Ep 55: Quieting the Food Noise: Obesity, GLP-1s, and Bariatric Surgery with Dr. Eric Smith

Obesity is complex—and it’s not a willpower problem. Bariatric surgeon Dr. Eric Smith joins us to break down what really drives the obesity epidemic. We discuss the modern food environment, food addiction, food noise, stress, GLP-1 medications, and how surgery fits into the modern obesity treatment landscape.  We'll unpack why body composition—not just pounds lost—matters, explore how to choose the right tools, and why long-term success always comes back to lifestyle and habit change.

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The content in this podcast is for general reference and educational purposes only. It is not meant to be complete or exhaustive, or to be applicable to any
specific individual’s medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis or treatment. This podcast does not create a physician- patient relationship and is not a substitute for professional medical advice, diagnosis or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different so make sure you consult your own healthcare professional before seeking any new treatment and before you alter, suspend, or initiate a new change in your routine.

Transcript

Ep 55: Quieting the Food Noise: Obesity, GLP-1s, and Bariatric Surgery with Dr. Eric Smith

[00:00:00] Before we start today's episode, I would like to quickly read you our podcast disclaimer. The content in this podcast is for general reference and educational purposes only. It is not meant to be complete or exhaustive or to be applicable to any specific individual's medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis, or treatment.

This podcast does not create a physician patient relationship, and it's not a substitute for professional medical advice, diagnosis, or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different, so make sure you consult your own healthcare professional before seeking any new treatment, and before you alter, suspend, or initiate a new change in your routine.

Welcome to The Starting Gate. We're your host, Dr. Kitty Dotson and Dr. Sarah Schuetz. Two internal medicine doctors who spent years practicing traditional primary care. Over time, we realized something was missing from modern healthcare, a [00:01:00] real understanding of how everyday lifestyle choices impact overall health.

We'll help you cut through the noise of the countless health influencers and their conflicting opinions because no matter who you follow, the basics of lifestyle medicine are at the heart of it all.

 Welcome back to the starting gate. We're your host, Dr. Kitty Dotson 

and Dr. Sarah Schuetz. 

\ Today we're talking about a topic that impacts many of us, and that is food addiction and obesity. Obesity affects over 40% of adults in the US and really is one of the most complex multifactorial conditions we face in healthcare because it involves biology and psychology and also the environment we live in.

And so today we're gonna try to unpack how we got here as a country and why obesity is so prevalent. Why we eat the way we do and how do we see the role of surgery, obesity, medications, and lifestyle fitting into a realistic approach to weight and health for patients. 

So we decided to bring in an [00:02:00] expert guest today.

We have Dr. Eric Smith, which we are so excited to have. He is a board certified general bariatric and robotic surgeon. He's the chief of surgery at Georgetown Community Hospital and Medical director at Kentucky Bariatric Institute. He performs more robotic bariatric surgeries than anyone in the state of Kentucky, and you may have also caught him on TLC series.

Thousand Pounds Sisters. So he is also famous. 

Is this our first famous guest?

Yes. It's Oh, yay. So thank you. We gotta raise 

your all standards call Famous. 

Thank you for joining us here today. And we're really excited to have someone who has been involved in obesity for decades I really feel like that , gives a lot of insight of where were we, where are we now, and what can we do to solve this epidemic that we're experiencing.

So to get us started, what is your take? Like, how did we end up here? 

Oh man. We're probably gonna have to do like multiple episodes. I'll first [00:03:00] apologize for my voice, like I told you guys earlier, I'm just getting through that, Kentucky crud this time of the year, but we'll weather through it.

It's a loaded question , we know obesity is multifactorial. I don't think anybody can argue that you'll still have people that will hang on to one component more than the other. But even how we got there, I think is even more complex. I've been doing this for 20 years, in practice essentially.

And then my training as well. And even how we were trained, not just the techniques that we use surgically, obviously medication options have changed, but just our perspective on looking at patients who battled with obesity, how we judged patients who would be successful with the treatments that we gave them has changed so much.

And I think that's a good thing. , you all know in medicine, if there's something that's been static for 20 years, that means we've made no progress and it shouldn't be that when we see that change that we're ashamed of where we were before, we should flip the script [00:04:00] and say, we're really proud that we're continuing to work to be better at this.

one of the things that I'm pretty passionate about as far as one of the underlying causes or the roots of the problem is our food system. And I think the reason that I enjoy talking about it so much is because I've always felt like, I hope there's one day that I'm not needed like I am now.

And in, in medicine that's our job. That's what pays our bills. But it also, it becomes this from the public's perspective, this almost conflict of interest of as long as patients are struggling with obesity, you've got a job. And that's concerning to me because I'll find something to do.

And I feel like we all can impact people in a positive way and a variety of things. I love to operate, I love to do surgery, but I love to help people. And I think the reason I enjoy talking about it is it has nothing to do with serving my occupation other than maybe eliminating it. And I think it doesn't get talked about enough, and [00:05:00] I think we've reached a point.

With the GLP one medications hitting the market, that we are continuing to put a bandaid on a cancer. And it doesn't mean bandaids aren't needed. That doesn't mean surgery's not needed. It doesn't mean the medications aren't needed. We prescribe the medications for everybody out there. I think I'm an obesity specialist.

I don't think I'm a bariatric surgeon, and we have to have different ways to treat it, and I'm sure we'll talk about that today. But we also have to get to the root of the problem as to why. And I think our food system , has doomed us to be honest with you. 

I love that take because , I feel like we are now, we've recognized obesity.

We recognize that we need lots of tools to be able to treat this complex condition. But where are we going to turn to, to actually stop it? We, we need these tools and we need, we don't need to take 'em away from patients that are already here, but we've gotta slow the actual [00:06:00] movement of everyone becoming obese down

and that's where I don't feel like we're making the progress that we need to today. 

And I totally agree with it's, the concerns is our food system because when our food environment is so poor. How can we help patients make long lasting change when everything around them is set up to make them fail?

Yeah, I think the question that was raised, I did an interview for one of the very popular magazines. . And it was the question when GLP one medications really hit the mainstream, and there was the question of is the government gonna provide access to 'em?

And the warm and fuzzy feeling thing to say is, yes, it should provide access to the medications for everybody. In a perfect world, that would be great for those that don't have to write the checks and figure out where the money comes from. But the question I had is are we only gonna provide the medications or are we gonna get to the root of the problem and provide the support from a nutritional standpoint and a mental health standpoint?

Or, all we've done is made big pharma richer, I equate it to [00:07:00] what if we never blew up the tobacco industry, but what if we continued to invest money and dollars into research for treating lung cancer? And we continued to come up with these great treatments for lung cancer, but we never impacted the rate of incidents of lung cancer.

Then all we've done is taxed the medical community and the financial system behind the medical community. But blowing up big tobacco allowed us to reduce the incidence of lung cancer. And oh, by the way, the people that do get it, we can treat it better. We can't just treat the problem without getting to the root of the problem.

And so we look right underneath our noses and we have a SNAP program. And I know that's, hot topic in itself right now. Yes. But we have a SNAP program that provides nearly half of the foods. Some would argue 60% of the foods on the list aren't even food, have zero nutritional value behind them.

So should we even call it snap? That's a [00:08:00] problem. 

Yeah. 

The lack of education behind that. And I do think the resources to figure out the mental health aspect, and that's a whole nother topic that hopefully we'll get a chance to talk about, because it doesn't mean everybody's addicted to food who's obese, and it doesn't mean everybody's depressed but we all know there's things in our life that we need to do for the betterment of us.

When I woke up this morning because I don't feel great, there's my time that I have mapped out that I do my workout and I didn't feel like doing it today. What is that? What was that disconnect of why I couldn't make myself do what I needed to do? That's mental health in my opinion, of that disconnect of I know what I need to do.

For some reason I can't put it into practice. If we don't give people those tools too, all we've done is made big pharma richer and richer. 

Yeah, no I totally agree. And I do wanna go into more detail about the mental health, but before we leave the food system. Our current food system of ultra processed [00:09:00] foods make it so challenging because of all the different ingredients in it, as well as the addictive nature of the type of food.

Where do you see food systems being able to actually make a change though? Like, is, Is it limiting ingredients? Is it, really just taking time to push whole foods over all these processed foods? Because I think where we really need to spend time and energy on a big standpoint is how can we make a change that will actually.

Help patients. 

Right.

Make a change. It will actually make a 

change. Right. Not just not, not just removing one ingredient at a time that's banned. 'Cause that, that, that method is not gonna get us anywhere.

No. And I get that, 'cause we could say we're focusing on dyes, , but is that really directly correlated with obesity?

It probably not a ton. , I think it's the perspective of we gotta start somewhere kind of thing. 

Exactly. Exactly. 

But yeah, , we could talk about GRAS. We could talk about what those laws are not really laws at all behind who gets to deem if something's safe to put it in [00:10:00] food.

Most people don't know that 90% of the ingredients that are in our food, the food companies themselves get to determine if it's safe or not. 

Yeah, that was new to me just a couple years ago. Yeah. As I started looking more 

into this. Absolutely. And things like that, the intention was good when it was first founded for things like vinegar and , baking soda, and now it's turned into a free for all.

Here's the most concerning part about that and the ultra processed foods is the people that they are preying on the most right now are the people that are trying to lose weight. we don't realize that the protein bars of the world, all these other things are technically ultra processed foods. many of them are marketed towards the people who are now aware of the fact that I need to control my calories.

I'm not saying protein bars are bad, but my point is now you found a very susceptible population that can be persuaded to buy, not just because foods are fast. I don't think people are buying the ultra processed [00:11:00] foods just because they're convenient anymore. It's also the same population that's struggling the most with obesity because they're trying to figure out, how do I eliminate sugar?

They can follow words on the front of packages that it's low fat, that it's low calorie. I've had some pretty interesting conversations with even obesity medicine specialists who prescribe the medications who are very smart people and they'll say, this is ridiculous. A diet Coke doesn't make someone gain weight.

There's no calories in it. And I'm like, look, I can tell you that a individual Diet Coke Yes, will not. Cause you to gain weight, it's physically impossible. We all know that there's a caloric requirement here, but I believe that there are many people, myself included, that what's in a diet Coke will cause us to crave things throughout the day.

And the net sum throughout the day ends up sabotaging, our caloric requirements for the day. 

Yeah, I love that you brought that one up. 'cause that was one [00:12:00] for people who may be new listeners here. I was a dietician before I became a physician and I always had that mindset about diet drinks., And I'll profess I was a Diet Coke addict, I will call it that because it just took one, then I wanted two and then I would want three in a day.

I literally couldn't control that. And when I finally, after my third child, I was like, you know what, I'm done with diet sodas. Because I've really gotten into lifestyle medicine and was like, I don't think , the artificial sweeteners are helping me either. I think I need to get rid of all this, and I went off of it and not.

Only was it great just , I was drinking more water 'cause I wasn't drinking all this diet soda, but I was able to eat so many fewer sweets. 

Yes. 

When I got rid of the diet soda because I wasn't always chasing that really sweet taste of the artificial sweeteners in it. And that stuff made me feel like garbage too.

Yeah. And the argument that I have and this one person in particular, he was like, look, you're trading regular soda with calories and sugar for a diet [00:13:00] soda. I said, yeah, that's a good short-term fix, but are we setting them up for long-term success? And I'm not saying you can never eat a diet soda.

 We all react differently. We know people who can go to the bar with their buddies, watch the ball game, have a beer, and they don't need another one for months. We also know those people that can't do that one time or it's over for them. We all respond differently to that stimulus that we take in.

But what we do know, without question the science is very clear, is when we take in that artificial sweetener, we know what the M MRIs show and how our brain responds. We know how our body gets fooled of wait, you were supposed to give me sugar. I didn't get any, and how it responds. And we have to take that into consideration.

So yeah, I might get somebody to drop a lot of weight quickly over a period of months if I say, trade your Coke for Diet Coke. But have I set them up for long-term success? And that's just a really small example. So the food companies are designed to sell a product. , There's no secret behind [00:14:00] that.

And there's also no secret that the things that they put in their food have addictive properties. If anybody wants to argue that right now, they're completely out of touch. We've proven that. We know that. That's, there's a reason that when Big Tobacco bought the food companies years ago, and they've sold 'em since then, but they employed the same chemist that worked for them at the tobacco companies to make things what they called hyper palatable.

And we've gotta be upfront with that. I don't believe we take people's choices away, but we need to be really honest and clear with people with , what is happening. And so I tell our patients, the best advice I can give you is you have to find a way to eat that you can be compliant with long-term, but you need to base it off of Whole Foods, because I do not believe for one second that people.

Have food noise for another apple or a steak or an avocado. They have food noise for the chemicals that are in our [00:15:00] food. And one could argue that something like an Oreo or a Dorito doesn't have a single ingredient in it that qualifies it as food. I could take a piece of cardboard and I could add sweeteners to it.

I could add texture to it. I could make it visually appealing, but if I ate it, no one would say I'm eating food. And I think we've gotta take a step back and really decide what is food and what isn't food. 

 Yeah, I think that's a great point. And I think food noise has gotten so much press since the GLP one medications came out since they seem to help with that aspect of it so much.

What do you think food noise actually is? Is it a release of hunger hormones? Is it food addiction? 

Yeah. 

What is it? 

It's interesting 'cause a lot of people say, what's the difference in food addiction and food noise? I said I don't know if we can safely answer that. 'cause one was created by Big Pharma and one's a term that's been used medically for years and that's food addiction.

We've used that [00:16:00] term for years. I'm gonna ask you this question. , Did y'all ever hear the word food noise before GLP one hit the market? 

No. 

No. 

But then once they did, and I 

was, everybody could connect. Yeah. And that's what I had. 

Exactly. They were able, they couldn't ever explain why it was so hard.

I think we used cravings more honestly. Correct. Yeah. I think we said, I am always craving sugar. I'm always craving salt. 

And now that lingo has converted into food noise in general. 

Yeah. And I completely agree. I think big pharma took it. They ran with it. But I think people are like, oh my gosh, I've never found an answer to this.

And I finally do now. I've made a, you, y'all may have seen, I made a couple social media posts that got a lot of people up in arms when I talked about food noise. Or was it even a real thing? Here's the question that I ask a lot of people. If you tell me that you crave sweetss. If you tell me you, crave salt.

Let's take it a step further that you crave cocaine. Do you think it would ever be [00:17:00] appropriate for me to say It's okay if you crave cocaine, I'm gonna ask you to use it once a week, but the other six days I'm gonna ask you to take a medicine so you don't crave it at all. I would tell you that the part of the reason you crave cocaine is the underlying thing that you crave in the first place.

And how do we find a way to remove that completely? I get concerned when I see people turn to GLP one solely for food noise when they have not removed the things that are causing the noise in the first place. I've done this a long time. You let me go to Tony's and eat a steak. I'd love to have another one, but I physically can't.

I love how it tastes. We all will eat more than we probably need, right? That's normal. But I have yet to see someone have true food noise for Whole Foods, but I see it every day for them to have food noise for things like chocolate, sweets, [00:18:00] salts, things like that. If you think about it, the chocolate that we eat in the United States isn't even really chocolate.

If you look at the definition of chocolate, none of our chocolates really meet that definition. There's additives to that high fructose corn syrup. There's other dairy products that are add to it. We could go on and on. So should we be treating a noise without removing the underlying culprit that causes it in the first place?

There's drugs out there to get people off of illegal drugs, but they don't take those forever. And the first thing you have to do is you have to remove it, right? That's the problem that I have with it. And I think we need to call a spade a spade. Now, if someone removes those and they still struggle with it, then great.

We have a drug out there that can help treat that. But I would be willing to argue 80% of those people, , if they're taught the awareness behind that, that they may not need that drug to do it. And I can tell you, I've watched people in our industry, there's a massive social media community in the bariatric space, the [00:19:00] weight loss space.

You guys see it too. I have watched patients behind closed doors privately who have lost hundreds of pounds, who will admit I now need a medicine because I have so much noise. And I'm scared of that weight coming back. And that's devastating for them. I get it. It breaks my heart. But I've had some people say to me, honestly.

I also make hundreds of thousands of dollars a year of how I've incorporated skinny syrups into my diet. How I've incorporated a variety of ultra processed foods into my diet that are low in calorie that at the beginning help me lose weight. And now I'm not sure that this is making that noise worse.

Yeah, that's devastating. It really is. And I think the other thing, and why I think that we still need all these tools for patients in today's world is because our environment is so far from helping patients with this noise. You can't even walk into a [00:20:00] hospital without being surrounded by these foods.

The place that's supposed to make you well

Is literally loaded with the foods that are making them sick. And so that's somewhere I always try to have So much compassion for patients that are struggling with this and wanting to use as many tools as possible. 'cause we have created such a scary environment to even walk through.

You can't go to the gas station, you can't go to the hospital, you can't even go to your place of work because you're afraid to go into the, community room that is loaded with everybody's, sweets that they've brought it, it's a scary place, yeah. Trying to stay away from it because it's everywhere.

And so it just makes me very sad knowing we have created such an environment that it is, it makes it so hard for anyone to have success without using a tool today. 

Absolutely. And even when they make alterations, when they go through a drive-through, 'cause we, we have busy lives sometimes that's necessary.

Those alterations may still be sabotaging them. I can't [00:21:00] look at a patient anymore and say, eat three ounces of grilled chicken. Without specifically saying, I need you to cook it yourself. 'cause if you get it from, you can bleep this out if you need to. Chick-fil-A, it actually has 47 ingredients in it. There's a reason that their drive-throughs the longest of anybody.

'cause they also have the highest levels of MSG of any fast food restaurant that's out there. If we look up the purpose of MSG, it's really clear it's a preservative that has the highest addictive property. They use it in lab rats to create obesity, but MSG doesn't have any calories in it. So why would they give it to lab rats to create obesity?

'cause we can't make a rat eat unless we give it a drug that makes it want to eat. MSG has been proven that it raises their appetite. They eat more food. They're an obese rat. We can do studies on obese rats So when do we be honest with people and say, if you don't remove this.

We're just putting a bandaid on the problem. And on one hand I would much rather [00:22:00] someone make that conscious effort. I've got five minutes, I'm gonna go through a drive-through, I'll get a grilled chicken sandwich, I'll ditch the bread. Is that better than some of the other things they could order?

Absolutely. But we need to be upfront with them of what is that gonna lead to the rest of the day, and how often should you do this? And is this a really good idea? Should we maybe come up with a different solution and at least be transparent about it? 

Yeah. No I totally agree. 'cause I do think in this world it's hard to always eat whole foods.

There are people that can absolutely make it occur, and I applaud them. I can't always make it occur, and I'm always. Talking with patients and letting them know, what I have taken a lot of time to do is recognize personally to me, which foods do I struggle with? Cravings and addictions to, for instance, Cheez-Its are not allowed in our house period.

, That is one of those foods for me. Like even if I visualize 'em, I think about them. I want them, I can't stop eating them. And so even trying to do personal inventory on those [00:23:00] specific foods, that, those are my that's my food, diet Coke and Cheez-Its, man, they are like, they're like my crack and I have recognized that and they're not in my house.

Right? 

And so I think that's also something that is helpful for patients is identifying that, looking at it that way. I can't quite eat all whole foods. I try to do as much as possible. Sure. But I also wanna find those foods for me that are, I can't just have one. It's just not possible. 

Exactly the same and own it.

We all have those. And so I think, there isn't one rule that applies to everyone, but I do think that if we can try to eat the majority of our foods through whole food sources, it becomes easier to identify what those couple things are for each of us. Exactly. 

Yeah. And so pay attention if you have not really paid attention to yourself, notice if you're eating something and then you go back for more, just stop and think, did I actually feel full after eating that?

Or why am I going back for more? And probably it's because you got no [00:24:00] sensation of satisfaction or feeling full except enjoyment. And so then you want, yeah, that enjoyment again. And then pay attention to what it feels like to eat something. That does make you feel full, and do you find yourself wanting to go back for that?

And if you can just start paying attention, that'll help you get an idea of what foods you need to look at. For me, I know it helps for me to , get kind of annoyed if I find one of those foods that I wanna go back and I'm like, oh, what did they figure out to put in this food to make me wanna keep opening that pantry door?

And so that might help you in just thinking about it instead of just thinking, oh, I guess I can't have that. Just think about what kind of trick are they trying to pull on me? 

Sure. 

To get me to eat this again. I just ate it. 

There was a study in Nature Magazine that the GLP ones were looked at for a variety of different foods.

And they looked at brain activity, MRIs and response to that, reward center, we'll call it. The medications and the companies who make the medications use this to [00:25:00] reiterate, see how we conquer food noise for different categories of food. Salty, sweet. We could go on and on.

High fat. There was one food category that, if you look in the findings, it was very briefly mentioned where not only did the medications not impact the feedback, but the feedback was minimal to nearly non-existent without the medication in the placebo group. What do you think that was? Fruits and vegetables.

I was 

gonna say fiber, 

but fiber, 

yeah. 

Fruits and vegetables. Not non sugar, not low carb whole food. Fruits and vegetables, meaning the baseline response was extremely low. And when you took the drug, it didn't impact it at all, even as what little bit of response we had. We saw no statistically significant difference of how we dropped it.

All. The other ones baseline was high by itself and then we dropped it down or we impacted it with [00:26:00] the medication. It's right there in front of us. I looked at that and I'm like, we are missing the boat of what this study actually showed us. Again, I want everybody to understand, I'm not saying that there aren't people who will need these medications.

We all suffer differently. It is a disease. I believe that wholeheartedly. But I think what if we could eliminate the majority of the people of needing something like this, who we are now seeing that once they start it, it ain't going away. You've committed to this medication for the rest of your life.

And it was made to do that. 

we touched on it a little bit, but I wanna go back to it, is how we have also failed in the sense that we have not treated patients that are struggling with obesity and doing appropriate either screening specifically on their mental health or they're stress management, and how when we don't attack that we're not also not giving them all the tools to have success.

What have you seen over the years with your patients, the [00:27:00] difference when that approach is taken versus when it's completely left off the table? 

Obviously the people who utilize that success is directly correlated to it. Years ago it was required by us many years ago for bariatric surgery to get covered by insurance, to have a mental health evaluation or psychological evaluation.

And I think the reason behind that was good, but let's be honest, that was the check a box to really eliminate eating disorders, severe mental health diagnoses that may be put them at harm's way to even be compliant with what we're asking them to do Postoperatively, that's not uncovering big, long-term problems.

And the reality of it is most insurances aren't gonna cover that long-term. We always suggest that we actually have in-house nurse practitioner who is a, specializes in psychology. And we, so we have mental health support in-house, but we outsource [00:28:00] that too. 'cause I, I'm a doctor, but I'm not an expert at everything that has to do with medicine.

So people who have eating disorders, we have, groups that we use for that. Things like that. , I just had a husband last week asking about transfer addictions and what happens because of weight loss surgery to cause transfer addiction. I says there, look, there's not a switch that we flip on when I change your anatomy, but if I take something away that you haven't identified as you turn to, to comfort you you'll find a replacement.

And throughout my career, I have seen transfer addictions to alcohol, to drugs, to sex, to shopping. You name it, it, it happens. I always encourage people, I think we all could benefit from therapy. I know 

I'm a believer, 

Used it, life changing. 

Absolutely. I think we've all been through things in our life where it just gave us the tools to cope and it gives us a new perspective to how to look at what life has thrown us.

But in a perfect world, I wish it was [00:29:00] mandatory forever, but many of our patients can't afford that. 

Yeah. That's such a big problem with it. As primary care physicians, we could identify that there was a need to have more coping skills. You could identify that a patient was really stressed and it was affecting them, but you were really limited in what you could do in your small amount of time.

Sure. To help them. Or if they're theirs telling you, I can't afford to pay for counseling. It really puts you in a quandary. Although, I will say there are a lot more self-guided online resources now, and I've never really looked in to see if there are any good ones specifically for dealing with food as you're coping mechanism for stress.

But I imagine those, there's some 

great platforms in our space online. There's one that we work with at KBI called Berry Nation is three former weight loss patients, surgery patients who started this online community. They charge a monthly fee and it's reasonable. But you get, [00:30:00] you access to all these different support groups.

You can't make people go to 'em. We encourage it. There, there are resources out there. It's one of those things, if people want it bad enough, they'll find that, but there is that barrier, of it's not quote required. But we preach it consistently. And the ones that really lean on that and turn to that I think are they're so much more successful because what we do is just such a small part.

Yeah, I know that is something that I've adopted more in my practice that I never did before, was always asking about how do you cope with stress? And starting there before we even talk about changing how we eat. Because if we don't figure out are we using our food to cope with our stress and work on that problem, I can give you all the education in the world and what to eat, but I haven't helped, part of probably what's may have started at all 

As a poor coping mechanism. So I, I do appreciate that. And I guess this brings up another question because I [00:31:00] know we're seeing an increase in some mood disorders while taking GLP ones. Do you feel like that is something that is probably brought on by lack of requirements of addressing this in order to prescribe it?

Or do you think it's from the medicine itself? 

I think the majority is the first thing that you suggested. Here's the thing, anything in life that has power, has power for good or evil, right? Anything that has a huge upside if it's abused, has a huge downside. If I wanna put myself in the weight loss medication, shoes of this is the best option, some would argue, Hey, in this study or this study, we're seeing results that are approaching, some of the more conservative surgeries that we do.

Okay, great. But if that's the case, then the same downsides outside of the surgical risk have to come with it. We see no one encourage daily [00:32:00] multivitamins with GLP ones that I see. , I know of a patient who is younger than me in a wheelchair because of an undiagnosed thiame deficiency that she was being placed on a GLP one for nearly two years before someone figured it out.

 If she is unable to eat a lot of food, she's susceptible to a vitamin deficiency. But the reality of it is a medi spa, a plastic surgeon, a family practitioner, anybody can prescribe these meds. I'm not saying they shouldn't, but there's no requirements of what has to go along with that. But yet we're saying that this may have great power in weight loss.

I think that's the biggest, the first problem. I'm not saying that we should be the only ones to be able to give these medicines. I just think anybody who is interested in treating this disease has to truly be interested in treating this disease and having all the resources. At their disposal that we've been using in the past that we deemed necessary to treat this disease.

The psychological support, the dietary [00:33:00] support, the education that's required. And unfortunately, we have plastic surgeons all over the country who never had this soft spot in their heart to treat the obese patient. And now suddenly they are all really interested in treating obesity. Is it because they just had a, that, that come to Jesus moment that I want to help the obese population or become transactional Again, I'm not, I know I'm gonna tick some people off.

There's some people out there that did maybe make that change. But let's be honest with ourselves. And I think that we're now starting to see studies where they're saying real world data versus clinical trial data and there's a massive gap in the outcomes of clinical trial data with weight loss in the meds and real world data in the meds.

Part of it is because there's no other resources that are provided in the clinical trial data. They're included. 

Yeah. That's something I like always to point out is like all these trials that are showing all these [00:34:00] amazing things. It was more than, it was, I'm giving you this tool, this medicine great, but I'm also backing it up with all the other things that you need to get this great success.

And that's being left out for the majority of patients in the real world. 

We're providing the medicine cost free. We're providing the nutrition, we're providing the follow up visits to track the data. Same thing with surgery, but there was a recent trial that looked at real world data versus clinical trial data in surgery and in medicine.

There was a, slight drop off in the weight loss percentage in the surgery group because it's real world. Can't make 'em come to their follow up. Can't make 'em take their vitamins, can't make 'em meet with the dietician. The drop off for the meds was huge. And I don't how 

much,

How much? 

So less than half.

Yeah. Now, I'm going to talk from both sides. The first study that came out showing that was from the New York Bariatric Group. So if I'm an obesity specialist person, I say, oh, it's a bunch of bariatric surgeons. Of course they want this to look bad, but who out there is able to provide both treatment [00:35:00] options?

It's surgery groups. They do both bariatric surgery and medicine. If you're just obesity medicine, you don't have that surgery group. And is that a fair trial because it's a different protocol, people following? I don't think it's a shot against the meds. I think the level of compliance with medicines and surgery is drastically different.

We just did a post about this. I don't know if it's been even released yet, but, if I want you to be compliant with the treatment versus compliant with maintaining control, your disease, those are different asks because compliance of treatment for surgery means you show up for surgery and you wake up.

You have now been compliant with the treatment. You may not be compliant with what I ask you to do to make your treatment work for you, right? But you have now complied with the treatment treatment's done. If I ask you to be compliant with the treatment of medications, that is a decision you have to make every week for the rest of your life.

Factors like, how do I feel? I'm really nauseous. Do I want to take this injection? I'm on [00:36:00] vacation. I didn't bring it with me. My insurance no longer covers it. I don't feel like taking it. You have to make the decision every single week. So it's not really a fair comparison of compliance of treatment.

'cause one, it's over. Now you can choose, but you've always got the surgery there. You can choose to use that tool to your advantage or your disadvantage. So I don't think we should be surprised by that because that compliance of treatment is dynamic on a weekly basis. Forever. 

Yeah. And I mean I've seen that with patients, they could take it over a year, but there's many months that they may not have just wanted to take it.

'cause they had a vacation. They're like, me, don't wanna mess up, up, my vacation or Sure. Or they're ill and they're like, I don't wanna take this medicine in until I'm recovered. Yeah. 

And that's okay. Yeah. And that's their free will. But we have to accept what comes with that. 

 We're doing a lot of comparison.

A bariatric surgery is a tool and GLP ones is a tool, and we're grateful we have these tools. A question I think that [00:37:00] always came up for patients considering bariatric surgery, and I'd love to hear your response on this is, but it's, at least with the medicine, I can stop it. I can't undo my surgery.

So what is your take on that question? 

It's a great question. It's a great question 

because I feel like that's what a lot of patients that struggle with this that's what they're thinking about in their mind. 

Yeah. It's a fantastic question. But I think and I know it sounds like up to this point, I've done a lot of picking on big pharma and the medications, and that's not the case at all.

I think it's an extremely powerful thing. I think it's brought a lot of positive things to our specialty because we're providing options. For years, we, as surgeons, saw how impactful this could be for people who truly took the tool and ran with it. But yet we were shocked. Why did, why is there such a small percentage of people, less than 1% of those that qualify, come to have surgery?

Duh. If you had a SVT and you went to see a cardiologist for the first time and he said, okay, yeah, we can do an ablation on you. You'd be like, whoa, hold [00:38:00] on. People aren't ready to make that big of a commitment and now we have options. But the thing that I would say to someone who says at least I can stop it, is the same thing I said. When bands were really popular, you can stop it. But we can't say this is a disease, but not treat it like a disease and our blood pressure doesn't go away for good, if we take the medicine for six months and stop it, our treatment of diabetes that requires medicine doesn't go away.

If I can stop it, you can stop it, but your diabetes is coming back. So , the question I always ask is, yes, you do have the freedom to stop it, but do you want to be dealing with obesity again? And if not, then let's find a permanent fixture that will give you the best chance to treat that. And then I think we have to sit down and talk about the real risks involved with surgery.

The short term risks, the perioperative risks, the long-term risk, things like that. There [00:39:00] is so many misconceptions out there about what we do surgically. It is not perfect. And if you ever meet a surgeon that says nothing bad will happen, you should find another one. 'cause they're too either ignorant, arrogant, naive, or they haven't done enough.

But but I do think on the same token, if I have a patient that says I'm not sure I'm ready to commit to that kind of makes me nervous. I wanna try the medications that has opened the doors up for so many people. And man, if that works and that's all they need, great. We just want them to know what they're signing up for.

I, I love that you all in, in your practice are able to offer both tools and work with a patient where they're at, what meets their needs in trying to manage this. Another question that I wanna ask is, for these patients that do decide to use bariatric surgery over GLP ones, what, because we were talking about food noise, what is their thoughts on, food noise?

Does it just go away right after surgery?

Yeah, I think it's very different for people like we've talked about earlier, what's [00:40:00] interesting is awareness about GLP ones for weight loss was not just raised because they were treating diabetes and saw people lose weight.

But it was also raised because we knew hormonally what happens to patients who have weight loss surgery. We'll see people. Who have their diabetes resolve in a matter of weeks before they've really lost enough weight from the surgery, there's something going on, right? We know weight loss surgery and , they all impact this differently depending on which surgery you do.

But we know weight loss surgery increases GLP one levels. We've known that for years. We know it increases PYY, we know it increases. GIP levels the same thing that the drugs are made for. Yes, our natural GLP one levels, GLP doesn't hang around near as long as the medication, the peptide that's created or whatever, however you wanna look at it.

But we know that's why the quote, food noise will quiet after surgery. But what I'm saying is, look, but we gotta get to the root of the problem in that meantime, early on, it's gonna be [00:41:00] great. But if you don't start eliminating those things while it's quiet, it can creep back. And we want patients to understand that this is a surgery that doesn't just make you eat less.

It doesn't just maybe make you absorb less. There's significant hormonal changes that occur as to why we know that this can be successful. And there's no other explanation behind it other than when I watch somebody who's on four diabetic medications in a matter of weeks is off everything. That's not, they didn't lose enough weight to, to impact that.

Yeah. And I'm sure you guys have 

seen this. Definitely saw that. Yeah. It was. Just absolutely incredible. 

Yeah. 

A little bit scary. I mean, Definitely as the primary care doctor, I'm like, oh crap, let me, right. You know, I was like, message me every day with your sugars. We gotta get this medicine off. It was a little Yeah.

Overwhelming to try to get these medicines off so quickly. 'cause it usually happened. Depending on the patient, faster than I would've expected. 

We tell every patient in within the first [00:42:00] week, if you're on something for blood pressure or diabetes, I need you to have some form of follow up with your primary care physician within that first week.

Be a phone call, be a televisit, be in person. But I'm telling you, many of 'em are surprised how quick this happens. And I'll say this just because, you guys come from the primary care side. I think there is a massive disconnect between us and the primary care. What we do, how well it works, what we're supposed to be doing on our end.

I'll tell you a really quick story that you'll probably get a kick out of. But I had primary care physician who sent me a lot of patients for years. Obviously, they believed in what we did. And this was back when insurances required monthly weigh-ins. And I got this letter, my, my insurance coordinator brings me this letter says, I need you to read this.

And it says, we'll just, Mrs. Jones was on her six month weigh in. Unfortunately, Mrs. Jones gained eight pounds. And at this time, I don't think she's a great [00:43:00] candidate for weight loss surgery, but, we'll keep trying. And I looked at my, my office manager who was standing there. I said, gimme the phone.

And she's Nope, you're not gonna call anybody right now. You're gonna calm down. So I calmed down and a couple days later I called this person who I had a good relationship with. Like I said, they sent us a lot of patients and I said, Hey, I wanna call you about Mrs. Jones. Yeah, yeah, Yeah. Um, it's, It's so frustrating.

But, hopefully we'll get there. I says, I just have a question for you. Mrs. Jones is on three diabetes medications. I'm going to guess I know how thorough you are that each time you added one, her A1C continued to climb and you added the next one. Oh yeah, of course. And I said, I also know how thorough you are.

I know you talk about lifestyle changes. Absolutely, I do, Eric. You know that, that I think that's so important. I said, okay. So I'm just curious, why did you give her that third medicine? And it was like, silence. She's what do you mean? I'm like she obviously wasn't compliant with what you were asking her to do.

Why did you treat her? And she said that would be withholding care. That's immoral. I said, isn't [00:44:00] that kind of what you're doing right now? And man, you could hear a pin drop and it got a little heated. And I said, look, I can push you a little bit 'cause I know you, but my point is I don't blame you for this.

I blame me because you must be under the assumption that , you are supposed to get them in perfect compliance tip top shape. 'cause I just wanna take her to the operating room. Here's what I need you to know that we do or don't do. Why would we give up on this patient if she's not ready to go to the operating room?

Why would we not continue to educate her? Give her dietary advice, work with her. And so maybe I've not, I've missed that boat. We as surgeons, we want 'em ready to just take to the operating room. I want you to know that's not us. We have to nurture this patient until they're ready. It's not when I'm ready.

It's when they're ready. But what I'm able to do for them, just because they gained eight pounds, life probably sucked last month for them. But if I can show them how we can impact this, this can change their life. And I think that there's been [00:45:00] such a big disconnect between surgery and primary care of this is so drastic, this is so dangerous.

We've not done a good enough job of opening up those conversations about how impactful what we do can be. 

Yeah. And I can say from the primary care standpoint, I did have a number of patients have bariatric surgery or lap band and regain the weight.

And so when you see that happen a few times and then you see somebody that you don't feel like is ready, from a mental standpoint to put in the lifestyle change. And then I think is it worth them doing this when I think most likely they're gonna be in that category to regain the weight and then they've been through this and now they have GERD or whatever else.

Sure. 

, Those were the times when I would maybe not push it as much, but I think part of that problem was because I never really had communication from our bariatric team. Yeah. As far as are you gonna address that? 

Yeah. What's the education like? Absolutely. 

And that was [00:46:00] before I had personally found lifestyle medicine, didn't really know how to educate people on that well, myself.

And so yeah it would leave me with, gosh, I feel like this is gonna be that person. That three years later we're right back here. 

Right back to where we started. Yeah. And then what? Yeah, because we've tried the most aggressive therapy out there and it didn't work. And now they're devastated and they don't know where to go.

Today was clinic day and the last talk I give these patients before they're, they go to surgery it has nothing to do about the surgery itself. It's about body composition. And I give them that example of that person who just focuses on a number on a scale. And what they don't realize is they've taken their caloric requirement from here and dropped it to here, and they are destined for weight regain.

And I look at them in a way as saying, you're not scared of dying from the surgery today. You're scared because you don't want this to fail. 'cause that is like the worst thing ever of you go through all this process and this doesn't end up working. But I'm, I say, I'm gonna tell you [00:47:00] how you can prevent that.

And I cannot tell you it's easy and I can't tell you it's a magic pill or a magic shot or whatever that is. But there's pure science behind this. If you prioritize losing body fat and preserve your muscle mass, you will be able to eat as many calories as you can today, a hundred, 200 pounds lighter, which means you've got a lot more room for error to not exceed that number.

And you'll watch these people you watch a 250 pound female who will lose down to 150 pounds, but did not prioritize their body composition. Just believe, believed the scale that she bought for 15, 20 bucks. And now her calorie number at was, at two 50 was 1300 calories. Now she's 150, but her calorie number's 800.

She physically can't stay at that calorie number on a daily basis. It's impossible. And then what happens is she gains the weight back and she has those people in her ear that were telling her, I know somebody gained their weight back. I told you so. I [00:48:00] told you so. and did the surgery fail? Or did the system fail her?

Because we didn't actually educate her on, we gotta stop talking about how many pounds lost. That's the sexy thing. That's the great thing on Instagram. But we gotta start talking about how do we change someone's body composition for the better. 

Yeah. I can't wait till doctor's offices have that instead.

Yes. 

Yeah. I 

found, we have two in bodies in our office. We probably spent 30, 30 plus thousand dollars on those. We don't bill for 'em, we don't charge their insurance, we don't do anything because I said this is so vital for patients to truly track their progress the 

wrong way. And I've enjoyed having to InBody myself at my practice just because nothing is more rewarding than letting someone see that their weight number is the same.

But they lost body fat and they might've even gained muscle mass. And I'm like, look what you did. Because they were working hard. Yeah, they were putting in all the hard work, but the only data point they had showed that they did nothing. But they clearly did a lot. 

That, in my practice, that's called a plateau.

And how do I get out of [00:49:00] it? And if had a dollar for every time someone sends me a message on social media, how do I break through this plateau? I'm like, it might not be a bad thing at all. Yeah. I hope you stay in that plateau if you're actually adding muscle mass and. Losing body fat 'cause you're gonna be set up for success long term.

Now as you're mentioning this, what do you find, I know it's very detailed for each patient, but what are those big things that you try to emphasize with your patients to have that success? 

So you mean from a body composition standpoint? Yes. Prioritizing protein. We, so every patient who has weight loss surgery, they go on a pre-op diet.

We deprive 'em of carbs. , We don't put 'em on liquid diets. Liquid diets have proven nothing. It's we 35 carbs or less for the, for two week period. And it's primarily to get them to shrink their liver, because, and I, the way I explain it to 'em is, look, if you don't put energy in your mouth, your body will find the next best option.

And that's in the form of stored fat. So yeah, you'll see the scale drop a little bit. You might like what's happening, but for you, it's gonna pull some of that fat outta your liver [00:50:00] and make surgery a little bit easier. But we want 'em to eat food, so we don't deprive 'em of that getting there.

'cause it also subconsciously teaches them how to find those foods that's real life. So I use that example to say, if you don't eat energy forms, your body will find it. If you don't eat the protein that your body requires, your body will find it. But it finds it in the form of muscle you have to not only feed your muscle, you have to use it. And strength training does not get talked about enough. I think weight loss in general, especially 80% of our patients are female women for years. I think it's better now. We 

finally have gotten 

better. Yeah, absolutely. Women are proud of their muscles and they're proud.

But I'm like, look, it's so hard for you to build muscle. If we can just get you to hold onto it. Very few people that are morbidly obese. Are low in muscle mass. They are low in muscle mass compared to the fat that they carry, but their muscle mass on an InBody is above that neutral range. Oh 

yeah. And that's something I didn't expect to see. Then I started seeing, [00:51:00] I was like, oh, like that. Yeah. You have muscle, you have a, we just gotta hold onto. 

Exactly. I think sometimes we go overboard 'cause people almost look at protein, like a weight loss drug.

I'm like, listen, protein's, calories. Getting them to prioritize their protein. And then I also think importantly, getting 'em to understand how to find good protein sources. So what do you bring, 

so the new um, Starbucks cold protein foam or the protein Doritos that are Yeah, 

absolutely. So they get us, they go to Starbucks and they're like, I just got 20 grams of protein.

And they ignored what came with it. You as a dietician, I'm sure you use this all the time, but I use the little. The one-to-one ratio rule. 

Yeah. 

If you, if it's got 200 calories, move the decimal point by one. Call that 20. You gotta get at least that many grams of protein in that food serving, or it's not a good protein source.

And how many times do we see people eat the peanut butter for protein and all this other stuff? And it's so far off. Oh, yeah. 

Or those wonderful protein bars you mentioned. 

Yeah. Yeah. And some are good, some 

are better, some are good. But I always tell people, I was like, [00:52:00] sometimes the, you gotta look at the sugar that comes with it.

But why did Starbucks come out with protein foam? Not because they're interested in weight loss, because it's a trigger word everybody is interested in. There's nothing illegal about it. I'm not degrading Starbucks for doing that, but let's call a spade a spade. 

Yeah. Yeah. Every, everyone has recognized that.

But then I would follow it up with some of the, what you mentioned. Earlier that I don't think is as talked about or as sexy as proteins become to everybody is fruits and vegetables. 

Absolutely. 

And I was like, we always have you joke about making sure your kids eat their fruits and vegetables and it's always been something I feel like everyone knows, but they don't do.

And I don't understand why we have just tried to find every single way to dodge 'em. 

Number one, it's really hard to make a fruit or a vegetable processed without it being obvious. Most very minimally educated people [00:53:00] can figure out that if I buy a can of peaches, what it's floating in.

Not to pick on 'em again, but you can go to Chick-fil-A and get a piece of grilled chicken and order the fruit. The fruit sits soaking in lemon juice and sugar water, but the fruits and vegetables are that really easy, affordable whole food that you can grab. And I always tell people, if you want an orange juice, drink orange juice.

Just squeeze it if you want an apple. We've demonized carbs so much that it's all carbs aren't created equal. And I think people, when they look at food, they're like, what is this gonna accomplish for me? Is it gonna make a change in the mirror? Is it gonna make a change on the scale? Or does it have that magic ingredient that everybody says is good for me, like protein?

But they forget the fact that maybe this just fills me up. Maybe it's low in calorie, I get satiety from it. I got my snack and I go on about my business. Because. Vitamins aren't sexy, which what? Fruits and vegetables fiber's. Not sexy, [00:54:00] right? Not at all unless you tell 'em. But when you to started telling people fiber helped with weight loss.

Everybody was like, Ooh, I wanna get my fiber. So again, I think it's back to that perspective and to round that out of saying, yes, we're trying to help you lose weight, but we're trying to make you healthier. We can't always be waiting on that visual stimulus of, did this change something in my life?

I'm putting fuel in my body that's gonna make it last longer. Getting adequate sleep, eliminating things in our bodies that just aren't good for us. We have to stop expecting a immediate response to something if we truly been convinced in the literature that this is beneficial to our body.

I love that statement. Yeah. If you can focus on how you feel, if you can focus on the fact that you can be assured from the research that's been done, that eating those fruits and vegetables , are reducing your risk of having a heart attack or stroke down the road. Instead of focusing on, did this meal make the scale look better [00:55:00] tomorrow?

You're gonna be more likely to stick to it, because it is really hard to move that number on the scale. 

Yeah. It's, I think, man, when somebody comes to see you to lose weight, everybody has goals in mind. Usually it's a number, it might be something they want to accomplish with their life, and goals are great, but, I always say goals bring short-lived happiness habits, bring long-term results.

And if you solely are motivated by a goal, you might reach it, but when you reach it, what motivates you now? And I've seen so many patients, they're like, I hit that goal and I looked around, I'm like, yeah, it's just a Tuesday and I still gotta go to work. What motivates you to get there? The habits, man.

Celebrate those habits. They're not sexy, and I always tell people I can make anybody lose weight. Losing weight isn't hard. Maintaining weight loss is really hard and maintaining weight loss comes from habits. It doesn't come from establishing a goal. 'cause if somebody who's 10 years out from weight loss surgery posts a picture of them at 10 years versus [00:56:00] seven years, you're like, so what?

You look the same. You have no idea how much commitment it took to just stay there. But that comes from habits. 

Yeah. And I think that's also something that. Is not taught well in medicine is really the importance of habits in how to help patients achieve new habits or adjusting old habits. Even talking about a habit loop with a patient, just because so much of all these chronic diseases start with our habits.

Yeah. 

And somehow that's just not even part of any of our curriculum. 

It's not. And it's, I think it, it also goes back to for years we looked at obese patients and treated it like it was a self-inflicted disease. 

Yeah. 

And I don't think that was fair because we didn't look at diabetics and say that, yeah, we didn't at not lung cancer patients and say that, 

right?

Yes. Many of the diseases that we treat, there are behaviors involved that [00:57:00] exacerbated or make it harder to treat, but there's still diseases because some people get 'em and some people don't. And you, we could go on and on with that. But we also can't ignore it. And I think like anything in society, when we've done something so screwed up, we sometimes go so extreme to the other direction and then we have to backtrack.

And so we now have raised awareness that obesity's a disease. It absolutely is. But we can't ignore the habits. We can't be so afraid to talk about people's habits and how it's played a role in their obesity, because 20 years ago we told 'em that was the only reason that they were obese.

We can't ignore that or not talk about that at all because it's still a really big part of why that disease is present. And more importantly, how do we keep it at bay? 

Yeah. And prevent it in the beginning. Yes. Yeah. Just trying 

to 

be like, 

yeah. Which goes back to what we said earlier. Exactly. It's great to have a treatment for something, but let's really talk about how do we.

Decrease [00:58:00] it, as you guys know, I do all my surgeries robotically and it's fascinating technology and I love it. I sit on the advisory board for Intuitive that's developed the technology, and so I get to peek into the future years in advance before stuff comes out and it's mind blowing.

I've had a lot of people make comments of you're just training ai, it's gonna take your job. And I'm like, I hope it does, because if I train AI with what I'm doing and AI can do it better than me, then why would I wanna hold onto my job? That's for selfish reasons. I'll find a way to help somebody, but why?

Let's figure out how we can prevent this instead of just dragging it out and treating it. 

and nobody wants to have that discussion. 

No, they don't. 

 I would like for you to just at least touch on the different types of surgeries that you can do today, because I don't even think people know what a bariatric surgery looks like with all those options today.

Yeah. So what are the most common available surgeries that you can do? 

Sure. So in a nutshell, the three most common [00:59:00] surgeries that are out there right now are sleeve gastrectomy and sleeve gastrectomy is basically, if you look at the stomach, looks like a big kidney bean, you turn the stomach into the shape of a banana.

So you remove the greater curve of the stomach, you remove the distensible part of the stomach. So we reduce the volume of the stomach down to about an eighth or a 10th of what it used to be, but it can expand 10 to 15 times its size, so from top to bottom, anatomies in the same order. The stomach also has a lot of ghrelin in it.

When you remove ghrelin's, that hunger hormone, so it's definitely a hormonal surgery as well. It's been shown to impact GLP one levels, things like that. So that's one. Another one is room wide gastric bypass. That's the one that's been around the longest. We've got the most information about it.

It's got a bad name because it has been around so long. Everybody thinks a bypass today is what a bypass was 25 years ago, and it's evolved a lot. Also, the education back then was totally different. People were taking a Flintstones vitamin and thinking, oh, that should be enough. And we saw nutritional deficiencies.

[01:00:00] And so that wasn't necessarily, the surgery was bad, the education was poor, and we didn't have the right amount. Gastric bypass is creating a small gastric pouch, so you do eat less, but you're bypassing the first part of the small intestines, which has a lot of impact on insulin sensitivity, some of those hormones that we talked about.

And then the last one is for years there was something called a duodenal switch. Very powerful in weight loss. But as we said earlier, everything that has power has good and evil. A lot of nutritional issues with it. They bypassed a lot of the intestines and we've seen a procedure called the Sadie, or Single Anastomosis du Auto an ileostomy, which is a modification of the ds, but we leave a lot more intestines for absorption, and we're seeing similar weight loss in those patients as the old Ds, but not near, at least early on the nutritional issues not perfect, but that's probably the most powerful one.

LAP band is really almost non-existent now. It was [01:01:00] served its purpose, but it's just be, there's better options out there. But I think the one thing that I would hope people listening to this take from this is not a round peg square hole. If you found out you had high blood pressure tomorrow at a health fair.

You wouldn't go to your family doctor and say, doc, I just found out I have high blood pressure. I don't wanna have a stroke. And Pfizer had this really cool commercial where this family was in a field of sunflowers and they take their medicine and life is great. Put me on that. You would say, doc, help me with my blood pressure.

I'm worried I'm gonna have a stroke. And your doctor would look at you and your comorbidities and your history and find the right medicine to treat your blood pressure. That's what bariatric surgeon used to do. So if you see a bariatric surgeon who only does one procedure run, because everybody can't have the right treatment to fix the problem, the same.

Like you mentioned earlier, [01:02:00] there's patients who get reflux after sleeve because they probably shouldn't have had a sleeve in the first place. Now it can still happen. I've had patients get it and they were a great candidate, but our job as a bariatric specialist is to look at a patient, say, how much weight do you need to lose?

What other comorbidities do you have? I really want your diabetes to go away. This one's better than this one. I don't wanna deal with reflux. This one's better than this one. Hey, I have to take chronic steroids. You can't with this one, you can with this one, we have to look at the whole patient and customize the treatment for them.

And so I'll always warn patients, just because your neighbor had surgery X and they had a great result, it wasn't because of that procedure, it was because they were matched with the right procedure for them. So just know that one of these surgeries can more than likely get you there, but let us find the right one.

For you because at the end of the day, your length of stay is almost identical. Your incisions are identical. Times of surgery are very close in experienced hands. So [01:03:00] don't make , a judgment because you think one is less invasive when it really isn't and it may not get you what you need. 

And what would you tell a patient that's struggled with obesity, that is contemplating GLP one medications versus surgery?

What would you tell them to reflect on in order to help them make that decision? 

Yeah, that's a great question. I think just know what you're signing up for. So you know, when any anyone's interested in GLP ones, the first thing I'm gonna look at is if someone's BMI is pretty high, we're getting into the mid forties or higher, especially if they had diabetes.

This is probably not gonna give you the weight loss that you need long term. My goal is to make you non-obese. And look, BMI is not perfect. We know that, but my goal is make to make you non-obese. 'cause if I can do that, I can flatten your mortality curve. That's a separate conversations.

But if they are a good candidate for both, I would say, look, I just want you to realize that this medicine's for life, this is not a, I take it for six months, I [01:04:00] get the weight off and then I can stop it. The date is very clear. You're gonna gain that weight back. So are you okay with that? Are you okay with the financial burden that it brings?

Your insurance may cover it now, but you may change jobs in the future. And we're nowhere near patents running out right now. So this is gonna be this way for a period of time at least. And do you want to take a medication? For the rest of your life, if you do and I think those are the same fair questions.

Say, are you okay with me changing your anatomy? Are you under okay with undergoing a procedure? And if they say, yeah, no I totally get it. But if someone says whoa, I thought I could take this for a short period of time. It gives us the opportunity to make sure we show them the data. So many people out there still think is well, I know people say that, but I'm gonna be the, I'm gonna be the different person.

I maybe you will be. 

Yeah. Maybe 

you will be 

there. There are people that are, there 

are people that are just don't. Yeah. But I [01:05:00] don't, but I, it would be like me saying, this is my rockstar patient and not putting in the fine print results aren't expected. 

Yeah. Like we see all the time.

, 

I think giving them that, that perspective, is important. And then also making sure they don't have misconceptions about surgery. There's a huge study that looked at risk ratio, and the mortality rate of bariatric surgery is no greater than an elective cholecystectomy.

An appendectomy, and sleeve gastrectomy actually has a mortality rate as low as childbirth. So we let's put this in perspective. The mortality rate of a hysterectomy or a joint replacement is multiple times higher than bariatric surgery. 

That is good information. I, thanks for breaking that.

'cause things have changed rapidly. Yeah. Over the last few years and so it's hard to keep up. So having that is great. And I know we have listeners right now they're like, oh my gosh, kitty and Sarah are lifestyle medicine doctors and we're here talking about bariatric surgery and GLP ones.

What is going on? [01:06:00] And so I want our listeners to know, and I hope you realized in this entire discussion after you actually hit play and listen to it, is no matter what tool you use to help manage obesity in order , to have success, lifestyle is still there. The lifestyle changes are still gonna be a part of it.

It's not an us versus them. World, like we all need to be making lifestyle changes in order to live our happiest, healthiest lives. And there's not shame in the fact that if you need one of these tools to be able to do those lifestyle changes, great. But we're still gonna have to do the lifestyle changes.

Absolutely, 100%. And I would even go far enough to say in our lifetime, if you ever see a treatment that provides a result that we're striving for with no effort and no lifestyle changes for the betterment of your [01:07:00] health, I promise you it is not real. And we will discover the faults with it very quickly.

It doesn't make any sense if I were to able to do a surgery and say, you can eat anything you want. It's not just a matter of making you overweight. What is it doing to your body? How is it impacting your body? We are trying to make ourselves healthier across the board. And so if anyone ever markets something that says, if I do this surgery, it will let you eat pretty much whatever you want.

Either that surgery is not for you, or that doctor is trying to sell a bill of goods that they can't back up. 

Yeah. When it comes down to it, the habits are always going to matter. They are, 

absolutely. 

Yeah, they are. 

. So I think just, wrapping up, you gave us a lot to think about and really I think. People just need to take some time to think about what their personal food environment looks like. Take some time to think about what do you feel like you have power over? When do you feel like food has [01:08:00] power over you?

And recognize, do you need to do something about it? Recognize where food comes in your life in the form of managing stress or managing how you're dealing with certain situations that come up and then decide what you need to do about it. Is lifestyle enough for you? And if it is, definitely keep following along with Sarah and I.

We're happy to guide you on that. If lifestyle's not enough and you wanna look towards GLP one medications, or you wanna look towards bariatric surgery to help you get over that hump. Definitely look into it, definitely talk to someone who's well trained on all your options, and then look at how you can integrate lifestyle into that to really get the success that you're looking for.

'cause I don't think anyone's really looking to lose weight and just be a sack of bones.

Yeah. 

You wanna be able to lose weight and go do these things that you're limited from doing now, and that's gonna take effort on all the different fronts of that. So just take [01:09:00] some time to self-reflect and see what would be the best route for you 

and for our listeners.

How could they find you? 

Yeah. So obviously Kentucky Bariatric Institute, where I'm medical director we are located in Georgetown. We our, all our surgeries are done at Georgetown Community Hospital. Our office is right beside the hospital. We also have a clinic in Winchester. And we will be launching a new clinic in the Maysville area very soon to just try to improve access for patients.

The website Kentucky bariatric institute.com, they can find us. I'm on social media both on Instagram and TikTok. Really just try to post content from an educational standpoint. But that's probably the easiest ways to find me and what we do. 

That's great.

And just a little takeaway here is for our listeners. I feel very passionate about this. I don't want people to think negatively about this, but obesity is not a failure of willpower. We want you to [01:10:00] realize that this is a chronic multifactorial disease and it's requires compassion, evidence-based tools and lifelong attention related to your lifestyle to have success.

Really try to find those providers that are going to be there for you and with you to travel on this journey to reach your health goals. And then next week we're going to continue talking about lifestyle changes and we're gonna have Jessica Jackson on the show for Jack Nutrition. She's diving into motivation and how she coaches people in making lifestyles changes and continuing to show up for themselves.

It's a great show, so be sure to listen in next week. 

See you next time.