Latest / Bryan Health Podcasts / Is Weight Loss Surgery Right For You?

Transcript

Is Weight Loss Surgery Right For You? · Bryan Health Podcasts

• 0:03
  Melanie Cole, MS (Host): Welcome to Bryan Health Podcast.
• 0:05
  I'm Melanie Cole.
• 0:06
  And today, we are talking about weight loss surgery.
• 0:10
  Joining me is Dr.
• 0:11
  Chris Seip.
• 0:11
  He's a general surgeon with Bryan Health.
• 0:14
  Dr.
• 0:14
  Seip, thank you so much for being with us today as we get into this topic.
• 0:18
  And wow, there's so many tools in your toolbox today.
• 0:21
  It's really an exciting time in your field.
• 0:23
  But I'd like you to start by kind of giving us a working definition
• 0:26
  of obesity and the economic burden.
• 0:30
  I mean, we're really seeing an epidemic in this country with
• 0:33
  our children and with our adults.
• 0:35
  Speak a little bit about how you define it so that then we can talk
• 0:39
  about what we're doing about it.
• 0:41
  Chris Seip, MD: You bet, Melanie.
• 0:42
  Thanks.
• 0:42
  And yeah, it's a pleasure to be here.
• 0:44
  Obesity, when we start talking about that and, specifically, I'm a surgeon,
• 0:48
  so when we start talking about patient's who might be candidates for, say, weight
• 0:54
  loss surgery because of their obesity, we in general are talking about patient's
• 0:58
  who probably weigh around a hundred pounds over their ideal body weight.
• 1:04
  And so, that means when we calculate what we talk about in medicine, the
• 1:08
  BMI is going to be around a BMI of 40.
• 1:12
  So for the average person, if an average person is 70 kilograms
• 1:17
  or 150 pounds or so, that's going to be weighing around 250 pounds.
• 1:22
  So, it's a fair amount of weight for people to try to lose.
• 1:27
  Unfortunately when you look at our statistics in society, we know
• 1:31
  that it varies a little bit by region, by state in the country.
• 1:35
  But in general, the population is at least 40% overweight.
• 1:41
  And that would be, say, BMIs between 25 and 35.
• 1:45
  And then, the rates of morbid obesity, so, like, I was just suggesting a
• 1:50
  hundred pounds over ideal weight, those numbers approach 15-20% in some states.
• 1:56
  So, it's a really common problem, one that impacts so many aspects of life.
• 2:02
  It's an expensive problem from a medical perspective to take care of illnesses
• 2:07
  that are directly a result of the weight.
• 2:10
  And so, it really does impact almost every aspect of life.
• 2:15
  Melanie Cole, MS: Well, I'm glad that you mentioned there are comorbid
• 2:19
  conditions as a result of obesity.
• 2:22
  Just speak a little bit about those, because I think that they have a
• 2:25
  bearing on why it's so important to consult your provider because
• 2:32
  they cause so many complications that then lead on down the line.
• 2:36
  Chris Seip, MD: Yeah, they really do.
• 2:37
  And they compound each other.
• 2:38
  So, some of the more common associated comorbidities, which are just illnesses
• 2:44
  that are directly related to obesity, would be type 2 diabetes, which
• 2:49
  is an insulin-resistant condition.
• 2:52
  And with that condition, there's numerous other systems that are involved, as a
• 2:56
  consequence, which include the kidneys, heart disease, risk of stroke goes up.
• 3:03
  And so, hypertension included in that group.
• 3:06
  So, there's several things that, as a result of maybe having type
• 3:10
  2 diabetes, the other systems are going to be impacted as well.
• 3:14
  And it's not just the diabetes and/or cardiovascular disease that's at risk.
• 3:19
  One of the more common conditions is obstructive sleep apnea.
• 3:23
  And that condition also is most commonly somebody whose symptoms
• 3:27
  are snoring at nighttime.
• 3:29
  And that directly impacts other systems as well.
• 3:32
  So, it's a pulmonary condition, but it impacts the heart pretty substantially.
• 3:37
  And patients who suffer with obstructive sleep apnea, they really feel miserable.
• 3:41
  Their energy levels are completely down.
• 3:43
  Because of that, their stress level or cortisol levels are really high.
• 3:47
  And as a result of that, their metabolism is completely messed up.
• 3:52
  And so, it's a vicious cycle.
• 3:54
  All of these things spiral out of control, trying to get the weight off.
• 3:58
  Oftentimes medically is really difficult, especially when you're looking at the
• 4:02
  amount of weight we're talking about.
• 4:04
  And so, that's kind of where my specialty comes into play.
• 4:08
  Weight loss surgery has statistically been well documented over decades to
• 4:14
  really provide substantial weight loss.
• 4:17
  Melanie Cole, MS: Well, as I said at the beginning, this is such an exciting time.
• 4:21
  There are so many options.
• 4:22
  And before we discuss those, what had been done previously, Dr.
• 4:27
  Seip, in terms of weight loss?
• 4:29
  Were we just kind of throwing up our hands and telling people
• 4:32
  to exercise and eat less?
• 4:33
  When we think of these historical weight loss efforts, which people found
• 4:39
  very, very difficult, I mean, there are weight loss programs out there.
• 4:42
  And so, I'd like you to just speak briefly about some of the things that we used to
• 4:47
  do and why we're looking at all of these different interventions now, and then you
• 4:52
  can tell us about what's available now.
• 4:55
  Chris Seip, MD: Yeah, you bet.
• 4:55
  So for decades, it's primarily been just like you suggested, you need to
• 5:01
  exercise and you need to eat less.
• 5:03
  And unfortunately, when you look at studies, the success rates with those
• 5:07
  two measures or lifestyle modification alone are really discouraging.
• 5:12
  Five percent of excess weight on average can be lost over 12 months with those
• 5:16
  two efforts alone for the average person.
• 5:18
  And that's not enough to impact any of the illnesses that we're talking about.
• 5:23
  And so, again, that was decades.
• 5:24
  Surgery has been around for a long time.
• 5:27
  It's been around since maybe the mid-1970s, and that's evolved in
• 5:32
  what it would've originally looked like to what it looks like now.
• 5:35
  Some of the more durable procedures like a gastric bypass, they've been around for
• 5:40
  30 years or so, maybe just a bit longer.
• 5:43
  Those have also evolved as to how that's done now.
• 5:46
  And so now, as opposed to telling people you just have to change
• 5:51
  what you eat and exercise more, we do have some options surgically.
• 5:56
  There are also some newer medications coming down the
• 5:58
  pipeline that help with weight loss.
• 6:00
  So all of those things, when you look at any given patient, number one, they
• 6:04
  will need to change their lifestyle.
• 6:06
  That's part of the deal.
• 6:08
  Even with a surgery, even with some of the newer medications, it still
• 6:12
  requires those lifestyle modifications.
• 6:14
  But we really can achieve much greater results with weight loss.
• 6:18
  We're talking about weight loss, but honestly we call it metabolic surgery.
• 6:22
  And so, not only do the patient's lose weight, but really we
• 6:26
  affect their metabolism and that's probably the greatest.
• 6:29
  When you look at long-term stuff, changing their metabolism is the key.
• 6:33
  And some of the newer meds, they also work by changing metabolism.
• 6:36
  So, they provide weight loss.
• 6:38
  But really, they dramatically change this system.
• 6:41
  Melanie Cole, MS: We're going to touch on some of those meds later on, but
• 6:44
  I love for you to tell us the options that are available because some of
• 6:47
  them are tried and true, and some have changed a bit over the years.
• 6:51
  Chris Seip, MD: So, gastric bypass, like I mentioned, would've been done
• 6:54
  around the early '90s to mid '90s when it started, And that was done
• 6:58
  through an open, regular big incision.
• 7:01
  That has persisted and it's been a gold standard for weight loss for many years.
• 7:06
  It works by restricting how much a person can take in, but it also
• 7:10
  bypasses a portion of the intestine, so there's malabsorption of nutrients.
• 7:14
  And so, calories that are taken in are not absorbed, even though
• 7:19
  what you take in is restricted.
• 7:20
  And so, that, for a lot of patients, has been the gold standard.
• 7:24
  It provides 70-80% of excess weight loss potential.
• 7:27
  The alternative surgically when you look at them, another one is a duodenal switch,
• 7:32
  which is somewhat like a gastric bypass.
• 7:35
  There's a restrictive component to that, as well as a malabsorptive bypass segment.
• 7:40
  And so, that similarly will provide great weight loss, 70-80% of excess weight.
• 7:46
  Both of those because of rerouting the intestine and bypassing a
• 7:50
  portion of absorption, they do have long-term nutritional consequences.
• 7:55
  And so, those are patients that have to be followed lifelong for many of
• 7:58
  the nutritional potential deficiencies.
• 8:01
  Really, one of the other mainstays of surgery now is a sleeve gastrectomy,
• 8:05
  and that's where we just take out 75-80% of the stomach and
• 8:09
  leave behind a long gastric tube, which does a couple of things.
• 8:13
  It is restrictive as to how much a person can take in.
• 8:16
  But it's also metabolic.
• 8:18
  The part of the stomach that's taken out with that surgery really
• 8:21
  contributes to much of a person's hunger, desire for food, the
• 8:25
  problems with insulin sensitivities.
• 8:27
  So when we take that part of the stomach out, it does change
• 8:30
  immediately those hormonal things.
• 8:33
  And that's a consequence of the surgery that's immediate and longstanding, So,
• 8:37
  the sleeve gastrectomy for a lot of patient's when it's considered also
• 8:40
  one of the lower risk procedures is for, many people, the right decision.
• 8:45
  Those are the three mainstays.
• 8:46
  The gastric band that has been around decades now.
• 8:50
  It's been probably 25, maybe just longer years.
• 8:54
  It's fallen out of favor to some degree because much of the time, when
• 8:57
  you looked at average weight loss with a band in place, which was a
• 9:01
  mechanical device put at the top of the stomach to restrict how much a person
• 9:04
  could take in, it had many potential failures from a mechanical perspective.
• 9:10
  It also had long-term complications of erosion and/or malpositioning
• 9:14
  requiring additional surgeries.
• 9:16
  Most patient's didn't achieve over 50% of their excess weight.
• 9:20
  And so, as a surgical society, we really have felt like if you can't get to 50%
• 9:24
  of excess weight off, it's really not something that should be considered as
• 9:28
  a longstanding option for a patient.
• 9:30
  So, it's kind of fallen out of favor anymore.
• 9:32
  We take more bands out than are put in
• 9:34
  Melanie Cole, MS: Yeah, that's really interesting.
• 9:36
  That was a great explanation of the types that you offer.
• 9:39
  So, there are parameters.
• 9:41
  This isn't something someone can just walk in and say, "Okay,
• 9:44
  I'd like a sleeve gastrectomy.
• 9:46
  Can you please tell us the parameters for bariatric surgery as you look at your
• 9:51
  patients, what they have to go through for sleeve gastrectomy or bypass, and what
• 9:57
  you tell them every single day about these parameters, why they're so important.
• 10:03
  Chris Seip, MD: So in general, when we look at people who we talk about
• 10:06
  as candidates for these surgeries.
• 10:09
  Again, it's back to the BMI as one of the first things we look at.
• 10:12
  And a person with a BMI that's 40 or over, because that puts them at around
• 10:17
  a hundred pounds on average over their ideal body weight, those are people that
• 10:21
  immediately we think, yep, even without other associated illnesses, they would
• 10:25
  be a candidate to talk about surgery.
• 10:27
  And in that, if a patient doesn't have those illnesses at this time,
• 10:30
  it just means not at this time, they very well down the road are going to.
• 10:34
  And so, it's a preventative thing for patient's without illnesses.
• 10:37
  But when you look at patient's who do have those comorbidities in place, especially
• 10:41
  type 2 diabetes and cardiovascular disease or sleep apnea, we lower
• 10:46
  that criteria down to a BMI of 35.
• 10:49
  And even for some studies now, it's well documented the BMI is down even to 30.
• 10:54
  Because of this metabolism component of the surgeries, if we offer that to a
• 10:59
  patient with type 2 diabetes and a BMI of 30, it cures their diabetes, it'll
• 11:03
  cure patient's with higher BMI also.
• 11:05
  But because of that metabolic change, these surgeries in general would
• 11:09
  be offered for specifically type 2 diabetics down to a BMI of 30.
• 11:14
  If those other comorbidities aren't present, then we usually stick pretty
• 11:19
  strictly to that 40 BMI and above.
• 11:22
  And certainly, those patients stand to benefit terrifically
• 11:25
  by losing substantial weight.
• 11:28
  Melanie Cole, MS: Dr.
• 11:28
  Seip, what do you want them to do if you've discussed this
• 11:31
  with them and it's a shared decision-making in advance of surgery?
• 11:35
  Should they be trying to lose weight?
• 11:36
  Should they be exercising?
• 11:38
  Are they getting counseling?
• 11:40
  Because I know that's a part of it as well.
• 11:42
  Chris Seip, MD: We'll do a either monthly or every other month seminar where any
• 11:46
  potential patient who's considering this comes in to have a thorough understanding.
• 11:51
  It's presented usually by the surgeon to discuss, like, "This is the
• 11:55
  reason that we're talking about this.
• 11:57
  Are you a candidate?"
• 11:58
  And we really to educate them about what's involved with the preoperative
• 12:02
  process, what goes on in the OR and what the postoperative process looks like.
• 12:07
  And preoperatively, then we get full medical evaluation, we get
• 12:12
  also psychological evaluation.
• 12:14
  We have most patient's seen by pulmonology and cardiology to assess
• 12:19
  what their current illnesses are and what their future risk might look like.
• 12:23
  And then, really, try to pull that all together for the individual to see
• 12:28
  what's their potential benefit to go through this, make it sure that they
• 12:34
  have a good understanding of what the risk is, but also on the other side of
• 12:38
  it, what their success might look like.
• 12:40
  And we do encourage them, even from the very beginning to make
• 12:43
  those lifestyle modifications.
• 12:46
  We used to have criteria to say patients who were, say, super morbidly
• 12:50
  obese, where we'd be talking about BMIs over 60, that they had to lose a
• 12:54
  set amount of weight coming into the surgery before we could consider them.
• 12:57
  What you find if you've done this long enough is that's a really difficult thing.
• 13:01
  There's a reason those patient's have gotten to the point they are, and to
• 13:04
  require that preoperatively for most of them isn't going to be successful.
• 13:09
  So, a lot of times they'll be down some as they come into the
• 13:12
  process, but they don't have the benefit of the surgery in place yet.
• 13:16
  So, we encourage the lifestyle modification knowing that there's success
• 13:20
  preoperatively, it will be difficult.
• 13:23
  And postoperatively, at least, they'll have those changes in place to really
• 13:27
  catapult themselves into the success.
• 13:29
  Melanie Cole, MS: And as we say, this is a tool.
• 13:32
  And for people that think that this is an easy way out, it's not, and it
• 13:36
  is a lifestyle complete change, right?
• 13:40
  Chris Seip, MD: Yeah, you're exactly right.
• 13:41
  I mean, we will hear oftentimes a family member or friend who has said that they're
• 13:45
  going the easy route by doing this.
• 13:47
  And it's honestly not.
• 13:49
  It's just the person taking responsibility.
• 13:51
  And it's simply a tool, like you said, that really, in studies, shows it's
• 13:56
  going to help them be more successful than they could ever be without this
• 14:00
  tool, but it's simply a tool, because it still requires all of the changes
• 14:04
  we just talked about to be successful.
• 14:07
  Melanie Cole, MS: Well, I agree.
• 14:07
  And I think that people that endeavor to do bariatric surgery are brave and taking
• 14:14
  charge of their own health, and that's really what's so important that we all
• 14:18
  have to be our own best health advocate.
• 14:21
  Now, as we think about what's going on today, Dr.
• 14:25
  Seip, we see medical weight loss.
• 14:27
  And we see medications that are out there like Ozempic and things.
• 14:32
  Speak about the results for bariatric, as you've seen in
• 14:36
  your career versus these kinds of medications that are out there now.
• 14:41
  When you're talking to your patient's every day, what do you tell them?
• 14:44
  Chris Seip, MD: You bet.
• 14:44
  And even most recent studies just in the last several months, when we
• 14:47
  look head to head from a surgical weight loss perspective versus even
• 14:51
  the newer medications, hands down, surgery beats them, every study done.
• 14:56
  So when you talk about medical weight loss, even with the new GLP-1
• 14:59
  medications, in general, we're talking about patient's being able at most
• 15:04
  to lose 25% of their excess weight.
• 15:07
  And I just mentioned that we don't consider it right to put bands in people
• 15:11
  anymore, because we couldn't achieve 50% of excess weight loss in patients.
• 15:16
  So when we're talking about surgical weight loss, we're talking 50-70
• 15:22
  and 80% of excess weight off.
• 15:24
  And when you compare that to medical weight loss, it's not
• 15:27
  even in the same ballpark.
• 15:29
  So again, 25% versus 70-80% is a big difference.
• 15:34
  And the impact on their life is similarly a big difference.
• 15:37
  The changes too, with these medications, there are consequences and side effects.
• 15:42
  And many times, the patient has to be on them lifelong.
• 15:45
  And so, that's the challenge.
• 15:47
  The thing that we don't quite understand yet in medicine is what
• 15:49
  that's really going to look like.
• 15:51
  These surgeries, like we're talking about, if we can get a patient
• 15:55
  through them safely and into that postoperative lifestyle, they can
• 15:59
  be successful for the remainder of their life at keeping the weight off.
• 16:04
  And so, we really consider them durable, permanent solutions
• 16:07
  as opposed to medication, which is not proven to do that yet.
• 16:11
  Melanie Cole, MS: Yeah.
• 16:11
  And I think that maybe even some of those medications might be for people that
• 16:15
  don't qualify for bariatric surgery.
• 16:18
  As you said, maybe they only have 10, 20, 30 pounds to lose.
• 16:21
  They're not in the morbidly obese category or the parameters that
• 16:26
  you've discussed here today.
• 16:27
  But it's always good to talk to your provider and get this information clearly.
• 16:33
  Now, Dr.
• 16:34
  Seip, what is it like for the patients?
• 16:36
  What is it like after surgery, lifestyle management, supplementation,
• 16:41
  going out to restaurants?
• 16:42
  What is life like as you've seen it for your patients?
• 16:46
  Chris Seip, MD: It definitely changes it.
• 16:47
  So, what we hear back when patient's come in.
• 16:50
  And really, the first month is the recovery process for most patient's.
• 16:53
  Once they're past that, it's into maintenance, as far as what they're able
• 16:57
  to take in in amounts and those things.
• 17:00
  So, so say when they go out to eat, what they find is many patient's actually ask
• 17:05
  if we can give them a medical card so that when they go somewhere, they can either
• 17:09
  order off the kiddy menu or at least have reduced portions to have to pay for.
• 17:14
  Because if they get a regular sized portion, they will not be able to complete
• 17:18
  the meal and will have leftovers for days.
• 17:21
  So if they're able to do that, great.
• 17:23
  But oftentimes, again, they just are able to take less.
• 17:25
  And that's the thing they grow accustomed to.
• 17:28
  It does take some time, and I'll tell you that patient's vary a lot
• 17:31
  as to how quickly they adapt to how limited of intake they can achieve.
• 17:37
  It's initially sometimes pretty surprising to them that, man, it's
• 17:41
  just feels like a fraction of what they normally were used to, and they're full.
• 17:46
  And that sensation of fullness also changes.
• 17:48
  And so, that's a learning process for most patients.
• 17:51
  It takes maybe three to six months to kind of adjust and
• 17:54
  really see what that looks like.
• 17:56
  With bariatric surgery patients, we keep them and our studies really
• 18:00
  have shown that we need to keep them in close follow-up, to keep
• 18:04
  them accountable, keep watching that they're not developing any problems
• 18:08
  or symptoms related to the surgery.
• 18:11
  And so for patient's after that, we follow them up pretty
• 18:14
  closely the first six months.
• 18:15
  And then, we start to stretch that out.
• 18:17
  But for most programs, we like to follow those patient's out to five
• 18:20
  years to be sure that they've remained successful and kept the weight off.
• 18:24
  Melanie Cole, MS: This is really such an interesting topic and an exciting
• 18:28
  time in your field, really helping so many people increase their quality
• 18:33
  of life, and that is so important.
• 18:35
  And indeed, even possibly the length of their life and certainly all the
• 18:41
  pain and the comorbid conditions that go along with obesity.
• 18:44
  Dr.
• 18:44
  Seip, I'd like you to summarize for us, giving your best advice.
• 18:48
  For people who are severely overweight, what you want them to think about.
• 18:53
  what are you telling them to think about when they're considering bariatric
• 18:56
  surgery and including their family in these decisions and those support groups?
• 19:03
  Chris Seip, MD: Yeah, you bet.
• 19:04
  So in general, when we talk about that with a patient, it's what areas of
• 19:09
  your life are impacted by your weight.
• 19:12
  And for most people, it involves every aspect of their life.
• 19:16
  And so, it's not only that they have these other illnesses that can
• 19:19
  consume their time, consume their money and really limit their lives.
• 19:24
  But it's also their life is limited from an activity perspective because of the
• 19:27
  weight, whether that's the relationship with their spouse, the relationship
• 19:31
  with their kids, or grandkids.
• 19:33
  They just can't do the things they want to do or even maybe were
• 19:36
  used to being able to do before.
• 19:39
  And so, when they look at those things in life, we try to tell them
• 19:44
  that's how things are restricted.
• 19:46
  And postoperatively, if we can get the weight off, those are
• 19:50
  the things that will come back.
• 19:51
  Not only, like you said, will we prolong their lives potentially, but
• 19:56
  we will improve the quality of the remainder of their life so that they
• 20:00
  can be more active, they'll have fewer illnesses to worry about, and as a
• 20:04
  result, have more fulfilling lives.
• 20:07
  Melanie Cole, MS: Agreed completely.
• 20:08
  Thank you so much Dr.
• 20:09
  Seip, for joining us today and sharing your incredible expertise in
• 20:13
  giving us so much to think about for people that are considering bariatric
• 20:17
  surgery and the ones that we love.
• 20:19
  So, thank you again for joining us.
• 20:22
  And I'd like to thank our Bryan Foundation partner, Union Bank and Trust.
• 20:26
  To listen to more podcasts from our experts, you can always go
• 20:29
  to bryanhealth.org/podcasts.
• 20:32
  That concludes this episode of Bryan Health Podcast.
• 20:35
  Please always remember to subscribe, rate and review Bryan Health podcast on Apple
• 20:39
  Podcast, Spotify, iHeart and Pandora.
• 20:42
  Until next time, I'm Melanie Cole.