A Bariatric Surgeon Schools Me On Food Addiction and Weight Loss Surgery

Food isn’t just fuel and obesity isn’t just willpower. We sat down with bariatric surgeon Dr. Mark Vierra to unpack what weight-loss surgery really changes, why genetics and hormones can overpower the best intentions, and how a careful program decides who needs a scalpel and who needs a different plan. From GLP‑1 surges and ghrelin drops to PYY’s “brake,” we walk through how surgery reshapes appetite signals and why even modest weight loss can dramatically improve diabetes and cardiovascular risk.

The conversation goes beyond the operating room. Dr. Vierra explains why five of six referrals don’t get surgery, how he and his partner analyze food diaries, depression, and daily constraints, and when medications like bupropion or GLP‑1s make more sense. We explore binge patterns, the messy reality of predicting who will do well after weight loss surgery, and the tough calls around patients who’ve been told their BMI is destiny when their labs and function say otherwise. The story shifts sharply when we talk alcohol: after gastric bypass, blood alcohol rises faster and stays higher, which raises the risk of alcohol use disorder over time. We share practical ways to screen motives for drinking, plan safeguards with families, and use craving meds thoughtfully.

What ties it all together is respect for biology and the person in front of us. Genetics like MC4R variants and syndromes such as Prader–Willi can drive lifelong hyperphagia; ultra‑processed foods and liquid calories amplify the problem; stigma keeps people from care. We push for a different bias—against soda and engineered foods, not against people—and for care that follows patients long after the incisions heal. If you want a grounded, humane guide to obesity treatment, this conversation delivers clarity without blame.

If this resonated, follow the show, share it with a friend, and leave a review so others can find it. Your support helps us keep building informed, stigma‑free conversations about health.

To contact Dr. Grover: [e-mail]

Episode Transcript

SPEAKER_00 (00:00):
Welcome to the Addiction Medicine Made Easy
podcast.
Hey there, I'm Dr.
Casey Grover, an addictionmedicine doctor based on

(00:20):
California's Central Coast.
For 14 years, I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now, I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is an interviewwith Dr.

(00:43):
Mark Vieira, who is a bariatricsurgeon in my area.
He's an exceptionally talentedsurgeon and a very intelligent
and thoughtful person.
After I released the Weight LossSurgery Doesn't Treat Food
Addiction episode on my podcasta few weeks ago, I knew that
there was more to the story withobesity and weight loss surgery
than just my perspective inaddiction medicine.

(01:05):
So I've worked with Dr.
Vieira for several years, so Isent the podcast episode to him,
and he told me there is more tothe story, and I am really
grateful that he offered histime to speak to us about his
work in bariatric surgery toclarify what it is that
bariatric surgery really does.
And we discussed in this episodea few points that I made about

(01:26):
my perspective on food addictionand weight loss surgery in that
episode that I put out a fewweeks ago.
So if you haven't listened tothat episode, you may want to go
back and listen to it just soyou know what we are talking
about.
Now, a few points that I wantedto call out as we get ready to
start.
First, Dr.
Vieira's focus as a bariatricsurgeon is on the treatment of

(01:46):
obesity regardless of the cause.
If someone has binge eatingdisorder and is developing heart
disease and diabetes because ofthe weight they have gained, he
will treat them.
His goal is to help people thatare overweight and obese for any
reason live happier andhealthier lives.
And you might be surprised thathis treatment plan for his
patients often does not involvesurgery.

(02:09):
Second, not everyone who isoverweight or obese has a
problem with eating.
As Dr.
Vieira lays out in this episode,there are certain genetic
syndromes that predispose peopleto obesity.
And for them, weight losssurgery can be incredibly
helpful.
Third, some people who areoverweight or obese do have a
problem with eating, where theymight have an addictive behavior

(02:31):
towards food.
And I was so impressed to hearthe work that Dr.
Vieira and his surgical partner,Dr.
Steve Chang, do to really diginto a person's relationship
with food as they treat them andbefore they consider surgery.
And finally, we talk aboutstigma.
And people who are overweightand obese face significant
amounts of stigma.

(02:52):
And we have talked about on thispodcast how much stigma people
with addiction face and how muchit harms them.
People who are overweight andobese face intense stigma as
well, and it harms them just asmuch as it does people with
addiction.
And with that, let's get startedon this episode.

(03:13):
All right.
Well, I have to say I respectyou enormously as a colleague,
and I am really excited to learnfrom you.
Why don't we just start byhaving you tell our audience who
you are and what you do?

SPEAKER_04 (03:23):
So my name is Mark Vieira, and I'm a surgeon, and I
finished my medical school in1985.
Did a surgical residency atStanford and I had a circuitous
route to get to medical school.
I was studying politicalscience, decided that college
was a waste of time.
I dropped out of college, butone of my professors said,

(03:45):
Listen, I really need a researchassistant.
Would you come work with me forsome time?
And he was an anthropologist.
I took an anthropology class,physical anthropology class,
because I couldn't get into thepolitical science class I needed
to.
I loved it.
It was fascinating.
And I went to work with him fora while at a research center in

(04:07):
the Caribbean where we werestudying the biochemistry of
affective disorders.
And so that actually fascinatedme.
I actually was going to drop outafter my first quarter.
He actually let me take graduateseminars for the entire rest of
my first year of college.
Otherwise, I would have droppedout.
I said, This is wonderful, it'sfantastic, but it's not real
life.

(04:27):
I'm going to head off and I'mgoing to learn something else.
He said, Come watch monkeys.
I became completely fascinatedwith what they were doing.
It's a group of physicalanthropologists and
psychiatrists at UCLA and Texas.
And we were doing absolutelyfascinating work.
They were really interested inthe way behavior and
neurotransmitters interfaced toinfluence affective disorders.

(04:50):
So I actually went back tocollege, got a degree in biology
and biochemistry, also politicalscience, because that's what I
was interested in.
And I went to medical schoolonly to do research in
biochemistry of affectivedisorders.
So I went to become apsychiatrist, basically because
they said that to do the kind ofwork I wanted to do, I really

(05:12):
needed an MD degree, not a PhDdegree, because I was interested
in more the behavioral issuesalong with that.
So I was pretty interested inthat.
I went to Stanford.
They asked me to stay on when Ifinished my training.
And so I stayed on and became aGI surgeon.
And at that time, there were nofellowships in bariatric
surgery.
There were no fellowships insurgical oncology.

(05:33):
A lot of those didn't exist backthen.
I'd always been reallyinterested in nutrition.
So I became the person whotaught nutrition for the
surgical residents and for themedical students.
And it that was mostly nutritionof injury, what happens during
sepsis, during metabolism, howdo you feed people
appropriately?
But since I was so interested init, I wound up getting people

(05:54):
who were severely malnourished,sometimes from cancer and from
radiation injury and things likethat.
But I also then wound up takingcare of all the severely sick
anorexic patients.
So if you were really sick andhad to be hospitalized, I was
the one who came in and did thenutritional rehabilitation for
those patients.
And it was it was anextraordinary experience taking

(06:16):
care of these young people whohad what legitimately was often
a fatal illness.
Legitimately often a fatalillness.
And so I tried to figure out howto safely refeed them, and it
was it was quite an experience.
But I became interested in doingthat.
I also wound up getting, becauseof my interest in that, I wound

(06:38):
up getting referred patients whohad had old weight loss
operations that prevented peoplefrom absorbing calories.
So GI bypass and things likethat.
And some of those people woulddevelop some metabolic problems,
had to be reversed.
And so they would get sent tome.
And I remember standing at theaward table one day reversing
somebody who had lost from 400pounds down to 150 pounds.
And I remember saying, anyonewho does an operation to promote

(07:00):
weight loss should be arrested.
Okay.
A year later, he came back to meat 400 pounds and said, I don't
care if I was developing oxalatenephropathy and was going to be
on dialysis.
I can't live this way.
You need to help me.
And that was the that was thememorable episode that made me
think that maybe I didn't knowenough about this and I needed

(07:23):
to learn about it.
And at the time, there wasn't,there wasn't a lot that you
really could learn.
It wasn't commonly done.
The the cardiologists approachedme because they wanted me to do
some crazy operations, JIbypasses, for patients with
familial hyperlipidemia.
These were people who died ofheart disease in their early 20s
before we had statins.
And the only thing that had beenshown to help them was this

(07:45):
operation.
But that was a huge commitment.
And it was really hard to giveme a bite on.
We did one patient, I think, butI, you know, he was, he was at
22, he was the oldest patient,oldest looking patient in his
family.
So so anyway, so that's how Igot interested in weight loss
surgery.
And then I started slowly doingthem and saw that actually,
compared to the cancer surgery Iwas doing, I was actually

(08:06):
improving people's lives muchmore than I was with a lot of
the other operations I wasdoing.
And we didn't really know itback then, of my strong census
was true, but we didn't reallyknow it back then.
But what we went on to learn wasthat we were dramatically
improving people's lifeexpectancy and saving lives by
doing this surgery.
I mean, this was when it was oldsurgery, open surgery.

(08:28):
The only thing we did wasgastric bypass.
But a number of studies cameout.
The first was from Sweden, wherethey were doing an old
operation, which wasn't veryeffective.
But in fact, a number of studiesshowed that we reduced the risk
of death by about 40% for heartdisease, diabetes, and
interestingly enough, cancer.
And this is within six to sevenyears, because no other

(08:51):
intervention that we have,actually, that's an
environmental intervention,reduces your risk of cancer in
that shorter period of time.
It's usually 20 years.
But we we keep coming up withthe same numbers.
So we dramatically, wedramatically decrease that that
risk of death from thosediseases.
Since I was the only one doingit, I got to design the program

(09:12):
the way I wanted to.
And since I was reallyinterested in patients with
eating disorders and anorexia,and also with nutritional
disorders, before this wasstandard, everybody had to see a
psychologist or psychiatrist,and everybody had to see a
dietitian, then they would spendtime with me.
And back then, there weren'tmany people doing it, and we

(09:32):
were really selective about thepeople we operated on.
It was a big operation, and wedidn't know that it was good as
good as it turned out to be backthen.
And I worried a lot that I wasdoing an elective operation that
I didn't have to do compared tothe cancer operations I kind of
had to do.
So I took it really seriously,and I devoted devoted a decade

(09:54):
to doing that and built aprogram at Stanford, and we've
brought in a fellow and thatkind of stuff.
So I've done this now since theearly 1990s, and it has been an
absolutely fascinatingexperience.
I have a young partner who isSteve Chang, and he's a fabulous
partner for me.

(10:15):
Steve was out doing somethingelse, I think, working in his
family's business.
He actually started volunteeringit as Suicide Hotline on that
basis, went to medical school tostudy psychiatry, and wound up
being a surgeon.
And so he's the perfect, theperfect person for me to work

(10:35):
with because he he has amazinginstincts about people.
He's a great psychiatrist.
And so that's kind of what wedo.

SPEAKER_00 (10:44):
When you say he's a psychiatrist, do you mean he
takes psychiatry andincorporates it into his
surgical practice?

SPEAKER_04 (10:50):
Yeah.
So he has amazing insights aboutpeople.
It's so interesting.
He was talking to you about apatient he's struggling with and
that I was struggling with, anduh, and he said, Well, where's
dad?
And I said, What do you meanwhere's dad?
He says, Well, you didn't askthem where's dad?
I said, No.
He says, Stupid.
You need to ask them where'sdad.
These little things that hepicks up on that that other

(11:12):
people just aren't clear on.
We both prescribe psychoactivemedications.
We both prescribe a lot ofdifferent antidepressants and
and well-butterine and and youwe were prescribing GLP1s.
We were advocating for these waybefore this was common.
I have a I have a talk that Iused to give and it that I
realized I wrote in 2011 where Iwas talking about how GLP ones

(11:33):
were going to become reallyimportant.
They should become more widelyavailable and they should be
first-line therapy for diabeticsrather than insulin, for
example.
So so we both approach it fromthat, and he's he's a fabulous
person for that.

SPEAKER_00 (11:45):
So it sounds like you have to get to know
someone's relationship to foodin your first visit with them to
understand if they might even bea candidate for weight loss
surgery.

SPEAKER_04 (11:55):
Sometimes in the first visit, it usually takes
more than that.
Okay.
Sometimes you can tell prettyquickly.
I thought about bringing somefood diaries in to show you what
it's like because it I thinkyou'd be astonished if if you
watched me go through a fooddiary and say, what do you learn
from this?
Because it would be a reallyinteresting experience.
I've probably looked at uh tensof thousands of food diaries
now, and it's so interestingwhat they choose to write down,

(12:15):
how they write it down, whetherthey estimate calories.
We spend as much time as we cantrying to figure out.
It's really hard.
It's really hard.
And I have some questions foryou about how to get to some of
these answers better because Ireally struggle with knowing
what actually happens whenpatients are not in my office,
how much I really can gain fromthem about what they're about
what they're doing.

(12:35):
I think Steve is actually betterat this than I am, but just by
repetition, I think I've gottenrelatively good at it.
So, yeah, we do need tounderstand what their, what
their relationship with withfood is.
We have them see a dietitian, wehave them see a psychologist or
a psychiatrist.
But Steve and I are much morelikely to turn down somebody
either for dietary reasons orfor psychological reasons than a

(12:57):
psychologist or a psychiatrist.
We see about 600 new patientsper year who come to us who have
been referred to us for weightloss surgery.
You can see us without areferral, but only on a
case-by-case basis.
So almost everybody has to bereferred by a primary physician.
So we see about 600 new patientsa year.
We do about 120 cases a year.

(13:18):
So the vast majority of patientswho come in to see us are not
going to have surgery.
And they won't have surgery fora whole bunch of different
reasons.
They may be too sick to havesurgery.
And we take great pride in this.
We can usually take somebodywho's really sick and get them
so that they can tolerate anoperation.
But sometimes patients will comein and they'll be huffing and

(13:38):
puffing, and you're worriedthey're going to code in your
office, and they just say, Well,I'm going to die this way.
I'm willing to roll the dice.
I'm sorry that that doesn'twork.
We're willing to work with you.
We followed patients.
I think the longest I followedsome patients who wound up
having surgery was seven yearsbefore they had surgery.
We've had several patientswho've lost 150 pounds or more
before they had surgery.

(13:59):
So we we do that.
Sometimes we prescribemedications for them as a trial.
Some patients qualify if theycome in, their height and their
weight, and comoribities aresuch that most patients qualify,
some don't.
Some come in thinking that theyneed surgery because they're
overweight and they're going todie because they're overweight

(14:19):
and their weight is reallydangerous to them.
And we sit down with them and wesay, listen, you know, the fact
is that these BMI tables werenever intended to be used to
treat individual patients.
That's not the way it's supposedto happen.
Those are only useful forresearch purposes and should
never apply to an individual.
I look at your blood pressure, Ilook at your lipid profile, I

(14:41):
look at your hemoglobin A1C,your liver function tests, all
this sort of stuff.
And I look at the amount ofmuscle mass you have and the fat
mass.
And the best evidence is thatyou're not going to die early
because of being overweight.
Now, you may want to lose weightfor cosmetic reasons, you may
want to lose weight forfunctional reasons.
All those are legitimate.
I don't mean to dismiss those.
But if your concern is thatyou're going to die early

(15:04):
because you're overweight, I cantell you that there's just no
evidence that that is true.
And frankly, if it my advice toyou would be come to grips with
how much you weigh, as long asit isn't too emotionally
distressing for you.
And I don't mean to dismissthat, but focus on eating a
better diet.
Just because far more importantfor your longevity and your

(15:28):
health is going to be a healthydiet, not losing weight.
So there's that was aconversation yesterday with a
woman who's so grateful to hearthat, because she didn't want to
have surgery.
And she's being pushed by allsorts of people and she didn't
want to have it, and she doesn'tneed it.
She absolutely doesn't need it.
She does need a better diet.
Her diet could be so muchbetter.
And she was really receptive toa lot of the a lot of those

(15:50):
things.
But so a lot of people just windup not getting it.

SPEAKER_00 (15:54):
So, in terms of phenotypes, if you will, of
patients and their relationshipto food, in my work in addiction
medicine, not everyone'srelationship to alcohol is the
same.

SPEAKER_03 (16:04):
Right.

SPEAKER_00 (16:04):
So not everyone responds to certain medications.
And a lot of what I do is I tryto get in there and say, what
does alcohol do for you?
Because if you think about it,my patients spend their time,
their money, and they take risksto get their substance.
They're clearly invested ingetting it.
Their brain has an unmet need,and I have to find what that is
to know how to help them.
So if you had to say if there'sa phenotype around a

(16:27):
relationship with food, do yousee different patterns of
behavior around eating?

SPEAKER_04 (16:31):
Oh, absolutely.
They're amazingly differentpatterns.
And it's really hard.
So I don't like BMI.
I actually don't like thoselabels for food behavior because
I think that those are, again, Ithink they're only useful if
you're doing a research project.
And I don't think that they arehelpful to me when I'm taking
care of an individual patient inmy office.
I have a real hard timeunderstanding, for example,

(16:54):
binge eating disorder.
So I asked a patient one time, Iwas going through this, I said,
So do you have a binge eatingdisorder?
And they said, You mean likeThanksgiving?
And I thought that was aninteresting observation.
Do I have it?
Do I eat to the point that I'muncomfortable?
So, for example, binge eatingbehavior.
Some people have a clear, youknow, you're clearly going to
put them in that category.

(17:15):
But more common and more subtlethan that is people who
regularly eat to the point thatthey're really uncomfortable.
I put that in that same categoryfunctionally for me in terms of
outcomes and counseling them andthat sort of stuff.
And that is a huge number ofpatients that I take care of who
regularly eat to the point thatthey are really, really, really
uncomfortable, may or may notvomit.

(17:37):
That's not something common.
But I worry about that a lot.
And I worry about that a lot.
The reason we mostly worry aboutbinge eating disorders is
because those patients have waymore side effects after surgery.
They're much more likely to haveside effects after surgery.
They're much more likely to comein complaining of having pain

(17:58):
after surgery, feeling nausea,vomiting, that kind of stuff,
and they don't lose weight well.
So that's the concern.
Now, the studies looking atthis, and there have been
several, the studies suggestthat actually, they actually
don't do that differently thanother people in terms of their
weight loss.
So their weight loss is kind ofsimilar.
You can show that that theretends to be an improvement in
binging, however you want todefine it, for the first couple

(18:21):
of years.
Some people who didn't havebinge disorder may satisfy
criteria later, so it mayactually appear later, but but
it's it's highly variable andit's absolutely not predictable.
So one of my most inspirationalpatients was a woman who came to
see me.
I saw her just recently 11 yearsago, and she weighed 350 pounds,

(18:42):
which is a lot for a woman.
And her food diary horrified me.
I remember one page of it whereshe, at one sitting, she ate 50
hot chili peppers.
And I thought she had thisterrible BNG disorder, and I was
just really worried about her,but she really needed to lose
weight.
And I tried a bunch of stuffwith her, and we didn't really

(19:03):
make much progress.
Her food diaries that she'dbring in, they they looked
better, they looked good.
It looked as though she hadcontrolled it.
Do I trust the food diaries ornot?
But it looked as like it wasbetter.
So I did a gastrin bypass onher, and now 11 years later, she
comes back and she she comesback every single year, and her
labs are perfect.
Her vitamin D level is alwayslike 80.

(19:24):
She walks nine miles everysingle day, she weighs 126
pounds, and she's a vegan.

SPEAKER_02 (19:32):
She speaks only Spanish.
And I I really had gravereservations about doing that.

SPEAKER_04 (19:44):
And it's one of the best outcomes that I've had.
Binge eating is an interestingthing to take care of.
So we do a fair amount ofwell-butrement in those
patients.
Right.
We we do, and I think for someof those people, it it really
helps.
It really helps.
We do a lot of sort ofone-on-one counseling.

(20:04):
And one of my one of myresidents started one of the
first pediatric programs in thecountry, and I helped them set
all that up.
And it's an academic center,University of Cincinnati.
They had a very well-resourcedprogram with lots of
psychiatrists and psychologistswho are interested in eating
disorders in these patients andexercise physiologists and
dietitians.
And he said, you know, theproblem is the only person

(20:26):
they'll come back to see is me,the surgeon.
They they won't keep theirappointments after surgery with
those other people that won'tcome back to see us.
And that doesn't surprise me.
That doesn't surprise me.
And so Steve and I consider itour responsibility to see those
patients afterwards.
And those conversations have todo with all sorts of things

(20:48):
about how their life is goingand whether they have time,
whether they have the resourcesto buy good food, how are they
how are they organizing theirhouseholds?
A very wise patient oncerecently told me the thing that
they had learned during thecourse of all this didn't have
anything to do with nutrition,it had to do with time
management.
Because this got something Steveand I sort of focus on about in
terms of eating behaviors andand and such.

(21:10):
So do you use any naltrexone?
So so I have tried naltrexoneseveral times on patients.
I I have yet to have anybodybenefit from it.

SPEAKER_00 (21:20):
So this is not science.
And this is what I say, what I'mabout to t tell you is not
science.
I'm going to give you an exampleof one patient.
As you and I both know, theplural of anecdote is not data.
Right.
But I took naltrexone to seewhat would happen.
And as I shared with you, Istruggled with binge eating, and
naltrexone made nothing tastegood.
Aaron Powell So I think that'sfascinating.

SPEAKER_04 (21:41):
And I think that's a really, really good and
interesting point.
So the data, the with thepublished experience, says
naltrexone doesn't help, right?
I mean, there's just nopublished data saying that that
helps.
Buproprion, there's there isthere's some.
I was so interested in how thesepatients were responding to
buproprion.

(22:02):
I thought it was justfascinating.
The interesting thing to meabout it was I'd put people on
it and I'd, when they come back,I'd ask them, do you feel any
different?
They'd say no, but their eatingwas better.
And it was fascinating to mebecause the family members would
say they seem more at peace.
They seem less impulsive.
So I thought this isfascinating.
I took it, I took a single doseof Wellbuchon once to try it.

(22:24):
I thought I was gonna crawl outof my skin.
It was the most awful dysphoricexperience.
And so I always warn patientsabout that because rarely
somebody will have that.
But it I think it really speaksto the different physiology.
When you talk about phenotype, Iassumed you were going to talk
about something different.
I'm going back to when I wasgoing to be a
psychopharmacologist, right?

(22:45):
It really speaks to howdifferent it is.
An an antidepressant, an SSRI inthe right substrate is magical.
In the wrong substrate, it'sawful.
So I have no objection to peopletrying naltrexone.
Listen, the surgery that we dois such a big commitment that
Steve and I, when the GLP onesfirst came out and primary care

(23:08):
doctors wouldn't prescribe it.
We were happy to prescribe it.
We were anxious to prescribe it.
And the same would be true forlots of these other things, then
and Topamax and stuff like that.
So we were prescribing it waybefore anybody else was out
there doing it.
Because our threshold cancompared to surgery made that
seem like a a really trivialcommitment.
You can start, you can stop it,just tell your family members.
So I have, and although thestudies don't say denaltrexone

(23:31):
helps, I don't think that's theway to think about it.
Because if you said, well, doespenicillin help for infections?
And you did a big study and yougave everybody with infections
penicillin, you show thatpenicillin wasn't effective or
marginally effective.
If you give it to the rightperson over the right c
condition, it's magicallyeffective.
And and I I have little doubtthat naltrexone for the right

(23:55):
person, for let's say you ismagical.
But I I really hesitate whenpeople generalize from their
experience about relationship toweight or obesity to the
experience of other people.
For example, we've Steve and Ihave talked about this.
If we were going to get amid-level in an office, we would
not choose somebody who's hadweight loss surgery because it's

(24:17):
so easy for them to generalizefrom their experience to the
experience of other people.
And one of my concerns aboutsometimes some of the dietitians
who take care of patients withis that they they tend to
generalize from theirexperiences and assume that it's
gonna be the same for everybody.
And I just gotta tell you, it'sjust not.
It's just not.

SPEAKER_00 (24:38):
In my world, an addiction, usually what I tell
people, and this is my favoritejoke, is Dr.
Grover, I put mayonnaise on myleft ear and I'm sober.
I tell them, put mayonnaise onyour left ear.

SPEAKER_04 (24:49):
Absolutely.

SPEAKER_00 (24:50):
And so to your point about well-butrin, it's in my
world an addiction medicine, weuse it for nicotine, cocaine,
and amphetamine addiction.
And for some people, it's justtoo stimulating.
And for others, they respondvery well.
I don't know if you use this atall in your practice, but we do
pharmacogenomic testing to seewhich medications people respond

(25:10):
well to.
This is a company calledGeneSight.
I have no financial relationshipwith them, but basically it's a
cheek swab, and you get somecheek cells and send it off to
the company and actually sendyou back a profile of their
liver metabolism profile, theiryou know, SIP system, and
they'll actually tell you whichmedications are
under-metabolized andover-metabolized.

(25:30):
And you can actually make aguess as to which medication a
person might respond to in termsof how they metabolize it.
And it's interesting becauseI've had a couple of people and
they'll say, man, this med justreally doesn't work.
And we look and they're anover-metabolizer.
Okay.
And so that's something I'vefound.
But to your point, I think whatI try to do with, again, a
person's relationship to asubstance, and I have a few

(25:51):
patients I treat for bingeeating, is I just try to ask
them, what does it do for you?
And I just try to find out, isit self-soothing, is it numbing
PTSD, is it they just have anintense euphoric response?
And then I try to think aboutwhich medications I can do to
match that.
And so that's why I was askingabout a phenotype in terms of a
food behavior.
Because presumably some peoplebinge eat because it tastes

(26:14):
really good.
They've maybe got a geneticpredisposition to release more
dopamine to sugar than theaverage person.
Then there's the person withanxiety who finds that food is
soothing.
There might be the person withPTSD who eats because they don't
know what to do when they'reanxious or restless.
So that's kind of where I wasgoing with that question.
And I'm curious, now that Iframe it better, do you have a

(26:35):
different answer?

SPEAKER_04 (26:37):
I have a different paradigm.
Please.
I have a completely differentparadigm.
That's why we're here.
I have a completely differentparadigm.
So I actually think that a lotof maladaptive eating behaviors,
okay, that's really one way Iwould put it.
Anorexia is interesting anddifferent.
One of the biggest mistakes wecan make is to do a weight loss
operation in a patient who's hasa prior history of anorexia

(26:59):
because there's a highprobability that we will trigger
it.
It may have been 20, 30, 40years ago, and there's a very
high probability.
So that is that is one of theone of the most striking
contraindications that we have.
You do not do it in a patient.
You don't always know, but weworry about it a lot.
Kind of counterintuitive.
But it makes sense to me.

SPEAKER_00 (27:20):
But I mean, essentially the way I look at it
in in my world from addiction isthey have some sort of unmet
mental health need, and it comesout in their relationship with
food.
And anorexia, as as I often seeit, is you know, body dysmorphia
and anxiety and depression, andthey control what they're going

(27:40):
to control, which is their foodintake.

SPEAKER_04 (27:42):
Yeah.

SPEAKER_00 (27:43):
And so it makes perfect sense to me that a
change in their body appearancecould be very triggering.

SPEAKER_04 (27:47):
Yeah.
Yeah.
So when we talk aboutphenotypes, I think about these
two people.

SPEAKER_00 (27:53):
Oh yes.
I remember when you gave thistalk at community hospital.
Yeah.

SPEAKER_04 (27:57):
You know, 650 pounds, no comorbidities at all.
This is her CT scan, this littletiny person in this amazing
amount of subcutaneous fat, andthis is a man much smaller who
has all the comorbidities.
Interesting.
They have, they might as wellnot be the same species.
They have essentially nothing todo with each other.

(28:17):
And you can't just treat thatpatient based on their BMI or
the fact that they'reoverweight.
It it is so much morecomplicated than that.
And then the biology is reallyimportant.
So these little mice, so I'mshowing a picture right now of
two mice.
There's a little brown mouse andthere's a much bigger yellow
mouse, and they're brothers.

(28:40):
And they differ from one anotherbasis on on the basis of a
single gene which codes for anabnormal protein in the yellow
mouse that codes for a proteincalled the aguti protein.
And that circulates and binds tothe four melanocortin receptors
in the brain.
And because of that, this mousewas overweight even when it was

(29:01):
drinking milk when it was firstborn.
It will be much fatter than thelittle brown mouse.
It will be much taller, longerthan the than the little brown
mouse.
This color is a consequence ofthat.
And it has very high levels ofinsulin.
And all of those are aconsequence of this one little
protein circulating in the inthe blood.

(29:25):
These are brothers.
So I'm showing you a picture oftwo brothers, and one is a very
tall, very overweight child, andthe other is a very skinny,
shorter child.
Heavy child is nine, and thebrother is 15.
And they differ from one anotherbecause the the heavy child has
a melanocortin four receptordefect.

(29:46):
Because of that, this child wasoverweight when he was
breastfeeding.
He has extremely high levels ofinsulin, which will decline as
he gets older.
He will always be huge.
He's gonna be he's gonna be fat.
But he also is going to havereally big strong bones and a
lot of muscle.
This is probably half the NFL.

(30:07):
Okay?
Now this kid is going to beassumed to have an eating
disorder, and people are goingto be telling him from day one
that you need to eat less, youneed to control your eating.
If this kid doesn't develop aneating disorder on the basis of
the social approbation thatoccurs because of this, it's

(30:27):
it's inevitable.
Yes.
In 2025, there is no drug, thereis no naloxone, there is no
psychotherapy, there is noamount of counseling or anything
that is going to ever make thatpoor yellow mouse look like the
brown mouse.
It's not going to happen.
He can try all he wants.
And when he lives in a societythat says, I know this speaks to

(30:49):
you, this is a fundamentalproblem with your soul, that you
can't control your weight, thatis damaging.
That is really damaging.
And this kid is going to go tothe same school as his as his
older brother, right?
And he's going to sit in theclass and they're going to say,
gosh, that was that your brotherwho came through a while back?
And yeah.

(31:09):
And because this kid is heavy,the teacher is going to spend
less time with him than if hethan with his brother.
They're going to assume thathe's not as smart.
They're going to give him poorgrades, even if he does the same
quality work.
And all of that is completelyunfair.
And we can help this kid partlyby accepting him, by
understanding what he has.

(31:30):
This is actually, by the way,one in 50 severely overweight
children.
So this is not some hugeanomaly.
And there are many otherconditions that are similar to
this, which also account forsome of the people who are
really heavy.
I think you imagine that theseaddictive behaviors or eating
behaviors somehow cause obesity.

(31:50):
There's actually very littleevidence that that's true.
I think what is the case is thatobesity can be coincident with
or sometimes can cause eatingbehaviors to be abnormal.
So if you live in a world wherewhere you have a biology where
your melanocortin IV receptor isblocked, you have a big
appetite.
You really want to eat.
If your melanocortin IIIreceptors is abnormal, you have
a binge eating disorder.

(32:12):
So that's actually a separate,slightly separate type.
They have a marked binge eatingdisorder if they have a
melanocortin III receptordefect.
If you happen to havePratter-Willie syndrome, okay,
which is the syndrome where youhave extraordinarily high levels
of ghrelin, your parents lockthe kitchen, they lock the
cupboards because you willliterally eat yourself to death.

(32:34):
And you need to keep the kniveshidden because your child may
try to kill you in order to getto food.
This is not an exaggeration.
So these maladapted behaviors, Ithink sometimes are a
consequence of this biology.
You talk about GLP1 medicineslike they're really good
medicines, and I think they are.

(32:55):
I think they're fabulous.
I'm so grateful that we havethem.
So I share that enthusiasm.
When you do a gastric bypass fora sleeve gastrectomy, your GLP1
levels go really high and theystay high.
So the mechanism for this wasactually proposed by a surgeon,
the first one really to proposethis in 1995 when he wrote a
paper titled, Who Would HaveThought It the Best Treatment

(33:17):
for Type 2 Diabetes is anoperation?
And he he, I think he was wrong.
I think the whole premise of thepaper was wrong, but he proposed
that there was an incretin,locally secreted hormone, which
actually changed insulinsecretion and stuff and led to
rapid resolution of diabetes.
Turns out that was GLP1.
And this was proposed back in1995 by a bariatric surgeon.

(33:40):
And I had always believed thatthese operations were largely
hormonal operations.
And the reason I believe that isthat I do a lot of cancer
surgery.
And if I take somebody's stomachout for cancer, their entire
stomach, I take it out forcancer, and they don't want to
lose weight, and they go throughchemotherapy and maybe

(34:02):
radiation, I can get peoplethrough that whole thing, a
total gastrectomy, chemotherapy,the whole thing with weight loss
of less than 20 pounds.
And long term, their weight'sgonna be pretty much what it was
before.
Maybe a little bit less, but nota lot less.
Isn't that interesting that youcan do that without them dying

(34:23):
of starvation, for example?
Now, if I do a gastric bypass,which is kind of like a total
gastroctomy, and somebody ismotivated to lose weight,
there's a reasonable possibilitythat they will lose about a
third of their body weight,which is pretty good.
We don't have anything that'sthat's comparable to that right
now.

(34:43):
GLP ones are not that good,they're very good.
And in fact, I I I I'm gonnaplug them even a little bit
more.
My bias is that you get 90% ofmetabolic benefits for the first
10% of weight loss.
So it doesn't have to be a wholelot of weight loss to actually
produce dramatic improvements inyour diabetes and your lipid
profile and all those sorts ofthings.

(35:05):
But I think that the phenotypethat causes somebody to be very
overweight actually often theirtheir eating behaviors are a
consequence of a huge appetitethat they have because they have
too much ghrelin or becausetheir GLP1 levels are or are off
or something like that.
If you want to make it aboutdopamine, I think 10 years from

(35:25):
now, I think we're gonna say,yeah, dopamine is important, but
it's not as important as as wethink.
I went through the phase wheneverything was serotonin, and
then I went through the phasewhere everything was insulin,
and I I went through trialswhere we gave people sandostain
to try to decrease that.
So I don't mean to discount it,but I'm not as enthusiastic as
you are that that's gonna be thefull explanation for what
happens.

(35:46):
And when you have a, forexample, a gastro bypass or a
sleep gastroctolate, your GLP1levels go way high, your ghrelin
levels go way down.
So ghrelin is a hormone that isproduced in the stomach.
When you fast, ghrelin levels goup.
When you lose weight, ghrelinlevels go up.
When you eat, ghrelin levels godown.
And some of my patients refer toit as the gremlin.
So is the gremlin going to goaway?

(36:07):
And so we think that's one ofthe mechanisms.
And of course, ghrelin is one ofthe things which drives hunger
in Pratter Willie's children.
So, you know, there's a lot of,there's a lot of interest in
actually trying to have aghrelin blocker, for example.
So that that's an effort.
There's a hormone called PYYthat's secreted in the small
intestine.
Some people refer to it as theallele break.
Food passes into the smallintestine faster.

(36:30):
That's the hormone that tellsyou that you're full when you've
eaten two slices of bread atdinner in a restaurant, and then
the dinner arrives and you're nolonger hungry, right?
Because that it's had time to dothat.
So all those things are hormonalconsequences of weight loss
surgery.
One of the things that I wasconvinced of way before we
started using GLP1s was thatthere was a hormonal effect in

(36:51):
gastric bypass patients inparticular, which could be
really troublesome.
So every once in a while,somebody would have severe
refractory nausea, which couldlast for a long, long, long
time.
And the symptoms are identicalto the symptoms that somebody
has when they have a badreaction to a GLP1.
The severe nausea, you can'teat, just absolutely miserable.

(37:11):
The thing is you can't take itaway.
And those people could bemiserable for months and months
and months.
And I I I think that that was aGLP response among those people.

SPEAKER_00 (37:22):
Yeah, I I think it's probably in some ways a referral
bias, if you will, in thatpeople come to me for addiction.
Many of them, when they get offof their substance of choice,
are low on dopamine, and so theylook to find it in other places,
which often goes to nicotine,caffeine, and food.
And so I think that probably iswhy I have my particular

(37:44):
perspective around the questionthat I asked, which is my
patients use food as areplacement for their substance,
which is why I was digging intothe eating behaviors.

SPEAKER_04 (37:54):
Okay, so that would be the biologic basis of
addiction transference.

SPEAKER_00 (37:58):
Or cross addiction, I think is another term for it.

SPEAKER_04 (38:00):
Okay.
So uh here, I need some help.
Okay.
I and I sincerely need some helpbecause about the biggest
concern Steve and I have isalcohol.
That's actually that's actuallythe the biggest thing that we
really struggle with.
And I don't really know how tothink about it, how to ask about

(38:22):
it.
So, so if you come into see mefor weight loss surgery, in
general, you've actually led amore sheltered life, it turns
out.
You're less likely to seedoctors, you're less likely to
be partnered, you're less likelyto have all those sorts of
things.
When we look at social attitudesfor people who are overweight,
they are more negative than theyare towards people who have
problems with alcohol or drugs.

(38:43):
So, so it's a huge problem.
So they come in, they actuallyhave a significantly lower risk
of alcohol use disorder whenthey come to see us than the
general population.
Two years later, they have aboutone and a half times the
incidence of alcohol usedisorder compared to the general
population.
And so obviously, this isaddiction transference or

(39:05):
whatever, cross-addiction orsomething like that.

But here's the thing (39:07):
this behavior was first described in
Korean men having gastrectomiesfor cancer.
And when you take out thestomach, you take out the
alcohol dehydrogenase, right?
We know that populations thathave baseline low alcohol
dehydrogenase, like AmericanIndians, are particularly
susceptible to alcohol usedisorder.

(39:29):
And it's definitely higher ingastric bypass patients or total
gastrectomic patients than it isin sleeve patients who do have
some preserved stomach.
So I think it's a biochemical.
Your alcohol levels go up muchfaster, they stay up longer, you
don't metabolize as easily.
So I I think of it very naivelyas kind of like injecting heroin
rather than snoring.
I don't know.
Sure enough.
Makes sense.

(39:49):
But so that is that is ourbiggest, our biggest
psychological concern.
I think where Steve and I havethe most anxiety about it.
And let me just give you somescenarios.
Person who's been abstinent fromalcohol for for 10 years may or
may not still go to AAA.
Can I can I do a gastrobypasspatient in them?

(40:09):
I think there's a substantialpossibility that they're that
they're gonna have a problemagain.
I think there's a really bigpossibility.
Do I make sure they have asponsor before?
I have them come with theirfamily members and talk to them
and what what's the plan gonnabe if you see them doing this,
all this kind of stuff?
But I don't think it's enough.
And I don't know, should I putthem all on Altrexone?
You know, should I should I dothat?

(40:30):
I just don't know what to do.
And let me give you anotherscenario.
What do I do about the25-year-old Hispanic man who
comes in and his food diaryshows no alcohol, no alcohol,
and then on the weekends it'sseven drinks in a night.
And he says, but I only drinkwhen we have our family parties.
We have our family parties and Ihave seven beers that night, you

(40:50):
know, and that's normal.
Do I worry about that?

SPEAKER_00 (40:54):
There's a lot to unpack here.

SPEAKER_04 (40:56):
See, because and I I don't know.
And I feel I feel like that'sone of the places where we do
the most serious harm.
I really do.
That is that is that is one ofthe areas where I feel we're at
risk for producing the mostserious harm.

SPEAKER_00 (41:11):
Aaron Powell So my understanding is that after a
gastric bypass, the alcohol isabsorbed more quickly.
Yes.
And therefore the levels go up.
Aaron Ross Powell More quickly,yes.
Yes.
And and I just want to make surewe're on the same page here
because I I think I may haveheard you say something that I I
thought I knew differently.
Men have alcohol dehydrogenasein the stomach, women do not.

(41:33):
Oh, I didn't know that.
So that's one of the reasonswhy, and I educate about this
when I go to schools, is youknow, my wife, the lovely and
intelligent Dr.
Red Close.
So she's 5'2 and 125 pounds.
Yeah.
I'm 6'1 and 185 pounds.
When I drink a drink, my alcoholstarts to get metabolized in my
stomach.
Hers does not.

(41:53):
And so because I'm bigger andshe doesn't have alcohol
dehydrogenase in her stomach,her alcohol level might be
double mine for the samedrink-to-drink comparison.
So if she and I drink a beer, myalcohol level might be like 0.01
or 0.02, or hers might be 0.04.
And so when you actually go to aBAC calculator and you put in
the numbers, and I do this whenI educated high schools, someone

(42:18):
like me versus someone like Reb,as you go through it, it's a
much bigger difference in howmuch the alcohol gets absorbed,
drink for drink, men versuswomen, if there's a big
discrepancy in body size.

SPEAKER_04 (42:29):
So I've assumed that that was always body size, is
what I assumed.
I'm gonna have to look that upbecause if it if it is, that
means that's an important partof gastric physiology that I
didn't know and I pride myselfon gastric physiology.
So so I'm gonna have to thinkabout that.
Alcohol is one of the substanceswhich is absorbed in the
stomach.
Not a lot of medications are notabsorbed in the stomach, most
are absorbed in the smallintestine.

(42:49):
Alcohol beta blockers areabsorbed in the stomach.
It's worth checking that I Ithought it was really that they
had less alcohol dehydrogenase.
So I think there is somedecrease in alcohol
dehydrogenase compared to men,and and size makes a huge
difference.
Of course.

SPEAKER_00 (43:04):
I as I tell the kids when they educate, there's
physically more of me to diluteout the alcohol as compared to a
smaller woman.

SPEAKER_04 (43:10):
And not just that, women have greater percentage of
body fat than men.
And so if you think about thevolume distribution for a
hydrophilic molecule likealcohol, the volume of
distribution is really only yourwater weight.
It's not the fat weight.
So that woman who is, you know,with two-thirds of your size

(43:30):
actually has only half of yourof your lean body weight,
really.
So so therefore you'd expect heralcohol level to go up twice as
high as yours, just based onjust based on that observation
alone.

SPEAKER_00 (43:42):
Yeah.
So in terms of so of alcohol,again, the way I talk to my
patients is I try to find outwhat does it do for them.
When we give people naltrexonefor alcohol use disorder,
probably about 50% don't noticea difference at all.
About 30% notice some differencein cravings, and maybe 20% are
just, I'm good, I don't want todrink.

(44:03):
And so usually what I do whenI'm treating alcohol use
disorder is I always put peopleon more than one medication for
cravings.
So it might be naltrexone andgabapentin, or naltrexonin
topiramate, or naltrexone in aGLP1 or a campersate and
gabapentin.
Because the meds for alcohol usedisorder don't work so well, I
use meds from different classesand they have an additive
effect.

(44:24):
So in my world, somebody comesin and like, I want to quit
drinking.
And I'm like, okay, well, whatdoes alcohol do for you?
And it's maybe I can't sleep, ormaybe I have PTSD and I don't
know what else to do, or maybe Ihave very significant comorbid
anxiety and I like the downereffect of it.
And then there's a certainpopulation that just get more

(44:44):
release of dopamine andendorphins than the average
person when they drink.
And that's largely genetic.
About fifty 40 to 60% ofaddiction is genetic.
So, first of all, we'd be happyto see any of your patients in
advance of surgery to try tounpack that relationship with
alcohol.
And yes, to the gentleman youmentioned, who's a young man who

(45:05):
doesn't drink throughout theweek and then drinks more on the
weekend, he probably has afairly good response in terms of
dopamine and endorphins when hedoes drink to encourage him to
go to seven.
And he might be a candidate foran oltrexone.
But it's everyone's a little bitdifferent.
And so I think that's when I sayphenotype is I look at like what
behaviors lead to drinking.

(45:26):
And that's the question that Iask in my standard intake.
There's usually two questionsthat I ask.
The first is, why do you want toget sober?
And if it's like I'm gonna losemy kids, that's a lot of
motivation.
If it's my wife is annoying me,that's not so much motivation.
And then the second is what doesthe substance do for you?
And then that allows me tofigure out what I'm gonna do.

(45:47):
And it might just be they reallywant to focus on behavioral
interventions like AA ortherapy, or there's really an
unmet need.
And in in my world,unfortunately, a lot of it is
PTSD that's untreated and peoplejust don't know what to do, so
they drink.
But I was actually gonna see doyou counsel patients when you do
their weight loss surgery thatalcohol might be more

(46:07):
pleasurable for them?

SPEAKER_04 (46:08):
Oh, absolutely.
Okay.
Absolutely.
We we uh that's a very explicitpart of our conversation.
How do people respond?
It's actually quite a longconversation, and often when the
conversation starts, sometimesthey feel defensive about it.
And by the time the conversationis done, and I explain that I
worry about this in allpatients, and this is the

(46:29):
physiology, and this is why Iworry about it.
And and and I tell them thatsome of the some of the
operations I have regretted mostin my entire career have been
weight loss operations wherepatients have become alcoholic
afterwards.
And I just and I just don't wantthat to happen to you.
Yeah.
I re and and I know that I knowthat that seems unimaginable to
you that that can be the case.

(46:50):
For a long time it seemedunimaginable to me that that
could happen to the peoplesitting in front of me, but I've
seen it happen enough times thatthat it's something that I
really do worry about.

SPEAKER_00 (46:59):
Yeah, in terms of the alcohol behavior, so we have
alcohol use disorder and we havehigh-risk drinking and we have
binge drinking, there's variouspatterns.
So someone who binge drinks islikely somebody who gets a lot
of euphoria from alcohol.
I go out with friends, I stopcounting, I black out, versus I

(47:19):
drink every night because Ican't sleep.
So I think both of thempotentially have a risk when you
decide whether or not you'regoing to do a weight loss
surgery on them.
The binge drinker might findthat the alcohol is even more
euphoric and it's even harder tostop at a particular night of
drinking.
And then the person who hasanxiety and can't sleep, their
use of alcohol, that alcoholmight feel even better because

(47:42):
it's more potent as a downer.
So I think that would be myrecommendation to you is just to
try to understand what theirrelationship with alcohol is.
And the one I would be leastconcerned about is more likely I
have one or two here and there,which I don't think you would be
concerned about either.
I'm concerned about even that.
Really?

SPEAKER_04 (47:58):
And actually, you one of the things that concerns
me is when they write downwhether it's red or white wine.
How come?
Because there's a there's apermission structure to to
drinking it.
I know that sounds crazy, butthere's a permission structure
that occurs you for drinking redwine because you heard that it's
good for your heart and all thissort of stuff.
So I I uh that absolutely is ais a red flag for me.

SPEAKER_00 (48:18):
Aaron Powell Interesting.
The type of alcohol, when wethink about this.
Yeah, I mean, in terms of whichtypes of alcohol usually result
in someone seeing me, it's mostoften liquor.
And you and I both know this,but as doctors, we define the
amount of alcohol as a standarddrink is 14 grams of alcohol,
right?
So it's a 5% 12-ounce beer, afive-ounce glass of 12% wine, or

(48:41):
a one and a half fluid ounceshot of 40% liquor.
And when I educate kids aboutthis, I'm like if someone gives
you a drink, take the beerbecause it's a finite container.
And once you drink it, it'sdone.
But if someone hands you abottle of liquor, there's
however many drinks in it.
So I I tend to find that whenpeople make their drinks, they
don't measure when they'reconsuming liquor.
And so the consumption is easierto go up and up and up,

(49:04):
particularly since a 750 ofalcohol has what, like 15 drinks
in it?
I mean, that's a lot of alcoholin a single purchase as composed
to a can of beer.
So I'd be interested to see, doyou notice a difference in what
people drink leading todifferent outcomes after
bariatric surgery?

SPEAKER_04 (49:20):
Aaron Powell I can't I can't say that I've ever
noticed that, but maybe I justdon't pay enough attention to
it.
I I can't say that I know.
But I've had some people whodidn't drink before who have
problems afterwards.

SPEAKER_00 (49:29):
Aaron Powell Interesting.

SPEAKER_04 (49:30):
Yeah.

SPEAKER_00 (49:31):
How does that come up?
Like in in the postoperativevisit, or or when does it tend
to come up?

SPEAKER_04 (49:35):
It comes up when I get called that they're in the
hospital with with hematemesis.

SPEAKER_00 (49:41):
And a perf ulcer.
Yeah.

SPEAKER_04 (49:42):
Interesting.
Or, you know, something likethat.
I mean, one of the mostdevastating calls I ever got was
this woman who I did her weightloss operation, and two years
later her husband called me andsaid, by the way, she shortly
after the surgery, she starteddrinking and she doesn't see her
children anymore, and she nevercomes home.

SPEAKER_00 (50:00):
And uh you know, just awful.
So if if I may ask, is is itthat they don't drink before
surgery and they drink aftersurgery, or they drink a little
before surgery and they drinkmore after surgery?

SPEAKER_04 (50:11):
Supposedly this woman never drank at all before
surgery.

SPEAKER_00 (50:14):
Aaron Powell What do you think leads people to drink
after surgery?

SPEAKER_04 (50:18):
So uh catching up for lost time.
So when when they started doingthe the the children's weight
loss surgery at university inCincinnati, one of the things
they learned was that when youdo a weight loss operation in a
young woman, a teenager, there'sa 20% risk of having an
unplanned pregnancy within twoyears.

(50:39):
And although we we cut majormortality in cancer, diabetes,
and heart disease a lot, we dosee an increased risk of deaths
from suicides, accidents, andoverdoses.
That that increase is is smallby comparison to what we save,
but those are the places wherewe see the where we see the

(51:00):
concern.
So for Steve and I, who couldhave just as easily been
psychiatrists, to us this isreally distressing.
But accidents, suicides, drugoverdoses.
And so what what is behind that?
Well, it may be that actuallypeople getting out there and
doing adventurous stuff thatthey couldn't do before.
Sure, right?
So you know you you can suddenlyget on a motorcycle and maybe

(51:22):
that's what happens.
So maybe that's what happens.
It may be that suddenly you'reattractive to the opposite sex
and you're going out and you'reyou're more likely to get
pregnant.
So it could certainly be that.

SPEAKER_00 (51:33):
I'm putting my addiction hat on here again.
So let's say you and I weretalking about it.
Someone is addicted to alcoholand they get sober.
They're craving some sort ofpositive stimulation.
So they'll go to alcohol,caffeine, and food.
Is if food is less enjoyableafter a weight loss surgery,
could they be searching fordopamine elsewhere?

SPEAKER_04 (51:53):
Well, I think we're all searching for dopamine.
We're rewired to do so.
It's just I I think I think itbecomes more accessible to them.
They couldn't get up, theycouldn't get on a ride in the in
the amusement park before.
Now they can.
There are things that they'reable to do now that they could
not do before.
Can date, they can have sex,they can do things that they
otherwise couldn't do.

(52:14):
Some of it may be making up forlost time.

SPEAKER_00 (52:17):
Is there a time frame after surgery when they
begin to drink?
Because if it's a biochemicalissue, you'd expect that once
the surgery is done and theyhave a different relationship
with food, they would go toalcohol or other things fairly
quickly.
If it's related to their weight,you would expect to see it
further down the road.

SPEAKER_04 (52:33):
I think it's further down the road.
Interesting.
Yeah, I think it's further downthe road.
You know, I'm trying to thinkwhether we knew anything about
that from Korea.
There, especially for mendrinking hard liquor, is such a
common part of the culture thatI I they probably just did it
pretty quickly.
I think there definitely is andsome making up for lost time,
and sometimes that'smaladaptive.
Sometimes it's really adaptive.

(52:55):
I can't begin to tell you thenumber of times people have come
back to see me and they say,Listen, I want to thank you.
I'm doing the same job that Iused to do before.
I'm not any smarter, I'm notworking any harder, but I've
gotten three promotions sincethen.
When, you know, our hesitationabout doing patients who have

(53:15):
serious binge eating disorders,for example, is is partly to
protect ourselves because it'sit's our impression that they're
really more likely to not loseweight well and to and to
struggle with a lot of sideeffects.
So we and that's protectingourselves.
A patient that I saw last weekcame back and said, I just want

(53:37):
to let you know Michael is doingso well, you know, he had his he
had his operation five years agoand he's doing so well.
He's got a daughter, he'sworking, he's doing great, he's
never been this good before.
I wouldn't do his weight lossoperation because he had a bad
binging disorder.
I had him see Steve for a secondopinion.
He said, No way.
He went someplace else, had hissleeve, and it's turned his life

(53:58):
around.

SPEAKER_02 (54:00):
I I was wrong.
I I I was wrong.
And and and it wasn't it wasn'tfair to him.
It wasn't fair to him.

SPEAKER_04 (54:14):
There are other concerns as well, and this is
one of my concerns about linkingobesity to things like addiction
and and things like that.
This is one of my concerns.
One of the most devastatingthings that can happen to
somebody when they have weightloss surgery is to have the
surgery and not lose weight orregain all of it.
That is really devastating.
I have a close family memberwho's a very smart, capable

(54:36):
person who basically says, Iwon't do it because I'm afraid
it won't work and I would feelso bad about myself if I do
that.
And my concern if if you link itto something behavioral and it
doesn't work, then it's just youneed to try harder.
You need to exercise more, youneed to walk more, you need to

(54:58):
go to church more, you need totake this drug.
And rather than acknowledgingthat this is fit, this is part
of the biology, you know, theset point of weight, I know you
know about that, but it'sfascinating.
Most people live at a kind of astable weight, right?
And they lose weight and theyalmost always go back to that.
That that set point goes up byabout 20 to 30 pounds between

(55:18):
the ages of 20 and 50, somethinglike that.
But it tends to be stable formost people over time.
It can be disrupted bymenopause, childbirth
medications, some things likethat.
But in general, that's what itis.
And some people have a desirableset point.
They can live in a candy shopand eat whatever they want and
never get overweight.
And other people, they seem tobreathe heavily and they gain

(55:40):
weight from the atmosphere ofphotosynthesize.
So I I'm a strong believer inthat.
And I and I am such a believerin that because I've seen people
over such a long period of timego through this.
And when you look at the studieslooking at it, it's just
fascinating.
So, so a lot of the studies youneed to be really careful when
you're reading these becausethey typically report outcomes
based on the people who do well.

(56:02):
So a lot of the studies, theysay of the people who do well,
this many did this this well.
And they don't report the peoplewho fell out of the program, who
didn't do well.
But you know, in the past,without without pharmacotherapy,
and even for the most part, withuntil we had the GLPs, the
likelihood that you were gonnalose and keep off a substantial

(56:22):
amount of weight for more than10 years was was under 5%.
It was it was really under 5%.
And it didn't matter whether youwent to weight watches, whether
you had psychotherapy, didn'tmatter whether you took fenfen,
you know, none of those thingsmattered.
You basically kind of inevitablywent back up to the same weight
that you're gonna be.
And that's that's that's justwhat the real numbers, that's

(56:43):
just what the real numbers withcarefully done studies with good
follow-up show.
Now, your point about the highlyprocessed foods and stuff, I
think is a really important one.
It's a really important onebecause for a long time I was
gonna argue that the the setpoint really isn't changing.
What we've seen in the last 30years is that although the

(57:04):
median weight hasn't gone upthat much, the average weight
has gone up, and that's becausethe people who were at the
heavier end of the spectrum aregetting much, much, much
heavier.
So they're getting much heavier.
And it does look as though maybeto some degree the set point is
is actually broken.
And what I don't know is wasthat set point always broken,
and just that our environmenthas become such that that they

(57:26):
can become all they wereintended to be, that they now
can become 400 pounds whenbefore they just couldn't get
above 300 pounds because you hadto walk more because food wasn't
as available, that kind ofstuff.
So I think that's true.
But it but in general, that setpoint for most people still kind
of holds.
I do think that maybe the setpoint is completely broken for
some people.

(57:46):
And I can break it with Zyprexa.
I could get you 200 pounds withZyprexa.
It's remarkable.
It's it's absolutely remarkable.
So I think that I think that'spartly partly broken by this.
As I was listening to you talkabout how desirable processed
foods have become and thescientific basis by which they
do this, and I was thinking, Iwant him to just play that back

(58:08):
to himself.
And rather than saying that thisis a food company and doing
doing this, I want them toimagine it's an Italian
grandmother preparing a meal andtrying to find the absolute
perfect combination of fat,sugar, and salt that is going to
make my child happy.
Right?
Interesting.
And it the listen to it again.

(58:29):
It's exactly the same thing thatwe all do.
And my wife is fabulous at this.
I mean, she can she can make thefood absolutely amazing.
And so it's not just industrythat's doing this.
This is true, this is trueeverywhere and in every way.
I do think that the processedfoods are a unique harm.
I truly, truly, truly believethat.

(58:51):
And one of the things I want toask you about is bias.
So, so I give lectures about howunfair I think bias is against
people who are overweight.
And I think that's it's a usefulthing to be careful of.
But I actually think that biascan be really helpful if it's

(59:12):
done in the proper way.
And here's a way to think aboutit.

SPEAKER_02 (59:16):
We live in California, very few people
smoke.
Why is that?
Compared to Virginia.
Why is that?
Is there an answer?
Well, I have an idea.
I have an idea.

SPEAKER_04 (59:34):
And I think and I think I think it's not because
maybe we're biased againstpeople smoke, but I think
because we're biased againsttobacco.
The industry.
Not just the industry, just theuse of tobacco.
We're biased against the use oft tobacco.
And I want people to be biasedagainst soft drinks.
Seven percent of our calories inthis country are pure sugar to

(59:58):
come from soft drinks.
That there no other foodprovides that percentage of
calories as soft drinks in thiscountry.
And nobody needs to drink a softdrink.
Nobody needs to.
And if you're drinking diet,well, the problem there is when
you give mice diet soft drinks,it turns out it it pro they
actually gain weight.
And it's probably because itchanges the gut biome, is
probably the that's thehypothesis.

(01:00:20):
But so I want people to bebiased against fast food.
I want people to be biasedagainst soft drinks.
So I want that bias to be builtin.
And I think that's differentthan being biased against people
who have a weight problem.
Because every time I think aboutthat, I think about that child

(01:00:42):
with a melanocorpin fourreceptor defect who's being
treated completely unfairlybecause people don't understand
that background.

SPEAKER_00 (01:00:51):
Yeah, I lecture professionally on stigma, and
stigma kills.
It is a big problem inhealthcare, and stigma casts a
very wide net.
There's stigma about epilepsy,there's stigma about
schizophrenia, there's stigmaabout urinary incontinence, and
there's actually some researchthat, in particular in patients
with obesity, weight stigma,there's an immortality
difference associated with it.

SPEAKER_04 (01:01:12):
Yeah.
They don't go to the doctor,they don't yeah, all those sorts
of things.

SPEAKER_00 (01:01:16):
So I I agree with you.
Just as there is a bias againstfentanyl.
Yeah.
People view it view it as anenemy, which it is.
I 100% agree with you.
The way I look at it and the wayI teach about it is that the
brain only knows one liquid, andthat's water, and it does not
recognize the calories innon-water drinks.
And so a soft drink should beviewed as dessert.

SPEAKER_04 (01:01:39):
Or poison.

SPEAKER_00 (01:01:40):
Yeah.
Well said.
Yeah.

SPEAKER_04 (01:01:42):
Or poison.
So if somebody comes to us andthey want weight loss surgery,
five of six are going to getturned away.
Okay.
And some because they don't needit, some because they don't
qualify, some because they'retoo sick and we can't get them
ready for it.
Some because we're concernedthat they're not going to
actually be able to use iteffectively.
And during the course of that,and and when I think about an
eating disorder or depression orsomething like that, I can't

(01:02:04):
take them to surgery until I'vegot their congestive heart fail
under control.
And I can't take them to surgeryuntil the diabetes is is under
enough control that they canthat they can have a safe
operation and heal.
And I can't take them to surgeryuntil I've got their eating
disorder treated.
Now, the problem is I don't havea way to cure somebody's eating

(01:02:26):
disorder.
I can manage it, I can help themwith it, but I can't cure it.
And I shouldn't withhold themost effective treatment we have
for them.
I shouldn't withhold that forthem because they happen to have
an eating disorder, unless maybeit's uh anorexia.
Right.
So that's that's that's that'sthe way I think about it.
So don't be mad at a baritagesurgeon because they did it that

(01:02:49):
operation.
We treat all those things.
I had a dietitian come stay withme one day and she was following
me around.
She was fascinated because thispatient came in and they weren't
losing weight and such.
And and and I walked in, myfirst question was, are you
picking up the mail?
Are you cleaning the house?
These kind of things.
And she wasn't doing any ofthose things.
I said, Well, your problem isdepression.
We had no conversation aboutwhat she was eating, not a

(01:03:10):
thing.
The whole conversation was abouther depression.
She was a couple years post-op,and what happened is that she
felt so much better aftersurgery, she stopped her well
butrin.
She stopped her well butrine andshe got depressed and didn't
realize that that's what it wasfrom.
And so if I'm trying to preparesomebody for cancer surgery, I
have to treat those things.
I have to treat theirdepression.
I have to treat all theirdiabetes, all those kind of

(01:03:32):
things.
So Steve and I are kind of likeprimary care physicians.
One of the really cool thingsabout it is that for an
underserved population, weactually get to do a lot of
primary care because they oftendon't have primary physicians,
but they can always get into ouroffice.
So it's kind of fun for us thatwe get to see that.

SPEAKER_00 (01:03:50):
What percent of bariatric surgeons approach this
the way you and Steve do?

SPEAKER_04 (01:03:54):
I don't know.
A lot do, I think.
But I don't, but I don'thonestly know.

SPEAKER_00 (01:03:58):
Well, I mean, this conversation was for you to
share your work as a bariatricsurgeon.

SPEAKER_03 (01:04:03):
Yeah.

SPEAKER_00 (01:04:03):
And I have to say I've learned a lot.
I will apologize for beingfrustrated on my podcast about
that particular case.
My point I was making in thatparticular case, it was a very
young individual, and there wasa lot of mental health issues,
and it was very clear that theteam managing his weight loss
did not recognize his mentalhealth issues, and that was what
made me frustrated.

SPEAKER_04 (01:04:24):
Yeah, and maybe it's because they didn't pay enough
attention.
Maybe it's because it's actuallyreally hard to know what people
are doing.
You know, it can be really hard.

SPEAKER_00 (01:04:32):
Well, and and I just have to compliment you and Steve
Chang for taking such a holisticapproach, and I'm very thrilled
to hear that you are practicingmedicine the way you are,
because I believe that's what Iwould think would be the ideal
circumstance in weight losssurgery would be to take the
whole person into consideration.

SPEAKER_04 (01:04:51):
Yeah, that's what we try to do.
It sounds like you're doingthat.
That's what we that's what wetry to do.

SPEAKER_00 (01:04:56):
I I I your point is also taken about somebody seeing
you and Steve and saying you'renot a good candidate and going
somewhere else.
We'd see in the emergencydepartment, patients who'd been
seeing here thought not to be agood candidate would go
elsewhere and then kept havingcomplications.

SPEAKER_04 (01:05:10):
Yeah.
And that creates an interestingdilemma because if you know
they're going to go have surgerysomeplace else and you don't
think they're an idealcandidate, maybe you should just
have it done here because atleast that way they're under our
umbrella and and maybe we'll doa better job.
So there there are thosepressures.
That's that's always reallytricky.
One of the things I like to tellpeople a lot is that if they

(01:05:31):
lose weight and they do well,they're a really good ambassador
for people who are overweight.
Oftentimes people find that theytreat somebody differently
because they've lost weight andthey learn a lot about
themselves when that happens.
So if you do well with weightloss surgery, if you lose
weight, if you do well, if youdon't act crazy, you will change
the way people think aboutpeople who are overweight

(01:05:52):
because they'll recognize thatthey had this bias against you
and they'll treat other peoplebetter.
So it's a really important thingthat try to be an ambassador for
this.
But I have a lecture abouttrying to predict who's going to
do well with surgery and who'snot.
And I go through what thedietitian said, what the
psychologist said, what we said.

(01:06:12):
We go through and look at allthat, and then how do they do?
And we are terrible atpredicting.
It doesn't matter how much Ilike you, it doesn't matter how
rich you are, it doesn't matterhow successful you've been in
the rest of your life.
It really doesn't.
It really doesn't.
And one of the objective thingsthat come out of the barrier
surgery literature is that we'renot very good at it, and that a
lot of the stuff that we'vetried to do in terms of mental

(01:06:34):
health and stuff like that turnsout doesn't actually affect the
outcomes.
Interesting.
It just doesn't affect theoutcomes.
For a long time, the insurancecompanies would require that
people wait six months or so.
And the idea was that it wasgoing to improve outcomes, and
it didn't.
It didn't improve the outcomesat all.
And there used to be programswhere they required people to go
through very elaboratepsychological preparation, stuff

(01:06:57):
like that.
Didn't improve the outcomes atall.
So I wish we had better ways ofassessing these things.
We just we just don't.
Steve is better at it than I am.

SPEAKER_00 (01:07:05):
Well, I have to say, Mark, we're both busy people,
and I'm sure you have lots to dotoday.
Anything else you wanted to addas we wrap up?

SPEAKER_04 (01:07:11):
I think that's it.
Thank you for having me.

SPEAKER_00 (01:07:13):
I was gonna say my life goal is to know what I
don't know, I don't know, andthank you for helping teach me
today.

SPEAKER_04 (01:07:18):
And, you know, thank you for what you do.
We really appreciate it.

SPEAKER_00 (01:07:24):
Before we wrap up, a huge thank you to the Montage
Health Foundation for backing mymission to create fun, engaging
education on addiction.
And a shout out to the nonprofitCentral Coast Overdose
Prevention for teaming up withme on this podcast.
Our partnership helps me get theword out about how to treat
addiction and prevent overdoses.

(01:07:46):
To those healthcare providersout there treating patients with
addiction, you're doinglife-saving work and thank you
for what you do.
For everyone else tuning in,thank you for taking the time to
learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together, we can make it happen.

(01:08:07):
Thanks for listening.
And remember, treating addictionsaves lives.