Do You Have the Obesity Gene?

Episode 33 of The Pound of Cure Weight Loss Podcast is titled, Do You Have the Obesity Gene? The title comes from our In the News segment, where we dive into an article by CNN titled, Researchers Have Found A ‘Clear Genetic Trigger for Obesity’ that Applies to Some People. According to the University of Exeter, a gene typically responsible for thyroid function and baseline energy expenditure named SMIM1, may be partially to blame for Obesity in those that carry two faulty copies of the gene. So, how does this affect the treatment of Obesity? Tune in to find out!
 
 In our Patient Story, we talk to Kate who had rapid weight gain after a partial hysterectomy due to PCOS. She needed bariatric surgery to get the weight off, but her insurance wouldn’t cover it. So, she went to Mexico for the surgery and joined our nutrition program for her post-op care. She has lost 100 pounds since her surgery and 130 pounds off her highest weight!
 
 In our Nutrition segment, Zoe offers tips on how to add more movement into your day if you work a desk job, without going to the gym or adding an exercise routine into your already hectic schedule. 
 
 Since the approval of GLP-1 use for the treatment of Obesity, one of the most frequently asked questions has been, “Why won’t my insurance company cover the medication?” It all comes down to the acronym, QALY. In our Economics of Obesity segment, I break down QALY’s and explain their purpose.
 
 Finally, we answer 3 of our listeners’ questions including, whether or not a sleeve patient can have the LINX procedure, how to maximize protein without eating meat, and how to minimize hair loss after bariatric surgery.

Transcript

Dr. Weiner: 0:17

So this is really interesting. So we found a gene that is directly linked to obesity. We know that obesity is genetic, there's no question about it. Finding those genes is a different story, but when I look at this stuff because I'm a physician, I spend my day treating patients, and so this is fascinating and interesting and revolutionary in many ways. But is it useful ways? But is it?

Zoe: 0:43

useful. Welcome back to the Pound of Cure Weight Loss Podcast episode 33.

Dr. Weiner: 0:53

Do you have the obesity gene? Huh, yeah.

Zoe: 0:53

I guess we'll find out.

Dr. Weiner: 0:54

There's probably a lot of obesity genes? I would think so, yeah. So, zoe, have you seen Lemmy Curb?

Zoe: 0:59

Yes, great marketing. Oh my gosh, their website is beautiful.

Dr. Weiner: 1:03

Isn't it gorgeous Very enticing.

Zoe: 1:05

It's almost as if they have billions of dollars at their disposal for marketing.

Dr. Weiner: 1:09

You would almost wonder. So one of two things is going on with Lemmy Curb, which is that the Kardashians have assembled a group of scientists who have cracked the code and developed an over-the-counter supplement that will curb your appetite. That's one possibility. The other possibility just hear me out is that the Kardashians have taken a very old supplement that has been demonstrated over and over to have very limited utility and created a brilliant marketing campaign that has suddenly made everybody want this. Which do you think it is?

Zoe: 1:52

Not sure.

Dr. Weiner: 1:53

I think, zoe, this is really very much the placebo effect for sale, and especially when it's kind of marketed and really makes you believe, then you're going to take this and be like yeah see, I don't have much of an appetite anymore.

Zoe: 2:07

Well, I mean, there is something to be said about riding that wave of the placebo effect.

Dr. Weiner: 2:13

I mean there's some value to it, but I don't know if you should pay 40 bucks a month.

Zoe: 2:17

Right when you could get the same thing for 10.

Dr. Weiner: 2:20

Yes, yeah, yeah, yeah, you can buy some chromium supplements, you can get your placebo effect much cheaper than in a pretty purple bottle. And I think that should probably be the take-home point here, which is we're not against the placebo effect. No, it works, it's real. Yeah, it doesn't last. That's the one problem with placebo effect, but it does work for short term. But if you're going to get the placebo effect, get it at a good price.

Zoe: 2:45

Discounted placebo.

Dr. Weiner: 2:49

All right, let's move into our in the news segment. So this comes from CNN and the title of the article is researchers have found a clear genetic trigger for obesity. That applies to some people and it comes from the University of Exeter in the UK. And they found this gene. They call it SMIM1. And they found that women who had two faulty copies of this gene weighed on average 10 pounds heavier than women who had at least one functioning copy. For men, it was only five pounds difference, which is interesting because men tend to weigh more than women who had at least one functioning copy. For men, it was only five pounds difference, which is interesting because men tend to weigh more than women, so clearly a greater percentage weight increase for women who had this gene than for men. And so this gene is actually responsible for thyroid function, and that's something that I think it's often discussed, but we don't really have any good answers on it, and you know we see a lot of people who come to us who've gained weight from Hashimoto's thyroiditis or being hypothyroid, and so having a dysfunctional thyroid certainly can cause weight gain. The problem is, once you fix the thyroid, you don't lose the weight typically, and but this gene shows that the thyroid clearly is involved in energy metabolism and basal energy expenditure, and if you have a faulty copy, you are more likely to develop obesity. So here's the thing. So this is really interesting.

Dr. Weiner: 4:12

So we found a gene that is directly linked to obesity. We know that obesity is genetic, there's no question about it. Finding those genes is a different story. Obesity is genetic, there's no question about it. Finding those genes is a different story. But when I look at this stuff because I'm a physician, I spend my day treating patients, and so this is fascinating and interesting and revolutionary in many ways. But is it useful? So, first of all, one in 5,000 people have this gene, so that's a very small percentage of people, right we're. We know that 40 of our country is obese. One in five thousand have this gene. So the overwhelming likelihood is, if you're overweight, it's not because of this gene right that's the first thing.

Dr. Weiner: 4:54

The second thing is what can we do about it? We're not at the level of off being able to offer gene therapy. That's going to happen. You and I have a friend who's actually involved in some of these in a biotech company and they're doing some pretty great things and it's going to happen, but probably not for another five or 10 years, to the point where they can say, hey, you've got this bum gene, we're going to inject a virus and it's going to repair this gene for you or create a new functioning copy of this gene.

Dr. Weiner: 5:24

What is really important from a genetic component, I believe, is looking at not the genes that cause obesity, but the genes that show a response to either GLP-1 medications or bariatric surgery. We've talked at length about the fact that 10 of people do not respond at all to glp1 medications. You take the medicine, you ramp up the dose, one out of 10 people lose basically zero pounds. We also see a huge variation in surgery. We see some people lose a very little bit of weight. I talked to a patient today who had lost only 25 pounds after her gastric sleeve and that was extremely hard for her. We also see the super responders right, the people who lose crazy amounts of weight and get down to a normal BMI. Why? We know it's genetic. Which genes we don't know. Are those genes actionable? Yes, they are.

Dr. Weiner: 6:17

If we could do a genetic test that would say, hey, you're going to respond really well to GLP-1s or you're not going to respond to GLP-1s, we can kind of skip that step. We could potentially take our limited supply of GLP-1 medications, our limited dollars for paying for these medications, and dedicate them to people we know are going to have the maximal response. Same thing for surgery. We can know before we do the surgery hey, you're going to respond great or you're not. And that can be part of your preoperative counseling or your pre prescription counseling, and that would be incredibly valuable. If I had those tools, I would use them, I would rely heavily on them and I'd make a lot of decisions. And so this is where I want to see some of the research going.

Zoe: 6:59

So if you had to predict how many years or decades it might take to get to that point, what do you? What would you think?

Dr. Weiner: 7:06

I don't know, because I've we've known about genetics for bariatric surgery and I've always thought like, why don't they just do it? I mean, all these people do. 23andme.

Kate: 7:15

Right.

Dr. Weiner: 7:15

So we have everybody's genome. I mean, we have probably millions of genomes out there. How hard would it be to look and say, okay, here's who did well with GLP-1 meds, here's who did well with bariatric surgery. I mean, there's got to be some way to put this together. I don't know if it's been tried and failed or if it's just never been tried before.

Dr. Weiner: 7:35

The truth is, I'm not a researcher. My take on things is it always takes twice as long as you think. So we're probably at least 10 years away from having these tools, because once you start to hear about them, once you start to see those first scientific studies, it can be three to five years because of the FDA process before they're in your hands, and so I haven't seen any of these studies out there. I hope they're done, but right now I'm not aware of them. But they would make a huge difference and I'd love to see more energy dedicated to those types of projects. So if you know someone who's a researcher, send this on, see what they have to say about this. I think there's a couple of great projects in this and probably a lot of money to be made. Maybe I'll talk to my buddy, the biotech guy. Yeah, there you go.

Zoe: 8:20

Well, I guess we'll stay tuned on that.

Dr. Weiner: 8:22

Yes, I'll keep you informed.

Zoe: 8:24

Stay tuned for 10 years.

Dr. Weiner: 8:26

Check in 10 years, hopefully we're still doing the podcast. Yeah, all right. So who do we have for our patient story this week?

Zoe: 8:32

Well, I'm excited to welcome Kate, who is one of our out-of-state patients, who has been really involved in the nutrition program, really embraced the community and I'm really excited for her to share her story.

Dr. Weiner: 8:46

Yeah, kate went to Mexico. It sounds like she actually had a really good experience in Mexico and then she's really come and become part of our post-operative community and I think you know we welcome patients from Mexico. I think there's a lot of surgery practices who kind of you know, turn their nose down and say why would you ever go to Mexico? I think if you, if you have the opportunity to go to the U? S I think in general we've we've talked about this in the past there's a way better safety record here, especially with experienced surgeons, and you'll get in Mexico. But if that's the only thing that's out there for you, then that might be your best bet. And so you know, if you're out there and you went to had your surgery in Mexico, you know we're not going to turn our nose down at you in our practice.

Zoe: 9:28

So we're really excited to have you on the podcast. So tell us a little, just a little bit, about your story, what maybe brought you to the decision to have bariatric surgery and how you came to our practice. All that great stuff, yeah.

Sierra: 9:43

So my story was a little bit different. I didn't initially seek out bariatric surgery strictly because of weight. I have PCOS with insulin resistance. I would have to take birth control every day without that monthly break or I would end up severely anemic and I, you know, have issues for literal months. Um, and in 2013, when my mom's breast cancer had returned, it was hormone positive, receptor positive, and my doctor knew my mom's history and told me like you can't just stay on birth control pills forever with the hormones and stuff like that. And so I ended up with a partial hysterectomy and I went from 170 to 220 in a matter of five months. I had my ovaries, so they told me that shouldn't have been an issue, but it was.

Sierra: 10:46

And with PCOS and insulin resistance, it's all hormone based.

Sierra: 10:50

So as soon as those are a little bit out of whack, the weight just balloons like crazy and once it's on it's on, it's super hard to get it off.

Sierra: 11:01

During the hysterectomy, there was a complication and they accidentally wrapped a stitch around my ureter and tied it off, sent me back to recovery overnight, and it wasn't until the next day, when my doctor came to do her rounds, that we found it by the time they got me into surgery, the ureter had ruptured and there was severe damage to my right kidney. So it just, you know, complication after complication. So then, fast forward three years that I had been living with that, with the weight I started working out at like a boot camp style gym. Love the atmosphere, I love that I could go in work out. I had a trainer who would just tell me what to do, I didn't have to think about it, I could go in, work out and go home. And part of that was increased protein right To maintain muscle and help with fat loss, and at one point I was at almost 200 grams of protein a day.

Kate: 11:59

Wow.

Sierra: 12:00

I was still. I was losing weight. I managed to get down to 198 after three years of working out consistently like that six days a week, and I was still seeing my urologist annually doing checks. And it wasn't until the third year that my kidney function test came back with a red flag. Well, nobody told me in all of the years dealing with my urologist or anything that your kidney is what processes protein. And so all that protein intake was slowly damaging my kidney more and more, to the point where after three years I was at 19% kidney function. And so the doctor said you need dialysis and potentially transplant or we've got to get weight off of you my highest weight and I quit checking at one point.

Sierra: 12:59

I stepped on the scale one day and it was 263. Normally I balanced around the 230s. When I hit 260, I didn't check again and I was just so beside myself. So my family doctor, who's known me since I was 12, I was his first patient to recommend gastric sleeve under 400 pounds he knew I had done everything. I had tried Belvique, which was, you know, an appetite suppression pill. Well, it also suppresses memory and it's no longer on the market. So I tried that. I had tried working out, I had tried, you know, weight Watcher points and all. I've done all the things and I thought I was doing everything right with, you know, working out and eating healthy, and the weight wasn't budging. And when my doctor doesn't believe that weight loss surgery is the best approach, all the time told me, you know, get this gastric sleeve, like it, it could save your kidney, it could literally save your life. It's not just about the weight, it's about more than that, and my insurance denied it and said I wasn't sick enough and they would rather pay for dialysis than a gastric sleeve, because I didn't have high blood pressure or high cholesterol, I wasn't diabetic, I didn't have any of the other comorbidities, and so my insurance denied the surgery. So I spent. That was in February of 2019. I spent the rest of 2019 researching and saving and figuring out ways to pay for it myself.

Sierra: 14:37

So I am one of those like went to Mexico people, but I really did my homework on it. First, my husband was terrified. I followed the doctor. We picked a doctor who also has a practice in San Diego and literally it would have been, you know, 12,000 plus in San Diego and in Mexico. It wasn't anywhere near. It was a quarter of that they have. I'm still in contact with my coordinator. I'm still in contact with the nutritionist there. My doctor still follows up. So it's a very um, not normal Mexico experience. Um, but it was 10 months of research before I felt comfortable on where I went. Um.

Sierra: 15:23

So, december 19th of 2019, I had gastric sleeve surgery. Right before Christmas, um, my, my Christmas dinner, you know, was a medicine cup of chicken broth, so we like to laugh about it, but, um, by September of 2020. So then COVID hit and I'm a, I'm a teacher, and so I was home, teaching online, um, and experiencing, like weight loss and stuff like that at home. I feel really set me up for success because I didn't have to juggle time management. I didn't have to juggle, like you know, breaks at work or anything like that. I was just able to dial in nutrition and make good choices. And so, by August, september of 2020, within about eight to nine months, I went from I was two 34 when I went for surgery. When I went for surgery, by August, september of 2020, I was 135. Wow, so I had lost from my highest at the 268.

Sierra: 16:31

I was down to, you know, in the one thirties one 38, one 35, I would bounce half the weight but yeah, but even from surgery day on, a hundred pounds down in eight months, I'm very happy that I feel fantastic, um, and I was nervous to come on.

Sierra: 16:48

When, when Zoe asked if I would be willing to come on and share my story, I was really nervous, but I have, just through the group and the you know being in the different support groups and just sharing my story there and I've talked with you about it also, dr Weiner, I think we talked so much about the shame that comes from being obese, the shame that comes from weight loss surgery and even now the shame that comes with like, oh, I take Ozimbic and I lost 20 pounds, you know.

Sierra: 17:22

And then there's all of these comments that come from the outside, and I think the biggest thing that I had to overcome wasn't even so much the comments from the outside, it's the comments in my own head. The reality is is that there are hormones at play that are bigger than anything my willpower will overcome, than anything my willpower will will overcome, um, and so I think the big thing was just overcoming the self shame that we put on ourselves, in addition to the public shame that comes from. You know, first you're, first you're too fat. And then, oh, you must've done something, because now you're, you know you're too skinny, or or you lost so much weight. What did you do? Or you know, just there's, there's no winning.

Zoe: 18:06

So that kind of thing makes me think about something that we've talked about in group before of the more that you put yourself in maybe seemingly uncomfortable situations and talk about your story, it allows you to take the power back and it allows you to remove the power and the shame from the story and actually feel empowered and feel like you can help other people by sharing your story. So, of course, I just really want to say thank you for overcoming that fear and how brave and wonderful it is that you are here sharing your story, and I'm sure so many people listening can relate to the struggle that you have overcome.

Sierra: 18:52

Yeah, it's interesting, I think it's important to know I'm so sorry, but I think it's important to know that it's not always the morbidly obese, it's not always like there's and it's not always that I need to lose 20 pounds for a wedding Like there's so many factors involved and ultimately, what I've come to realize really just in the past six months or so um was a like a real revelation for me was um, my health is nobody else's business, but I share it. To help educate those who have these stereotypical ideas of why that it's, you know, oh it's for vanity or oh it's this. And and I've, you know, learned my mom used to say all the time and it's a really hard lesson, you know but my mom would tell me all the time is their opinion of you is none of your business, and so getting over what other people think of me and just focusing on you know, me, my husband, my kids, yeah.

Sierra: 20:09

That's it.

Dr. Weiner: 20:11

This is kind of an age old trick that has been applied to every group that has ever been discriminated against. You know whether it's for racial purposes, religious, sexual orientation. It's that you take this group and you simplify their life. You pull this one, extract this one little thing and you take a very complex and intricate story and you make it into a little soundbite that you can use and leverage in a discriminatory way. And that happens with obesity all the time.

Dr. Weiner: 20:43

We saw this back a few episodes ago with some of the comments that were made about the woman who sued for access to GLP-1 medications and how you take someone's. Your story is so complicated you know the PCOS, the ureter injury, the. You know all of the factors that kind of contributed over the years that when you hear that story you're like, wow, that, what a difficult thing to go through. There's a tremendous amount of empathy people can have for that story once you understand the intricacies and the nuance of it, and so obesity bias is really rooted in just ignoring all that and taking a very simple, straightforward and untrue summary of your story and then applying judgment to it. And so I-.

Sierra: 21:31

Willful ignorance.

Dr. Weiner: 22:22

Yes, yeah, exactly, and so I think it's important for us to understand that a lot of those comments, that is bias, that is taking something that is much more complicated and simplifying it in a way that fits your narrative, your untrue narrative.

Sierra: 22:39

Yeah, yeah. I think. For me, though, finding Poundacure, finding you, dr Weiner, and you, zoe, has been such a game changer.

Zoe: 22:51

I want to talk a little bit about you. You're a teacher and you're on summer vacation right now. Talk to us about some of the habits that you've been putting into place to make sure that, when you go back to school, you're going to have a really successful school year in terms of maintaining those nutrition and lifestyle habits that you've worked so hard to create, that you know help you feel your best.

Sierra: 23:15

Yeah, so one of the positives that did come out of working out the way I did and um having a strict like diet type thing, um was meal prepping and so I meal prep. Different things now versus what I was limited on before, but meal prepping is a big deal. I have a small refrigerator in my classroom. I have a water dispenser that I brought to my classroom so I can have hot water or cold water, but meal prepping, and as soon as I buy my produce, as soon as I, if I have it delivered from Walmart or grocery store or whatever, and I don't even put it away, it does not go straight into the refrigerator. I intentionally do my shopping when I have the time to know I'm going to be ready to meal prep, when I have the time to know I'm going to be ready to meal prep. And one thing that I'm trying to do more and more is replace the condiments in my refrigerator and put them in the produce drawers and put my produce on the shelves, because those drawers your produce, they go there to die. And so when you open the fridge because you know your produce they go there to, they go there to die. And so when you open the fridge because you need ketchup. You you know you're going there specifically for ketchup or you know a condiment, and so you're going to open that drawer. When you go to the fridge and you're just mindlessly looking for something, you open the fridge, you're like, oh, it's a bunch of condiments, yay, no. So you open the fridge and you have all your produce and your veggies, your fruit, everything is there and it's already prepped in containers. So it's a lot easier to just see that and grab that and make that better choice and to then have my week planned out. I'll do, like my salad in one container, but all the toppings go into a separate container so that my lettuce isn't soggy by day five, and so I'll take those to work and I'll be able to just have all of that ready to go at work.

Sierra: 25:16

When it's the cold season I do a lot of soups and things like that, and so I bought super cubes, which are these silicone cubes. You can cook in them, but you can also freeze in them, and they come in half cup, one cup and two cup sizes. So for me one cup is perfect. So I meal prep a big thing of soup and then I put them all in these one cup containers. I pop those squares out, throw them in a Ziploc bag and then I can throw those in the little freezer at work in a Ziploc bag and then I can throw those in the little freezer at work. So there's always something in my refrigerator at work where if I'm running late and I forgot to grab something, it's there and it's a healthy choice. It's already portioned for something I know that is a good size for me. So it takes out that guesswork of portion size. It takes out the guesswork of is this the best, healthiest choice I could be making?

Zoe: 26:10

Well, so I know that we have kind of talked about the idea of you feel really connected with the teacher's community I know that's a big part of your life, obviously and we've talked about creating a special support group for teachers. So you and I are going to talk offline and more about getting that set up so listeners stay tuned for a teachers only support group. So if you're a teacher out there and you're already a member of our nutrition program, keep an eye out for that, and if you aren't yet a member of our nutrition program, be sure to join. So you can not only join Kate, but you can also join in on some of our other great support groups.

Dr. Weiner: 26:53

Absolutely.

Sierra: 26:53

Yeah. What's so great about it, too, is that, with Pound to Cure and Zoe, dr Weiner and this whole community, it's not just for people who have had weight loss surgery, it's not just for people who are taking a GLP-1. It's not even just for people who are on a combination. It's really about making better, healthier lifestyle changes.

Dr. Weiner: 27:20

Well, thank you so much, Kate. I loved seeing your success kind of the ups and downs. I love that this has been your journey and I think you finally are at a place after five years really, since surgery where you're starting to feel confident and comfortable that, hey, this is the weight you're going to be able to maintain. So thank you for sharing your story.

Sierra: 27:41

Thank you, thank you.

Zoe: 27:43

All right. Well, I'm excited to have Kate on board as a peer leader, so I'll keep to have Kate on board as a peer leader. So we'll stay. I'll keep you guys posted on when we get her up and running on the schedule.

Dr. Weiner: 27:51

We have a lot of teachers, as we do.

Zoe: 27:59

Yeah, that's really what sparked the. Besides hearing that Kate is a teacher, of course, but talking with so many people every day, I picked out teacher after teacher after teacher. I'm like, ooh, this is going to be a really great group.

Dr. Weiner: 28:07

Yeah, so I'm excited for that. Teachers used to have like the best benefits. Not so much anymore. We don't. We see a lot. We're seeing teachers without bariatric surgery coverage now oh wow, let alone GLP-1 coverage. Kate was lucky, though. She's got good coverage. Sounds like it All right. What do we have this week for our nutrition segment, zoe?

Zoe: 28:27

Well, you know, thinking about desk jobs and being kind of tied to work during the day, whether it's at home or, you know, at an office. We want to think about how can we add in those steps right, because you might not have that time to dedicate every single day to go for the gym or to go outside and exercise and this was a conversation I was actually having today of think about how you can sneak in I've talked about movement sprinkles before but how can you sneak in inefficiencies into your day to increase your steps? So if we're thinking specifically in the workplace and you're trying to increase your steps through little inefficiencies that don't create, you know, like that you're still in the path of least resistance to do your job. So maybe that's oh, I need to throw this piece of garbage away and you take it across to the other garbage. Or maybe it's that you go to the bathroom down the hall instead of the one right by your office. Or perhaps you park in the farthest parking spot away.

Dr. Weiner: 29:31

Print to the printer across the office Exactly. I love it.

Zoe: 29:35

If you have somebody in an office down wherever, instead of sending them an email, you get up and you go walk to them and tell them in person those sorts of things, Of course, also setting alarms. Maybe it's that you are dedicating to. Every two hours you're going to stand up from your desk and you know whether that's do a walk around the office, or I know a couple of our patients like to do 10 squats right there at their office, something like that. A couple of our patients like to do 10 squats right there at their office, something like that. So, just thinking about these little ways, you know, movement sprinkles, yes, but specifically in this situation, inefficiencies in your day.

Dr. Weiner: 30:16

I love it. What do you think about those under the desk treadmills, like the pedal things?

Zoe: 30:20

Well, there's a pedal, so you stay seated and you pedal. But then there's also the walking pad that you and I have, one of those.

Dr. Weiner: 30:27

Oh, do you.

Zoe: 30:27

Yeah, I love it, it's not so I can't do it while I'm talking, obviously partly because it's a little distracting with the head bobbing.

Dr. Weiner: 30:36

Yeah.

Zoe: 30:36

But any sort of like computer work and that kind of thing. I always just pop on over to my walking pad.

Dr. Weiner: 30:43

Yeah, that's some good food for thought, because my day is just jam-packed. I'm super busy from the second I wake up until I go to bed. I'm always doing something and I kind of pride myself on being so efficient and when I run errands I always make sure I map out the most efficient pathway. But maybe I shouldn't be quite so efficient and do a little bit more walking around the office and things like that. Yeah.

Zoe: 31:06

Another one that is not necessarily at the office, but we were talking about this today in one of the support groups is when you're at the grocery store, instead of being efficient, of going like, okay, I'm starting here and then I'm working my way through the store, it's grab something from over here and then grab something from over here and you're pushing the cart too, you're going back and forth across the store. I guess it depends on how much time you've got, how many people are at the grocery store.

Dr. Weiner: 31:31

Yeah, All right. Well, let's move into our economics of obesity segment. Today we're going to talk about why health insurance will cover will generally cover bariatric surgery but not GLP-1 medications, and this is a question I get from my patients all the time. They say why does my insurance company cover surgery but not the medications? That doesn't make any sense. It actually does if you think about it from an insurance company's perspective. Again, an insurance company's perspective is generally how do I extract the maximum amount of money out of the healthcare system? But then let's talk about exactly how they make treatment decisions, which is is based on a concept called qualis, which stands for quality, adjusted life years, and the idea is is if you if, let's say, god forbid you have a cancer and you're 30 years old, well, you would die from that cancer, but if you were treated with this medication, you could live to the age of 70 or 80 and have a decent quality of life through that. That would give you like 30, 40 qualities, and so that's why a lot of the cancer treatments are covered at very high prices is because you can potentially save 30, 40 years of life.

Dr. Weiner: 32:45

We don't see that same difference with either surgery or GLP-1 medications.

Dr. Weiner: 32:49

It's not like people are gonna die at 35, have bariatric surgery and then live to 75. You don't get that much of a difference from losing weight and from resolving diabetes and resolving chronic diseases. So they've done all these studies and they have all these computer simulations and what I found as I did research is the numbers are a little all over the place and the methodology you use and, of course, the country that you perform the study in matters a ton too, because medications are much more expensive here. Surgery is much more expensive here than it is in other countries. But the insurance companies generally consider a medical treatment to be cost effective if it is less than $100,000 per quality. So if you can spend $100,000 on healthcare and give someone one good quality year, insurance companies say, okay, that's worth it, we should approve it, or we should consider covering treatments like this. And so when you look at a gastric bypass surgery like this, and so when you look at a gastric bypass surgery, it's about $47,000 per quality adjusted life year Not a bad deal truthfully.

Dr. Weiner: 33:54

And that goes to the fact that in general these surgeries are not crazy expensive, especially now we can do them so safely, without readmissions and reoperations and things like that, and so oftentimes we see reduction in medication costs which kind of reduces the total cost of care. A sleeve is about $79,000. So sleeves cost about the same as a gastric bypass. Very, very little difference in price to the insurance companies. But we don't see quite as much weight loss. We don't see quite as much resolution of comorbidities.

Zoe: 34:26

Maybe the heartburn afterward.

Dr. Weiner: 34:27

The heartburn afterward may cause more revision. We definitely see more revision surgeries after sleeve than we do after gastric bypass, but still it fits that under $100,000. Now when we look at semaglutide, it's about $500,000 for non-diabetics, for non-diabetics for diabetics it's a little less expensive, but for non-diabetics it's about five hundred thousand dollars per quality adjusted life year math doesn't add up math doesn't add up.

Dr. Weiner: 34:55

Terzepatide, which is a little more effective and actually a little less expensive, is about three hundred and fifty thousand dollars per quality. So they they just don't meet the criteria that they've set. So they applied pre-existing standards to this and it just doesn't line up. Now, of course, the price of the medication. You do the same study in Denmark, which is where Novo Nordisk is headquartered and where some of Glutide's made, and they pay, I think, about 30% of what we pay for the medication. Then this might line up. And so this really gets back to something we've talked about at length and set aside the healthcare system and the inefficiencies there and the fact that a lot of the money that's being used for administration and for the profits in these large companies could potentially be used to treat patients. Large companies could potentially be used to treat patients.

Dr. Weiner: 35:53

But even if we straighten that out, there still really may not be enough money in the system to cover the medications at the current cost. These medications have to come down in cost. The only way this is going to happen is we can't be paying $1,000 a month or whatever is negotiated by the PBMs. When these come down to $200 a month. The math adds up and we're going to see wide adoption of the medications. But until we reach that number, we're not there and that number that could take quite some time. We'll see when. The semaglutide patent if we see semaglutide available in 2026, we could see something in that range. I'm not sure, but most likely it's not going to be until the 2030s, until we see prices even close to that.

Zoe: 36:37

I think it's so interesting that the trizepatide is cheaper to make and more effective.

Dr. Weiner: 36:43

Yeah Well, cheaper to sell, To make, who knows Well okay, cheaper to sell.

Zoe: 36:48

So what's the deal there?

Dr. Weiner: 36:50

Well, I think it's just they were second to market. It's kind of like semaglutide came in. We've talked about this, how Ozempic is like the Kleenex of GLP-1 medication. All the meds are Ozempic right, even if they're Monjaro no-transcript.

Zoe: 37:38

What do we've got?

Kate: 37:40

Okay, First question here is can a sleeve patient have the LINX procedure?

Dr. Weiner: 37:47

So the answer is yes, and this is something that is often talked about at the conferences. I've looked at the LINX, so let's first talk about what the LINX is. The LINX is basically a band of magnetic beads that you wrap around the esophagus and the idea is that the beads kind of push the esophagus closed, but then when you swallow, because it's a relatively loose force, it opens up and lets the food through, but then closes back down, and the idea is that it essentially reinforces, recreates or strengthens the gastroesophageal junction or the valve that prevents the acid from refluxing from the stomach up into the esophagus. So it's essentially an artificial valve and you wrap it around the esophagus. Now, first of all, I still have a little bit of PTSD from my early days in bariatric surgery with the lap band, and I put in I don't know 250 lap bands early on and I was less experienced of a surgeon. I didn't quite have the same skepticism that I have now. I kind of believed everything that I was told and I just saw that wrapping something around the esophagus never ends particularly well and at this point there are so few patients who still have a band left in it's. Almost. When I see one I'm like, oh wow, you still have your band, huh. And then we talk about how we're going to get the band out because it's it's run its course, and so I think the first thing is is that we and we've tried this before something called the angel chick device. There's a long history of trying to wrap stuff around the esophagus and it not working out well. My big fear is that this links is going to be just like that. There's a lot of industry money behind it. It's an expensive device for a cheapo string of magnets, but it's very expensive, of course, and so you know there's just too much. I just get the lap band vibes about this thing in many ways, both anatomically and then from the industry marketing perspective. So I'm immediately very skeptical of it.

Dr. Weiner: 39:41

The data is out there to show that it is mildly effective for the treatment of acid reflux. I am an impatient surgeon. I don't like to operate. Let's try this, let's try that. I don't like that. I want to do a surgery and have it work. Every time you came to me with a problem, I solved the problem and then you go live your life without that problem anymore. That's why I became a surgeon. That's what I like to do and that's what I can do when I convert a sleeve to a gastric bypass this LINX procedure I fear that down the road we're gonna have long-term complications with it.

Dr. Weiner: 40:14

I don't think it causes enough acid reflux, especially for those patients who have really severe symptoms, and the data would support that this is better for mild to moderate symptoms. Now, with this whole, with a lot of the scrutiny that and people don't want to be on PPIs or pantoprazole and other medications like that long term, this may have a role for mild to moderate reflux after a sleeve. If that's something you're interested in, you can see another surgeon. I'm just I'm not willing to go there. I've made this mistake once in my career. I'm not going to make it a second time. If eight years down the road the links is still big, maybe I'll consider it, but my hunch is like a band-aid kind of situation yeah, it's.

Dr. Weiner: 40:56

It's been around for a while. It just has never really taken off in popularity, and I think because there's a lot of surgeons like me. I just want to fix the problem. If it's not fixing the problem, I'm not interested in it. So I I yes, you can have it. There are absolutely surgeons out there who do this. Um, not every surgeon does this and I think the big question is why not? It's not a hard surgery. I could learn how to do the surgery probably in an afternoon course. That's my turf, the esophagus, and I work there every day practically, so doing the surgery is not difficult. It's really just a matter of is it going to work or not?

Kate: 41:30

Yeah, all right. Next question is from one of our group sessions. I am two weeks out from surgery and still struggling to get my protein in. How can I increase protein when I feel like I'm just tapped out?

Zoe: 41:44

This is such a common question.

Dr. Weiner: 41:46

I heard it twice today.

Zoe: 41:47

Yeah, right, and you know, I think we want to think of like our long-term goal is, yes, of course, of think of like our long-term goal is, yes, of course, eating as much whole, real, unprocessed food as much as possible.

Zoe: 41:58

But in these first two weeks and even the first couple months after surgery, we absolutely can and will use protein supplements to get that protein, especially with the volume restriction right, if you're super struggling to get your volume in, we need to fortify those protein sources, boost up the protein with more protein.

Zoe: 42:22

So maybe adding a scoop of protein powder to your ready-to-drink protein shake or to your yogurt, or making a blended bean soup with unflavored protein powder in there, or potentially drinking one of those kind of more like isopure protein waters so that you're sipping on fluids, helping with your hydration and also getting the protein in. So I think we were also what were we thinking about today in the session? Really making a super protein-rich smoothie with Greek yogurt, a ready-to-drink protein shake, an extra scoop of protein powder and some powdered peanut butter with some fruit, and then that's a really protein packed and then you know sip on that throughout the whole day, kind of thing. So, yeah, I think ultimately we want to be moving away from those protein supplements, those processed protein supplements. But, as I like to tell our fresh post-op patients, you don't need to be in a super rush to do that. So here are some ways that you can really fortify what it is that you are already having. Optimize and maximize your volume with the protein.

Dr. Weiner: 43:37

Yeah, what do you think is the most protein you can put in, like, let's say, a 10 or 12 ounce shake that is still palatable for a post-op patient, because I feel like you can't put 80 grams in that. It just becomes thick and undrinkable.

Kate: 43:50

Right.

Dr. Weiner: 43:51

You know, can you do 40? Because premier proteins are 30, right, can you do 40, because premier proteins are 30. Right, can you do 40. Is that still palatable, like at what point does the amount of protein make it like too hard to drink where you can't get any of it?

Zoe: 44:03

well, you know then also like kind of maybe you thin it out with some unsweetened almond milk and then that turns into a couple portions throughout the day, because you might only be able to drink two ounces in one sitting kind of thing, so it's more so like making this. You know you're not going to be drinking all that volume at once, but yeah, I'd say between the 40 and 50 gram mark we've we've been able to do.

Dr. Weiner: 44:23

So you can get one shake that has 40 to 50 grams and for the most part you're slow but you can get there maybe thinning it out toward the end and some yeah, okay, that sounds about right and that that'll get you two thirds of the way to your protein requirements for the day. So, um, yeah, that unflavored protein powder you can pretty much sneak into anything.

Zoe: 44:42

Right, you know I I like to think about it as like especially in the soft foods phase, you might be wanting foods that don't naturally have a lot of protein in them, such as applesauce.

Kate: 44:56

Right.

Zoe: 44:56

And then if we can put a little of that unflavored protein powder in there just to you're like you don't feel like you're eating another protein thing.

Dr. Weiner: 45:06

Right.

Zoe: 45:06

You're getting that other flavor. You're getting something that maybe your body is craving, but we're sneaking in some extra protein.

Dr. Weiner: 45:14

Yeah, All right. So this last question. It's pretty amazing that we have not gotten it yet.

Kate: 45:18

Yeah, let's hear it, sierra. Okay, so what recommendations, besides adequate protein, would you guys recommend to minimize hair loss? And this question is from Lori from our website. She also wanted to mention her gratitude towards A Pound of Cure and that she thinks that the work that you guys are doing will improve countless lives.

Dr. Weiner: 45:40

All right. So, Zoe, what are we talking about on the nutrition front for hair loss?

Zoe: 45:44

Yeah, well, obviously she said I know protein, but obviously that's a big one.

Kate: 45:49

Right.

Zoe: 45:49

But a question I get asked a lot is can I keep taking my hair, skin and nails or should I add in a hair, skin and nail supplement? And for most of those supplements, if you look at the back, which has mostly biotin in it your bariatric multivitamin has more biotin and B vitamins than that Costco hair, skin and nails, so it's just a waste of money if you're taking your bariatric vitamins as you should be.

Dr. Weiner: 46:17

Yeah, at some point, taking more vitamins doesn't increase your vitamins. I've heard people talk about 10,000 micrograms of biotin for hair loss. What do you think? Yeah, yeah, I mean Maybe.

Zoe: 46:30

It's hard to say right.

Dr. Weiner: 46:31

It probably can't hurt.

Zoe: 46:36

Yeah, it's hard to say cheap and probably can't hurt. Yeah, it's not gonna hurt you. Yeah, but you know how much of that you're actually absorbing?

Dr. Weiner: 46:40

I don't know. Yeah, I think. Another thing you know, there's copper and zinc, are big biotin people talk about and all of that is going to be covered by your bariatric vitamin. Um, iron is kind of the big in my mind. That's the big one, and I think there's two times when, when you know and when we see hair loss. The first in my mind, that's the big one, and I think there's two times when you know and when we see hair loss. The first is in the immediate phase and to some degree, hair loss is just from the stress of surgery. Right, there's the rapid weight loss, the stress of surgery. You're going to lose some hair. In that initial phase. It tends to be temporary and people will allow it to grow back.

Zoe: 47:12

The physical stress that your body is going under not the I mean the mental stress might cause some of your hair to be pulled out but I think you were just meaning like that physical stress that your body is.

Dr. Weiner: 47:21

They're both yeah and, let's be honest, after surgery there's both yeah, there's emotional and there's physical stress. I think another piece is that if, let's say, you're a year out, two years out, three years out and you start losing hair, that's a different cause. So if the hair loss is occurring during the weight loss phase, that's typically just the stress and we do everything we can. I've got one more tip I'll mention at the end. But when it comes out of nowhere, essentially that's almost always iron deficiency. So we see hair loss with iron deficiency. So if you notice your hair is thinning and you're a couple of years out from surgery, get your iron checked.

Dr. Weiner: 47:56

We've talked about this a lot in the past, that gastric bypass patients especially, but sleep patients too, should get their iron checked a minimum yearly.

Dr. Weiner: 48:05

And if it's low, you treat it, do not blow it off, do not ignore it. It will eventually come and get you and cause way more trouble than it needs to if you ignore it for long enough. I think the other thing to talk about is that minoxidil is relatively inexpensive and there's different doses, one for women, one for men. Truthfully, women can probably take the men's dose, but that's a topic for you and your prescribing physician. The thing you have to be careful about with minoxidil is that when you initially start it, you can actually lose a little bit of hair, and so before it starts to grow back, you can lose a little bit of hair. So if you start minoxidil right at the same time as your surgery, you could actually be accelerating hair loss. And so if you are concerned about hair loss after surgery let's be honest, pretty much everybody is then starting minoxidil a few months before may be helpful, and also the Rogaine supplements and things. You can either put it, you can put that in your hair.

Zoe: 49:04

Rosemary oil.

Dr. Weiner: 49:05

Yeah, rosemary oil, I think all of that stuff. They even have some UV light, oh yeah the red light. Yeah, the red light right. I thought of my face. Yeah, the red light Right. So yeah, so, so so I mean all of these things I think are reasonable, reasonable things that you can do to help prevent hair loss.

Zoe: 49:21

And then also just to think about like, if you do lose hair during that honeymoon period, most people see it come back after they stop that initial weight loss 95 plus percent regrowth of that weight, so that hair loss is almost always temporary.

Dr. Weiner: 49:37

Yeah.

Zoe: 49:37

All right, well, I think that about wraps us up. Thanks so much for listening, and if this was helpful to you or you learned something new, please share it with a friend or family member that you think might find it valuable as well.

Dr. Weiner: 49:48

Yes, this podcast is produced by Sierra Miller and Rhiannon Griffin and the editing is done by Otto Grow, and a special thanks to our guest Kate. Please check us out on social media, our website, consider joining our online nutrition program or our Pound to Cure Platinum program if you need more personal assistance. We'll see you next time.