A Patient’s Guide to Weight Loss Surgery

Seeking weight loss surgery can be a life-changing decision, but understanding the process from the first consultation through post-op can feel overwhelming. To help clarify what to expect, we spoke with Giovanni Dugay, nurse practitioner for Columbia’s Center for Metabolic and Weight Loss Surgery. He walks us through the journey step by step, covering everything from intake to insurance coverage and nutrition.

Starting the Process

When a patient contacts your office about weight loss surgery, what can they expect as the first step?

We start by asking for basic information like height, weight, and insurance details. Then, we schedule a consultation with either one of the nurse practitioners, an advanced practice provider (APP), or a surgeon. That consultation determines whether the patient is a candidate for weight loss surgery, and if they are, it sets off the process. At that visit, we also provide a checklist of things that need to be completed, including what is required by their insurance.

What happens during the consultation itself?

I try to break the ice by telling patients, ‘You're here for a consult—it’s just an opinion. You take it or leave it. You’re not committing to surgery today.’ Weight loss surgery is elective, meaning even if you are a candidate, it’s your choice whether to proceed. The consultation involves reviewing medical history, discussing prior weight loss attempts, and setting expectations. If the patient decides to move forward, we give them a checklist of medical evaluations and steps required by their insurance before surgery.

Insurance and Pre-Surgery Requirements

What kind of insurance requirements do patients typically face?

It varies. Some insurance plans require supervised weight loss management before they approve surgery. For example, Aetna requires 12 visits over 12 months with either a primary care doctor or our office. Some Medicaid plans require six months, while others, like Healthfirst, have reduced it to four months. Some private insurers—like Cigna, United Healthcare, and Oxford—have eliminated this requirement altogether. It’s frustrating, and the process has come a long way, but it still depends on the insurance company.

What happens during those pre-surgery weight loss visits?

It’s an attempt to lose weight, discussing diet, exercise, and prior medications. Some insurance companies use this as a way to ensure patients have tried non-surgical methods first. I personally think requiring six months of visits is unnecessary—what can you do in six months that you couldn’t do in one or two? But if it’s a prerequisite, we help patients get through it.

We really focus on mindfulness. I try to get that personally with my patients. I often tell them from the get-go, ‘You know what to eat, you know what to do, but you're not doing it, eating what you're supposed to. Why is that?’ They know why they’re here. And they have to accept obesity as a disease more than anything else. It's not a condition; they're not here because of their poor willpower. They’re here because they either have a comorbid illness or an illness related to their obesity that's making them not feel well.

What about additional medical evaluations before surgery?

There’s a lot of legwork before insurance will approve surgery. Patients need:

A letter of medical necessity from their primary care doctor
A nutritional evaluation
A psychological evaluation
Pre-op lab work and testing
A sleep study, if necessary, particularly if sleep apnea is suspected

We also check for vitamin deficiencies and correct them before surgery. Losing weight isn’t the challenge; keeping it off is. Weight loss surgery helps with that long-term goal.

Making the Choice Between Medications and/or Surgery

How have newer weight loss medications like Wegovy and Mounjaro changed the conversation around surgery?

A lot of people come in thinking about medications instead of surgery. I ask them, ‘What’s your expectation? Would you be happy losing 20 percent of your excess weight? Are you willing to take these medications for the rest of your life?’ Weight loss surgery remains the most effective long-term solution, especially for patients with a BMI over 40. While medications can help, they aren’t a permanent fix like surgery. However, these medications are here to stay. More are in development, but cost is still a huge factor and barrier.

Will you explain that a bit?

The use of these GLP-1s is critical, but they are very, very expensive. Did I say that twice? Because yes, there are only 13 states in the country that cover these medications, including California, which is the largest Medicaid population in the country. And New York is not one of them, but it should be covered in this state because it's here to stay. There are close to 200 to 210 clinical trials going on as far as the use of GLP-1s.

Do you see a wider range of patients now that these medications are available, even with the monetary barriers?

Yes, for sure. Some patients who have already had surgery want to lose additional weight, like that ‘last 10 or 20 pounds.’ Others come in seeking guidance on whether medication is a better option for them. I always emphasize that making lasting lifestyle changes is key, whether through surgery or medications.

The Pre-Op Diet and Surgery Day

What’s the purpose of the pre-op diet?

We put patients on a high-protein liquid diet for two weeks before surgery. This isn’t about testing willpower—it’s to shrink the liver. A fatty liver can bleed or crack during surgery, so we want to make it as small and smooth as possible. And I always tell patients, whether you use the word diet or not, it's the last diet I'm ever going to put you through. That’s the whole point! It's going to motivate you. Some patients lose 15-30 pounds just from this pre-op diet. If a patient struggles with it, we modify the plan to make it work for them. I always tell patients to call me if they’re struggling; we can always adjust it.

I often jokingly tell my patients, ‘Listen, you do half the things I'm telling you that you need to do. You're going to do well. You cannot always judge the number on the scale. Half the things that you've done in the past few weeks or the past few months, the changes that you've made leading to whatever weight you've lost, whether it's one pound or 10 pounds in the past few weeks, have led you to where you are.’ It's positive. It’s about progress, not perfection. Changes made, not the weight lost.

When do patients finally meet their surgeon?

Most patients meet their surgeon once their checklist is nearly complete. Some patients want to meet the surgeon earlier, which, of course, is fine. Whatever they want to do. But we do it this way because once they meet with the surgeon, they can book surgery and schedule it when they’re ready. This is elective surgery, so if you meet with the surgeon, you can have the surgery anytime you want. It's just a matter of whether you have a vacation already planned or your work schedule, all the matters of life.

Post-Surgery: What to Expect

What is the recovery process like?

There’s a structured diet progression:

Week 1: Liquids only
Weeks 2-3: Pureed foods
Weeks 4-5: Soft foods
Week 6+: Regular diet

We emphasize hydration and making good food choices. Patients typically lose about a pound a day for the first month, then the weight loss naturally slows.

What does long-term follow-up care look like?

We see patients at one week, five weeks, three months, six months, 12 months, and then annually for life. Many people don’t realize that after weight loss surgery, they need to take vitamins for the rest of their lives because they aren’t absorbing nutrients the same way. Low B12 and iron levels can cause fatigue and other issues, so we monitor and supplement as needed. The vitamins are actually very important!

A lot of patients think that just because they feel great and look great, they don't have to take their vitamins. But we check different things and look at your levels differently than your GP does, so it’s important to be seen by a bariatric physician or a bariatric surgeon. Some patients relocate to other states or other parts of the world. Just email me and say, ‘I moved to Japan, I moved to Hawaii, I moved to wherever.’ We'll find you a bariatric surgeon who can follow you.

Do patients ever regret having surgery?

Rarely. The day after surgery, some patients say, ‘What did I do?’ But nine months later, they tell me it’s the best thing they've ever done. This is not ‘the easy way out.’ It’s so important that the message gets out there because there is still so much stigma. Surgery is a commitment to yourself and your health.

Any closing thoughts?

I want to reiterate that surgery is the opposite of taking the easy way out. It's brave. We're saving lives. We're not working toward becoming professional athletes; we’re trying to achieve health by getting rid of things that can harm you along the way as you get older—diabetes, high blood pressure, sleep apnea, and heart disease, among other things. That's the bottom line.

Interested in learning more? Call our Weight Loss Team at (212) 305-4000 or request an appointment online today.