Nutrition Essentials: What You Can Eat After Bariatric Surgery

Podcast Transcript

John Horton:

Hello and welcome to another episode of Nutrition Essentials, an offshoot of our popular Health Essentials Podcast. I'm John Horton, your host.

Bariatric surgery is known first and foremost as a weight loss method for those with obesity. But in reality, it's about far more than dropping pounds. This is a procedure to improve quality of life and even extend life for those in unhealthy situations — but surgical tools are not magic wands. For bariatric surgery to bring the desired results, patients need to commit to healthier eating habits that work with their modified digestive system.

So today, we're going to take a closer look at bariatric surgery and the “forever” role that nutrition plays in reaching a successful outcome. As usual, we have registered dietitian Julia Zumpano with us to talk about all things food. To learn more about bariatric surgery, we brought in a surgeon and researcher from Cleveland Clinic's Bariatric and Metabolic Institute — Julia, who's our guest?

Julia Zumpano:

We're joined today by Dr. Rickesha Wilson, a national leader in the field of metabolic and bariatric surgery, whose research has been published in numerous high-impact medical journals. She calls it an absolute privilege to walk with people on their journey to weight loss and better overall health. I look forward to learning more about that journey and how nutrition fits in.

John Horton:

I'm with you there, Julia. So let's get started. Dr. Wilson, thanks so much for joining us on the podcast to chat about bariatric surgery and nutrition, plus their life-changing capabilities.

Dr. Rickesha Wilson:

Happy to be here. Thanks so much, John and Julia, for the invitation. Yeah, I'm excited to get down into some of the details.

John Horton:

Well, we are, too. To get started, let's spend a few minutes just going over bariatric surgery with an overview of what it is. Consider it Bariatric Surgery 101, which seems to fit, since I know you're an assistant professor of surgery at Cleveland Clinic Lerner College of Medicine at Case Western Reserve.

Dr. Rickesha Wilson:

Right, yeah, that's a great question, and it's a good place to start for people who are wondering about it, interested in it. So bariatric surgery, that's the traditional name, and that's a set of procedures that we do to change the GI system, or the GI tract, on the inside, in order to induce weight loss, but not just weight loss. The goal is to alter and change metabolism. So we are actually, as a professional and in our societies, we're trying to change the name really to “metabolic surgery,” not just “bariatric surgery,” just because these sets of procedures that we do to induce weight loss and alter metabolism have more than just the weight-loss effect. So that's a high-level way I would explain it.

John Horton:

When you do the surgery, what's actually done?

Dr. Rickesha Wilson:

Yeah, great question. So first off, after people go through the rigorous process of getting to surgery, and we'll talk about that later, but it's usually a one-night stay in the hospital and we use small incisions for the surgeries that we do. So those terms are called either “laparoscopic surgery” — some people have heard it like that — and even robotic surgery. No robots performing the surgery, but these are just our tools that we use for small incision surgery. But through small incisions, depending on what procedure we do, we're either making the stomach smaller. So for example, with the most common procedure, like the sleeve gastrectomy, we remove about 75 to 80% of the stomach and take it out of the body through a small incision. So if you know the shape of the stomach, you go from a balloon-shaped stomach to a banana. So that's one way to make the stomach smaller. That's one type of procedure.

The other procedure is like a gastric bypass. Not only do we make the stomach smaller, but we don't remove the stomach, but we exclude the majority of the stomach. So we create a small pouch, the size of an egg, and then, we alter the small intestine also, not just the stomach, with this procedure. So we will divide the small intestine at one point and connect it to that pouch. So we are essentially bypassing or skipping the majority of the stomach and some of the small intestine, which is why we call it a “bypass.” That's a way to not only restrict the amount of food one can eat, but also induce and alter how much you can absorb from what you eat. So it's an absorption and a restriction.

John Horton:

Yeah, it sounds like that's where that metabolism issue fits in that you were talking about.

Dr. Rickesha Wilson:

Correct. Surgery, these procedures, when we alter the GI system, we're also altering hormones in the body that control and regulate appetite. So our brain and our gut communicate through a number of hormones. After surgery, there is, in a sense, a reset to those hormones that we found in research studies. So the metabolism changes not just because folks are losing weight or their stomach is smaller, but the hormonal communication between the brain and the gut and how appetite is regulated also changes after these procedures.

John Horton:

Doing these podcasts, I'm always just left amazed with how the body works and communicates and does all of this. It's just truly fascinating that all this is happening and we don't even realize it.

Julia Zumpano:

One thing to add, Dr. Wilson, is that those hunger hormones you talked about, mainly ghrelin and leptin, they're one of the two main hormones that can control hunger and fullness. Ghrelin is produced in the stomach and it increases appetite. It's known as the “hunger hormone,” where leptin is produced in your fat cells and leptin actually decreases appetite and makes you feel more full. So that's the offshoot of how these surgeries can really help regulate those in a better way. So the patient doesn't necessarily always have to feel that constant food noise.

Dr. Rickesha Wilson:

Yeah, absolutely. Our body has a set point where it tells itself, "Hey, we want to be 300 pounds. This is where we are." That might be after hormone changes, certain diseases, medications people might be on long term. The body changes and those hormones like leptin and ghrelin are impacted. So they send a signal to our body: This is how we're going to store the nutrients from the food that we eat and what we choose. So after time, the body is so highly regulated by hormones that people don't really realize that you're not just fighting to get to the gym, trying to work out more and eat less. You, with obesity, are fighting biology, and that is hard to do.

Many people get discouraged because they may not be seeing results from their efforts to maybe diet or exercise, but obesity and our weight are highly regulated by more than just what we do and don't do. Hormones are a big part of that, and the disease of obesity dysregulates those hormones. So after a time, it's really hard to fight that disease because so much more is going on in the background with the physiology.

John Horton:

Dr. Wilson, you mentioned obesity here. I want to focus on that for a second because the reality is bariatric surgery is just not for everybody. It's not something you're going to do to get rid of those last pesky 10, 20 pounds. It's for if you have a more serious issue with your weight.

Dr. Rickesha Wilson:

Yeah, absolutely. Obesity is a chronic disease, and just like we would approach the disease of cancer with multiple therapies, whether it be chemotherapy, radiation, surgery, certain things are appropriate in certain cases. Obesity is just the same. As of 2023, more than 1 in 4 people in the United States deal with obesity specifically. So this is really an epidemic that has been on the rise the last several decades, impacted by several things, including the food industry and just socially our lifestyle changes and habits. But the disease of obesity is one to take seriously, and many of us don't understand that we're not just dealing with overweight or obesity. We're dealing with heart disease, diabetes, high blood pressure, sleep apnea, reflux, severe joint disease and pain, fatigue. Many medical conditions that people are trying to treat, getting into their primary care doctor's offices to treat, are related and heavily associated with the disease of obesity. We are finding that when we treat people's obesity, they overall experience a healthier and better quality of life. We even have research to show that treating obesity with significant weight loss — whether it be with surgery or medications or lifestyle changes, however you can do it — that can add years of life for an individual and improve the quality of life. So yeah, obesity is what we're tackling, but in the background, we're tackling overall health and quality of life.

John Horton:

Obesity is usually defined as a BMI of I think 30 or above. What's the line for bariatric surgery?

Dr. Rickesha Wilson:

So based on updated guidelines and recommendations and what insurance providers will recognize is a body mass index [BMI]. That takes into consideration your weight and your height. Now, this doesn't tell the whole story about someone's health. So BMI is what we've used historically, but there are better measures. But for a body mass index, a body mass index of 35 to 39 will put you in the class II obesity category. If you are in that weight category and have one to two medical conditions that are related to obesity, you would qualify for surgery. So this is longstanding high blood pressure. This could be high cholesterol, diabetes, sleep apnea. So providers that cover and would qualify you for surgery in that category, you would need to have related medical conditions.

Now, if your body mass index is 40 or higher, you don't even need to have any other medical conditions. It is considered such a severe state of obesity and a severe disease that that weight category alone would qualify you to at least be considered for obesity and programs would at least start to evaluate you to see if surgery is for you.

Julia Zumpano:

Dr. Wilson, I have a question on that. Do you use the BMI or what other factors do you use to decide which type of surgery you would suggest for a patient?

Dr. Rickesha Wilson:

Yeah, that's a great question because the surgery and procedure types really depend on not just the weight, but also other medical conditions that the patient is dealing with. For instance, those individuals who might come with really severe diabetes might be better served with a runaway gastric bypass based on results that the insulin levels and glucose sugar levels over time do better.

But also, let's say some people come to us really sick. They need an organ transplant, but they need to lose a certain amount of weight to even get on the waiting list. If you can even imagine that, weight is actually a limiting factor for many people to get a life-saving procedure. So for some individuals who are very sick who might need a liver transplant, we're going to keep it simple. So the sleeve is what we would go with as our simplest procedure that we can do the quickest. So they won't be under surgery a very long time.

Other people might come to us with severe hip disease or joint disease in the knees and they need a knee replacement or joint replacement, but they need to lose a significant amount of weight. So we would choose a stronger procedure that they could handle. Some people come with major hernias of their abdomen from prior surgeries. Maybe they've had multiple operations. So scar tissue plays a factor. We might do something simple just to get their weight down, but that's possible with surgery.

So it depends on a lot of an individual's baseline medical conditions, what their goal is, or they're just trying to meet a certain goal to get another procedure, or do they really need to lose more weight. So we take so much into consideration … and let me just add, some people come with habits and addictions. So if someone is a former heavy smoker — because no one who is currently smoking would qualify for bariatric surgery, you can't get the surgery unless you have proven by testing that you've stopped smoking. But we tell people, we're honest, some surgeries like the gastric bypass might lead you to have complications if you were to relapse back into smoking if life happens or if you undergo stress.

So for those kinds of people, we'll say, "Hey, why don't we do the sleeve instead? Because if you start smoking again, you won't be in as much danger compared to if we did the gastric bypass." So people's habits, their medical conditions — a lot of factors come into play when we decide what surgery we might recommend.

Julia Zumpano:

That's fascinating.

John Horton:

From what you've said, too, the results are pretty dramatic after bariatric surgery, too.

Dr. Rickesha Wilson:

Absolutely. Again, going back to really it's more than “Hey, eat less, work out more.” This is biology we're talking about. So you need a strong tool, not a cure, not a fix-all for obesity, but you need a tool.

So surgery compared to research, we have researched the disease of obesity and how it responds to simple lifestyle interventions, how it responds to medications for obesity that are, of course, more popular now than ever, and by far, surgery is the strongest tool that we have that we know about for weight loss that cannot just be achieved but then, maintained afterward.

So yeah, I think having that tool and having options I think is really important. But we really want to empower patients who come with questions about their obesity, bariatric surgery and even medical treatment for obesity. We want to just empower them with the knowledge of, here are the options that you have.

Julia Zumpano:

That's great.

John Horton:

So Dr. Wilson, you mentioned weight loss medications there. I know that is all the buzz right now and there's so much talk about it. I know a lot of people might be thinking about that. How do weight loss drugs and bariatric surgery … do they fit together? Is it one or the other? What's the relationship there?

Dr. Rickesha Wilson:

It's not one or the other. I think for people to have an option such as medication to treat their obesity, at least to some degree, we think it's a wonderful thing. So with medications, some of the challenges, especially with the newer medications that are on the market, people may have heard of Zepbound® or Wegovy®, but these trade names, like semaglutide, tirzepatide, a lot of those medications are very effective. However, some people cannot tolerate the GI side effects, most commonly nausea, vomiting, abdominal cramping. So we get a lot of people who have had intolerance to the medications.

They, for many, are unaffordable because insurances don't yet cover them for obesity, unfortunately. So people have a hard time keeping up with the cost. Then, for one, once you stop those medications — so some people will have to do weekly injections for life or daily injections — once you stop these medications, research has shown that you gain your weight back and it comes back aggressively. So I think that with medications, it is a good option for those who have access to it, but we're running into problems with people having good access for those medications. But some people, we do encourage them to try medications in addition to surgery, even after surgery. That's also an option because the disease of obesity sometimes requires multiple approaches.

John Horton:

Dr. Wilson, you've outlined just all the amazing things that can follow bariatric surgery, but as I understand it, those results depend largely on the eating habits that folks establish after surgery. So let's slide the conversation over that way. After all, this is Nutrition Essentials.

Dr. Rickesha Wilson:

Eating habits after surgery and really just lifestyle changes, the groundwork is really started before surgery because, of course, again, I'll emphasize surgery is only a tool. So nothing can beat the liquid sugar that's readily available all around. So the things that we emphasize in terms of after surgery: first off, vitamins. Everyone wonders, “Am I going to have to take vitamins?” Yes, lifelong, every day you'll need to take vitamins, but no big deal. I take vitamins every day or at least when I remember. So vitamins … they come in all types of formulations that people can tolerate. So there are so many options for tolerable vitamins to take.

But also, there are phases that we roll people out into after surgery that take weeks and months, but the emphasis will be high protein after surgery. Because when you're losing all that weight, you're losing a lot of muscle. So the goal is to get as much protein in as you can to keep yourself and your nutritional status appropriate, along with the vitamins and supplements. But you want to really be exercising to build muscle and to keep your lean body mass as your body burns the fat. So protein is essential after surgery.

Your vitamins are essential, and at least in our program, and in many others, we take you through phases of the diet, introducing liquids and then solids in a staged approach, so that you can safely return to "normal eating," although it's a life-changing and life-altering experience where you shouldn't go back to eating or binging the same way you did before surgery.

Julia Zumpano:

Just to piggyback on that, so just to explain, as Dr. Wilson said perfectly, is that it's a phased approach and each patient is phased a little bit different just based on how they react to each phase. So it really starts off with more of a liquid-based diet, a clear liquid, no-sugar diet for a couple days in the hospital.

And then, you may be trialed on some protein shakes before you're discharged. Then, it's a two-week regimen of protein shakes. So really, just consuming all your protein, vitamin, mineral needs through protein shakes, in addition to the supplementation. Then, after those two weeks, if you're doing well and tolerated the shakes well, we're advanced to more of a soft food diet mainly, again, still very focused on protein. So soft foods, easy to chew, easy to digest. That lasts for about six to eight weeks depending on the patient. So again, the main focus is protein.

Then, phase four is when we add in some vegetables. Then, lastly, is phase five, is when you're adding in more of those complex carbohydrates. So sometimes, it could take up to six to 12 months to get to the final phase. So it's really case by case, and we're moving slow and based on the patient's individual tolerance of each phase.

John Horton:

Now as you laid out at the start, Dr. Wilson, I mean, when you have the surgery, you're actually taking away part of that stomach capacity. I mean, does it just become, in the long term, where you are just able to eat less and that's what helps you lose that weight and maintain a healthier weight?

Dr. Rickesha Wilson:

Yeah, that is part of the mechanism for the weight loss. You essentially just can't consume the amount of calories in the same amount of time that you used to. But again, it's not only that you're eating less, but you're eating far less. So you have to pick and choose the right things because you only have a certain capacity. So filling up with complex carbs before your protein and then before your vegetables, it's going to reflect in whether or not you can maintain your weight or achieve your weight goals.

But also, again, it's also those hormones and the hormones that regulate appetite and satisfaction. Those are also going to play a role in how much weight you can lose. Then, it's your lifestyle changes, your ability to exercise, building muscle. But again, I always try to emphasize to patients after surgery especially, I'm not looking for a number. Every time I see you, are you healthier and are you stronger? OK, are you coming off of some of your high blood pressure medications? Are you no longer on insulin? One of my patients who was waiting on a heart transplant, he no longer qualified or needed a new heart after weight loss surgery.

John Horton:

Wow, it did that.

Dr. Rickesha Wilson:

That impacted him so much. So that's the goal. Again, muscle weighs more than fatty tissue. So the scale might not move "as much as you want it." But I encourage people, it's not just about the number on the scale. Are you a stronger and healthier version of yourself than you were before? Are you showing up for your loved ones and for yourself the way you want to? That's most important.

John Horton:

So Julia, we were talking ahead of time, too, with the vitamin supplements, and it sounds like a big reason why you need to add those to your routine is because you are eating less food. So you need that extra, extra boost.

Julia Zumpano:

Absolutely. Depending on the surgery you have, you're bypassing parts of your gut. So there's areas of your intestine and your stomach that are responsible for absorbing some of these nutrients. So by bypassing those, you bypass the absorption of them. So you really do want to look at getting in all your vitamins and minerals supplementally because you cannot consume it, and in some cases, you're not, again, going to absorb it as well as you had in the past.

So some examples of some vitamins you will need to be on lifelong post-surgery would be a basic multivitamin. But the multivitamin does have specific requirements on percentages of certain vitamins and minerals, calcium and vitamin D, your B12 and a B-complex, specifically with thiamine, iron, zinc and, in some cases, even biotin. So those are some of the few that you will certainly need lifelong.

John Horton:

Sounds like everything a person needs for a healthy life.

Julia Zumpano:

Absolutely.

John Horton:

So all of this that we've laid out here, it sounds like just massive changes for people after surgery. So as part of this process, do folks typically work with a registered dietitian or nutritionist to make that pivot?

Dr. Rickesha Wilson:

Yes, they do. When people first become interested, at least in our program and in many others, we first off check their benefits, make sure they have coverage for it and would be approved if they qualified. But also, they undergo rigorous appointments and evaluations by psychologists and nutritionists as well as they meet with some of our advanced practitioners, nurses and, of course, surgeons as well. But yes, a registered dietitian before surgery will be walking them through and evaluating eating habits and patterns, already trying to make changes even before surgery. That pre-surgery evaluation really is helpful to almost predict or see how patients will do after surgery and who may or may not be successful.

So for folks with maybe binge-eating habits or emotional eating in certain cravings or addictions, if they can't overcome those things or improve their habits before surgery, they wouldn't even get cleared by the dietitian or the psychologist. So insurance providers that approve and cover these surgeries are actually relying on and looking at the nutrition visits and notes, the psychology visits and notes to make sure these patients that they're investing in are also invested.

Julia Zumpano:

Absolutely. I mean, many insurance companies do mandate a minimum number of visits with a dietitian prior to surgery. So, however, if patients are still not ready to make the changes needed, they may have to come back to assess their knowledge base at a later time and work on some of those health goals and nutrition goals. I mean, it's really key that some of the best predictors of success is how well the patient sticks to the plan, even pre-operatively. So there's a lot of support in place, there's a lot of great guidelines in place, but really, that is one of the key determinants.

John Horton:

So let's look at the advice a registered dietitian might give someone following bariatric surgery. Luckily, we always have a fabulous registered dietitian with us. So Julia, where do we start?

Julia Zumpano:

So as I mentioned, we go through the phases. Each phase progresses. So we start with phase one through phase five, slowly introducing foods and, again, with the primary focus being protein and vitamin and mineral supplementation. Each patient is advanced as they tolerate. So it's case by case, but we do have a general guideline on how long we like each patient to be in each specific phase. But we do know there are certain things that we do want to really limit, especially in the beginning. So we do really have them limit caffeine in the first three months, make sure they're staying well hydrated, drinking between meals and not necessarily consuming a lot of liquids with foods. So minimizing that amount of liquid and food in the gut. We definitely advise against alcohol. If you can avoid alcohol lifelong, that'd be ideal, but specifically in the first three to four months.

We limit, again, processed foods and high sugary foods, a lot of sweets, especially, again, in that first three- to six-month period. We really try to be very cautious on any foods that can cause any more irritation or negative symptoms. Some patients may even experience something called “dumping syndrome,” and that occurs when foods high in sugar pass too quickly. That can lead to feelings of nausea or vomiting, abdominal fullness or pain. It can even lead to things like sweating and rapid heartbeat, diarrhea and dizziness, the feeling very fatigued or tired.

So sometimes if a patient may consume something that doesn't agree with them, that's a quick lesson learned that you have to be very cautious on how you reintroduce foods, reintroducing them slowly and at the right phase.

John Horton:

A lot of the things you mentioned, you said like three to six months, but looking years after, is what you eat going to have to change a ton?

Julia Zumpano:

Well, we want to focus on really healthy eating habits, so making sure you're consuming complex carbohydrates. Again, always, always consuming enough protein because again, as we're losing weight — and the hope is that you continue to gradually lose weight over time — you're also losing muscle. So protein and complex carbohydrates are key. Not consuming too much fat or too much sugar. So this style of eating in some cases is very different than the style of eating that someone may have been following pre-surgery. So again, some of these guidelines are set pre-surgery and the visits that you have with a dietitian, but yeah, these are lifelong goals of really establishing healthy eating habits.

John Horton:

Dr. Wilson, do you find with a lot of the people who come in for these procedures, is that something where they have not had a healthy relationship with food and just have built up some really bad eating habits over the years?

Dr. Rickesha Wilson:

That is the case for some individuals and they are having to relearn their relationship with food and change how they deal with stress and various triggers that might cause overeating. And then, we have other individuals who do well. They're on a regimen. They are watching what they eat and still find themselves with obesity and other conditions. So yeah. That's the benefit of going through the program, there's a psychological component meeting with the dietitian. I think people who already have good tools in place — whether they develop them through the program or already had good tools in place — they are the ones that do better after surgery because they can use the tool of surgery and add it to the work they've already been doing. We see them thrive more times than not.

John Horton:

Dr. Wilson, I'm so glad you said that because I think we all have a little bit of a complicated relationship with food, which is really one of the driving forces for our podcast here. So in looking at specifically with bariatric surgery and afterward and all of that, what tips do you give folks to help them make this transition? Julia, I'd love for you to weigh in here, too.

Dr. Rickesha Wilson:

The tip that I give patients — because I see them early after surgery and then I try to see them annually at the one-year mark — but the tips I give, of course, are you taking your vitamins? Are you taking your supplements? Because people might start feeling great and like, "Hey, I'm good. I don't need it." So are you taking your vitamins and supplements still faithfully? Because again, you've gotten accustomed to how much you can eat, but still, you need that extra support. Are you getting in your protein? And then, are you putting in some work? Are you walking maybe three to four times a week and are you doing strength training? I always encourage my patients, if you can't do a push-up today, in six months' time, I want you to be able to do two or three push-ups. Are you getting stronger? Are you putting in the effort? Are you able to measure your growth and your health improving? So that's a big tip.

Of course, I think other habits … I always encourage people, "Hey, join our support groups." This is not just, "Oh, I got surgery and then I'm out." We support people through the journey. This is a journey that requires support, it requires reminders. Life happens, changes happen. Are you making sure you are avoiding being around any smoke or smoking cigarettes, avoiding excessive alcohol? Alcohol dehydrates you. Caffeine will dehydrate you, and that can lead to a cycle of nausea, things like that. Smoking cigarettes, taking certain over-the-counter pain medications like Motrin®, Aleve®, ibuprofen, that can cause ulcers. That'll pop up in five years because someone maybe got an injury and developed chronic pain. Now they're popping Aleve and they forgot, actually, “This is harmful to me. I've had the bypass or I've had a sleeve. Now I'm having pain.” This could be an ulcer because of your lifestyle changes. So it's important to check in to see how has life changed, what are your habits? Let's remind ourselves, you may have achieved your goal, but your health is still more than a number. We got to make sure that the habits that we keep and are forming are appropriate and supporting our overall health and goals.

Julia Zumpano:

One thing I do, also just to add on to what Dr. Wilson said, is practicing diet changes early and often. So taking advantage of that pre-op process and pre-op time, meeting with the dietitian, setting up better eating habits and practicing them, trying to focus more on chewing your food slowly, thinking of your food as part of your medicine routine — that can really also help on some of the tough days. So really thinking of food as medicine and taking it slow, taking it one change at a time and really starting the process before surgery even starts and planning ahead. Like Dr. Wilson said, the patients who are prepared and have a plan and have a mindset do a lot better.

John Horton:

Now, I know any surgery can come with some potential complications, and I'd imagine bariatric surgery is no different. So what things could possibly happen that people might want to be on the lookout for?

Dr. Rickesha Wilson:

Sure, and I'm glad you brought that up because the safety of bariatric surgery is always paramount and important to patients who are just learning about it. Historically, bariatric surgery got a bad rep in the earlier days, but bariatric surgery … our research has shown that it is extremely safe. People may have gotten out their gallbladders or had a knee replacement or a joint surgery. Bariatric surgery is as safe as those procedures. There's a higher risk of complications for procedures like cardiac bypass, open heart surgery or transplant surgery or some of the others. So bariatric surgery is very safe.

Some early complications that you could have are just routine nausea, vomiting, dehydration that might send you to the emergency department, requiring some extra IV fluids. With any surgery, bleeding and infection are possible complications you can experience, and those are even fairly rare. Overall, the complication rate, 3% after the sleeve, 5% after the bypass. Rare complications and maybe the most serious that we would worry about are what we call “leaks.”

So when we cut the tissue with the surgical stapler to divide the stomach and make our connections, if there is a leak or a breakdown in that staple line or that connection between the pouch and the intestine, that can make you really sick. Our studies show that there's less than a 1% chance of that happening.

People could get blood clots after surgery because the combination of surgery and obesity can put you at higher risk of blood clots. So we use a calculator to calculate people's risk for developing blood clots, and we can put you on a blood thinner temporarily for about two weeks to lower your risk for that if you're higher risk.

The risk of death, of course, is people's major concern, whether it be from the surgery or anesthesia in less than 0.001%. So that is not the norm for these procedures. People do well. They come out of the surgery. So it's very safe, and I think that's important for people to know.

John Horton:

So we spent a lot of time talking about just the changes that somebody's going to have to adjust to just eating-wise and things like that, but I'd imagine, too, that getting bariatric surgery can be emotionally tough for people, too. I mean, there's just a lot happening and it's a significant life decision and life change. How difficult is it for people post-surgery to embrace, I guess, their new self?

Dr. Rickesha Wilson:

I found that patients who have gone through the rigor of the program, all the appointments and all the counseling sessions, and we have informed them very well before surgery — I mean, they are so ready for this change and so committed.

We try to educate people the risk and the change of surgery and the lifestyle change is required after are worth it when you think about the risk of having severe obesity for years and decades and what that does to your risk of heart disease, of fatty liver disease — which is now becoming one of the most common reasons people even need a liver transplant, not alcohol anymore. It is fatty liver disease. So when people have the knowledge of, “I'm understanding how obesity is actually putting me at higher risk for other complications, developing diabetes and actually taking years off of my life,” I think they can see that the tradeoff and the sacrifice that they make and can adjust to after surgery is well worth it.

John Horton:

Dr. Wilson, because I remember you told us this number and I can't remember it exactly, but it could potentially add a lot of years to your life, correct?

Dr. Rickesha Wilson:

Yeah. There are studies that show that for those with diabetes, significant weight loss and a transformation in your health can add nine years to your life; those without diabetes, about five years to your life. We at the Cleveland Clinic and our group does a lot of research on specific diseases and how patients who underwent maybe usual care for their diabetes or high blood pressure versus those who underwent bariatric surgery — the difference in their risk of some of these major cardiac events, developing liver failure, developing chronic kidney disease, leading to dialysis — so yeah, five years for those without diabetes can be added back to your life, nine years with diabetes just as an example of how transformational treating obesity and possibly with surgery is.

Julia Zumpano:

Not to mention the quality of life in those extra years, I think, is worth mentioning, that you're going to be living a better quality, a healthier life. You're going to be able to enjoy a lot more activities with your family and socially and personally. Mentally, you'll feel better. I think there's so many other benefits besides just the longevity piece. It's also just your state of health.

Dr. Rickesha Wilson:

You're absolutely right. So many patients who come for our appointments, they just say, "I have grandkids now. I can't chase them around." People are in their 30s maybe, “I can't keep up with my own kids. It's hard. I have to sit out when I want to swim with my daughter or I want to be able to walk around the theme park with my kids.” So this is a real thing for people. People are tired of injecting themselves with medications or they're tired of hurting all over or carrying around the weight, wearing down on their joints. So people are really motivated for a life change. I think that arming them with the knowledge of how getting healthier can improve that quality of life is very convincing and is worth it to many people.

John Horton:

So in many ways, it sounds like bariatric surgery requires folks to establish a new relationship with food and just to embrace a healthier lifestyle. It seems like there's value in that lesson for just about everyone. So I'd like, if you could, just a few final thoughts from both of you as far as what this adjustment means and the value that it brings.

Dr. Rickesha Wilson:

Yeah, I'll just say I think this adjustment for many patients, it's really nothing in comparison to the benefit and the quality of life that they get back in return. I've had so many people a year out, two years out, many years out say, "This is one of the best decisions that I've made. Now, I'm used to being able to get through crowded spaces, easily sit on an airplane, go on roller coaster rides with my family. These are moments that they are able to get back with their loved ones or “Hey, I ran my first marathon.” So I think that the changes and the sacrifice that you make as a patient, if you choose to undergo bariatric surgery, the providers on the other end are walking through this with you and we are just as invested as you are.

We have support groups follow up after. We have a whole thick guidebook to give you that you can have to educate yourself and remind yourself of how to be successful with the tips that we recommend. So I think that for those dealing with obesity or overweight, there are options to improve not just your weight but your overall health. I think it's worth exploring and visit the Cleveland Clinic's Bariatric website to learn more information. You can register online and we'll reach out to you with more information and get you an appointment to speak at least with the surgeon, to have a conversation to see if this is for you. But treating obesity and improving your health has a myriad of benefits that are worth the changes and sacrifices that you'll make.

Julia Zumpano:

I couldn't agree enough. I think just really utilizing the support of dietitians as well, I mean, pre-surgery and post-surgery, whatever your decision might be, but just overall, whatever your weight loss journey may look like, a dietitian can really fit into that journey and really support your health goals, whatever they may be and whatever stage you're at. So really utilizing the resources you have to be able to maximize on your success. I mean, no one expects anyone to do this alone. It's a very hard and tough journey. As Dr. Wilson discussed, there are so many facets that play into the role of the disease of obesity. I think a lot of those can be overlooked, but really, it is a disease and you need a lot of support and help and utilizing a team approach to really have long-term success and good outcomes.

I think the importance is starting with little simple changes to help improve your relationship with food as well. So practicing things more like mindful eating, making small health changes, health goals to reduce unhealthy foods that you might be consuming on a regular basis and starting to experiment with including more whole foods in your diet. So small little changes and prepping yourself along the way makes it less overwhelming. Again, that support piece is key.

One thing we did not discuss that I think is important from a lifestyle perspective is we talked about exercise and nutrition and diet, but sleep is really essential. A lot of times, if someone struggles with obesity, their sleep may be a big challenge. We know that sleep can throw off some of those hormones that are related to hunger and satiety. So I think just really getting good sleep habits or getting support to help you improve your sleep is very essential because some people may even associate lack of sleep or fatigue with hunger and they may be feeding the need for energy versus the need for food. So I think it's also deciphering what your body's trying to tell you and giving yourself the time to be able to listen to the cues and properly manage them and react to them in the proper way.

John Horton:

So this has just been an amazing discussion, and I want to thank both of you for just sharing so much valuable information on bariatric surgery and what it can do and the great life that can follow it. So thank you both, and I can't wait to have you back on again.

Dr. Rickesha Wilson:

Thanks so much you all.

Julia Zumpano:

Thank you.

John Horton:

There is no question that bariatric surgery can help people with obesity, lose weight and live healthier, but the procedure is only part of the process. For the surgery to truly make a difference, it needs to be combined with a commitment to healthier and more nutritious eating habits. Consider that the recipe for success.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, eat well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.