Doctor, former patient discuss bariatric surgery Sabrena Noria, MD: Good morning. My name is Dr. Sabrena Noria, and I'm one of the bariatric surgeons here at The Ohio State University Wexner Medical Center. Joey Dillon: And my name is Joey Dillon. I am a bariatric patient of Dr. Noria's, but I also work for the medical center on the social media team. Sabrena Noria, MD: So today, we'll be talking about bariatric surgery and Joey's experience with it. Joey Dillon: Dr. Noria, I'm curious, for our viewers here, what are the types of surgeries that are offered at Ohio State, and how are they different? [Text on screen: Sabrena Noria, MD Associate Professor of Surgery The Ohio State University Wexner Medical Center] Sabrena Noria, MD: So here at Ohio State, we offer two types of surgeries predominantly. One is the gastric bypass and one is the sleeve gastrectomy. The gastric bypass essentially is where you make a pouch out of the stomach and you reconnect the small bowel. The gastric sleeve, on the other hand, is where you essentially take the stomach, which looks like a football, and make it look like a banana. The differences are that the gastric bypass is a restrictive and a malabsorptive procedure, whereas the gastric sleeve is a restrictive procedure. [Text on screen: Joey Dillon Bariatric Surgery Patient The Ohio State University Wexner Medical Center] Joey Dillon: So I'm curious, when you're deciding which procedure to get, what are the pros and cons for each one? Sabrena Noria, MD: So when we are taking care of a patient and leading them through the process to get to surgery, really, we take their medical conditions into consideration, their anatomical conditions, like what does their stomach look like, as well as what the patient wants to get out of the surgery itself. In terms of overall weight loss with a gastric bypass and the gastric sleeve, usually, it's about the same, out to about 18 months to two years. After that, typically, patients that have a gastric bypass tend to do a little bit better with sustained weight loss. That being said, people do amazingly with sleeves as well. With respect to resolving the medical problems that are associated with obesity, including diabetes, hypertension, sleep apnea, both surgeries do well, but studies have demonstrated that for the gastric bypass, it occurs faster, especially for patients with diabetes. Joey Dillon: And she makes a really good point, so there are obviously underlying medical conditions people have who struggle with obesity, myself included, I struggled with GERD, so acid reflux for the most part, and at Ohio State, in our introductory meeting, they basically said, if you have GERD, you have one option, which is gastric bypass. Are there any other specific medical conditions that void... For me, I couldn't have the sleeve, but I had gastric bypass. Is there any specific conditions that some of our viewers might want to know that disqualify them from one or the other? Sabrena Noria, MD: Sure. So I would say, generally speaking, there's no such thing as disqualification, because if a patient is not interested in one surgery, even if that's the right surgery for them, as practitioners, we think, well, let's at least take care of the patient and help them achieve significant weight loss in order to get healthy and then focus on other aspects that may have been contraindicated for the surgery. That being said, typically, patients with poorly controlled diabetes, we tend to suggest that they have a bypass. Patients like you, who had terrible reflux, we tend to suggest bypass. For patients that are better sleeve candidates, those typically are patients that perhaps are transplant candidates and need a lot of stomach left over to absorb those medications. Additionally, patients that perhaps have had a lot of abdominal surgeries and are looking to get a hernia repaired but need to lose weight, we typically recommend a sleeve gastrectomy. Joey Dillon: And then, I guess, we're going to be talking mostly about gastric bypass today, even though you explained things, what are the pre-surgery- Sabrena Noria, MD: That's a good question. [Text on screen: Joey Dillon Bariatric Surgery Patient The Ohio State University Wexner Medical Center] Joey Dillon: ... steps that someone will have to take? I can talk a little bit on my end, I had to go through six months of monthly check-ins with my primary care provider... Realizing not only before and during surgery, but after. And then, I think one thing that I really wasn't prepared for was the liver shrink diet two weeks before, just to make sure that when you're doing a surgery, there are really no complications with the liver, just because with obesity, there is a lot of fat around the liver and everything's done laparoscopically, so you don't want the liver to basically break itself off. So I think that my biggest, like, "I have to do what for two weeks?" Which was just a lot of vegetables and protein shakes, just making sure that the liver's nice and healthy for the surgery. So on average, what are those steps that the patient would want to know, one, for the surgery, but two, maybe on an insurance and what they're looking for? [Text on screen: Sabrena Noria, MD Associate Professor of Surgery The Ohio State University Wexner Medical Center] Sabrena Noria, MD: So that's a great question, and basically, you summarized it in a nutshell. But essentially, all patients have both insurance requirements and our program-mandated requirements. The insurance requirements, they vary from carrier to carrier, but essentially, there is some component of a medically managed weight loss duration, meaning you have to go and see a provider to talk about weight, to talk about calorie restriction, to talk about exercise for a set period of time determined by your carrier, whether it's three months, six months, nine months, I believe sometimes it can be out to about a year. So that's one aspect of it. Then from a programmatic requirement, which also is in conjunction with the insurance requirements, we do a full head-to-tail medical evaluation, screen patients for sleep apnea, for any cardiac issues, for any liver issues, for reflux, things like that, diabetes as well. And then, they all undergo an endoscopy to look at the anatomical fitness of the stomach to make sure that the surgery that you want is a surgery that you can get. Additionally, as Joey said, there's a psychological evaluation that's mandated by the insurance requirements, and additionally, all patients see our dietitian to learn how to use the tool that we are essentially giving them. It's not about dieting, it's about understanding how to eat differently and how to drink differently. So that's all the pre-operative workup that patients typically need to go to. And on average, it's about six to nine months to get to surgery, really because of those insurance-mandated weight loss requirements. Joey Dillon: And you mentioned, a lot of my next question is Ohio State has a lot of great experts, what all makes up the team of the bariatric program at Ohio State? Sabrena Noria, MD: Well, we have a fantastic team. It's the Comprehensive Weight Management, Metabolic and Bariatric Surgery Program, and what that means is that we see patients really holistically. Not all roads lead to surgery in our program, certainly. We have multiple avenues that patients can take if they're not interested specifically in surgery. But because we have all those avenues, we have all those experts. So starting with our nurses that triage our patients, to our nurse practitioners who manage not only intake evaluations but also follow up our patients after the immediate post-operative period. We have an endocrinologist, Dr. Ben O'Donnell, who helps especially with those difficult cases in patients that have poorly controlled diabetes. We have psychologists, we have behavioral therapists and dieticians, and of course, the surgeons. So it's a very well-rounded program. But what's great about being here at Ohio State is that we can also reach out to our colleagues in different surgical specialties in order to get their input, for example, cardiac surgery, cardiology or hepatology, things like that. [Text on screen: Joey Dillon Bariatric Surgery Patient The Ohio State University Wexner Medical Center] Joey Dillon: And so, we briefly mentioned the pre-work for surgery. What are things that our viewers, potential patients, want to know about that post-surgery? Obviously, results, but what are things that they need to do? I could talk ad nauseum about the step diet, but I'm going to leave that to you. Sabrena Noria, MD: So before I answer that question, what was your experience like? Joey Dillon: Looking back, I didn't find it too challenging on my end. You go through that nine-month process with insurance and going through all these appointments, and then the liver shrink diet two weeks, really, it's totally all right. It was over the summer, so I was playing a lot of tennis, and so my biggest question was, well, I'm being restrictive with the calories, can I eat more technically? Because of the liver shrink diet, your big meal is a lean cuisine, essentially, so it's like, okay, what can I take to make sure I'm really not going too hard into negative caloric intake? And then, after, there's a steps one through four diet. The first one is basically just liquids. I think that was probably the hardest, especially in the hospital right after, you're on LiquaCel, which is basically just a liquid, making sure you get all of your nutrients, that was really rough. But then, eventually, a couple of weeks later, you go into baby food, and then you're able to progress your way into, I would probably say a month, month and a half, two months of post-surgery, you're able to fully break into a new normal of a diet. I will say the biggest challenge that I still struggle with a little bit is that new way of eating and drinking. I was 29 when I had my surgery, and so you're changing nearly three decades of habit. So making sure I'm chewing everything at least 20 times, making sure that it's fully processed, just because I can personally feel in the pouch that Dr. Noria created that it's not processed enough, I didn't chew it enough, so it's sometimes painful, it's a lot of the time uncomfortable, so I think things like that. And then making sure that I'm drinking enough water. I remember a follow-up we had, I definitely was dehydrated, and she was like, "Okay, we can give you an IV," but I was so dehydrated, I couldn't get stuck. So really just making sure that you're intaking not only the correct amounts, but the correct way, I think are those biggest things. [Text on screen: Sabrena Noria, MD Associate Professor of Surgery The Ohio State University Wexner Medical Center] Sabrena Noria, MD: Agreed. And everything that you said, Joey, really reflects what we try to do in terms of preparing you pre-operatively with our courses and our classes and things like that, as well as to reinforce post-operatively. So as you know, we see you two weeks after surgery, then we see you six weeks after surgery, and then six months, and then yearly after that. And really, our goal is to see patients at every diet change so we can reinforce those principles. And then, at about six months, it's when we do your lab levels to make sure that your vitamins are okay and all that kind of stuff. And additionally, it helps us also track your weight trajectory, because after six months, weight can plateau, and that's the time you want to catch it, make sure you guys are doing okay. [Text on screen: Joey Dillon Bariatric Surgery Patient The Ohio State University Wexner Medical Center] Joey Dillon: Yeah. And I will say, at Ohio State, you guys are so responsive, whether it's Kirsten, my CNP, you, another nurse. Usually, if I have a question, I always ask in MyChart and I get a really quick response. And I think something that we haven't really talked about in that post-surgery care is vitamins. So obviously, when you're having bariatric surgery, you're rerouting things, specifically in the bypass, and your body just doesn't absorb things the way it used to. So for instance, some of the medication that I was on before surgery was extended release. Sabrena Noria, MD: Extended release. Joey Dillon: I can't take that anymore. And the way most people process and their bodies break down their food to get their nutrients, mine doesn't do that anymore, so I have to take specific vitamins every single day, either chewables or a multivitamin that you swallow. So can you go into some of the things that maybe patients might not be thinking of, such as vitamins post-surgery? Sabrena Noria, MD: Sure. So a couple of good points you brought up there. So first of all, when it comes to gastric bypass specifically, people call it malabsorptive, but really, the malabsorption has to do with the vitamins specifically, because when we reroute the intestines, we cannot get nutrients from our food again, that's just the way it is, so that's why we need the vitamins. And people get a little bit nervous about having this litany of vitamins that they have to take, but really, what's your experience been? There are vitamins that are out there, just a couple a day, that will take care of things for you. Joey Dillon: Yeah. [Text on screen: Sabrena Noria, MD Associate Professor of Surgery The Ohio State University Wexner Medical Center] Sabrena Noria, MD: Additionally though, the other aspect of the malabsorption related to gastric bypass is dumping, specifically dumping with the gastric bypass, and that really is a response to taking too much sugar in and your body responding to it. And those symptoms are things like feeling sweaty, your heart racing, feeling like you may pass out, and unfortunately dumping, so patients either vomit or have terrible bowel movements, and that is because we don't follow the sugar rules, that's the way I like to talk about it. And really, it's a way of patients... It's like a negative feedback, essentially. So we actually recommend, back to our original question, we actually recommend that patients who have a weakness with sugar or their weight is related to sugar intake, we actually do recommend having a gastric bypass, because dumping is very prohibitive to eating more sugar. So those are the complications that can occur, definitely. Joey Dillon: And something I didn't mention, obviously, on top of new vitamin intake, I think one thing that I never really thought about when I was going through this process, obviously diet, that's probably why I was getting bariatric surgery, but was the protein intake, and because you're eating so much fewer amounts of food, essentially, with your new stomach, there has to be workarounds to make sure you're not only getting the right amount of liquid, but the right amount of proteins and other nutrients. What are things you would suggest for maybe someone who has just gone through surgery and is unsure of how to tackle that specific problem? Sabrena Noria, MD: Sure. So with respect to protein intake, you're absolutely right. Protein, protein, protein, protein, always first, because as you learned in the program and as patients learn in the program, a calorie from a protein is different than a calorie from a carb, is different than a calorie from a fat, and the way that our body processes it is different. Proteins keep you fuller longer, proteins help you heal, all that good stuff. So typically, we recommend that if people struggle with the confusion around what they should have, I say keep it simple. Protein shakes are your best friend, watch the amount of sugar in the shakes, obviously, but they're your best friend. And they're typically about 30 grams a bottle, and we recommend 60 grams a day. So if you bookend your day with a shake in the morning and in the evening, you're okay. And then, everything else in between, you can, of course, moderate. So protein is one, and then water, fluids, hydration is the other key. [Text on screen: Joey Dillon Bariatric Surgery Patient The Ohio State University Wexner Medical Center] Joey Dillon: Yeah, I pretty much always do a morning protein shake to at least make sure I'm getting half of my daily amount of protein. I try to do two, but I know at least I'm getting close to that 60 grams a day with at least one protein shake. I guess I should also ask, when it comes to diet, there are many things you can't really enjoy anymore after surgery that not a lot of people think about. Well, soda is really the big one. Are there any other specific items, food or drink, that people should be aware of following surgery? Alcohol, soda, things like that? [Text on screen: Sabrena Noria, MD Associate Professor of Surgery The Ohio State University Wexner Medical Center] Sabrena Noria, MD: Yeah, that's a great question, actually. So for alcohol, certainly the way that the body processes alcohol after surgery changes completely. We actually recommend that patients abstain for about six to nine months or a year, just because the intestines, as we've talked about, have been rerouted and we just don't know how a patient will react. We also recommend that they do it at home if they're going to have a drink so that they're safe. Now, alcohol, that's just for consuming it, but of course, alcohol has a lot of sugar in it, so you also have to be careful about things like dumping if you have a gastric bypass and you drink alcohol. So that's alcohol. The other, what was the... Joey Dillon: What are things that patients should be aware of that they can no longer have post-surgery? Sabrena Noria, MD: Food intolerances. So as you mentioned, anything with carbonation in it. It can expand the pouch and it's very difficult to burp after the gastric bypass, it makes patients very uncomfortable. Additionally, if you expand the pouch, you fill it, essentially, and so you're not going to eat that protein that you need to eat. Sodas that are sugary, obviously, that's going to cause dumping. And then, lastly, in terms of other food intolerances, and I don't know if you've experienced this, patients just generally will have food intolerances after gastric bypasses. Typically, I hear from my patients, tomato-based things and red meat. These intolerances start early on after surgery and can last about six months, but after that, typically resolve. And that has to do with the surgery, obviously. Not sure why it occurs, but it can be anything. Patients say, "I had chicken before, now I can't stand chicken." I don't know if you've experienced any of that? [Text on screen: Joey Dillon Bariatric Surgery Patient The Ohio State University Wexner Medical Center] Joey Dillon: Yeah. So pork has been the really big one for me, where even though I chew it quite enough, I process it, I break it down, it just doesn't always sit right, like pork loin, that type of pork. I can usually do bacon if it's pretty crispy. You mentioned carbonation. I haven't really missed soda, but one way I was always getting my water intake were those sparkling waters you can get at Giant Eagle or another grocery store, and I thought a good workaround was, okay, well, I'll open it and let it flatten and then I can have it. But I've realized the gas that makes up the bottle, that's sitting in there for however long it's been processed, still goes into your body and still creates... You can feel it expanding a little bit. So I think if some people are trying to think of a workaround of flattening carbonation, it's not going to work. But for me specifically, when it comes to foods that are troublesome, red meat a little bit. I usually don't eat a lot of red meat, I usually eat ground turkey. But the pork has been the biggest one for me. So I think, obviously, being upfront with the dieticians and your surgeon and making sure that you're listing everything that's going on. Sabrena Noria, MD: And that's the thing, dieticians are here to advise you. We've heard it all. Well, I think we've almost heard it all, and there's definitely workarounds, there's definitely different sources of protein, different types of food you can eat. I will say that it reminds me that initially after surgery, there's some patients that do experience a head hunger or a mourning or a loss of the ability to eat the foods that they loved, and that's a real thing. Gosh, maybe 10% of my patients mention that when I first see them in the follow-up clinic, and we have support groups for that, that definitely can help patients work through that, because that's a real thing, and that can definitely create obstacles to success. So we take everything that patients say really seriously to try to figure out how to best help them. Joey Dillon: Okay. Something we haven't really discussed is being active, exercise. For me, tennis is my biggest passion, so I play a lot of tennis, I played a lot of tennis even when I was a person of size. However, I think I can talk on my end, something I didn't do enough, especially right after surgery, was doing a lot of toning. So can you discuss what you would recommend for a patient exercise-wise, not only after surgery, but before, and how long they should wait, what their restrictions should be, stuff like that? Sabrena Noria, MD: So that's very patient-dependent, depending on if they're coming to surgery to lose weight for a hip replacement or a knee replacement. But just assuming the average patient, what we would recommend, if they can, to do just basic cardio exercises before or any sort of exercises they enjoy doing, and I think that's the key, you have to enjoy doing it. If you don't like going to the gym, don't go to the gym. If you like to play tennis, that's what you need to do, but just do it. That's the first thing. Now, after surgery, we recommend that patients are... We actually, you remember, we walked you the day of surgery, to get up and start walking around. And certainly, for the first two weeks of your recovery, we do want you to get up, walk around, take the stairs, do all that good stuff. And then, once you're seen in clinic, then we start introducing the cardio piece of the exercise, where on average, we say patients should be exercising about half an hour a day, five days a week. And then, about a month later is when we add the weight training, the strength training. Why we do that is really because there is evidence to show that when you train and you build muscle mass, that increases your metabolic rate to sustain long-term weight loss, and that is really what we need to do over the long-term. The short-term, patients will lose weight no matter what they do because that's the surgery. But then, after six months, you have to start thinking, if I want to continue to lose weight, we have to exercise, and isn't it better to have established those habits prior to that six-month cutoff? That's the algorithm that we give patients, essentially. Now, how to exercise, certainly there are a lot of programs that are out there, certainly gyms, whatever patients want to do. But I will say that we have recently partnered with a great program here actually at OSU, it's called Exercise is Medicine, to help patients understand how to train, essentially. People can do treadmills, but lifting weights, things like that, you need a professional to train you. And so, that's something that we've just established in terms of a pathway, so really excited to develop that program as well. [Text on screen: Joey Dillon Bariatric Surgery Patient The Ohio State University Wexner Medical Center] Joey Dillon: And I'll talk a little bit about my personal journey at Ohio State. So I started the process in January of 2020, so right before COVID, so obviously the whole process was a little bit different because elective surgeries really weren't allowed until pretty much right before I had it that October. Since then, I've lost probably about 210 pounds. And I think the biggest thing for me has been, again, tennis being my biggest passion, so I've really been throwing all of my being into seeing how far I can take my tennis, and I think that the biggest and proudest accomplishment I've had has been playing a professional tennis tournament. It was always my dream growing up, and obviously luck has to fall in your favor to be able to get into the tournament, that did. Actually, I had a complication with my surgery, I had an ulcer that perforated, so I was actually back in the hospital, and the tournament, it was at Ohio State, actually, a minor league event, and I was in my hospital bed and I signed up, and I was like, it's in a month, we'll see what happens. And I got in, and I got crushed, obviously, but- Sabrena Noria, MD: It doesn't matter. Joey Dillon: ... being able to last on the court, hang in these rallies with professional caliber players. I don't know for a fact, but I'm pretty sure I'm the only professional tennis player who has had bariatric surgery. But having the surgery has had an incredible impact, not only on me physically, but mentally. I've never been happier. I tell so many people that I was definitely insecure in myself and I would always mask by trying to be funny and just blaming it, oh, I don't want to do so-and-so because I have school or I have class or I have work. But it was really just because I was insecure with myself, and I'm a lot more confident now and I'm able to put myself out there, make new friends, make new relationships, travel and play a lot of tennis, really try and maximize this, I call it a new lease on life, and that's really what the surgery is. [Text on screen: Sabrena Noria, MD Associate Professor of Surgery The Ohio State University Wexner Medical Center] Sabrena Noria, MD: And that's the point. So we, as physicians, we want your medical problems to go away, that's the first thing. We want you to lose about 50% of your excess body weight. But then, patients ask me, "Well, Dr. Noria, how much should I lose?" After that, it's what you want to achieve in life, that's all it is. And you're achieving it, which is fantastic. Joey Dillon: I think just to wrap things up, what makes Ohio State so successful, not only locally, but nationally, as a bariatric program, and why should a patient choose Ohio State? Sabrena Noria, MD: So why we're so successful, one, we have a very comprehensive program. It is one of the first in the state. And I think what I love about being a surgeon in this program is that we're always looking to improve, we're always looking to be better, and through our research, through our interactions with patients, I think that that is what sets programs apart. And the longevity, the reputation, the number of patients that we've done, all that experience, I think really makes this one of the best programs in the country, as far as I'm concerned. Joey Dillon: Awesome. Well, not only thank you for joining us today, but for basically changing my life for the better. It's night and day of where I was just under two years ago to where I'm at now, and I can't say enough good things about the program at Ohio State, that you guys care, and I'm not just saying that just to say it. Being able to have the responses so quickly and have the support from all the staff, not just you, but all the nurses and admins and things like that. Even going back to the complication I had, I was in the ER, had a scan done, and you were right there, being able to basically assist in that process of surgery. So I can't say enough thanks and I can't say enough praise about the bariatric program at Ohio State. If you have any specific questions, please leave them in the comments. And if you want to reach out to Dr. Noria or anyone else on the bariatric team, we'll make sure to leave a link to the website in the description. Thank you. Sabrena Noria, MD: Thank you.