May 2, 2024 • 39 mins
When a fellow physician's offhand remark about obesity struck a nerve, it brought home the reality of the insensitivity that pervades our medical community. It's discussions like this that Tammie and Maria tackle head-on, breaking down the complexities of weight management far beyond the oversimplified calories in versus calories out. Their conversation sheds light on the multifaceted influences of genetics, metabolism, and lifestyle choices on an individual's weight, underscoring the urgent need for a more educated approach within healthcare.
As they peel back the curtain on bariatric care, they're confronted with the stark realities of accessibility, especially in rural areas. The advancements in surgery and evolving outpatient policies come into sharp focus alongside the role of primary care physicians in the referral process. Maria gets personal, sharing her own experience with binge eating disorder, and together, Tammie and Maria expose how few eligible patients receive the care they need. They also explore how telemedicine, a beacon of hope post-COVID, could revolutionize follow-up care and bridge the healthcare divide.
The finale of the episode takes on a proactive stance, stressing the significance of early intervention in weight management. They emphasize the value of a multi-disciplinary approach and the necessity for primary care doctors to be well-versed in weight management. Wrapping up, they extend an open invitation to our listeners to connect with them on social media for further discussions and insights. With Tammie's invaluable perspective, they hope their candid dialogue resonates with listeners and sparks a much-needed transformation in how the healthcare field addresses weight management.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to Core Bariatrics Podcast hosted by
Bariatric Surgeon Dr MariaIliakova and Tami LaCos,
Bariatric Coordinator and apatient herself.
Our goal is building andelevating our community.
The Core Bariatric Podcast doesnot offer medical advice,
diagnosis or treatment.
On this podcast, we aim toshare stories, support and
(00:22):
insight into the world beyondthe clinic.
Let's get into it.
Speaker 2 (00:26):
Hi Tami, hello Marie, I wanted to tell you a story
today about something thathappened to me, actually around
a year ago at this point wherewe were working.
So I was in the doctor's loungehanging out I think I was in
between cases or something likethat and I remember one of the
other docs was in there and wejust struck up a conversation
and this guy out of the blue I'mnot sure exactly what triggered
(00:46):
this, but decided to starttalking about weight and he
basically explained to me mebeing a Bariatric surgeon and
him being not that the problemis very simple, it is ins and
outs, and that people shouldjust stop eating and, if they
can't, that he has a really goodsolution for it and that's just
to slap duct tape over theirmouth to fix the problem.
Speaker 1 (01:07):
What do you think about that?
I feel like I could use ducttape in a totally different
manner towards him.
What's that?
Well, that right there is goingto send a patient into a binge
eating or just like a mentalbreakdown.
Oh my gosh, says that tosomeone's face, at least.
Speaker 2 (01:28):
Honestly, I couldn't believe he said it to me,
because I do this for a livingand obviously really care about
it, but it was said so casually,I believe, while he was eating
whatever his lunch was at thetime, just in between bites.
Here we go, and I didn't justsuper catch, super catch.
This guy, by the way, hasdaughters, is married and is
(01:50):
around my age, so in his 30s or40s, maybe younger person.
Yeah, I was pretty blown away,honestly, because I think he is
saying out loud what a lot ofpeople think.
Speaker 1 (02:01):
Absolutely, because I was actually just going to say
there's people out there.
I don't want to throw you underthe bus because you don't.
All the time you can eat, I canpack it away.
That's true.
And again, you have had yourown eating and your own body and
all of that.
But again, if a calorie was acalorie, we would all be the
(02:21):
same size.
Speaker 2 (02:22):
Exactly, or at least a lot of us would be the same
size and we wouldn't have 60% ofthe population having extra
weight or what we consider extraweight.
Yeah, it's pretty honest thatyou're absolutely right, because
my body has also changed overtime, which is interesting
because I have had binge eatingdisorder myself and so whenever
you have an eating disorder it'sa lifelong thing.
I've learned to manage itreally well, but I have it, and
(02:44):
in the past there were timesthat, yes, I would go on yo-yo
diets, I would do extremes ofdieting and exercise, and I'm at
a really healthy point in mylife right now, so I'm
stabilized, but I still havetendencies of in residency.
You eat when you can, you sleepwhen you can, you go to the
bathroom when you can.
Those are the rules.
Speaker 1 (03:02):
You're still afraid to drink water because you have
to go to the bathroom.
Speaker 2 (03:06):
I have to pee and I can't, I know right Even though.
So my brain is still there, andso the way that I eat is I eat
when I can and I shove it in myface because I might not have
time to do it otherwise, eventhough my lifestyle is pretty
different now.
Old habits die hard.
I'm a good example of thatmyself, but the thing is I have
lucky genes or something.
The way that my body works isI'm able to metabolize things
(03:28):
pretty well and I can't eatquite a bit without it with
being a big issue.
But I also do workout.
Speaker 1 (03:33):
I also do try to you do very much.
I was hanging out in the poolin Orlando while you were
working out, yep.
Speaker 2 (03:40):
But that's the whole point is basically absolutely.
Calorie is not a calorie.
It's not ins and outs, and ifit were, I would probably be a
much bigger size than I ammyself, people would be much
smaller sizes.
Speaker 1 (03:50):
Yes, yes, because I know people that eat so healthy
and just struggle to lose weight.
Not that they're trying tonecessarily lose weight, but
like they should be smaller.
Speaker 2 (04:05):
So let's get into it, absolutely so.
The one other thing we want totalk about is exactly that.
We're leading in perfectly intoit.
It's an excellent segue intotalking with healthcare
providers, which is what thisepisode is all about, and what
healthcare providers know aboutweight management in general is
that most healthcare providersdon't know more than the general
public about this topic.
Speaker 1 (04:24):
No, they do not, or at least not much more.
This again if they did, theydid.
They're not before they areeither.
As healthcare providers, we beeating all the food when we can
too.
Speaker 2 (04:34):
That's right.
A lot of healthcare providers,just like the general population
, struggle with weightmanagement the same way that the
general population does.
There's a couple of reasons forthat.
There's very little weightrelated or metabolism related
training in any healthcareprofession, including medicine.
There's very little nutritionexercise training.
In fact, in my own curricula,what I learned I think it was
(04:56):
under three hours total out ofthe thousands of hours that we
learn, which is astounding whenyou think about what impact it
actually has.
Absolutely yeah.
I think the idea basicallybeing oh, there's dietitians for
that.
That's just ludicrous, becauseone dietitians are really hard
to find.
Speaker 1 (05:13):
They're not enough for them.
Speaker 2 (05:14):
Your insurance doesn't like paying for them
your insurance doesn't pay fordietary visits for most people,
unless they're diabetic for themost part, even in bariatric
programs, a lot of people haveto self-pay their dietary visits
, which is bonkers, but true,right.
Then the other thing is weabsolutely to be well-rounded
physicians, to be well-roundedhealthcare providers would
benefit from understandingsomething about nutrition and
(05:37):
how we eat and how it getsprocessed, and the fact that
when you diet over and overagain, you're messing up your
metabolism more than you'rehelping it, which is not
publicly known information, eventhough it's really true.
Speaker 1 (05:47):
I know that until last week Yep.
Speaker 2 (05:50):
Then there is a lot of misinformation in this field
that's guided by opinion ratherthan science, even in healthcare
.
I think that this person, thisdoctor in the lounge who said
let's just slap duct tape oneveryone, he is just saying out
loud what a lot of peoplebelieve in a kind of maybe
extreme way of saying that Alittle.
Yeah, no kidding.
(06:11):
I think a lot of peopleactually have that kind of
misconception of people are justout of control and they can't
do anything about it.
And why can't they controlthemselves better?
That's just super not how itworks for the majority of people
who have challenges.
The other thing about this isthe history of medical care in
(06:31):
weight management has a reallybad rap.
Some of it is warranted, Someof it is fair and some of it is
not fair.
Let me explain that just alittle bit.
Weight loss surgery is a fairlynew field and it dates back to
the 90s.
Now most and most insurancecompanies really didn't start
covering any kind of procedures,at least for weight loss, until
(06:51):
the 2000s and until the 2010s.
There's still a lot of plansactually insurance plans that
don't cover bariatric surgery atall.
Yeah, there are.
Yeah, it's still a fairly newfield and access is its own
problem that we'll talk abouttoo.
Back in the 90s and earlier thekinds of surgeries that were
being done for weight managementwere gastric bypasses and
(07:12):
duodenal switches.
Both of those surgeries can bepretty intense.
The follow up for those can bepretty intense and they were
being done as big open surgeries.
People had lots ofcomplications and they had the
hospital.
Stays for them would last fiveto seven days.
Sometimes more people would getleaks or would have narrowings
(07:34):
or would have obstructions orwould have all these nutrition
problems afterwards dehydrationand that honestly largely is a
thing of the past for thesekinds of surgeries because now
we do them small cuts.
We do really good patientselection overall.
There's professionalorganizations that help us be
really standardized and makesure quality is good overall.
That's not to say that'simpossible to have a
(07:55):
complication or impossible to doit badly, but it's a way
different field than it was inthe 90s and 2000s and the
insurance is wanting you to doit same day have surgery and get
out.
Yeah, it literally advanced tothe point where the Centers for
Medicare and Medicaid last year,in 2023, wanted to push through
a new rule that basically madeall of these surgeries required
(08:19):
to be outpatient, meaningpatients could at most only stay
overnight, which that's sobonkers, going from where we
were required in five to sevendays to now, centers for
Medicare and Medicaid andinsurance companies are trying
to push people out the door thesame day which that also that's
the same as hip replacements andstuff.
Speaker 1 (08:37):
As soon as you are to get up and walk around, you're
walking around and then theykick you out the door and you're
at physical therapy the nextday.
Speaker 2 (08:44):
Exactly, and I think there will be another episode
about insurance as one thing andthen there's another episode
about how we do these surgeriesand things like that.
But the field has advanced byleaps and bounds in terms of
quality and safety anddetermining who benefits from
these surgeries and how wefollow up on them and how we
prepare them.
But I think the perceptionwithin the healthcare industry
(09:05):
has not really shifted to thatapproach and so a lot of folks
who are not in this world don'tnecessarily know that it has
advanced so much since that time.
The other thing that's a reallybig obstacle, I think, for
people is that it's really toughto reach bariatric care and
it's really tough to coordinateit.
So even if a provider, even ifyou're a health primary care
(09:27):
provider or a cardiologist orwhoever you are really think
that a person would benefit fromthis, one, you have to find a
bariatric program.
Two, you may have to figure outif that person has insurance or
something that covers it, whichthey may or may not.
And then, three, you have to doa little bit of that
quarterbacking of that person,getting the right referral,
making sure they know how tofollow up with it, all of that.
(09:49):
So it can be a little bit morethan what people necessarily
want to bite off like, more thanwhat most providers want to
choose.
Speaker 1 (09:56):
But really in rural areas.
I actually just found out thatwhere I work, the closest
bariatric program is at least anhour and a half away, and
that's where we're located.
People south of that, you'regoing even further, and so
that's why I'm trying to recruitthis bariatric surgeon, I know.
(10:18):
but you're absolutely right.
You have a day of just oneappointment and you have to have
three to six months worth ofthose just appointments, not
including your other testing andappointments you may need.
Yeah, and so I feel like I'veeven felt that from my primary
care doctor in the past that hemay have thought it was a good
(10:41):
idea.
He just didn't know where tostart to help me because a
bariatric surgery program was sofar away.
Speaker 2 (10:49):
Exactly, and I do think that there is this sort of
a lot of providers actuallyfeel helpless here and so
they're not necessarily tryingto not refer people or restrict
care or something like that, but, like you said, you don't even
know where to get started,sometimes in a realistic way for
patients.
And something that I think Imay have mentioned in some other
episodes, but I just I find itsuch an astounding number, is
(11:11):
that, as a result of all thesebarriers, less than 1% of
eligible people ever see abariatric specialist.
Speaker 1 (11:19):
That's still so shocking to me too.
Speaker 2 (11:22):
Yeah, so less than 1% of people who are eligible for
weight related care ever seesomebody who can provide them
specialized weight related careLike worth repeating.
Because if we, if that werehappening in heart health or
cancer care or diabetes or evenmental health, honestly maybe it
does happen in mental health,but I actually think at this
(11:43):
point mental health is betteraccessible than this right there
Because we've been figured out.
Speaker 1 (11:49):
You have online options for mental health, like
better health.
Speaker 2 (11:53):
There is a lot of movement now on telemedicine,
especially after COVID, but itdoes seem like we still have to
fight for that year after year,because insurance every year,
health care insurance companiesreassess and centers for
Medicare and Medicaid does toowhether or not to make this kind
of care available by telehealth.
And so far they've told yes forthe 2023 year and 2024, but it
(12:14):
does still feel like a fight andit feels for a lot of providers
, ourselves included.
When we were in Iowa City, itwas downplayed and made to be
not the preferred mechanism evenfor people who were traveling
hours to get to us on a regularbasis.
So there's a lot of room yeah,there's a lot of room there for
programs that are hybrid,programs that can do both
(12:36):
in-person care when it'snecessary.
So far we can't do telemedicinesurgery, for instance.
So that's a we have to do withthis person.
Stay tuned, yes, but for nowthat's the case.
But a lot of the other visits,a lot of the other visits could
be done.
Telehealth for most patients,that's something that we need to
.
Speaker 1 (12:52):
I'm still wrapping my head around that.
You would say it all the timeand I'm always like but they
need you in person and you'relike they really don't.
I'm here for them if they needme but at least they need an
appointment.
Speaker 2 (13:09):
Exactly because the difference between what's
perfect and what's ideal andwhat's available is that's the
difference is like.
I think we rely a lot of timesin healthcare on getting it
perfect rather than getting itgood enough, and I think that is
a massive problem, because goodenough care, that's quality,
that's consistent, that is basedon evidence, that's well
(13:30):
supported, is what people need.
It doesn't have to be perfectand in person and Mayo Clinic
every time.
If it can be Mayo Clinicquality but not telemedicine,
why the heck not?
You know what I mean and Idon't think there's anything
actually stopping us from doingthat.
I mean there are many thingsstopping us from doing that,
including, like insurancereimbursement and I feel like
(13:51):
you're calling me out.
Speaker 1 (13:53):
Hey, I am we don't have to be perfect.
It just need I'm fine.
Okay, okay, Try to get over it.
Speaker 2 (14:01):
This is perfect as the enemy or sorry, yeah,
perfect as the enemy of donethat is.
I live by that rule.
Oh, you're not.
Speaker 1 (14:08):
All right.
Speaker 2 (14:09):
And in healthcare, I think we sometimes get really
tripped up over the perfectrather than the done and the
good enough.
Speaker 1 (14:15):
And when I say good enough, I'm not saying I am
probably super guilty.
Speaker 2 (14:20):
Yeah.
And when I say good enough, Ijust want to be super clear.
I do not mean unsafe, I do notmean rushed, I do not mean poor
quality, I do not meanunevidence based, I don't mean
any of those things.
I just mean if you're waitingfor an in-person appointment
every single time with yourbariatric team and you live
three hours away from them oreven 45 minutes away from them,
or you're a busy mom, or you'rea busy dad, or you're like 95%
(14:43):
of the population that can spenda whole day over and over again
in someone's office, face toface, then maybe that's not the
best solution for this access inthis kind of care.
You make a good point, tammy,and then the other thing that I
really want to make clear is, ashealthcare providers, we're
(15:04):
people too, we are human, and sowe are vulnerable to the exact
same biases that are present inour overall society.
So if our overall society isfatphobic and our overall
society is the kind that thinkseverybody should pull themselves
up by their bootstraps andeverything that happens to
people is their own darn fault,then a lot of healthcare
providers will have thatmentality too.
(15:27):
Yeah, and it's not surprisingthat a lot of healthcare
providers have those judgmentsseep into how they perceive
their own patients and what kindof treatment pathways they
recommend or what they'rewilling to do to have
conversations with people orhelp people.
So there's those factors, andthen I will say actually one
(15:49):
more, yeah, and one more that'sa really big one is time and
money and the way that is ifyour primary care doctor, for
instance, has one visit with youa year, that's usually best
case scenario for most people,right?
Is one visit per year?
That's maybe, if you're lucky,30 minutes and if you're like
(16:09):
out of this world lucky 45minutes to talk with that person
and address all of the thingsgoing on with them that year,
whether that's their bloodpressure, their weight, their
blood sugar, their hair loss,their menopause, their birth
control, their whatever it isright, whatever is coming up oh
mental health.
Ditto, and these are notconversations that are at all
(16:38):
amenable to a discussion aboutweight management, which is
complex, which is stigmatized,and allow somebody to actually
even form a triage plan in mostcases about that topic.
So I understand that a lot ofpeople don't necessarily want to
open that can of worms in thatlimited visit where they have
pretty defined goals and prettydefined things they already have
to do that are on their platewith that patient and then
(17:01):
especially, especially as apatient who really I love my
primary care doctor.
Speaker 1 (17:06):
I know how cut short he is because he again so he had
to stop taking new patientsbecause he birth until you die,
though some people keep him as aprimary care and so actually
never.
I talked to him about bariatricsurgery one.
Otherwise he didn't know.
I don't even know if he stillknows I've had, even though I
work in the same place.
(17:27):
I don't know if he knows I'vehad bariatric surgery because I
didn't want to bother him withall of that footwork and his
nurse.
I absolutely I already botherhim enough for my kids, but so I
didn't want to bother him withall of that.
And same with my mental healthstuff is I just did the footwork
myself.
But not a lot of people havethat ability.
Speaker 2 (17:50):
Exactly, and typically in most programs we do
require at least a primary caredoctor or someone to give an.
Okay, do an assessment ofsomeone doing eval for people
who have had that in the pastyou had it recently, I think, so
we had some documentation onthat.
Yeah, and in many programs wedo interact at least with
primary care or with OB-GYN orcardiology or others.
(18:10):
But I again, it's not likewe're having super in depth
conversations about each personand those are actually the
providers that are referring.
Those are the providers thatare engaged in the process, are
making a huge difference inpeople to reach this kind of
care and to help reach surgerywhen people need it and to help
(18:30):
follow up for it.
I even I was so appreciative ofthat where we work together in
Iowa City there were primarycare doctors that wanted
guidelines of how to follow upfor people after surgery and how
they could be involved inhelping and supporting.
That was so amazing to mebecause people were recorders.
Speaker 1 (18:47):
I had messages from those primary care doctor nurses
of like what exactly labs dobariatric patients need, and it
was nice to be able to be thatresource for them because
clearly they, those providers,want this resource, have it.
So you, if you're allowing themto feel comfortable enough to
reach out to ask those things,Thanks.
Speaker 2 (19:10):
And actually, tammy, you were involved in creating
some materials that helpedliterally put this like on a
card, on an email, on abroadcast, our entire system
wide, where it said exactly whatkind of follow up people need
at least once a year, what kindof labs people need at least
once a year, and made it reallyaccessible to the entire system
of providers that we had.
Like it was just reallyincredible to see.
(19:32):
Like you said, it's a two waystreet, right.
We have to be willing, asprofessionals in this space, to
be able to share the informationand to be able to share why
it's important, and then othersalso need to be willing to
receive that information and toparticipate in the kind of
follow up and care that peopleneed long term.
So it's yeah.
That was, I think, a reallygreat example of how that can go
(19:53):
right in a system.
Absolutely yeah, absolutelyyeah.
And there's also some problemswithin healthcare.
So on the flip side of that,where people are very well
meaning but offer maybemisguided help and I do want to
address some of those things tooI see a lot of folks who
actually want to provide somemanagement or some care that
(20:15):
addresses weight, but that itmay not be as helpful as maybe
they're thinking it is.
And this is where I want totouch on that dieting, that
thing that we talked aboutearlier over dieting and that
actually does more damage.
So I've seen a lot of veryrestrictive diets, low, very low
calorie diets or intermittentfasting One.
(20:36):
I want to say that those dietsactually do have some
applications, like for thingslike epilepsy and other kinds of
medical conditions In somecases, when they're overseen by
a medical professional anddietitian or kidney failure,
like there are situations inwhich those kinds of diets are a
treatment plan and are a veryvalid and good treatment plan
for people.
But obesity is not one of them.
(20:57):
So I just want to say thatsuper out loud and super clearly
that very low calorie diets,restricted diets and those that
are intermittent fasting are notan appropriate solution for
obesity.
For x zero carbs.
Speaker 1 (21:12):
I was still afraid of curbsy, probably six months
post-op.
Speaker 2 (21:15):
Great.
And exactly because not only dothey actually damage people's
understanding of their ownhealth and their own eating
habits, they actually damagepeople's metabolism in ways that
are not reversible.
That is something I don't thinka lot of health care providers
understand.
But when people try dieting andexercise alone, more than 95%
(21:39):
of people will regain weight andmost of those people will
regain more than they startedwith.
And if we're doing that overand over again which is really
common in the US, especially forwomen that is setting somebody
up for metabolic problems theirentire life and the inability to
ever lose weight in a healthyway and ever reach a healthy
(22:01):
weight.
Speaker 1 (22:03):
So again, I believe that, right like Dr Jessica
Smith was saying, she asks women, or we ask women how many diets
you've been on, and all of themright, and we wonder why we can
never lose weight, especiallyas we get older.
And then you have the men whoyou ask how many diets they've
been on, and usually it's one ornone.
(22:23):
And then they usually it's alittle bit easier for them to
lose weight, so it honestly allmakes sense to me.
Speaker 2 (22:31):
It was a bit of a moment when Jessica said that
and I will say there is, I dothink, a misconception too about
men and dieting, because a lotof men actually diet and have
dieting behavior.
It's just perceived as, oh,high protein diet or paleo.
For women it would beinterpreted as a diet, but for
men they see it as a lifestyle.
Maybe they don't perceive it asa diet or a dietary change,
(22:54):
even though it's the same thingbasically, just men versus women
and how it's perceived.
So men do this kind ofrestrictive eating too, and the
problem with all of these thingsis, if you're a lab rat and
your diet is controlled by ahuman being and you don't have
access to any kind of food otherthan what they feed you and
when that is maybe a sustainablediet for that rat, you are not
(23:18):
a rat.
You are not being fed by somehuman being who's put you in a
cage and controls your diet.
For human beings, for a diet tobe sustainable and healthy is
very different than what ispossible in laboratory
experiments, and so even thestudy that Dr Smith had
mentioned was the greatest loser, one where people went through
(23:38):
really extreme dieting andreally extreme physical activity
and they were able to lose over100 pounds on average and
things like that.
Really extreme weight loss too.
I hate to use the word extreme,I shouldn't use the word
extreme A lot of weight peoplewho are able to lose a lot of
weight.
The problem is that theirbodies became so much more
efficient at dealing with thecalories that they had that,
again, a calorie is not acalorie when you change your
(24:00):
metabolism in a way that makesit more efficient.
So when they started eating alittle bit more than that
unsustainable diet, they startedregaining weight, and a lot of
them regained more than theystarted off.
In fact, over 90% of themregained the weight, and so I
think a lot of health careproviders would be astounded by
how many people come into abariatric program that have BMI
(24:25):
over 30 but are eating less than2,000 calories a day.
I have been told by health careproviders that is impossible.
There are now many studies thatdocument this.
You don't have to trust me.
Speaker 1 (24:37):
Yeah, I am one of those.
Most of the time I didn't evenhave enough time in my day to
eat 2,000 calories, honestly.
Speaker 2 (24:46):
And I think a lot of us, anecdotally at least, may
have experienced this because,again, if we're really busy in
residency or really busy in ourtraining programs, we're
sometimes not eating 2,000calories a day either.
But we're not necessarilylosing weight when we're doing
that, because there's so manyother factors like stress and
your body adapting to that andother factors.
But I think that there is thisvery persistent misconception,
(25:08):
even amongst health careproviders, that everybody who
has excess weight is overeatingand is eating more than their
allotted number of calories aday based on their basal
metabolic rate and theiractivities above that, and that
is simply not true.
So that's absolutely not true,not true, and so that's
something that I hope over timepeople will understand more.
(25:31):
There's a lot of evidence ofthat.
There's a lot of anecdotalevidence that we see in our
lives that, hopefully, will helppeople recognize that, even if
they don't want to logic throughit, but they just see it around
themselves in their lives,maybe they can connect to it too
.
Because I think if weunderstand that excess weight is
not necessarily a foodaddiction because that's another
misconception I sometimes hear,even from health care providers
(25:53):
it's not necessarily peopleovereating, it's not necessarily
a behavior at all Then maybewe'll start to understand that
people don't need to proveanything about their weight,
that they don't need to provethat they have a lack, that they
have a will to change theirhabits or that they're trying to
do the right thing or they'retrying to do whatever the right
(26:15):
thing may be.
They don't have to deserve care, medical care for weight
management, because that is avery prevalent feeling in the
health care community.
Speaker 1 (26:27):
Let's be real, any of us that are dealing with
obesity.
We have all the will and we'vegiven all the efforts.
There's a lot of will and evenstrong.
There's so many people thathave done all and I feel like I
did for quite a while all theright things.
Lost a little weight in thebeginning, probably the water
weight just could not get it off, no matter what I did.
Speaker 2 (26:52):
And there are a lot of metabolic conditions, like we
mentioned repetitive dieting isone of them that make it very
difficult for people to loseweight down the road and a lot
of other medical conditionsinsulin resistance so not even
diabetes, but even pre-diabetesand insulin resistance that's
not related to diabetes cancause people to have a really
difficult time losing weight.
(27:12):
So can liver problems andkidney problems and pancreas
problems and endocrine problemsrelated to fertility, for
instance, can make it reallydifficult for people to lose
weight, regardless of their willand effort, and we know that as
healthcare providers, we haveactually been trained medically
in this knowledge, but we do notapply it to our patients often,
(27:32):
and oftentimes we do holdpeople accountable for something
they can't be held accountablefor.
Speaker 1 (27:38):
Something to think about, and I have a question for
you.
What do you think is whensomeone asks a group of patients
that have had bariatric surgerywhat is something you wish you
would have done differently,what do you think their answer
is?
Tell me I'm curious it is notdoing it sooner.
Yeah, exactly, I stepped footin that office two or three
(27:59):
years prior to seeing you and Ijust didn't do it.
Granted, I did end up having achild, but why are we not doing
it sooner?
Oh my God.
Speaker 2 (28:09):
Yeah, I'm so glad you brought that up because we do
now have a lot of evidence thatwe should be considering these
surgeries, potentially not justfor weight, but for metabolic
problems like diabetes, likePCOS, like NASH or non-alcoholic
liver disease and many otherconditions too.
So it's this idea that it hasto be the last resort or it's
(28:31):
someone's last option.
Instead, it should beconsidered much, much earlier in
people's lives.
If we can treat somebody'sdiabetes in their early 20s,
that means that we spare thempotentially decades of suffering
, decades of cost, decades ofdisability even related to that,
and I just I can't think of areason to not consider the full
(28:54):
spectrum of care for people fora condition, a medical condition
.
We don't do this for any othermedical condition except for
obesity and it really Iunderstand the stigma and I
understand the general publicnot agreeing with this somewhat,
even though I don't agree withthat, but to see it from within
(29:17):
the healthcare industry, I thinkis honestly, I think is
unacceptable.
Speaker 1 (29:23):
Actually, now that I know as much as I do, I just
went to a dance competition forone of my best friend's
daughters, because I don't haveany daughters.
But I was just thinking tomyself like my friend's daughter
is dance, she's a competitivedancer.
She's been a competitive dancersince she was young.
(29:44):
She struggles with weight andI'm just like this girl is
dancing like ridiculous amountof six to seven nights a week,
10 months out of the year.
There's so much more and I'mthinking what happens after high
school?
What happens?
You're no longer in dance, Iget worse and that's where I
blew up, or when I gained asmuch weight as I did high school
(30:06):
, because I wasn't a competitivecheerleader anymore.
If we just battled this asprimary care doctors, looking at
these young kids who are sosuper active and realizing you
cannot out eat that muchactivity.
You are a dancer as well, butsame competitive cheerleading, I
could not out eat.
Speaker 2 (30:29):
No, unless you're Michael Phelps or a wrestling
wrestler.
Speaker 1 (30:33):
So, yeah, if primary care doctors looked at that for
their pediatric patients of,especially those very active
ones, of putting this in theirparents' ears, and sooner, that
could save them a whole life ofissues, and so I think referring
when the issue of weight comesup, where somebody says I'm
(30:55):
struggling with this or I'd liketo do something about it, their
actual number on the scale isirrelevant.
Speaker 2 (31:01):
Referring to somebody who can help A bariatric
specialist is indicated at thatpoint.
And then, in terms of surgery,at least our professional
societies recommend theconsideration of bariatric
surgery at BMI of 30 if theyhave other medical conditions
like diabetes or high bloodpressure, or even arthritis is
an indication.
Pcos, there are many others,and then over 35 for everyone,
(31:24):
so over a BMI of 35.
And I think I've heard this alot even in the medical field
that people have to be over 100pounds overweight or they have
to be a BMI of 60 or somethinglike that, or they have to be
600 pounds, and that is just nottrue.
In fact, the biggest benefitfrom these kinds of surgeries is
when they're done earlier inlife, before the comorbidities
are piled on, and before thecomplications of those
(31:47):
comorbidities are piled on, andbefore people reach a BMI of 40.
Like that's the best outcomepeople can have, and I think
that, yeah, if more people knewthat, if more healthcare
providers internalize that andactually helped people get the
care that they need, that theydeserve, that they shouldn't
have to prove they need anddeserve, then maybe we would all
(32:08):
be better off and we would bepaying less and we would be
having fewer complications.
We'd be having people who were,yeah, just better able to live
lives they want to live.
Speaker 1 (32:20):
I think of this analogy and if this ends up
coming out completely wrong, Icould delete it out, but I
almost think of this as our skin, especially people that have
obesity.
Yeah, the bigger you get, themore.
And even pregnancy, let's behonest, pregnancy the bigger
your belly, your skin, gets andstretches out, more it's harder
(32:46):
to get back in.
So I feel like that's almostlike medical conditions of the
further you let it get, theharder it is to get it more
under control and back to normalAbsolutely.
So why not Absolutely Do thepre?
Yeah?
Speaker 2 (33:04):
100%.
Yeah, because it's the whole.
Prevention is worth an ounce ofprevention is worth a pound of
cure, kind of thing.
And so you're absolutely right.
Instead of us waiting untilpeople have diabetes and high
blood pressure and they havekidney problems and they have
liver problems and they havejoint problems and all these
things are spiraling, if we wereto consider these kinds of
interventions earlier, we wouldspare people a lot of morbidity
(33:27):
and a lot of days off work, alot of days where they're
struggling to do the activitiesthey want to do and participate
with their families in the waythey want to.
So what I do think.
I'm just going to end thisbriefly with a couple of things
I really want other healthcareproviders to know, and that's to
refer.
If you're having conversationsabout weight or considering
weight with your patient, refer.
(33:47):
Refer them to a barrierspecialist.
Refer them to somebody who canhave that conversation with them
.
Also, be aware that there's aspectrum of care.
That spectrum of caredefinitely includes surgery as a
consideration for some people,but it also includes things like
medications and dietary supportand mental health and physical
(34:08):
activity and a review of overallhealth and follow-up.
It's not one or the other andit's not one is more extreme
than the other.
It's what's right for thispatient and what combination is
it right for this person?
Speaker 1 (34:21):
I look at this, even Beatrix is a specialty.
I come from, pauline.
So many times where primarycare doctors have ordered a
pulmonary function test, theythink they know how to treat it
or they feel like, oh yeah,there's some reversibility there
, let's give them some albuterolso they know the bare minimum.
That's where specialties suchas pulmonary or bariatrics come
(34:45):
into play.
A primary care doctor knows alittle bit about everything,
them to the specialty that knowsthat's all they do all day.
They know the workarounds withinsurance.
They know how to help thepatient more, because even with
respiratory, primary caredoctors might not even know that
breathing, teaching breathingtechniques, can actually save a
(35:07):
COPD patient a lot of misery,yeah absolutely.
Speaker 2 (35:11):
I think it's not to say that we're trying to exclude
anybody from this process,because if more primary care
doctors want to be trained onbariatric care, there's a lot of
prepare, absolutely I raise myhand.
I am super interested inhelping people understand how to
use med weight loss and how toincorporate nutrition and mental
health and how to follow upafter surgery.
There are people out there thatare really, I think, available
(35:34):
resources for including morepeople in this work.
Speaker 1 (35:37):
And.
Speaker 2 (35:37):
Lord knows, we need more people doing it.
So it's not.
I hope it's not seen asexclusionary and if anyone.
Speaker 1 (35:45):
No, those primary care doctors just have so much
on their plates.
We see you, primary caredoctors.
We see you.
Speaker 2 (35:51):
We're trying to create more work and definitely
we're trying to recruit morepeople into this field, because
we need more people doing this.
We absolutely do Right, and Ialso want to make sure that
people understand in thehealthcare industry that
bariatric surgery isn't a lastresort.
It is a pretty unique approach.
That is the only thing thatactually accomplishes a
metabolic reset.
I think you and I coined theterm metabolic conversion the
(36:13):
other day, which I love thatterm too, but it really allows
people to reset their metabolismlike a thermostat, and there
really is no other mechanism fordoing that.
It also has the greatest effecton weight and metabolism versus
any other approach.
It's the most durable and it'salso the best covered by
insurance.
So, for the right person,surgery should be considered as
(36:35):
one of their first optionsrather than one of their last.
Speaker 1 (36:39):
Yes, yes.
Speaker 2 (36:42):
And that BMI alone is not a health indicator that
warrants any kind of treatment.
Bmi is a starting point for anevaluation of an individual and
that anchors the discussion inthe very beginning, and then we
go from there to recognize that,just like a calorie is not a
calorie, weight is not weightfor everyone and there are many
people at a BMI of over 40 thatcan be very healthy and there's
(37:04):
many people under a BMI of 40that can be very unhealthy.
So it is just the startingpoint to an evaluation.
The other thing to remember isthat weight management requires
a village, much like raising achild.
I think we need to reallyforget about blaming individuals
and thinking of keeping peopleisolated and struggling.
(37:25):
We need to include people inour community and in our village
, basically in terms ofsupporting people in lifelong
weight management.
Speaker 1 (37:34):
Yes, absolutely.
And as a patient, I want totell other patients that if you
have a primary care doctor thatjust isn't listening to you,
it's okay to step away from thatprimary care doctor.
It doesn't mean you haveanything against that primary
care doctor, it's just you needmore out of them and that's okay
.
And if they just aren'tlistening to you, please reach
(37:56):
out and try to find someone thatis willing to listen to you.
Ask for a referral to abariatric program if they don't
offer you one.
See, if that program allows andyour insurance allows you, to
make yourself a self-referral.
But, as Maria has said, a lotof healthcare providers don't
understand a lot of this, and sohave patience with them.
(38:19):
For sure, they are stilllearning just as much as even
the expert Maria here.
Or bariatric surgeon.
Like their experts in theirprofession or that specialty,
they're still learning.
So definitely have patiencewith your providers as well, but
don't hesitate to tell themwhat you need and go fight for
(38:40):
what you need.
Speaker 2 (38:41):
Exactly, and I think it's up to all of us, as
individuals, as communities, ashealthcare providers too, to
take a stand against stigma onthis topic.
I think that if we're not partof the solution here, we are
part of the problem, and it'stime for people to own that, for
us to say this is not a moralissue, this is not.
(39:02):
It makes no sense to excludepeople from this care.
It makes no sense to makepeople feel bad about this.
It makes all the sense in theworld to help people get the
care they need.
Speaker 1 (39:12):
Yes, absolutely.
So on that note, I think thatwe can't beat that, so don't
forget to follow us.
Go over to Instagram or TikTok.
I'm still figuring out theTikTok part, but we'll get some
videos going.
We'll get some anyways, corebariatric, especially Instagram,
to let us know if there'sanything you want to talk about
(39:32):
questions, concerns but don'tforget to follow us so that you
get notified of when our nextepisode comes out.
I think this was a great oneand I'm so excited to have this
one come out so people can hearall this.
You're right.
Speaker 2 (39:46):
Thank you so much, tammy.
Thanks for listening.
We'll see you next time.
Bye, bye, bye.
Welcome to Core Bariatrics Podcast hosted by
Bariatric Surgeon Dr MariaIliakova and Tami LaCos,
Bariatric Coordinator and apatient herself.
Our goal is building andelevating our community.
The Core Bariatric Podcast doesnot offer medical advice,
diagnosis or treatment.
On this podcast, we aim toshare stories, support and
(00:22):
insight into the world beyondthe clinic.
Let's get into it.
Speaker 2 (00:26):
Hi Tami, hello Marie, I wanted to tell you a story
today about something thathappened to me, actually around
a year ago at this point wherewe were working.
So I was in the doctor's loungehanging out I think I was in
between cases or something likethat and I remember one of the
other docs was in there and wejust struck up a conversation
and this guy out of the blue I'mnot sure exactly what triggered
(00:46):
this, but decided to starttalking about weight and he
basically explained to me mebeing a Bariatric surgeon and
him being not that the problemis very simple, it is ins and
outs, and that people shouldjust stop eating and, if they
can't, that he has a really goodsolution for it and that's just
to slap duct tape over theirmouth to fix the problem.
Speaker 1 (01:07):
What do you think about that?
I feel like I could use ducttape in a totally different
manner towards him.
What's that?
Well, that right there is goingto send a patient into a binge
eating or just like a mentalbreakdown.
Oh my gosh, says that tosomeone's face, at least.
Speaker 2 (01:28):
Honestly, I couldn't believe he said it to me,
because I do this for a livingand obviously really care about
it, but it was said so casually,I believe, while he was eating
whatever his lunch was at thetime, just in between bites.
Here we go, and I didn't justsuper catch, super catch.
This guy, by the way, hasdaughters, is married and is
(01:50):
around my age, so in his 30s or40s, maybe younger person.
Yeah, I was pretty blown away,honestly, because I think he is
saying out loud what a lot ofpeople think.
Speaker 1 (02:01):
Absolutely, because I was actually just going to say
there's people out there.
I don't want to throw you underthe bus because you don't.
All the time you can eat, I canpack it away.
That's true.
And again, you have had yourown eating and your own body and
all of that.
But again, if a calorie was acalorie, we would all be the
(02:21):
same size.
Speaker 2 (02:22):
Exactly, or at least a lot of us would be the same
size and we wouldn't have 60% ofthe population having extra
weight or what we consider extraweight.
Yeah, it's pretty honest thatyou're absolutely right, because
my body has also changed overtime, which is interesting
because I have had binge eatingdisorder myself and so whenever
you have an eating disorder it'sa lifelong thing.
I've learned to manage itreally well, but I have it, and
(02:44):
in the past there were timesthat, yes, I would go on yo-yo
diets, I would do extremes ofdieting and exercise, and I'm at
a really healthy point in mylife right now, so I'm
stabilized, but I still havetendencies of in residency.
You eat when you can, you sleepwhen you can, you go to the
bathroom when you can.
Those are the rules.
Speaker 1 (03:02):
You're still afraid to drink water because you have
to go to the bathroom.
Speaker 2 (03:06):
I have to pee and I can't, I know right Even though.
So my brain is still there, andso the way that I eat is I eat
when I can and I shove it in myface because I might not have
time to do it otherwise, eventhough my lifestyle is pretty
different now.
Old habits die hard.
I'm a good example of thatmyself, but the thing is I have
lucky genes or something.
The way that my body works isI'm able to metabolize things
(03:28):
pretty well and I can't eatquite a bit without it with
being a big issue.
But I also do workout.
Speaker 1 (03:33):
I also do try to you do very much.
I was hanging out in the poolin Orlando while you were
working out, yep.
Speaker 2 (03:40):
But that's the whole point is basically absolutely.
Calorie is not a calorie.
It's not ins and outs, and ifit were, I would probably be a
much bigger size than I ammyself, people would be much
smaller sizes.
Speaker 1 (03:50):
Yes, yes, because I know people that eat so healthy
and just struggle to lose weight.
Not that they're trying tonecessarily lose weight, but
like they should be smaller.
Speaker 2 (04:05):
So let's get into it, absolutely so.
The one other thing we want totalk about is exactly that.
We're leading in perfectly intoit.
It's an excellent segue intotalking with healthcare
providers, which is what thisepisode is all about, and what
healthcare providers know aboutweight management in general is
that most healthcare providersdon't know more than the general
public about this topic.
Speaker 1 (04:24):
No, they do not, or at least not much more.
This again if they did, theydid.
They're not before they areeither.
As healthcare providers, we beeating all the food when we can
too.
Speaker 2 (04:34):
That's right.
A lot of healthcare providers,just like the general population
, struggle with weightmanagement the same way that the
general population does.
There's a couple of reasons forthat.
There's very little weightrelated or metabolism related
training in any healthcareprofession, including medicine.
There's very little nutritionexercise training.
In fact, in my own curricula,what I learned I think it was
(04:56):
under three hours total out ofthe thousands of hours that we
learn, which is astounding whenyou think about what impact it
actually has.
Absolutely yeah.
I think the idea basicallybeing oh, there's dietitians for
that.
That's just ludicrous, becauseone dietitians are really hard
to find.
Speaker 1 (05:13):
They're not enough for them.
Speaker 2 (05:14):
Your insurance doesn't like paying for them
your insurance doesn't pay fordietary visits for most people,
unless they're diabetic for themost part, even in bariatric
programs, a lot of people haveto self-pay their dietary visits
, which is bonkers, but true,right.
Then the other thing is weabsolutely to be well-rounded
physicians, to be well-roundedhealthcare providers would
benefit from understandingsomething about nutrition and
(05:37):
how we eat and how it getsprocessed, and the fact that
when you diet over and overagain, you're messing up your
metabolism more than you'rehelping it, which is not
publicly known information, eventhough it's really true.
Speaker 1 (05:47):
I know that until last week Yep.
Speaker 2 (05:50):
Then there is a lot of misinformation in this field
that's guided by opinion ratherthan science, even in healthcare
.
I think that this person, thisdoctor in the lounge who said
let's just slap duct tape oneveryone, he is just saying out
loud what a lot of peoplebelieve in a kind of maybe
extreme way of saying that Alittle.
Yeah, no kidding.
(06:11):
I think a lot of peopleactually have that kind of
misconception of people are justout of control and they can't
do anything about it.
And why can't they controlthemselves better?
That's just super not how itworks for the majority of people
who have challenges.
The other thing about this isthe history of medical care in
(06:31):
weight management has a reallybad rap.
Some of it is warranted, Someof it is fair and some of it is
not fair.
Let me explain that just alittle bit.
Weight loss surgery is a fairlynew field and it dates back to
the 90s.
Now most and most insurancecompanies really didn't start
covering any kind of procedures,at least for weight loss, until
(06:51):
the 2000s and until the 2010s.
There's still a lot of plansactually insurance plans that
don't cover bariatric surgery atall.
Yeah, there are.
Yeah, it's still a fairly newfield and access is its own
problem that we'll talk abouttoo.
Back in the 90s and earlier thekinds of surgeries that were
being done for weight managementwere gastric bypasses and
(07:12):
duodenal switches.
Both of those surgeries can bepretty intense.
The follow up for those can bepretty intense and they were
being done as big open surgeries.
People had lots ofcomplications and they had the
hospital.
Stays for them would last fiveto seven days.
Sometimes more people would getleaks or would have narrowings
(07:34):
or would have obstructions orwould have all these nutrition
problems afterwards dehydrationand that honestly largely is a
thing of the past for thesekinds of surgeries because now
we do them small cuts.
We do really good patientselection overall.
There's professionalorganizations that help us be
really standardized and makesure quality is good overall.
That's not to say that'simpossible to have a
(07:55):
complication or impossible to doit badly, but it's a way
different field than it was inthe 90s and 2000s and the
insurance is wanting you to doit same day have surgery and get
out.
Yeah, it literally advanced tothe point where the Centers for
Medicare and Medicaid last year,in 2023, wanted to push through
a new rule that basically madeall of these surgeries required
(08:19):
to be outpatient, meaningpatients could at most only stay
overnight, which that's sobonkers, going from where we
were required in five to sevendays to now, centers for
Medicare and Medicaid andinsurance companies are trying
to push people out the door thesame day which that also that's
the same as hip replacements andstuff.
Speaker 1 (08:37):
As soon as you are to get up and walk around, you're
walking around and then theykick you out the door and you're
at physical therapy the nextday.
Speaker 2 (08:44):
Exactly, and I think there will be another episode
about insurance as one thing andthen there's another episode
about how we do these surgeriesand things like that.
But the field has advanced byleaps and bounds in terms of
quality and safety anddetermining who benefits from
these surgeries and how wefollow up on them and how we
prepare them.
But I think the perceptionwithin the healthcare industry
(09:05):
has not really shifted to thatapproach and so a lot of folks
who are not in this world don'tnecessarily know that it has
advanced so much since that time.
The other thing that's a reallybig obstacle, I think, for
people is that it's really toughto reach bariatric care and
it's really tough to coordinateit.
So even if a provider, even ifyou're a health primary care
(09:27):
provider or a cardiologist orwhoever you are really think
that a person would benefit fromthis, one, you have to find a
bariatric program.
Two, you may have to figure outif that person has insurance or
something that covers it, whichthey may or may not.
And then, three, you have to doa little bit of that
quarterbacking of that person,getting the right referral,
making sure they know how tofollow up with it, all of that.
(09:49):
So it can be a little bit morethan what people necessarily
want to bite off like, more thanwhat most providers want to
choose.
Speaker 1 (09:56):
But really in rural areas.
I actually just found out thatwhere I work, the closest
bariatric program is at least anhour and a half away, and
that's where we're located.
People south of that, you'regoing even further, and so
that's why I'm trying to recruitthis bariatric surgeon, I know.
(10:18):
but you're absolutely right.
You have a day of just oneappointment and you have to have
three to six months worth ofthose just appointments, not
including your other testing andappointments you may need.
Yeah, and so I feel like I'veeven felt that from my primary
care doctor in the past that hemay have thought it was a good
(10:41):
idea.
He just didn't know where tostart to help me because a
bariatric surgery program was sofar away.
Speaker 2 (10:49):
Exactly, and I do think that there is this sort of
a lot of providers actuallyfeel helpless here and so
they're not necessarily tryingto not refer people or restrict
care or something like that, but, like you said, you don't even
know where to get started,sometimes in a realistic way for
patients.
And something that I think Imay have mentioned in some other
episodes, but I just I find itsuch an astounding number, is
(11:11):
that, as a result of all thesebarriers, less than 1% of
eligible people ever see abariatric specialist.
Speaker 1 (11:19):
That's still so shocking to me too.
Speaker 2 (11:22):
Yeah, so less than 1% of people who are eligible for
weight related care ever seesomebody who can provide them
specialized weight related careLike worth repeating.
Because if we, if that werehappening in heart health or
cancer care or diabetes or evenmental health, honestly maybe it
does happen in mental health,but I actually think at this
(11:43):
point mental health is betteraccessible than this right there
Because we've been figured out.
Speaker 1 (11:49):
You have online options for mental health, like
better health.
Speaker 2 (11:53):
There is a lot of movement now on telemedicine,
especially after COVID, but itdoes seem like we still have to
fight for that year after year,because insurance every year,
health care insurance companiesreassess and centers for
Medicare and Medicaid does toowhether or not to make this kind
of care available by telehealth.
And so far they've told yes forthe 2023 year and 2024, but it
(12:14):
does still feel like a fight andit feels for a lot of providers
, ourselves included.
When we were in Iowa City, itwas downplayed and made to be
not the preferred mechanism evenfor people who were traveling
hours to get to us on a regularbasis.
So there's a lot of room yeah,there's a lot of room there for
programs that are hybrid,programs that can do both
(12:36):
in-person care when it'snecessary.
So far we can't do telemedicinesurgery, for instance.
So that's a we have to do withthis person.
Stay tuned, yes, but for nowthat's the case.
But a lot of the other visits,a lot of the other visits could
be done.
Telehealth for most patients,that's something that we need to
.
Speaker 1 (12:52):
I'm still wrapping my head around that.
You would say it all the timeand I'm always like but they
need you in person and you'relike they really don't.
I'm here for them if they needme but at least they need an
appointment.
Speaker 2 (13:09):
Exactly because the difference between what's
perfect and what's ideal andwhat's available is that's the
difference is like.
I think we rely a lot of timesin healthcare on getting it
perfect rather than getting itgood enough, and I think that is
a massive problem, because goodenough care, that's quality,
that's consistent, that is basedon evidence, that's well
(13:30):
supported, is what people need.
It doesn't have to be perfectand in person and Mayo Clinic
every time.
If it can be Mayo Clinicquality but not telemedicine,
why the heck not?
You know what I mean and Idon't think there's anything
actually stopping us from doingthat.
I mean there are many thingsstopping us from doing that,
including, like insurancereimbursement and I feel like
(13:51):
you're calling me out.
Speaker 1 (13:53):
Hey, I am we don't have to be perfect.
It just need I'm fine.
Okay, okay, Try to get over it.
Speaker 2 (14:01):
This is perfect as the enemy or sorry, yeah,
perfect as the enemy of donethat is.
I live by that rule.
Oh, you're not.
Speaker 1 (14:08):
All right.
Speaker 2 (14:09):
And in healthcare, I think we sometimes get really
tripped up over the perfectrather than the done and the
good enough.
Speaker 1 (14:15):
And when I say good enough, I'm not saying I am
probably super guilty.
Speaker 2 (14:20):
Yeah.
And when I say good enough, Ijust want to be super clear.
I do not mean unsafe, I do notmean rushed, I do not mean poor
quality, I do not meanunevidence based, I don't mean
any of those things.
I just mean if you're waitingfor an in-person appointment
every single time with yourbariatric team and you live
three hours away from them oreven 45 minutes away from them,
or you're a busy mom, or you'rea busy dad, or you're like 95%
(14:43):
of the population that can spenda whole day over and over again
in someone's office, face toface, then maybe that's not the
best solution for this access inthis kind of care.
You make a good point, tammy,and then the other thing that I
really want to make clear is, ashealthcare providers, we're
(15:04):
people too, we are human, and sowe are vulnerable to the exact
same biases that are present inour overall society.
So if our overall society isfatphobic and our overall
society is the kind that thinkseverybody should pull themselves
up by their bootstraps andeverything that happens to
people is their own darn fault,then a lot of healthcare
providers will have thatmentality too.
(15:27):
Yeah, and it's not surprisingthat a lot of healthcare
providers have those judgmentsseep into how they perceive
their own patients and what kindof treatment pathways they
recommend or what they'rewilling to do to have
conversations with people orhelp people.
So there's those factors, andthen I will say actually one
(15:49):
more, yeah, and one more that'sa really big one is time and
money and the way that is ifyour primary care doctor, for
instance, has one visit with youa year, that's usually best
case scenario for most people,right?
Is one visit per year?
That's maybe, if you're lucky,30 minutes and if you're like
(16:09):
out of this world lucky 45minutes to talk with that person
and address all of the thingsgoing on with them that year,
whether that's their bloodpressure, their weight, their
blood sugar, their hair loss,their menopause, their birth
control, their whatever it isright, whatever is coming up oh
mental health.
Ditto, and these are notconversations that are at all
(16:38):
amenable to a discussion aboutweight management, which is
complex, which is stigmatized,and allow somebody to actually
even form a triage plan in mostcases about that topic.
So I understand that a lot ofpeople don't necessarily want to
open that can of worms in thatlimited visit where they have
pretty defined goals and prettydefined things they already have
to do that are on their platewith that patient and then
(17:01):
especially, especially as apatient who really I love my
primary care doctor.
Speaker 1 (17:06):
I know how cut short he is because he again so he had
to stop taking new patientsbecause he birth until you die,
though some people keep him as aprimary care and so actually
never.
I talked to him about bariatricsurgery one.
Otherwise he didn't know.
I don't even know if he stillknows I've had, even though I
work in the same place.
(17:27):
I don't know if he knows I'vehad bariatric surgery because I
didn't want to bother him withall of that footwork and his
nurse.
I absolutely I already botherhim enough for my kids, but so I
didn't want to bother him withall of that.
And same with my mental healthstuff is I just did the footwork
myself.
But not a lot of people havethat ability.
Speaker 2 (17:50):
Exactly, and typically in most programs we do
require at least a primary caredoctor or someone to give an.
Okay, do an assessment ofsomeone doing eval for people
who have had that in the pastyou had it recently, I think, so
we had some documentation onthat.
Yeah, and in many programs wedo interact at least with
primary care or with OB-GYN orcardiology or others.
(18:10):
But I again, it's not likewe're having super in depth
conversations about each personand those are actually the
providers that are referring.
Those are the providers thatare engaged in the process, are
making a huge difference inpeople to reach this kind of
care and to help reach surgerywhen people need it and to help
(18:30):
follow up for it.
I even I was so appreciative ofthat where we work together in
Iowa City there were primarycare doctors that wanted
guidelines of how to follow upfor people after surgery and how
they could be involved inhelping and supporting.
That was so amazing to mebecause people were recorders.
Speaker 1 (18:47):
I had messages from those primary care doctor nurses
of like what exactly labs dobariatric patients need, and it
was nice to be able to be thatresource for them because
clearly they, those providers,want this resource, have it.
So you, if you're allowing themto feel comfortable enough to
reach out to ask those things,Thanks.
Speaker 2 (19:10):
And actually, tammy, you were involved in creating
some materials that helpedliterally put this like on a
card, on an email, on abroadcast, our entire system
wide, where it said exactly whatkind of follow up people need
at least once a year, what kindof labs people need at least
once a year, and made it reallyaccessible to the entire system
of providers that we had.
Like it was just reallyincredible to see.
(19:32):
Like you said, it's a two waystreet, right.
We have to be willing, asprofessionals in this space, to
be able to share the informationand to be able to share why
it's important, and then othersalso need to be willing to
receive that information and toparticipate in the kind of
follow up and care that peopleneed long term.
So it's yeah.
That was, I think, a reallygreat example of how that can go
(19:53):
right in a system.
Absolutely yeah, absolutelyyeah.
And there's also some problemswithin healthcare.
So on the flip side of that,where people are very well
meaning but offer maybemisguided help and I do want to
address some of those things tooI see a lot of folks who
actually want to provide somemanagement or some care that
(20:15):
addresses weight, but that itmay not be as helpful as maybe
they're thinking it is.
And this is where I want totouch on that dieting, that
thing that we talked aboutearlier over dieting and that
actually does more damage.
So I've seen a lot of veryrestrictive diets, low, very low
calorie diets or intermittentfasting One.
(20:36):
I want to say that those dietsactually do have some
applications, like for thingslike epilepsy and other kinds of
medical conditions In somecases, when they're overseen by
a medical professional anddietitian or kidney failure,
like there are situations inwhich those kinds of diets are a
treatment plan and are a veryvalid and good treatment plan
for people.
But obesity is not one of them.
(20:57):
So I just want to say thatsuper out loud and super clearly
that very low calorie diets,restricted diets and those that
are intermittent fasting are notan appropriate solution for
obesity.
For x zero carbs.
Speaker 1 (21:12):
I was still afraid of curbsy, probably six months
post-op.
Speaker 2 (21:15):
Great.
And exactly because not only dothey actually damage people's
understanding of their ownhealth and their own eating
habits, they actually damagepeople's metabolism in ways that
are not reversible.
That is something I don't thinka lot of health care providers
understand.
But when people try dieting andexercise alone, more than 95%
(21:39):
of people will regain weight andmost of those people will
regain more than they startedwith.
And if we're doing that overand over again which is really
common in the US, especially forwomen that is setting somebody
up for metabolic problems theirentire life and the inability to
ever lose weight in a healthyway and ever reach a healthy
(22:01):
weight.
Speaker 1 (22:03):
So again, I believe that, right like Dr Jessica
Smith was saying, she asks women, or we ask women how many diets
you've been on, and all of themright, and we wonder why we can
never lose weight, especiallyas we get older.
And then you have the men whoyou ask how many diets they've
been on, and usually it's one ornone.
(22:23):
And then they usually it's alittle bit easier for them to
lose weight, so it honestly allmakes sense to me.
Speaker 2 (22:31):
It was a bit of a moment when Jessica said that
and I will say there is, I dothink, a misconception too about
men and dieting, because a lotof men actually diet and have
dieting behavior.
It's just perceived as, oh,high protein diet or paleo.
For women it would beinterpreted as a diet, but for
men they see it as a lifestyle.
Maybe they don't perceive it asa diet or a dietary change,
(22:54):
even though it's the same thingbasically, just men versus women
and how it's perceived.
So men do this kind ofrestrictive eating too, and the
problem with all of these thingsis, if you're a lab rat and
your diet is controlled by ahuman being and you don't have
access to any kind of food otherthan what they feed you and
when that is maybe a sustainablediet for that rat, you are not
(23:18):
a rat.
You are not being fed by somehuman being who's put you in a
cage and controls your diet.
For human beings, for a diet tobe sustainable and healthy is
very different than what ispossible in laboratory
experiments, and so even thestudy that Dr Smith had
mentioned was the greatest loser, one where people went through
(23:38):
really extreme dieting andreally extreme physical activity
and they were able to lose over100 pounds on average and
things like that.
Really extreme weight loss too.
I hate to use the word extreme,I shouldn't use the word
extreme A lot of weight peoplewho are able to lose a lot of
weight.
The problem is that theirbodies became so much more
efficient at dealing with thecalories that they had that,
again, a calorie is not acalorie when you change your
(24:00):
metabolism in a way that makesit more efficient.
So when they started eating alittle bit more than that
unsustainable diet, they startedregaining weight, and a lot of
them regained more than theystarted off.
In fact, over 90% of themregained the weight, and so I
think a lot of health careproviders would be astounded by
how many people come into abariatric program that have BMI
(24:25):
over 30 but are eating less than2,000 calories a day.
I have been told by health careproviders that is impossible.
There are now many studies thatdocument this.
You don't have to trust me.
Speaker 1 (24:37):
Yeah, I am one of those.
Most of the time I didn't evenhave enough time in my day to
eat 2,000 calories, honestly.
Speaker 2 (24:46):
And I think a lot of us, anecdotally at least, may
have experienced this because,again, if we're really busy in
residency or really busy in ourtraining programs, we're
sometimes not eating 2,000calories a day either.
But we're not necessarilylosing weight when we're doing
that, because there's so manyother factors like stress and
your body adapting to that andother factors.
But I think that there is thisvery persistent misconception,
(25:08):
even amongst health careproviders, that everybody who
has excess weight is overeatingand is eating more than their
allotted number of calories aday based on their basal
metabolic rate and theiractivities above that, and that
is simply not true.
So that's absolutely not true,not true, and so that's
something that I hope over timepeople will understand more.
(25:31):
There's a lot of evidence ofthat.
There's a lot of anecdotalevidence that we see in our
lives that, hopefully, will helppeople recognize that, even if
they don't want to logic throughit, but they just see it around
themselves in their lives,maybe they can connect to it too
.
Because I think if weunderstand that excess weight is
not necessarily a foodaddiction because that's another
misconception I sometimes hear,even from health care providers
(25:53):
it's not necessarily peopleovereating, it's not necessarily
a behavior at all Then maybewe'll start to understand that
people don't need to proveanything about their weight,
that they don't need to provethat they have a lack, that they
have a will to change theirhabits or that they're trying to
do the right thing or they'retrying to do whatever the right
(26:15):
thing may be.
They don't have to deserve care, medical care for weight
management, because that is avery prevalent feeling in the
health care community.
Speaker 1 (26:27):
Let's be real, any of us that are dealing with
obesity.
We have all the will and we'vegiven all the efforts.
There's a lot of will and evenstrong.
There's so many people thathave done all and I feel like I
did for quite a while all theright things.
Lost a little weight in thebeginning, probably the water
weight just could not get it off, no matter what I did.
Speaker 2 (26:52):
And there are a lot of metabolic conditions, like we
mentioned repetitive dieting isone of them that make it very
difficult for people to loseweight down the road and a lot
of other medical conditionsinsulin resistance so not even
diabetes, but even pre-diabetesand insulin resistance that's
not related to diabetes cancause people to have a really
difficult time losing weight.
(27:12):
So can liver problems andkidney problems and pancreas
problems and endocrine problemsrelated to fertility, for
instance, can make it reallydifficult for people to lose
weight, regardless of their willand effort, and we know that as
healthcare providers, we haveactually been trained medically
in this knowledge, but we do notapply it to our patients often,
(27:32):
and oftentimes we do holdpeople accountable for something
they can't be held accountablefor.
Speaker 1 (27:38):
Something to think about, and I have a question for
you.
What do you think is whensomeone asks a group of patients
that have had bariatric surgerywhat is something you wish you
would have done differently,what do you think their answer
is?
Tell me I'm curious it is notdoing it sooner.
Yeah, exactly, I stepped footin that office two or three
(27:59):
years prior to seeing you and Ijust didn't do it.
Granted, I did end up having achild, but why are we not doing
it sooner?
Oh my God.
Speaker 2 (28:09):
Yeah, I'm so glad you brought that up because we do
now have a lot of evidence thatwe should be considering these
surgeries, potentially not justfor weight, but for metabolic
problems like diabetes, likePCOS, like NASH or non-alcoholic
liver disease and many otherconditions too.
So it's this idea that it hasto be the last resort or it's
(28:31):
someone's last option.
Instead, it should beconsidered much, much earlier in
people's lives.
If we can treat somebody'sdiabetes in their early 20s,
that means that we spare thempotentially decades of suffering
, decades of cost, decades ofdisability even related to that,
and I just I can't think of areason to not consider the full
(28:54):
spectrum of care for people fora condition, a medical condition
.
We don't do this for any othermedical condition except for
obesity and it really Iunderstand the stigma and I
understand the general publicnot agreeing with this somewhat,
even though I don't agree withthat, but to see it from within
(29:17):
the healthcare industry, I thinkis honestly, I think is
unacceptable.
Speaker 1 (29:23):
Actually, now that I know as much as I do, I just
went to a dance competition forone of my best friend's
daughters, because I don't haveany daughters.
But I was just thinking tomyself like my friend's daughter
is dance, she's a competitivedancer.
She's been a competitive dancersince she was young.
(29:44):
She struggles with weight andI'm just like this girl is
dancing like ridiculous amountof six to seven nights a week,
10 months out of the year.
There's so much more and I'mthinking what happens after high
school?
What happens?
You're no longer in dance, Iget worse and that's where I
blew up, or when I gained asmuch weight as I did high school
(30:06):
, because I wasn't a competitivecheerleader anymore.
If we just battled this asprimary care doctors, looking at
these young kids who are sosuper active and realizing you
cannot out eat that muchactivity.
You are a dancer as well, butsame competitive cheerleading, I
could not out eat.
Speaker 2 (30:29):
No, unless you're Michael Phelps or a wrestling
wrestler.
Speaker 1 (30:33):
So, yeah, if primary care doctors looked at that for
their pediatric patients of,especially those very active
ones, of putting this in theirparents' ears, and sooner, that
could save them a whole life ofissues, and so I think referring
when the issue of weight comesup, where somebody says I'm
(30:55):
struggling with this or I'd liketo do something about it, their
actual number on the scale isirrelevant.
Speaker 2 (31:01):
Referring to somebody who can help A bariatric
specialist is indicated at thatpoint.
And then, in terms of surgery,at least our professional
societies recommend theconsideration of bariatric
surgery at BMI of 30 if theyhave other medical conditions
like diabetes or high bloodpressure, or even arthritis is
an indication.
Pcos, there are many others,and then over 35 for everyone,
(31:24):
so over a BMI of 35.
And I think I've heard this alot even in the medical field
that people have to be over 100pounds overweight or they have
to be a BMI of 60 or somethinglike that, or they have to be
600 pounds, and that is just nottrue.
In fact, the biggest benefitfrom these kinds of surgeries is
when they're done earlier inlife, before the comorbidities
are piled on, and before thecomplications of those
(31:47):
comorbidities are piled on, andbefore people reach a BMI of 40.
Like that's the best outcomepeople can have, and I think
that, yeah, if more people knewthat, if more healthcare
providers internalize that andactually helped people get the
care that they need, that theydeserve, that they shouldn't
have to prove they need anddeserve, then maybe we would all
(32:08):
be better off and we would bepaying less and we would be
having fewer complications.
We'd be having people who were,yeah, just better able to live
lives they want to live.
Speaker 1 (32:20):
I think of this analogy and if this ends up
coming out completely wrong, Icould delete it out, but I
almost think of this as our skin, especially people that have
obesity.
Yeah, the bigger you get, themore.
And even pregnancy, let's behonest, pregnancy the bigger
your belly, your skin, gets andstretches out, more it's harder
(32:46):
to get back in.
So I feel like that's almostlike medical conditions of the
further you let it get, theharder it is to get it more
under control and back to normalAbsolutely.
So why not Absolutely Do thepre?
Yeah?
Speaker 2 (33:04):
100%.
Yeah, because it's the whole.
Prevention is worth an ounce ofprevention is worth a pound of
cure, kind of thing.
And so you're absolutely right.
Instead of us waiting untilpeople have diabetes and high
blood pressure and they havekidney problems and they have
liver problems and they havejoint problems and all these
things are spiraling, if we wereto consider these kinds of
interventions earlier, we wouldspare people a lot of morbidity
(33:27):
and a lot of days off work, alot of days where they're
struggling to do the activitiesthey want to do and participate
with their families in the waythey want to.
So what I do think.
I'm just going to end thisbriefly with a couple of things
I really want other healthcareproviders to know, and that's to
refer.
If you're having conversationsabout weight or considering
weight with your patient, refer.
(33:47):
Refer them to a barrierspecialist.
Refer them to somebody who canhave that conversation with them
.
Also, be aware that there's aspectrum of care.
That spectrum of caredefinitely includes surgery as a
consideration for some people,but it also includes things like
medications and dietary supportand mental health and physical
(34:08):
activity and a review of overallhealth and follow-up.
It's not one or the other andit's not one is more extreme
than the other.
It's what's right for thispatient and what combination is
it right for this person?
Speaker 1 (34:21):
I look at this, even Beatrix is a specialty.
I come from, pauline.
So many times where primarycare doctors have ordered a
pulmonary function test, theythink they know how to treat it
or they feel like, oh yeah,there's some reversibility there
, let's give them some albuterolso they know the bare minimum.
That's where specialties suchas pulmonary or bariatrics come
(34:45):
into play.
A primary care doctor knows alittle bit about everything,
them to the specialty that knowsthat's all they do all day.
They know the workarounds withinsurance.
They know how to help thepatient more, because even with
respiratory, primary caredoctors might not even know that
breathing, teaching breathingtechniques, can actually save a
(35:07):
COPD patient a lot of misery,yeah absolutely.
Speaker 2 (35:11):
I think it's not to say that we're trying to exclude
anybody from this process,because if more primary care
doctors want to be trained onbariatric care, there's a lot of
prepare, absolutely I raise myhand.
I am super interested inhelping people understand how to
use med weight loss and how toincorporate nutrition and mental
health and how to follow upafter surgery.
There are people out there thatare really, I think, available
(35:34):
resources for including morepeople in this work.
Speaker 1 (35:37):
And.
Speaker 2 (35:37):
Lord knows, we need more people doing it.
So it's not.
I hope it's not seen asexclusionary and if anyone.
Speaker 1 (35:45):
No, those primary care doctors just have so much
on their plates.
We see you, primary caredoctors.
We see you.
Speaker 2 (35:51):
We're trying to create more work and definitely
we're trying to recruit morepeople into this field, because
we need more people doing this.
We absolutely do Right, and Ialso want to make sure that
people understand in thehealthcare industry that
bariatric surgery isn't a lastresort.
It is a pretty unique approach.
That is the only thing thatactually accomplishes a
metabolic reset.
I think you and I coined theterm metabolic conversion the
(36:13):
other day, which I love thatterm too, but it really allows
people to reset their metabolismlike a thermostat, and there
really is no other mechanism fordoing that.
It also has the greatest effecton weight and metabolism versus
any other approach.
It's the most durable and it'salso the best covered by
insurance.
So, for the right person,surgery should be considered as
(36:35):
one of their first optionsrather than one of their last.
Speaker 1 (36:39):
Yes, yes.
Speaker 2 (36:42):
And that BMI alone is not a health indicator that
warrants any kind of treatment.
Bmi is a starting point for anevaluation of an individual and
that anchors the discussion inthe very beginning, and then we
go from there to recognize that,just like a calorie is not a
calorie, weight is not weightfor everyone and there are many
people at a BMI of over 40 thatcan be very healthy and there's
(37:04):
many people under a BMI of 40that can be very unhealthy.
So it is just the startingpoint to an evaluation.
The other thing to remember isthat weight management requires
a village, much like raising achild.
I think we need to reallyforget about blaming individuals
and thinking of keeping peopleisolated and struggling.
(37:25):
We need to include people inour community and in our village
, basically in terms ofsupporting people in lifelong
weight management.
Speaker 1 (37:34):
Yes, absolutely.
And as a patient, I want totell other patients that if you
have a primary care doctor thatjust isn't listening to you,
it's okay to step away from thatprimary care doctor.
It doesn't mean you haveanything against that primary
care doctor, it's just you needmore out of them and that's okay
.
And if they just aren'tlistening to you, please reach
(37:56):
out and try to find someone thatis willing to listen to you.
Ask for a referral to abariatric program if they don't
offer you one.
See, if that program allows andyour insurance allows you, to
make yourself a self-referral.
But, as Maria has said, a lotof healthcare providers don't
understand a lot of this, and sohave patience with them.
(38:19):
For sure, they are stilllearning just as much as even
the expert Maria here.
Or bariatric surgeon.
Like their experts in theirprofession or that specialty,
they're still learning.
So definitely have patiencewith your providers as well, but
don't hesitate to tell themwhat you need and go fight for
(38:40):
what you need.
Speaker 2 (38:41):
Exactly, and I think it's up to all of us, as
individuals, as communities, ashealthcare providers too, to
take a stand against stigma onthis topic.
I think that if we're not partof the solution here, we are
part of the problem, and it'stime for people to own that, for
us to say this is not a moralissue, this is not.
(39:02):
It makes no sense to excludepeople from this care.
It makes no sense to makepeople feel bad about this.
It makes all the sense in theworld to help people get the
care they need.
Speaker 1 (39:12):
Yes, absolutely.
So on that note, I think thatwe can't beat that, so don't
forget to follow us.
Go over to Instagram or TikTok.
I'm still figuring out theTikTok part, but we'll get some
videos going.
We'll get some anyways, corebariatric, especially Instagram,
to let us know if there'sanything you want to talk about
(39:32):
questions, concerns but don'tforget to follow us so that you
get notified of when our nextepisode comes out.
I think this was a great oneand I'm so excited to have this
one come out so people can hearall this.
You're right.
Speaker 2 (39:46):
Thank you so much, tammy.
Thanks for listening.
We'll see you next time.
Bye, bye, bye.
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