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In the Age of the GLP‑1: Who Should Consider Bariatric Surgery? · Flourish- A Prisma Health Podcast

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  Joey Wahler (Host): With GLP one, medications becoming so popular, who
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  should consider Bariatric Surgery?
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  Our guest is Dr.
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  John Scott, a bariatric surgeon.
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  This is Flourish, a podcast from Prisma Health.
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  Thanks so much for joining us.
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  I'm Joey Wahler.
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  Hi there, Dr.
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  Scott.
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  Welcome.
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  Dr John Scott: nice to be here.
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  Joey Wahler (Host): Great to have you with us.
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  We appreciate the time.
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  So first, how has the rise of GLP one meds like Ozempic of
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  course, and other's, changed the conversation around obesity treatment?
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  What are you hearing?
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  Dr John Scott: So one of the most important things about the new
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  GLP one era, it is changed how society thinks about obesity.
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  You know, for decades obesity was framed as this failure of willpower,
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  but now we have medications that clearly demonstrate that obesity is more about
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  the biology of appetite regulation and gut hormones and energy balance.
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  And that's really shifted the conversation, from the blame
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  from the patient to biology.
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  And the second major change about obesity treatment, it's finally being discussed
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  alongside other chronic diseases.
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  Nobody expects a patient with like hypertension or cancer to manage
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  their condition with willpower.
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  so we're starting to apply that same framework to obesity, for, doctors,
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  the conversation has expanded.
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  Instead of having a, choice of just between, surgery and lifestyle, we now
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  have a whole spectrum of therapies.
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  So there's behavioral treatment, medications like
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  GLP one and metabolic surgery.
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  The real progress is that we can start matching the right treatment to the
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  right patient instead of pretending that there is just one single solution.
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  Joey Wahler (Host): Gotcha.
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  And that being said, in this age of these highly effective GLP one drugs,
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  how should patient's and clinicians alike think about the role of bariatric
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  and metabolic surgery these days?
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  Dr John Scott: I think the key point is that, the difference between GLP
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  one medications and bariatric surgery is that they're not competitors.
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  They're different tools that treat the same disease.
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  Now, GLP ones are very powerful.
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  They're powerful pharmacologic therapy that can help patient's
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  lose meaningful weight.
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  And bariatric surgery, on the other hand, remains the most effective and
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  durable treatment that we have for severe obesity and metabolic surgery.
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  The way that I frame it for patient's is this, medications and surgery
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  exist on the same treatment continuum.
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  For some patient's, medication will be the right first step.
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  But for other's, especially for patient's with severe obesity, diabetes,
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  obesity-related complications, surgery may offer a more durable metabolic reset.
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  The goal is not medication versus surgery.
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  The goal is the right therapy for the right patient at the right time.
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  Joey Wahler (Host): So let's delve into that a little bit more.
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  Who would you say is an ideal candidate for GLP one therapy, And what are
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  the expectations that patient's should realistically have regarding
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  weight loss and using them long-term?
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  Dr John Scott: So for patient's that want a non-surgical approach to
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  treatment, I think GLP one therapy is, the perfect option for them.
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  if you look at clinical trials And in real-world practice, patient's often lose
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  about maybe 10 to 20% of their body weight depending on which medication you use.
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  And that can have a significant, I impact on some of the diseases
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  like diabetes, hypertension.
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  fatty liver disease, sleep apnea.
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  But expectations are important.
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  These medications were designed to treat a chronic disease, And that
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  means you have to take them long-term.
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  When patient's stop the medications, weight regain is common because
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  the biology hasn't changed.
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  so that's what I tell patient's.
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  these work best, but they're viewed the same way that you view
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  taking a blood pressure medication or a medication for cholesterol.
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  They are a long-term therapy for a chronic condition.
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  As far as surgery's concerned, surgery is a much more durable,
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  long lasting option for patient's.
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  Joey Wahler (Host): so when is GLP one therapy?
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  Not an option because of other factors, side effects, access,
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  cost, or maybe the challenges of adhering to what needs to be done.
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  Dr John Scott: The biggest barriers that we see for patient's when it comes to
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  GLP one therapy are cost and access.
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  Many insurance plans don't cover anti BC medications, And the
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  out-of-pocket cost can be substantial.
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  And there's also an issue of long-term adherence.
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  These medications require long-term ongoing use, and some patient's
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  prefer a more definitive treatment.
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  So when patient's cannot tolerate the medications or can't access it
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  or simply just prefer a different approach, metabolic surgery
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  becomes a very important option.
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  There was a recent study that showed that almost 50% of patient's that
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  were placed in GLP one therapy.
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  We'll discontinue use of those medications within the first year.
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  Joey Wahler (Host): Interesting indeed.
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  So which patient's would you say, doctor, better serve them by
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  metabolic and bariatric surgery rather than just medication?
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  Dr John Scott: So recently, the indications for bariatric
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  surgery, were updated.
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  Patient's that have A BMI over 30 with comorbidity related to weight, or
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  patient's that have A BMI greater than 35 are potential candidates for bariatric
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  surgery and would show the most benefit.
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  Surgery is very powerful for patient's that have type two diabetes,
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  metabolic syndrome, or significant obesity-related complications.
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  In these cases, surgery does more than just produce weight loss.
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  It fundamentally changes the metabolic physiology and can
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  lead to remission of diabetes.
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  And other diseases related to weight.
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  Another group of patient's, that have benefits are those that have
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  struggled for many years with multiple different treatments,
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  multiple different medications, and want a more durable intervention.
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  So when we talk about surgery, we're not talking about a last resort.
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  We're talking about the most effective therapy that we have for certain
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  patient's with metabolic disease.
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  Joey Wahler (Host): Gotcha.
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  And so naturally doc people joining us, I'm sure, wondering more so
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  than anything else about outcomes, results at the end of the road, if.
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  There is such a thing here.
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  How do outcomes compare then between GLP one meds and bariatric surgery in terms
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  of things like weight loss, durability, metabolic disease, remission, and of
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  course overall quality of life, period.
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  Dr John Scott: In real-world studies, GLP medications typically
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  produce anywhere from 10 to 20% total body weight loss, depending on
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  the medication that you're taking.
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  And if you continue with treatment, bariatric surgery, once again, varices
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  between which, metabolic procedure you have produces about 25 to 30.
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  Total body weight loss, and most importantly, much of that weight loss
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  can be maintained long-term after your surgery from a metabolic standpoint.
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  Surgery also has very high rates of type two diabetes, remission,
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  and significant improvements in cardiovascular risk factors.
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  Quality of life often improves with both therapies.
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  What patient's care about most, mobility, energy, metabolic
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  health longevity can substantially improve with either approach.
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  So the difference isn't what works And what doesn't.
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  but what's been shown substantially is that surgery currently provides
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  the most powerful And the most durable metabolic effect of the two options.
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  Joey Wahler (Host): so.
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  What about GLP one meds and bariatric surgery working together?
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  Medication before surgery or after surgery, or perhaps as part
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  of long-term weight maintenance?
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  Dr John Scott: Absolutely.
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  One of the most exciting things about the current area is
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  that we can combine therapies.
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  Some patient's benefit from medication before surgery to
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  help reduce operative risk.
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  Other patient's use medications after surgery to treat weight recurrence,
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  or optimize metabolic control.
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  We're increasingly thinking about obesity the way we think about
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  cancer or cardiovascular disease by using combination therapy.
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  So rather than asking whether medications replace surgery, the better question
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  is how can we integrate medications and surgery together to achieve the
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  best long-term outcomes for patient's?
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  Joey Wahler (Host): Misconceptions, of course, are always a factor here with
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  people reading things on the internet that may or may not be as accurate as possible.
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  What are the misconceptions you find that patient's commonly have about
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  bariatric surgery And this GLP one era, and how do you help patient's make
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  individualized evidence-based decisions rather than poorly informed ones here?
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  Dr John Scott: One of the most common misconceptions about metabolic
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  surgery is that it's somehow either outdated or an extreme treatment.
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  Now that medications exist In reality, metabolic surgery is probably one
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  of the most studied operations in modern medicine and remains the most
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  effective treatment for severe obesity.
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  another misconception that people have about, these surgeries, that
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  it's purely about weight loss.
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  In truth, it fundamentally, changes the metabolism of a patient.
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  It alters hormones.
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  It changes the way your body signals about appetite.
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  It alters your glucose metabolism in ways that medications
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  alone cannot fully replicate.
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  The way that I help patient's think about This is obesity
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  is a complex chronic disease.
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  Some patient's do well with medications.
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  Other patient's will do better with surgery.
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  Some patient's will do better with a combination of both.
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  The most important step is not choosing a specific treatment first.
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  It's making sure that patient's are evaluated by clinicians who can offer
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  the full spectrum of therapy and help them choose the best approach
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  that fits their weight loss goals.
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  Joey Wahler (Host): Couple of other things for you.
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  One being, how important is it for experts here like yourself to remind
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  those, using either of these routes that.
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  They're going to have work to do for the remainder of their lives,
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  regardless of which option they choose.
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  Right.
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  You're gonna have to change your ways when it comes to exercise
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  and diet one way or the other.
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  Yes.
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  Dr John Scott: I think that's a true statement.
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  there's no doubt about it that, you know, behavioral.
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  changes, in combination with these different options like surgery
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  and medications will definitely enhance, weight loss and some of
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  the resolution of the comorbidities that we see, with these therapies.
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  This is a total lifestyle change and regardless of which route you decide
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  to go with medication or surgery.
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  We are trying to make patient's.
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  Able to eat healthy, be more active, and live a full lifestyle.
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  Joey Wahler (Host): And then in summary here, doctor, having said all of the
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  above, what's the best way for those joining us to decide inevitably,
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  which weight loss route is best?
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  For them.
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  Dr John Scott: The best way to get on the path to this healthy lifestyle is to
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  have a conversation with your physician.
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  Physicians can prescribe GLP one therapies themselves, or they can refer
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  you to a comprehensive center that has access to all of these treatment
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  modalities, like surgery and medications.
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  Joey Wahler (Host): Well, doc, no question, it's an area of medicine
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  that's growing in terms of participation and a thirst for knowledge out there
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  on the part of patient's, so very important to discuss it right here.
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  We appreciate all your expertise, folks.
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  We trust you are now more familiar with bariatric surgery in this GLP one era.
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  Dr.
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  Scott, keep up all your great work and thanks so much again.
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  Dr John Scott: Appreciate it.
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  Joey Wahler (Host): Same here, And for more information, please
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  visit prisma health.org/flourish.
• 11:39
  If you enjoyed this podcast, please share it on your social channels and
• 11:42
  check out our entire podcast library.
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  For more topics of interest to you, I'm Joey Wahler and thanks
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  again for being part of Flourish.
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  A podcast from Prisma Health.