From 369.5 to 19,341: Lynsey’s journey to the top of Mount Kilimanjaro

Episode 25 of The Pound of Cure Weight Loss podcast is titled, From 369.5 to 19,341: Lynsey’s journey to the top of Mount Kilimanjaro. The title comes from our Patient Story where we talk to Lynsey who came to us at 369.5 pounds. She lost a ton of weight after her gastric bypass but she didn’t stop there. She embraced physical activities that led her to the tallest free-standing mountain in the world! Her story is truly inspiring!
 
 Our In the News segment features an article from US News that talks about another beneficial side effect of taking Zepbound. In clinical trials, Zepbound has been proven to drastically reduce sleep apnea. Does that mean that insurance companies will now approve the use of Zepbound for the treatment of sleep apnea? Tune in to find out!
 
 BMI or Body Mass Index is a measure of body fat based on height and weight. It’s used, almost universally, by both the medical and insurance industries. In our Nutrition segment, Zoe explains why BMI is unreliable and, in her words, “trash”.
 
 The Zepbound shortage has left a lot of people struggling without their medication. So, in our Economics of Obesity segment, we talk about the Wegovy coupon and how some patients may be able to switch from Zepbound to Wegovy to help get them through.
 
 Finally, we answer 3 new questions from our listeners including, our thoughts on Poppi prebiotic soda, whether or not Medicare will cover revision surgery, and hypoglycemia while taking GLP-1 medication. 

Transcript

Zoe: 0:17

BMI is something that insurance companies use, that the medical field has used for a very, very, very long time. But that I think we both agree that it's kind of trash.

Dr. Weiner: 0:29

Yeah.

Zoe: 0:34

Hi everybody, Welcome back to the Pound of Cure Weight Loss podcast, episode 25. 25?.

Dr. Weiner: 0:42

I know, I know, I know that's pretty good, that's a lot.

Lynsey: 0:44

It went fast, didn't it go fast? Yeah, yeah.

Zoe: 0:46

But it also feels like we've been doing it for a long time. Yeah, I don't know. So the name of our episode today is from 369.5 to 19,341. Any guesses on what that is? Lindsay's journey to the top of Mount Kilimanjaro, our patient guest today. Oh my gosh, wait till you hear this story.

Dr. Weiner: 1:07

Unbelievable story, I think the things that people can accomplish after bariatric surgery. I've heard a lot this is up there. I know I'm like, wow, this is up there, yeah, so anyway. So, zoe, for our next two episodes, you're going to be on your honeymoon, I will, and so we actually have decided we're going to have two guest hosts. So we have two other people in our practice who are really kind of critical to our day-to-day function. We have lots of people, truthfully, who are critical to our day-to-day functioning, but, in terms of providers, we have Bethar and we have Deidre. So any of you who are out there who are patients most likely know Bethar and Deidre, but they're going to be my co-hosts for these two episodes, so we're going to do that. I think that's great because they're so critical to how our office runs and functions, and I think it'll be great to get them on the podcast and so everybody can get to know them a little bit.

Zoe: 1:55

Yeah, I'm excited to listen to those no-transcript.

Dr. Weiner: 2:29

But then once they have the data, once they have the patients, they really look at all of these other medical factors and then they run additional studies based on some of these other data points. And so what they did is they looked at sleep apnea and they looked at the people in the trial who had sleep apnea and if they're dealing with overweight patients, they probably had plenty of them and then they looked at what their sleep apnea looked like after taking the medication. And so this is from the Surmount trial. When you're looking at sleep apnea, we measure it using something called your AHI or apnea hypoxia index, and it's actually quite a simple number. It really is just a measurement of the number of times you essentially stop breathing or breathe less per hour of sleep. So normal is less than five, and then we classify things as mild to mild, moderate or severe based on that number. And over 30 is severe, 5 to 15 is mild and 15 to 30 is moderate. And so what we found was, in once starting, zep bound patients had an AHI reduction of 27.4 events per hour. So keep in mind, severe is greater than 30. So if you were just over 30 in severe, you would drop down almost into the normal range. It's amazing. So this isn't a minor difference, this is a major difference.

Dr. Weiner: 3:50

The control group did receive a lot of nutritional counseling and when we looked through the studies, a lot of them lost some weight. We saw a reduction of 4.8. So if we're looking at diet alone, we saw 4.8 fewer apneic episodes per hour versus 27.4 on Zepbound. This is, without question, a major result. This isn't like, oh, it's a little bit better. And I think the thing you also have to realize in medicine is you don't see results like this that often.

Zoe: 4:17

And I feel like this keeps happening over and over again with so many different comorbidities.

Dr. Weiner: 4:23

Yeah, and we saw this. It's not surprising because we saw this with all the bariatric studies. So I remember there's and I don't even remember the name of the trial. Honestly, it was probably 15 years ago when a study came out that just showed head-to-head maximal medication management versus bariatric surgery, and the endocrinologists were up in arms that surgeons are fixing diabetes way better than they are and that's their specialty. But we saw just a massive improvement in diabetes after bariatric surgery compared to a very, very modest improvement using glipizide, metformin and optimal glucose control. And so we shouldn't be surprised, because substantial weight loss causes substantial improvement in your health.

Dr. Weiner: 5:04

Now a lot of people will say well, that means CPAP's expensive. I got to have this machine and everything and so they got to approve ZEPP bound and they should cover it because they'll save money. Not true? Unfortunately, zepp bound is $1,500 a month right now Again, 10 times more than they pay in Britain and France. A CPAP machine is also pretty pricey. They run anywhere between $500 to $3,000. $3,000 is like for the kind of the top of the line. Most insurances probably won't pay for that full amount, so insurances maybe are paying one month's worth of Zepbound for a CPAP machine.

Zoe: 5:43

Yeah, they'd much rather do that.

Dr. Weiner: 5:44

Yeah, so versus Zepbound, which you got to take for 12 months a year. So, despite all the overwhelming clinical evidence and really this study comes as absolutely zero surprise we see the same thing after bariatric surgery. But, despite all the clinical evidence, until the cost of these medications comes down, we're not going to see the widespread coverage that we all want, and so this is great news, and if you have sleep apnea, this is another reason to consider glp-1 meds or bariatric surgery, but I would not expect any major coverage changes as a result of this. As we mentioned in our last episode, there's absolutely no way that we can support the widespread use of these medications in our obese patient population in the US at these current prices, and so the only reasonable way that we're going to start seeing people with sleep apnea get access to these medications is if the price of them comes down. All right, well, now it's time to move into our patient story. If you are ready to be inspired, then buckle up, because this is a great story.

Zoe: 6:44

Welcome Lindsay. Welcome Lindsay, happy to be here.

Dr. Weiner: 6:47

So it was right when we started the podcast. Lindsay came in for a visit and she told me some stuff that, in all honesty, I don't hear this from every patient, and she's going to share all of this with all of you today. But since she said that, I said, oh my God, we have to get you on the podcast and I've been eagerly waiting this day because she has an awesome story. So before we get into the awesomeness of your story, let's first start by having you tell us just a little bit about what brought you initially into our office and what surgery you had and all that kind of stuff.

Sierra: 7:21

Sure. So like a lot of bariatric surgery patients, I really struggled with my weight my whole life. Definitely had some genetic predisposition. I think I went to my first Weight Watchers meeting with my mom in like seventh grade probably. I feel like I mean I've definitely had some bad eating habits, but nothing like egregious. I've always tried to be kind of active. I was in marching band in high school and just could never lose weight. I'd lose maybe 20 pounds here Once I think I lost 50 pounds, but then it would stall out and it would come back. So I moved to Tucson after college and started really getting into some of the outdoorsy stuff. Really wanted to start hiking. I went on my first. The first hike I ever recorded with my Apple watch was this little two mile paved flat thing in Saguaro National Park and I remember it being so hard and I went back and looked at the stats and my average heart rate was 137.

Sierra: 8:18

You're working hard working hard compared to I recently uh hiked to the bottom of the Grand Canyon and back up in a day, and my average heart rate for that was one 21.

Dr. Weiner: 8:28

Oh my gosh.

Sierra: 8:31

Um, but so then about uh, 2019 and a 2019, my mom actually went and had a gastric bypass and so she was kind of the canary in the coal mine, um, and she, she told me, she said, hey, I've been reading all these books. Uh, one of these books I read, the guy practices in Tucson. You should go see him. I was like, oh, we'll do. And so I actually read your second book, how weight loss surgery really works, and it blew my mind. I mean really, um, a lot of science behind it and stuff that really spoke to me. And so I was like, it's great, I'm going to totally do this. Um, so I came in pretty much with my mind made up.

Dr. Weiner: 9:04

Yeah, so you had a gastric bypass. How much did you weigh before your surgery?

Sierra: 9:07

so my highest weight. Granted, this was kind of in the middle of covid, uh, but I got up to 369.5.

Dr. Weiner: 9:13

Oh my gosh, so 370. Let's round it up.

Sierra: 9:16

Just, I don't know, I prefer not to really okay, all right, 369.5 you're right and when did you get your surgery? April 21st 2021.

Dr. Weiner: 9:25

Oh, so we're right at three years. I was one of the first ones.

Sierra: 9:27

Yeah, one of the first ones after kind of COVID.

Dr. Weiner: 9:30

Okay.

Sierra: 9:31

And then, yeah, just came up on three years.

Dr. Weiner: 9:32

And so how'd your first year go out from surgery?

Sierra: 9:36

Really smoothly. I'm a huge rule follower, so you know you give me the routine, give me take your vitamins, eat this, don't eat this. Um, here's how much protein you need. I was able to kind of just follow all that Um lost. I don't remember what I was at at one year, but definitely I think the most I lost was like 165 or something, wow, wow, and so that wasn't enough for you, though.

Dr. Weiner: 10:53

Was it 165 pounds? You had to take a few. You had to, you know, push this a little bit further. So why don't you start talking about some of the things that you've accomplished since your surgery?

Sierra: 11:07

Sure. So, um, one of the biggest things I always wanted to do was hiking and get more into hiking. I'm a nature photographer, I visit a lot of national parks, I do a lot of traveling and there's so much you don't get to see when you stick to the driving loop Right. And so I really wanted to get out and do some of these hikes, and so I actually I started doing the it's called the 52 hike challenge. Um, and really great organization. Um. So the idea is you try to hike on average once a week through the year. Um, so I did that two years in a row. Um, did some bigger and bigger hikes. I tried to always keep outdoing myself. Um, uh, then it would have been last summer, last May, we uh summited Mount Wrightson here, uh, south of Tucson with a group of friends.

Dr. Weiner: 11:55

How high was that?

Sierra: 11:57

9,000 something.

Dr. Weiner: 11:59

Wow, I should have looked this up. Yeah, yeah. Um how long did that take you?

Sierra: 12:04

It was all day, I think it was seven or eight hours. Um, we went up, had lunch at the top, came back down, so at the time that was the hardest thing I'd ever done. And then, maybe a month later, I got the monthly email newsletter from the 52 Height Challenge and they were advertising this trip they were trying to put together to go climb Mount Kilimanjaro. And I looked at it and I was like, oh, that's something I'd love to do someday. And I kind of clicked on it just to kind of see like, oh, I bet it's expensive, I bet it's really hard. And I'm reading through it Not that I mean it's not cheap, but it wasn't as expensive as I expected.

Sierra: 12:43

I was looking at the day by day breakdown. None of the days individually were harder than Mount Ritzen that I had just done. Like I can do this. And I kind of started to think like maybe I can do this. And so I texted my husband, I sent him the link and I was like I can't find a reason not to go do this. And he goes you should do it.

Dr. Weiner: 13:04

Oh wow, that's awesome.

Sierra: 13:05

And then I said to him I was like maybe I should sleep on it. You know, I don't want to like jump into this huge thing I'm making. I'm pretty impulsive sometimes and he goes there's only eight spots, you should sign up right now, like don't let it get away. And so I actually made him click the button for me to register.

Dr. Weiner: 13:25

I was like if you're really sure I should go do this. So you signed up. So what kind of training did you do before this? So so let's keep in mind you're you used to be what a year and a half before you've signed up, you used to be 369.5 pounds.

Lynsey: 13:41

Yep.

Dr. Weiner: 13:42

And now you're signing up to climb Mount Kilimanjaro.

Sierra: 13:44

The highest peak in Africa and the highest freestanding mountain in the world.

Dr. Weiner: 13:48

Yeah, oh my gosh so. So what kind of training did you do beforehand?

Sierra: 13:53

So I was. They sent over a training plan and I'm kind of looking through it and a lot of it was what I was already doing. So one of the biggest things after my surgery was I really wanted to be active. I really wanted I had all these things I always wanted to do. I had I think you checked that box. I had a home gym set up in my house. I started doing taekwondo shortly after my surgery. I was lifting weights, I was starting to get into some running, and so I was actually doing more than the initial stages of the training plan. So I kind of just kept doing what I was doing, kept doing my weekly hike. Once it got a little closer I was ramping it up a little bit, trying to go to more like an hour of exercise a day, work in more running and kind of stuff. But overall, um, it wasn't too much. I had to do beyond what I was already doing.

Zoe: 14:42

Yeah, so when was your, when did you get?

Sierra: 14:44

when did you do your hike? Uh, we summited on February 28th of this year.

Dr. Weiner: 14:49

this year, so you are just a few months out from this. So you fly into Tanzania and you talk to us take us from there. Like what happened? How many days did this take, how hard was it Was? Were there any moments when you thought you, you know, weren't going to make it?

Sierra: 15:06

So I mean, it was incredible, it was completely life-changing. Um. So I get into Tanzania. I didn't know anybody else, I couldn't find any. I had a couple of friends. I was like, hey, you want to go do this with me? And they were like no. So I was like, all right, I'm going to go do it. Um. And so it's with a group. But I didn't know anyone in the group and so I show, I show up in Tanzania, I kind of meet everyone, we have dinner, the you know the night before. Um seems like a really cool group of people, uh. And then we uh get going and it was so.

Sierra: 15:35

It's a seven day climb and it was kind of the first couple days. You start out go up through the jungle. Um, kilimanjaro is cool because it has four or five distinct biomes as you go up. So we started up going through the jungle and it's, it's hot and it's humid, there's monkeys in the trees. We get to our first camp. The next couple of days are more through. They call it the moorland, so it's rocks and scraggly bushes and it's starting to get a little chillier during the day and we get up to the and so you're carrying your tents.

Sierra: 16:05

So we don't actually carry the equipment. So they have porters that carry. You carry a day pack and then the porters carry your equipment, your tent, they set up camp and stuff. So that was really nice. I don't know that I've been able I would have been able to do it as like a carrying everything I mean.

Dr. Weiner: 16:20

Whatever, however, you make it to the top of Mount Kilimanjaro, you don't have to explain yourself there, lindsay, yeah, so we actually had a team of 42 porters supporting our group. Okay, wow, and I want to give them credit because it was, and they do this just every day. Yeah, oh my God. So how many days did it take you to get to the top?

Sierra: 16:42

So we summited on day six.

Dr. Weiner: 16:44

On day six. So how many feet did you do every day?

Sierra: 16:47

It varied. So we had some that were longer days. I think on average it was between 2,000 and 3,000. There might have been one day it was a little bit more. There was one day where they call it climb high, sleep low, thousand something to have lunch and it kind of helps your body acclimatize, but then you go back down and sleep at I think it was like 12,500 or something. Um, so it wasn't like straight up the whole time, it was a little bit of up and down and then, um, the final, the base camp to the summit is it sits at about 15,000 something so then did you get transported back down to the bottom.

Zoe: 17:28

You said you summited at day six, but but it was a seven day hike. Yep, what the entire way back down in one day and a half. Yep, oh my god.

Sierra: 17:37

So, some at night, you actually leave your camp at midnight, yeah, and so you get up. They wake you up at 11 pm. They say, okay, breakfast time, your breakfast. You leave your camp at midnight. It's called an alpine start and the idea is to summit about sunrise, oh and so, and so it takes a solid. It took us a solid eight hours to get from our camp to the summit, which is only and it's snow at that point right.

Sierra: 17:58

So we actually yeah, we summited in a blizzard, which is unseasonable. It wasn't expected, and so that added a whole other layer of challenge and adventure to it.

Dr. Weiner: 18:08

I mean, how hard was it? Like? Were you at any point? Were you thinking I'm not gonna make this?

Sierra: 18:17

So I don't think so. The thing that really has stuck with me is I went into it very intimidated, nervous, and everything was better than I expected and I certainly wouldn't call it easy, but I felt pretty confident the whole time. And it definitely really helped to have a group with me that everybody you know, we all lifted each other up, we motivated each other. It was a fantastic group of people who are now probably going to be lifelong friends Lifetime experience.

Dr. Weiner: 18:49

It kind of sounds a little bit like bariatric surgery when done right, like it seems like a little intimidating. If you go through it with some people, it's better. It's generally easier than you think it's going to be. So you kind of had an experience like that before that. So that's absolutely amazing. But that's not all you've accomplished since your surgery. What else have you accomplished?

Sierra: 19:14

So I earned my black belt just in December. So I started Taekwondo shortly after my surgery I think it was about the summer after so three or four months, and it was kind of cool watching my progress going down in weight as I went up in belts. I actually went down two uniform sizes throughout the time.

Dr. Weiner: 19:32

Oh, my God.

Sierra: 19:33

Oh nice.

Dr. Weiner: 19:34

So I mean, I think there's so much to take out of your story. I think the first thing and I hear this quite frequently as patients say oh, I don't want to have a gastric bypass because I want to be able to be strong, I want to be able to perform, and I don't think this has held you back very much at all, Would you agree?

Sierra: 19:53

Not only has it not held me back, I would never I mean I never in a million years would have thought I'd be able to hike. I didn't know you could hike to the bottom of the Grand Canyon. I didn't know you could hike to the bottom of the Grand Canyon, let alone that I'd ever be able to, or that I'd be able to summit one of the seven summits.

Zoe: 20:10

I still can't believe I did it and that it happened. So do you have your sights set on another huge summit in the upcoming future, or have you thought?

Sierra: 20:16

about that at all. So I've got a couple in mind that I might do someday, but we've actually been calling this my season finale of the adventuring part of my life before my husband and I are going to settle down and start having a family.

Dr. Weiner: 20:30

So you've got pregnancy planned.

Sierra: 20:32

Pretty. Yeah, hopefully soon-ish.

Dr. Weiner: 20:34

That's exciting.

Dr. Weiner: 20:36

So that's kind of a whole other topic that we really haven't covered nearly as much as we probably should on the podcast topic that we really haven't covered nearly as much as we probably should on the podcast.

Dr. Weiner: 20:45

You know, I think the first thing actually, I was just talking today to a high-risk OB specialist and we were talking about, you know, bariatric surgery and the medications and how it influences pregnancy, and what she said which is what I've heard every single time I've had this conversation is there is nothing that is higher risk than obesity when it comes to pregnancy, and it's higher risk for the mom, it's higher risk for the baby and it's something that the high risk OB docs are really, really, you know, concerned about. So you come in at 370 pounds and the risks are through the roof. Now you're more than 18 months, which is our recommendation, which is based on the data and the safety curves of bariatric surgery and pregnancy you are at far less risk I mean exponentially less risk for having a obstetric complication during your pregnancy. So I think that's the first thing to keep in mind is that you know how's bariatric surgery gonna influence us. It made it way safer for you, way safer Plus your current fitness level is huge.

Dr. Weiner: 21:48

So what you know eat for two. Is that what we're telling pregnant moms?

Zoe: 21:51

these days Not quite. I think that's a huge misconception, right, and it's also become kind of like culturally, the norm that it's. It's almost like that extra eating for two is being pushed Um, but it's. Ultimately, this is the time to really have your best nutrition well-balanced, getting all those micronutrients and protein. You know the the amount of extra calories that your body needs during pregnancy is not nearly as much as people think. So I think that you know, with a little bit of extra tweaking and maintaining your current fitness level as well, that's going to really help you have a super safe pregnancy.

Dr. Weiner: 22:31

So that's so exciting. Well, lindsay, oh my God, what a story. I think the last thing I want to talk to you a little bit about is our last conversation we had, because you know you said, hey, I'd listen to the podcast and everybody's talking about these GLP-1 meds and you know what do you think Is this something I should do? So I think, just kind of touching on our last topic, you can't take GLP-1 meds when you're pregnant. So anyone planning for pregnancy, glp-1 meds are off. But we kind of talked about it because you're, what's your current weight right now?

Sierra: 22:59

I've been hovering around the low 220s Low 220s.

Dr. Weiner: 23:02

And how tall are you? 5'9", 5'9". So your BMI is still, you know, on the life insurance table, is a little high, right, it's higher than 25. Let's just put it that way. So you asked me well, what do you think? Do I need to lose more weight and everything like that? And so my comment was that any BMI that you can climb Mount Kilimanjaro at is a healthy BMI, and I think this case really points out that BMI is not the end-all, be-all when it comes to measuring your success after weight loss surgery.

Dr. Weiner: 23:37

I personally would consider you one of my most successful weight loss surgery patients, Absolutely, With all that you've accomplished, all that you've done. I mean you should be so proud of yourself and at this BMI. Whatever this BMI is, it's the right one for you right now. It's where your body is healthy, it's where your fitness level is elite. I mean what you've accomplished is an elite fitness accomplishment. I mean what you've accomplished is an elite fitness accomplishment. So I think it's so important when you look at success or failure or did we meet our goals after surgery, that you take a second and pause and not just look at the number, but look at what you've accomplished the meds you've come off, the lifestyle changes you've made, the physical fitness things that you're capable of, the way you've changed the activities you perform All of those things are how you should be measuring success after surgery, not just your BMI. Well, thank you so much. I think this was awesome. It was so good to hear from you. I'm so proud of everything you've accomplished.

Sierra: 24:37

I mean you should be proud, are you?

Dr. Weiner: 24:38

proud of yourself. Absolutely yeah, you should be, Good, you should be.

Zoe: 24:42

Thanks so much, oh go ahead.

Sierra: 24:43

Oh, I was just going to say that one of the things that really resonated with me as I was kind of working towards the hiking and stuff, is I got from I can't do things most people can do to I can do things most people can't do.

Zoe: 24:55

Oh that's awesome Mic drop. All right, all right, wow. I mean, I had never thought of climbing Mount Kilimanjaro as even within the realm of possibility but, she proves that she was in just a year and a half.

Dr. Weiner: 25:12

I know.

Zoe: 25:12

That is what's crazy to me 369.5 pounds.

Dr. Weiner: 25:16

Yeah.

Zoe: 25:27

Right, I mean to go from that to Not only losing that much weight, but also making such a drastic change in her physical fitness. Not being able to barely do the two miles versus a seven-day 19,000-foot elevation hike. Oh my gosh Wow.

Dr. Weiner: 25:38

So there's Blackett's Ridge, which is a hike that I love, that you've done before, and it's a tough hike. Yeah, it's a great hike. That's Ridge, which is a hike that I love, that you've done before.

Lynsey: 25:44

And it's a tough hike.

Dr. Weiner: 25:44

Yeah, it's a great hike. That's 2,000 feet and, honestly, when I get to the top of that I'm pretty wiped out. So Mount Kilimanjaro, 19,000 feet, that's impressive. Yeah definitely All right. Well, what do we have for our nutrition segment this week?

Zoe: 25:58

Well, for our nutrition segment, I actually want to talk about BMI. Okay, are you on board with that?

Dr. Weiner: 26:04

Go for it.

Zoe: 26:04

All right, great. So I mean BMI is body mass index. So body mass index is a ratio of your weight to your height Squared, squared. Okay. So basically, this ratio is just taking into consideration your height and your weight. That's it. What does your weight comprise of? Your muscle, your fat, your bones? So something called body composition. The number on the scale, your body weight, does not take into consideration your body composition. So somebody who weighs 200 pounds could have a 50% body fat and have the same BMI as somebody who weighs 200 pounds and is at 20% body fat, and according to the BMI chart, they would both be. Let's just use overweight, right? You know, we didn't say the height, but you get the idea. So BMI is something that insurance companies use, that the medical field has used for a very, very, very long time, but that I think we both agree that it's kind of trash.

Dr. Weiner: 27:14

Yeah, absolutely.

Zoe: 27:17

So I think Lindsay really exemplified that she maybe her BMI is technically still in the obese range, but she is extremely fit, she has a lot of muscle. Her body weight does not show her body composition and I want to just kind of really drive that point home and your maybe percent body fat and doing your you know different body composition measurements, if you have access to that some gyms have access to that or give their gym members access to that. So just to kind of keep that in mind, that, um, the BMI is not something we want to put so much emphasis on.

Dr. Weiner: 27:57

Yeah, absolutely it's, it's, there's so much more to it and it doesn't tell the whole story of health at all. Right, first of all, when we look at let's look at older people. Right, you might think, well, bmi 25, well, the older you get, you got to be in perfect health. But what we find is actually, if your BMI is between 25 and 30, you don't live as long, as if your BMI is between 30 and 35.

Zoe: 28:17

You need that protective.

Dr. Weiner: 28:18

Yeah. So BMI as a absolute measure of health is, as you said, trash, and I think it's much more nuanced and you have to look at it. Look at body composition, look at your overall health, look at what you're able to accomplish and, like I said, if you can climb Mount Kilimanjaro, whatever your BMI is, it's working for you. Yeah, all right, so let's move into the economics of obesity segment. We're going to talk today about the WeGoV coupon, and this is a little bit of an extension, because we talked about the shortages last week and the WeGoV is more available right now than ZipBound. So let's just talk briefly about this coupon, and it's very similar to the ZipBound coupon that's out. So they offer up to $225 of savings off of your copay. We see patients have $100, $200, $300 copays for these medications, or they may have a deductible of $3,000, $5,000. And so the first time they go, it can be very expensive and so they can save up to $225, which is, you know, you can save a real amount of money, and there's a lot of patients who get these medications using these cards for 25 or $50 a month, which is amazing. The other thing is is that it can be used for cash pay patients as well. So if you don't have coverage and we're seeing fewer and fewer commercial plans with coverage we're seeing that you can use this for up to $500 of savings, which will bring the price per month to about $600 to $700, depending on what your pharmacy prices are at. You may want to shop this around, because you could find significantly different prices from pharmacy to pharmacy, and I think the most important thing and the most common limitation we're going to see is that if you have a Medicare plan or a Medicaid or in the state of Arizona, we call it Access or VA or Tricare or some federally funded healthcare plan then this coupon cannot be used, and so what we see honestly which it always ends up being a little bit crazy to me is like we see patients who have commercial plans and they can get this med for $600 or $700. But if you have Medicare and receive funding from the government for your healthcare, well now the price is $1,100. And so it doesn't necessarily make a lot of sense, but there's rules and regulations for why that is.

Dr. Weiner: 30:43

I think because there's such a significant shortage right now of ZEP bound. We are seeing some patients to kind of bridge this gap and get through this time of shortage, switching over to WeGoV. For the time being and again we've talked about this there's a time for you to kind of be aggressive with your weight loss and there's a time for you to circle your wagons and just work on weight maintenance. And right now is that time to just work on weight maintenance because it's so hard to get these medications. And so we see that if you're on ZepBounce of 7.5 milligrams or higher, you probably can make the switch over to the 2.4 milligram dose of WeCoV, which is widely available. Again, this is something you should work with your provider on and make sure that they agree about making this shift.

Dr. Weiner: 31:30

But it is an opportunity if you're having trouble getting ZepBound and you're at a higher dose, because ZepBound we've only got the 2.5 milligram dose available. So if you're on a higher dose of Zepbound, you're out of luck right now, unless you get lucky and find the drug in a local pharmacy. But if you're on that higher dose, you can switch over to the WeGoV and we do see wide availability the 2.4 milligram. So that is a reasonable thing and we are working with patients on that, and that WeGoV coupon is going to make that much more affordable. You would have to go through a whole other prior auth, which is a big pain in the butt, but you got to do what you got to do right now. All right, sierra.

Lynsey: 32:08

Question time.

Zoe: 32:09

Yep.

Dr. Weiner: 32:09

Question time.

Lynsey: 32:10

All righty. First question here is from Amber. It says Zoe, what about these? Drink Poppy probiotic sodas for a fun treat, Gave up soda and enjoy LaCroix water now, but was wondering if Poppy is any good.

Zoe: 32:27

Well, I saw this question when we were preparing our podcast today, and I have been seeing Poppy all over the place.

Dr. Weiner: 32:35

So I've seen it on social media.

Zoe: 32:35

I've seen it in Sprouts and I have been seeing poppy all over the place. Okay, so I've seen it on social media, I've seen it in sprouts and I have never tried it, so I picked one up for us Right. So I think the pack first of all One glass.

Dr. Weiner: 32:49

I want to have some.

Zoe: 32:50

Well, that's for you, I'm going to drink it out of the can.

Dr. Weiner: 32:51

Oh, you're going to drink it out of the can. Okay, all right, all right yeah.

Zoe: 32:54

Yeah, don't worry, I got you. So I just first want to talk about okay, it's being kind of marketed as a prebiotic soda, and do you remember a couple of I don't know what podcast? It was a while ago? In a podcast we were talking about the difference between prebiotic and probiotic. So prebiotic being the fiber rich foods that feed the probiotic, meaning the good bacteria. So, um, not the prebiotic soda, not to be confused with a probiotic, something like kombucha, right? So first off, I want to applaud you for eliminating soda, because I think that's amazing. But I wanted to go ahead and look at the nutrition facts. So this has a 5% fruit juice, 20 calories. There are 4 grams of added sugar and 2 grams of fiber.

Dr. Weiner: 33:37

Okay, so does the fruit juice count as the added sugar, or did they add sugar on top of the fruit juice?

Zoe: 33:41

So it's sparkling water. Organic cane sugar, organic apple cider vinegar.

Dr. Weiner: 33:46

It's organic Zoe, so it's okay, right, so much healthier.

Zoe: 33:49

Apple cider vinegar. So that's kind of one of those also health halo foods, especially in something like this. The only thing the apple cider vinegar is going to do is give it a specific taste. It's not like you're going to get any of those probiotics in there with it. Lime juice, agave inulin so the agave inulin is your fiber source and then we've got lemon juice, stevia and ginger extract. So if we're comparing four grams of added sugar to a regular soda, it seems like a pretty good swap Right.

Dr. Weiner: 34:20

Was it like 20 grams in a soda?

Zoe: 34:22

Oh gosh, I would think yeah, like that much. But then you know, a diet soda has a huge long ingredients list.

Lynsey: 34:30

Right.

Zoe: 34:30

Maybe there's zero added sugar, but it's full of artificial sweeteners, so I don't know. I figured we'd give it a little test. Let's taste it. Cheers I actually really like it.

Dr. Weiner: 34:46

I do too. So, let's think about yeah, it tastes good, yeah, it tastes really good. It's kind of like Fresca Remember Fresca?

Zoe: 34:52

I do remember Fresca Ginger lime it's kind of like a virgin Moscow mule. Ruska Ginger lime it's kind of like a virgin Moscow mule, anyway. So a lot of things I talk about in the nutrition program is about how so much in nutrition falls on the spectrum, right. So over here on the spectrum maybe we have our fully leaded Coca-Cola full sugar sodas and over here we have LaCroix sparkling water, right, right. So then maybe the first swap might be diet soda and then the next swap might be something like this, and then the next swap might be dropping some fruit into your LaCroix and then you got your sparkling water. So I don't know, I think if this is every once in a while as a special treat, I'm happy with four grams of added sugar. I think it's quite tasty.

Dr. Weiner: 35:39

Yeah, no, I think it's pretty good.

Zoe: 35:41

I would not say it's like a healthy food. The two grams of fiber you're getting here is not like the beneficial fiber that we get from vegetables and fruit, but as a little tasty every once in a while treat, I'm happy with it.

Dr. Weiner: 35:54

Yeah, and I think inulin they've shown to to to help stabilize your blood sugar, um, kind of like metformin E a little bit. In terms of um, I'm helping with that, which which does help with weight loss. So, yeah, I think I think your point of of this being somewhere in the middle of the spectrum is right.

Zoe: 36:11

On Um, I don't know that the second ingredient is still sugar, so let's just be real.

Dr. Weiner: 36:17

So, yeah, I think there's a lot of times these foods are like how do you view them? So someone who views this and says, well, I'm going to drink a six pack a day because it's healthy, that's not at all what we're saying. Someone who says, hey, listen, once a week I might have one of these as a refreshing treat on a Friday night to just kind of relax. Okay, right, right, yeah, all right. What's our next question, sierra?

Lynsey: 36:40

Okay, next question is what if you had a gastric sleeve, regained all the weight, have GERD and would like a revision under traditional Medicare with the G supplement? Would that be covered?

Dr. Weiner: 36:51

Absolutely yeah. So when you have a sleeve and the primary indication is heartburn, then we have no problems getting it covered, right? I mean truthfully, sierra should probably be answering this question more than I am, so, sierra, please correct me. We have no problems getting these covered. What about for weight regain? Can we get with Medicare?

Lynsey: 37:13

Much. I don't know that we've ever tried that. Yeah, we always. It's definitely more difficult, like across the board, with different insurance companies, to get this covered.

Dr. Weiner: 37:24

There's a number of insurance companies where, if it's weight, regain no right yeah, you know.

Dr. Weiner: 37:28

And then there's the once per lifetime policy as well, which is which is that's a hard no if you've had any surgery and a lot of people think, well, well, I had a different insurance when I had that first surgery. That doesn't matter, they don't cover any revisions. It's not that they're only going to pay for one for you, it's that you can only have one in your lifetime, whether you had it under a different insurance policy or not. But when we're doing a sleeve for treatment of heartburn, the diagnosis is heartburn and I would urge you to go back a few episodes where we talk about how diagnosis matters when it comes to insurance approval. So if you submit this as a morbid obesity, a weight loss surgery, then you're going to have a lot of you're going to get a lot of pushback, and if you submit it as a heartburn surgery, then it generally passes right through, and I really can't think of anybody. We've had a lot of issues getting our sleeves to bypasses covered. Would you agree with that, sierra?

Lynsey: 38:27

I would agree.

Dr. Weiner: 38:28

Yeah, you're closer to it than I am, but I don't see that happening. So, yeah, I think if heartburn is the indication, then that's what you should do. And again, just getting back to what we recommend, if you've had a sleeve and regained weight and have significant heartburn, we generally recommend converting to a gastric bypass. You have to understand all the things that come with a gastric bypass, but if that works for you, then that's generally a good approach. Some people will lose a lot of weight. Some people lose not so much weight with that surgery. If weight regain is the only thing that you're targeting, then we've seen more reliable results with the GLP-1 meds. Of course, with Medicare you're not going to be able to use a WeGovi coupon. Medicare doesn't cover any of these meds, so that we get into this major caustic issue. But if we're just looking at the clinical algorithm, then for weight regain alone, without heartburn, I would recommend trying the GLP-1 meds.

Lynsey: 39:24

Okay, and the last question is from Cassie, through our website. I am seven years post gastric bypass and have mostly kept off the weight, but I still have a BMI of 36. My appetite is definitely back. I have bouts of low blood sugar for a while now and they seem to be worse than starting Moonjaro to lose additional weight. Should I stay on Moonjaro? Are there additional medications I could take? Can you suggest any changes to help avoid or limit the low blood sugar incidence going forward?

Dr. Weiner: 39:54

Zoe, why don't you talk about nutrition for low blood sugar? I know we've covered this in the past, but I think going over it again because we hear about this so frequently.

Zoe: 40:03

Yeah, absolutely. So what we want to avoid is your blood sugar going on a roller coaster, right. And so what happens is, if you experience a low blood sugar, what a lot of people are told if they are diabetic or something like this is, oh, have a little bit of soda or have a little candy so that it brings your blood sugar back up, and then you have that spike and then you drop again, and that's what we want to avoid. So, in order to avoid that, we want to have these small, frequent mini meals like we were talking about before, with protein and fiber, so that your blood sugars kind of stay doing this nice little wave within a normal range, so you don't get too low and you don't get too high.

Dr. Weiner: 40:50

I think when it comes down to the medications and other things that you can do to help stabilize your blood sugar, initially there was some talk and I heard much more about Ozempic for the use of hypoglycemia. I will tell you I have not seen that to be particularly effective. In fact, what I'm seeing is what Cassie's talking about, which is that it makes it worse, and we see hypoglycemia in our mongiro patients. We've had a few patients who had to stop it because they kept getting too hypoglycemic. So people respond to these medications differently.

Dr. Weiner: 41:22

But the idea that these GLP-1 somehow stabilize your blood sugar, I'm not seeing it and I'm not really buying that as an indication. I don't think the insurance companies are buying it either as an indication, and so I'm not aware of any really compelling evidence. I've heard people mention it and talk about it anecdotally, but I haven't seen any good science to back up the use of these medications for treating reactive hypoglycemia. I think the first step is to work with Zoe and focus on beans and greens and protein with every meal and things that are going to prevent the spike, so that you don't get that over release of insulin, and a lot of times reactive hypoglycemia is really a sign of someone kind of slipping on their diet a little bit, and so it's time to really focus and get back and I put yeah.

Zoe: 42:08

Especially if your appetite is back, and that's something that you're struggling with. That means that we have room for opportunity to work with that hunger without gaining weight back.

Dr. Weiner: 42:19

Yeah, I put people on the metabolic reset diet because I think that's kind of the ultimate blood sugar stabilizing eating plan.

Zoe: 42:25

And appetite suppressant.

Dr. Weiner: 42:27

And appetite suppressant too. However, there is a medication that is cheap and super effective at treating reactive hypoglycemia. I've been using it for 10 years and it's called A-Carbose and A-C-A-R-B-O-S-E. It costs like $14 a month or something, and the 25 milligram dose is super effective, and almost everybody that has come to me with hypoglycemia that I put on this medication has had significant improvement. When we couple the A-carbose with an improved diet, we can almost always get this controlled. So the medication that I use is A-carbose. I've been using it for 10 years. It really works like a charm.

Dr. Weiner: 43:14

I think the final point I would make is that alcohol use can also cause some of this reactive hypoglycemia. So we've talked a lot about probably not as much on the podcast as we should but alcohol use after a gastric bypass is it's a problem. It's one of the weaknesses of the surgery. I advocate zero alcohol consumption after a gastric bypass because about 4% of people develop alcoholism, and alcoholism is a terrible, awful problem. You lose all the weight but become an alcoholic, and this is not a success story, and so I think the last thing I would advocate in this situation is complete avoidance of alcohol. All right, that wraps up our 25th episode. All right, that wraps up our 25th episode.

Zoe: 44:12

This podcast is produced by Sierra Miller and Rhiannon Griffin and the editing is done by Autogrow. Special thanks to our guest Lindsay, and again, props for climbing Mount. You'd like us to answer next time or in a future podcast? Definitely submit it to us over on your favorite social media platform. We're on all of them Instagram, facebook, tiktok, youtube. You can submit it on our website. So definitely shoot your questions over and give us a follow so you can stay updated on everything. So we really look forward to seeing you next time.

Dr. Weiner: 44:38

You're not going to see him next time. You're not going to see him next time.

Zoe: 44:39

I'm not going to see you next time. I'll see you next time.

Dr. Weiner: 44:42

Zoe will be on her honeymoon next time.

Sierra: 44:44

I'll see you sometime.