December 16, 2025 • 36 mins
GLP-1s are everywhere. But are they the only medical weight loss intervention worth considering? On today’s episode, Dr. George Fielding - a pioneer of laparoscopic adjustable band surgery and a patient of the procedure himself - offers an insider’s look at the world of weight loss surgeries. How do these surgeries work? Who are they really for? And how should we think about them alongside the surge of GLP-1 medications? We also dig into the stigmas people face when trying to lose weight with medical support, and the biggest misconceptions around obesity.
Links to resources mentioned in this episode:
Genomics reveals eleven obesity endotypes with distinct biological and phenotypic signatures
Obesity Drugs May Drop to as Little as $149 a Month
The lung is a site of platelet biogenesis and a reservoir for haematopoietic progenitors
Note: In this show, we use “women” as shorthand for people with XX chromosomes. We understand sex and gender are more complex, and acknowledge the experiences we describe reach beyond that word.
See omnystudio.com/listener for privacy information.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:17):
Pushkin. Hi everyone, Doctor Poyter here, I'm popping in to
let you know that we're working on a special episode
of Decoding Women's Health. We're i'll be answering your questions
about one of my favorite topics, hormone therapy. If you've
been wondering about the different types of therapy, when it
(00:39):
might make sense to start possible side effects, are really
anything else? This is your chance to ask. You can
leave us a voicemail at four FI five two one
three three eight five, or send an email to Decodingwomen's
Health at Pushkin dot fm and let us know if
you'd like to stay anonymous, or if you're up for
(00:59):
having your voice featured on the show. I'm so excited
for this one. Hormone support is such a misunderstood area
of medicine, and there's a ton of new and fascinating
research to talk about together.
Speaker 2 (01:11):
I can't wait to hear what you're curious about. This
show is not a substitute for professional medical advice, diagnosis,
or treatment. It is for informational purposes. Please consult your
healthcare professional with any medical questions. This episode includes discussion
of weight and health. We know these conversations can be sensitive,
(01:34):
Please listen in a way that feels right for you.
Speaker 3 (01:37):
It used to be all why do you want to
go and see Fielding to have an operation where you
can just do it on your own with willpower you know,
and go to the gym and run for an Now,
do you know how much it hurts when you're an
obese person to run for an.
Speaker 1 (01:52):
How Welcome back to de coding Women's Health. I'm doctor
Elizabeth Pointer. Today on the show, we're talking about medical
weight loss, the drugs, surgeries and strategies that have changed
the way that we can help patients manage their weight.
And to help me unpack all of this, I've invited
(02:12):
onto the show doctor George Fielding. He is one of
the pioneers of laparoscopic adjustable gastric band surgery, or what
we commonly refer to as lap bands. But he's not
just a leader in bariatrics. He's also a patient. He
had the surgery himself, and I think his experience and
his perspective are key to helping us all understand the
(02:35):
bigger picture. I wanted to bring him on today to
discuss not only weight reduction surgery, but also to address
some of the major misconceptions about obesity, including what new
research is teaching us about how we've historically misunderstood it.
I also wanted to talk to him about GLP ones,
something we've discussed before on this show, and how they
(02:57):
can be used to improve patient outcomes. George and his wife,
doctor Christine Renfielding, work together at the weight management program
at NYU Langone, which she actually founded. When it launched
in two thousand, it was one of the first comprehensive
programs of its kind, offering not only surgical options, but
(03:18):
exercise guidance, nutritional support, and psychological care and to be transparent.
Both George and Christine are dear friends of mine. Earlier
this year, after a hysterectomy, I developed a high grade
bowl obstruction. If my digestive system didn't start working quickly,
I was potentially facing a second surgery. It was a
(03:41):
frightening and overwhelming moment, and then I got an incredible
text from George. There was a video of him sitting
on his porch in a rocking chair, sipping a bourbon,
and he looked directly at the camera and said, calmly,
my dear, all you need is a good fart. I
(04:02):
laughed for the first time in days, and eventually my
digestive system kicked into gear. His ability to bring humor
and empathy to difficult situations is one of the things
that makes him such a remarkable physician and friend. We
kicked off our conversation talking about his early career, which
started in Australia.
Speaker 3 (04:30):
I was really one of the first people in Australia
to start doing surgery lapiscopically, which is with the little
holes and no big cuts. And then at about ninety
three or four, I started doing what's called Barry out
for surgery, which is weight loss surgery. I had a
special interest in it because I've been heavy my whole life,
(04:51):
on and off, and like a lot of people I've
looked after over the years, I tried everything I knew
to lose weight and just couldn't. I lost sixty to
eighty pounds five times and then always regained it. So
I started doing this new way of doing weight loss surgery,
which is the lap band. You put a little ring
(05:13):
around the top of the stomach and that compresses it.
You know. I'd done bazillions of them, and then in
ninety nine I had it myself and it was one
of the best things I ever did for myself. And
you know I since then, I've lost one hundred and
twenty pounds. I've actually retired from operating in the last
(05:35):
year or so, but I still go. I love going
into the office seeing patients. Our average patient at NYU
needs to lose one hundred pounds and it's given me
a great insight into how to help heavy people.
Speaker 1 (05:50):
And I think that in medicine, we as physicians develop
a deeper empathy when we experience an issue or a problem.
And I know I'm a walking textbook of Duane oncology
now myself. Congratulations, great, I have great empathy related to
HPV related cancers and brocco mutation. But how is that
shape how you approach your patients. Do you think the.
Speaker 3 (06:14):
Patients know that I know what they're going through because
I've been there, done that, got the T shirt, and
got the lap band to prove it.
Speaker 1 (06:23):
Do you think that other healthcare professionals are becoming more
empathetic as we learn more about being overweight and obesity.
Do you see more empathy in the field.
Speaker 3 (06:32):
Yeah, it's definitely better than it was. They used to
get guilt tripped a lot.
Speaker 1 (06:39):
Were you guilt tripped, Like, what was your early experience
before you were working in the field.
Speaker 3 (06:44):
No, I was sort of sneered at a bit, Like
I definitely had the why can't you keep it off?
You just lost eighty pounds? Would take me a year
to lose eighty pounds. I would go to the gym
every lunch hour at the hospital when I was a resident,
and I would do all that stuff you're supposed to do,
and it would work, but it would always come back.
(07:08):
You've got to be so focused on that and nothing else.
And here was I building a surgery practice and doing
all this stuff, and I was I had to be
focused on you know, I had a wife and kids
in school, and it's just something would change not for
the good, or I'd be worried about something. You know,
(07:29):
maybe I had a sick patient and they were taking
up a lot of my energy, and yeah, it just
always comes back.
Speaker 1 (07:38):
How long were you doing light bounds before you had
a light bound.
Speaker 3 (07:41):
I was doing them for four years.
Speaker 1 (07:44):
What was the ultimate turning point for you that you
said I'm going to just go ahead and do this.
Speaker 3 (07:49):
Yeh. I had what's called ventric to the tachic cardia.
Speaker 1 (07:53):
Well, that's a serious one. Can you tell us what
the tack is orcs?
Speaker 3 (07:57):
So the ventricles, you know, the big pumping part of
the heart, and it should beat what's called sinus rhythm,
which is, you know, like sixty seventy beats a minutevent
trick to the tachicicadia is basically clear. It just goes
completely crazy and races and jumps and does all sorts
of stuff. The danger with it is that it can
(08:19):
trigger a heart attacker, and it's a very potent cause
of sudden death. The hospital where I worked, I went
in there and the guy running in the er i'd
known since we were five, and he said, shit, mate,
you've got v TAC. And he goes, don't die and
I said, well, don't bloody let me, Yeah, keep me alive.
(08:43):
And so then they find out I've got high cholesterol,
I've got high blood pressure and everything else.
Speaker 1 (08:47):
So you use the term, I notice heavy people. Let's
talk about the term obesity. Is there a stigma attached
to it? Is it time to get rid of that term.
Speaker 3 (08:56):
That's a very contemporary question. You know. It's based primarily
on what your body mass index is. Body mass index
is a way of relating your weight to your height
and is a medical calculation. It's weight divided by heighth squared,
and so heavy we would say is like twenty six
(09:18):
to thirty five. If it's thirty five and you've got
these medical conditions we've been talking about, you know, blood pressure,
cholesterol or everything else, or over forty, then you qualify
as morbid obesity. And I think that's the one that's
got the stigma within our organization and in our group,
(09:41):
we don't use the term morbid obesity.
Speaker 1 (09:43):
So you also mentioned that you had tried many different
ways to lose weight and didn't lose weight until having
a LA bound. There was a great study that came
out recently that says that there's really eleven different types
of obesity correct, And we've always in our medical profession said,
you know, exercise nutrition, and we all have had many
many patients that that doesn't work for. So can you
(10:05):
impact that a little bit for us, the different types
of obesity and why some people respond to different treatments,
and that type.
Speaker 3 (10:10):
Of that paper was just an enormous body of work.
What they did, you know, a couple of million patients
worldwide they tested and found these genetic differences and worked
out these subgroups based around that. Some people who are
O beast get super sick. They have every known what's
(10:32):
called a com morbidity, blood pressure, cholesterol, sleep, apnear arthritis.
Some people who are a beast don't.
Speaker 1 (10:40):
It's got to be just completely different physiology, no question.
Speaker 3 (10:44):
It's just got to be the way their body is made.
And there's definitely those people. You know, some three hundred
and fifty pound guy. I'll come in and he's on nomads.
He's never had a sick day in his life. He's
just beat.
Speaker 1 (10:59):
Just to add a bit more context, this new research
we're discussing here was first published in July of twenty
twenty five at the time we're running this episode, it's
not yet pure reviewed, but basically it divides obesity into
two broad categories that doctor Fielding mentioned, metabolically healthy and
(11:21):
metabolically unhealthy. It then goes on to identify nine additional
genetic subtypes linked to issues such as insulin production, immune
system function, and hormonal regulation of hunger. We've included a
link to this research in the show notes. Okay, back
to our conversation.
Speaker 3 (11:42):
The most common thing, which is what I had. You're
just starving all the time. You're just never not hungry,
and so you're eating a lot, way more than you
need because you're just always hungry and just never full.
I never felt full one day in my life until
I had the lap band.
Speaker 1 (12:03):
Is that same as food noise?
Speaker 3 (12:05):
Food noises where people just think about it all the
time and it drives them a bit crazy. This is
just a relentless I have to eat something. I just
have to eat it. Those people aren't eating huge amounts
of food at one time, they're just eating, eating, eating, eating, eating,
(12:25):
And that's food noise. One of the other groups of
people people that just have intense sugar craving, and that
is the hardest thing to combat.
Speaker 1 (12:36):
Women have more sugar cravings than men, I think so,
And how about women with pcos?
Speaker 3 (12:41):
Definitely more sugar craving. Definitely.
Speaker 1 (12:44):
Does that related to insulin resistance?
Speaker 3 (12:45):
You think, George, Yeah, I do. Yeah.
Speaker 1 (12:47):
Can you describe to this what happens to the physiology
the metabolic physiology of women at midlife. Is it just
insulin resistance, is it inflammation or what's really happening at
midlife with hormone shifting?
Speaker 3 (12:58):
Insulin resistance yeah, because it really affects hunger, it affects fullness.
So if you have inchin on that doesn't work, which
is the classic thing in PCOS just doesn't work, that
will flow onto how your stomach emptied, how full you feel?
Are you more hungry because the insulent is not working,
(13:20):
your blood sugar levels go up, and so you get
this perpetual cycle of I'm really really hungry, I need
something now. Oh I'm still really really hungry because you're
not getting the normal flux of insulin affecting sugar absorption.
You're just not getting it because the insulnce not working.
(13:43):
And I think that's what happened.
Speaker 1 (13:46):
Coming up, Doctor Fielding and I discussed when it's potentially
appropriate to use weight loss medications like glp ones and
when it might be worth considering surgical options.
Speaker 4 (13:58):
We'll be right back, Welcome back to the show.
Speaker 1 (14:20):
Doctor George Fielding has been doing lap band and other
weight loss surgeries for over twenty years, but today he's
got even more options to help his patients, namely this
much talked about class of drugs called glp ones. So
I asked him about how golp ones have changed his
approach even for patients who do undergo surgery in terms
(14:45):
of just the different forms of obesity. So different people
are just going to respond to different things. Right, do
you have people that don't respond to lap band surgery?
Speaker 3 (14:53):
Most will respond, But with the band and the sleeve
and the boipass put me twenty to thirty percent. Starting
three or four years out, we'll just stop putting white
beck on. And it's because they get hungry again. As
substantial percentage of these people regaining weight. That's where I
(15:15):
personally use these medications to stop that happening. And these
are people that might have lost one hundred hundred and
fifty pounds. Once you see this uptick again, and then
their sense of sort of failure in this, and also
the chastisement from their families who say, you took this
(15:36):
enormous risk, So why on earth are you being so
weak that you can't keep the weight off. I've heard
this hundreds of times from the patient saying this is
what their spouse or parent is saying to them. And
that's the stigma part of it. You know, you must
be weak because you couldn't keep it off, Whereas what
(15:58):
happens is you just get hungry again.
Speaker 1 (16:02):
So it's a dance then between the GLP wines and
bariatric surgery, and then the glp wines have a role
after bariatric surgery.
Speaker 3 (16:11):
People that we're seeing for surgery need to lose at
least one hundred pounds. You know, their average BMI is
forty five. Now the golp ones will I've never seen
anyone with these medicines lose one hundred pounds. I've seen
tons of on them lose thirty, forty to fifty. But
the minute you stop taking them, it'll come back because
(16:35):
your physiology hasn't changed. Right.
Speaker 1 (16:38):
So the role of beriatric surgery then, as it is
evolving now in the age of our golp wines, really
is for the person who is very, very very overweight,
and then you can reset them with the bariatric surgery
and then come in as you need with the golp ones.
Speaker 3 (16:55):
Exactly the way I feel. But now that there are medicines,
they've always been diet pills. Like fentamine is something I
prescribe me thousands of times.
Speaker 1 (17:05):
Tell to me a little bit about fentamine.
Speaker 3 (17:07):
I still think pentamine is really effective.
Speaker 1 (17:10):
Yeah, that's so interesting because that's like kind of forgotten. Yeah, no,
and people got to think because the fen fen, people
are scared to use it, right.
Speaker 3 (17:17):
Right, because fenfen is pretty much a disaster. It's basically
a stimulant which worked as an appetite suppression. And the
problem with the fenfen is that there are a lot
of dangerous complications side effects that happened. And this is
like nearly thirty years ago, right, But so they split
(17:37):
the phantomene part of Fenfen off as a separate thing,
and the main side effect you get with that is
just a racing heart and sometimes high blood pressure. It
basically revs you up. You have to take it in
the morning. You can't take it at night because you
will not sleep. But it really does somehow stop feeling hungry.
Speaker 1 (17:59):
So do you use these other medications instead of DLP
ones For some people, we.
Speaker 3 (18:05):
Used to use met Foreman now relatively frequently. Met Foreman
was one of the original diabetes drugs. And so what
it does. It affects the absorption of sugar by improving
insurance resistance. If they're just sort of starving hungry all
the time. I think phantomine works great.
Speaker 1 (18:27):
Can you review with thos just because I think this
is just such interesting information. When you would use these
other weight loss medications, and when you would use a
GLP one if.
Speaker 3 (18:37):
You can get the golp ones, I would use the
GLP one because I've really seen good results with them.
But an enormous percentage of the population can't afford what
they cost off the shelf. But a lot of patients
are insurance won't go near the injectibles just so expensive.
Speaker 1 (18:58):
And plus it's a drug too that you don't usually
get off of right like once you start.
Speaker 3 (19:02):
So if we go through the whole process and our
staff try and get the prior authorizations and the insurance
companies go nope, then that's when I definitely would give
them fantomazing.
Speaker 1 (19:15):
I want to jump in here for a moment to
note that there are additional pathways to explore if you're
qualified for obesity medication but you're not able to afford
the sticker price. For example, her zeppetier zepbound come in
bials that are less expensive than the pre filled pens.
A new executive order also promises to make certain brands
of these drugs more affordable in the near future, at
(19:38):
least for Americans who meet the government's medical criteria and
buy them through the government's website. Okay, let's get back
to the interview. Now. In your program, do you have
a weight cutoff or a BMI cut off and say, okay,
this GLP one is not going to work for you,
or how do you we know that you use them
intermittently afterwards and there's a dance with them, how do
(19:59):
you upfront them in your practice?
Speaker 3 (20:01):
So upfront, we have a medical weight loss team separate
to a surgical m and so new patients coming in
will say, ah, well, I'm a bit anxious about doing
the surgery. Can I try something else first and see
if I can get the weight of And then they
have a whole protocol for how to do it, and
(20:23):
they see a lot of people for that who are
not there primarily to have surgery. They're there to treat
their weight and see if they can make an impact
enough on their weight to not have surgery. It very
much depends how much they've got to lose.
Speaker 1 (20:40):
What percentage of people do you think that go for
medical weight loss who come to your program at NYU,
what percentage eventually go on to have bariatric surgery?
Speaker 3 (20:50):
I would think not more than ten or fifteen. Yeah,
because I think the ones who just need a stronger
tool in the main needers come and have the operation. Now,
if they need to lose one hundred and fifty pounds
or one hundred and twenty pounds, which is what I lost.
If you need to do that, have the operation. But
if you need, as I said, fifty sixty pounds, then
(21:12):
have a go with these injections.
Speaker 1 (21:15):
So do women have unique aspects to bariatric surgery or
especially like a midlife woman.
Speaker 3 (21:22):
So a midlife woman, the biggest thing to find out,
I think is does she have insulin resistance? Does she
have pcos? Because any operation that really works for those
people is a gastric bypass. Why is that because it's
the change in the production of their hormones made in
the intestinment.
Speaker 1 (21:41):
So let's break that down. Tell us what a gastric
bypass is versus a lap band. Tell us what hormones
are made in the intesting So.
Speaker 3 (21:49):
The lap band is a ring made out of silicone
that has an internal balloon that you can adjust through
a needle into what's called a port under your skin.
Bond's right here, I'm tapping it right now, you're not
actually cutting anything. You're not cutting it or moving an organ.
The gastric bypass was always done through a gigantic open incision,
(22:12):
and I remember seeing them done when I was a
resident and think these people would have a cut from
what they used to say, chin to chaps, and they'd
be in hospital can days. They could barely walk. So
it was never popular, but the technique was always there
and there were some good results, especially with the resolution
(22:34):
of diabetes. So when we were able to work out
these techniques on it, they had to do this operation lapiscopically.
They were going home the next day and they didn't
have a big cut and they still got the same results.
You cut across the top of the stomach. Your stomach's
about the size of a football. So when you cut
(22:57):
across the top and leave a little bit below your esophagus,
which carries food, if you leave a little piece there,
it's about as big as a small apple. So then
you bring in testine from down below up to join it,
and so the food goes straight down esophagus into that
(23:17):
little pouch and then skips the rest of the stomach
and the first part of the intestine, which is why
it's called a bypass. Looks like a bypass on a highway.
You're just going around and the food not going through.
There generates a lot of intestinal hormone response, which has
(23:40):
a great benefit with diabetes, but it also really affects
feelings of fullness and loss of hunger.
Speaker 1 (23:50):
Is that Lupton and Grellen? Yeah, yeah, so the hormone.
So you're actually getting a physiologic change that's not just
a structural change with a bypass.
Speaker 3 (23:59):
Correct but the issue is that it's more invasive. You're
cutting the stomach, you're cutting the intestine, You've got to
join them all back together, so there's a high risk
of complications. It's definitely more than a band. It's probably
not that much more than the sleeve gastrectomy, which is
the most common operation done where you're turning that football
(24:21):
sized stomach into a banana, so you have a long,
narrow stomach that you definitely get resolution of the hunger
as well. You get very full very quickly. The sleeve
people tend to lose weight very quickly because it's such
a dramatic change into this little banana.
Speaker 1 (24:41):
There's a lot to unpack here. Lap band surgeries like
the one that doctor Fielding had are actually quite rare
these days. Gastric sleeve and gastric bypass surgeries are much
more common now, and it's worth noting that these methods
don't just change the mechanics of the body, they also
change your hormones. They actually alter the structure of the
(25:04):
stomach and the production of hormones in the gut, so
that midlife women who undergo these surgeries often benefit not
only from the mechanical intervention, but also from improved insulin function,
reduced hunger signals, and better metabolic regulation overall, in part
because of those hormonal shifts and the intestines. This connection
(25:27):
between surgical changes and hormonal changes is utterly fascinating to me,
and it makes me wonder about the hormonal consequences of
surgeries outside of the realm of weight loss. After the break,
doctor Fielding and I discussed some of the overlook consequences
of hysterectomies.
Speaker 4 (25:45):
We'll be right back.
Speaker 1 (26:00):
We were drinking a bourbon in Montana one night and
somehow we landed on weight gain after hysterectomy. I remember,
and because most people just blow that off and they'll say,
you know, no, you're not going to gain any weight.
And indeed, in preparation of this conversation today, I relooked
it up to see if there's anything in the literature,
and there's nothing in the literature. But you and I
(26:20):
both noticed that women gain weight after hystrotomy.
Speaker 3 (26:23):
I still remember that conversation. I remember the burden too. Yeah,
I do too. That was good. But it's a very
real thing, you know. And we definitely have a group
of patients who, you know, older women who've had hysterectomies,
and they're just putting on weight, and I don't quite
(26:46):
understand why it is, but I know it's real.
Speaker 1 (26:51):
My thoughts on why women gain weight after hysterectomy are
that there's a disruption to the blood flow to the
ovary and we're actually seeing subtle hormonal ships that if
we really spoke with women and listen to them, that
we would hear that they're having some hormonal ships. Because
many times we can't measure these shifts, and we have
to say, oh, my sleep is disrupted a little, or
(27:11):
I feel a little bit warmer at night, or I
have vaginal dryness, or my libidos off. That will signal
many times the estrogen levels are changing, and we know
that a portion of the blood supply to the ovaries
some of it comes from the uterus, basically the uterine artery.
So I've always thought that maybe there's some subtle hormonal shifts,
and if it's subtle hormonal shifts, we should see more
(27:32):
insulin resistance after hysterectomy.
Speaker 3 (27:34):
Logically it has to be that. I mean, there's just
no other way you can look at this and say
you've made this very important change for the woman's health,
and now as a result of that, this is happening. Yeah,
logic would tell you that there's a change in some
physiology in the pelvis, which then will fixed the whole body.
Speaker 1 (27:55):
You know, we think of the uterus as an ind organ, right,
We don't think of it as really producing any hormones
or anything such. But maybe it's producing something that we
don't know about. We haven't looked at many times in medicine.
If we can't measure it, it must not be there.
It's not there, and I think recently there was some
and this is way out of the scope of my
knowledge and subject area expertise, but you know, platelet production
(28:15):
in the lungs or some platelet kind of processing in
the lungs. In Eastern medicine has always said something goes
on in the lungs with blood, So maybe there's something
in the uterus. We just don't know. Yeah, so here's
the bigger question. You and I are sitting in Montana
over Bourbon talking about this. I mean, we're both experienced surgeons.
We both see a lot of patients. But why does
nobody talk about this? Because women tell us this. It's
(28:38):
listening to our patients and our narratives. But why don't
you think people talk about this?
Speaker 3 (28:43):
Maybe because there's separation of church and state between general
bariatric surgeons and gnecology litutrition. It's not a lot of
cross linking.
Speaker 1 (28:52):
Well, that's the whole problem in women's health. That's why
you're on decoding women's health, because we're trying to take
things out of silos and have crosstalk. We all need
to sit in a room and have just a conference,
you know, with different subspecialties occasionally. Shortly after this conversation,
new research was confirming our suspicions that hysterectomies could actually
(29:15):
impact metabolic function in women. This is such an important
finding and I'll be interested in seeing further data on
this topic. And is these types of conversations and research
that are really so critical to providing patients with the
care and information that they deserve, especially when treating conditions
as multifaceted as obesity. Doctor Fielding and his wife, doctor
(29:39):
Christine Renfielding, have been navigating those complexities for decades now
at their weight management program in New York. How's your
program grown? Over the plust twenty has been around for
about twenty twenty five years, right.
Speaker 3 (29:50):
It's twenty five years. Yeah, so last week was Chris's
twenty fifth anniversary starting the program.
Speaker 1 (29:56):
Congratulations, Yeah, that's crazy. That is totally huge.
Speaker 3 (30:01):
The obesity epidemic was just surging then, and and so
she developed this whole a program, not just all come
in and have an operation, see our psychologists, see our nutritionists,
then talk about the surgery again. So basically it just
grew and grew and grew, and then there's no doubt
(30:25):
in the last couple of years that the numbers have
taken a hit because of the injections. But now the
numbers are coming back up again.
Speaker 1 (30:32):
But are did you ope ones? Now? Are they just
putting it more on the radar screen because everybody's talking
about them, So maybe that will bring more people into
converse about I can do something about this, not necessarily
a medication, but like a combination.
Speaker 3 (30:43):
Absolutely, and I think that's fascinating. I honestly think that's
why our numbers are creeping back.
Speaker 1 (30:48):
Yeah, you've been in this field since the inception. What
do you wish that other physicians knew, or that patients knew,
or midlife women?
Speaker 3 (30:57):
Losing weight on your own is really hard, and then
when you get in middle life and hollmental changes. But
as that comes into the picture, it's just hard. And
the thing that is still lurking there is society, including
a lot of doctors. I think people who are doing
(31:19):
bariactric surgery or doing the injections are taking the easy
way out because there's this absolute myth, and it's a
myth that you can do this sort of weight loss
on your own and keep it off.
Speaker 1 (31:33):
How do we change that attitude because you're giving me
real physiologic reasons.
Speaker 3 (31:37):
Yeah, Well, it's interesting. I mean when the ozembic explosion happened,
where two or three years ago, the bulk of media
and commentary was these people are pathetic. They're taking the
drugs away from diabetics. They should remember that they should
be able to do this on their own. And you
(31:57):
know that's the hardest part is But the other thing
that's interesting, and this number has not changed, less than
one percent of eligible people in the world for bariatric surgery,
and these are people with a BMI over forty, so
ninety nine percent of them don't come. And the reason
(32:18):
they don't come, I really believe is they're scared or
they just don't think it maddest, But the biggest driving
force is what I was mentioned before about family and
friends telling them they're coppying out and taking an easy
way out. You should be able to do on your own.
Speaker 1 (32:35):
It seems like we have to take away initially the
stigma of you are the size because of how you
live your life, it's not your physiology. Taking that away
then will take away I think some of that. We
have to crack down on that.
Speaker 3 (32:51):
That's the biggest issue.
Speaker 1 (32:53):
Yeah, what are you hoping to see in the future.
Where do you see this field a bariatric medicine ten
to fifteen years from now?
Speaker 3 (33:00):
I mean the cost to the healthcare system for treating
WAWS people is gigantic, right, and the personal cost of
feeling horrible, being sick, dying young is a huge cost
of society, And what I would love to see is
just more people get help.
Speaker 1 (33:20):
We have effective treatments, Yeah, we now.
Speaker 3 (33:22):
Have treatment platforms that can really fix that. Taking those platforms,
whether it be surgery or medicine or whatever, it doesn't
mean you're taking an easy way out. It means you're
taking a strong step for yourself to end up with
a fitter, happier, healthier lot, because we all want to
(33:44):
be healthier, we all want to live longer, and we
all want to be happy.
Speaker 1 (33:53):
I'm certainly happy to have hosted Doctor Fielding on today's show.
While most listeners will never need bariatric surgery, there's still
a lot to take away from our conversation. First, having
obesity doesn't automatically mean you're unhealthy. Someone could have a
BMI of forty and be metabolically healthy. Obesity is not
(34:15):
a monolithic condition. There are many biological reasons people struggle
with their weight that have nothing to do with lifestyle.
Some people can eat well, exercise regularly and still find
it difficult to maintain a healthy weight. That doesn't mean
you're doing anything wrong. There's no shame in asking for
(34:36):
additional help from a doctor. So many midlife women deal
with persistent insulin resistance. If that sounds like you, it
may be worth discussing the options that we covered with
doctor Fielding. Finally, it's important to remember that the mechanical
aspects of the body are strongly linked to hormones. This
is an under researched area, but it's worth paying attention
(34:59):
to signs of hormonal imbalance after major surgery and talking
with your doctor if you notice any of the changes
that we discussed today. Up on the next episode of
Decoding Women's Health, I talked to a leading happiness expert
about why we struggle with well being in midlife, as
(35:20):
well as some actionable steps we can take to feel better.
Speaker 5 (35:23):
There are lots of structural things that make midlife hard,
but a lot of what makes midlife hard is that
we have very high standards for ourselves, like the world
has high standards, but we mirror those standards and sometimes
we're worse than the world.
Speaker 1 (35:35):
Decoding Women's Health is a production of Pushkin Industries and
the Atria Health and Research Institute. This episode was produced
by Rebecca Lee Douglas. It was edited by Amy Gaines McQuaid,
mastering by Sarah Bruguier. Our associate producer is Sonia Gerwit,
fact checking by Abigail Abrams. Our executive producer is Alexandra Garreton.
(36:00):
Our theme song was composed by Hannis Brown. Concept and
creative development by Shabon O'Connor. Special thanks to Alan Tish,
David Saltzman, Sarah Nix, Eric Sandler, Morgan Rattner, Owen Miller,
Jordan McMillan, and Greta Cohne. If you have questions about
(36:21):
women's health and midlife, leave us a voicemail at four
FI five two oh one three three eight five, or
send us a message at Decoding Women's Health at Pushkin
dot FM. I'm doctor Elizabeth Pointer. Thanks for listening. Until
next time.
Pushkin. Hi everyone, Doctor Poyter here, I'm popping in to
let you know that we're working on a special episode
of Decoding Women's Health. We're i'll be answering your questions
about one of my favorite topics, hormone therapy. If you've
been wondering about the different types of therapy, when it
(00:39):
might make sense to start possible side effects, are really
anything else? This is your chance to ask. You can
leave us a voicemail at four FI five two one
three three eight five, or send an email to Decodingwomen's
Health at Pushkin dot fm and let us know if
you'd like to stay anonymous, or if you're up for
(00:59):
having your voice featured on the show. I'm so excited
for this one. Hormone support is such a misunderstood area
of medicine, and there's a ton of new and fascinating
research to talk about together.
Speaker 2 (01:11):
I can't wait to hear what you're curious about. This
show is not a substitute for professional medical advice, diagnosis,
or treatment. It is for informational purposes. Please consult your
healthcare professional with any medical questions. This episode includes discussion
of weight and health. We know these conversations can be sensitive,
(01:34):
Please listen in a way that feels right for you.
Speaker 3 (01:37):
It used to be all why do you want to
go and see Fielding to have an operation where you
can just do it on your own with willpower you know,
and go to the gym and run for an Now,
do you know how much it hurts when you're an
obese person to run for an.
Speaker 1 (01:52):
How Welcome back to de coding Women's Health. I'm doctor
Elizabeth Pointer. Today on the show, we're talking about medical
weight loss, the drugs, surgeries and strategies that have changed
the way that we can help patients manage their weight.
And to help me unpack all of this, I've invited
(02:12):
onto the show doctor George Fielding. He is one of
the pioneers of laparoscopic adjustable gastric band surgery, or what
we commonly refer to as lap bands. But he's not
just a leader in bariatrics. He's also a patient. He
had the surgery himself, and I think his experience and
his perspective are key to helping us all understand the
(02:35):
bigger picture. I wanted to bring him on today to
discuss not only weight reduction surgery, but also to address
some of the major misconceptions about obesity, including what new
research is teaching us about how we've historically misunderstood it.
I also wanted to talk to him about GLP ones,
something we've discussed before on this show, and how they
(02:57):
can be used to improve patient outcomes. George and his wife,
doctor Christine Renfielding, work together at the weight management program
at NYU Langone, which she actually founded. When it launched
in two thousand, it was one of the first comprehensive
programs of its kind, offering not only surgical options, but
(03:18):
exercise guidance, nutritional support, and psychological care and to be transparent.
Both George and Christine are dear friends of mine. Earlier
this year, after a hysterectomy, I developed a high grade
bowl obstruction. If my digestive system didn't start working quickly,
I was potentially facing a second surgery. It was a
(03:41):
frightening and overwhelming moment, and then I got an incredible
text from George. There was a video of him sitting
on his porch in a rocking chair, sipping a bourbon,
and he looked directly at the camera and said, calmly,
my dear, all you need is a good fart. I
(04:02):
laughed for the first time in days, and eventually my
digestive system kicked into gear. His ability to bring humor
and empathy to difficult situations is one of the things
that makes him such a remarkable physician and friend. We
kicked off our conversation talking about his early career, which
started in Australia.
Speaker 3 (04:30):
I was really one of the first people in Australia
to start doing surgery lapiscopically, which is with the little
holes and no big cuts. And then at about ninety
three or four, I started doing what's called Barry out
for surgery, which is weight loss surgery. I had a
special interest in it because I've been heavy my whole life,
(04:51):
on and off, and like a lot of people I've
looked after over the years, I tried everything I knew
to lose weight and just couldn't. I lost sixty to
eighty pounds five times and then always regained it. So
I started doing this new way of doing weight loss surgery,
which is the lap band. You put a little ring
(05:13):
around the top of the stomach and that compresses it.
You know. I'd done bazillions of them, and then in
ninety nine I had it myself and it was one
of the best things I ever did for myself. And
you know I since then, I've lost one hundred and
twenty pounds. I've actually retired from operating in the last
(05:35):
year or so, but I still go. I love going
into the office seeing patients. Our average patient at NYU
needs to lose one hundred pounds and it's given me
a great insight into how to help heavy people.
Speaker 1 (05:50):
And I think that in medicine, we as physicians develop
a deeper empathy when we experience an issue or a problem.
And I know I'm a walking textbook of Duane oncology
now myself. Congratulations, great, I have great empathy related to
HPV related cancers and brocco mutation. But how is that
shape how you approach your patients. Do you think the.
Speaker 3 (06:14):
Patients know that I know what they're going through because
I've been there, done that, got the T shirt, and
got the lap band to prove it.
Speaker 1 (06:23):
Do you think that other healthcare professionals are becoming more
empathetic as we learn more about being overweight and obesity.
Do you see more empathy in the field.
Speaker 3 (06:32):
Yeah, it's definitely better than it was. They used to
get guilt tripped a lot.
Speaker 1 (06:39):
Were you guilt tripped, Like, what was your early experience
before you were working in the field.
Speaker 3 (06:44):
No, I was sort of sneered at a bit, Like
I definitely had the why can't you keep it off?
You just lost eighty pounds? Would take me a year
to lose eighty pounds. I would go to the gym
every lunch hour at the hospital when I was a resident,
and I would do all that stuff you're supposed to do,
and it would work, but it would always come back.
(07:08):
You've got to be so focused on that and nothing else.
And here was I building a surgery practice and doing
all this stuff, and I was I had to be
focused on you know, I had a wife and kids
in school, and it's just something would change not for
the good, or I'd be worried about something. You know,
(07:29):
maybe I had a sick patient and they were taking
up a lot of my energy, and yeah, it just
always comes back.
Speaker 1 (07:38):
How long were you doing light bounds before you had
a light bound.
Speaker 3 (07:41):
I was doing them for four years.
Speaker 1 (07:44):
What was the ultimate turning point for you that you
said I'm going to just go ahead and do this.
Speaker 3 (07:49):
Yeh. I had what's called ventric to the tachic cardia.
Speaker 1 (07:53):
Well, that's a serious one. Can you tell us what
the tack is orcs?
Speaker 3 (07:57):
So the ventricles, you know, the big pumping part of
the heart, and it should beat what's called sinus rhythm,
which is, you know, like sixty seventy beats a minutevent
trick to the tachicicadia is basically clear. It just goes
completely crazy and races and jumps and does all sorts
of stuff. The danger with it is that it can
(08:19):
trigger a heart attacker, and it's a very potent cause
of sudden death. The hospital where I worked, I went
in there and the guy running in the er i'd
known since we were five, and he said, shit, mate,
you've got v TAC. And he goes, don't die and
I said, well, don't bloody let me, Yeah, keep me alive.
(08:43):
And so then they find out I've got high cholesterol,
I've got high blood pressure and everything else.
Speaker 1 (08:47):
So you use the term, I notice heavy people. Let's
talk about the term obesity. Is there a stigma attached
to it? Is it time to get rid of that term.
Speaker 3 (08:56):
That's a very contemporary question. You know. It's based primarily
on what your body mass index is. Body mass index
is a way of relating your weight to your height
and is a medical calculation. It's weight divided by heighth squared,
and so heavy we would say is like twenty six
(09:18):
to thirty five. If it's thirty five and you've got
these medical conditions we've been talking about, you know, blood pressure,
cholesterol or everything else, or over forty, then you qualify
as morbid obesity. And I think that's the one that's
got the stigma within our organization and in our group,
(09:41):
we don't use the term morbid obesity.
Speaker 1 (09:43):
So you also mentioned that you had tried many different
ways to lose weight and didn't lose weight until having
a LA bound. There was a great study that came
out recently that says that there's really eleven different types
of obesity correct, And we've always in our medical profession said,
you know, exercise nutrition, and we all have had many
many patients that that doesn't work for. So can you
(10:05):
impact that a little bit for us, the different types
of obesity and why some people respond to different treatments,
and that type.
Speaker 3 (10:10):
Of that paper was just an enormous body of work.
What they did, you know, a couple of million patients
worldwide they tested and found these genetic differences and worked
out these subgroups based around that. Some people who are
O beast get super sick. They have every known what's
(10:32):
called a com morbidity, blood pressure, cholesterol, sleep, apnear arthritis.
Some people who are a beast don't.
Speaker 1 (10:40):
It's got to be just completely different physiology, no question.
Speaker 3 (10:44):
It's just got to be the way their body is made.
And there's definitely those people. You know, some three hundred
and fifty pound guy. I'll come in and he's on nomads.
He's never had a sick day in his life. He's
just beat.
Speaker 1 (10:59):
Just to add a bit more context, this new research
we're discussing here was first published in July of twenty
twenty five at the time we're running this episode, it's
not yet pure reviewed, but basically it divides obesity into
two broad categories that doctor Fielding mentioned, metabolically healthy and
(11:21):
metabolically unhealthy. It then goes on to identify nine additional
genetic subtypes linked to issues such as insulin production, immune
system function, and hormonal regulation of hunger. We've included a
link to this research in the show notes. Okay, back
to our conversation.
Speaker 3 (11:42):
The most common thing, which is what I had. You're
just starving all the time. You're just never not hungry,
and so you're eating a lot, way more than you
need because you're just always hungry and just never full.
I never felt full one day in my life until
I had the lap band.
Speaker 1 (12:03):
Is that same as food noise?
Speaker 3 (12:05):
Food noises where people just think about it all the
time and it drives them a bit crazy. This is
just a relentless I have to eat something. I just
have to eat it. Those people aren't eating huge amounts
of food at one time, they're just eating, eating, eating, eating, eating,
(12:25):
And that's food noise. One of the other groups of
people people that just have intense sugar craving, and that
is the hardest thing to combat.
Speaker 1 (12:36):
Women have more sugar cravings than men, I think so,
And how about women with pcos?
Speaker 3 (12:41):
Definitely more sugar craving. Definitely.
Speaker 1 (12:44):
Does that related to insulin resistance?
Speaker 3 (12:45):
You think, George, Yeah, I do. Yeah.
Speaker 1 (12:47):
Can you describe to this what happens to the physiology
the metabolic physiology of women at midlife. Is it just
insulin resistance, is it inflammation or what's really happening at
midlife with hormone shifting?
Speaker 3 (12:58):
Insulin resistance yeah, because it really affects hunger, it affects fullness.
So if you have inchin on that doesn't work, which
is the classic thing in PCOS just doesn't work, that
will flow onto how your stomach emptied, how full you feel?
Are you more hungry because the insulent is not working,
(13:20):
your blood sugar levels go up, and so you get
this perpetual cycle of I'm really really hungry, I need
something now. Oh I'm still really really hungry because you're
not getting the normal flux of insulin affecting sugar absorption.
You're just not getting it because the insulnce not working.
(13:43):
And I think that's what happened.
Speaker 1 (13:46):
Coming up, Doctor Fielding and I discussed when it's potentially
appropriate to use weight loss medications like glp ones and
when it might be worth considering surgical options.
Speaker 4 (13:58):
We'll be right back, Welcome back to the show.
Speaker 1 (14:20):
Doctor George Fielding has been doing lap band and other
weight loss surgeries for over twenty years, but today he's
got even more options to help his patients, namely this
much talked about class of drugs called glp ones. So
I asked him about how golp ones have changed his
approach even for patients who do undergo surgery in terms
(14:45):
of just the different forms of obesity. So different people
are just going to respond to different things. Right, do
you have people that don't respond to lap band surgery?
Speaker 3 (14:53):
Most will respond, But with the band and the sleeve
and the boipass put me twenty to thirty percent. Starting
three or four years out, we'll just stop putting white
beck on. And it's because they get hungry again. As
substantial percentage of these people regaining weight. That's where I
(15:15):
personally use these medications to stop that happening. And these
are people that might have lost one hundred hundred and
fifty pounds. Once you see this uptick again, and then
their sense of sort of failure in this, and also
the chastisement from their families who say, you took this
(15:36):
enormous risk, So why on earth are you being so
weak that you can't keep the weight off. I've heard
this hundreds of times from the patient saying this is
what their spouse or parent is saying to them. And
that's the stigma part of it. You know, you must
be weak because you couldn't keep it off, Whereas what
(15:58):
happens is you just get hungry again.
Speaker 1 (16:02):
So it's a dance then between the GLP wines and
bariatric surgery, and then the glp wines have a role
after bariatric surgery.
Speaker 3 (16:11):
People that we're seeing for surgery need to lose at
least one hundred pounds. You know, their average BMI is
forty five. Now the golp ones will I've never seen
anyone with these medicines lose one hundred pounds. I've seen
tons of on them lose thirty, forty to fifty. But
the minute you stop taking them, it'll come back because
(16:35):
your physiology hasn't changed. Right.
Speaker 1 (16:38):
So the role of beriatric surgery then, as it is
evolving now in the age of our golp wines, really
is for the person who is very, very very overweight,
and then you can reset them with the bariatric surgery
and then come in as you need with the golp ones.
Speaker 3 (16:55):
Exactly the way I feel. But now that there are medicines,
they've always been diet pills. Like fentamine is something I
prescribe me thousands of times.
Speaker 1 (17:05):
Tell to me a little bit about fentamine.
Speaker 3 (17:07):
I still think pentamine is really effective.
Speaker 1 (17:10):
Yeah, that's so interesting because that's like kind of forgotten. Yeah, no,
and people got to think because the fen fen, people
are scared to use it, right.
Speaker 3 (17:17):
Right, because fenfen is pretty much a disaster. It's basically
a stimulant which worked as an appetite suppression. And the
problem with the fenfen is that there are a lot
of dangerous complications side effects that happened. And this is
like nearly thirty years ago, right, But so they split
(17:37):
the phantomene part of Fenfen off as a separate thing,
and the main side effect you get with that is
just a racing heart and sometimes high blood pressure. It
basically revs you up. You have to take it in
the morning. You can't take it at night because you
will not sleep. But it really does somehow stop feeling hungry.
Speaker 1 (17:59):
So do you use these other medications instead of DLP
ones For some people, we.
Speaker 3 (18:05):
Used to use met Foreman now relatively frequently. Met Foreman
was one of the original diabetes drugs. And so what
it does. It affects the absorption of sugar by improving
insurance resistance. If they're just sort of starving hungry all
the time. I think phantomine works great.
Speaker 1 (18:27):
Can you review with thos just because I think this
is just such interesting information. When you would use these
other weight loss medications, and when you would use a
GLP one if.
Speaker 3 (18:37):
You can get the golp ones, I would use the
GLP one because I've really seen good results with them.
But an enormous percentage of the population can't afford what
they cost off the shelf. But a lot of patients
are insurance won't go near the injectibles just so expensive.
Speaker 1 (18:58):
And plus it's a drug too that you don't usually
get off of right like once you start.
Speaker 3 (19:02):
So if we go through the whole process and our
staff try and get the prior authorizations and the insurance
companies go nope, then that's when I definitely would give
them fantomazing.
Speaker 1 (19:15):
I want to jump in here for a moment to
note that there are additional pathways to explore if you're
qualified for obesity medication but you're not able to afford
the sticker price. For example, her zeppetier zepbound come in
bials that are less expensive than the pre filled pens.
A new executive order also promises to make certain brands
of these drugs more affordable in the near future, at
(19:38):
least for Americans who meet the government's medical criteria and
buy them through the government's website. Okay, let's get back
to the interview. Now. In your program, do you have
a weight cutoff or a BMI cut off and say, okay,
this GLP one is not going to work for you,
or how do you we know that you use them
intermittently afterwards and there's a dance with them, how do
(19:59):
you upfront them in your practice?
Speaker 3 (20:01):
So upfront, we have a medical weight loss team separate
to a surgical m and so new patients coming in
will say, ah, well, I'm a bit anxious about doing
the surgery. Can I try something else first and see
if I can get the weight of And then they
have a whole protocol for how to do it, and
(20:23):
they see a lot of people for that who are
not there primarily to have surgery. They're there to treat
their weight and see if they can make an impact
enough on their weight to not have surgery. It very
much depends how much they've got to lose.
Speaker 1 (20:40):
What percentage of people do you think that go for
medical weight loss who come to your program at NYU,
what percentage eventually go on to have bariatric surgery?
Speaker 3 (20:50):
I would think not more than ten or fifteen. Yeah,
because I think the ones who just need a stronger
tool in the main needers come and have the operation. Now,
if they need to lose one hundred and fifty pounds
or one hundred and twenty pounds, which is what I lost.
If you need to do that, have the operation. But
if you need, as I said, fifty sixty pounds, then
(21:12):
have a go with these injections.
Speaker 1 (21:15):
So do women have unique aspects to bariatric surgery or
especially like a midlife woman.
Speaker 3 (21:22):
So a midlife woman, the biggest thing to find out,
I think is does she have insulin resistance? Does she
have pcos? Because any operation that really works for those
people is a gastric bypass. Why is that because it's
the change in the production of their hormones made in
the intestinment.
Speaker 1 (21:41):
So let's break that down. Tell us what a gastric
bypass is versus a lap band. Tell us what hormones
are made in the intesting So.
Speaker 3 (21:49):
The lap band is a ring made out of silicone
that has an internal balloon that you can adjust through
a needle into what's called a port under your skin.
Bond's right here, I'm tapping it right now, you're not
actually cutting anything. You're not cutting it or moving an organ.
The gastric bypass was always done through a gigantic open incision,
(22:12):
and I remember seeing them done when I was a
resident and think these people would have a cut from
what they used to say, chin to chaps, and they'd
be in hospital can days. They could barely walk. So
it was never popular, but the technique was always there
and there were some good results, especially with the resolution
(22:34):
of diabetes. So when we were able to work out
these techniques on it, they had to do this operation lapiscopically.
They were going home the next day and they didn't
have a big cut and they still got the same results.
You cut across the top of the stomach. Your stomach's
about the size of a football. So when you cut
(22:57):
across the top and leave a little bit below your esophagus,
which carries food, if you leave a little piece there,
it's about as big as a small apple. So then
you bring in testine from down below up to join it,
and so the food goes straight down esophagus into that
(23:17):
little pouch and then skips the rest of the stomach
and the first part of the intestine, which is why
it's called a bypass. Looks like a bypass on a highway.
You're just going around and the food not going through.
There generates a lot of intestinal hormone response, which has
(23:40):
a great benefit with diabetes, but it also really affects
feelings of fullness and loss of hunger.
Speaker 1 (23:50):
Is that Lupton and Grellen? Yeah, yeah, so the hormone.
So you're actually getting a physiologic change that's not just
a structural change with a bypass.
Speaker 3 (23:59):
Correct but the issue is that it's more invasive. You're
cutting the stomach, you're cutting the intestine, You've got to
join them all back together, so there's a high risk
of complications. It's definitely more than a band. It's probably
not that much more than the sleeve gastrectomy, which is
the most common operation done where you're turning that football
(24:21):
sized stomach into a banana, so you have a long,
narrow stomach that you definitely get resolution of the hunger
as well. You get very full very quickly. The sleeve
people tend to lose weight very quickly because it's such
a dramatic change into this little banana.
Speaker 1 (24:41):
There's a lot to unpack here. Lap band surgeries like
the one that doctor Fielding had are actually quite rare
these days. Gastric sleeve and gastric bypass surgeries are much
more common now, and it's worth noting that these methods
don't just change the mechanics of the body, they also
change your hormones. They actually alter the structure of the
(25:04):
stomach and the production of hormones in the gut, so
that midlife women who undergo these surgeries often benefit not
only from the mechanical intervention, but also from improved insulin function,
reduced hunger signals, and better metabolic regulation overall, in part
because of those hormonal shifts and the intestines. This connection
(25:27):
between surgical changes and hormonal changes is utterly fascinating to me,
and it makes me wonder about the hormonal consequences of
surgeries outside of the realm of weight loss. After the break,
doctor Fielding and I discussed some of the overlook consequences
of hysterectomies.
Speaker 4 (25:45):
We'll be right back.
Speaker 1 (26:00):
We were drinking a bourbon in Montana one night and
somehow we landed on weight gain after hysterectomy. I remember,
and because most people just blow that off and they'll say,
you know, no, you're not going to gain any weight.
And indeed, in preparation of this conversation today, I relooked
it up to see if there's anything in the literature,
and there's nothing in the literature. But you and I
(26:20):
both noticed that women gain weight after hystrotomy.
Speaker 3 (26:23):
I still remember that conversation. I remember the burden too. Yeah,
I do too. That was good. But it's a very
real thing, you know. And we definitely have a group
of patients who, you know, older women who've had hysterectomies,
and they're just putting on weight, and I don't quite
(26:46):
understand why it is, but I know it's real.
Speaker 1 (26:51):
My thoughts on why women gain weight after hysterectomy are
that there's a disruption to the blood flow to the
ovary and we're actually seeing subtle hormonal ships that if
we really spoke with women and listen to them, that
we would hear that they're having some hormonal ships. Because
many times we can't measure these shifts, and we have
to say, oh, my sleep is disrupted a little, or
(27:11):
I feel a little bit warmer at night, or I
have vaginal dryness, or my libidos off. That will signal
many times the estrogen levels are changing, and we know
that a portion of the blood supply to the ovaries
some of it comes from the uterus, basically the uterine artery.
So I've always thought that maybe there's some subtle hormonal shifts,
and if it's subtle hormonal shifts, we should see more
(27:32):
insulin resistance after hysterectomy.
Speaker 3 (27:34):
Logically it has to be that. I mean, there's just
no other way you can look at this and say
you've made this very important change for the woman's health,
and now as a result of that, this is happening. Yeah,
logic would tell you that there's a change in some
physiology in the pelvis, which then will fixed the whole body.
Speaker 1 (27:55):
You know, we think of the uterus as an ind organ, right,
We don't think of it as really producing any hormones
or anything such. But maybe it's producing something that we
don't know about. We haven't looked at many times in medicine.
If we can't measure it, it must not be there.
It's not there, and I think recently there was some
and this is way out of the scope of my
knowledge and subject area expertise, but you know, platelet production
(28:15):
in the lungs or some platelet kind of processing in
the lungs. In Eastern medicine has always said something goes
on in the lungs with blood, So maybe there's something
in the uterus. We just don't know. Yeah, so here's
the bigger question. You and I are sitting in Montana
over Bourbon talking about this. I mean, we're both experienced surgeons.
We both see a lot of patients. But why does
nobody talk about this? Because women tell us this. It's
(28:38):
listening to our patients and our narratives. But why don't
you think people talk about this?
Speaker 3 (28:43):
Maybe because there's separation of church and state between general
bariatric surgeons and gnecology litutrition. It's not a lot of
cross linking.
Speaker 1 (28:52):
Well, that's the whole problem in women's health. That's why
you're on decoding women's health, because we're trying to take
things out of silos and have crosstalk. We all need
to sit in a room and have just a conference,
you know, with different subspecialties occasionally. Shortly after this conversation,
new research was confirming our suspicions that hysterectomies could actually
(29:15):
impact metabolic function in women. This is such an important
finding and I'll be interested in seeing further data on
this topic. And is these types of conversations and research
that are really so critical to providing patients with the
care and information that they deserve, especially when treating conditions
as multifaceted as obesity. Doctor Fielding and his wife, doctor
(29:39):
Christine Renfielding, have been navigating those complexities for decades now
at their weight management program in New York. How's your
program grown? Over the plust twenty has been around for
about twenty twenty five years, right.
Speaker 3 (29:50):
It's twenty five years. Yeah, so last week was Chris's
twenty fifth anniversary starting the program.
Speaker 1 (29:56):
Congratulations, Yeah, that's crazy. That is totally huge.
Speaker 3 (30:01):
The obesity epidemic was just surging then, and and so
she developed this whole a program, not just all come
in and have an operation, see our psychologists, see our nutritionists,
then talk about the surgery again. So basically it just
grew and grew and grew, and then there's no doubt
(30:25):
in the last couple of years that the numbers have
taken a hit because of the injections. But now the
numbers are coming back up again.
Speaker 1 (30:32):
But are did you ope ones? Now? Are they just
putting it more on the radar screen because everybody's talking
about them, So maybe that will bring more people into
converse about I can do something about this, not necessarily
a medication, but like a combination.
Speaker 3 (30:43):
Absolutely, and I think that's fascinating. I honestly think that's
why our numbers are creeping back.
Speaker 1 (30:48):
Yeah, you've been in this field since the inception. What
do you wish that other physicians knew, or that patients knew,
or midlife women?
Speaker 3 (30:57):
Losing weight on your own is really hard, and then
when you get in middle life and hollmental changes. But
as that comes into the picture, it's just hard. And
the thing that is still lurking there is society, including
a lot of doctors. I think people who are doing
(31:19):
bariactric surgery or doing the injections are taking the easy
way out because there's this absolute myth, and it's a
myth that you can do this sort of weight loss
on your own and keep it off.
Speaker 1 (31:33):
How do we change that attitude because you're giving me
real physiologic reasons.
Speaker 3 (31:37):
Yeah, Well, it's interesting. I mean when the ozembic explosion happened,
where two or three years ago, the bulk of media
and commentary was these people are pathetic. They're taking the
drugs away from diabetics. They should remember that they should
be able to do this on their own. And you
(31:57):
know that's the hardest part is But the other thing
that's interesting, and this number has not changed, less than
one percent of eligible people in the world for bariatric surgery,
and these are people with a BMI over forty, so
ninety nine percent of them don't come. And the reason
(32:18):
they don't come, I really believe is they're scared or
they just don't think it maddest, But the biggest driving
force is what I was mentioned before about family and
friends telling them they're coppying out and taking an easy
way out. You should be able to do on your own.
Speaker 1 (32:35):
It seems like we have to take away initially the
stigma of you are the size because of how you
live your life, it's not your physiology. Taking that away
then will take away I think some of that. We
have to crack down on that.
Speaker 3 (32:51):
That's the biggest issue.
Speaker 1 (32:53):
Yeah, what are you hoping to see in the future.
Where do you see this field a bariatric medicine ten
to fifteen years from now?
Speaker 3 (33:00):
I mean the cost to the healthcare system for treating
WAWS people is gigantic, right, and the personal cost of
feeling horrible, being sick, dying young is a huge cost
of society, And what I would love to see is
just more people get help.
Speaker 1 (33:20):
We have effective treatments, Yeah, we now.
Speaker 3 (33:22):
Have treatment platforms that can really fix that. Taking those platforms,
whether it be surgery or medicine or whatever, it doesn't
mean you're taking an easy way out. It means you're
taking a strong step for yourself to end up with
a fitter, happier, healthier lot, because we all want to
(33:44):
be healthier, we all want to live longer, and we
all want to be happy.
Speaker 1 (33:53):
I'm certainly happy to have hosted Doctor Fielding on today's show.
While most listeners will never need bariatric surgery, there's still
a lot to take away from our conversation. First, having
obesity doesn't automatically mean you're unhealthy. Someone could have a
BMI of forty and be metabolically healthy. Obesity is not
(34:15):
a monolithic condition. There are many biological reasons people struggle
with their weight that have nothing to do with lifestyle.
Some people can eat well, exercise regularly and still find
it difficult to maintain a healthy weight. That doesn't mean
you're doing anything wrong. There's no shame in asking for
(34:36):
additional help from a doctor. So many midlife women deal
with persistent insulin resistance. If that sounds like you, it
may be worth discussing the options that we covered with
doctor Fielding. Finally, it's important to remember that the mechanical
aspects of the body are strongly linked to hormones. This
is an under researched area, but it's worth paying attention
(34:59):
to signs of hormonal imbalance after major surgery and talking
with your doctor if you notice any of the changes
that we discussed today. Up on the next episode of
Decoding Women's Health, I talked to a leading happiness expert
about why we struggle with well being in midlife, as
(35:20):
well as some actionable steps we can take to feel better.
Speaker 5 (35:23):
There are lots of structural things that make midlife hard,
but a lot of what makes midlife hard is that
we have very high standards for ourselves, like the world
has high standards, but we mirror those standards and sometimes
we're worse than the world.
Speaker 1 (35:35):
Decoding Women's Health is a production of Pushkin Industries and
the Atria Health and Research Institute. This episode was produced
by Rebecca Lee Douglas. It was edited by Amy Gaines McQuaid,
mastering by Sarah Bruguier. Our associate producer is Sonia Gerwit,
fact checking by Abigail Abrams. Our executive producer is Alexandra Garreton.
(36:00):
Our theme song was composed by Hannis Brown. Concept and
creative development by Shabon O'Connor. Special thanks to Alan Tish,
David Saltzman, Sarah Nix, Eric Sandler, Morgan Rattner, Owen Miller,
Jordan McMillan, and Greta Cohne. If you have questions about
(36:21):
women's health and midlife, leave us a voicemail at four
FI five two oh one three three eight five, or
send us a message at Decoding Women's Health at Pushkin
dot FM. I'm doctor Elizabeth Pointer. Thanks for listening. Until
next time.
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