Here Wegovy! Medicare Coverage for Heart Disease

Episode 20 of The Pound of Cure Weight Loss podcast is titled, Here Wegovy: Medicare Coverage for Heart Disease. We called it that because of the NPR article we cover in our In the News segment which states that Medicare will now cover Wegovy for patients who are overweight and suffer from heart disease. How does this impact the future of GLP-1 medications? Tune in to find out.
 
 In our Patient Story, we talk to Larry. He came to us after receiving a high blood pressure diagnosis from his primary care physician. He didn’t want to take medication for the rest of his life so he decided to embrace a gastric bypass and has surpassed our expectations of weight loss by combining the surgical tool with weight training. It’s a truly inspiring story.
 
 In our Nutrition segment, Zoe offers her #1 tip for grocery shopping that will encourage you to be successful in your weight loss efforts.
 
 Our Economics of Obesity segment covers the GLP-1 shortage. Mounjaro, Wegovy, Zepbound, Saxenda, Trulicity, and Ozempic are on the shortage list. So we are offering some creative solutions to get you through.
 
 Finally, we answer 3 of our listener’s questions including, fluid choices for energy and hydration, whether or not revision surgery causes the same amount of weight loss as the initial surgery, and exercise recommendations after weight loss surgery.

If you have a question that you'd like for us to answer on the podcast, please reach out to us through social media (Instagram, Tik Tok, Facebook or YouTube), or the website.

Transcript

Dr. Weiner: 0:17

All right, welcome to episode 20,. Here we Go-V Medicare Coverage for Heart Disease. Guess who came up with that.

Zoe: 0:26

I would guess your wife.

Dr. Weiner: 0:29

My wife. I'm not clever enough, for sure.

Zoe: 0:31

Yes, so, lauren, thank you Great title she's so creative in every way.

Dr. Weiner: 0:34

She really is so we're really kind of in the midst of one of the worst medication shortages we've seen since GLP-1s even became a thing. It's rough out there right now finding meds. We have patients calling every day. We even added a new support group.

Zoe: 0:51

Yeah, I did. I added a new support group navigating GLP-1 shortages, because that's the common narrative that we're hearing from patients. So I figured let's go ahead and create this support group where we can double down on nutrition and and really have the support of the community that we've created for other people to.

Dr. Weiner: 1:11

Just kind of weather, the storm. We're also talking internally about, you know, using some of the first generation, the older medications. Just these medications aren't long-term solutions, but are they something that we can help get people to kind of bridge the space while they're waiting for their medications to come in? But yeah, we started out we put a how to eat on GLP-1 medications and now we've got a support group for how to eat when you can't get GLP-1 medications.

Dr. Weiner: 1:37

So it's going to be a while before this whole mess gets fixed, but I do think that at some point this is going to get addressed and there's going to be ready access to these meds. But I think we've got some time before that happens. Weather the storm. So let's move into our In the News segment. Our first topic is an article from NPR, and it's titled very creatively Medicare plans can now cover Wegovy for patients at risk of heart disease.

Zoe: 2:03

Well, they certainly didn't ask Lauren Weiner. No, they did not.

Dr. Weiner: 2:08

So we've talked a lot about treatment of obesity and medications coverage for Medicare. It is a federal law that Medicare cannot pay for weight loss medications, but now we've just seen this change and they're doing this actually very similarly to the way they've handled bariatric surgery. So Medicare is covered, medicare covers bariatric surgery, but they don't cover it for the diagnosis of obesity. We've talked, I think in the last episode, about how it's the diagnosis that matters for a lot of insurance coverage. So when we submit a billing slip for a bariatric surgery and a Medicare patient, we can never use morbid obesity as a diagnosis. We always have to use high blood pressure, high cholesterol, diabetes, we've used one of the comorbid conditions, and so essentially we're seeing that same thing, but now with WeGoVe. So we know WeGoVe shows about a 25% risk reduction cardiovascular events for patients taking it, and so Medicare has now approved it and we've gotten a lot of calls and everyone's like, well, I'm on Medicare, now I can get it, because everybody's at risk for heart disease, and so I think I wish it was going to be that easy. But we know that it's not going to just be that everybody can get WeGovi for reduction of heart disease risk when Medicare puts out the rules, then what happens is the individual Medicare policies will set specific criteria. Our suspicion in all the early signs of this show that they're going to be extremely restrictive in what those criteria are, and it's not going to be for anybody with a heart, right. It's going to be most likely for someone who has already had a cardiac event or a stroke. A stroke is generally put in that same category, a cardiovascular event, so in someone who's had a heart attack or myocardial infarction or a stroke or cerebrovascular accident, those patients may be able to get Wegovy if they're also overweight.

Dr. Weiner: 4:12

Some of the good things, though, is that Medicare in general sets the standard for insurance coverage for all the commercial payers. So what Medicare does? We often see Blue Cross and United, and Aetna and Cigna then follow with. This is a good sign for the future, because it's very likely that at some point we'll see coverage for this same indication on these commercial plans as well. The other thing to keep in mind is that Medicare actually doesn't pay for the drug. It's the Medicare Part D plan or the Medicare Advantage plan, and they will have very robust prior authorization programs in place, and also they change their medical policy once a year and so they're really under no obligation to change their medical policy and start to cover this until January 1st of 2025. So we probably have, you know, nine months, eight months, before we're going to even see the first Medicare policies that are agreeing to cover for this indication.

Dr. Weiner: 5:07

So while this is a good thing, I think in general and in the trend of coverage, it's not going to change anybody's life. The other thing is that ZEPP bound is not included, so this is only WeGoV that's covered, because WeGoV has the science. They've put out the studies that demonstrate the risk reduction. Zepbound hasn't yet, but you know they're working on this study for sure. So, in general, this is a good thing. Another really good thing about Medicare coverage and that does speak to more access to these medications in 5, 10, 15 years is that with the Inflation Reduction Act, we now have gone from a max out-of-pocket cap for medications from $8,000 down to, in 2025, it will be $2,000. It's a big reduction, huge reduction. So we're seeing some possibility for better coverage for these meds. It's just going to take a long time, unfortunately.

Zoe: 6:07

Well, I think it's kind of interesting and encouraging that these meds are now being covered. Well, maybe not right now, but knowing that this future is coming for not only weight loss but obviously diabetes, as we already know, but the cardiovascular events, all these other comorbid conditions that are also that we see in the practice being reduced while on these medications, but that it can actually be covered as a piece of it.

Dr. Weiner: 6:33

Yeah, I think it all speaks to the insurance and Medicare and everything. It's just about money. And you know how much do you think a heart attack costs Medicare? It's six figures minimum, easy. So all of a sudden, when you have someone who has a pretty substantial risk of having a heart attack, if you can reduce that risk, then there's a huge savings in that, and so I think that's another important thing. As much as we kind of complain and say why don't they cover it, these meds are so good, they're so great for everybody, they're really. If we're going to get some momentum on this, if we're going to get some things done, we're going to have to respect the financial side of this and we're going to have to target things like cardiovascular events, which are very expensive, and if we can show a reduction of that, we're going to see increased coverage. So let's move on to our patient story.

Zoe: 7:22

All right. Well, we're really excited because we have our patient guest here today, Larry. Larry, thanks so much for being here with us.

Larry: 7:29

It's a pleasure, pleasure, to be here.

Zoe: 7:31

So, to get us started, why don't you just kind of share with us how long ago your surgery was and what led you to make that decision?

Larry: 7:39

And what led you to make that decision. So it's almost one year anniversary April 10th of 2023. And what really led me to it? And actually just kind of fell into my lap and I just went to a routine area I wanted to set up, because I never went to doctors. I thought I was perfectly fine At 360 pounds. Nothing was wrong with me, except that everything started hurting my knees and everything. So I just went to a I wanted to set up with my primary, just to have history so in case.

Larry: 8:10

I need prescriptions or anything. So I just went for a routine area and then they checked my blood pressure and it's like, wow, you're 180 over 110 or something like that. So then they wanted to put me into prescriptions, you know, for blood pressure and I'm like I'm not taking those. So we just started talking. And then I remember Lisa. She said have you ever considered, you know, a gastric bypass? And I'm like, well, no, because you know it's expensive. And I said, well, you know insurance actually could get covered. I'm like, oh, let's talk a little bit more about it. And she said I know a really, really good doctor in town. He's one of the best and nice guy. And so then she talked about Dr Wine. I said, oh, I'm interested.

Larry: 8:53

And then I made the appointment and I just went through the process and then once I learned that the insurance can cover it, and you know, then we talk about you know, the gastric bypass of the sleeves and the percentages and all that, and I'm all in. And then just started thinking like I want to live for a long time, I want to be able to marry my kids, I want to be able to play with my grandkids and my dad he's 69 years old, he still plays sports and he works out every day. And here was, you know, a 41, 42-year-old man. I could barely run or I'd go up the stairs. So that was an inspiration, just to get my health back and just get myself back and go out there and play some soccer also. I love playing soccer.

Dr. Weiner: 9:36

So I just wanted to take a second because for those of you listening at home, you can't see. But larry has a picture in front of us. Larry, tell us about this picture. When did you take it? Share with everybody what this picture means because, you brought it with you today. So clearly this is. There's something here.

Larry: 9:50

Yes, it means a lot. Um, I'm gonna get emotional. Um, my family's everything, um, and that's you know, got my two kids and my wife in there and that was me just getting close to getting a heart attack from my blood pressure and everything. And that's what it means so much and I brought it here. Yes, my family is everything. It's everything to me and my family. I've been happily married, 23, together 26 and just seeing just the influence and as a leader of a home, one should take a step to anything, you know, let it be faith, let it be eating better. Then you start seeing everybody else follow and just seeing my kids, you know, working out. And now my wife is going with me in the gym and that was one of the things 26 years she's never worked out in her life and you got yeah she's in the gym with me and we actually went to.

Larry: 10:50

You know, we just picking up a nice routine and just seeing that influence and now doing what I'm doing and understanding that I'm going to be able to live longer because of the decision that I have made.

Dr. Weiner: 11:02

Ten years.

Larry: 11:04

Ten years. You added ten years to your life, absolutely, and I'm just blessed. My dad is also on inspiration, so, yeah, that's why that picture means so much, because my family is everything to me and I'm doing it. That was not only for myself.

Dr. Weiner: 11:26

I mean, you get a little religious here, but you know, my, my god, this is the temple of the holy spirit that lives in me and that's my first reason and also but then my family. Let's talk about your kind of shift toward fitness, because I think, more than almost any of our other patients, you've really embraced fitness. So talk to us. Where'd that motivation come from? How'd you get started? Because you were 360 pounds, recovering from surgery and we, I kind of held you back for a few months, but then, when I let you go, how'd you start? What was that first workout? Like you know, if someone else is out there and they're like I want to do this, I want to be like larry, but I don't know where to start. What's the first thing?

Larry: 11:55

so, and it goes back to my biggest thing was like doing some research and studying and looking it's like what is going to be sustainable, Because I mean I could get some of this weight back and maybe it's going to be hard to attain my objectives and my goals. And it was you've got to build muscle. That was one of the biggest things. Build muscle because that's going to help you sustain, it's going to help you burn fat, and I'm like, okay, and that's what really got me. Okay, I'm going to build that muscle and then just try to stay fit. But that was what my biggest motivation but another motivation was my dad.

Larry: 12:33

Um, you know, and I looked at him. He's 69 years old and he works out every day. So he came to visit me, uh, sometime last year. You know I had already had surgery and you know every day. So he came to visit me sometime last year. You know I had already had surgery and you know, every day, hey, well, we're going to the gym, hey, we're going to the gym. What time are we going to the gym? I mean, and he does that, he lives in Columbia, but every day and you'll see him and you know he'll flex and you'll see the little and I'm all floppy, all big. I'm like 69 years old, 41, 42 years old. I got to get in the gym. So that kind of really, really motivated me.

Larry: 13:06

And I guess one of the things that I learned with fitness and lifting is a lot of patience, Because you start working out, you feel sore, you feel you're going to die and little by little you stay consistent and then you start seeing those results. Then you start seeing the muscles and that transformation, especially when all you see in your life is being a big guy and you start seeing the little pup here and the little pup here and it's like this is a good feeling, you know, and that kind of you know got me going and again, just seeing those results and then also seeing that man, he's doing the purpose that I learned, that he helps me lose weight, Because I know my weight that Dr Weiner told me that I will lose will be 125 in a year and I did that in 10 months. Yeah, Because of that working out Now I am two pounds as of this morning away from 150 pounds. Wow, oh my gosh. Total loss I'm 211. Wow.

Zoe: 14:06

Well, when you hit your one year anniversary, I bet you're going to be there.

Larry: 14:10

Yeah, and that is my goal. That's why, also, I'm doing that two week liquid diet in anniversary of last year, but also my ultimate goal is being 200 pounds. Yeah.

Dr. Weiner: 14:22

There's a lot of fitness gurus out there. You know Zoe is a total fitness guru. I think you know she's very, very fit and really great shape. I think most, if you're a real fitness guru, if someone of your friends comes to you and is like Zoe, listen, you know I'm really struggling with my weight, I'm really struggling with my fitness, can you help me? To me that's almost an honor. Would you agree with that, zoe? I think a lot of people may be intimidated to ask for that help. But I think if someone's really at that elite level and Josh kind of alluded to this in his really brilliant discussion about obesity bias but if you're at that elite level and someone comes to you, man, you're so excited to help that person, like that's, to me that's almost a privilege.

Zoe: 15:03

Yeah, absolutely, especially when somebody like Larry is so committed to the process, and actually we were talking at the beginning about how you're going to be joining our peer leader team, so we're going to connect and get you on the schedule. So, for anybody listening, stay tuned for Larry's peer group.

Larry: 15:24

I would love to influence and help anybody. So you can be that person for people.

Dr. Weiner: 15:29

So if you're out there and you want to start a fitness program and you want to start putting some SMART goals together and measuring things, you can join the support group with Larry and start putting that together. That's awesome. I love that. That's cool.

Zoe: 15:42

Thank you so much for being here. It was a real honor to have you share your story and I think I feel inspired. I know that everybody else listening is, I'm sure, super inspired, and we'll be talking soon.

Dr. Weiner: 15:53

Absolutely.

Zoe: 15:54

I love this Larry.

Dr. Weiner: 15:56

Thank you for being here, thank you for sharing your story. There's so many other people out there who are where you used to be and to be able to see your success, to see that, that commitment, that energy, it is possible to do this. It's possible to go from this to this, absolutely so, and then to this, and then to that. We couldn't have. We couldn't have without a flex, we need a flex.

Zoe: 16:21

Well, I'm really excited to have Larry get all ready to go with us. A peer leader. That's really exciting. We're growing our peer leader team.

Sierra: 16:29

Fantastic.

Zoe: 16:30

And it's going to be really good, great addition.

Zoe: 16:32

Yeah, absolutely. Well, now we're going to go into the nutrition segment and this has to do with mindset and grocery shopping, so something and it might get. You know, stay with me. So stay with me for a second, all right, I'm buckling in.

Zoe: 16:48

So I talk a lot with patients in our groups about how success is the biggest motivator. Right, when you're feeling successful and proud, that motivates you to continue that positive choice. And that's why we start off all of our support groups celebrating wins. You know, celebrating those little wins get that momentum going, and so I like to carry that same mindset of celebrating the wins and stacking your successes into the grocery store as well.

Zoe: 17:18

So always starting your grocery shopping trip in the produce section. Maybe you do it just naturally, maybe you don't, but by starting in the produce section, filling your cart with a variety of colorful, beautiful, vibrant, fresh produce, that puts you in a winning mindset to start your grocery shopping trip. If you were to start in the alcohol section or start in the bakery, you're kind of already in this mindset of like, I just don't, I'm going to get whatever. But when you start and you have this visual reminder of these nutritious foods that are fueling you, you're starting with a win, so you're more likely to continue those positive choices throughout the rest of your grocery shopping trip.

Dr. Weiner: 18:08

I love it. Yeah, you just get yourself in that mindset Like let's, let's do this, okay. So, yeah, great, you know, with everything kind of starting in that positive mindset, making yourself positive it always is is just going to continue that trend and lead toward toward better decisions and better choices. So, as we mentioned earlier in the show, there's a massive shortage of these medications. Here's my theory on this and again, I don't have that kind of insight inside info on the pharma industry, but my suspicion is that, eli Lilly, they knew Zepion was going to be approved for obesity and they started stockpiling this med like crazy because they saw everything that happened with the Wegovy shortage and they said, well, that's not going to be us, we're going to get a massive stockpile. And they just produced, produced, produced, knowing they're going to get the FDA approval and be ready to go. And the problem is the drug was extremely popular. We've been prescribing it like crazy and I think they've burned through their stockpile and now they're kind of facing some of the same issues that Novo Nordisk is with the shortages, because we're seeing ZepBound shortages, we're seeing Monjaro shortages. We never really saw those medications as having major issues with shortage. It was really WeGoV and Ozempic that we saw the limitations. We've heard that in Canada there's not going to be any Monjaro available until the end of the year. We're hearing pharmacies here in town saying it might be a couple of weeks before they have some stock back in town and then as soon as they get some stock, it's just going to go like that Absolutely. And so I think we all have to acknowledge that we're about to run through some shortages, and so if you're taking a GLP-1 medication and you're dealing with a shortage, you're not able to access your medication.

Dr. Weiner: 19:55

I do think that there's some things that you can do in order to ride this out. And so when we look at weight loss, there's kind of two types of weight loss. There's the long-term, durable weight loss. That's what our entire practice, our entire mission, is really about sustainable weight loss. What Health and happiness through sustainable weight loss? That's our mission statement as a practice. But then there's also the short-term weight loss. This is the stuff you know lose weight fast, seven pounds in seven days, that kind of stuff. And so that's another form of weight loss. It's not something that I look at as kind of a healthy or useful technique. As kind of a healthy or useful technique. But if we're looking at short-term weight loss and if we're trying to bridge to, to get some access to these medications, maybe we start pulling out some of these short-term weight loss tricks.

Dr. Weiner: 20:37

And so, zoe, you talked a little bit about, about the support group you're starting and I think that's going to be really helpful for people to use some nutritional techniques to double down on the metabolic reset diet. And you know, as we work through this with patients, we may pull out some other tricks too. We've got these first generation meds like Phentermine, metformin, contrave. They're not my favorite medications but in a pinch to get you through a few months, they might be really helpful. They might cut. You know, if you were going to gain back 10 pounds, you might be able to make that two pounds or three pounds.

Dr. Weiner: 21:10

You know, I think there's going to be some people out there looking at the compounding pharmacies because they are still available. Again, I would really urge you to be very careful with that decision. If you do opt to compound which we do not recommend that you make sure that you understand where this medication comes from. Just because it comes from a doctor's office does not mean it's been tested, and so you know, you see it for sale in a wellness spa. You see it for sale in some doctor's offices. Most likely it came from the same place and has been tested. The same amount Zero, zero, in general zero. And so just be really careful with that decision to purchase the compounded medications and then again really dial in the nutrition. What are you going to be talking about in your support group for these patients really struggling?

Zoe: 22:01

Yeah, like you mentioned really emphasizing that metabolic reset diet, and it's not about eating less and that's something that, as we see people involuntarily taking time off of the medication, what that medication does as a tool for weight loss is decreasing their hunger, right. So after being off the medication, that hunger is probably going to come back. They're going to be able to eat more food and what I really help people understand is that it's not about trying to eat that same small amount that you were eating while you were on the medication, but it's about adding more of the right food so that you are not trying to fight against that hunger.

Dr. Weiner: 22:43

Yeah, so I think you know. The truth is is is that this is, to some degree, uncharted territory, like how do you manage patients who are coming off these medications? How do we bridge people to maintain the weight loss that they've achieved? How do we support people through this process? I think we're committed to doing it. If you're struggling with the meds and you want to tune in with Zoe and get some tips on what you can do from a nutritional perspective Our non-surgical weight loss program we're working through some algorithms with some of these first-generation medications that we can use to help people bridge the gap until the meds are more available.

Zoe: 23:18

Yeah, and so for people who maybe still have some of their medication left, what are your? You guys are kind of spacing out.

Dr. Weiner: 23:27

Yeah, that's a great. That's a great point is is, if you do, if you've managed to stockpile some of these meds and a lot of people have yeah. Space out the dosing.

Zoe: 23:38

You know it's supposed to be every seven days. Maybe space it longer or something.

Dr. Weiner: 23:41

Yeah, Some other things you can talk to your prescribing physician about. You know, we had Chrissy on a while ago and she was taking a pretty high dose of Wegovy once a month, and that's certainly something I've heard a lot of patients say is when the dose goes up. Sometimes you know, especially if you tolerate the meds pretty well, increasing the dose may cause a slight increase in your side effects, but it makes the medication last longer. And so if you are, you know, if you are able to get your hands on meds, maybe talk to the prescribing physician about moving up the dose. If you're comfortable where you are, don't make yourself sick, but if you're comfortable at the dose you're at, move up the dose and then maybe space it out a little bit longer.

Zoe: 25:10

And you can definitely work with people on like creating a more personalized dosing strategy.

Dr. Weiner: 25:14

That's what we're doing right now.

Zoe: 25:17

That's the name of the game I'm thinking about all these patients that I know like one. One is like when they reach a certain weight, one is like every certain day. So it's you know, it's, it really is so individualized.

Dr. Weiner: 25:27

Yeah, you gotta you gotta create something that works for each person and you gotta you know, what we do is we work with people and try to understand their physiology How's their body responding to the meds, how what's, what's their nutritional capacity for change, and we kind of help them figure out the best way to get through this. And so I think we're going to you know, we're going to have to do a little bit improvisation over these next few months as we kind of navigate through this.

Dr. Weiner: 25:51

So I think, if you're out there, I wouldn't. I wouldn't give up. There are people still getting the medications. It is definitely possible, but I think we're going to have to make some adjustments.

Zoe: 26:01

Patience and perseverance.

Dr. Weiner: 26:03

Yeah, absolutely All right. Well, why don't we move on to our questions from social media? We've got Sierra, our office manager, here and she's going to start reading the questions for us.

Sierra: 26:15

All righty First question here is from YouTube. The questions for us. All righty. First question here is from YouTube Small weight loss after gastric sleeve. What is a good, fluid choice in terms of getting energy and hydration?

Zoe: 26:26

Yes. So let's think about hydration and energy, because there's this misconception something that I see a lot when people are dehydrated, they're low energy, they think they just need to keep drinking more coffee, but in fact they need low energy. They think they just need to keep drinking more coffee, but in fact they need more hydration. And once they are adequately hydrated, they're like oh wow, I have so much energy, it's great. So obviously, water is going to be my tried and true recommendation, but that's not the only thing that you can be drinking to be hydrated, especially if you're somebody who might want it to be a little bit more special. Right, I kind of like jazz it up a little bit. Fruit infused water, like those spa waters, are great, you know. Obviously, if you put some fruit in there, you get that natural sweetness. That's really great.

Zoe: 27:10

Tea I'm not a huge tea drinker myself, but over the past two days I've had two cups of tea here in this office because I'm so dang cold, it's April and it bubbly water. So I love sparkling water, whatever it is LaCroix or bubbly, whatever you like to have. But what I love about those is that you get that flavor, but there's no artificial sweeteners, no added sugar, that kind of thing. Now, if you're wanting specific, let's say you are adequately hydrated and you're now wanting to boost up your energy, so you are needing some, desiring or wanting some caffeine. Green tea is a great option. And coffee you don't. You can drink coffee, that's okay, I was going to ask you about coffee.

Zoe: 27:56

Yeah, but the thing is with coffee is is what are we putting into it, right? Um, I don't count coffee as part of a fluid goals. I say, if you want to drink coffee, that's fine, but that's going to be above and beyond your. You know, whatever your fluid goal is, Interesting so that's just how I look at it.

Dr. Weiner: 28:15

Okay, here's my theory, because everyone is really into those electrolyte waters and the hydration or the liquid IV, that kind of stuff, which personally I think is primarily a scam.

Zoe: 28:27

The majority of people don't need it. I have so many patients who ask me about do I need to be adding electrolytes? And I'm like, unless you are exercising and sweating, sweating, sweating, sweating, we don't need to, Because if you're eating these whole foods and you're getting your sodium and your potassium and your potassium and your magnesium in through foods like we really don't, that's where I was going with this is that I think if you want that liquid IV, you want those electrolytes.

Dr. Weiner: 28:56

Then drink water and eat a banana. There's going to be. If you think about that little powder, how much potassium, how much sodium, how many of these electrolytes could be in whatever that tiny amount of powder is that you throw in there versus what's in a banana right, bananas loaded with electrolytes, any type of fruit. But I think we should really look at electrolytes as coming from the food you eat, not what you drink. And those liquid IVs, artificial sweeteners, sugar in a lot of them.

Zoe: 29:25

You have to be careful with the liquid IVs. They just recently came out with a sugar-free option.

Sierra: 29:30

The majority of them have sugar. Okay, next question is from the website from Elizabeth, and this is I had a gastric bypass in 2006 and lost 110 pounds. If I had a revision, would I have the same success?

Dr. Weiner: 29:46

So I've heard this question over and over again Like can you do the gastric bypass again and get the same results? And sometimes we'll see that with patients who've regained weight. Sometimes we'll see that with you know patients who are 450 pounds and got to 350 pounds or 325 pounds and want to lose another 75 pounds or something along those lines. So the first thing is is that the primary surgery really matters when it comes to your revision options. With a sleeve gastrectomy you've got some revision options. You can convert to a duodenal switch. You can convert to a SADY procedure, you can convert to a gastric bypass. With a gastric bypass you really don't have any realistic revision options. There's kind of two things you can do. You can make the pouch smaller.

Dr. Weiner: 30:29

The problem with making the pouch smaller is most pouches were made small to begin with. They don't stretch out the way people think and you only have so much tissue to work with. And if there's one thing when I'm doing any kind of complicated revision surgery like I've got a complicated patient who's got a gastrointestinal ulcer that has perforated three times and she struggled when I did her endoscopy she had a huge gastric pouch huge and that's why she developed the ulcer. The surgery I don't think was done properly from the beginning and so when I have a big pouch it's not that hard of a surgery. I got a lot of tissue to work with. When you're trying to go from you know two inches long to one inch long. You trying to go from you know two inches long to one inch long, you're not making much change and it gets very tricky and very risky. So that pouch reduction is really only appropriate in patients who did not have the surgery done properly the first time. The second thing you can do is move it down, bypass down, make it longer so that you're bypassing more of the small intestine. That typically causes more malnutrition, more symptoms like diarrhea, more food intolerance and maybe about 5% to 10% total body weight loss. Probably not worth it. Not worth it. A lot of issues. Revision surgery has twice the risk and half the weight loss, and that half the weight loss is probably generous. For gastric bypass it might be 10% of the weight loss, 20% of the weight loss. It's very, very modest and now with the meds out there again, if you can get them, they're a far better option in this setting. So I think, elizabeth, if you're struggling with weight regain after a gastric bypass, then I would look at the medications first.

Dr. Weiner: 32:03

The only thing that would make me want to know more about this is that her surgery was done in 2006. And that was pretty early in the history of gastric bypass surgery laparoscopic gastric bypass and so there was a lot of variability back then. If I see, one of the most important questions I ask people is when was your surgery done? Your surgery was done in 2015. By that point there were some industry standards, there were centers of excellence, there was a lot of regulation, a lot of science, a lot of understanding how to do these procedures. 2006, much less so.

Dr. Weiner: 32:39

So it's possible the surgery was done open. Patients who had open surgery tend to have much larger pouches just because you can't get there from an open surgery. If I was you, elizabeth, I would reach out to a bariatric surgeon in town, or I'd be happy to see you here in Tucson. You could get a pretty comprehensive evaluation, an upper GI, an upper endoscopy, a CAT scan to really get a good handle on your anatomy and make sure that surgery was done correctly. I think if the anatomy is normal, then I would look at the meds. If the anatomy is abnormal, then, depending on what's abnormal about it, there might be some option for revision success. So worth looking at. Interesting question though.

Sierra: 33:22

Okay, final question is from Mary, from our website. I've been doing a lot of research and I've come across a medical doctor who recommends that weight loss surgery patients should not exercise until they have lost a significant amount of weight. What do you think about exercising right after weight loss surgery, or what has been your experience with your patients?

Dr. Weiner: 33:41

All right, zoe, why don't you handle this one first? When it comes to exercise, you're definitely you got more on this than I do.

Zoe: 33:47

Well, I think that perhaps where this doctor was coming from was more so about what Larry was talking about, that you were saying like we want to be careful right off the bat. You're not going to go be pushing around a whole bunch of weight two months after surgery. But my perspective on this is that exercise and movement is unique to the person, and walking is a form of exercise. Swimming, doing seated body weight, you know exercise, whatever it is, all of this is a way of meeting yourself where you're at and making those strides in the correct direction and building over time. So I I absolutely encourage our patients to start exercising, but knowing that what exercise looks like for them might be different than what looks like for the next patient.

Dr. Weiner: 34:41

Yeah, and I think, first of all, you know, listening to Larry, he started out slow and now he's, you know, back and by his five days a week and and he's really pushing it and understanding that becoming fit, exercising at a high level, is not something you start with. You have to really ease your your your way into this. There's a lot of nuance to this question because you can go wrong and we see this, we've seen this many, many times, that you can do this wrong. First of all, when I see patients who are 450 pounds, 500 pounds, I tell them like walk, preserve your mobility, you know, chair exercises, kind of the stuff that you're doing, but don't go to the gym, don't really start pushing the exercise.

Dr. Weiner: 35:21

Don't use exercise as a method for weight loss because the likelihood of injury in that patient pushing that and pushing themselves too far, that's a real risk and that risk is going to set us back even further. And those patients you know they're already a higher risk patient Sometimes you're kind of one false move away from not getting the patient to surgery and so you got to be real careful in that, especially now we've got the meds and the nutrition and everything we can 450 pound patient you can almost always get to lose weight even without the meds and the nutrition and everything we can. 450 pound patient you can almost always get to lose weight even without the meds. Right, there's just there's so much opportunity for weight loss in that population.

Zoe: 35:55

And I also think it's important to note that exercise should not be viewed as a means of weight loss alone. It's more so, as that means of building muscle, building cardiovascular endurance, creating the healthy habit, and it's not about burning calories.

Dr. Weiner: 36:13

Right, Getting to kind of our set point model right. Four ways to lower your set point nutritional change, medications, bariatric surgery and then building muscle and using it, and so recognizing that it's about building muscle, building strength, building stamina and that helps to bring your set point down, Not, like you said, like getting on the treadmill and, you know, putting on the calorie mode and stopping when you hit 500 calories.

Zoe: 36:36

That's why I absolutely I don't like using the word hate, but I hate those charts that it's like how many burpees does it take to burn off like a candy bar or whatever it is? It's like that's just the completely wrong way of thinking about it.

Dr. Weiner: 36:49

Yeah, that's exactly the wrong way of thinking about it. Well, anyway, yeah, great questions today, fantastic questions.

Zoe: 36:55

Yeah, great episode. I'm so excited about our patient story and we just had a lot of really great value. So if this was valuable to you, we would love to hear about it. We'd love for you to share it with somebody who you think would also find it valuable, so we can continue spreading the word and making sure that there's no weight loss patient left behind.

Dr. Weiner: 37:15

Absolutely. We'll see you next time.