The Pound of Cure Weight Loss Podcast
Ablation Conflation and Healthcare Inflation
Episode 26 of the Pound of Cure Weight Loss Podcast is titled, Ablation Conflation and Healthcare Inflation. The title comes from our In the news segment where we discuss an article from Forbes about a new bariatric procedure called Gastric Mucosal Ablation. This procedure uses a laser to burn the Fundus Mucosa. Does it work? And, will this procedure cause long-term weight loss? Tune in to find out!
In our Patient Story, we talk to Barb who is our Bariatric Coordinator. Barb is unique in that she is a Registered Nurse, has worked in the industry for decades, and is also a bariatric patient. She started with a lap band which was revised to a gastric bypass and is now on GLP-1 medications to help control her weight regain.
In our Nutrition segment, Deidre talks about the benefits of walking after eating. This is especially good for bariatric surgery patients but also aids in digestion for those who haven’t undergone surgery.
In our Economics of Obesity segment, we talk about what to do if you need bariatric surgery and you either don’t have insurance or your insurance won’t cover the surgery. Should you travel to another country where the self-pay costs are cheaper? Dr. Weiner addresses the options for those without coverage for bariatric surgery.
Finally, we answer 3 of our listeners questions including, whether Ozempic could stop working, constipation after surgery, and alternative options for Protein Pump Inhibitors (PPI’s).
Episode 26 of the Pound of Cure Weight Loss Podcast is titled, Ablation Conflation and Healthcare Inflation. The title comes from our In the news segment where we discuss an article from Forbes about a new bariatric procedure called Gastric Mucosal Ablation. This procedure uses a laser to burn the Fundus Mucosa. Does it work? And, will this procedure cause long-term weight loss? Tune in to find out!
In our Patient Story, we talk to Barb who is our Bariatric Coordinator. Barb is unique in that she is a Registered Nurse, has worked in the industry for decades, and is also a bariatric patient. She started with a lap band which was revised to a gastric bypass and is now on GLP-1 medications to help control her weight regain.
In our Nutrition segment, Deidre talks about the benefits of walking after eating. This is especially good for bariatric surgery patients but also aids in digestion for those who haven’t undergone surgery.
In our Economics of Obesity segment, we talk about what to do if you need bariatric surgery and you either don’t have insurance or your insurance won’t cover the surgery. Should you travel to another country where the self-pay costs are cheaper? Dr. Weiner addresses the options for those without coverage for bariatric surgery.
Finally, we answer 3 of our listeners questions including, whether Ozempic could stop working, constipation after surgery, and alternative options for Protein Pump Inhibitors (PPI’s).
If there's an option for profitability, people move into the space and it kind of all works out naturally. Healthcare doesn't allow for that process. Healthcare prices are set arbitrarily and randomly. Welcome to episode 26 of the Pound to Cure Weight Loss podcast, titled Ablation, conflation and Healthcare Inflation. Zoe is not here. She is on her honeymoon so I have brought in Deidre. Many of you in our practice know Deidre. Deidre is pretty much my right hand. I can't really do much without Deidre being involved in it. Somehow. She assists me in the OR. She sees all of our patients preoperatively and postoperatively. She makes sure everybody's prepared for surgery. Our office runs extremely well.
Dr. Weiner:Our patients get tons of support and education and, honestly, deidre plays such a huge role in this. We've been working together for how long now, deidre? I was here before you came here. Yeah, deidre, beat me to the punch. I've been here the whole time you've been here.
Deidre:So over five years. Yes, I've been in this bariatric for almost nine years, now eight and a half years.
Dr. Weiner:Yeah, and we've probably done what.
Deidre:1,500 cases together, yeah at least a lot cases together. Yeah, at least a lot, A lot of cases Not including the revisions and the emergency cases.
Dr. Weiner:Yeah yeah, I think a lot of people think, oh, dr Weiner, he's a surgeon, here's. What you don't know is that I'm not that good if Deidre's not around, like it takes two people. She knows every step, she kind of can read my mind a little bit in the OR and that makes it so that I don't have to think quite as much.
Deidre:All right. She says the mind is very important in the OR. Yeah, Nobody's, you know each of us not perfect together much better.
Dr. Weiner:Another little thing about Deidre she's the only person to ever call me Matt, which I actually like. That's one of my things I'm kind of working on. I want everybody to call me Matt instead of Dr Weiner that I work with.
Deidre:I was in the operating room before I became a nurse practitioner. I was a nurse in the operating room and, like, the very first thing I call you when I meet you is what I'm going to call you for the rest of your life. And so you know, an operating nurse can't call a doctor, matt, you know.
Dr. Weiner:But you can now. It's been whining.
Deidre:from the beginning and probably forever, she's called me mad every now and then.
Dr. Weiner:The other thing Deidre is is she has absolutely no problem telling me I'm wrong and telling me that she disagrees with me and also that makes her so valuable. Like that's not, that is not a downside. Like I need people to keep me, somebody has to do it.
Deidre:Yeah, it's a big job right? Yep, I don't like being a devil's advocate, but it's necessary, yeah, so anyway.
Dr. Weiner:Well, welcome Deidre. We're going to have a good time hosting these next two podcasts, so let's move into the news. This segment is from Forbes and it's called what to Know About New Minimally Invasive Weight Loss Procedure Gastric Mucosal Ablation. So we see this. What?
Deidre:every few months, something new comes out, a new procedure that's minimally invasive, that's going to cause weight loss without surgery, right.
Dr. Weiner:The balloon Right.
Deidre:Do you remember that?
Dr. Weiner:sheath that you would put over the first portion of the duodenum. That thing was a disaster that caused like all kinds of perforations.
Deidre:Not a good idea from the very start.
Dr. Weiner:The hooks would penetrate into the blood vessels and cause massive bleeding.
Deidre:Seems like a good idea, you know minor problem.
Dr. Weiner:So this was a study they did on 10 female participants. The average age was 38. The average BMI was 40. So these are people who would qualify for bariatric surgery and they perform what's called endoscopic mucosal ablation.
Dr. Weiner:I actually do quite a bit of endoscopy in my practice. I think as a bariatric surgeon you kind of have to be good with the endoscope. We use it in the operating room a lot. When things are tricky, when we're doing these complicated revision procedures, kind of being able to look from the inside can be very helpful to figure out what's what. And so what they do in this procedure is they put a scope, they put you to sleep, they put a scope through your mouth. It's an outpatient procedure and the first thing they do is they do a saline lift, so they inject saline kind of just underneath the lining, and what that does is it protects all the tissue beneath the stomach lining. And then they use something called an argon beam, which is a laser, and they burn what's called the mucosa, which is just the lining of the stomach, and so they do it only in the fundus, that's the portion of the stomach that we remove during the sleeve gastrectomy, the part that stretches, that allows you to eat past your portion size.
Dr. Weiner:Exactly Right. And so they looked at weight loss outcomes and they showed 8% total body weight loss. What do you think about?
Deidre:that. That is. I mean 8%. That's nothing.
Barb:Nothing yeah.
Deidre:Not impressive yeah.
Dr. Weiner:Not so impressive At six months.
Deidre:Yeah, even less impressive 18 pounds on average. But they did decrease ghrelin production by 45%. Well, because ghrelin is produced in the fundus. So you're blunting that production until the mucosa goes back, which is what every.
Dr. Weiner:Week or two.
Barb:Yeah. So, it's not going to last very long.
Dr. Weiner:They may damage it and it might take longer than a week or two, but your gastric mucosa turns over very, very quickly and they decrease hunger cravings by 43%.
Deidre:Which makes sense because you're not producing ghrelin, but I mean, these people are going to gain all the weight back. Yeah, there's no way that that's going to be long lasting.
Dr. Weiner:No, I agree, Not impressive, no yeah.
Deidre:I mean diet and exercise alone. 5% to 8% weight loss right.
Dr. Weiner:Absolutely, Absolutely. To me, this is equivalent to nutrition, and my hunch is is they also had these patients make some nutritional modifications. So we might, just we may. They didn't talk about placebo, but really to do this study, especially with such modest weight loss, you would need a placebo group.
Deidre:Well, they only had 10 patients.
Dr. Weiner:Yeah, and the article talks a lot about the lap band. So you know any article to me that talks a lot about the lap.
Deidre:That's a warning sign, that's a red flag.
Dr. Weiner:Right there there's not a lot of research being done I mean I haven't put a band in in 10 years uh, there's not even that many out there. It's definitely fallen out of favor for sure how often do you see a patient with who still a band in? I saw one today actually.
Deidre:Yeah, I mean occasionally, because we do band adjustments, but I mean Not a lot yeah.
Barb:Not as much as we used to.
Deidre:Not very many people put in new bands because they're just. They're not great in the long term.
Dr. Weiner:So yeah, to me that's immediately suspect. I think we know what the story is with a band and in my mind, any provider who's still putting in bands is doing it for their own benefit, not the benefit of their patients. Yeah, so the other thing is that this is totally not applicable to bariatric surgery patients, right? How can you ablate the fundus after? A gastric bypass or a sleeve you can't.
Deidre:There is no fundus after a sleeve Right.
Barb:And after a gastric bypass there still is a fundus, but it's no longer connected.
Dr. Weiner:Right, it's no longer connected. So, deidre, let me ask you a question. Do you know another term for mucosal ablation?
Deidre:Yeah, an ulcer, an ulcer.
Dr. Weiner:An ulcer right An ulcer is a wound in the mucosal lining.
Deidre:Yeah, so it's the same thing.
Dr. Weiner:So they're essentially inducing an ulcer. Seen it and, quite honestly, they mentioned the lap band and I think that's something that I saw a lot of times. Um, with a band is that people get sick right it's too tight vomiting esophagitis, just really, and so they lose a lot of weight. But illness causes weight loss, right?
Deidre:they're miserable in the process.
Dr. Weiner:Yeah, and then as soon as you resolve that illness, then people gain weight back Because they can eat again but it's not real weight loss, it's not set point lowering weight loss.
Deidre:Yes, absolutely, it's punitive weight loss. Weight loss is punishment, exactly.
Dr. Weiner:And so my concern is that that's where this is, and I think the final thing is you know, there's an industry behind this, I mean if they're talking about the weight band, there definitely is. So there's the Argon Beam Maker is who sponsored the study, of course, yeah. So there's a company that wants to sell more Argon Beam machines, and so that's where this is coming from. So I think you know this one to us. I think I don't know. I'm giving it a thumbs down.
Deidre:Yeah, definitely Double thumbs down as a future weight loss.
Dr. Weiner:I think this one's not quite as good of an idea as the balloon. Anyway, All right Well yeah, so this in the news segment, I think, didn't make the cut for something that we're going to see a lot in the future? No, definitely not, but I think it's important too, as you look at these new treatments. Just because it's new Doesn't mean it's better.
Deidre:Doesn't mean it's better. You have to look at it critically. What are the long-term side effects?
Dr. Weiner:In medicine, new is usually worse.
Deidre:Well, because it's untested, untested, it's untested in the long term.
Dr. Weiner:The things that are still around have really been proven. It's in the test of time.
Deidre:Yeah, still around, have really been proven. So the test of time, yeah.
Dr. Weiner:And that fact is lost on a lot of people, and there's a lot of surgeons out there and a lot of other manufacturers out there like I want to do the new thing. The new thing is going to be better. We're going to brand it. Everybody wants to get in on it and we've seen that time and time again. I mean, the world of bariatric medicine, both on the medication side and on the surgery side, is just littered with failures.
Deidre:Yes, I mean. I think the gastric bypass is the perfect example, which is the surgery that stood the test of time right. It's the most effective long-term.
Dr. Weiner:All right. Well, let's move into our patient guests. We've got Barb here. Barb is actually our coordinator at Tucson Medical Center, tmc, which is where we do all of our surgeries. Coordinator at Tucson Medical Center, tmc, which is where we do all of our surgeries, and she's really a bariatric veteran in many senses of the word. Right, yes, so, barb, why don't you just kind of share how you first got interested in bariatric surgery and where this all started, with you as an individual, but also as a nurse?
Joel:Personally, I chose to have bariatric surgery in Mexico.
Deidre:Interesting. Oh, that is interesting. Wow, how did I?
Dr. Weiner:not know that Insurance coverage Exactly. So tell us that story.
Joel:I went to Mexico for a lap band.
Dr. Weiner:So first of all, you're a nurse.
Joel:I am a nurse.
Dr. Weiner:You were a nurse at the time of the lap band.
Joel:I was a nurse at the lap band, but we're talking 10 to 12 years ago, absolutely when coverage was scarce, right.
Dr. Weiner:So the band was 10 to 12 years ago.
Barb:At least. At least I was going to say probably more yeah, maybe more Probably 15 years yeah.
Joel:So I went to Mexico and paid cash for it, right?
Dr. Weiner:Zero coverage at the time, and what was the price in the US?
Joel:Probably, maybe $12,000, $15,000. In Mexico it's $5,000.
Barb:Yeah.
Deidre:Which I mean. Compared to a bypass and sleeve, that's almost the same price, so it's significantly more in the US than in Mexico. You can get a sleeve now for that cost, right. Slightly more than that, right.
Dr. Weiner:So 20 years ago. That was a lot. The device was what was expensive. The BlackBand was like three or 4,000 bucks, Right. So you went down to Mexico.
Joel:What was?
Dr. Weiner:that experience like.
Joel:The hospital had armed guards. It was in Tijuana. Outside of Tijuana we were picked up at the airport and transferred down to the hospital and then transferred back. The coverage that's part of the disappointment. Part is getting follow-up maintenance for your band.
Deidre:I was going to say was there any follow-up at all? So where did you have to have adjustments at here in town?
Joel:So that was left to my own devices and fortunately, because I am a nurse, I knew who to call whom to call. I found someone that came out of the White Mountains that came down to Mesa every month, wow. She would do the adjustments in the office. And if it was too tight, you were kind of out of luck until the next time she came.
Deidre:Sorry, you have to vomit until we see you again. Geez, sorry, you have to vomit until we see you again.
Dr. Weiner:I don't think a lot of people really understand the beginnings of bariatric surgery and how different things are now. I think you probably understand that better. So you had this lap band and it sounds like not the best experience. Did you lose much weight with it?
Joel:No, I only lost about 20 to 25 pounds. And then I started having complications nausea and vomiting, inconsistent management Right, my receptors were always elevated. I don't markers.
Barb:Yeah.
Joel:Markers, so I ended up going for consults for consideration for bypass and my insurance denied me. Yeah.
Dr. Weiner:Yeah, so you didn't have coverage to begin with. Did they deny you because they wouldn't cover bariatric surgery? Did they deny you because of a once per lifetime clause?
Joel:They deny me because of non-covered benefit.
Dr. Weiner:Okay, so you don't have coverage. At this point they say bariatric surgery is an exclusion, correct. So what'd you do?
Joel:So I dealt with it for maybe a year and a half.
Dr. Weiner:Kept the band in.
Joel:Kept the band in yeah. And left it. I was miserable during that time, uh-huh yeah and left it with no adjustments.
Dr. Weiner:Right, that's probably the best thing to do Constantly had GERD treatment for it.
Joel:Eventually I ended up with aspiration pneumonia, yeah, so that was my saving grace.
Deidre:Unfortunately, I had to get sicker before I could even be.
Barb:You had to have a medical complication before.
Dr. Weiner:So the diagnosis of aspiration pneumonia is what, and and we've we've actually talked about this on the podcast how important. On revisions, diagnosis is correct. When the diagnosis is further weight loss, they're like, sorry, correct. But when the diagnosis is GERD and aspiration pneumonia, and they're like, oh, we just paid forty thousand dollars for treating a pneumonia for this hospital stay all of a sudden right all of a sudden. Maybe we'll cover this. Yes, so you got pneumonia, and then that allowed you to leverage a different diagnosis.
Joel:With the insurance companies. And I still took a letter or two on my behalf writing the letters. I had esophagitis, I had the GERD. We had to send in the data, the EGD and the labs.
Dr. Weiner:Yeah. So what was your weight before you were banned? 300. So you got down to like 280, 275 ish, right, and then you ended up having a gastric bypass, correct? And that was that was a while ago, still right yes, more than 10 years. More than 10 years ago and so how was that experience? Wonderful yeah and you had that here in the.
Joel:You had in it at Banner.
Dr. Weiner:At Banner.
Joel:Okay, banner here Banner in Tucson.
Deidre:Banner in Tucson.
Dr. Weiner:Okay, oh, that's right, galvini did it. Yeah, exactly Got it. Okay, so you have a gastric bypass and it goes very smoothly, and it's a revision gastric bypass, right, it's band removal and conversion to gastric bypass. And so how much weight did you lose from that?
Deidre:I lost another. I would say 70 pounds. I was about 190. Okay, actually that's good for revision. Yeah, because you're also. You're quite tall.
Dr. Weiner:Yes, yes, yeah. So so you get down to 190. That's a fan. You're probably loving that way yeah, is that like?
Joel:it? Was that your high school weight? I actually won 70s with my high school a little bit A little bit over your high school weight, but not much.
Deidre:That's very impressive yeah.
Dr. Weiner:And really you're 110 pounds down from your heaviest weight.
Joel:Yes, right, more so now, and then COVID hit.
Barb:Yep.
Dr. Weiner:So before well, covid hit and that's when we started working together. Yes, it was right at the beginning of COVID. So we had a real kind of switcheroo at the hospital and that's when I became the medical director of bariatric surgery and we didn't have a coordinator and I knew, especially because of some of the things that had happened there in the past, that we needed a quality person. We needed someone who was experienced and we put out the feelers and Barb kind of limped in.
Deidre:She's like I've heard some things about the hospital.
Dr. Weiner:I'm like well, here's how things are going.
Deidre:We're going to do things a little differently.
Dr. Weiner:We're going to follow our outcomes every single month. We're going to talk about them, we're going to discuss them and we're going to make sure that we have the lowest complication rate in the country. That is our goal and we've gotten pretty close to that, I mean we've really moved in that direction very much.
Joel:I'm very impressed, thank you.
Deidre:But a lot of that was your leadership at the hospital. Yeah, Setting up the program is so important. Having the nurses know how to take care of our patients, setting up our before and after surgery protocols I mean all of that plays into like what incredible success rates we've had.
Dr. Weiner:That's the most. It's such a team effort, it really is. You know I mean the nurses on the floor, the.
Barb:OR team. The OR team is so critical.
Deidre:And you know, Barb even gets to know them a little bit through this. Yeah, really just care from beginning to end.
Dr. Weiner:And so talk to us about where you were in your bariatric journey. At that point You're about seven or eight years out.
Joel:And I started to regain a little bit.
Dr. Weiner:So so about seven or eight years from surgery, covid hits Right. Anything else contribute to that weight regain? Or you think it was just COVID, the timing, or Life, life, life, life, and we manifest the self and poor behaviors on my part.
Joel:Yeah, so that's when I consulted with you.
Barb:Right.
Joel:And I do have some challenges, but we decided to do meds.
Dr. Weiner:Yeah, I think we originally didn't we talk a little bit about revision surgery? We did, and I said no, yes, yeah, yeah.
Deidre:Truthfully, the success rate of the GOP1 medications after bariatric surgery is even greater than before bariatric surgery. You probably have lost more weight using the medication than you would have with a second revision.
Dr. Weiner:You're right, oh for sure, definitely how much weight. So how much weight? So you're down to one 75. So you're five pounds over your high school graduation weight, correct?
Deidre:Yeah, that's great.
Dr. Weiner:That's awesome, it's so awesome.
Joel:At retirement age. At retirement age yes.
Dr. Weiner:Barb is retiring and she's kind of working part-time now, and so how much weight did you lose with the medications?
Joel:I think we started at 225 and I'm down to 175, so 15 pounds, yeah, and you're 15 pounds lower than your lowest post bariatric surgery weight. Easily yeah.
Dr. Weiner:So, so this is also exactly where the combination therapy comes in right, and it is the surgery, is the medications together, and it is also the nutrition and exercise and lifestyle components as well. And so Barb's put every one of those pieces together and she's had a you know, you kind of have like the quintessential lifetime experience of treatment, right.
Deidre:Going from band to bypass to meds.
Dr. Weiner:I mean that's yep, you're such a good coordinator because you've kind of experienced it all on the nursing side and also experienced it all on the individual side. Yeah, and I think that that really is is makes you, that's what makes you so effective is that you know when you're talking to our patients, you know exactly where they are. Um, but you're, it's been a journey yes it's been a journey, and so what medication are you using now?
Joel:well, because I'm on medicare, I'm not eligible for any medication. Oh no, there's no coverage.
Deidre:Yeah, this year, as of January 1st, no Medicare, medicare Advantage plans.
Dr. Weiner:So are you off the meds?
Joel:I stopped them probably seven months ago.
Dr. Weiner:And you've been able to maintain your weight.
Joel:I gained 10 back, but I've lost five. Okay, so I'm trying to use my behaviors modifications and working towards that.
Dr. Weiner:I think that's going to be that's something we're also seeing is that a history of bariatric surgery makes you a little more flexible in term when we stop the meds. You know when I'm thinking about a lot of the patients who we have and I think we've had people on the podcast in the past where they're on monthly dosing as opposed to weekly dosing. A lot of them are post-bariatric surgery patients and we're looking at this in our own database that there's definitely some synergism between these medications and the surgery and we're seeing better responses. We're seeing a little bit more durability of the medication induced weight loss and I think for you, what you may find is that you may once a month or once I sorry, once a year have to take a couple of doses of the med just to kind of really pull it back a little bit right and and that might be your journey in terms of weight maintenance, but it sounds like you've been able to tolerate stopping the medications quite well.
Deidre:Yeah, yeah, we do see like a rebound weight gain of about five to 10 pounds just because of the withdrawal of the hormone. That's pretty standard. But with nutrition and, you know, maintaining good dietary behaviors, you were able to lose that weight you gained and then maintain it. So yeah, that's great.
Dr. Weiner:Yeah, so is there anything else that you want to share? I think we've talked a lot offline about health care affordability.
Joel:The affordability for individuals. The marketplace is not a good option for people. They need to understand that when they're searching Right, they need to use liaisons with their employers. That if their employer doesn't carry bariatric benefits, they need to rally together.
Deidre:Right Advocate for those Advocate for those I have seen some success stories with that. Believe it or not?
Dr. Weiner:Yeah, that's really when you have a bariatric exclusion and for you it kind of got pushed through as a revision. But if it's a first time surgery, if you have an exclusion I've never seen an exclusion overturned. Have you seen that where my employer doesn't cover it and the insurance company overturns it, you can get the employer to overturn it, but never the insurance company, where United says oh, you have an exclusion.
Deidre:Yeah, I have not seen that. Oh, but we're going to prove it anyway. I've never seen that. Um, it's the employers, right, that's where the decision is turn here.
Dr. Weiner:And they speak to their hr department and work that way they'll do a one off yeah an individual case yeah, and you know, when we look at health care affordability in every other space, as technology ages we tend to see it come down in cost and as competition enters the market we see reductions in costs. And that's generally how a market works and we all kind of at some point have learned about supply and demand right. Supply goes down, price goes up, demand goes up, price goes up. These market forces just kind of change the prices and affordability and over time if there's an option for profitability, people move into the space and it kind of all works out naturally. Healthcare doesn't allow for that process. Healthcare prices are set arbitrarily and randomly and that results in bariatric surgery costing $38,000 when it's paid through your employer, through UnitedHealthcare, and then a self-pay price somewhere is $15,000. And Mexico is $6,000 in ambulatory surgery. You get all these kind of crazy prices and the health insurance payments don't line up with the rest of the market forces.
Deidre:Right.
Dr. Weiner:And that's really unfortunate, and that's a huge component of it. The underlying problem is that the bodies that are determining the prices, which is the insurance companies, right.
Dr. Weiner:UnitedHealthcare is the ninth largest company on the planet. They set the prices, which is the insurance companies right. United Healthcare is the ninth largest company on the planet. They set the prices. This is what they're going to pay, and they're kind of like Walmart used to be, maybe still is, I don't know but they set the prices. The higher the prices, the more money United Healthcare makes and they get a portion of the healthcare expense, and so for a long time, we've just had very little incentive for the insurance companies to set the prices low.
Dr. Weiner:And so that's why we're seeing what we're seeing. So there's so much room for improvement in healthcare affordability. But, barb, I think your story, your journey, it really illustrates to me what it takes to successfully battle obesity. And you've really, you're there, you've kind of accomplished it.
Dr. Weiner:And I think the other part of that is that you still have some obstacles ahead as you kind of wean off the medications and dealing with that affordability and and I think that's to some degree true for everybody who struggles with obesity is that there is no moment where you get to say I won, I'm done, I can relax Right.
Deidre:I don't feel that way ever, yeah, your experience has allowed you to be your own advocate through this whole journey and you're going to have to continue to be your own advocate now that you are not going to be able to get the medications through your insurance company anymore, and there's things that patients can do, but they have to have the initiative and the knowledge.
Dr. Weiner:Yeah. And somebody to help them along sometimes, I mean look at Barb as an insider in the whole situation and she still struggled and ended up in Mexico for crying out loud, and so if someone like you is having to go through that, what hope do the rest of us have? You know Right so well. Thank you so much for sharing your story. I think so many important and interesting things.
Deidre:No idea, it was all of that.
Dr. Weiner:Crazy. Yeah Well, thank you, barb, we really appreciate you being on and honestly, it has been such a pleasure to work with you all these years I take a lot of pride in our bariatric program.
Dr. Weiner:I think Deidre does as well, and um and and you're, you're, you have played such a huge role in making it, you know what it is. Yeah, no question, so so we wish you so well in your retirement and we know you've trained Amanda up very nicely and that she's going to fill in and take over and do a great job. But we will miss you we will miss working with you Likewise. And you have to make sure you always stop by and say hello, we'll definitely hear from you, thank you, thanks Barb, thanks Barb.
Dr. Weiner:It was so great to hear from Barb. She's just had so much experience in this. All right, deidre, yes.
Deidre:It's your turn Nutrition segment.
Dr. Weiner:Yes, you're replacing Zoe.
Deidre:You're going to do the nutrition segment.
Dr. Weiner:So what do you have for us today?
Deidre:I found a great article and actually a dietician, I read a lot of dietician articles while I was preparing for this so I found a great article about walking after eating. And this is really good for bariatric patients, because something bariatric patients experience in the beginning, especially in the first few months after surgery, is a lot of bloating. They get full very fast Sometimes there's, you know, kind of a hard time digesting. It takes a long time to eat your meals, drink your protein shakes. And I found an article about all the benefits of walking for even five minutes after you eat.
Deidre:Walking decreases your glucose levels. It makes your glucose rise more slowly and fall more slowly, so you kind of maintain a more even blood sugar which, especially after gastric bypass, your blood sugars can be a little bit labile. They can go up rapidly in response to some foods like carbohydrates and fall rapidly, which can not make you feel very good, right, nauseous, dizzy. It can increase the motility for your intestines and stomach. So for when you have to eat very slowly and you can fall very fast, it can be very uncomfortable. Also, you get a lot of gas from swallowing while you eat and that can make you feel very bloated. So walking helps kind of push the gas through, push the food through your stomach and into your intestines and through your intestines so that you're more comfortable.
Deidre:It helps with blood pressure, which is another thing that can be a little erratic after surgery sometimes. So even walking for 10 minutes a day or 10 minutes three times a day, can decrease both your systolic and diastolic blood pressure, which is great. And the most important thing is that it helps with mood, and we see a lot of mood changes after surgery which a lot of people don't expect, just because of the hormonal change in your GI system that's connected to your brain in this gut-brain access right, and so changes in your GI hormones can affect depression. Anxiety, can make it difficult to sleep, can affect depression.
Deidre:Anxiety can make it difficult to sleep and walking actually increases endorphins, increases oxytocin, which is just a hormone that makes you feel really good. And so it can make you feel better. It elevates your mood, it helps you sleep more regularly, which a lot of gastric patients or a lot of bariatric patients after surgery can't stay asleep for very long, so that's really helpful.
Dr. Weiner:I mean, I think there's so many reasons to do that and I think it's actually. Isn't it like an Instagram or a TikTok thing?
Deidre:I mean, I think it's a very popular trend right now. But really I mean it's been around forever right. Your parents used to go for walks after they ate dinner you know, because it makes you feel better.
Dr. Weiner:That's what I was going to say. Is it really? Like you know, I try to do that as often as I can and I just feel so much better when I walk after eating. Yeah, absolutely I think, when it's so tired, you know.
Deidre:And then eating makes you tired. Yeah, that because of the spike in insulin, the drop of insulin, right, you get the reactive hypoglycemia that we don't want to do anything, walk kind of leveled everything out.
Dr. Weiner:Yeah. So if you're looking for some help in controlling your food cravings, controlling your blood sugar, your mood, go for a walk after every meal, all right. So let's move into our economics of obesity segment, and today we're going to talk about self-pay bariatric surgery. Now we heard from Barb who had to go to Mexico to end up getting her lap band and almost found herself in a position where she was going who had to go to Mexico to end up getting her lap banned and almost found herself in a position where she was going to have to go to Mexico for a revision which, yeah, I mean if the primary surgery makes you nervous, I mean revision surgeries.
Dr. Weiner:We've done, you know, probably 500, 600 of these complicated revisions. Together they're hard.
Deidre:They're hard. The tissue integrity is not as great. There's a lot of scar tissue. The complication rate is slightly higher.
Dr. Weiner:And also the long-term care is more important.
Deidre:Absolutely Right.
Dr. Weiner:When we do complicated revisions we're seeing patients a little more frequently in the office afterward and more phone calls. It's just a more difficult surgery. So let's just talk a little bit about self-pay. So first of all, who is self-pay for?
Dr. Weiner:A lot of patients don't think that their insurance will cover bariatric surgery, but 95% of policies will cover bariatric surgery. Whenever someone has coverage for bariatric surgery, that's what they should do. They should not self-pay, they should use their insurance. It just saves them a lot more money and it kind of takes some of the financial stress out of this. Unless you're just fabulously wealthy, then you should just use your insurance policy. And what we find is actually and again, this kind of gets back to what we were talking about with Barb how there's really no market forces in terms of healthcare payments. But when we look at self-publiotic surgery, actually the market is. It makes some sense. So you can go to Mexico and for somewhere between five to 10 grand get a sleeve or a bypass, which that makes sense, because I think we all understand that the safety standards in Mexico are not quite.
Dr. Weiner:Less regulation, right Less regulation, so the safety standards aren't what they are here, and so you're basically saving some money, but taking some additional care, which is which is going to be less right exactly, um. And then there's a big move right now um to to perform bariatric surgery in an ambulatory surgery center, and well, and what that really requires is that you go home that day right, which again no fall care.
Deidre:So you save money but you don't get the benefit of, you know, iv nausea medication making sure you're hydrated If you need to stay extra time. You know you get less. You get less.
Dr. Weiner:Post-operative support. Yeah, I think that first night after surgery can be rough for some patients. It can.
Deidre:We were doing for self-pay patients in another practice.
Dr. Weiner:We were doing it for insurance patients too.
Deidre:Right, well, we would send them home and they would be in the office for IV hydration. Yeah, the next day. Nine times out of ten. The next day, yeah.
Dr. Weiner:So I do think it is possible to do ambulatory surgery safely, but it is a little bit of a rougher experience. We see the price for surgery in an ambulatory surgery center somewhere around $10,000 to $15,000. The other thing about an ambulatory surgery center is they don't necessarily have blood on site. They don't have an ICU and again, that's not. I mean, our patients don't get blood.
Deidre:Those things are rare, but it's nice to be available. Extremely rare If it's necessary. You want to have it there.
Dr. Weiner:But when you need it, you need it, Right, right. And so when you do have surgery in an ambulatory surgery center, that tiny fraction of a percent chance that things go very, very quickly south, that that could. You don't have that backstop that you have in a hospital. And then you know, our self-pay prices are somewhere, I think, around in the $15,000, high $15,000 for a sleeve and mid $17,000 for a gastric bypass, and that's in an actual hospital and that's what we're seeing is somewhere in the $15,000 to $20,000. There are a lot of hospitals that don't have a self-pay price and then it becomes $50,000.
Deidre:There are a lot of hospitals that don't have a self-pay price, and then that becomes $35,000, $40,000, $50,000.
Dr. Weiner:Right, the add-ons, the anesthesia, the facility costs, the billing by time, and so I think if you go to a place that doesn't have a self-pay program, you're going to probably pay twice as much as one who's actually put something together. So when you're looking at self-pay, you got to ask yourself what's included, right? Is anesthesia included, like you said, all of these add-on costs? Is there an overnight stay? What about post-op care? You know in Mexico, no post-op care. Is there nutritional support? All of those things? Our program, we include all of those in our price. We have it set up so, like it's just, this is what you pay and then that's all you pay. We're done, done.
Dr. Weiner:And a big question that a lot of people have is complications. And so what happens if there's a complication? Will your insurance pay for it? Because the price can go from $15,000 to $20,000 to $100,000 like that. Over the years I've had a few patients have some relatively minor complications and we've always been able to get insurance to pay for it. Yeah, especially if you leave the hospital and then come back Many times it's seen as a separate event.
Deidre:Right, it's seen as a separate event.
Dr. Weiner:So usually complications work out. There are some insurance policies you can get that will pay up to $50,000 and you pay like $2,000 or $3,000 for those and those are interesting and I think the problem is if you have to pay, if you have a bad complication, it's going to be a lot more than $50,000 most likely.
Dr. Weiner:So you should have your eyes wide open with this right you know Mexico is the cheapest. You get less of the safety standards. Ascs in the US are going to be a little safer, but you may have a rough night at home and also you don't have that backstop in case of disaster. And then full hospital is the safest option, but also the most expensive.
Deidre:Right, there is some risk involved, so you definitely want to, you know, research all the options and kind of minimize like, do what you can to minimize the risk prior to making a decision this big, so All right.
Dr. Weiner:So let's move on to our questions. From social media land oh, we have Howell here. Media land oh we have Joel here. Joel works in the office and he handles a lot of our workups for our insurance patients, and so if you're one of our surgical patients, you've probably talked to Joel in the past and he's going to read the questions. He's helping Sierra out. Sierra's got some trips planned and she won't be around to help us produce the podcast, so here we go. So, joel, what do we got for our first question?
Barb:All right. So the first question is could Ozempic stop working? After taking for two years, I've suddenly started gaining weight and can't stop it.
Deidre:So what we see with these medications is not that they stop working, but patients build tolerance to the dosage. And how much tolerance and how quickly a patient builds tolerance is based on their response which to the medication, which is many times genetic, right, how you know how good of a fit is the receptor with the protein right, so that they, you know, are they getting the maximum response on medication. I have some patients that after three months they are no longer losing weight on that dose and they have to move the next dose. I have some patients that after three months they are no longer losing weight on that dose and they have to move to the next dose. I have some patients that two years later they're on a very low dose of Ozempic and they're still at their high school weight. So it's very individual on how quickly you build that tolerance.
Deidre:What people don't conceptualize as their weight loss plateaus is that they are still getting some benefit from the medication. They're still getting smaller portion sizes many times they're still getting smaller portion sizes. Many times they're still getting appetite suppression. It helps with their cravings and until they actually have to stop the medication do they realize that it's still having a positive effect. The problem is that the medication itself is not affecting weight loss, it's not causing weight loss, and that's where nutrition really comes into play, nutrition and exercise. If you are going back into those healthy habits, as some of the effects which are present but kind of start to wane they become less effective but are still there you start to slip back into some of those old habits and let the nutrition kind of slide. And that's, you know, usually where weight gain starts to come back and so you have to get back into kind of a set point lowering nutrition plan to help reverse the effects of that.
Dr. Weiner:I think this is really a set point question.
Dr. Weiner:Yeah, I think, if you look at this from a set point perspective it'll make a lot of sense. So let's start talking about bariatric surgery. We see sleeve gastrectomy, nice lowering of the set point from the beginning, but then we start to see the set point creep up and people regain weight 18 months, two years down the road. We see that quite frequently and so we know that the sleeve as a medical treatment kind of causes the set point to shift down and then to slowly go back up. We know gastric bypass causes an even greater set point shift and it tends to be much more stable. But we still see, like Barb talked about, patients start to regain weight at year 8, 10, 15, 20, sometimes never. But that durability of that set point lowering is much better. So the big question I have is what's it going to be for Ozempic and Monjaro, right? We don't know. I don't know that. This is a known answer. I was talking to a patient today who had been on Wegovi for two years and she was still doing exceptionally well in maintaining her weight.
Deidre:I think it's going to be very individual.
Dr. Weiner:Yeah, I think we're going to see a lot of variation. A lot of variation, yes, but so the question is could ozepic stop working after two years? And the answer is it could be. My guess is it's going to take a little longer. I think we're going to see the meds somewhere between a gastric bypass and a sleeve, where we start to see some of the effects wear off. The advantage of a med is you can increase the dose, you can switch to a different drug.
Deidre:So there are options out there you can. You can use two medications together, yeah, but the first step because, again, it's not that it's really stopped working, it's just that the effects have lessened to the point where it's not really giving you the response that you are looking for is nutrition. That's the number one thing you can do to help yourself without having, even if you don't have, coverage for other medications, even if you don't want to be on medications for the rest of your life, nutrition is where to start.
Dr. Weiner:Yeah, I think the final thing to talk about is whether or not there's some other set point raising event going on. Have you started a new medication?
Deidre:that causes weight gain?
Dr. Weiner:Did you have an injury and suffered some muscle loss? Is there processed food addictions and nutritional sliding, like you just mentioned? You know what else could be driving that weight gain besides the Ozempic no longer working? And again this points to the fact that nobody's going to get through this whole obesity thing without having to constantly monitor, adjust and change what they're doing to find success, and so I think this is something that is just going to continue. We're going to be in business, whether we're in the.
Dr. Weiner:GLP-1 business or the surgery business. We're going to be in business for a while helping patients with all of these tools, and I think the more tools we have, the more success we're going to see. Yeah absolutely All right. So what's our next question?
Barb:The next question is from Joan and it says I had surgery a few days ago and I'm really struggling with constipation. What is the best way to treat it?
Deidre:Oh, this is my favorite subject. This subject is near and dear to my heart.
Barb:I love constipation Okay.
Deidre:So it's very common to have constipation after surgery, and there's two reasons why. In the immediate postoperative period in the first week, it's ileus your bowels go to sleep a little bit. With anesthesia Also, for bypass, we are rearranging your intestines and so that causes them to not function as well, won't even have a bowel movement until everything kind of starts to wake back up and function properly. We do prescribe Miralax after surgery, which is fine to use until you are it's as needed, though. So once you start having regular bowel movements, you can stop using it. However, a lot of patients will continue to experience constipation for one to three months following that.
Deidre:And that's more dietary You're getting a lot of protein volume, not very much fiber, right, and fiber is what is basically a bulk laxative. It forces the stool through your intestines so that you can have a bowel movement. Without that fiber you just have a lot of hard stool. That's not going anywhere, and so in that period it's still okay to use stool softeners, kind of as needed. There's a lot of research that says that stool softeners are self-limiting. And's a lot of research that says that stool softeners are self-limiting and you shouldn't really take them after four weeks. However, sometimes you, they may be more necessary than we realize.
Dr. Weiner:You got to do what you got to do, but still, we don't want it to be long-term right.
Deidre:The more natural way and what we try to move towards over the first one to three months is using dietary changes, adding fibers to your diet to help with constipation. So the first thing you can do in the immediate postoperative period, when you're in the liquid stage and the soft stage for that first month, is adding fruits and vegetables through smoothies, making protein smoothies with Greek yogurt or Fairlife milk, which is a protein fortified milk, and adding fruits and vegetables to increase the amount of fiber in your diet. You can also do things like beans, which are full of fiber, and other legumes. As you're eating a more regular diet, a more varied diet with more whole food, fruits and vegetables, you're going to see less constipation.
Deidre:Now there's a small percentage of patients after bariatric surgery that continue to have constipation and some of that has to do with your GI system prior to surgery. People have idiopathic constipation and people have IBS with constipation and GI system. You know it's not just about the bariatric surgery. The GI system was there beforehand. And then we can look at prescription medications for constipation like ametizumab and Zest. People on GOP1 medications, especially semiglutide, really struggle with chronic constipation even with high fiber diets, because that's kind of where you want to go. Your cravings tend more towards fruits and vegetables when you're on GOP1 medications, and many times we do have to look at the prescription medications so that you're not on laxatives, osmotic laxatives, especially long-term, because they're starting to show more and more long-term side effects. Yeah, oh, one more thing about constipation.
Barb:You know a lot about constipation.
Dr. Weiner:Hydration, hydration Super important, hydration Super important.
Deidre:And that's another thing. That is, you're always even if you're meeting your fluid goals after bariatric surgery you're kind of relatively dehydrated, because 64 ounces is kind of just what you need to survive. You really should be drinking like 96 ounces or more, especially in the desert. So everybody's kind of always dehydrated and that makes you constipated. Fluid is what helps stool move through the GI, system.
Dr. Weiner:So yeah, I think Deidre pretty much covered everything that anyone would ever need to know about constipation Literally every single day. If you're out there suffering from constipation after bariatric surgery, book a consultation with Deidre, all right. What's our last question here, hoel?
Barb:The final question is from Renee and it says I understand the risk of long-term use of PPIs. What other options are available to patients like me?
Dr. Weiner:All right, deidre, why don't you cover the medication side of this? Besides PPIs, what else works?
Deidre:So there are other types of acid blockers. The most common one that you can get over-the-counter and prescription are the H2 receptor blockers. The most common one that you can get over-the-counter and prescription is are the H2 receptor blockers. We like to use faminidine, which is Pepsid. You've probably heard that Tagament is another example of an H2 receptor blocker. They also block acid, but from a different pathway, from the histamine pathway versus a proton pump pathway.
Deidre:Proton pump inhibitors do have a lot of long-term side effects. We're starting to find, you know, decreased calcium or hypocalcemia because of that, bone fracture, some gastric cancers and now possibly dementia, although that's a little controversial. H2o-ceptor blockers tend to have less long-term side effects and so they have more immediate side effects like bloating. They're also more immediate release. They take effect faster but they don't last as long in terms of coverage as PPIs, but overall probably a better choice for kind of acute reflux. Now we do require PPI use for six months after gastric bypass. For patients who cannot take them, patients who have renal problems, patients who some patients actually have allergies to ppis, we can use h2 receptor blockers as an adequate alternative yeah, what about, uh, like gaviscon tums and some of the?
Deidre:definitely things like tums or caraphate is I kind of think of caraphate like pepto-bismol and that it coaches the sliding of the stomach so it makes you feel better, because you get a lot of gastritis and inflammation when you have reflux, you get bloating, you get spasm, you don't feel good and that helps kind of just make you feel better. I'm not sure it doesn't decrease the acid production, but it protects the lining of the stomach from the acid production. Um, gaviscon helps with bloating for sure. I mean, I love to use tums, I eat them all the time I have reflux, so they work really well and you get good calcium from them.
Dr. Weiner:I think the other part of this question is what if this is a sleeve patient? What are the options there? And I think there's a lot of pieces to that puzzle. So for mild acid reflux we certainly don't recommend revision to a gastric bypass. But if you're kind of contemplating long-term use, or once a day, ppi isn't working and you're up to twice a day, and we know the natural history of reflux after sleeve is it just keeps getting worse.
Deidre:Right Two years plus. It's the highest percentage Right, and especially if you're experiencing some weight regain.
Dr. Weiner:then we talk about how diagnosis matters for revision surgery, and so I you know, I think we're starting to see more and more patients opt for revision from a sleeve to a gastric bypass with really less severe acid reflux. We'll see if the insurance companies catch onto this and start getting picky.
Deidre:There's a lot of long-term side effects to having suboptimal treatment of reflux. You know ulcers. You obviously don't feel good.
Dr. Weiner:Nausea Barrett's esophagus Barrett's esophagus Reflux aspiration, which can cause respiratory problems like pneumonia, like Barb was talking about.
Deidre:Yeah, and so I think it's totally reasonable to both avoid the long-term consequences of chronic PPI use and those more serious side effects that consider revision at an earlier stage.
Dr. Weiner:I think, even if, especially if, the course is worsening, right. If your symptoms are getting worse, then you know, do you want to wait until you're absolutely totally miserable, right? Or?
Deidre:Which, if you can't control your reflux with max dose of proton pump inhibitors, it's very likely it's going to get worse.
Barb:Yeah, no, I agree. All right, Deidre you did an awesome job. I'm so proud of you.
Dr. Weiner:Thanks, All right, this podcast is produced by Sierra Miller and Rhiannon Griffin and the editing is done by Autogrow, and I want to make a special thanks to our guest Barb, not just for being on the podcast but for all of the service she's provided to all of our patients and to the two of us over the years.
Dr. Weiner:Please check us out on social media at our website. Consider joining our online nutrition program or our Pound to Cure Platinum program, and, if you like seeing Deidre or hearing from Deidre, drop us a comment, let us know, and maybe we'll get her to make some Instagram or TikTok videos. What do you say you in Deidre or hearing from Deidre? Drop us a comment, let us know, and maybe we'll get her to make some Instagram or TikTok videos. What do you say, you in Deidre? Sure, okay, we'll see you guys next time.