appointment with Dr Jordaan twelve months after surgery. After that you will have annual reviews with our bariatric nurses to ensure you sustain your improved weight and health.

For gastric band surgery: In addition to the above, six weeks after the operation, you will have an appointment with Dr Jordaan to check on your progress and to perform the first adjustment. Dr Jordaan will continue to see you every four weeks until your optimal level of restriction has been reached. After you have reached optimal restriction, you should ideally lose between 0.5 to one kilogram per week. You will have follow-up appointments every three months until you reach your goal weight. This usually takes around 18 months – some patients reach their goal weight in 12 months, while others may take up to 24 months.

Maintenance

Once you have reached your goal weight, we would still like to see you once a year for a check-up to ensure your ongoing weight loss success. These visits are important to your long-term health and all efforts should be made to attend.

Before these check-ups you will need to have a blood test to ensure you are maintaining adequate nutrition. Nutritional deficiencies are hard to sense, and blood tests are the only reliable way to identify abnormalities.

Firstly, it must be noted that your weight loss journey is uniquely personal to you and you should never compare your progress with anyone else except your former self.  That being said, we would usually consider weight loss surgery a success when we are able to get rid of at least 50% of your excess weight and then being able to keep that weight off for a further 5 years. As many as 95% of patients are able to reach these numbers with a successful gastric bypass surgery and 85% of patients will lose ⅔ of their excess weight.

As with any surgical procedure, there are some risks associated with bariatric surgery. The risk of complication, however, is very low at 1-2%. We’ll explain any risks to you before you undergo surgery and answer any questions you may have.

The pre-surgery diet is between 2-4 weeks depending on the individual patient’s needs. This will be assessed by your dietitian.

The pre-surgery diet reduces the size of the liver and reduces some of the fat stores around the stomach. This is important as it makes the procedure safer, faster and less painful as well as creating better weight loss after surgery.

We encourage all of our patients to quit smoking lifelong. If you currently smoke you will need to quit completely at least four weeks before surgery. We can help you do this with medications. After a gastric sleeve you will need to avoid all forms of nicotine for a minimum of 8 weeks. People having gastric bypass will need to avoid nicotine lifelong.

We recommend taking 2 weeks of off work for optimal recovery.

You will be able to drive once you are home. However, you will not be able to drive if you are taking strong pain relief such as Endone and will also need to check your car insurance policy to find out what their policies are with regards to driving a motor vehicle post-surgery.

You will be on liquids for 2 weeks, purees for 2 weeks and soft foods for 2 weeks before transitioning to a wholefood program.

Yes, we have both dairy free and vegan options. Please let your dietitian know if you require vegan or dairy free options.

Once you transition onto purees and soft foods you will be having between ¼ to ½ a cup of food per meal, however long term you will be able to increase your portion size to approximately 1 cup per meal when you are on the maintenance phase.

We encourage you to stay away from alcohol for the first three months. However, a small glass of wine, occasional cocktail or spirit mixed with water and ice (such as scotch) on a special occasion will be fine. Avoid carbonated beverages (including beer, champagne and cider) as these can cause discomfort and stretch your stomach.

In hospital you will be encouraged to get up and go for small walks around the ward within 24-48hrs. We recommend you continue to get up and move regularly once you get home. Starting with just 10-15mins and then increasing it as you are ready. Walking, running, biking can all be started as soon as you feel ready after surgery. Gym programs, weight lifting, yoga, pilates, team sports etc  can be re-started 6 weeks after surgery.

We do not recommend lifting anything heavier than 5kg in the six weeks after surgery so it may be beneficial to ensure you have help at home in the first 14 days if you have small children.

Each patient is different and it largely depends on your genetics. However cardiovascular exercise  can significantly boost collagen levels to help reduce loose skin after surgery.

We help you to maintain most of your lean muscle by consuming adequate amounts of protein in your diet and starting regular exercise.

When you go through the many bodily changes that are associated with weight loss surgery, you can always expect to have some skin that is less saggy or loose. For a lot of patients this is actually only a temporary and when it does occur its severity can be based on a number of other factors including how much weight you have lost, how old you are, genetics and lifestyle. A good rule of thumb, though, is to wait at least 18 months after weight loss surgery, before considering any cosmetic procedures.

Ensuring you are focusing on a nutrient dense diet, having adequate amounts of protein and using bariatric surgery specific multivitamins can help to reduce hair loss. Hair loss does not occur in everyone. If it does occur it is most commonly a thinning of the hair as hair growth rate slows while loss rate remains the same. It occurs most commonly around 3 months after surgery and returns to normal within around  6 to 12mths.

Yes. Adequate vitamins and nutrient intake Is essential and you may not be able to consume large enough portions to meet your daily needs. This is why you will need to supplement your diet with at least multivitamins daily.

Yes, it is possible. You may gain back weight because of changes in your stomach and small intestine that allow you to eat and absorb more calories. It could also mean that your diet and exercise have been neglected and you have regained your old habits.
In some instances, a second surgery can be done, especially if your stomach and small intestine have changed. But be warned this can cause complications during the surgery. In light of this, revisional surgery isn’t usually performed if weight is regained because of poor diet and exercise.