Sometimes a healthy diet and regular physical activity aren’t enough to fight obesity. Group fitness instructor Sabra Bonelli, MS, struggled for years to lose a substantial amount of weight, fearing that she would develop diabetes, hypertension and dangerously high cholesterol levels later in life. In 2002, the San Diego–based Bonelli opted for gastric bypass surgery as a last resort. Nearly 4 years later and many pounds lighter, she has finally won her personal battle against obesity, thanks to this increasingly popular surgical technique—and a commitment to healthy lifestyle changes.
Bonelli is just one of hundreds of thousands of severely obese Americans who have resorted to weight loss surgery. In fact, the number of surgeries performed annually rose by 400% in the 5-year period from 1998 to 2002 and continues to increase steadily (Buchwald et al. 2004). More than 130,000 surgeries were expected in 2005, while a whopping 218,000 operations per year are predicted by 2010 (Santry et al. 2005).
With many physicians encouraging their postsurgery patients to participate in physical activity to sustain weight loss, fitness professionals will soon encounter a growing number of clients who have had weight loss surgery. To help you provide these clients the highest quality of care, here is a primer on the most common weight reduction procedures.
What Is Bariatric Surgery?
The term bariatric surgery refers to a number of different surgical operations intended to promote weight loss in morbidly obese patients. In the United States, the two operations that are most commonly performed are gastric bypass surgery (also known as “Roux-en-Y”) and gastric banding surgery (also referred to as “lap band”).
Most patients (like Bonelli) undergo gastric bypass, a procedure in which surgeons reduce the stomach to about the size of an egg and then reattach it to the small intestine. During the surgery, the vast majority of the stomach and about 2 feet of the small intestine are stapled shut, or bypassed. This procedure leads to weight loss for two reasons: First, the small stomach pouch cannot hold very much food, so caloric intake is dramatically reduced. Second, the majority of nutrient absorption occurs in the small intestine; when 2 feet of this small intestine are bypassed, fewer calories and nutrients are absorbed. On average, patients end up losing about 62% of their excess body weight after gastric bypass (Buchwald et al. 2004).
In the lap band procedure, the surgeon uses an adjustable band to reduce the size of the stomach opening to about the dimensions of a walnut so that less food can be comfortably consumed. The amount the stomach is reduced varies, and the size of the opening can be changed or the band can be completely removed at the patient’s request. Unlike gastric bypass, the lap band technique does not affect food absorption. The average lap band patient loses about 48% of his or her excess body weight (Buchwald et al. 2004).
Both procedures can be performed as regular open surgery or through a minimally invasive laparoscopic procedure. During laparoscopy, the surgeon operates with the help of a small, thin tube equipped with a miniature video camera–like scope on its tip; this procedure requires a few small abdominal incisions rather than a large opening and reduces postsurgical recovery time (Steinbrook 2004).
Who Is a Candidate for Surgery?
According to a 1991 consensus statement issued by the National Institutes of Health (NIH), ideal candidates for bariatric surgery are people who
- are severely obese with a body mass index (BMI) greater than 40 (or 100 pounds overweight for men, 80 pounds overweight for women) or a BMI of at least 35 coupled with other high-risk conditions, such as diabetes, sleep apnea or life-threatening cardiopulmonary problems;
- are well-informed and motivated (based on a comprehensive assessment of surgical, medical, psychiatric and nutritional factors by a multidisciplinary healthcare team);
- are an “acceptable” operative risk determined by age, degree of obesity and other pre-existing medical conditions;
- have been previously unsuccessful at losing weight through a nonsurgical program integrating diet, exercise, behavior modification and psychological support;
- have been carefully selected by a multidisciplinary team with medical, surgical, psychiatric and nutritional expertise (Consensus Development Conference Panel 1991).
Bariatric surgery is not recommended for the overweight or mildly obese person who is trying to lose 20 or 30 pounds. Furthermore, only those patients who are committed to permanent lifestyle changes—including regular physical activity and a healthy diet—are considered good candidates for weight loss surgery (Consensus Development Conference Panel 1991).
Are the Results Fleeting or Long-Term?
Horror stories of stretching stomachs and failed attempts to keep weight off after bariatric surgery make headlines. Some of these stories are true. For example, a lot of people who are not ready to make the lifestyle changes necessary to maintain the weight loss find ways to cheat the surgery—and gain most or all of their weight back, says Bonelli. She is quick to emphasize that “gastric bypass is a tool, not a solution.”
But many patients maintain most of the weight loss over the long term. “There can be weight gain, . . . [but] on average it’s usually about 10% or less,” says surgeon Philip Schauer, MD, director of bariatric surgery at The Cleveland Clinic in Ohio. “So, in other words, if a patient has 100 pounds of excess weight and loses 75 pounds in the first 2 years, over the next 10 years [he or she] may gain back 10 or 15 pounds. That’s a typical scenario” (WebMD 2005).
The research bears this out. One study comparing bariatric-surgery patients to controls found that postsurgical patients maintained a weight loss of about 16.1% during the 10-year period following surgery (Sjöström et al. 2004). During the same time frame, the control group gained 1.6% over their initial weight. Also, the postsurgical patients more often recovered from and/or avoided the onset of diabetes, elevated triglycerides and low HDL (good) cholesterol.
Another review found similar health benefits from bariatric surgery. Blood glucose levels were completely normalized in most diabetics who had the procedure, sometimes as soon as the day after surgery! Blood pressure, cholesterol levels and sleep apnea also dramatically improved in most surgical patients (Buchwald et al. 2004).
What Are the Potential Complications of Surgery?
Weight loss surgery is not without its risks. Although death is an unlikely result, the 30-day postoperative mortality rates are 0.1% for gastric banding and 0.5% for gastric bypass (Buchwald et al. 2004). This risk is lower than for many other surgeries, says Schauer, who cites 5% mortality rates for heart or colon surgery (WebMD 2005).
Men, the elderly and patients of less experienced surgeons appear to suffer more serious and sometimes deadly complications after weight loss procedures (Flum et al. 2005). Infections, bleeding, nutritional deficiencies, blood clots, respiratory failure and bowel obstruction are just a few of the surgical risks. And following surgery, most patients experience what is known as the dumping syndrome, which occurs after eating too much or too quickly. The condition is the result of inadequate food absorption and is characterized by nausea, vomiting, bloating, diarrhea, shortness of breath, weakness, sweating and dizziness (Steinbrook 2004).
Surgeon Schauer encourages patients to carefully weigh the risks of surgery against the risks of severe obesity: “One must expect that complications are possible when having this surgery, just [as for] any patient who is contemplating heart surgery or other major intestinal surgery or even gallbladder surgery,” says Schauer. “It’s important for patients to understand that there certainly is a risk, but there’s also a significant risk from severe obesity” (WebMD 2005).
What Are the Exercise Risks for Patients?
For those who opt for bariatric surgery, adherence to a postsurgical exercise program is a key determinant of successful weight loss maintenance, says Cathy Nonas, RD, MS, director of the obesity and diabetes programs at North General Hospital in New York City and a spokesperson for the American Dietetic Association (ADA). “Surgery is a head start but not an easy way out,” she says. “You can’t maintain weight loss without exercise.”
For this reason, most surgeons strongly advocate that patients regularly participate in an exercise program. In fact, some institutions use a patient’s stated willingness to exercise after surgery as a screening tool to assess whether the patient should be considered for bariatric surgery, Nonas says.
“Exercise is one of the strongest predictors of long-term success for gastric bypass patients in terms of maintaining weight loss,” says Cedric Bryant, PhD, chief exercise physiologist for the American Council on Exercise. “And the medical community does a good job of emphasizing the importance of lifestyle change and not a quick surgical fix.”
This emphasis on exercise appears to work. One study found that 10 years after bariatric surgery, nearly 80% of patients reported being active during their leisure time (Sjöström 2004). If the numbers are accurate, this means that more than 100,000 people who have just had gastric bypass will begin an exercise program this year. Fitness professionals will likely see increasing numbers of postoperative bariatric-surgery clients walking through their health center doors. But these individuals may not know exactly what it is that they are supposed to do.
Nearly all patients are given instructions to begin walking at least a little as soon as they are discharged from the hospital (generally 1–2 days following the surgery). Some facilities provide patients with pedometers to encourage them to build up to 10,000 steps per day. Others recommend 20–30 minutes of activity three times per week. And if the patients have orthopedic problems, such as low-back pain or bad knees, they are advised to see an appropriate specialist before starting to exercise. But beyond such general recommendations, these patients—who usually have very little previous experience with physical activity, a disdain for exercise and a variety of potentially limiting health conditions—are on their own to find an exercise program, says Bonelli.
“Physicians don’t provide guidance on exercise [after surgery],” she says. “They just say, ‘Go exercise.’”
How Can the Fitness Industry Help?
“I know that a personal trainer would help with compliance and motivation, and would therefore benefit [weight loss surgery] patients,” says Timothy Farrell, MD, associate professor of surgery and director of the Laparoscopic Institute of North Carolina at the University of North Carolina at Chapel Hill. In fact, in recognition of the importance of regular exercise after surgery, Farrell has been trying to improve continuity of care for his bariatric-surgery patients by developing a partnership with the university’s wellness center and its trainers.
To provide optimum care for these high-risk clients—and earn acknowledgment as valuable members of their postsurgery healthcare teams—fitness professionals should first understand how best to approach the challenges and limitations such clients face. Here are five key considerations to keep in mind when developing exercise programs for those who have had bariatric surgery.
1. It Takes a Village of Healthcare Providers
Any person who undergoes bariatric surgery needs to have an entire healthcare team looking after her to make sure that she is appropriately recovering from the surgery, losing weight and following the surgeon’s recommendations. The team usually includes the surgeon, the patient’s primary-care physician, a registered dietitian (RD) and a mental health professional. Ideally, the patient will also attend a weekly support group with her peers.
The fitness professional is often an unrecognized but critical member of the healthcare team. To best serve a postsurgery client, take the following steps:
- Contact the client’s primary-care provider and/or surgeon to obtain medical clearance to exercise, and to discuss exercise recommendations and precautions.
- Stay within the fitness professional’s scope of practice by strictly adhering to the physician’s exercise recommendations and developing an exercise program that is safe and effective for the individual.
- Reinforce healthy lifestyle habits recommended by other providers; for example, remind the client to keep physician appointments and to stick to the RD’s nutrition recommendations.
- Refer the client to the appropriate health professionals when concerns arise.
Many patients are lost to follow-up. Fitness professionals can prevent that from happening by communicating clearly with their clients and the other providers, says Lona Sandon, MEd, RD, LD, a Texas-based spokesperson for the ADA. This will help postsurgical patients experience fewer complications and more rewards from their surgery.
2. Bariatric Surgery Is a Major Surgery
Keep in mind that gastric bypass is a major surgery that requires adequate recovery to prevent future complications. After surgery, patients generally spend 1–2 days in the hospital before being discharged. During this time, wounds start to heal, and the damaged stomach and intestinal tissue begins to scar and strengthen. Leisurely walking for a few minutes at a time is the most vigorous activity that patients can do immediately following surgery. Resistance training and strenuous activity are not recommended until at least 3–4 weeks after surgery, cautions Farrell.
3. Weight Loss Occurs Rapidly at First and Then Tapers Off
Loss of excess weight occurs mostly in the first 18–24 months, says Nonas. Weight loss can vary considerably, depending on how obese the client was initially, but about 10 pounds per month is typical, according to Nonas. She estimates that, in total, people lose about 30% of their body weight within 12–18 months after the surgery.
While these results sound promising, Nonas says it is important to remember that many very obese clients will still be obese after surgery. In fact, most will never achieve their ideal body weight. Someone who weighs 400 pounds and gets down to 280 is much healthier but still obese. Trainers should consider that a client in this category may be unable to do sit-ups and may not fit on the regular-sized seat of an exercise bicycle, cautions Nonas.
4. Clients May Lack the Energy to Exercise
In the first month following surgery, patients are placed on a very low calorie, stomach-friendly diet. They are advised to consume mostly liquids and soft or puréed foods. About 1–2 months after surgery, they can begin to eat a regular diet—but with a substantially restricted caloric intake. The average postsurgery intake is about 800 calories, eventually leading up to 1,200 calories per day, according to Sandon. “Personal trainers need to understand that within the first 6 months [after the surgery] these people are on very low calorie levels,” she cautions. “Understand that they may not be able to work out at high intensities.”
5. Self-Esteem Needs Bolstering After Weight Loss
Fitness professionals also need to remember that losing weight doesn’t immediately change a client’s self-image. “After surgery, you still feel like a huge person for a long time,” says Bonelli. “Self-esteem issues are the biggest thing trainers can help with.”
With challenges ranging from mustering the courage to walk into a health club to coping with a dramatically different body, the psychological toll of weight loss surgery is sometimes heavy.
But for most people, the psychological benefits of the surgery can be positive, says Bryant. Many patients report improvements in mood, self-esteem and confidence.
According to Bonelli, all these changes take some getting used to. Relationships change, work performance is altered, and life becomes very different. Although surgery is a good tool to facilitate weight loss, the emotional and psychological components of eating don’t just go away. Fitness professionals can help in several ways:
- “Be equipped to talk about self-esteem,” says Bonelli. That may mean just listening and empathizing; be prepared to refer a client to a qualified professional if the psychological issues exceed your scope of practice.
- Encourage clients to attend a support group regularly and to keep appointments with psychologists and other health professionals in their team.
- Help clients set achievable fitness goals, and dole out rewards when they achieve those goals.
One thing not to do, though, is judge, cautions Bonelli.
“It’s important not to look at people who have chosen to have surgery as weak or as quitters,” she says. “By the time they have surgery, it’s a last-ditch effort; nothing else works. They think, ‘If this fails, I’m doomed.’”
How Do I Design the Right Exercise Program?
When creating a fitness program for these clients, keep the above considerations in mind and then start with an initial goal of simply promoting movement.
“As a trainer, you have to focus on encouraging participation as opposed to perfection,” says Bryant. “Don’t get so caught up in the frequency, intensity and duration of exercise design. Just try to get people to a beginner level.”
One thing to keep in mind is that many of these clients will experience a variety of performance deficits as a result of the surgery. Most notably, they will have substantial balance deficits from adjusting to the rapid weight loss, and these deficits may limit the types of activities and exercise machines they can use. Pre-existing orthopedic problems, such as back injuries and bad knees, may also impede their ability to participate in many types of exercise.
Once these clients have adopted a consistent pattern of exercise and are ready to progress, consider implementing the following American College of Sports Medicine guidelines for working with overweight or obese clients (ACSM 2006):
- Frequency: Aim for 5–7 days per week.
- Intensity: Initial intensity should be moderate (40%–60% of heart rate reserve) with an emphasis on increased duration and frequency of exercise, rather than increased intensity. Also note that obese clients are at an increased risk for orthopedic injury and may need to stay at a lower exercise intensity.
- Time: Build up to 45–60 minutes of activity per session, with the goal of achieving at least 150 minutes of activity weekly.
- Type of Activity: The primary focus should be on large- muscle-group cardiovascular activities, although resistance training is also important. Non-weight-bearing exercises, such as water aerobics and recumbent cycling, may be most comfortable for these clients after surgery.
Each individual’s exercise program should be based on his or her specific needs, goals, strengths and limitations, with adherence being the ultimate goal (ACSM 2006).
Encouraging Lifelong Success
Bariatric surgery is a tool to lose weight, but successful maintenance of weight loss requires healthy nutrition habits and regular physical activity. The rapid growth in the number of bariatric surgeries performed each year and the postsurgical emphasis on exercise offer fitness professionals a wonderful opportunity to ignite a passion for activity in a population that until now was unreachable.
In addition to physical activity, optimal nutrition is vital for clients who have had bariatric surgery. Patients are encouraged to see a registered dietitian (RD) regularly for at least the first 6–12 months following the surgery. The RD will provide a specific meal plan and nutrition recommendations, which the fitness professional can reinforce during training sessions. Although each institution has slightly different nutrition guidelines following surgery, most will be consistent with the following instructions, which are provided by the dietitians at The Cleveland Clinic Bariatric Surgery Program:
- Aim for a total of 6–8 cups of fluid each day. Sip drinks slowly and without a straw, and stop drinking within 30–60 minutes of a meal.
- Eliminate high-calorie and high-fat foods from the diet.
- Take a multivitamin each day for life. Additional vitamin B12, iron and zinc may also be necessary.
- Eat very slowly to prevent stomach blockage and subsequent nausea and vomiting.
- Eat only when you are hungry, and stop when you are full.
- Focus on protein. Eat protein first at each meal to maximize intake.
Source: Cleveland Clinic Bariatric Surgery Program (www.clevelandclinic.org/bariatricsurgery).Skin, Skin and More Skin:Is Exercise Enough?
Flabby arms. An abdominal flap. Saggy breasts. The biggest postsurgical complaint for most bariatric patients is the excess skin that remains after dramatic weight loss (Kinzl et al. 2003). Although exercise works many wonders, unfortunately it doesn’t tighten up loose skin, experts say.
“Exercise is going to help with toning muscle and reducing fat, but once skin is stretched, it can only contract so much,” says Clara Lee, MD, a plastic surgeon at the University of North Carolina Hospitals in Chapel Hill. “Exercise can’t really help that.”
For people who lose 75 or 100 pounds, that extra skin may not be all that noticeable, says Philip Schauer, MD, director of bariatric surgery at the Cleveland Clinic in Ohio. But people who lose more weight will likely need some type of plastic surgery to reduce all that excess skin. The surgery isn’t always for cosmetic reasons: Fungus can grow within the skin crevices. People can have difficulty fitting into clothes. And some people have so much extra skin that they can’t even exercise comfortably, says Lee.
With the dramatic increase in bariatric surgeries, a subspecialty of plastic surgery is booming with post-weight-loss-surgery body contouring. This additional surgery is typically not picked up by insurance companies. And it’s not cheap. Try $20,000–$40,000 for the hot new “total body lift” recently featured on ABC’s Today Show.
Still, people are lining up for the surgery, which promises not just to get rid of the extra skin but to reshape the entire body. More traditional body contouring of the abdomen, buttocks, arms and/or breasts is also popular and slightly more affordable. In both cases, the surgery is long, recovery generally takes at least 1–2 months, and large scars remain permanently. But the skin is tight.ResourcesAmerican Society for Bariatric Surgery (www.asbs.org): Written by bariatric surgeons, this site contains a lot of useful information, including a “Patients” section and a search engine to find local surgeons.
Cleveland Clinic Bariatric Surgery Program (http://cms.clevelandclinic.org/bariatricsurgery): Provides a wealth of information on what happens before, during and after surgery. Also addresses patient concerns such as insurance coverage, risks, nutrition recommendations and other hot topics.
Medline Plus (www.nlm.nih.gov/medlineplus/ weightlosssurgery.html): Maintained by the U.S.National Library of Medicine, this site provides links to the latest news, research, and information about weight loss surgery.
ObesityHelp (www.obesityhelp.com): Devoted to helping people who have had or are considering weight loss surgery. Includes information about the surgery, a search engine to find local surgeons and a chat room for members.
Other Sources: Local hospitals can provide information on the bariatric-surgery services they offer, their surgeons’ credentials and qualifications, and local support groups and upcoming events. Also, look around your own fitness facility for clients who have had the surgery. Those people can serve as a wealth of information for fitness professionals and other clients considering the procedure.
Buchwald, H., et al. 2004. Bariatric surgery: A systematic review and meta-analysis. Journal of the American Medical Association, 292 (14), 1724–37.
The Cleveland Clinic Bariatric Surgery Program. 2005. Nutritional guidelines for weight loss surgery. http://cms.clevelandclinic.org/bariatricsurgery/body.cfm?id=88; retrieved Nov. 6, 2005.
Consensus Development Conference Panel. 1991. Gastrointestinal surgery for severe obesity. Annals of Internal Medicine, 115, 956–61.
Flum, D.R., et al. 2005. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. Journal of the American Medical Association, 294 (15), 1903–08.
Kinzl, J.F., et al. 2003. Psychosocial consequences of weight loss following gastric banding for morbid obesity. Obesity Surgery, 13, 105–10.
Santry, H.P., et al. 2005. Trends in bariatric surgical procedures. Journal of the American Medical Association, 294 (15), 1909–17.
Sjöström, L., et al. 2004. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. The New England Journal of Medicine, 351 (26), 2683–93.
Steinbrook, R. 2004. Surgery for severe obesity. The New England Journal of Medicine, 350 (11), 1075–79.
WebMD. 2005. Bariatric surgery: Is it right for you? www.webmd.com/“>http://www.webmd.com/ content/chat_transcripts/2/110166.htm; retrieved Nov. 6, 2005.
"Natalie Digate Muth, MD, MPH, RDN, FAAP, is a board-certified pediatrician and obesity medicine physician, registered dietitian and health coach. She practices general pediatrics with a focus on healthy family routines, nutrition, physical activity and behavior change in North County, San Diego. She also serves as the senior advisor for healthcare solutions at the American Council on Exercise. Natalie is the author of five books and is committed to helping every child and family thrive. She is a strong advocate for systems and communities that support prevention and wellness across the lifespan, beginning at 9 months of age."