How a Gastric Bypass Could Ruin Your Life

Episode 28 of The Pound of Cure Weight Loss Podcast is titled, How a Gastric Bypass Could Ruin Your Life. 

The title comes from our In the News segment we cover an article in Medscape titled, Alcohol to Blame: Weight Regain After Bariatric Surgery. It should come as no surprise that alcohol consumption could lead to weight gain. What could be surprising is the 5x increased risk of alcoholism after a gastric bypass and 2x increased risk of alcoholism after a sleeve. Tune in to learn why!

In our Patient Story, we talk to Janet about her struggle to lose weight after surgical menopause. As a nurse she was conflicted about working in the healthcare industry because she was battling her own weight issues. She tried everything to lose weight on her own but nothing worked. Finally, she reached out to us for help. 

In our Nutrition segment, Zoe is back from her honeymoon with some great tips on how to avoid weight gain while on vacation. It’s a common-sense approach that won’t rob you of your fun or enjoyment of food. 

In our Economics of Obesity segment, we talk about how much money people spend on weight loss medications and the socioeconomic aspects of GLP-1 use. Would you be surprised to know that more than half of all GLP-1 users pay less than $50 per month? 

Finally, we answer 3 of our listeners questions including, our thoughts on green drinks, how to lose more weight after a permanent stall, and how to avoid losing too much weight after surgery.

Transcript

Dr. Weiner: 0:17

After bariatric surgery, specifically a gastric bypass, but we do see this with sleeve patients as well. The alcohol it's almost like you injected it into a vein. It just goes boom.

Zoe: 0:31

Welcome back.

Dr. Weiner: 0:32

I'm back, I know you miss me, we miss you totally.

Zoe: 0:37

Welcome back to the Pound of Cure Weight Loss Podcast, episode 28. Yep, how a gastric bypass could ruin your life.

Dr. Weiner: 0:45

Yeah.

Zoe: 0:46

Uh-oh.

Dr. Weiner: 0:46

I know.

Zoe: 0:47

What are we going to talk about?

Dr. Weiner: 0:48

I bet most of my patients know the answer to this.

Zoe: 0:51

I think so too.

Dr. Weiner: 0:52

Yeah, and very soon. You will too. So, zoe, talk to us. How was the honeymoon?

Zoe: 0:57

Oh, it was a dream.

Dr. Weiner: 0:58

Yeah, oh it was a dream.

Zoe: 0:59

It truly truly was. I mean, 40 hours of travel time on either side to get there and get back was less of a dream.

Dr. Weiner: 1:07

Yeah, that sounds rough.

Zoe: 1:09

You know we made up for it by. You know it felt like I was there for a long time.

Dr. Weiner: 1:13

Can't they get to the moon faster than that? I feel like they can.

Zoe: 1:18

So I mean, I don't know, I've never been to the moon, but the maldives was incredible. They had really great food. I ate a lot of seafood. Matt, my husband does not like seafood so I ate plenty for the both of us good lots of great tropical fruit and veggies and and so anyway I have you can't really tell I have the most natural tan I've had, probably my entire life perfect you went to u of a so that was part of the rule book was you got to have some kind of fake tan, right?

Dr. Weiner: 1:45

Yeah, fake, fake, yeah, exactly, fake fake. Is that what they called it? All right, well, so let's move into our first segment. This is in the news. This is an article from Medscape and it's where our title came from, and it's Alcohol to Blame Weight Regain After Bariatric Surgery. And so this article kind of talks a little bit about how alcohol can cause weight gain and how there is an increased risk of alcoholism after the surgery. I think it was about eight years ago. Our National Society, the American Society for Metabolic and Bariatric Surgery, or the ASMBS. They put out a position paper talking about alcoholism after bariatric surgery, and I think you know for a long time people talked about transfer addiction and how this is taking your addiction for food and now transferring it over to alcohol because you can't eat food. I think, as we've kind of learned more about this, we realize that's probably not the mechanism.

Zoe: 2:41

It's more so about the absorption it's about the absorption Exactly.

Dr. Weiner: 2:45

So first of, all, one alcoholic beverage can put you over the legal limit for driving after a gastric bypass if you're a woman, and possibly for some men too, and so I think that's something that you have to recognize. And normally when you drink, if you have a normal stomach, the alcohol kind of sits in the stomach and we've all kind of experienced this. You have a drink and it doesn't hit you right away. It takes 10, 20 minutes, and then suddenly it kind of starts to creep in a little bit.

Dr. Weiner: 3:13

After bariatric surgery, specifically a gastric bypass, but we do see this with sleep patients as well the alcohol, it's almost like you injected it into a vein. It just goes boom right into your. It's absorbed very rapidly because the alcohol goes right through your tiny stomach into the small intestine where alcohol is absorbed very rapidly. There's people sober up at different rates, but a lot of people will tell me they get drunk very quickly and then sober up very quickly. And with alcoholism what they see is sometimes it's that change in your alcohol levels. That's what triggers the pleasure centers in your brain.

Zoe: 3:47

Chasing that high yeah.

Dr. Weiner: 3:49

And so you can, kind of, because of the change in your alcohol levels, amplified after the surgery, it can be more addictive. And we see a five times higher rate of development of alcoholism after a gastric bypass. And if you look at the absorption pattern of alcohol, it's very different after a bypass than it is after a sleeve. And so the way a gastric bypass could ruin your life is if you go through and you lose 100 pounds and you have resolution of your diabetes and all your health problems and everything is great, but then you lose control of your ability to modify your alcohol intake and you become an alcoholic the wheels fall off the bus, right, and it's kind of similar to what we see when we talk about weight gaining medications.

Dr. Weiner: 4:56

Right, we see Abilify and some of these other medications that, for some people, are so critical to their mental health and that, even though they may be causing weight gain, it's that mental health that is even more important than your weight, than your diabetes, and if you aren't healthy from an emotional perspective, it doesn't matter what else is happening in your life. You know you're just not going to be able to be happy or enjoy it.

Zoe: 5:24

Well, in addition to the increased risk of alcoholism is there's a lot of weight gain, a lot, I mean, we think about. Alcohol has seven calories per gram, so that's basically halfway between what a carbohydrate has and what fat has. So carbohydrates have four calories per gram. Fat has nine calories per gram. Alcohol has seven. Guess what? You don't feel full and satisfied when you're drinking alcohol. That's what we call empty calories.

Dr. Weiner: 5:51

Right and that's. And truthfully, alcohol. People talk about how marijuana makes you eat, but alcohol probably makes you eat a lot too.

Zoe: 5:57

Well, and also it decreases your inhibitions. So you know, then maybe you've been really good. I hate moralizing food, so don't use good and bad in terms of food. But for this example, maybe you've been really good all week and then you have some drinks and then you no longer want to have the salad that you have prepped at home for dinner. On Friday night let's go and get pizza. So it's not only the empty calories from the alcohol, it's the snowball effect of the and then maybe the hangover food the next day.

Dr. Weiner: 6:30

Right, yeah, so I mean it just keeps going. So I'm a big believer in harm reduction. You know, I think that there's one school of thought that we should criminalize drug addiction and lock up everybody who struggles with addiction or alcoholism, and I think a lot of times that misses the point of the disease, just like we missed the point of the disease of obesity. And so I talk openly about patients and Arizona. Marijuana is legal and we don't see an increased rate of dependency. We see plenty of dependency and plenty of problems with marijuana. Don't get me wrong. I'm not saying you know, smoke up, everything is great. Marijuana is a wonder drug. I don't think that at all. The right amount of marijuana to use is zero as well. However, if we're comparing alcohol to marijuana, alcohol has a five times increased risk. Alcohol is the only drug that you can actually die of withdrawal from. No other drugs, not even heroin, heroin. Withdrawing from heroin is a miserable experience, but you will not die. But you can absolutely die from alcohol withdrawal.

Zoe: 7:30

And it's the most legal one.

Dr. Weiner: 7:31

And it is the most legal and most accepted drug Absolutely, and so I have an open conversation with my gastric bypass patients, especially when we ask about marijuana use, and what I find is actually marijuana use is more common now than alcohol use. Marijuana does not have an increased risk of addiction or dependency. You can still become dependent on marijuana. There is risk of using it too much, but having a gastric bypass does not change that risk. But it does change that risk with alcoholism and so I think that's something you know I recommend no alcohol for all or very extra patients, and if you don't follow that and I get it if you don't, then less than you drink currently.

Zoe: 8:10

Yeah, and avoid the sugary drinks.

Dr. Weiner: 8:13

Yeah, absolutely, I mean most. So you get the seven calories from the alcohol and then there's usually 15, 20 grams of sugar in. You know most of the drinks out there, right? Well, let's move into our patient story and hear from Janet. Janet's really a great advocate for our program and has had a remarkable success with both Monjaro and a gastric bypass.

Zoe: 8:36

All right. Well, welcome Janet. We're super happy to have you on the podcast today. Welcome, Thank you.

Janet: 8:41

I'm very excited to be here.

Dr. Weiner: 8:42

So why don't you tell us your story, just kind of you know? First of all, tell us a little bit about who you are, okay, and kind of what led you to look at bariatric surgery and to seek out some help with weight loss.

Janet: 8:53

Okay, so my name is Janet and I am a nurse at a local hospital and I've worked in healthcare for about 15 years and I felt like a fraud. So, being overweight, it felt very weird to be in healthcare and not be a product of what I should be selling in essence. So what led me is probably a very typical story. I was not overweight at all as a child. I didn't get overweight probably until I had my daughter, was close to 30. Then I had some issues where I had to have a hysterectomy and that was all. I gained probably 70 pounds the year after I had a hysterectomy.

Dr. Weiner: 9:35

Did they take your ovaries too?

Janet: 9:37

Yes, so I had one over removed and unfortunately I had to go back and then have everything removed.

Dr. Weiner: 10:34

Yeah, so you basically had surgical menopause at a relatively young age.

Janet: 10:38

I was 39.

Dr. Weiner: 10:40

39. Yeah, that's a recipe for massive weight gain.

Janet: 10:42

Yes, it was awful.

Dr. Weiner: 10:44

And how old were you when you at your last pregnancy?

Janet: 10:48

She was, I was born. She was born when I was 27.

Dr. Weiner: 10:50

27. Okay, so pregnancy older in life causes a lot of weight gain too, yeah, um, but but for you it was really surgical menopause. It was at 39. At 39, yeah, I mean. So you lost probably 10 years of menstrual cycles and normal hormonal functions um, and so you gained weight very rapidly, very rapidly. That must have been. It was devastating, devastating.

Janet: 11:12

It was devastating I felt, um, and then I did some very unhealthy things to lose weight and none of them stuck, and it was awful and I really I didn't want to be that person, but I felt like, no matter what I did, I never could lose weight. You'd lose the 10 pounds here you lose the 15 pounds there and then you gained back double. Whatever you lost, it was awful.

Zoe: 11:33

That yo-yoing just kind of kept depressing your metabolism and that really is the definition of the disease, of obesity right?

Dr. Weiner: 11:44

There's kind of obesity, the condition, where, oh, I eat fast food and drink soda and I eat an incredibly heavily processed diet and I just gain weight and weight and weight, and but when I pair off and when I started eating like a normal person, then the weight comes back off. That's not obesity the disease, that's obesity the condition. And we see that right we see that, zoe, and but you had it where you were doing everything right.

Janet: 12:07

It was. It was crazy to me that I was overweight. I just could not fathom that I was overweight.

Dr. Weiner: 12:13

The food that you ate did not match the weight that you gained.

Janet: 12:17

Initially. After that I gave up hope and all bets were off, screw it, that's exactly how I felt. It didn't matter, because no matter whether I ate healthy or unhealthy. So it was then. All bets were off after that. I just had no hope.

Zoe: 12:30

How? How long ago did you first see Dr Weiner and kind of start your process?

Janet: 12:35

to get surgery. So, funny thing, I was of the mindset that it was a cop out to have surgery. I really felt like what is wrong with me? That I cannot lose weight on my own. I just felt like, no matter what I did, I couldn't lose weight and it just was my failure. And it was a personal failure rather than any type of problem within my body.

Janet: 12:57

And so I was talking to a colleague of mine at work and she was telling me that she had had the surgery and had been very successful, and I was amazed by the way she looked. She, you know, she's just fantastic. And I was like I don't know, I still want to try to do this on my own. She's like, okay, crazy, but you know, you're going to come around to my way of thinking. And then I actually ran into a client of yours that I work with and she had phenomenal results, and I was talking to her and then it just kind of like the stars kind of aligned, and so it took about six or seven months to go through the process. So I had surgery in December of 22. And so I came and started chatting and seeing all the results of people around me, and then I suddenly started hearing more stories, seeing people that you have seen and the success stories, and so then you start to go OK, maybe this isn't crazy, maybe this really is what's going to make a difference me, and thank god because it was so it probably was the only thing that would have worked, because you were also diabetic at the time yes yeah, and and not like a little bit of diabetes, not a little bit, yeah, you had relatively pretty high a1c and were we able to get you on the medications before surgery

Dr. Weiner: 14:10

so I I actually came to you on Trulicity you came to me on Trulicity, which is not one of the best weight loss meds.

Janet: 14:16

Definitely, when you switched me over. Definitely a big difference.

Dr. Weiner: 14:20

So we switched you over to Monjaro before surgery.

Janet: 14:23

No.

Dr. Weiner: 14:23

That was after surgery.

Janet: 14:25

I stuck with Trulicity probably until about six months ago, I think, monjaro probably wasn't, was probably just coming out or wasn't, I'm not sure.

Dr. Weiner: 14:31

I don't remember exactly when Monjaro came out, but it was probably right around then and I bet you Trimston covered Monjaro.

Janet: 14:37

Probably. I don't think it did initially, because I think somebody was like hey. So I went to Barb and was like hey, and she's like I don't think so. Yeah, but so I've been on Monjra probably six or seven months.

Dr. Weiner: 14:49

Okay, it's been relatively. And so we did a gastric bypass. Correct, correct, okay. And how soon after your bypass did your sugar start to get better? And what happened with your diabetes? Just from the bypass alone?

Janet: 15:01

Immediately, probably three or four months. I definitely had a huge reduction.

Dr. Weiner: 15:05

my Wednesday Huge reduction, because I think we did laps at three months. Yeah.

Janet: 15:08

And significantly different.

Dr. Weiner: 15:12

And labs at three months, yeah, and significantly different, and I think we kind of rushed to get you on. We did. Yeah, I was like your diabetes. Yeah, it's gonna go away really quickly and we're not gonna be able to get you approved for mojaro yeah yeah, so. So we did end up getting you on mojaro so you're. You're a bypass plus mojaro. How much weight have you lost? 124 pounds, yeah, wow what a difference huge.

Janet: 15:30

It's a person. It's a person.

Dr. Weiner: 15:32

It's a person. It is a person I'm going to tell you also. You know, you kind of said that you had someone. You bumped into someone who, who said that they had had surgery and they were really happy. Do you know how many people I've bumped into who said, oh, janet, I talked to Janet and Janet told me I didn't walking billboard.

Janet: 15:48

I just wanted to know. I feel like I should have a position here, frankly, because I'm like hey, she goes to Dr Weiner.

Dr. Weiner: 15:55

You're always welcome. We're always looking for some PR people. I'm serious, I'm like hey, so how's life different now than it was, say, 120 pounds ago?

Janet: 16:06

I can touch my toes, yeah, I can sit on the floor. I can walk seven miles at the hospital and not be out of breath. I can walk up four flights of stairs, um, but my knees don't ache, my hips don't ache. Oh, it's very different.

Dr. Weiner: 16:23

It's very different. How's your?

Janet: 16:24

eating. It's amazing. I feel much better. I've always been a big meat eater and it's kind of funny because I feel like my taste buds have changed a little bit. Far less meat. Meat is less appealing to me, and not that I think meat is bad, it's just I still enjoy meat. It's just very different. I love vegetables now, where before I wasn't just never really had kind of the same satisfying taste or whatever. It's a very different relationship with food Very different.

Dr. Weiner: 16:55

Yeah, the bypass plus the Monjaro, yes, and you got to feel very much in control of your hunger and food, noise and all that stuff.

Janet: 17:02

For sure it is very, very quiet. Socially it's a little different.

Dr. Weiner: 17:08

How's that different?

Janet: 17:09

First, not drinking. I've never a big drinker, but a social drinker. Um people are freaked out when you no longer drink, which I find very interesting yeah, what do you mean you don't drink? You know, it's like you get this crazy look and I'm like just choose not to, just better, I just choose not to and they're like okay, but it's weird. Um, so learning how to socialize when most socialization in America is around food or alcohol? So, how do you, how do you work around that?

Zoe: 17:37

Have you been able to, in your own social circles, maybe suggest other activities to have that quality of time without it being centered around food or alcohol?

Janet: 17:48

So in the process of having surgery, I actually moved purposefully to a house that had a pool. I love to swim. I've always loved to swim. It's one of my favorite exercises because it doesn't feel like exercise to me. I don't like exercise per se, but I love to swim and so actually having social events around swimming, hanging out by the pool right, you can eat and drink, but I don't need to.

Zoe: 18:11

I'm going to be playing in the pool.

Janet: 18:13

Exactly Sit in the hot tub, whatever. But yeah, so it's just been different and, just frankly, learning how to socialize differently.

Zoe: 18:20

And learning, maybe, how to advocate for yourself. In a way that's like creating boundaries respectful boundaries, but also knowing how to express them for people to know that they don't need to keep asking you questions because it's none of your business.

Janet: 18:38

Yeah, it is funny. People want the story of why you don't drink alcohol, which I've. Oh, you know, like they, they assume there's some thing in the background that it's just. I just choose not to um, which I think is a healthier choice for people with the bypass.

Dr. Weiner: 18:53

It's a it's a hundred percent the right move for that I think I told you not to drink? Yes, and that is my recommendation is that people don't drink. You shouldn't drink alcohol after right a gastric bypass, specifically because we see about a four percent rate alcoholismism. I'm sure here you are. You're 120 pounds down. Your A1C has gone from high to normal, right You're pretty much, you're probably right at totally normal you are able to do all these things. Your quality of life has just increased dramatically.

Janet: 19:24

If you were to become an alcoholic, your life would be dramatically worse than it was even before surgery For sure your life would be dramatically worse than it was even before surgery, for sure, and why would I want to ruin everything that I just did to make my life better?

Dr. Weiner: 19:36

And so because that 4%, that's one in 25. Yeah, it's too high, right. I mean we do more than that number of surgeries in a month, and so that means once a month we're essentially ruining someone's life, right? And so that's not an acceptable percent. I mean, for me, I'm 100% and 0%. I want 100% of my patients to say what you say I am better off because of this surgery.

Zoe: 20:00

For sure.

Dr. Weiner: 20:01

And I want 0% of my patients to have any serious complications or have their life be worse than it was before surgery.

Janet: 20:07

I can't even imagine it, just would be a waste.

Dr. Weiner: 20:16

It would be a waste, yeah, and and. But it's also just like you know, when you were gaining weight and when you were struggling and you're, you're putting on the weight and you're kind of you felt like you were not in control of your weight. Absolutely, that happens with alcohol too, where this surgery, by changing the absorption of alcohol, it just just kind of takes away your ability to control your alcohol intake and again, that's just such a devastating problem. It's something we don't talk about often enough. But I'll tell you, when I see someone one year, two years after a gastric bypass who's gaining weight, that is my very first question Is there alcohol use?

Dr. Weiner: 20:48

And it's not the first year, it's the second year. That's when we typically year it's the second year interesting, that's when we typically see it interesting. Yeah, um, and so I I really applaud your decision. Actually, I'll tell you, lots of patients have made that decision after surgery it just doesn't make sense, yeah and you don't.

Janet: 21:02

It's funny because there are so many alcohol alternatives out there, right, which I didn't realize. But it cuts down on the questions when you have a mocktail in your hand.

Dr. Weiner: 21:10

You know yeah.

Janet: 21:11

I went to a birthday party on Friday and had a mocktail and nobody said anything to me Like oh, you're not drinking. I'm like.

Dr. Weiner: 21:18

Here's a little secret Just put a lime wedge on the edge of your glass and everyone will assume it's you.

Zoe: 21:24

This is part of my car.

Dr. Weiner: 21:25

Totally.

Janet: 21:26

With a lime wedge on the rim and you Totally, with a language on the rim and you won't get any questions.

Dr. Weiner: 21:30

It's hilarious.

Janet: 21:31

Actually it's honestly been baffling to me, but I find it humorous now. It used to really offend me, but now I've just accepted that it's just the way it is and I don't care. But most of the people close to me don't care anymore. They don't ask anymore. They support it 100%.

Dr. Weiner: 21:45

How's eating now? Is it comfortable to eat? Like you know, a lot of people are like oh, I don't want to have a gastric bypass because I'm going to have all these side effects. Do you have? I mean, you're on Mojaro and a gastric bypass, so that's kind of a double whammy if you're going to have some GI issues.

Janet: 21:57

I have no GI issues. I truly have. I really feel blessed. I've I had a great recovery. It just was so meant to be. I never have once regretted. You told me you may regret this decision a month out For the first few weeks.

Joel: 22:19

Right and.

Janet: 22:19

I, not once have I regretted it.

Joel: 22:21

Not once.

Janet: 22:23

It was just meant to be, and so eating has been very comfortable. But I'm also, I get shoulder pain if I eat too much and I'm I don't like the way that feels and I don't want to feel that way. So I tend to kind of you kind of get to know after a while that this is my portion and this is where I'm at, and that's okay.

Joel: 22:41

And.

Janet: 22:42

I've never, like I said, I can eat meat. I love chopped salads um salads. I wanted to sell it so desperately when we first started this journey, and it's. You can't really have a lot of salad initially, it's so chopping it up, doing different things, made it much more palatable and easy. I really have no gastric issues.

Dr. Weiner: 23:01

Amazing, that's amazing. You probably see that a lot.

Zoe: 23:04

Oh, my God, I was going to say so many people with those. The first couple of weeks after surgery.

Joel: 23:16

I just want a salad. I'm like I know and I want that for you? Just not yet.

Zoe: 23:18

It takes a little bit of time. So what's next for you?

Janet: 23:23

Anything on the horizons that you're looking forward to, that you're working toward. I would like to stop sugar-free. That has been something I've struggled with it's. I love coffee and I used to have a protein coffee. I've got to say I'm not a big fan of protein shakes right now. That's okay.

Joel: 23:36

That's okay, where you are, I don't know what you're doing.

Janet: 23:39

So I really don't want protein shakes, but I used to use them as my creamer. Like that's, I would have a nice coffee in the morning and get my protein, so I started going to like your stevia as your true. Yes, I would like to get rid of them, but I'm not there yet.

Zoe: 23:52

I don't know how to try putting cinnamon or vanilla extract in your coffee to add kind of that essence of sweetness without adding actual sweetness. That could be a next step for you.

Janet: 24:04

I will try that because I would really like to quit, quit the sweeteners, but not, not there yet. Yeah.

Dr. Weiner: 24:10

Baby steps.

Janet: 24:10

You'll keep us posted, I will.

Zoe: 24:12

I sure will. Thank you so much for joining us and being patient, cause I know we were running a little bit late. No problem, I got it.

Dr. Weiner: 24:19

Thank you for sharing your story. Thank you for being such a great advocate for our program. Absolutely you know and for all was the thing that kind of struck me when I first met you. I was like I bet she's a really good nurse. I just kind of saw how you kind of approached everything and how you kind of went through it, and I could tell that there was a real compassion.

Zoe: 24:51

No-transcript which is hard to do it's hard to do.

Dr. Weiner: 24:55

It is, and I think maybe the first day we met. I don't know if that was there, but I think it is now.

Janet: 25:01

Thanks, yeah, it really. It's been a journey and it's truly the greatest thing I ever did for myself, and I don't regret it at all. Fantastic, amazing, all right.

Dr. Weiner: 25:09

Thanks for joining us.

Janet: 25:10

Thank you, appreciate it.

Dr. Weiner: 25:12

Oh fantastic, what a great story. I'm so happy for her success and definitely and you know all that she's accomplished and how much it's improved her life Absolutely and she's really done everything kind of right, like she put the energy, the time and energy into. She eats well. She really follows every rule.

Zoe: 25:28

Nurses are good patients let's be honest, Doctors probably not so much.

Dr. Weiner: 25:33

Not so much at all. No, no, for sure not. I would definitely probably fall into that category.

Zoe: 25:41

So, zoe, what do we have for nutrition today? Well, I figured since I'm recently back from vacation and I talk with patients all the time on how to optimize their vacation for not like throwing away all their progress out the window when they go on a trip, but still enjoying themselves Right. So thought it'd be appropriate to talk about my recommendations while on vacation, and I kind of. Yes, we have our, our nutrition plan and you have your goals each week that we work on in our smart goals session with the nutrition program. But if we're thinking about overall tips and general concepts, one would be hydration. So you're off of your regular schedule, you're maybe out and about more, you're not in your normal environment and so hydration tends to go way down and you tend to maybe eat out a lot more, which means you're increasing your sodium intake, so you could be feeling more bloated, etc. So, Really, making sure that that hydration stays on point. I always bring a refillable water bottle with me through airport security, empty of course, and then refill that thing the whole week or however long you're gone. So making sure you keep your water bottle with you, that's huge. I also like to say make sure you're getting vegetables at least once a day. If you're eating out a lot, you're not in your normal routine, it's very easy to let vegetables slide, but just thinking back to how vegetables are that secret weapon to eat a big volume, feel full and so shoot for having vegetables at least once a day while you're on vacation. It's not going to be perfect, it's not going to be what you're normally doing, but at least get them in once a day. It's not going to be perfect, it's not going to be what you're normally doing, but at least get them in once a day. And then the third piece is steps. So you're on vacation, Maybe you're walking around a new city, walking on the beach, whatever you're doing, knowing that it's okay if you're not in your normal exercise routine, offsetting it with extra steps. Go exploring, see new things and get your movement in that way. Yeah, I mean, those are my tips.

Zoe: 27:54

A little bonus tip is for when you get home. It's pretty easy to like. You know you generally get home Sunday or whenever, and then you have to get right back to reality and the house is empty. You don't have any food. You know. Hopefully you've been stocking up your freezer with some of the tips we've been talking about, but a huge help is ordering groceries to be delivered around the time that you're going to get home. So I did on the air, you know, at the airport set it up to be delivered right before we're going to get home. It doesn't help that I forgot all of my food this week, but it was ordered, it was prepped, the intention was there. But anyway, hopefully that helps for the next time you have a trip planned, especially because it's summertime, lots of trips, lots of vacations. So keep that in mind and don't get stressed out Just when you get back, get back on track.

Dr. Weiner: 28:45

Love it. Yeah, Great tips, and I think the truth is you don't really have to gain weight over vacation. I think most people don't. I think you have to be careful when the vacation becomes a very food-centric vacation. I think if that is what it is and sometimes that happens then the walking is just key and the exercise.

Zoe: 29:05

We've had a couple of patients that we've I can actually think of two different patients who lost weight on their cruise.

Joel: 29:13

Oh, wow.

Zoe: 29:14

And that's hard to like. Cruises are kind of food central, right, but they both different cruises. Different people walk their laps around the perimeter, so it can be done. It can be done, you can be, I would say more so like feel success with maintaining your weight, but if you lose weight, even better yeah, all right.

Dr. Weiner: 29:33

Well, let's move into our economics of obesity segment. It's going to be a fairly quick segment. We're just going to talk a little bit about what we're seeing in terms of the patient spending on these medications. So, of course, the number one issue with glp-1 meds is affordability, right, I mean, if these things were 50 bucks a month and were reliable, there was no shortages. Pretty much 40% of the country would probably be on them and we'd have just-.

Zoe: 30:01

A lot of up-in-arms food companies.

Dr. Weiner: 30:04

Yeah, right, right for sure. So I think the first thing that I want to point out, there's this really really well-designed study that actually looked in Phoenix, two hours north of us, and they looked at the average lifespan based on zip code. All right, zoe, from the shortest lifespan zip code to the longest lifespan zip code, what do you think? How many years difference was it?

Zoe: 30:31

Like 10,. Is it like 10 years?

Dr. Weiner: 30:33

14.

Zoe: 30:34

No kidding.

Dr. Weiner: 30:34

Yeah, and I think Phoenix is kind of a very-.

Zoe: 30:38

There's a big wide range of demographics.

Dr. Weiner: 30:40

Huge, yeah right, because you got a lot of wealthy, older people who are retiring there with lots of resources, and then there's also lots of poverty in Phoenix, as there is in pretty much every major city in this country, and so we saw that in South Phoenix the average lifespan is 71 years old and in Scottsdale it's 85. 14 years I mean that is a tremendous amount of time and there is almost nothing. No other factor diabetes, heart disease, history of heart attack almost no health factor has that same amount of impact on your lifespan than your socioeconomic status.

Dr. Weiner: 31:19

Yeah, I think that's the first thing and I think that's something that we have to really talk about with these medications Because, first of all, obesity affects people of lower socioeconomic status unfairly, and access to these medications we're seeing a lot more access in the higher socioeconomic patients as well. So there is a substantial out-of-pocket cost for these medications and there's two important things. First of all, we're seeing actually about half the people spending $50 or less a month.

Zoe: 31:51

That surprises me actually.

Dr. Weiner: 31:52

Yeah, I know, I was just surprised that it was that many, but there are a number of insurance plans that have really good coverage for this and what happens is when you have good coverage, you're going to be more likely to use the meds. So it's probably that the insurance coverage is what's driving a lot of that use.

Zoe: 32:10

Insurance coverage and access are maybe two different things.

Dr. Weiner: 32:12

Totally, totally so. 16% of people spend somewhere between $50 to $300. It's a pretty wide range 21% $300 to $500 and 9% over $500. But what we're seeing is that over the last six months, the average amount that people are spending on these meds has increased substantially.

Zoe: 32:35

I think we know that just by talking with patients and what we are seeing, but it's good to see the data that supports it.

Dr. Weiner: 32:41

Yeah. So there are some people out there and I think if you have insurance coverage and a really great plan and they cover it, then these meds are a great option for you and we're seeing a lot of success. But I think that the majority of people should expect to spend probably a minimum of a hundred more likely two, three, four, 500 bucks a month, which for a lot of people is just especially. You get a husband and wife and they both want to use it and all of a sudden it gets pretty crazy. We work with patients pretty aggressively.

Dr. Weiner: 33:12

We have a lot of creative dosing strategies I think that's what we call them on the show. We won't really go into details about exactly what they are. There's a number of reasons why we don't, and so with these we can usually get people on a decent dose of the meds the real meds, not compounded stuff for about $200 a month. A weight loss dose Maybe not the max weight loss, but a weight loss dose for about $200 a month. That's difficult now because of the shortages, but I think the shortages are going to improve. But yeah, the out-of-pocket costs are still quite substantial. My thinking on this is that they will be for at least another four or five years, yeah, until the factories really get ramped up.

Dr. Weiner: 33:54

There's one little sliver of hope, and that's what I've talked about in the past, about the drug patents and specifically with Ozempic, how there's two patents, one that expires in 2026 and one that expires in 2031. That patent in 2026, I think there's some people taking a shot at it and so we'll see. I mean, there's a lot of money to be made, so we may see some of these generic drug companies. We may see some capital investments where people are putting a lot of money into fighting that patent, knowing that if it pays off, that there could be a big payout for a generic manufacturer. So I could see that happening In 2026, we could potentially big payout for a generic manufacturer. So that could. I could see that happening. You know, in 2026, we could potentially see generic semaglutide, not compounded but FDA approved, regulated, from a factory, you know, that follows the standard manufacturing principles.

Zoe: 34:43

Here's to hoping. Here's to hoping.

Dr. Weiner: 34:44

We'll keep you posted, yeah we for sure will be watching that, so that'll be interesting All right Now.

Zoe: 34:48

We've got our questions submitted by followers, whether it's YouTube, social media, from our website, and we have Joel here, because Sierra, our normal producer and extraordinaire, is out, but we've got Joel here to read us our questions today. So what do we've got?

Joel: 35:10

a while here to read us our questions today. So what do we've got? All right? So this question comes from YouTube, from the your post-op diet video, from blue sky vibes, and they ask what about green drinks?

Zoe: 35:20

Okay, green drinks. So I assume we're talking about the powder, the green powder that you mix with water that tastes like dirt. Now, some of them taste pretty good. Here's the thing. Yes, you're getting micronutrients. Yes, you're getting phytonutrients. You're getting some good stuff in there. What are you not getting? You're not getting fiber. So the whole key piece of eating a pound of vegetables each day and working towards increasing your vegetable intake like I was talking about earlier on the vacation and the nutrition segment it's about the feeling of fullness, satisfaction, the benefits that we get from the fiber Green drinks. You're not getting any of that. It's kind of like a waste of money, in my opinion. If it's something that you enjoy to drink, make sure that there's no added sugar, but if it's a little extra, kind of something to spice up the water that you maybe want to add into your day, fine, does not replace your vegetable intake.

Dr. Weiner: 36:21

Yeah, what about matcha tea? What do you think about matcha?

Zoe: 36:23

tea, yeah Great.

Dr. Weiner: 36:25

Yeah, I think there's a lot of value to matcha tea, but again there's no fiber in it.

Zoe: 36:33

Right, it's a drink. It's a drink. Yeah, maybe it's an alternative to you know, coffee, if you're wanting some caffeine Right.

Dr. Weiner: 36:37

And I think the other important point is that the smoothies are good. We're big on the. We call them the set point smoothies, Right, and that's the you know.

Zoe: 36:43

Because you're not removing the fiber.

Dr. Weiner: 36:45

Exactly.

Zoe: 36:45

I have a funny story about matcha. Real quick. I had a friend that was like oh yeah, when I don't want to have caffeine, I just get a matcha. I'm like there's caffeine in matcha.

Dr. Weiner: 36:56

So she's like oh no, really, no wonder I haven't been sleeping, right? Yeah, I think about half as much caffeine as there is in regular coffee or black tea, which is a fully caffeinated tea, in the green tea. Yeah, there's decent caffeine in it for sure. Yeah, all right. What's our next question, hoel?

Joel: 37:13

All right. The next question is also from YouTube what to eat after bariatric surgery. This one from Mr Rhino12667. I'm one year out and stalled down 200 pounds, 450 to 250. Still want to lose another 30 pounds. What can I do? I had a bypass. Should I go DS?

Dr. Weiner: 37:37

Yeah, so DS is a duodenal switch.

Zoe: 37:39

Can we first celebrate that he's lost 200 pounds, like that's amazing. Yeah, okay, continue.

Dr. Weiner: 37:45

No, I mean, but in all honesty, I think that is the essence of the answer that I think that we need to give here. So, first of all, converting from a gastric bypass to a duodenal switch is a Herculean effort. It is probably a five or six-hour surgery with, I would estimate, somewhere in the neighborhood of a 15% to 20% rate of serious complication and when.

Zoe: 38:12

I say serious Sounds like a double black diamond.

Dr. Weiner: 38:14

Yeah, it's more than a double black diamond. We'll cover double black diamonds next episode, but it's an incredibly difficult surgery with a very high complication rate.

Zoe: 38:27

And how much extra weight do people tend to lose?

Dr. Weiner: 38:29

You know, there's really no studies on this, because it's just such a boneheaded idea.

Dr. Weiner: 38:36

If someone got up and presented this, then honestly I would like to believe, and our national society it's a pretty responsible group, but I think they'd be throwing Molotov cocktails from the audience. You know, in an academic way, people would get up and really really lean into someone and say what you're doing is irresponsible and dangerous. I've seen that People do say that and usually appropriately. So it was very interesting. I saw this very early in my career with a band when there was a couple of kind of shills out there who were in the pocket of the company that made the band and they were talking about how great this band was. And there were some people who came up and they were like I don't know what's happening, because my patients aren't losing any weight and are having all kinds of terrible problems. So what am I? Either I'm doing something wrong or your data is totally inaccurate and it got really hostile.

Dr. Weiner: 39:29

So you know, in the academic communities people think, oh, doctors are. You know, I think doctors have a mixed opinion. Some people think doctors are, in general, good. I'd like to think that most of us are. Some people think doctors are kind of money grubbers just like everybody else. But I'll tell you in the academic societies that's not the case. I mean, there's really. There's a lot of honesty. At least I can speak about the ASMBS, which I'm pretty active in. There's a lot of honesty in that group and people tell the truth and they. Something like this just really wouldn't fly in our society. So it's not. I think you'd have a very hard time even finding a surgeon willing to do this If you come into my office First, do no harm right First, do no harm Absolutely.

Zoe: 40:07

If you come into my office first do no harm right First.

Dr. Weiner: 40:08

Do no harm Absolutely. If you come into my office and ask me to convert your bypass to a duodenal switch, I would say you know that's. You got the wrong guy here. So what can you do to lose another 30? You know it's. It gets down to our whole set point. Lowering conversation. Right, there's four ways to lower your set point. There's improved nutrition, eating higher quality food. There's building muscle and using it. There's the medications and then there's revision. I just told you revision is not really an option. Most people for revision. Surgery for bypass will either make the pouch smaller or lengthen the limbs, and even that really isn't done much because it doesn't work very well and causes issues too. So, 30 pounds? At this point I would really just push you to follow the metabolic reset diet. Work on the nutrition. I don't know that I would dig into GLP-1 meds until I was certain that you'd optimize nutrition.

Zoe: 40:59

Exhausted all those options, yeah.

Dr. Weiner: 41:01

Yeah, for 30 pounds, it's a lot to add the GLP-1s. Something that we're seeing and I think this is going to be really interesting is that people respond differently to GLP-1 meds than they do when they've had bariatric surgery and so where typically we're saying like if you're going to be on these meds, you're on them for life, and for non-bariatric surgery patients that's probably the case. I think we may see a little bit longer durability of these meds in bariatric surgery patients. So I would probably exhaust everything nutritionally, exercise-wise, and then you know what I might have a conversation with this patient about is like let's try three or four months of these meds, see what happens. Maybe you know, once a month we have to, once a year we have to touch you off of something, touch you up with something. But I would give that a shot and see.

Zoe: 41:54

But I would still. I'd focus on nutrition for sure, and we welcome you to join the nutrition program and I can help you with getting that nutrition dialed in, that exercise dialed in to help you get those last 30 pounds off.

Dr. Weiner: 41:59

Yeah, for sure. All right, Hawal. What's our last question?

Joel: 42:03

All right. The last question came via email from Angela. She says she is five foot eight inches tall and she had gastric bypass surgery in April of this year. Her highest weight was 254 pounds and her lowest was 161. She's struggling with not going below 161. She feels like she looks unhealthy at that weight. What suggestions do you have for how to maintain a healthy weight of 165 without going too low and looking unhealthy?

Dr. Weiner: 42:36

what do you think, zoe?

Zoe: 42:37

um, well, I would say if. If she's concerned about looking unhealthy, that means that there's probably not very much much muscle mass. So maybe instead of thinking about oh, do I have to add bread back in?

Zoe: 42:52

or whatever it is maybe just not really focusing so much on just eating as little as possible, really optimizing the quality of the food, making sure you're still getting in enough protein, but maybe ramping up that strength training to build a little bit of extra muscle and give maybe a more healthy look. If that's kind of what you're going after.

Dr. Weiner: 43:19

Yeah, I think when we look at too much weight loss and we see these kind of super responders people who lose a ton of weight and I don't know that this would quite categorize this patient as a super responder. To me, this is probably a little better than average what we'd expect. We have a calculator on our website that you can use and plug these numbers in and see. But my hunch is it's a little more than we'd expect, but nothing crazy. I think the biggest mistake you can make is like well, I'm going to eat a bunch of crap now and I'm going to intentionally gain weight.

Zoe: 43:48

Don't want to get too thin.

Dr. Weiner: 43:50

You will overshoot every time, and I've seen that a lot.

Zoe: 43:53

And you also. You know now the metabolic thermostat has been brought to 161. If that's been your lowest weight, there tends to be a little bit of a buffer anyway. Generally was it like 10 pounds probably from the lowest weight is kind of where you're going to sit, where your body's going to feel the safest and happiest, so I wouldn't worry too much about it quite yet.

Dr. Weiner: 44:17

There's probably going to be a little bit of natural rebound, like you said.

Zoe: 44:19

Yeah, Maybe just hang in there, keep us updated and we can help you out if that does happen.

Dr. Weiner: 44:28

Yeah, I think the last thing that I would kind of point out is that if you continue to lose weight, and sometimes when people do look unhealthy, I can almost when I walk into the office and I see a new patient and they kind of they just they look a little too thin, they look a little unhealthy that that can be from an ulcer. So you're a year out. I mean we see ulcers at a year out for sure. So if you have any, if you have significantly low iron or any difficulty eating, any abdominal pain, then it's worth talking to your pediatric surgeon, getting an endoscopy making sure you don't have an ulcer. Those can be treated with medications. You want to get on those before they perforate or bleed.

Dr. Weiner: 45:08

But I think that's when people lose too much weight First of all. The other piece of that is smoking. So if you know they don't mention if they're smoking, I don't know if they are, but if you smoke after a gastric bypass, that gives you an ulcer and that makes you lose too much weight and also makes you look very unhealthy. So I think the first thing is no, you know, make sure there's no tobacco use. Is no, you know, make sure there's no tobacco use. If there's tobacco use, that has to be stopped immediately. Scope for an ulcer. And then I think, like what Zoe said, just really wait for that rebound, weight work on the muscle training and all the healthy eating, but it's it.

Zoe: 45:40

There are a lot of unknowns here.

Dr. Weiner: 45:42

Yeah, but I, but I, my hunch is is that at this point, if they just kind of work on their lifestyle and focus on the things you mentioned, it'll all correct itself in the next six to eight months.

Zoe: 45:53

All right, wonderful. Well, that about wraps us up.

Joel: 45:56

Yep.

Zoe: 45:56

This podcast today was produced by our guest producer Hoel and, of course, rhiannon Griffin, and the editing is done over with our team at Autogrow. And, of course, a special thanks to our patient guest today, janet.

Dr. Weiner: 46:11

Yeah, and please tune in next week. We have one of my most memorable patients. I operated on her 10 years ago and managed to get in touch with her, kind of through the podcast and she really tells a harrowing story of survival after surgery gone wrong in Mexico and she's doing fantastic now and it's great to catch up with her. But I think there's, you know, really fascinating stories. So tune in next week for sure to hear her story and, of course, check us out on social media or our website. And if this podcast is valuable and if you're enjoying it, please share it with a friend or family member or someone else who's struggling with obesity, who is looking for some kind of common sense, scientifically accurate and also empathic advice on how to manage your obesity. And, of course, join our nutrition program or, for personal assistance, our Pound to Cure Platinum program.

Zoe: 47:06

Absolutely See you next time. Bye-bye.