The Checkup with Doctor Mike - Will Ozempic Put An End To Weight Loss Surgery? | Dr. Christine Ren-Fielding

Episode Date: November 20, 2024

I'll teach you how to become the media's go-to expert in your field. Enroll in The Professional's Media Academy now: https://www.professionalsmediaacademy.com/ 00:00 Intro 01:06 Set Point Theory 11:24 Calories In / Calories Out 18:47 Biggest Hurdles To Weight Loss 23:05 What Is Bariatric Surgery? 30:10 Success Rates 36:08 BMI 40:50 My 600 Pound Life 48:22 Side Effects of Surgery / Patient Satisfaction 54:23 Ozempic vs. Surgery 1:06:42 Life After Ozempic 1:10:28 Is Ozempic Unethical? 1:15:18 Food Addiction / Muscle Loss 1:18:05 The Process / Misconceptions 1:25:35 Innovation / Motivation Find out more about Dr. Christine Ren-Fielding here: https://nyulangone.org/doctors/1811981608/christine-j-ren-fielding Help us continue the fight against medical misinformation and change the world through charity by becoming a Doctor Mike Resident on Patreon where every month I donate 100% of the proceeds to the charity, organization, or cause of your choice! Residents get access to bonus content, an exclusive discord community, and many other perks for just $10 a month. Become a Resident today: https://www.patreon.com/doctormike Let’s connect: IG: https://go.doctormikemedia.com/instagram/DMinstagram Twitter: https://go.doctormikemedia.com/twitter/DMTwitter FB: https://go.doctormikemedia.com/facebook/DMFacebook TikTok: https://go.doctormikemedia.com/tiktok/DMTikTok Reddit: https://go.doctormikemedia.com/reddit/DMReddit Contact Email: [e-mail] Executive Producer: Doctor Mike Production Director and Editor: Dan Owens Managing Editor and Producer: Sam Bowers Editor and Designer: Caroline Weigum Editor: Juan Carlos Zuniga * Select photos/videos provided by Getty Images * ** The information in this video is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained in this video is for general information purposes only and does not replace a consultation with your own doctor/health professional **

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If someone was to say to you what you just described, cutting off of amputating 80% of the stomach, reconnecting the GI system in a way where it's not the correct way, doesn't that seem barbaric? How would you respond? Yes. It appears barbaric. However, cutting out 80% of your stomach means very little if it's going to extend your lifespan for over 10 years. Today, we're joined by the incredible Dr. Christine Renfielding, a pioneer in bariatric or fat,

fat loss surgery. She's actually the chief of bariatric surgery at NYU Langone Health, where she's helped transform lives through innovative, life-saving procedures, and has been at the forefront of advancing surgical techniques for weight loss. We go into depth covering what bariatric surgery is, who needs it, why insurance makes it so hard to get it, and most importantly, if GLP1 medications like Ozempic are going to make fat loss surgery a thing of the past. Dr. Renfielding does a phenomenal job with all these questions, and I truly think you'll benefit from this conversation, so let's get started with the Checkup podcast. Excited to chat, because this is a topic that I've actually gotten a lot of hate on on

social media about, and it kind of confused me because when I was in my training, bariatric surgery was something that we knew helped a lot of patients. But then with the way media is and the way that headlines are often sensationalized and made to be very dramatic, people started getting angry about bariatric surgery. And that fueled a rise of misinformation. So I'm excited that we get to talk with one of the leaders in bariatric surgery to tell us what's what, to separate fact from fiction. And I think a good place for us to start would be, what is bariatric surgery?

Let's define the terms, what procedures there are, what options there are, so that if you're the view where you can kind of wrap your head around from the beginning what we're talking about. Right. So thank you for the opportunity for letting me come and talk about this because it as a person who's within the field of bariatric surgery, it's been around since the 1960s, if not the 1950s. And yet there are so many people who don't know about it or they fear it or they don't want to know about it. So bariatric surgery. What do you think created that? Why are people confused by it? Oh, well, there's a judgment thing going on. And it's about are you taking the easy way out, or you're cheating, or you're doing it the old-fashioned way? It is judging people who are

obese or morbidly obese and saying, why aren't you doing, once you're losing weight with diet and exercise, you know, and it's probably because that's how many people maintain their weight. But being a slender individual like you or an I, doing diet and exercise works in maintaining our weight. However, if you are my height, 250 pounds, you can't do it. Diet and exercise is not statistically possible for you to lose 100 pounds and keep it off for a long time. And I think it's not understanding why that is that makes people judgmental about why can't, if you're 300 pounds, why can't you diet and exercise your way down? And what is the answer to that? Why can't...

Ah, so that, whoever figures that out is going to win the Nobel Peace Prize, because there's many different hypotheses and thoughts about what the human body does when it gains a certain amount of weight. You know, our bodies have been exposed to famine, to disease, to war, and to starvation for... entirety of human beings being on earth except for the last 100 to 150 years. And so now of a sudden our bodies are exposed to a plethora of calories and flavors and tastes. I mean, sugar was... In most parts of the world. In most parts of the world. I want to be inclusive. Thank you. Thank you for clarifying that. But really, sugar never

entered our vocabulary until the early to mid-1800s. You know, there were three, cases of type 2 diabetes in the scientific literature in 1847. Wow. And so all of a sudden, over the last century, the health epidemic of obesity and also type 2 diabetes has exploded. So going back to why does our bodies resistant to losing weight is because it's never had to deal with that genetically or evolutionarily about having too many calories. It was always too few calories and so the body is more prepped to be in storage mode rather than burn off mode that's absolutely correct and there was there's no need to manage your weight you know our bodies can manage our blood pressure it self-regulates temperature it self-regulates heart rate but it doesn't know how to

self-regulate weight only if you're exposed to starvation can it self-regulate but when you're have too many calories, it does not know how to burn off the excess. So it doesn't know how to correct for excess calorie intake. So the set point can only go up. That's right. So, which brings me to the set point theory, that the human body is set at a certain sort of weight. However, the set point will always go up. It will never go down. Because when it goes up, the body says, okay, your new normal is 250 pounds as a 5-foot-5 woman. That's your new normal. So when you try to calorie restrict and lose weight, your body thinks it's starving, that it's pestilence. And it doesn't mean that you should eat more or eat six times a day, which used to be told to us in the 1980s, 1990s, that you

should eat more in order to lose weight. No, you should calorie restrict and stay at that calorie restriction. But it's very, very difficult to do that, because especially in a first world country, let's put us as the baseline, it's very difficult because, number one, food is part of our lives in terms of family, in terms of events, reward, but also the type of foods that are available to us. And usually the more convenient foods have higher calorie content. And are not super satiating. not supersatiating. And what happens is when you start to get used to these fast food or convenient foods, that's what you want more. So the food industry has contributed a lot to the difficulty in losing weight. So when the human body creates the set point for itself as you

gain weight, and then you try and combat that by decreasing calories, the body slows down the metabolic rate, decreases the basal burning of calories. How long can you stay at that amount before the body says, okay, this is the new norm? Or does it never lower that set point? You know, I don't think it ever resets the set point to lower because I've had, I've had patients who've kept their, kept 150 pounds off for 20 years. And then something will happen and their weight will just come back up much faster than it would for you and I. And I tell my patients, you know, just because I've manipulated your stomach and your intestine so that you are satiated with only a thousand calories a day, if you eat three Oreo cookies, you are going to gain

five pounds. I am not because my body is a completely different physiology. I've never been overweight. My body is not in this mode to fill up the empty fat cells, right? I think that we have to look at anyone who's never been obese, fat cells are stable. Someone who's been obese, when they lose weight, their fat cells are empty, and they still have the same fat cells they're just empty and the body is striving to fill them. So the question is, how can we medically or scientifically stop that? Interesting. Do you ever hear of a book called The Secret Life of Fat? No. It talks about fat being its own organ almost, where it has its own hormone receptors and influence on hormones in order to keep itself alive, much like the kidney will

manage blood pressure and all that. So it reminds me of that thought process. And I think about how does the implication of muscle mass play into this? So if you were to, let's say you were at a weight of 300 pounds, you did a very strict diet, good exercise program, you lowered your weight by 100 pounds to 200. And now you've significantly increased the amount of muscle you have. Does that combat or play a role in that set point theory? That is a very good point that you brought up. So I only recently learned about this experiment that was performed in the 1950s. They took men of normal weight, which was six foot tall and 160 or 170 pounds. They calorie restricted all of them, so they lost 20, 30 pounds, became underweight.

And then they watched them, then they gave them regular food. They all regained more weight than they lost, but when they looked at the body composition, they found that the body will regain enough weight so that it can replicate or go back to its pre-diet muscle mass. So one of the driving forces for the body to regain weight is to regain its muscle balance or muscle mass. So going to your point, I do encourage my patients that after they lose a lot of weight after surgery, they've got to do exercise, but specifically weight resistance so that they can build muscle mass. I don't think there's been a study out there that's shown this to show that to prove that increase in muscle mass or replacing it will stave off the weight regain. Yeah, that would be an

interesting point, because these days, everyone's talking about muscle being really the factor that drives aging or keeps you metabolically healthy, and that's what we should be using to determine biological age even. And I feel like all those are wonderful theories, but until they're proven, we have to take it with a bit of caution. So yes, it's a good thing to exercise. It's a good thing to put on muscle. Metabolically will improve certain factors, keep you independent for longer, keep bone stronger, but to say that it definitely will decrease the amount of weight regain is not so clear at this point. That's correct.

Okay, well, that's an interesting point where we are now, where the topic of calories in calories out gets thrown around both as a myth and as a hard truth. And I'll tell you my stance on and I'm curious about yours. I think calories in calories out is the truth, and anyone who tries to debunk it is largely talking about extreme situations and or specific outliers. Because if you take someone and you say, I'm going to limit you in a metabolically locked ward to a calorie deficit, they will lose weight. But at the same time, people don't live in a metabolic ward.

They live in real life where there's options, there's cravings, there's behavioral issues, there's life stressors. so I think calories and calories out is the truth, but then how it plays a role in our lives is going to be dependent on a lot of variables. But to say that calories and calories out is not true, I think is a wrong statement because it kind of defies science, physics, all of that. Curious in your stance. So I agreed with you to a point. So calories in calories out, at the end of the day, that's the bottom line. However, certain calories, will make you gain weight more easily,

particularly if you have lost weight by calorie restriction. So the calories I'm talking about are processed carbohydrates and primarily glucose. So glucose has a certain number of calories. However, if you have lost 50 pounds or 100 pounds from either surgery or diet or medications, that glucose will be more efficient in making you gain weight. Is that because of an intrinsic factor of glucose, some chemical composition of it,

how it reacts hormonally in your body, or is it more of the fact that it's easy to overeat and leads to more cravings than a behavioral change? So in this, both, both, that biochemically it is the easiest to absorb and then to be changed into glucagon in your liver, to cause fatty liver, and then go on to be fat. But at the same time, sugar, especially in people who have insulin resistance, like polycystic ovarian syndrome, their response to glucose is a very rapid rise in blood sugar, which will then drop and then make them self-correct by craving for more glucose or foods that turn into glucose like crackers or pretzels or cereal. Yeah, I see that in my patients who, if they're walking around

with an average glucose of 200, even not post-pranial, not after eating, but throughout the day in a fasting state. And then I lower them to a normal range. They sometimes feel unwell if they're in this new normal, which is normal for the human body, but not normal for them. They almost experience hypoglycemia at a normal glucose level. Is that the process you're describing? I think that's very similar. That's very similar. And again, a very interesting thing that I've, that came out of some studies internationally

was that, you know, we talk about these diet, these sugar substitutes, right? and artificial sweeteners. And they have zero calories. Right. However, some studies show that if you intake a significant amount of artificial sweetener, it changes the microbiome in your gut, which then makes you more efficient at processing the glucose. Yes, and increasing your weight with processed carbohydrates. So you've heard of that study.

It's fascinating. There's so many of these mechanisms with the microbiome and how artificial sweeteners react with the body that we still don't even fully understand. At the same time, I still feel like it's fair to say if a patient is consuming 10 glasses of Coca-Cola day, which is not recommended, and we swap them to diet Coca-Cola, in general, I would view that as a risk-reduction method. Completely agree. completely agree. And then the response is, well, isn't that causing you cancer? Isn't it terrible? I said,

well, if you want to lose weight, it's much better. Certainly water and carbon and, and, and, and, and, and, and, and, and, and, and, and, and, and, and, and, and, and, and, and, and, and, and I feel like people get caught up on the microbiome and start saying these things. It's true, and I'm curious how that's going to play out of, maybe there will be a day where we recommend a probiotic that will impact someone's craving. Great. I would love that. But right now, it just doesn't exist. And I feel like what happens, I know you're not spending a lot of time on social media, as we talked about earlier. But these days on social media, the things that take forefront, which get the headlines, the viewership, is when a scientist goes on a health podcast with a

non-health expert host and says things like artificial sweeteners are 10 times worse for you than the real sugar. And it's like, based off what? Your theory? I don't know what to do with that. And I think they're just jumping the gun on what they believe is going on versus what has been proven thus far.

And I feel like that's just taking them at their opinion. Yes, completely agree. Completely agree. And of course, it's an extremist thing. Of course. You know, there's always moderation. And I think we just have to think about, you know, what?

do our bodies know how to process or break down? And certainly artificial sweeteners haven't been around that long. So who knows what they're going to do? We also don't know what those gums or preservatives that are intrisket crackers, you know, not to put labels, but, you know, the things that we, pretzels, Cheerios, I mean, we have no idea what all those preservatives are doing. Long-term. Yeah, or even short-term.

We just don't know. you know but there are theories but yes there's been no studies on on these preservatives on weight yeah and I think when we talk about those situations they could be interesting to chat about but I think it shifts a person's focus who's interested in losing weight into things that are not going to yield them the best results it's like talking to someone who's trying to put on as much muscle as possible talking to them about their need for supplementation of creatine as opposed to actually getting them in the gym. Like, it's way more important how much protein you're taking in

and whether you're working out or not, as opposed to if you're taking a supplement to put on muscle. Yes. So the problem is that's where people get excited. All right, so we got a little off track. So calories and calories out true, but there's an impact on certain calories, how they alter your body's absorption of those calories

and how they impact behavior. So that's the more nuanced take of it. where do you feel the biggest struggle for your patients comes from when it comes to losing weight? Is it cultural, behavioral, addiction? Is it even fair to say the word addiction when it comes to food? Right. So let's just clarify that my patients, I'm a surgeon, I'm a bariatric surgeon, and my patients are a certain amount overweight or obese.

This is not the individual who has 20 pounds. to lose. This is someone who's a 5-foot-4 woman who weighs 240 pounds or more or a six-foot man who's weighing 310 pounds. That's a BMI of 40. And surgery is meant to help you do the undiate. What does that mean? You're less hungry and you're full with smaller portions of food, period. It doesn't do anything magical with metabolism. It doesn't change necessarily your relationship, your emotional relationship with food. It merely blocks the food noise. It blocks the cravings and it makes the container smaller so that you feel full with a smaller portion. And it allows you and enables you to push away from the table. All the things that we've been told about

weight loss can actually be accomplished after surgery. And I think it's an important point that I didn't bring up earlier, which I should have. The reason I'm assuming, and I don't want to put words in your mouth, that you're saying dieting and exercise to lose this huge amount of weight is not really feasible. It's not because of your disbelief of diet and exercise, not working to lose weight, not because you disbelieve calories in calories out, as we've stated, but because when you look at the evidence of people who have tried, the percentage of success is in the single digits, especially long term.

Yes, that's correct. Thank you for summarizing that. Because when someone has 100 pounds to lose and they calorie restrict, the feeling of hunger is doubled by what the body's doing, physiologically in the primitive brain. And therefore, maintaining a calorie restriction for long term is nearly impossible for the majority of people who need to lose, say, 100 pounds for long term. To play devil's advocate, is it because the people who are trying to lose weight that are not having success, so the 90 plus percent? Is that because they're doing it incorrectly? They're getting bad

guidance? Is it because they are not as motivated? Or is it a combination of all these things? I think it's a combination of all these things because many people lose motivation when they stop losing weight. But what they don't realize is you lose weight because of the consistency of the calorie restriction. And the way the body loses weight is not like a machine. oh, I want to, every time you weigh yourself, you're going to be losing five pounds a week. That doesn't work that way. You lose five pounds. You plateau, you plateau for a week or two as you plateau your body shrinks, and then you'll lose weight again.

I mean, really, to impact fat cells, it takes three weeks. So diet always, you know, puts into your mind temporary, and then I'm going to go back and do what I used to do once I achieve my goal. So, you know, it could be all those factors. At the end of the day, statistics show that in order to lose more than 50 pounds and keep it off, it's like one in a hundred. Right. Very hard.

Takes high level of motivation, good quality strategy, because some people honestly get bad guidance from their physicians. Physicians sometimes don't do a great job of counseling on this. And it might not even be their fault as the system is set up in such a way where they have five minutes with their patient. They give them a hand down and they walk out of the room. So that's tough all across the board for physicians, for patients alike. With Amex Platinum, access to exclusive Amex pre-sale tickets can score you a spot trackside.

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Conditions supply, visit your local Volvo retailer or go to explorevolvo.com. So now we have an option in bariatric surgery. And what is exactly the definition of bariatric surgery? Right. So bariatric, the word bariatric comes from the root word barros, which means pressure or weight in the Greek language. So it's weight loss surgery. And it's surgery that manipulates the internal organs.

so that the individual can eat less, feel full, feel less hungry, and therefore lose weight. But this is with the caveat that you're working with are nutritionists so that you are filling a smaller container with healthy foods. If we're not promoting having surgery and continue to eat chips and Oreo cookies and drinking regular soda. That's not what anyone is saying in our field. It is in conjunction with healthy food choices and healthy lifestyle. We also try to identify if there are any emotional connections with eating,

which is why in the main everyone gets an evaluation by psychologist just to make sure that we're not glossing over any abnormal or dysfunctional relationship with food, that may actually get worsened after bariatric surgery. Right. And that's so important. I do it kind of in the opposite way. When someone comes in feeling depressed or feeling anxious, I try and rule out medical causes. So I try and look for thyroid issues.

I look for adrenal issues to make sure that it's not a medical reason for why the patient feels that way and not just ascribing them a diagnosis of mental health disorder. So kind of in the opposite way of that spectrum. but it's great that that's done. What's interesting about bariatric surgery is while it's anatomically implemented and its effects are anatomical to some degree because you're having a smaller container of food, but it's also in a neuroendocrine standpoint, an impact on the patient. Because when you change anatomy, you also change the way the body functions from a hormonal

standpoint. Can you take us through that? That's correct. So there are different types of operations which actually implement both, changes in the gut hormones or neurologic changes, depending on what operation we're talking about. So right now, the most commonly performed operation is called a sleeve gastrectomy. And the name of the operation is quite a misnomer. There's no sleeve being put on.

It's really, to be frank, it's amputating 80% of your stomach. Now, it's very horrifying to say it that way, but that's what it is. with trimming off 80% of your stomach and removing out of your body, sort of like when you take your bell bottom jeans to the tailor and he or she makes them into skinny jeans, you're just removing or trimming off a section of fabric and the same thing with your stomach, so that it's physically smaller.

Now, not only is a container smaller and you get full, but the section of stomach that we're removing has a significant number of cells that make a hormone called grellin, and that grelin is what can drive the feeling of hunger. So we're implementing this significant decrease in grelin hormone so that you feel much less hungry. So that's one way that this operation works. Another operation is the gastric bypass.

That operation involves cutting off and separating the very top of the stomach and nothing's removed except the piece of intestine furze. down is brought up and reconnected to a much smaller stomach so that food is diverted away from the normal digestive process and this way when food goes from the small stomach into the intestine it modifies and changes all those hormonal ups and downs that we get if it was going in the proper direction or the correct direction so there's things like p y there's glp1 there's there's many of these hormones that we're tapping into medically, and I know we'll probably get there, but we're doing this surgically, we're doing this anatomically so that there's less

hunger. After you eat, there's many different changes in the gut hormone that we're trying to subvert so that you don't want to eat again. And when I have talked in the past about bariatric surgery as an option for patients, I've been attacked. I've been labeled as fatphobic on my social media. I had to do a video discussing it and explaining why that's not barbaric to do this type of procedure. If someone was to say to you what you just described, cutting off of amputating 80% of the stomach, reconnecting the GI system in a way where it's not the correct way, doesn't that seem barbaric? How would you respond? Absolutely. You know, when I saw my first bariatric operation in 1993, I was horrified. I'm like,

there's this 35-year-old woman. She's beautiful, except she weighs 100 pounds over what she's supposed to, and she's having her stomach stapled. Yes, it appears barbaric. However, when you dive into the medical problems that this individual or these people, these individuals have caused by their obesity, meaning they may have type 2 diabetes, they have sleep apnea, they're not getting enough oxygen to their heart or to their brain. They're having joint pain. They can't keep their hygiene. They can't wash themselves. They're having skin irritation. They can't play with their kids. The kids are embarrassed to bring mommy to school with them. I mean, it's horrible. And when you couple that with the shortened lifespan that comes with being

morbidly obese, cutting out 80% of your stomach means very little if it's going to extend your lifespan for over 10 years. Now, I'm glad that you say that because that's why people are looking for less invasive operations. And quite honestly, back in the 2000s, there was a device called the lap band that was very popular. It's less popular, much less popular now, but it's still available. And I forgot to mention that, but it's a device that goes inside and it squeezes around the vagus nerves of the stomach, which seem to decrease appetite. So yes, it does appear to be barbaric. There are some non-barbaric options, but I think in the context of the barbaric nature of obesity, it's the lesser of the two evils. So it's a risk reduction

modality. You're trying to improve not just length of life, but quality of life as well. And I've seen that in my patients as well. You can get protein at home or a protein latte at Tim's. No powders, no blenders, no shakers. Starting at 17 grams per medium latte, Tim's new protein latte, protein without all the work, at participating restaurants in Canada. This episode is brought to you by Mew-Mu-Mu. Introducing Mutein, the new feminine fragrance by the iconic fashion house. Mutein captures the youthful, unconventional essence of the Miu-Mew Girl, brought to life by a gourmand, intimate and enveloping scent of wild strawberry and brown sugar accords. Mutine is not a statement, but a knowing glance, a sweet rebellion, lighthearted and laced with wit, a gesture made for oneself.

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lifestyle changes. People lose 30 to 40% of their body weight and keep it off for decades, but not everyone. What we need to start looking at or changing is the mindset of obesity. Being fat is not just about being fat or having excess fat cells. It is a whole biology and physiology of having an excess of fat organ that the body wants to preserve forever. So it is a chronic condition. And you can do the most drastic bariatric surgeries, and guess what? Some people regain all their weight back.

And oftentimes we say, why is that? Because the body at the end of the day wants to fill up the empty fat cells, and we'll do so many things to achieve that. So what I'm trying to say is just doing surgery won't guarantee that you'll lose a significant amount of weight forever. It needs to be monitored for recurrence, which may require maybe a psychologist to address the mental health aspect. Maybe it requires seeing a nutritionist again to educate that certain foods or snacks will go on to. to weight gain, or maybe you need medication. So the long-term chronicity of obesity and its tentacles being everywhere.

Yes, constantly. I think it needs to be monitored and then treated long-term. So what are the percentages? I know you sometimes use five-year, ten-year of how long you've kept the weight off. What are the current accepted statistics on that? Overall, in the main, when we talk about all bariatric operations, 10 years, you certainly maintain 20% of your body weight. So if you're 300 pounds, you'll maintain 40 pounds off.

Now, it doesn't seem like a lot, but some people lose more. 60 pounds. 60 pounds. I'm sorry, I can't do math. 60 pounds. But this is an average. Some people lose more. Some people lose less.

And depending on procedures and stuff. That's correct, depending on procedures. And do you have a preference in what you recommend or is it going to be super dependent on patients? You know, I have a preference in terms of what I feel will be the best outcome for the patient. Now, what do I mean by that? I don't have a crystal ball or a computer that says, you know, this is a 50-year-old woman who has so much weight to lose. But it depends on what the post-operative management that the patient can do, and if they need to do vitamins or supplements. So it depends on the individual's medical conditions and also their environmental conditions. Do they live far away? Do they live close by? Can they do frequent follow-up or not? In the main, I'm a minimalist. I always believe that you should try the least invasive thing. and then if it doesn't work, go on to the more invasive thing.

I actually view obesity similarly to the cancer model. So if a woman has breast cancer, a man has breast cancer, but if someone has breast cancer, you don't just go for doing a radical mastectomy. You try lumpectomy with radiation, sometimes chemotherapy, then possibly surgery, and then you look for recurrence. there's also much more focus on tumor biology. We don't have that with obesity. Not everyone is morbidly obese for the same reason.

And so that is the Holy Grail. Really the solution is trying to figure out what is making this person's body so dysfunctional and how can we address this? Do you feel like AI will help us in risk-stratify patients better? Yes, yes, absolutely, because we know how people, we've been trying to answer this question for decades, I certainly have, and we've looked at habits, we've looked at genetics, we've looked at certain blood samples, we've looked at, you know, does it run in the family, we've looked at mental health conditions, to try to find out who is a responder and who is not a responder to certain operations. And we've never gotten a very reliable answer because there's so many variables. Right. Yeah, I think that's like where the biggest power, people oftentimes ask me on interviews, where is AI going to help us the most?

And yeah, like you could say in imaging, maybe it could help radiologists, things like that. But the biggest factor is risk stratifying patients. The number needed to treat pharmacologically speaking for me is so high in the most basic of conditions. The blood pressure patient, the odds are that I'm, going to control their blood pressure and actually stop the stroke or heart attack is almost like not valuable for that person because odds are it's not going to help them in mass on a population level it definitely will and it's the right thing to do but if we can narrow down the

amount of people that need to take the medicine because we see who's a responder who will have side effects versus who's not i think that's where a i is going to be beautiful even with surgical approaches yes yes i agree that i know a lot of the decisions made in bariatric surgery even from an approval standpoint from insurance companies largely stems from BMI so you have to have assert BMI in order to qualify for a procedure do you like the BMI system period as an equation right so yes and no yes meaning it is very very easy and straightforward to use that because But it does discriminate against people who have a lower BMI but may be more ill or sicker due to their excess weight. So the individuals who suffer from the BMI system tend to be people of Asian descent, whether they're from China or from the continent of India, whether it's East Asians.

but their accumulation of fat tends not to be underneath the skin or subcutaneous, but tends to be in their organs, internal organs, or visceral fat. And that's more of this central obesity. And that's what drives metabolic syndrome, which is type 2 diabetes, high cholesterol, high blood pressure, heart disease. So the BMI system discriminates against them because they tend to get sicker at a BMI that is much lower than what makes Caucasian sicker or even some African-American sicker. And it should be a combination. I mean, recently, the American

Society for metabolic and bariatric surgery lowered the BMI requirements, but the insurance companies ignored that. So they're not paying attention. It went from 40 to 35. Correct. Okay, got it. Yeah, that's always interesting to me that the BMI formula has been around for so long and its start was not great in terms of why it was created in general. And the fact that it hasn't been updated with some other variables to be included, whether it's like a, we have in cardiology the ASCVD risk score, which tells us a 10-year risk score that takes into account blood pressure, cholesterol, age, smoking status diabetes. But the BMI system has largely been just this formula.

And I know it's easy, but it could be easy to factor in another variable that will stop the discrimination of certain groups, make it a little bit more gender favorable so it's clear amongst genders, take into consideration metabolic health of a patient. So I'm looking forward to the day where that's somehow upgraded in a way that's meaningful. You mentioned that your approach, much like the cancer approach, is to not necessarily have mass removal of an area, unless mandatory, of course. course, are you saying that you would try to avoid bariatric surgery if possible, or I've seen statements from even, I believe it was the obesity society, but it might have been the bariatric society as well that said people wait oftentimes too long to get bariatric surgery. So what is the timing recommendation in your mind when it comes to bariatric procedures?

Right. So when someone has a BMI of 40, there's really not. nothing, even medications that will promote a significant amount of weight lost for long term. So typically, if someone's BMI is 40 or greater, surgery should be seriously evaluated as an option. The problem is that we, I don't want, I don't think everyone is a candidate for surgery because it may not work or may make existing conditions worse, or that it may work, temporarily, but then they'll be weight regain. So I think everyone has the potential to be a successful bariatric surgery patient, but it's my job to try to enable them and to facilitate their success,

which means evaluation of their nutritional education or evaluation of their emotional health and their relationship with food. And so once that is evaluated and we have an understanding, understands that that surgery is not going to make everything better and make them lose weight forever, that there requires long-term maintenance. Yeah, there's still effort required in order to make this successful long-term. A lot of people's only exposure and understanding of bariatric surgery comes from these TLC shows, My 600-pound Life, terrible titles, all these things. view those shows is not great. I feel like they're a bit predatory on the people participating, although they are helping them to some degree by facilitating procedures that may not, they may not

be able to afford on their own. So there's some ethical issues there. But in general, do you think those shows have helped or harmed the message behind bariatric surgery? Well, I have to say that I've never watched that show, my 600-pound life, because I don't think it represents the average individual who is having bariatric surgery. Now, I'm from the Northeast, right? I'm from New York. So the extent of the severity of obesity that's up here. The incidence of obesity and morbid obesity is the same in New York as it is in the rest of the country. However, the number of people who are 600 pounds, there's many more down in the south than in the northeast for a variety of reasons. But in the main, if someone is

600 pounds, it is, bariatric surgery is not the only thing that they need. They need that, but they need a lot more psychological and nutritional support. Because to be that heavy means that there's a lot more calories, especially processed calories that are being taken in. And someone who lives in a nutritional desert is going to continue to live in a nutritional desert. And so they have to make an extra effort to find foods that are healthier for them so that they can lose the weight. And from a health literacy standpoint, getting them to understand what's a carbohydrate, what's a protein, what to limit, what to eat more of that sort of basic understanding, I think goes a long way in not just helping them lose weight, but also empowering them to take

control of their lifestyle, because it's not just about diet and extra. It's a lifestyle thing that needs to change. And what I don't like about the show is, and the reason I watch the show is I don't watch it for fun. We've reacted to the show while on camera. So I would give my feedback on it. And I saw one of the doctors on the show to be talking about. to a patient who's 600 plus pounds looking to go for the procedure and he says that before you go for the procedure I need you to lose X number of pounds and that's true and I know that's part of the requirement in order to go for the procedure but then the guidance he gives is a paper and he says you need to decrease your caloric intake get ready for this to 1,200 calories a day and go low carb

and I'm like for what human being do you expect this to be possible and it feels like the patient is almost fully set up for failure now I try and be charitable in my thinking and I say

is this terrible advice and we could do way better or is this doctor giving the most extreme level of advice in hoping that they do at least 10% of it and I'm curious what you think. Right. Okay. And what is the correct version of that? Right. Okay. So, so I think it's

multi-layered, right? It's, uh, the reason why speed limits 55, because everyone's going to go up 10, 10 points. Um, but, but I think it is, uh, you know, I don't know why he, uh, does that for his patients. I think he's probably testing to see how motivated they are and if they can make a change for short term. You know, a lot of patients say to me, well, why should I go on a diet? That's the reason why I'm here to see you, because I haven't been able to lose weight with a diet. I mean, specifically, my motivation for a 600-pound person to lose as close to 500 pounds

as possible before surgery is for safety. For perioperative safety. Lose down to 500 pounds? As close as possible. Got it. Okay. Now, that may not be possible, but there are, many OR tables that don't go over 500 pounds. There are many beds, so on and so forth. The

anesthesia risk is typically higher as someone is higher. So I usually ask patients to lose as much weight as they possibly can, but I give them guidance, and it's not, and I learned, don't give them a choice. Put them on meal replacement protein shakes and say, you can drink up to eight protein shakes a day and then eat crunchy vegetables and water full stop and we do that routinely for everyone before surgery for two weeks

so that their liver which is sitting above or on top of the stomach where we're operating it shrinks and becomes defatted because that's where we lose weight initially is the fat is the liver

so we put them on a fat shrinking, liver-shinking diet for two weeks beforehand, but it's with guidance. Protein shakes as meal replacements, water, and crunchy, and raw vegetables. And they do it. But it's not to prove anything. Right. That's the thing. It feels like in this situation, it's to prove that they're capable of keeping the weight off. Is there no component of that? There's no, I don't think it's right. I don't know, I don't think that's, because everyone knows that it's not sustainable. Was there guidance?

Maybe this is 10 years ago in my residency training where there was some sort of 5% that you have to lose before going for bariatric surgery in order to feel like it's successful? Or is that completely, I'm making that up in mind? No, no, no. Certain insurance companies require that. Interesting.

Certain insurance company. I mean, listen, down in Tennessee, the insurance companies required the patients to get an IQ test. I mean, insurance companies are horrible. What? Yes. So there's a lot of very,

variation in insurance policies that are usually state-dependent. We are very fortunate that in the state of New York, we have very... Consumer protection laws. Yeah, the insurance companies, for the most part, they all cover bariatric surgery, and they have a lot of requirements, but it's far away from those psychological requirements. I mean, they do need to see a psychologist. but there's no requirement for losing a certain amount of weight. Got it.

Yeah, I feel like these days insurance companies just create more roadblocks in order to hope that people won't go through them. Yes. In order to decrease their spending, which is the most messed up thing that you can imagine. Well, no, but it makes sense. They're a publicly traded company. So they're... On one hand, in a fiduciary responsibility, it makes sense.

But from an ethical moral standpoint, it feels very... Oh, 100%. I mean, we're not talking about ethics or morals right now. We're talking about dollar signs. Right, right. Sad that it has to come down to that. Okay, so we have that knowledge. We have the amount of weight they're needing to lose.

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You're richer than you think. Side effects of going for these procedures. And I know it's going to be different depending on which of the procedures, the sleeve, the ruin Y bypass or, you know, lap band, if they're even considering that. What are the common side effects versus uncommon and really rare? Because I feel like there's a lot of myths surrounding this. Right.

So probably the most common side effect of all the operations is vomiting or regurgitation due to eat not failure to change behavior when the stomach is manipulated or narrowed then the food is passing into your internal system slower and it's going to be also narrower so it is important to chew your food and to eat slower or pause in between bites the number one thing that everyone does is chew twice and swallow and then go back and you're picking up food while food's still in your mouth and we all do this because sometimes we're really hungry sometimes we're in a rush we're not even thinking about it it's it's almost like eating is like breathing we don't think about it so so you have to become more mindful about how you eat and then

also what you eat because very grisly steak is not going to digest well it's not going to pass well doughy bread is not going to pass well. So the most common side effect is regurgitation and vomiting, which can be avoided by mindful eating. And then there's weight loss is the most common side effect. But also things such as vitamin deficiencies can happen, particularly in the bypass type of operations. There's stomach bypass, there's intestinal bypass.

where you're manipulating the absorption of your body's ability to not absorb as many calories in terms of fat, but you can also decrease the vitamin absorption. So that has to be monitored and supplements have to be taken. How does the body absorb the supplements if it has trouble absorbing the vitamins from food? So for example, and this only applies to say gastric bypass. surgery. Vitamin B12 is broken down, and then it needs intrinsic factor, which needs to be in an acid environment. But now that there's a, you're separating the top of the stomach, there's much less acid there. So B12 cannot be absorbed in food, but it can be absorbed through a supplement. And the supplement is typically absorbed through the mucosa, the mucous membrane. So it's either

a dissolvable tablet or a nasal spray or an injection in the skin. Got it. And then I know we really try and not say that we can cure conditions like type 2 diabetes because technically once you fall into the category of a type 2 diabetic patient or a person with type 2 diabetes, you have that risk for the rest of your life. But there have been instances, or at least it's not completely uncommon, to see patients who are once having blood levels of a type 2 diabetic, that then after bypass, after significant amount of weight loss, they're no longer having those blood levels.

Is that true? Absolutely. And it's not just with gastric bypass, it's with sleeve gastrectomy, with lap band. We track how patients' medical conditions improve or worsen, and type 2 diabetes can be reversed, or at least the signs of type 2 diabetes. can be controlled better, either to the point where you don't need medications or you need lesser amount of medications. And for different varying periods, not everyone's the same.

If someone has type 2 diabetes for longer than seven years, it typically is a little bit more difficult to control the type 2 diabetes so that you don't need medications because of the health of the pancreas. But if you've been recently diagnosed with type two of diabetes, then chances are that we will put the type two diabetes in remission and maybe it won't come back until for another 20 years. Got it. You may delay. Which is huge in terms of risk factor modification.

Yes. Being a family medicine, doctor, I very much think about patients, not always the labs. What is the rate of patient satisfaction postage? It's tremendous. It's tremendous. And, you know, I think we sometimes focus on what's the most weight that I can lose is the winner of the options to, you know, to help me lose weight. It's not. It's losing 25 pounds, 50 pounds, and you still may be a size, going from size 20 to size 40. but you're keeping it off and you feel better about yourself and your quality of life is better and your medical problems are under control.

So the patient satisfaction is tremendously high, over 95% if not more. The biggest regret, the biggest complaint people have is that they should have done it sooner. And you may say, well, I'm biased because I'm doing this, but I see my patients long term, many of them. long term. And patient satisfaction is incredibly high. That's great to hear because that's the most deciding factor, right, in a lot of these cases. For the uncomfortable portion of this conversation, what's the future of bariatric surgery given the uptick in GLP1 medication prescriptions? I think last week there was a study in JAMA that showed there's a 130x% rise in prescriptions for GLP-1 medications like OZMPIC, Wagovi,

and there's a 25-ish percent drop-off in bariatric surgeries. What does that say to the field, to the future, to those who are considering training in it, programs that might be at risk, what's the kind of overwhelming consensus? Yeah, I mean, I don't think it's uncomfortable at all. I think this is reality, and it's a wonderful reality. So, yes, all that is true.

It has affected us at NYU, but nationally, every practice and surgeon that I've ever spoken to, they have a 20% decrease in their bariatric surgery numbers. And it's twofold. Number one, there's the reality of decrease in production, for lack of a better word. So we have to either supplement it with other operations, general surgery operations, which we all perform. You know, I take out gallbladders, particularly I do a lot of general surgery on my own patients. But even more so, I think the evolution of GLP-1s has opened the door to the conversation of treatment for obesity. So there's a lot of fat shaming out there, right? And why can't you

Why can't you lose weight? You must be lazy. You must be, you know, not caring. A lot of judgment. But the only thing that's worse than fat shaming is shaming those who are looking for treatment for their obesity, meaning bariatric surgery. So there's a lot of bariatric surgery shaming. Why can't you do it on your own? Why can't you take the easy way out?

So that's where GLP-1s come in. And GLP-1s are really the most reliably effective medications that help people lose weight because it's stabilizing the blood sugar. So you're not having these highs and lows and you're not craving, which is causing the food noise. I mean, a lot of people say, oh, I'm on Ozempic, the food noise is gone. that's because your blood sugar's managed. I mean, I'm simplifying it, obviously. Yeah, gastric emptying slows down so you feel full or longer, all that good stuff. So now it offers the conversation about, you know what, I now realize that I can, it's not just in my head.

I can lose weight. I've always tried to lose weight, but now I can because now I'm not so hungry. I'm not craving. So now I can eat healthy. Oh, look, I lost 25 pounds. Now my joints don't hurt. I can go to the gym, I can exercise, and I'm losing more. So I, and we're now seeing that GLP-1s are not for everyone, right?

I think it's a good starting point. If you have a BMI of over 40, GLP-1s will not give you the long-term weight loss that you are looking for. However, it's very good to start off with because it can show you, well, am I eating because I'm hunger? or am I eating because I'm self-soothing because I'm emotionally eating? And for those people who don't respond to GLP-1s, then we can have that conversation about why. But it uncovers a lot of the reasons why people are struggling with their obesity. Here's a harder question.

As GLP-1 medications like OZempec and Wagovi improve, and you have the newer generations coming out that decreased the amount of muscle loss and focus mostly on fat loss. Do you have a fear that bariatric surgery becomes obsolete? You know, I have to say that by the time that happens, I probably won't be practicing. But that's not the question.

It may, but again, I think there's going to be a significant number of people who won't be able to get access, because the cost to the public health system is going to be bankrupt if everyone has access and insurance companies pay for these medications. So I think there's going to be an access problem. Wouldn't you say that as time goes on and these medications become generic and as more people will buy them, the costs will go down and public pressure and all these things? I agree.

I don't know. I really don't know. I don't think that it will replace bariatric surgery because, again, access, potentially, tolerance, human body is a resilient thing. It gets tolerant to medications now. I see it every day. People needing higher doses and there's no higher dose to go. Or relying on medications. You know, a lot of people don't like taking medications, and they do prefer a surgical option.

some people will get side effects from them or there are certain patients who want to get pregnant and they have to stop the medication so they can't have it so you know I truly I don't know the answer to that I could make an argument for both that bariatric surgery will become obsolete I don't think it's going to be in the in the near future do you if you were having a conversation and I was a med student and I said I want to be a bariatric surgeon would you steer me away from it no why no I think it's a it is an incredible incredibly valuable treatment option that will still be around, particularly for people who say have weight regain after being on GLP-1s for two years or three years, which can happen.

It's part of the armamentarium. I don't think we've gotten rid of mastectomies for breast cancer. Certainly they've gone down. But, you know, the incidence of obesity, even though it's plateaued for the first time this year. It doesn't really mean much. The incidence of obesity can continue to go up, and there's a lot of people who are struggling with obesity. When you were talking with me earlier, you mentioned that if you're talking about a significant amount of weight loss that needs to happen for a patient, bariatric surgery is the gold standard. Why are GLP-1 medications not efficacious, as efficacious,

as bariatric surgery when a huge number of pounds need to be lost? because the statistics show that there you can certain gLP ones they'll give you 10% 20% of your body weight some maybe even 30% of your body weight but say if you have 600 pounds to lose you'll have to help me with the math but uh 60 right so it's 120 pounds that you'll lose but you're still 480 pounds so it may be that you'll need combination therapy medications plus surgery. And the way that things are going in this country that people are getting the intensity of bigness is increasing. There are more and more, there's going to be more and more 600 pound people out there. Yeah, I've seen a research article, I believe in June of this year,

that was published by one of your colleagues in NYU that talked about the need for bariatric surgery and how bariatric surgery is still doing very well in comparison to GLP1 medications in these situations. What are the conversations like at bariatric society meetings right now? Oh, yeah. It's all about GLP-1s. It's multimodal therapy. And the bariatric surgeries. Translate that to the audience. Oh, sorry. So I think everyone expresses concern that the numbers are decreasing in our field. However, we, I don't think anyone is angry about it. They are welcoming it because now it's a focal point of disease treatment. And we talk about multimodal therapy, which means using medications in conjunction with surgery

in order to magnify the effects. Because bariatric surgery, again, not 100% of people are going to lose over 100 pounds and keep it off for 20 years. This is a chronic disease condition. So it may be that we start medications, we have surgery, we then may have to add medications again in the long term because the body will always want to return to the state of obesity. I'm someone who thinks that people should live a healthy lifestyle irrespective of weight. Because I think weight is just a number. It doesn't give you a complete crystal ball

into someone's risk factors and to their current medical conditions. So it needs to be taken in context. So I still want patients to exercise. I still want them to eat healthy. There's a whole other slew of illnesses that can happen as a result of not doing those things. So my fear with these GLP-1 medications that I've expressed before, and I'm curious how it lands for you, is are we decreasing the potential motivation to start exercising and eating healthy by having a medication so readily available to help with that process? or is that a minor thing that we should not be focusing on

and instead be celebrating the fact that we have something to help people who are overweight or obese? I mean, that's a very interesting philosophical question because at the end of the day, we should be happy that people are losing weight because that will improve their health. Whether they buy into the whole healthy lifestyle,

I think that is going to, to be what causes people to not continue to lose weight and it will stifle their weight loss or promote their weight regain because we are seeing, as I said, we're seeing tolerance, but also once you calorie restrict and lose weight from these GLP1 agonists, the body is going into the same fearful starvation mode and it will catch up to that individual that, that if they don't change their eating habits and their food choices, that their weight loss will stop or even go back into the other direction. Because I always viewed the fact that people would lose weight once they started exercising

and, I guess, educating themselves about what they're eating. And that was a big motivating factor to do those things. Does that hurt that motivating factor in your eyes? I think it depends on the individual. Right. Some people feel empowered and they say, wow, this is actually working and they get positive reinforcement to eating healthy and exercising. I've seen that after surgery. Some people become empowered and some people look at it as the easy way out. And look, I can lose weight and I'm still eating M&Ms. So I understand where you're coming from and I think it just depends on the individual.

Yeah. So philosophically, you don't have that fear as some do. in this space? No. No. Just taking it as a medical treatment. It's a tool. Let's use a tool where appropriate and go from there. It's a very logical way of approaching it.

There's a lot of fear mongering that happens around these medications and also stigma that happens with the medications. I think it's important to have these discussions, even when there are triggering for some people. Just because a conversation is triggering doesn't mean we shouldn't discuss it, especially when we're trying to do the best for our patients. When you think about GLP-1 medications, there's been this discussion on doctors who are obesity specialists that they say these medications ideally should be a bridge to help people establish a healthy lifestyle,

which means dieting, exercise, sleep, all these things, improve their quality of life with the goal of ultimately getting them off the medication, which is similarly how I treat depression. So when I start a patient on an antidepressant medication, SSRI, I will tell them that we're going to do check-ins, X number of months, to see if they're ready to taper off the dose and we'll do it safely, because the goal shouldn't be to be on the medication for the rest of your life. That is seemingly the goal for GLP-1 medications. But when I ask doctors who are obesity specialists about how many patients, they have gotten off GLP-1 medications, the answer is almost always zero. Do you think it's feasible to treat these medications as not lifelong, or should we accept

the fact that they need to be lifelong? No, they have to be lifelong. They'll only be effective for appetite control and satiety if you're taking them. And I guess different from the depression model is the hypertension model. Right? So some people are salt-sensitive hypertension. And again, to your depression model, not everyone. Some people have biochemical depression. And they will be, they need medications because they have chemical imbalance. But there are significant people who don't. Same thing with- And there's also ways to change biochemical imbalance through action. So there's all these variables. And again, I don't want to harp on extremes. But in the main, I think, again, it depends on the disease process,

pathology of that patient. So, yes, some people, so high blood pressure, most people need medications to control their blood pressure. But some people who are salt sensitive, meaning they'll only have high blood pressure if they eat salt, they can control their blood pressure through diets. Great. Same thing with obesity. I mean, most people, once the body is in an obese, super obese state, and we don't know where that tipping point is, by the way.

So I would say that if someone is over 300 pounds, they're going to be dependent on these medications. But if it's someone who has a BMI of 26 and they want to lose 10 or 20 pounds, that may be a person who they'll be on the medication, lose weight, and then they can come off the, medication. I think it depends on the severity. Why do you think so many obesity doctors talk about it as if it's not a lifelong medication? I think that's weird. I, you know, because everyone that I've ever seen that stopped the injectables, they start gaining weight. So I don't know. I don't, I don't, I don't The evidence has them been clear, I guess, in this space. Yeah, because I think it's a little bit scary to think about if we're at a place where more than 50% of the population is in OB state,

does that mean that more than 50% of the population needs to be on a medication for the rest of their lives? You can say the same thing about heart disease. Aspirin. Well, we don't. Aspirin has fallen out of favor in primary. How about this? Livetor, yes.

Cholesterol lowering medications. I agree with you. But this is the state of our country or of the world. Right. And I think it's a bigger conversation because we are surrounded by contaminated foods that is very difficult to remove out of our lives. I don't think we should ever do one or the other, but people make the argument that we're medicalizing a problem.

that should be treated societally. What do you say? Yes, I agree, but society has prevented us from taxing sugary beverages, soda in this city, in New York City. Remember, there was this push to tax regular soda? Like the big gulps or something? Biggulps, yeah. There was a public outcry.

That was Bloomberg, right? That was Bloomberg. I thought, oh, my God. That's so terrible. So how can you fight that? How can you lose weight successfully if your kids are bringing that stuff in? Even though you tell your children or you tell your teenager, you shouldn't be drinking that, they do anyway. And society, not everyone has the wherewithal to or the finances to have a healthy lifestyle, a single working mother.

You know, it's much easier to bring your kids to McDonald's. I mean, yeah, that's a sad part about food deserts. Where do you think from a societal standpoint, where if you could wave a magic wand that you'd get the biggest bang for your buck in terms of improvement, society as a whole, that if you could change one thing, what would that thing be? Getting rid of the processing or preservation of food and getting rid of food in boxes and bags. So processing food is also a tricky term Because if you cut up a chicken, it's processed food So like you're saying the ultra-processed foods maybe Yeah

Those types of lunchables Crackers, cookies, cereal cereal is So you would ban cereal So you would ban cereal. Wow So that's your hot take Well because most parents are buying cereals Because on the box it says

fortified with you know vitamins and minerals right but why are you eating something that you have to add vitamins and minerals to when you know something on on the outside of the supermarket actually has vitamins and minerals naturally yeah that's hard to do in a democratic society completely agree yeah so that's why we can't solve this societally yeah at least not directly because there are steps we can take you know eliminating food deserts providing funding for healthy food choices like Are you familiar with WIC, like the food funding program? So, like, there, there are certain prerequisites about foods that you can or cannot select so that you're trying to help institute healthier choices.

Perhaps we might institute the same thing when it comes to food stamps. So there are some things we can do to some degree, but it's very difficult to make a recommendation for all of society that not necessarily is good or bad, but that people will agree with and vote for and support. and that's ultimately what you need in order for things to pass in a democratic society.

Yes, yes. So it's like we're all fighting against ourselves. Mm-hmm. Yeah. On a scale of 1 to 10, how satisfied are you with the career choice of becoming a bariatric surgeon? Oh, 10 being the highest?

10. Really? What drives that decision? Oh, it's the most satisfying profession that I could ever have. I take care of people who are primarily stigmatized, but they're not, they may have significant dangers in their medical condition and their quality of life, but I can, they're not dying from a cancer, so I don't have to deal with a cancer diagnosis, which is heart-wrenching to me, but I can offer them, and I do provide them a way to reclaim their life back and reclaim control, where they're not ruled by food thoughts. They have now the ability to make healthy food choices, change their

lifestyle, and make a huge impact on their health and on their quality of life. And they're so much happier. It's really transforming. And there's more hugs in the office than there are tears. Oh, that's awesome. Maybe happy tears. They're happy tears, yes. When I found out my friend got a great deal on a wool coat from winners, I started wondering, is every fabulous item I see from winners? Like that woman over there with the designer jeans. Are those from winners? Ooh, are those beautiful gold earrings? Did she pay full price? Or that leather tote? Or that cashmere sweater? Or those knee-high boots? That dress, that jacket, those shoes. Is anyone paying full price for anything? Stop wondering. Start winning. Winners, find fabulous for less.

You mentioned the idea of food thoughts. What's your belief? Because I know DSM-5 and all these categories will probably argue one way or another. Is food addiction real? You know, I think in certain people who are addicts, I think food addiction is real. But I think more calm, more pervasive is sugar addiction. And it is something that chemically is a true entity because your blood sugar is going up and down. And certain health conditions, it's predisposed to that, as I said, something like polycystic ovarian syndrome specifically. Right. So sugar is the addictive ingredient as opposed to food in the main. Got it.

For the GLP-1 medication, something I wanted to touch on since we talked about side effects of them, there's a lot of conversations in the health podcast space. I would say fear-mongering, because I think they're taking it a little bit further. But there's been documentation that there's muscle loss in addition to fat loss. And we know that keeping on muscle is valuable, especially as you age. And we know that if you decrease caloric intake, whether you like it or not, you'll lose some muscle mass. The idea is that if you follow it correctly and you do resistance training, you continue with the correct nutrition standpoint from a nutritionist guidance of maintaining protein intake, you lose less muscle than you will fat. Do you have a concern about the muscle loss with GLP1 medications?

Certainly in individuals who are losing weight rapidly, absolutely, because muscle is a very important organ in our body or tissue on. our body and it will drive the need for the body to regain weight. And, you know, I think that, you know, having a medication that's muscle sparing, I'm curious to know how that would happen only because if you're calorie restricting and not using your muscles and replacing them with activity, I don't know how else you could, you can spare the muscle. Because typically, we say in our bariatric surgery area that if you lose more than 10 pounds in a month, then you're losing a lot more muscle. So usually 10 pounds or less, it's water, fat, a little bit of muscle, but you don't want to lose more than 10 pounds in a month. So, yeah, I mean, I'm concerned about

the muscle loss. Got it. When a patient comes to your center, let's say I'm that patient. and I have a BMI of 35. I'm looking to lose weight. What is the process like? Am I right away discussed about bariatric surgery? Are we trying the GLP-1 medications? What's the process? You know, I think to be just not create false hope,

we follow what the insurance company options would dictate as options. So if that BMI of 35 patient had no medical problems, no type 2 diabetes, nothing, then I would not talk to them about surgery. I would talk to them about medication, diet, increased activity, and then, of course, medications. However, if that person had heart disease, had stents, was on insulin for diabetes,

then forget about the medications. You can do the medications after surgery, or you can do the medications now, but let's plan for surgery. because the severity of damage that the obesity has caused on the patient's body is already so terrible that we need to act quickly and give you a very effective treatment option, which is surgery. Yeah.

What do you think is the biggest misconception surrounding bariatric surgery? That's the easy way out. And I think, my goodness, who? wants to have surgery to be skinny. Nobody does. Nobody wants to have surgery if they can avoid it. And it actually is a very brave thing for people to come to my office and see me and discuss having surgery because there's always the fear of anesthesia. Am I going to die on the table? You know, am I going to be able to live a different life with eating small amounts? I think that's another fear that am I going to be successful or am I going to be a failure? That's the second

most biggest concern that people have. Yeah. For people who are considering going for bariatric surgery, what should they ask themselves before having an appointment or should they go in with an open mind and have the conversation with a doctor first? I think they should go in with an open mind because there's, most people do, do their research, excuse me, by going on the internet. And, um, and, and you know, there's, the internet, as you know, is very, very good for, for medical information, but, um, you can't control what is true and what's not. Um, or maybe magnifies. What doesn't apply to you or something. Right. Um, it's not accurate in the situation. So I think certainly with an open mind go in, we actually offer an online seminar that talks about the difficulties of treating obesity, the different types of operations, the pros and cons using illustrations, and then possibly, and what are the BMI requirements for that?

So that it gives people some objective information, and then they come in and see us. Makes sense. Now, you're talking about what your guidance would be. your advice would be once the patient has landed in your care. I'm a primary care doctor. I see patients with BMI's over 35 very often these days. Should I be thinking about bariatric surgery more often than I am? Yes.

Yes. Because just in case the medications cannot be obtained or do not work or they become tolerant or they can't have it, there's contradictions, you need a plan B. And I think combination therapy is going to be the way that things start to move because neither just medications or just surgery is going to be effective for everyone. Yeah. How would that work?

Would it be do the procedure first and then once you're healing be on the medication or is it like a pre-medication phase where there's some weight loss initially and then procedure? Well, that's what we're trying to study now. The answer is not out yet. Okay. What's your presumption guess, if you will? Well, I think, certainly if someone say is a BMI 50, right? I just saw someone in her 20s, BMI 50.

And put in perspective what that would look like weight and height-wise. So a 28-year-old who's 5 foot 6 and is 350 pounds. And she's really trying to lose weight but can't. and it's actually going the opposite direction. She's gaining weight. Someone like her, she asked me about the medications. I said, if you can get access to medications, you should start the GLP ones now

while we're going through this process in preparation for surgery because it's going to be a three to six month process anyway. So you might as well start being healthy, try to lose weight so that your risk during surgery is less than it is now. And then we'll do surgery. We'll see how you're going.

go, and then if we need to continue your weight loss, maybe the weight loss will plateau, or if we want to magnify it, then we can add the medications back. When you think about strategizing with patients in this way, have you ever had a patient that sticks out in your mind as someone that had great success going through the GLP1 and then surgical approach or is that something that's too new that you haven't even had a patient that's done that? I've had patients who've done very, very well, but then they had interruption in their medications. So it's those people, those patients that I'm seeing is that they had an interruption and they got fed up because then they had to go shopping at different pharmacies to see if that

the exact dose that they wanted was available. And I understand that it's, the shortage is less now. but I think that there's been frustration in the dependence on these medications and then they'll come and see me. Right. And there's been an uptick in people taking these medications for superficial reasons, less so for health reasons.

Someone saying, oh, for a wedding, for an event, celebrities have very popularly taking them for roles. What's your stance on that? You know, it's mixed because there we go fat-shaming again. You know, just because someone wants to lose 10 or 20 pounds, and this is a reliable way, why are aesthetics being sort of demonized? And I think the only real criticism of that would be that you're taking away the supply

for someone who needs it for a medical benefit as opposed to an aesthetic benefit. it. But, you know, it's, there's, we have plastic surgeons, right? That we have, we have Botox that people take all the time and it's okay to want to look good. Right. That's totally reasonable. What, um, we talked a little bit about AI and risk stratification, but do you see a future advancement in bariatric surgery that we can be excited about? Um, right. I think it's going to be, in several levels. The answer is yes and no. There's no real new operations out there, but there are some devices out there that will be getting tested through the FDA. There's certain intestinal liners or there's clips, restrictive devices that may be coming out. And also

endoscopic procedures to reduce the inner lumen of the stomach, which just received a CPT code, which means that insurance companies may start, I mean, certainly Medicare is going to start covering. How do they impact the lumen from an endoscopic procedure? That's so interesting. So endoscopically, there's a device that will stitch, put sutures in to the inside of the stomach. Decreasing the surface area. That's correct.

Yeah. Decreasing the surface area. Interesting. It's always so interesting to see the different worlds between medical and surgical, because I obviously perform very few, if any, topical surgical procedures, and the thought process is so different because there's so much buy-in that has to happen from my standpoint when it comes to taking medications, making lifestyle changes, whereas you can have such a big impact surgically right away. That's a little bit more controlled and objective. It's really

interesting. My last question is, have you found any strategies to help motivate your patients because your patients that are going through surgery also need to continue a healthy eating habit, also need to exercise. Has there been any motivational strategies that have worked very well for your patients? Yes. I mean, I really talk to my patients from the hip. And I think I try to use analogies. And I tell them that, you know, you've been given a gift as service.

and you've lost weight. But what you need to know is that being fat is a forever condition. Your body is obisogenic. It will want to gain weight forever. And you must always keep an eye on that. And as we get older, we need less and less food to eat. So don't think about, I have to eat so much protein. I have to eat three times a day. I sort of talk to them about intuitive eating to to embrace that. And if you're not hungry, it's okay to skip a meal because you would now have something that can give you some feedback about not being hungry. So I don't want, I want them to get out of the, what they've been told all their lives in terms of losing weight because it was never useful for them. And to also bring exercise into their lives because of the muscle mass

conversation that we've had. I tell them, I use that a lot, that the lack of muscle mass will be the number one, one of the major driving forces to weight regain. And I think it really sticks with them. Is there such thing as healthy fat?

Being overweight and also being healthy as possible. The only thing I would say is that being overweight or obese does increase the strain, on joints that will accelerate arthritis and so you see football players like that. So if it's an athlete that's BMI overweight, then they're healthy. But most of us in the real world are not like that. So I think that if you're fat and you're healthy by blood tests,

then you're not necessarily healthy. Yeah, because it's a, the way that I think about it is you can be overweight, obese, and healthy for now. Because it's a risk factor situation. When we talk about BMI's and the term obesity, we're not talking about your health right now. We're talking about your health in the future and what can happen.

And the risks changing is what we're trying to get ahead of and be preventive. So, like the idea of fat shaming is people, fat-chain people and say you're unhealthy now, that might not necessarily be true. The way that I think about is how will they be in the next 20, 30, 40, 50 years? Because I feel like medicine is moving towards preventing as opposed to just curing or acting when a condition already happens. Which medicine, unfortunately these days, modern medicine gets a lot of flack for. People say, oh, doctors don't look at root causes. Doctors are not looking for prevention. We absolutely are.

The reason the term obesity exists is because we're looking at prevention. And when I see, like, I'm curious, and if you don't want to answer it, that's fine. I have a very negative view of functional medicine doctors because they make advertising-friendly statements like, we are looking for the root cause, as opposed to me, as a family medicine doctor, I'm not, or you're not. So I don't quite understand that world, and I think there's a lot of overtesting and advertising related in that world? Do you have any thoughts on the functional medicine side of things?

I don't have a... No, I don't. Because I don't really deal with a lot of... That world. Yeah, those physicians. You know, I think maybe the idea is attractive, but I agree with you that we're trying to, I mean, I look at it as a holistic approach. And you're right, obesity will accelerate any disease process that your body is

prone to. So if there's diabetes in your family or high blood pressure in your family, if you are at a healthy weight, it probably won't rear its ugly head until you're 60 or 65, but obesity will bring it on when you're 40. A lot of people start developing old people, medical problems at much younger age. Yeah. And again, I think back to quality of life as well, are you going to be able to be independent if your hips are osteoarthritic, if your knees are killing you, and then when you become more sedentary, does it compound the problem? So I think about it down the line as much as possible without obviously fat-shaming anyone because we've seen that to be very not helpful and rude from a personal standpoint. Well, do you think we covered the topic

well? I think we did a, you did a great job. Now, you did an amazing job and I very much appreciate your nuance takes on all of these issues because these days it's hard to find someone who's willing to talk about it honestly and openly about what we know, but also about what we don't know with the future holds. So I thank you for your honesty in that regard. It's been a pleasure. Thank you very much. Thank you. Where can people learn more about what you do or if perhaps they'd like to seek out medical care for me? Well, I'm at NYU Langone Medical Center, which is on 1st Avenue and 34th Street. But if you visit our website, it's NYU Langone in the Manhattan campus.

But you can also watch our online seminar located at www. NYU weight loss.org. Cool. Thank you so much. Thank you. Huge thanks again to Dr. Renfielding for coming by the studio. Honestly, this is one of my favorite episodes of the year. If you felt the same, please leave us a five-star review and comment,

as it's one of the best ways to help the show find new listeners. And if you enjoy this conversation, I know you're going to like my deep dive on nutrition and fitness with Lane Norton. So scroll on back through your library and download that one right now. As always, stay happy and healthy.