How to End Obesity Bias

Ever wondered how the convoluted marketing strategies of Medicare Disadvantaged Plans influence our healthcare choices? Join us as we unravel the complexities of these plans, and the limitations seniors face when choosing a Medicare plan. During a riveting general surgery marathon at Tucson Medical Center, I was reminded of how our personal health journeys intertwine with the broader healthcare narrative. We'll also celebrate life's milestones, from weddings to weight loss triumphs, and discuss  maintaining muscle while you melt away the pounds. We also offer insights from our guest Elizabeth, who tackles the tough topic of obesity bias within the weight loss surgery community.

Weight regain can be a daunting prospect after the triumph of weight loss surgery. Hear the story of one individual's experience with vertical sleeve gastrectomy, her subsequent weight regain, and how GLP-1 medications like Ozempic and Mounjaro have become game-changers in maintaining control. We'll dig into the biological factors of weight control and the diverse responses to GLP-1 medications among those with and without a history of surgical weight loss. It's an eye-opening glimpse into the ongoing battle for sustained health and the critical role of medications post-surgery.

Join our conversation on the power of community post-weight loss surgery, GLP-1 medications, obesity bias, and how to preserve muscle while losing weight. We round up with a look at delicious, healthy pasta options and practical tips for preventing weight regain after gastric sleeve surgery. Tune in for a hearty dose of knowledge and motivation to fuel your journey toward a healthier you.

Transcript

Zoe: 0:17

All right, welcome back to the Pound of Cure Weight Loss podcast. We have made it to episode 15. Title today is Medicare Disadvantaged Plans.

Dr. Weiner: 0:26

Yes, it's going to be a good show. That's how they're marketed, that's how I think about them. Yeah, so I had my last general surgery call probably in a really long time this weekend. I actually took both Saturday and Sunday, so I've basically been working for seven days straight, oh my gosh. So we'll see See if I can keep it together when I talk about Medicare Disadvantaged Plans.

Zoe: 0:48

You'd like it all riled up.

Dr. Weiner: 0:51

But a general surgery call in Tucson is brutal. I've worked in downtown Detroit. I did all my training at Bellevue Hospital and NYU Hospital and nothing compares to the complexity of the disease, the amount of surgical pathology we see at Tucson Medical Center. It is insane. The stuff that I see is stuff that I read about in medical school. I never really saw much in my training, Didn't see it early in my career, but I see it regularly at TMC. It is really. You know, that really is an amazing hospital and how they serve the community and they really take on a lot of very difficult cases. So my hats off to the general surgeons who take that call regularly because it is not an easy job. But anyway, you've got some exciting stuff coming up. Yeah, we've got it. Can you talk to me about what's going on there? Talk to everyone about?

Zoe: 1:45

it. Well, yeah, wedding was coming up here in like less than three months, oh my gosh. And so going actually and tasting the food on Thursday. So you know I love foods.

Dr. Weiner: 1:59

Now, what are you doing here? So this is a little tricky for you. You're a dietitian. You really emphasize healthy eating. It's your wedding, though.

Zoe: 2:07

Yeah, so you're going to be able to Well, you mean for me or for the gas? Both Okay. Well, for me, I like to eat foods that make me feel good and I, you know, allow a treat here and there. But like I'm not wanting to feel icky on my wedding day and so I was actually talking to my mom about that this morning, or I think it was yesterday what we were going to do for breakfast the day of, and like I might just make my like veggie eggs scrambled, because I know it's one thing that we feel my best in the morning. So we'll see. So, yeah, no, I wanted to make sure we got a good amount of vegetables, a good protein, a lot of chicken, and then we're also throwing in there some like pasta, and we are having a gelato cart, something related about that. So should be fun, all right.

Dr. Weiner: 2:50

Well, we're excited for you.

Zoe: 2:52

Sorry, that's going to be awesome.

Dr. Weiner: 2:53

All right. What's on the show today?

Zoe: 2:54

All right. So of course we've got our in the news segment to GLP ones in, specifically people over 65. So we also have Elizabeth, our guest today, who is going to be discussing more about obesity bias and the weight loss surgery community strategies to reduce muscle loss during weight loss. I love this talk back. We have our Medicare disadvantage plans in our economics of obesity segment and then our questions from the followers. So is surgery the easy way out? I think we have some strong opinions about that. Then to start GLP ones after surgery and then those Bonsa pasta varieties.

Dr. Weiner: 3:33

All right, fantastic. So let's start with in the news. So this article came to us from the Atlantic, which, for obesity coverage, is one of my favorite news publications, and it talks about older Americans using Osempic for weight loss and what are the pros and cons. About 25% of all the GLP one users for weight loss are over the age of 65. And I'll tell you we see that in our practice that's changed a little bit since a lot of the Medicare rules came around January 1st and made it much more difficult to get these medications. But there still are a substantial number of people who are going to qualify for the medications.

Dr. Weiner: 4:12

And what we see with weight loss and this is common in weight loss, no matter how you achieve it is you never just lose fat It'd be great if you did but you also lose muscle Muscle, very metabolically active and so if you're in some form of calorie deprivation or some form of famine mode, your body's smart. It's going to use some of the muscle because muscle is much more metabolically active than fat. So it's kind of like if you lose your job, you stop spending as much. Same thing happens with your body. If you are having a lot of calories coming in. Maybe you burn up some of your muscle, so you're burning less calories on a daily basis, so to some degree that's unpreventable. There are strategies, though you'll talk about later on in the podcast, that you can apply from a nutritional perspective and an exercise perspective. But to some degree you're always going to lose some muscle, and so the question is in the younger people that have some muscle to spare, there's a little less risk of injury and fall in younger people. So with older people, muscle loss is really dangerous, and your goal as you age is to reduce your muscle loss as much as possible. I can tell you personally that's my number one goal when I exercise is build and preserve muscle. Flexibility is number two. I'm not very flexible, I'm working on it but preserving muscle loss, preserving muscle is really, really important.

Dr. Weiner: 5:43

And so how does the GLP1, this is a question about how does taking these medications affect your muscle mass if you're over 65? And is it really a good thing in this patient population? I don't know that. We know the answer. I think we're going to Is there a greater risk of falls? We know from bariatric surgery that in general, there's a lot of benefits for people over 65. And I think. Really, in my opinion, what this comes down to is are we dealing with clinically significant obesity or are we trying to lose 10 pounds? And I think if you're trying to lose 10 pounds and you're over the age of 65, I'm not sure using GLP-1s makes a lot of sense. I think if you're struggling with clinical obesity, if you're 50, 75 or more pounds overweight, you have substantial comorbid conditions, diabetes, high blood pressure, high cholesterol then these medications are gonna make a lot of sense.

Dr. Weiner: 6:38

The other important thing that I talk to my patients over 65 about all the time is something we call the obesity paradox. So we've all been told hey, the lower your weight, the thinner you are, the healthier you are. But as you age, that's not necessarily true. All of us have seen these kind of frail older people and they just don't have a lot of reserves, so kind of we look at BMI and we'll talk about this, I'm sure, a future podcast how unhelpful BMI can be.

Dr. Weiner: 7:05

But if you had to throw a BMI number out there 25 or so for normals that would you kind of use in your practice. So as you age, that number might be 28, it might be 30. And so you have to also keep that in mind. So this was a great article. If you're taking GLP ones or thinking about taking them in your 65 or older, check out this article in the Atlantic Zoe. What do you do nutritionally for patients who are over 65 that are in the process of losing weight? What's your approach? And we'll talk about it a little bit more later, but just give us a little bit of thoughts on it.

Zoe: 7:39

Yeah. So the two main things is number one, to make sure you're getting enough protein, and I mean just even if you aren't losing weight. As we age, we are more prone to decreasing our muscle mass without those intentional efforts. So protein, and then also creating that stimulus on the muscle. So whether that's through weight training or some sort of weight bearing activity that could be yoga or some sort of activity that's going to help put that resistance on your muscles, to create that stimulus.

Dr. Weiner: 8:10

Yeah, no, I think that's great advice. As you get older, you know our pound of cure program. We don't really push high amounts of protein. We don't discourage it either, but it's not a 100, 120, even 200 gram protein program, like you'll see with some keto or carnivore diets. That's certainly not what we encourage in our patients and I think there's a lot of good reasons, particularly for younger people. But I agree it completely. As your older, protein really is very, very important, ideally from plants, but it's hard to get a lot of protein from plants isn't it.

Zoe: 8:41

Right, right, you got filled up, but really fast if you're trying to get 80 grams of protein from beans.

Dr. Weiner: 8:48

Yeah well, I think we nailed our timing. Elizabeth is ready to share her story of weight loss and obesity and to talk a little bit about obesity bias. So let's get Elizabeth on the line.

Zoe: 8:59

Well, welcome Elizabeth. We're super excited to have you here, Just to kind of get us started. Will you do us the honor of sharing your story so far?

Elizabeth: 9:08

Sure, so overweight to some degree my entire life. At when my son was getting ready to go to college, I was like, if I don't do something about my weight, finally, I'm gonna be the crazy cat lady who never leaves her house. So I was 48 when I decided to have weight loss surgery. At that time I was 402 pounds. That was almost exactly 10 years ago. It was April of 2014. I had vertical sleeve gastrectomy. I don't know that that's what I would have if I had the choice to go in and do it today, but I think overall I've been super successful with VSG. Right now I'm about 223. So that's an 180 pound weight loss maintain for like nine years.

Elizabeth: 9:52

So, I'm pretty happy with that. But I did start experiencing significant regain A couple of years ago. My highest regain weight was around 270. And then I called Dr Weiner's office because I had heard him talking about GLP ones and have been on GLP ones I think almost two years now.

Dr. Weiner: 11:01

Yeah, yeah, elizabeth and I go way back. Actually, this is kind of coming full circle, because I was on the Naked Truth, right? Was that the name of your podcast way back when? Yeah, I was on that, yeah.

Elizabeth: 11:14

Yeah, a few times.

Dr. Weiner: 11:16

Yeah, so I was on Elizabeth's podcast. That was a while ago, probably five or six years ago. That was back when I was in Detroit. We actually started on GLP one medications, and how much weight did you regain after surgery and then?

Sierra: 11:31

what was your GLP ones, starting with?

Elizabeth: 11:33

So, I think my lowest weight was, I think, 198 for five minutes approximately it's amazing.

Elizabeth: 11:42

And then I started bouncing up and of course I was somebody who said they talk about the regain and get as low as you can, because you're gonna have this bounce back. And I was like that's not gonna happen to me. I'm working out like a crazy person, I'm eating the way I'm supposed to be. It's not gonna happen. Well, it did. So my regain, I guess if you look at it from my lowest weight, was about 70 pounds, and if you take into consideration the fact that in that space I had plastic surgery and they removed 22 pounds of extra skin, that's a lot of skin it may have been even a little bit more than that, if you factor that in.

Dr. Weiner: 12:17

Mm-hmm, yeah, so what GLP one did you start?

Elizabeth: 12:21

I started on Ozympic and stayed on that. I think the reason I went off of Ozympic was, I just think, in general your practice was recommending Manjaro but you stopped being able to buy Ozympic in Canada and there was a Manjaro coupon. So that was why I switched and I prefer Manjaro and Zephoun which I'm on now to Ozympic.

Dr. Weiner: 12:45

What dose you want?

Elizabeth: 12:47

I'm on 15 milligrams, so I'm on the highest dose, so you're maxed out.

Dr. Weiner: 12:50

but do you feel in control of your weight now?

Elizabeth: 12:53

Oh, 100%. I feel in control and there have been little periods of time when I've had to go off of it just because financially or whatever reason, because my insurance doesn't cover it and it's not a cheap drug.

Dr. Weiner: 13:04

No, it's not.

Elizabeth: 13:06

And I understand for the first time what that actually means to be in control of my weight and my eating. And even with weight loss surgery, I still felt like this was my fault, that being overweight was my fault. I didn't have the willpower, and that's one of the things I always enjoyed about you was that you really put that out, that it's not your fault. It's not your fault. This is a biological thing. Talk about set point, talk about all those things. But really, until I took GLP-1s, I really did still somewhere in the back of my mind, think it was my fault. But this was like I mean, instant, you're not thinking about food. I mean, it's just so hard to even describe it if you haven't taken it, because it's so even significantly different from weight loss surgery.

Dr. Weiner: 13:54

Yeah, I think the thing that I've noticed is that and we see lots of patients who haven't had weight loss surgery and we're putting my GLP-1 meds that the results and the response in patients who have not had weight loss surgery is quite variable. Some people have an experience like what you've described. Other people don't tolerate, doesn't work. It seems to me like people who've had surgery and particularly sleep because that's really where we see the weight regain have this kind of almost uniform experience. Do you see this too, zoe? I mean, you talked to probably more people than I do about how they're feeling after these meds. Is that what you're seeing?

Zoe: 14:34

Yeah, I would say overall they tend to respond really well.

Dr. Weiner: 14:39

Yeah, I think something about surgery that I think primes you for the medication.

Zoe: 14:45

The muscle almost like the muscle memory yeah.

Dr. Weiner: 14:49

I think it's like your set point. This idea that your set point is exactly where it's at is probably not entirely true. There's some history in where your set point is. You got down to a set point of, like, say, 200 pounds and then started to regain. How much did you regain again? 70, you said I think the highest was 27. Yeah, you've gained 70 pounds. That's a lot of weight, yeah, and now you've lost 50 of that, right, are you still losing and you feel like you're at a stable weight?

Elizabeth: 15:19

I was off for a couple months and I just have started retaking it again. So I lost the weight that I had put on during those few months pretty quickly and we'll see, because I'm just getting ready to pick up the second, my second month, after probably about four months off.

Dr. Weiner: 15:33

Yeah.

Elizabeth: 15:35

But I immediately lost the weight. I mean, it's so weird how it works that it's not even. It's like 10 days later you've lost 10 pounds.

Dr. Weiner: 15:45

It's crazy, yeah, without really kind of feeling like you're changing much about your life. So let's talk a little bit about the weight loss surgery community. You've been really involved in it. What do you think the weight loss surgery is doing right? What do you think they're doing wrong? And then, how has it changed since we started, since the GLP One Meds became popular?

Elizabeth: 16:04

So I started pretty early on in my journey I started a YouTube channel. That was the thing at the time. I don't think it's the thing anymore. I think TikTok and other things have taken over YouTube, but I had a channel for probably five years where I made a video every weekend. It's still there if anybody wants to go see it, and what's been so great about having that is.

Elizabeth: 16:26

So many people have responded to me and said it's because I watched your YouTube channel that I wasn't afraid to get surgery or I wasn't.

Elizabeth: 16:34

I was 48 when I had surgery, which is a lot older than most of the people, at least who were active in that community at the time were, but so that's been great. I made a. I think that the people that I know who were very active in that community around my weight loss surgery class that we are all more successful because of having been really involved in that, because we're talking about it. We're thinking about it. We're learning strategies from each other, and when I first started watching videos, it was like the week that I was recovering from surgery and I learned so much more than I was taught in the Kaiser class that I went to about how to eat after weight loss surgery. So for me it was a huge, huge, huge benefit, and my best friends in my life now came from that community. And now it's not about weight loss surgery anymore, now it's about GOP1s, because we're all, pretty much everybody's on, pretty much everybody is on GOP1.

Sierra: 17:33

All the sleep patients and it sort of started with yeah, all the sleep patients.

Elizabeth: 17:35

Yeah one friend did it and then we're like, hmm, what is this? Let's, let's go check that out. But I think the community is hugely helpful. I don't know what it's like as much now. I follow people on Instagram and it has been super interesting because now the people that are still active are talking about GOP1s and so it's interesting to hear their experiences and to know. You know, I heard on someone's Instagram about this manjarra coupon. Before I heard about it, before I called you, I mean, I knew that it was the thing, because there are people who are as focused about this community as they were with the weight loss surgery community, and I don't even I can't think of anything negative about it. For me it was purely positive. I had a show for years, the Naked Truth that you were on. That brought a lot of stories to people and all this stuff is still out there. But I say it was probably. It was probably the best thing that came out of weight loss surgery for me was being part of that community.

Dr. Weiner: 18:35

Yeah, yeah, I can imagine.

Zoe: 18:37

So what do you think that we all can do to help eliminate obesity bias?

Elizabeth: 18:44

So I work for the Gina Davis Institute on Gender and Media, which looks at representation and media, and originally it started just looking at gender, but now we look at six different identities. We look gender, race, ethnicity, lgbtqia, disability, age over 50 and large body type, which I've sort of decided to spearhead, and it's really the last space where it's okay, you know, it's okay to make fun of it, it's okay to you know if you look at. So we're focused on media content and what people see on screen, because sort of the idea is, if they can see it, they can be it. Right, if you have kids who are consuming media where they're seeing themselves doing amazing things, they know that that's a possibility for them. And we added this large body type just not that long ago, a couple years ago, and I realized when I was doing that that I was probably 54 before I saw someone on screen who I felt like was a well rounded character that was overweight, or in my world we use the word fat. I know that's kind of a sensitive word for many people, but it's the word that the activists in this space like to use and from my personal perspective, I like to use it to destigmatize it. So it's just a characteristic. It's like you have red hair, you have blue eyes, you're tall. You know, it's just a descriptor, that's all it is.

Elizabeth: 20:20

In the sort of value judgment that we placed on it gives it so much more energy than it actually has, but you just don't see. You don't see characters who are married, have jobs, have you know lives. The storylines are always super focused on their way, and so what we try to do is reduce some of the stigma through working to get just that people as a normal character who's part of the story? Because we make up a very large portion of the population 40%, yeah, yeah. And so it's getting people comfortable seeing those people in the media and part of their daily life, because the discrimination is huge.

Elizabeth: 21:01

I mean, it's getting hired for jobs, how much you make when you have a job. It's the clothes you have access to, which are changing, which are changing. It's medical care. I mean there's huge bias in terms of medical care, which I'm sure you're super aware of, and it's the first thing. I went to a new doctor just on Friday and I was like I'm so anxious because they're going to want to talk to me about my weight, even though you know, I've kept off 180 pounds for a year and I probably know more about this and how to do it than most people do. But what was so great about this doctor is they're like we don't need to weigh you.

Dr. Weiner: 21:40

Oh, wow.

Elizabeth: 21:41

I was like, wow, okay, I like you, I picked the right, I picked the right doctor she was. You can tell us our weight if you want to, but it's not. It's not going to drive what we're talking to you about, but that's not the case in a lot of instances.

Sierra: 21:52

No.

Elizabeth: 21:53

So people I hear so many stories of people who have been. You know, serious illnesses have been overlooked because people want to blame it on them being overweight.

Dr. Weiner: 22:03

We see that a lot.

Elizabeth: 22:04

Yeah, and so our sort of my goal personally and our, one of our goals at the Institute is to really try to fight for media representation, because so many were cons, were consuming media all the time and if you never see yourself, I mean, I grew up believing that, you know. The first, like I said, the first character I saw was Kate on this Is Us, because she was married, she was a singer and she had a job and some of the episodes in the beginning were about her weight, but that sort of went away and it's just this character who's there living her life, like all the rest of us are, and there are so many kids that struggle with obesity. Now, the fact that you don't, you don't ever see yourself represented, you don't think that any of these things are open to you, and that's what I thought too as I was a kid growing up, because you think it's there were none when I was a kid.

Dr. Weiner: 22:51

There was nobody who was overweight, no weight.

Elizabeth: 22:53

None, so it's super important.

Dr. Weiner: 22:56

So let's talk about the F word. You know there's kind of two F words, one I like when I don't like. The one you're referring to is the one that I don't, One you use One, you don't use One.

Zoe: 23:06

I use while I don't.

Dr. Weiner: 23:07

I don't use the other F word because we're trying to keep our clean rating on our podcast. But you know, zoe and I we're talking neither of us really use that word with patients. You know, we don't use it in our home. It's really not something, a word that we use. You know what's your thoughts. I think there's kind of two parts of this too, and it's it's like a lot of these other derogatory terms where if you're in the demographic that it applies to, then you can use it, but if you're not, it's kind of, you know, off limits. Is is the F word.

Elizabeth: 23:40

Yeah, it's. I mean, it's probably one of the most complicated words out there and it took me a long time to get comfortable saying it. And we have, like, because we use it at this we have a paper that's written up on why we use it. Because it is and it can be here, and if it offends you I'm super sorry. It's my choice, I'm okay with it and for me it's sort of taking taking that word back and having power over it. It's. It's just like saying you know you're tall, but I get that. Not everybody feels that, feels that way, but it's just. I'm trying to destigmatize it a little bit because it has had so much power over so many of us for so long.

Dr. Weiner: 24:18

I really applaud what you're doing. I think that you're approaching it in a really intelligent way, as opposed to saying like, don't say that word, don't be biased against people who are overweight. Instead, you're trying to get people represented in the media and that's what we see on Instagram, on television shows, and getting people who are overweight to be represented doing all the things that everybody else is doing and they really haven't been, as you pointed out To me. I think that's a brilliant way to approach it. It's very pragmatic, it's it's it makes the problem a little more solvable, Instead of it just being another term that people have to talk quietly about behind other people's backs. It's getting more to the root of the problem and addressing it for the people most vulnerable, which is children.

Elizabeth: 25:08

Yeah.

Dr. Weiner: 25:09

I love that.

Elizabeth: 25:10

Good Gina. Gina, I would like to hear that.

Zoe: 25:13

We are so grateful that you you know we're able to come on and share your message today. I think. I think a lot of people are going to feel really empowered and relate to what you have to say is that we really appreciate you sharing today Elizabeth.

Elizabeth: 25:27

Well, thank you so much for having me.

Dr. Weiner: 25:28

Thank you, Elizabeth.

Zoe: 25:30

All right. Well, that was just great to hear from Elizabeth. She has a lot of really wonderful value to share.

Dr. Weiner: 25:35

Yeah, I'm so happy to see that she's working with Gina Davis on addressing obesity bias and in such a, I think, appropriate and clever and effective way. So let's hope they make some headway with that, because there's still a lot of room for improvement there.

Zoe: 25:51

So, going on to our nutrition segment today, I want to discuss a little bit about how to prevent muscle loss while you're losing weight because, as I always like to say, I don't really care if you're just losing weight. I want the most of that weight to be coming from fat and not from muscle. Just like you mentioned earlier in the show, muscle is more metabolically active. I like to say it's expensive, it requires more resources to maintain, so we really do want to maximize our effort to minimize that muscle loss.

Zoe: 26:28

So the two heavy hitters here, like I mentioned briefly earlier, are going to be reaching your protein goals and creating that muscle stimulus through resistance training. So reaching your protein goals primarily through whole, real, unprocessed food. I know I sound like the broken record with that, but that's the truth, because not only are you getting the protein, but you're getting all these other wonderful micronutrients as well. And so, in addition to prioritizing whole food protein and some of that protein coming from plant-based proteins as well, such as beans and legumes, we want to combine that protein with your resistance training so that can be body weight, that can be bearings, that can be free weights, that can be machines, that can be going to a group class that can be working with a personal trainer, there are that can be swimming right. There are a lot of really great ways to create that stimulus to your muscle so that it has to work, so that it can be maintained, and the combination of the stimulus with the protein can, over time, combined with intentional training, can help to increase your muscle mass as well.

Dr. Weiner: 27:45

Yeah, that's the two together. One without the other doesn't work Right. Yeah, and I think that's really important too when you're in that weight loss phase. That's when it's really critical, because if you don't, your body's going to preferentially lose muscle. And I think that's some of the criticism that's been levied at Osempic is that if you take Osempic you're going to lose tons of muscle. And I think the truth is if you take Osempic and eat like crap and don't exercise, yeah, you're going to lose tons of muscle. But if you eat really well, focus on protein, plant as much plant protein as you can and exercise, then we can reduce that muscle loss and optimize it for fat loss. So, yeah, that's really the critical part of weight loss. Once you hit your kind of lowest weight and reach more of a steady state, then the protein consumption becomes a little bit less important. I'm not saying don't eat protein, but you may not have to maximize it the way you are during the weight loss.

Dr. Weiner: 28:46

So let's move to our economics of obesity segment and I want to talk about Medicare Advantage plans. So there's two different ways that you can get a Medicare policy. So Medicare is provided to by the government. It's healthcare that's provided for anybody over 65 and then anybody who has been deemed disabled, which is a topic for another conversation about what disability means and how Medicare is sometimes used in that light. But the old school way was a supplement. So Medicare covers 80% 80% of everything, and then you're responsible for the remaining 20%, which healthcare is super expensive. 20% of super expensive is a lot of money. So these supplement plans would come in and they basically would fill in the gaps and if Medicare pays 80%, they pay 20%. They may have a little deductible or however it works.

Dr. Weiner: 29:38

And those plans worked out pretty well and most people were happy. But as the cost of care went up, the cost of these came went up as well, and so the insurance companies because they're really good at making money went to the government and said hey, listen, us government, you don't know what you're doing. The government stinks at managing healthcare. Let us do it. We're the insurance company, we're much, much better at it. They said here's what you do you pay us for the Medicare plans, you give us the money you were going to spend for the patients and you give it to us and we're going to manage it much, much better. And that's what a Medicare Advantage plan is. It's an insurance plan that is paid for partially by the government, and then you pay your own portion as well, and they take over everything.

Dr. Weiner: 30:26

And so one thing they did initially was they did things like add dental and vision coverage, which sounds amazing, but dental and vision coverage is extremely inexpensive. Medicare doesn't cover dental and vision, so if you have a Medicare supplement plan, you don't have dental or vision coverage. But the truth is, compared to the total amount you spend on healthcare, dental and vision is peanuts. Peanuts, I mean, most of us pay for that stuff out of our pockets and very few people are going broke because of their glasses and their dental work. It's expensive and it hurts, but it's not a $100,000 hospital stay. And so the insurance companies took over this, and so what they ended up doing is what insurance companies do, which is they take the money that's being assigned for healthcare and they profit by not spending it on healthcare. And it became this game of deny and refuse, and so that all of a sudden, now they're in charge, medicare would cover most things, like we saw Medicare covering Osempic and Monjaro very liberally. The Medicare Advantage plans are going to limit that drug significantly, and so the Medicare Advantage plan now kind of takes over all the prior authorization and essentially they're making money by refusing treatment.

Dr. Weiner: 31:43

So the attractive part of Medicare Advantage plans is that they pay for 100% of a lot of things instead of 80%, and they offer this dental and vision. But a lot of them also are very regional. So there are some situations where patients are able to get. They live right on the county line and they're only able to get healthcare on one side of that county line. Outside the on the other side of the county line, their Medicare plan doesn't cover them. So they create these incredibly narrow networks. If you vacation and, let's say, you need something electively, you can't get it because you could only get healthcare in your county. So these things are regional down to the level of the county. The other thing that happens is you they're really great for people who are healthy and so they get you when you're 65, these Medicare insurance brokers will put out these big seminars and they'll educate you and they'll talk to you about how great these Medicare Advantage plans are. Do you know why insurance brokers like Medicare Advantage plans? They get paid about twice as much when they sell a Medicare Advantage plan as they do when they sell a Medicare supplement plan, because Medicare Advantage plans are much more profitable.

Dr. Weiner: 32:53

The most important healthcare's primary center of profit right now is Medicare Advantage plans, more so than their supplemental, their commercial policies or the supplemental or commercial policies. So we've got all these brokers pushing these Medicare Advantage plans to the healthier seniors and they work out great. They go to the dentist cares covered. They get to my glasses it's covered. Problem is, as soon as they get sick and inevitably as we age you're going to get sick that's what an unfortunate truth they all of a sudden you can't get it paid for, oh the good doctor that you really want to see. They don't accept your Advantage plan anymore because that doctor got sick and tired of not being paid by the and having to submit the bill 17 times before they finally got paid, and so they decided to drop the plan. And all of a sudden you're seeking care, you're sick and you're like well, I'm just going to go to a supplement plan. There's only one type of plan right now that can deny you coverage if you have preexisting conditions. Obamacare basically said none of the commercial plans can do that anymore.

Dr. Weiner: 33:57

Way back when, when I've kind of first started having healthcare. It was a big thing about preexisting conditions and insurance companies would refuse to pay for something because, hey, we just started taking over care, starting in 2010. And in 2009, you had a health problem and this is a result of that, and so we don't have to pay for it. So they made that illegal, except for Medicare supplement plans. So now, if you are on a Medicare Advantage plan and you want to switch to a supplement plan, all of a sudden it's way too expensive and they're denying you or pricing it through the roof because of your preexisting medical conditions. And now you're stuck in this Medicare Disadvantage plan.

Dr. Weiner: 34:38

So there are Medicare star ratings, so the Advantage plans are rated and you do have recourse here. So if you are stuck in a Medicare Advantage plan, the star rating of Medicare Advantage plans determines a lot of how much the government pays to the insurance company. So they want to have a four star above. If you're a four star above, you get paid more. It's a more profitable plan. A big component of the star ratings comes from the patient surveys. So if you're on a Medicare Advantage plan and you get one of these surveys and you don't like your plan, let them have it. It's going to affect them.

Dr. Weiner: 35:18

If you are in a situation where they're not paying for something, you can complain by calling 1-800-MEDICARE and filing a complaint about drug coverage. If you feel like they should be covering your OZEPIC or your Monjaro, or if you're not able to find a provider in the right specialty, if you're having trouble getting stuff covered, you can file a complaint against Medicare and it will hurt this Advantage plan. They are very aggressive in reducing these complaints and addressing them because it costs them lots of money. So these complaints are important. Do not blow this off. You actually do have some leverage here. So that's something to consider if your Medicare Advantage plan is a working. But I think if you're a healthier senior and you're just getting started, maybe looking at a Medicare supplement plan and trying to resist some of these temptations of maybe initially lower premiums may actually benefit you in the long run. May serve you very well as you age.

Zoe: 36:18

It's all so complicated.

Dr. Weiner: 36:20

It really is way too complicated, and the rules are designed by the people who are making all the money the insurance companies, the hospitals to some degree as well, but the hospitals are struggling right now, and they're actually struggling because insurance companies are refusing to pay. We're seeing tons of this in our office, where we're getting called by our hospital, and our hospital is kind of one of the last good, honest hospitals in this country. They're a not-for-profit and they actually function that way. Every other hospital in town is host as either a for-profit system or a not-for-profit system that is really for profit. That pays their CEO $32 million a year.

Dr. Weiner: 37:04

Our hospital CEOs still make a lot of money, but far less than what other CEOs are at similar-sized hospitals, and I do believe that they have a mission to serve the people of Tucson. I really do believe that about our hospital. I don't think they're perfect, but I do think their heart's in the right place, and so I think that this is really something that we have to. The problem is, if you don't know the rules, people can't play the game Exactly. All right, sierra, what do we have in terms of our user questions?

Sierra: 37:34

What should I say to someone who thinks weight loss surgery is the easy way out? The other F word yes, Zoe.

Dr. Weiner: 37:44

I have a video about that. But yes, I do agree with you on that. I think, first of all, it's not other business. People really shouldn't be commenting on your medical history, your medical decisions, unless they're a close loved one and really have a vested interest in your health. I think also, you've seen lots of people go through weight loss surgery. Does it seem very easy to you?

Zoe: 38:06

No Kind of fall, no, and it requires a lot of hard work. It requires the dedication to long-term habit change in order to have lasting result and I think that you just have to. It's hard, but get down like a little sentence or a little mantra, something that feels good and right in how you would say it, but could be something as simple, as I'm not open to your feedback on my medical choices at this time. Thank you so much, but I've had good ones in the past, but I can't think of any other ones right now.

Dr. Weiner: 38:49

But I think, just being your own self advocate and knowing that you don't have to explain yourself, I think that's the big point is you owe this person nothing and they're judging you for biases that they have.

Zoe: 39:03

And I also think we have several patients who choose not to disclose that they get surgery. If you have been maybe met with this sort of feedback from a lot of people in your life, maybe that's an opportunity to say that you're not going to share it anymore. I don't know.

Dr. Weiner: 39:23

It's your choice.

Dr. Weiner: 39:24

It's your choice about that.

Dr. Weiner: 39:25

I think it's important to understand that this is coming from a place that is not kind, and so when people say things that are not kind to you, you two responses the first is to internalize it and get really upset about it, and the other is to ignore it, and this is clearly somebody who doesn't have your best interest at heart and is not saying something to help you.

Dr. Weiner: 39:50

And so, I think, recognize where it's coming from and treat it as the invaluable comment that it is. There are other people out there, whether they're in the weight loss surgery community or, quite frankly. There's a lot of people out there who are not obese, who are not struggling with their weight, but also recognize that people make these decisions to better their lives and that this is their decision, and that you trust that any reasonable person would do plenty of research and really do this, and most practices do a decent job of providing support and guidance through the process. So I think this is an unkind statement, and unkind statements really don't require a lot of our thought and should be just largely ignored.

Sierra: 40:32

Okay, next question. I had a gastric sleeve 29 days ago and I'm aware that weight regain is real after gastric sleeves. I'm wondering whether it is more effective to start GLP once a few months after the surgery to prevent weight regain, or if it's just as effective once the weight regain starts.

Dr. Weiner: 40:51

Well, there's really two parts of this decision which is really true for pretty much all of the medical decisions about surgery, or specifically the men's. The first part is insurance coverage. So if you have insurance coverage going in and you have a sleeve, you might dip below that line where your insurance will cover it, but if you take too long of a hiatus from it then you may lose your coverage for it. So I think that's the first thing you got to keep in mind is that if this is something you think you're going to be on, you might want to keep fill of that prescription and stock it away, even if your surgeon is not recommending that you start it. If we get to the clinical piece, it's very complicated. There's no right answer for this. There's some practices who will start it as soon as a month or two after surgery and I think it depends. What I will do is, let's say I have someone who has a BMI of 55 who chooses to have a sleeve Before GLP ones. I would say that's crazy. It's just not going to work the way you think it is. That's a bad choice for you.

Dr. Weiner: 41:55

Now, with GLP ones, I've had a lot of patients with BMI's mid 50s, even higher who've chosen a sleeve. We add the meds in and they do well. But this person we're choosing sleeve and meds. We know that's going to be part of the equation. We can always pull back later. That's someone I would probably start on as soon as they're eating and drinking comfortably and I don't have any concerns about meeting fluid and protein requirements. I'd start a mile on low dose and kind of titrate up very slowly depending on how they're doing.

Dr. Weiner: 42:19

I think if someone maybe BMI 35, 38, lower range who may be able to do this without meds and keep in mind, not every sleeve patient needs meds probably 50, 50, maybe even 30 or 40% don't need meds. So there's a decent chunk of people who walk need the meds long term. In that situation I might ride it out especially if there's no insurance coverage concerns and wait until you're four to six months out and see what your weight loss is looking like and at that point consider restarting it. There's guidelines and expectations. Again, on our website we've got this calculator and you can plug it in and by four months you should be about halfway to your final weight. If you're well behind that, then I would start it. If you're well ahead of it, I might hold off.

Sierra: 43:07

Okay, last question. This is from Rafael from our website. Hi, you mentioned Bonsa as a grain alternative. I noticed that they sell pasta variations, but they also sell rice mix and mac and cheese variations. Are those acceptable? They include soy and xanthan gum and mac and cheese includes cheddar cheese. Is xanthan gum acceptable?

Zoe: 43:29

This is a really good example of food that has been taken over and given to health halo Mac and boxed mac and cheese and rice aroni type. Whatever, they are going to have a lot of ingredients. They are going to be highly processed. They are going to have a lot of added sodium. No, that's not the point. Right? Not lovingly, of course, but having a Bonsa chickpea-based penne that has one ingredient and it's literally chickpeas, versus a long ingredients list of all these other more processed artificial ingredients, it's not really accomplishing what we want. I would recommend to stay away from those boxed processed products and maybe get creative with making your own versions that you can be in control of the ingredients, you can add the flavors and spices that you want and you can add vegetables, of course.

Sierra: 44:28

Yeah.

Dr. Weiner: 44:30

This is just over and over again. We see this. Right, yeah, take the thing that everybody's onto and thinks is healthy, add a bunch of crap to it and sell it as healthy. Right, it's not anymore and people will eat it, and for three times the price. Three times the price, totally, totally. All right, another great episode. Thank you, zoe, staying late tonight, thank you Sierra as well, and thank you to all of you out there listening. If you want to ask us a questionable answer on the podcast, check it out with us on TikTok, instagram, youtube, I think, even still Facebook. Hope you guys have a great week and we'll see you next time.