Wegovy for the Long Run

Episode 29 of The Pound of Cure Weight Loss Podcast is titled, Wegovy for the Long Run. The title comes from our In the News segment where we discuss an article in US News titled, More Studies Support Wegovy's Long-Term Weight-Loss Benefits. This article details the outcomes of the Select trial which showed that long-term use of Wegovy provided continued weight loss and cardiovascular benefits. 
 
 In our Patient Story segment, we talk to Armetta - one of my most memorable patients. She ended up having surgery in Mexico because of an exclusion policy on her insurance plan. After a serious complication, she became one of my double black diamond cases, and her insurance company ended up spending 1.5 million dollars on her treatment because of the complication. It’s a fascinating story.
 
 Before the invention of popular sports drinks, most people didn’t know what electrolytes were. Now it’s one of our most frequently asked questions. Do you really need to drink sports drinks to replenish your electrolytes? Zoe answers this question in our Nutrition segment.
 
 In out Economics of Obesity segment, we talk about going to Mexico for bariatric surgery. Many people choose this option thinking that it’s less expensive. But when 95% of all insurance plans cover bariatric surgery coupled with the higher complications rates and lack of post-op care, is it really the best choice? 
 
 Finally, we answer 3 of our listeners questions including, whether or not the Metabolic Reset Diet works for Vegans, the mechanics of the sleeve that contribute to GERD, and what strategies to employ to maintain your weight while on GLP-1 medications.

Transcript

Dr. Weiner: 0:17

So the question that all of us have had is you know, are people going to be on semaglutide, be doing well with their weight loss, and all of a sudden, the effects start wearing off and the weight starts coming back, turns out this study says no, they're not.

Zoe: 0:36

Hello everybody, welcome back to the Pound of Cure Weight Loss Podcast Wigovi for the long run, episode 29.

Dr. Weiner: 0:43

Absolutely.

Zoe: 0:44

And you're taking off on Saturday. Where are you going?

Dr. Weiner: 0:47

I'm going to Guatemala. Tell us more about that, so this is my third time going. It's one of my best friends from my residency has been going down for like 10 or 12 years and he asked me a couple of years ago to go and do the general surgery down there. So I do. 90% of our practice is bariatric surgery but I do complicated hernias and I've done so many gallbladders and inguinal hernias and everything over the years that you know I still know how to do those surgeries.

Zoe: 1:12

And you've been on call for general surgery.

Dr. Weiner: 1:14

And, yeah, I still take a little while not so much anymore, but not too long ago I took some general surgery calls.

Dr. Weiner: 1:20

So I do a lot of the general surgery and it's kind of like, to some degree, a lot of it's like riding a bike and the same skills you use in bariatrics you use in general surgery too. So I go to Guatemala and I do hernias and I've gone a couple of years. So I'm getting some more difficult cases as I kind of get to know you. And actually what's really exciting to me is that I'm bringing my daughter, yeah, and she just graduated from high school and she's kind of at that age where she's like come on world, I'm ready to take you on, and she's just interested in new experiences and she has zero interest in health care, but she's interested in kind of going down and seeing a part of the world that she's never seen and spending time with people that she wouldn't normally interact with and also just serving other people. I think you know, whether you go into healthcare or not, just being good and helping others is something that I think a lot of us get a lot I get benefit from. So so the two of us are going down to Guatemala and along with my best, one of my best friends, and we're having it's going to be a great time, and and you know I

Dr. Weiner: 2:26

like operating. So it's not. It's not work to me. It's a great time for me too. Well, I can't wait to hear all about that. Yeah, so I'll, I'll send, maybe we'll post some pictures and and and and let you know how we, how we do, when we get back. So so let's move into our our in the news segment, and this is where the title of our show comes from, and this article comes from US News and it's called More Studies Support Wegovy's Long-Term Weight Loss Benefits.

Dr. Weiner: 2:48

This was actually this is a really important study that just came out. So there were two trials that they did with Wegovy. The first is the STEP trial, and the STEP trial was what they use for the weight loss and that's what showed that the higher dose semaglutide or Wegovi shows about 15 to 16% total body weight loss, and that's what their stage three trials were. For FDA approval. They also have been running for about four years something called a select trial. The select trial measured not necessarily weight loss as the outcome, but cardiovascular disease, and this is where we came up with this statement about 20% risk reduction, and this is how they got Medicare to approve WeGo for cardiovascular risk reduction. So what they did was they looked at the select trial and because the trial I think has been going on a little longer than the step trial and they kept everybody on semaglutide for the four years they said, hey, how was the weight loss four years down the road? And this is a question that all of us are dying to know Because we see, with weight loss surgery, particularly the sleeve, we see weight regain and certainly we see it within four years quite commonly A lot less weight regain with a gastric bypass, less weight regain with a gastric bypass. So the question that all of us have had is are people going to be on semaglutide, be doing well with their weight loss and all of a sudden the effects start wearing off and the weight starts coming back? Turns out this study says no, they're not, that we're seeing excellent maintenance of weight loss at four years out. So after four years they saw 11.7% total body weight loss.

Dr. Weiner: 4:23

Now in the STEP trial I think it was 68 weeks or something, it was a little over a year they saw somewhere in the range of 15 to 16% total body weight loss. But when we look at the SELECT trial because this is a different set of patients and there's a really important component that I think you're going to have a lot to say on. They didn't see as much weight loss in this trial as they did in the STEP trial. And again, I think the patients were a little bit younger in the STEP trial and these patients all had cardiovascular risk, so there's probably not nearly the same degree of exercise.

Dr. Weiner: 4:54

But the big difference in the STEP trial and the SELECT trial, and what I think accounts for the difference between 11 or 12% total body weight loss we saw in the select trial and 15 or 16% that we see in the step trial, is that they did not receive nutritional counseling in the select trial, and so that nutritional counseling counted for probably about a quarter of 25% more weight loss, about three or 4% total, but about 25% of their total weight loss. We saw, and we've seen this over and over again. And so there's two really important take-home points, and the first is that this medication works over the long run, and so that's, I think, incredibly reassuring. Of course, the patients all took it.

Zoe: 5:58

It wasn't. They took it and then didn't take it for three years and maintain the weight loss. They took the medication for all four years. Our patients, the best results. We use science and backed by data to show the benefit of it. It's not just because, like we want to be mean, yeah, you know, it's we want to give them the best results, and this is a huge 25% of total success with this. Is that nutrition piece?

Dr. Weiner: 6:29

Right, right, and I think, especially as people have to weather the shortages right If you're going to weather these shortages or potentially lose access altogether. And we see, you know, I think one in eight people have tried a GLP-1 medication at this point in our country, but we do not have one in eight people actively taking these medications, so the overwhelming majority of people who start these medications actually don't finish them, and so the nutrition is going to be so critical to prevent that inevitable weight gain. And I think this study really shows that there is a difference, that nutrition does matter. We see this all the time. We see it not only in the weight loss, but also in the, in the side effects. Um, if you don't, if you don't follow the, the, the nutritional guidelines, it's a lot less comfortable yeah.

Dr. Weiner: 7:13

It's a lot less comfortable to be on the meds, um, but this I think the great news is, though, that these medications don't wear off over time, um, at least at four years. Again 10 years. We might see something different at 10 years, but at four years that's really, really great. That's a great finding, um, and and I I haven't seen this as much in the news as I I would have expected it to be, because this has been a major criticism we talk about tachyflaxis, where and we see this a lot with Phentermine, which is, up until these meds, was probably the most effective weight loss medication, where people are on it and it just starts wearing off over time, but we're not seeing it here, and the truth is, yeah, I haven't seen it so much in my practice either. I've not seen patients gaining weight back while continuing to take the med.

Zoe: 7:59

Well, now we're starting to get those years of just data with the patients to see. You know, yeah. So all right, Well, now we have our double black diamond special story. Today, dr Rinder, share a little bit more about what Armada has to share.

Dr. Weiner: 8:19

Yeah. So Armada is a patient of mine from 10 years ago and certainly one of my most memorable patients, and she has a pretty harrowing story to tell us. So let's hear from Armada. She's remote to from us. She's coming to us remotely from Michigan. I want to introduce one of my most memorable patients of all times. Of course, I remember all my patients and I love all my patients, but there are some people who I really have been through a lot with and I think Armeta is absolutely one of the people who comes to mind when I look back on my 15 years of bariatric surgery and think about some very challenging and difficult cases. So, armeta, why don't you set us up? Why don't you talk about the first time we met, maybe even a little bit before then, when, armetta, why don't you set us up? Why don't you talk about the first time we met, maybe even a little bit before then, when you know what brought you in to see me in the first place?

Armetta: 9:58

Well, looking back then, I moved to Detroit, michigan, back in 2012 to take a job at WJR and I'm really excited about it.

Armetta: 10:11

But you know I had issues, some health issues, before again. Um, before I moved to Michigan, um, I tried several times to look into bariatric surgery, but I never had the right insurance or something didn't work, so I couldn't, I couldn't get it done there. So, um, fast forward, I decided to still move on to take the job here in Detroit and I said, well, once I get settled and you know, kind of check out what's going on, maybe I can find somebody to help me. My primary physician at the time, Dr I think her name was Paulina Singh suggested that I see a Dr, Matthew Weiner, and she says he's been really great about helping people, Maybe he can help you. I said, okay, I'll give it a shot. I was just crazy, I just didn't know what to do. And there were still insurance issues even after meeting you. And I got the bright idea to say, well, you know something, maybe I could go to Mexico.

Dr. Weiner: 11:08

It's a little cheaper, Get this thing done and just get it over with. And that is a conversation I had with you and I think at this point.

Armetta: 11:20

What was your reaction? Well, first of all, how much did you weigh when we met 400. I think I topped out at 412 pounds.

Dr. Weiner: 11:26

Yeah, yeah, I mean I think that's the first thing is that you had very severe obesity. You weren't a few pounds overweight and you also had a lap band right. So you'd already had one procedure and a lap band would have made this a revision procedure. And I have this kind of you know test I do in the office where if I want to assess the patient's readiness for surgery, I'll have them get up on the exam table unassisted. There's a step up. Then you've got to climb up and sit down, swing your legs around.

Dr. Weiner: 11:58

You know it requires, truthfully, it requires a little bit of physical strength and if you're really severely disabled from your obesity, that's tough and you know, when I had you do that, it was like you were climbing Mount Kilimanjaro, like Lindsay did a couple episodes back. I mean, it took every ounce of strength and ability. You had to kind of get up and get yourself situated on that exam table. You also had significant pulmonary hypertension, which for me is one of the most concerning things I can see in a patient. It was awful. Yeah, yeah, yeah.

Armetta: 12:32

You could barely breathe right. I could tell you how bad it was and I didn't want anybody to know what was going on. Wjr is in the Fisher Building and we had a parking area where we parked but we had a long walk to the building to get to the eighth floor. I would have to plan on getting there at least a half an hour earlier, just to be able to walk through the hallway, stop and rest praying. Nobody saw me because it was embarrassing until.

Armetta: 12:58

I could get to the studio. So yeah, it was a challenge.

Ashton: 13:02

Yeah.

Dr. Weiner: 13:03

And so I think you know putting everything together. From my perspective, we had a lot of obstacles going into that surgery. Number one your BMI. You're 412 pounds. You were just. Your BMI was way up there. Number two is your pulmonary function. Your lung function was heavily compromised. It was a combination of this pulmonary hypertension and also just what we call obesity hypobetalation syndrome, which is, as your weight gets up there, you just can't breathe anymore. And one of the most amazing things that I see from patients is they go from barely being able to take 30 minutes to walk up to their office to being able to walk without stopping, and that just makes a huge transition in their life. You also had a lap band, so this was a revision surgery, so this was not going to be anything easy. Oh yeah, that's right.

Armetta: 13:51

That was an earlier Mexico situation.

Dr. Weiner: 13:55

But the final and the real issue that kind of brought all of this on was you didn't have coverage for bariatric surgery on your insurance policy, exactly.

Ashton: 14:04

It was excluded.

Dr. Weiner: 14:05

That was really yeah, yeah, it was an exclusion that was kind of that was of all of those things. We could have worked through the first three, but the exclusion was really what ended up causing all the problems that you had. So you've gone to Mexico in the past. You had a lap band. You came to see me I said you know, we need to convert your lap band to a gastric bypass, but you have to do all of these things. Also, it's not covered, it's very expensive, and so you elected to go to Mexico, correct?

Armetta: 14:36

Yes, I did, yes, I did, yeah, yeah, I think.

Armetta: 14:41

Sometimes you know, you think desperate times call for desperate measures and sometimes you're acting out of emotion, because you don't feel there's any other answer, and at that point it was. I made the decision. I didn't tell a lot of people that I was going I think you knew, and maybe a couple of other people and I said well, dr Weiner, I'm heading out. This was in August. I'll call you when I get back. Well, as I got down there, you know it was a flight down to San Diego and what they do is they come to the border to pick you up, to take you over the border for the operation. My breathing was so bad. I thought about that today.

Armetta: 15:20

My breathing was so bad when I got off the plane in San Diego I guess, like the bariatric or something, the temperature is different, the air quality or something was different I got off the plane and couldn't breathe. I couldn't even make it through the airport. That's how bad it was. So we finally, you know, got me over the border and we got situated, um, and they prep you um for, uh, what they're going to do.

Armetta: 15:51

But it's really scary because these are people that aren't really connected to anything that's really has gone on with you, health wise, and it's only so much that you're going to tell them because you want this operation and you know they prepped me. The next thing I knew I went in for the surgery, woke up in the wrong bed that should have been a red flag right there but I kept telling them I didn't feel well. I didn't feel well and they said, well, no, you went through everything fine. I said something's wrong with my stomach and with my stomach and I guess what is that? When you take the image of people when they're drinking something, you can actually watch it go down and they say, oh no, look.

Dr. Weiner: 16:39

Upper GI swallow yeah.

Armetta: 16:41

Right. So I did that, but I am almost convinced and maybe I could be wrong I am almost convinced the film that I was looking at was filmed that I think that they used for everybody, because as many holes as I felt that I had in my stomach what was going on. They should have seen something and they didn't. And at that point, if they decide that they don't want to have this conversation, they don't speak English anymore, and that night I'm there with nobody to talk to sick. I finally called a friend and said I'm in Mexico. If you don't help me, I'm not going to make it out of here yeah, wow.

Dr. Weiner: 17:23

So you know, I think a lot of people listening might be like how could she do that? Why would she go to mexico? That's so crazy, that's so dangerous. You know, some nasty people would probably even say she deserved what happened to her. Um, but I I don't think they really understand how miserable it is to be over 400 pounds and to not be able to walk. How old were you at that time?

Armetta: 17:49

You don't have a quality of life period. Let me see that was about God. Oh yeah, Happy 10 year anniversary. It's about 10 years it's been about 10 years. So I'm 64 now. I was 54.

Dr. Weiner: 18:03

Yeah, I mean 54, I'm not that far from that age. You should have a lot of life ahead of you, you know. And so when you're in that kind of physical state, you'll do anything if you think it's going to make it better. And the truth is, without the financial resources to afford a self-pay surgery in the US and without bariatric coverage, going to Mexico to sleep was your only realistic option. It really was the only thing. Talk to us a little bit about your nutrition at that time, prior to surgery.

Armetta: 18:37

You know and that's a very good point to bring up too A lot of people probably would think that, wow, she must eat a lot. My goodness, to be 412 pounds, you have to eat a lot. No, that's not true at all. I wish I could show you the picture I found earlier myself when I was 16. The typical average looking kid. I wasn't an emotional eater or anything like that, but I like the typical average American kid hot dogs, pizza, whatever. You know, when you're 15, 20 years old and you take those habits into 25, 30 and 40 and you don't change them, you're bound to run into some problems because you can't eat the way you did when you were young. Going into, you know, getting older, Some things have to change and it didn't, I didn't, and it eventually caught up with me.

Armetta: 19:24

You know, then you're older, you're have to change, and it didn't. I didn't, and it eventually caught up with me. You know, then you're older, you're sedentary, your lifestyle changes, you're working, and this is a lot of factors.

Dr. Weiner: 19:33

Yeah, so we talked to us about that. I mean, how often do you see people who are 400 pounds and you really feel like they're not eating that badly?

Zoe: 19:41

Yeah, well, and the other piece of it too, is what we talk about a lot with dieting history, right, like going on and off and on and off all of these other diets throughout the years, armada, is that something that you feel as though you cycled through or tried to work towards in your adult years of on and off different diets to try to lose the weight, diets to try to lose the weight, and it just kind of kept creeping. That metabolic thermostat that we talk about, you know, chronic dieting and this yo-yoing of weight can also be a really big predictor of difficulty to lose weight for the long term as well.

Armetta: 20:20

I would say that that's probably. I mean, you're absolutely right, you're the expert in that area. I would say that that's probably. I mean, you're absolutely right, you're the expert in that area. I would say there were efforts to change some of the you know, some of my eating habits, but it wasn't like I was a chronic dieter or anything like that, but it was just the fact that, wow, you just woke up one day. It's just like how did this happen, you know? And it brought on other problems. I ended up with cervical cancer well, endometrial cancer, and one doctor actually said I think you got it because you were overweight, because of the estrogen levels I had a total hysterectomy before I moved to Michigan, to you know, go ahead and continue to pursue a better, healthy lifestyle.

Armetta: 21:15

Yeah, so it did cause a lot of problems.

Dr. Weiner: 21:16

Let's go back to Mexico and let's talk about what's happening. You feel like you're not going to make it. You're in trouble. What happens next? Tell us're not going to make it, you're in trouble. What happens?

Armetta: 21:28

next, tell us what you can remember of it.

Dr. Weiner: 21:29

What I can remember is like yeah, I told my friend.

Armetta: 21:32

Yeah, yeah, a friend of mine. Again, like I said, I called a friend because I was so. I was like I don't know what to do. You got to get me out of here. So she called I'm not exactly who she got in touch with, but she ended up talking to Sharp Memorial Hospital. That's very close to the border between Mexico and California and I'm glad it worked out that way. I work out at LA Fitness and I worked out with an emergency room nurse. She says Armita, I don't like that you're going, but do me a favor, make sure that you're near a hospital that's near the border. If they have to get you back to the United States and I remember Dr Weiner you even say what did you say? You said Armada, that's exactly what's going to happen. Something's going to go wrong. All they're going to do is patch you up and, just like, push you over the border into a hospital.

Dr. Weiner: 22:26

And that's exactly what happened. Um, yeah, you and I spoke before and I urged you not to go to mexico, right and uh, if I can use the, the term that you used at the time.

Armetta: 22:33

You said I met, you're too sick to go to mexico. And I looked, it was like I understand. It was like no, I don't think you understand. And you're famous double jack diamond or something.

Dr. Weiner: 22:42

Yes, yes, yes, that's Zoe, zoe also, but I'll refer when Zoe and I are talking about cases and I'll say, oh, that one's a double black diamond, kind of referring to skiing, which is like that's the one that's straight down with the moguls and the ice off the cliff. And that really was the nature of your surgery, cause you know, when I look at patients, you had kind of all of it. You had the medical issues, you had the size, and then it was a revision surgery on top of it. So when you look at complexity of surgery, it doesn't add, it multiplies, and so you have all three components that make surgery challenging and that made you very much a double black diamond. I mean, getting you through surgery safely at 400 pounds, with a history of a lap band and severe pulmonary problems, that really required a tremendous amount of planning and, just, you know, generally good luck and a strong team to get you through that safely.

Dr. Weiner: 23:37

And you weren't going to get that in Mexico. You were, without question, a double black diamond, very big. I mean. I don't want to say, you know, not every bariatric center in mexico does a terrible job. There are actually some places that do decent work and I think for some patients in in that situation, not the double black diamonds, but you know the simple, straightforward cases without any um, without any bariatric coverage, who are maybe going down for a sleeve and then planning to use up, like, say, our nutrition program for the post-op support. That may be your best option if you've got a bariatric exclusion, but for you I don't think any center in Mexico is appropriate, let alone the one you went to.

Armetta: 24:16

Absolutely. I mean I totally, totally agree, and I think the recovery was very, very long. In fact, what ended up happening? Two weeks into arriving at Sharp Memorial, I was put in a medically induced coma because it was just going from bad to worse. I guess I remember looking up at the doctor saying, how am I doing? And he wouldn't say anything and I just kept getting transferred from room to room to room in ICU. And I just kept getting transferred from room to room to room in ICU and it was quite some time before I actually woke up and could figure out what was going on. So I remember one of the first questions they asked do you know where you are?

Ashton: 24:55

And I cried because I didn't even know where I was.

Dr. Weiner: 24:57

Yeah, yeah. So the way I piece this all together is, when you have a lap band, you wrap the stomach around the band. That's how you keep it in place. And then when you convert to another procedure, and you went to have a conversion of your lap band to a sleeve which is another conversation to have because in general we don't see great results with that surgery but you have to really flatten out the stomach completely and that's the key. You get the stomach perfectly flat, remove the band and then you do the sleeve.

Dr. Weiner: 25:30

And I think my guess is what happened is you started to have issues with your lungs and that he didn't take the time necessary and he just stapled, stapled, stapled. And where the stomach was folded over, he stapled through two layers of stomach and then it probably just pulled apart, because the staple is really not designed to go through two layers of stomach, and you developed a sepsis and a leak and they ended up doing drainage procedures. They haven't operated on you in San Diego, but what happened is the infection ultimately kind of decompressed into your large intestine and so you had a direct connection between your stomach and your large intestine, which is a complication I've seen exactly once in my life after pediatric surgery and that was on you.

Dr. Weiner: 26:17

And it is a rare and very unfortunate surgery that is also very largely preventable with proper surgical technique. And so you ended up spending five or six months there and ultimately they called me up. One of those doctors there said hey, listen, we got to transfer her back, but she still needs some help. Will you take care of her? I said absolutely. So we transferred you back and you came into my office and I took one look at you and I said go to the ER. You got to admit you to the hospital. You were not in any shape to kind of be out there and so we admitted you to the hospital, did all the tests and then I did probably a five hour surgery to get things, the first of many surgeries truthfully to get she straightened out and you had all of it.

Dr. Weiner: 27:09

You had the colostomy, you had a hernia. After it was all said and done, but and I really I kind of at that time, it was the first time I'd ever done the surgery. I've done it since, actually in similar situations. I call it the Armeta procedure.

Armetta: 27:25

Well, I'm honored.

Dr. Weiner: 27:28

You have kind of a combination of a sleeve and a gastric bypass where I connected the intestine to this. We give it a hole and I connected the intestine to that hole and you ended up getting through all this.

Zoe: 27:44

And I was just going to say. You've clearly come so far in these 10 years and I'm sure your life is completely different. Will you share with us a little bit more about what that quality of life is like for you now in comparison, and and what are some of the things you're enjoying to do these days?

Armetta: 28:02

Life is a lot better. Life is a lot better. Life is a lot better able to, you know, enjoy things with friends. Go after 30 years riding a bike for the first time about a month ago or so.

Armetta: 28:13

I can't do a lot of running still because of the legs of what happened, you know, with my back, but able to. You know I still play racquetball a little bit still. I can still do that. So I'm kind of back to my, my tomboy years time, growing years or whatever, just out playing, just doing a lot of stuff. So yeah.

Dr. Weiner: 28:32

So what have you learned from this whole situation? You know, from an emotional perspective, from a spiritual perspective, I mean, this is as close to a near-death experience as you can get.

Dr. Weiner: 28:46

And you know you also ended up on the other side in, like, you ended up kind of getting what you wanted out of the whole thing. Right, you wanted all these things you've achieved. You wanted to eat better, to have a better quality of life, and so, you know, you went through this thing, man. You came so close to dying. You should have died like probably four or five times in that whole story and yet you are on the other side. You know what's that like, spiritually, emotionally, you know.

Armetta: 29:15

Oh, wow, I'm so glad that you asked about the spiritual aspect. It changed my whole life entirely. I'm spiritually not the same person, came out of that coma totally, totally different. Gosh People ask me what was it like? I tell people I didn't see the white light, I didn't see Jesus.

Armetta: 29:36

So I didn't see any of those things like that, but it was kind of. It was like being between life and death. You were just in a place, not a bad place, so when it's time to go, not scared ready. But yeah, it's different. I remember the social worker in California coming in several times. She said she was in tears because they were putting together end of life I guess materials to say goodbye. But I pulled through. But it changes your life. You respect life a lot more. I think the things that are important to me are the people that you love and the people that you spend time with, because at the end of the day, that's all that matters. So I think I love a lot harder, I live a lot harder and I try to give more that's wonderful great words of wisdom.

Dr. Weiner: 30:30

I had a good doctor, oh yeah well, any other thoughts, zoe or Armeta, on this kind of crazy experience, everything you've been through and any recommendations you'd give to somebody who's maybe considering bariatric surgery maybe higher risk patient, you know, because you higher risk but also higher rewards for you I mean, would you, would you do this all again Honestly, yeah?

Armetta: 31:03

Well, no, the earlier joke today was I'd rather have 10 Mexican surgeries than have to learn a new piece of software Period Period. But no, I would tell somebody again. This is an emotional, such an emotional time for people. Talk to your doctor, get a good team of people that you can talk to and see if there's something you can do, because at the end of the day, one bill coming from Sharp for me, whereas maybe you would have spent $20,000, $30,000 on an operation, I think one bill was like $1.5 million.

Ashton: 31:43

Yeah.

Armetta: 31:44

It was quite a bit. So talk, you know. Spend time, talk to your medical team, see what you can do. Just don't make a hasty decision. Or any, most definitely it's tough though because, yeah, you were desperate though.

Zoe: 32:00

Yeah. I think maybe having that team of people that you can really trust and who know have your best interest in mind, and that's going to help you. You know, connect that emotional desperation that you're feeling with the logistical and you know, objective next steps that make sense for you, having the best outcomes and kind of combining them together with people that you trust, who are professionals yes, it's.

Dr. Weiner: 32:29

Sometimes it's really difficult to separate the emotional need and kind of the desperation from the the right thing to do, um and uh. But I think your point about about the cost of it really speaks to the dangers of a bariatric exclusion, because my guess is that you blew up WJR's insurance spending for the year with that claim. Probably, probably, yeah, they probably could have saved a lot of money had they offered bariatric surgery. So I think that's something that we really need to get out to employers is that that little short-term savings you may get by eliminating or excluding bariatric surgery may end up biting you in the long run and causing this catastrophic claim, because insurance for companies is complicated but catastrophic claims do. They do pay a portion of it and it does influence their spending going forward. And so I think you know, particularly for higher risk patients, if you put exclusion on that policy, that can be quite expensive in the long run.

Armetta: 33:42

I agree.

Ashton: 33:44

Yeah.

Dr. Weiner: 33:45

All right. Well, thank you so much for your time, Armetta. It was so good to catch up with you.

Zoe: 33:49

Gosh what a story. I can understand why she's one of your most memorable patients and has a procedure named after her Again.

Dr. Weiner: 33:58

I've done it, I've done it since and it worked. It's a good procedure and it's actually out there in the literature too. When I did the procedure it really wasn't in the literature 10 years ago, but there's other people who have kind of talked about this and it's now the actual. The actual technical name in in our, in our specialty, is a fistula, j? Uh or the j stands for jejunostomy. That means we connect the fistula to a loop of small bowel. Um 10 years ago that that really wasn't out there because, um, the most common treatment at that time was a total gastrectomy, right, which is it's a rough procedure.

Zoe: 34:33

Well, and also I mean what a much better quality of life you were able to give her by not doing that.

Dr. Weiner: 34:39

Yeah, Now that we're 10 years out, I think if I asked 10 surgeons what to do now, I think probably at least nine of them would have agreed with the fistula judge. I think at the time it was I got probably more people telling me to do a total gastrectomy because that was kind of the standard answer back then. But we, you know, we learn and that's why they call it the practice of medicine, right. Yeah absolutely, Zoe. What do we have for nutrition this week?

Zoe: 35:03

Well, you know I wanted to talk today about sodium because I get a lot of questions about replenishing electrolytes, right? Patients asking should I add electrolytes to my water? You know the liquid IV, the different things like that, and most of the time my answer is you don't need it. Most Americans get far too much sodium. And also, unless you're like running a sweaty marathon, you know you don't need to be running quite that much that was an exaggeration, but still like unless you're doing an hour of intense, sweaty exercise.

Zoe: 35:45

In the heat, in the heat regularly, you don't need to replenish those electrolytes. You know, if you're eating a wide variety of whole foods, a lot of foods have natural sodium in there, and the other electrolytes of course as well, so don't really worry about it, honestly. And so, in terms of specifically with sodium, most of the time, I do generally recommend to pick low sodium options of things, whether it's canned beans or you know whatever, the whatever, whatever sort of option it is to get a lower sodium because of that. That uh statistic of most americans I think it's get. They get over 4 000 milligrams of sodium every day. The the daily recommended dose is 2300 or or about less, depending on your cardiovascular status. That you know. If you have hypertension and those different types of things, then we want to have less sodium. But most people could benefit from watching their sodium intake, but you don't need to really worry about it. So so much unless you've been diagnosed with a cardiovascular condition.

Dr. Weiner: 36:56

Yeah, I think there's a couple of important points too about sodium. The first is it doesn't contribute to obesity.

Ashton: 37:03

Right.

Dr. Weiner: 37:04

That's the first thing, like how much sodium or how low of sodium you eat.

Zoe: 37:07

But what is related is where do most people get all that sodium from? Is highly processed foods, which are obesity, obesogenic, right yeah.

Dr. Weiner: 37:19

Yeah, so the high sodium content is absolutely a marker for processed foods or heavy or fattening foods. A good guideline that you can use to look and determine if a food is high in sodium is the ratio of the number of calories in the food to the milligrams of sodium, and it should be kind of one-to-one. If you look at 2,300 milligrams as the recommended allowance for sodium, 2,300 calories is probably about the average amount of food that people eat in a day, so that's kind of a good. If it has more sodium than calories, it's probably a little bit more processed. That's not an absolute rule, but that's a general guideline.

Zoe: 37:57

You know, I've never heard that. You've never heard that rule. I'm so glad you shared that yeah.

Dr. Weiner: 38:01

So I think it just kind of makes sense. It's if you're going to eat 2,300 milligrams in a day and eat about 2,300 calories, then that'll show, that'll tell you more.

Zoe: 38:10

And just for a little visualization for you guys, 2,300 milligrams of sodium is the equivalent of one teaspoon of table salt.

Dr. Weiner: 38:21

Okay.

Zoe: 38:22

So think about a teaspoon of table salt, but that's not only for salting your food. That's all of the sodium in all of the different foods that you're eating throughout the day, and so you know people who salt their food heavily. Then that gives you like kind of a good gauge. But I generally, I personally, don't salt my food. I don't really cook with salt. I go for low sodium. I'm very active and I'm fine.

Dr. Weiner: 38:47

Have you ever been hospitalized for any electrolyte abnormalities? No, I think that's the really important point is that if you have ready access to food and water, your body will automatically correct for this. And if your potassium is low, you might look at that banana or that citrus fruit and be like, oh, that looks really refreshing and good. And so your brain knows. We have this inborn nutritional intelligence that kind of tells us what we should and shouldn't be eating, and just if you rely on that and eat healthy food and have ready access to them you're not marooned on a desert island starving to death then you'll correct your electrolytes pretty straight.

Zoe: 39:25

That's going to change my answer. If anybody asks, what food do you want with you stuck on a desert island, I'm going to look for electrolyte rich foods?

Dr. Weiner: 39:35

Totally Not licorice. Yeah Well, let's move into our economics of obesity segment. We're going to talk about overseas and really specifically weight loss surgery in Mexico, and there's a lot of people who go down to Mexico because the price is significantly less than it is here in the United States. I've seen this many, many times where I've talked to a patient and they've been like they've come to see us for some help with whatever happened after their bariatric surgery and I'm like well, where'd you have your surgery? They tell me they had it in Mexico. And I look at their insurance and we check everybody's insurance when they come in for an office visit. We know who has bariatric surgery coverage and who doesn't. A lot of the times the patients had bariatric surgery coverage. They could have absolutely had it done in the United States, but they assumed that bariatric surgery wasn't covered by insurance. 95% of all insurance policies cover bariatric surgery, and so the only people who should even begin to think about going overseas are people who have a bariatric exclusion, like what Armada had, and so if you have a bariatric exclusion, that's a different story. You're not going to get the bariatric surgery paid for. But there are some patients and there are some centers who do good work down in Mexico, there's absolutely no question, and they actually even publish in our journals, and so I look through some of the journal articles to see what the centers in Mexico are publishing.

Dr. Weiner: 41:04

The first thing that I will tell you is that their follow-up rate for even a one-week post-op visit is less than 50%. So one of the key components to bariatric surgery is long-term care, and that's why we've created our support group and we track down our patients and if you haven't seen us, if you're out there listening to this and you haven't seen us in a year or so, please come in, check in with us, get your labs drawn, make sure you're on track, make sure you maybe haven't started any weight loss, weight gaining medications, and if you have gained a few pounds, there's a lot of options we have to help you. So you know, postoperative care as part of the surgery is key, and when you have it overseas, in general you're not going back. Some of the places do offer telemedicine and I think that's great, but the majority don't. I mean this is really kind of a cash for surgery transaction.

Dr. Weiner: 41:57

The other thing that I saw is that there is a substantially higher complication rate in the couple of Mexico studies that I saw, compared to what our national averages are. So our national averages for a sleeve is about 1% serious complication rate and it's about 2% for a gastric bypass. In these studies they showed a 6.4% rate of serious complication. This was a gastric bypass study, so they had a 6.4% rate of serious complication for gastric bypass, which is about three times higher than what we see in the United States. They also had a 3.2% rate of fistula formation. That's what Armetta had was a fistula and that's what resulted in everything she went through.

Dr. Weiner: 42:43

I don't know that I've had three fistulas in the last 10 years and so that rate seems extraordinarily high, and so I think we do have to acknowledge that when we look at overseas surgery, it is not as safe as it is here in the United States. Especially, you go to a center of excellence, you go to someone who is an experienced surgeon who's done thousands of these things. We're seeing complication rates in our practice less than 1% and that's all surgeries sleeves, gastric bypasses. I've done 1,500 sleeves. I've never had a leak from a sleeve, and so I think it is possible to do these surgeries almost at that 0% serious complication rate.

Dr. Weiner: 43:21

I don't want to tell you I don't have a 0% serious complication rate. Nobody does but I absolutely don't have a 6.4% rate of serious complication. So I think surgery in Mexico is appropriate if you are young and healthy and it's not a revision surgery, it's a first-time surgery. I think bypasses are a more challenging surgery. I think I would probably stick to sleeves in Mexico. It's a much easier surgery to do. I think going there if you're high risk, going there for a revision procedure, you're potentially taking a substantial amount of risk with this.

Zoe: 44:00

Well, I mean, if we think about what you were saying earlier about, most people have bariatric coverage, 95% of people who are on insurance have bariatric coverage, whether they have an exclusion or they don't have insurance or whatever. So that means we're looking at paying out of pocket. So then it's like, okay, maybe look around your area for those self-pay options and it might be more affordable than you think.

Dr. Weiner: 44:30

Yeah, I mean, I think we talked about this in a past episode I think actually while you were gone, we talked about this and bariatric surgery in Mexico is five to 8,000 bucks, somewhere in that range.

Zoe: 44:43

Yeah.

Dr. Weiner: 44:43

That's not very much money truthfully for a major surgery.

Zoe: 44:45

Right, but I mean also, if you compare that to, for example, our self-pay surgery costs, it's not like that significantly different you know, so I don't know. It almost seems like, of course, do your research, like we've already talked about, but maybe it's a matter of not just automatically assuming that it's going to be the best, most cheapest option. I don't know.

Dr. Weiner: 45:12

I'm just kind of I think you start factoring in time off of work, the flight and all that kind of stuff and potentially the cost of a complication right we were talking about with our meta.

Zoe: 45:22

You know they the her insurance didn't want to cover. Uh, you know, let's call it ten thousand dollar surgery and they ended up spending 1.5 million dollars for a five month.

Dr. Weiner: 45:32

Yeah, you know yeah, her perspective honestly. She lost wages for six months, yeah, and then, you know truthfully, for another year after that until she recovered Absolutely.

Zoe: 45:41

So Talk about economics, yeah, yeah.

Dr. Weiner: 45:44

Yeah, so I think it's important to really factor in everything. I think, if you are looking at going overseas, be careful. There are good places. Do your homework. There are good places. There are bad places. The complication rate is a little bit higher, and so I would just be careful with that decision. Do your research. Yeah, all right. Well, we have a special guest today. We have Ashton, and she is going to help us with our questions. So, ashton, what kind of questions do we have out there from social media this week?

Ashton: 46:18

So the first question is from Gordon. He sent us an email and he said I am already on a mostly vegan diet, with the exception of eggs and fish. I do eat vegan junk food. However, the elimination of things like chips, chocolate, processed soy milk, packaged miso soup, canned bottled chili, olives, et cetera, from my diet will definitely result in hunger. I also have a tendency to binge at night. Will the MRD plan work for?

Zoe: 46:45

me so MRD being metabolic reset diet?

Zoe: 46:49

And the answer is absolutely, especially if you're already suffering from hunger by taking away those processed vegan junk foods.

Zoe: 46:58

Because here's the thing just because it's a vegan diet does not automatically mean that it's healthier or aligned with losing weight, right, and of course you know that and that's why you asked the question.

Zoe: 47:10

So the metabolic reset diet not only will help you with your hunger and with propelling weight loss if that's what you're wanting but it's also going to help, in my opinion and in my experience what I've seen with patients that binging at night because if you're eating enough during the day and your body is nourished and you're fueled and you're not feeling hungry, that helps to quiet that food noise and that helps to decrease that tendency to binge at night. So I would say head on into a metabolic reset diet session with me over at the nutrition program. We also have the free metabolic reset diet download. If you haven't gotten that handout yet, you can get that from our website. So know that there's a lot of resources and we're here to help. So I would say lean into the metabolic reset diet. We can adapt it to make it a fit with your modified vegan diet, and I know that you'll be able to help curb that hunger.

Dr. Weiner: 48:15

Yeah, I think the metabolic reset diet in our program is certainly very vegan friendly. It's not a vegan diet but if you are a vegan you can still follow it. Veganism is a tough lifestyle. There's a right way and a wrong way to do it and where, if you kind of eat the wrong way as a omnivore, eating meat and everything else, you tend not to get into any nutritional trouble. But you absolutely can get into nutritional trouble as a vegan if you do it the wrong way.

Zoe: 48:45

Yeah, I mean, I feel like, especially in college, I remember a couple of different people who were vegetarian or vegan and but didn't eat any vegetables, like they were just eating, you know, cereal and it's like, or you know whatever it's like if you're gonna be vegan, you gotta eat vegetables.

Dr. Weiner: 49:03

All right, what's our next question, ashton?

Ashton: 49:06

um, okay, this one's from instagram, from doc2w. Um, what in the mechanics of the sleeve contribute to the GERD that the RNY corrects? That's a great question that is a great question.

Dr. Weiner: 49:18

So in general the most common thing and we do a lot of endoscopy on patients who have acid reflux after a sleeve so in general the description I use is called hourglass stenosis, and part of it is because it's actually a great diagnosis for getting surgery approved. But it really does very accurately describe what we see, which is that you know, if you make the sleeve incorrectly at the very top, if you kind of go out and you get the top of the hourglass and then you have this kind of narrowing at this area of the stomach called the insesura, which is kind of this angle or bend, and then it kind of splays out and a sleeve shouldn't be sleeved all the way down to the bottom of the stomach. You do want to leave that part of the stomach called the antrum. You do want to leave a little bit of that part more in its normal state and so when you get this kind of hourglass formation, the acid that forms in the stomach can just reflux up and it kind of increases the pressure and it pushes it up. There's a couple of other things too. Hydal hernias contribute quite a bit to acid reflux after a sleeve and a hydal hernia is when the stomach slides up through the hole in the diaphragm. So the diaphragm is this big, thick muscle that separates your abdomen from your chest and it kind of connects your ribs together and it flattens out and that's how we breathe and there's a little hole in it where your esophagus comes through and then the stomach goes through and we'll tighten that hole up.

Dr. Weiner: 50:44

Often when we do sleeve gastrectomies or even gastric bypasses We'll fix hiatal hernias. The problem is with the sleeve you have a skinny tube and you have a hole and a skinny tube and that skinny tube can slide it back up into that hole and so we see quite a high recurrence rate of hiatal hernias after sleeve gastrectomy. And then that puts that junction between the esophagus and the stomach up into the chest and it just doesn't work right there because the pressure is it's a negative pressure when you breathe in and so that negative pressure kind of opens up the valve and lets the acid rush in. And so what we do when we convert to a gastric bypass is we separate the bottom part of the stomach, which is where the acid is made, from the top part of the stomach, and so we separate where the acid's made from the esophagus so that acid is still made but it can't go back up into that top part of the stomach and cause acid reflux, and so a gastric bypass is incredibly effective.

Dr. Weiner: 51:42

So it works by separating the acid from the esophagus and secondly, it decreases the pressure. Because of that hourglass stenosis the pressure can build up in the stomach and that high pressure pushes it up, especially with a hiatal hernia. And so when we divide the stomach, we divide it above that stenosis or narrowing, then the pressure in the stomach decreases by a factor of threefold. They've measured this and it's a three times decrease in pressure with a gastric bypass compared to a sleeve. So that decreased pressure also helps quite a bit.

Zoe: 52:14

Great explanation.

Dr. Weiner: 52:16

All right, I felt like I needed a drawing to do that.

Zoe: 52:19

I think you have a video on that, don't you?

Dr. Weiner: 52:21

I have a couple videos on that. All right, Ashton, what's our last question for the day?

Ashton: 52:31

Okay, Our last one is from Christine, also from Instagram, and she said I had the gastric sleeve done in 2020 and had a great success with it, losing a hundred pounds. I started to gain weight and once I was at a 17 pound regain I didn't want to spiral out of control, so I took the initiative and started Ozempic. In November I successfully lost the 17 pound regain and an additional 10 pounds on top of that. I started at the 0.5 milligram dose the first month, Then the second month I went to the 0.75 milligram, Then the third month I went to the 1 milligram. Now I am 5'8 and 142 pounds and don't really want to lose any more weight. What is the best strategy to maintain this current weight?

Dr. Weiner: 53:08

So, zoe, nutritionally, what are you going to recommend for this patient?

Zoe: 53:12

Well, I'm going to make sure that she's getting in enough protein, that we're adding in veggies, she's reaching her hydration and also that you know if she's exercising. We want to make sure that she has a good balance of those complex, healthy carbohydrates as well to support that energy.

Dr. Weiner: 53:29

Yeah, I think that the key here is that this is weight regain, and I look at weight regain in this patient a little bit differently than like. If you take out the sleeve from this patient, then I'm going to give you a totally different answer than I will, because this patient's had a sleeve, but she regained 17 pounds, and so typically we look at these medications as a long-term medication. The big question I have and I still don't know the answer to it is do we need long-term medications after bariatric surgery for weight regain? And I think we're starting to see a little bit of evidence that maybe we can get away with, if not completely stopping it, but really spacing out the dosing interval or even kind of putting patients, giving patients holidays from the medication. We're seeing this because of the shortages it's being imposed on us, and I'm seeing a number of bariatric surgery patients who've lost weight on the meds, not necessarily regaining weight the way I would expect and the way we're seeing in our non-bariatric surgery patients. So you know this is a lot to unpack.

Zoe: 54:36

There's a lot of questions this is certainly you know.

Dr. Weiner: 54:39

If you're out there, this would be a perfect poundicure platinum kind of scenario For sure, where we would help work with you and come up with a strategy for minimizing your use of the medications.

Zoe: 54:52

Creative dosing strategy.

Dr. Weiner: 54:54

Creative dosing strategy. Creative dosing strategy to minimize cost and honing in on that nutrition.

Dr. Weiner: 55:00

A lot of you know unanswered questions, because obviously there's just a, it's just a dm, so, um, you know, obviously there's a lot we don't know here I would work to to minimize the use of medications and really push you know over to zoe to help with the metabolic reset diet and the exercise and all that kind of stuff. And I push you know over to Zoe to help with the metabolic reset diet and the exercise and all that kind of stuff. And I think if we can put that in place we can get you to a point. You know you're talking about 0.5 or 0.75. I would be potentially looking at every other week dosing every other, you know even monthly, not staying at that one.

Dr. Weiner: 55:30

Yeah, we had had patients doing well with monthly dosing and it'll vary. And I think that's the important thing too. Is that the idea that you're going to be on this med and stay on the same dose, and this is how they did the trials and it makes sense and these are what the FDA is recommending. But because of the cost and because of the need to be on these long term, our goal really should be to minimize the use of the meds as much as possible and there are strategies that will allow us to do that and I think over time we'll find that these strategies are probably in people's best interest. And it takes away this like I'm gonna just max myself out on the meds and eat like crap because we know that's not gonna be a healthy option, and we really want people to push and make the best of nutrition and use the meds as little as possible. I think that's going to be the healthiest, best.

Zoe: 56:18

Supplementary.

Dr. Weiner: 56:19

Yeah, supplementary best strategy. So the best strategy is minimize the use of meds and maximize the use of the metabolic reset diet. And how exactly we do that, that's something you kind of have to figure out over time More individualized. Yeah, yeah, but interesting question and certainly something we're seeing a lot in our practice and there's no data on this. This is kind of what we've learned after putting a lot of people on these meds. Right, all right, another great episode.

Zoe: 56:45

Yeah, Very good. I just love hearing from all of our different patients and the wild stories and just how just you know how how much like people's lives can really change.

Dr. Weiner: 56:57

You know, I know, yeah, I mean, bariatric surgery is such an awesome field to to be in and weight loss because you get someone to lose a hundred pounds, you have a friend for life, you really do, and and being able to kind of spend our day and you spend your day this way, I spend my day this way kind of being a part of this amazing transformation in people's lives. It's pretty awesome.

Ashton: 57:19

Absolutely.

Dr. Weiner: 57:20

What a great way to spend your day or your life, really so we're lucky. We are lucky.

Zoe: 57:25

Absolutely All right. Well, thanks for being with us today and of course, we need to thank our guest producer, ashton and Rhiannon, and the editing of the podcast is done with our team over at Autogrow. And, of course, a special thanks to our double black diamond patient guest today, armada.

Dr. Weiner: 57:44

Absolutely so. Check us out on social media, consider joining our online nutrition program or Pound to Cure Platinum program, and we'll see you next time.