Gut Instincts: Can an Endoscopy Fix Weight Regain After Stopping GLP-1 meds?

Episode 44 of the Pound of Cure Weight Loss podcast offers a deep dive into cutting-edge treatments and strategies for long-term weight management, focusing on GLP-1 medications for weight loss, the emerging technology of duodenal mucosa ablation, and the issue of weight regain after GLP-1 treatment cessation. Hosted by Dr. Matthew Weiner, bariatric surgeon, and Zoe Schroeder, registered dietitian, this episode explores innovative methods to combat weight regain while delivering practical nutritional advice for sustained success.

The episode begins with a light conversation about nutrition, as Zoe highlights how bananas are often unfairly demonized. Dr. Weiner suggests a simple hydration solution—water and a banana—as a healthier alternative to processed electrolyte supplements, setting the tone for the podcast’s emphasis on whole, unprocessed foods.

Weight Regain After GLP-1 Medications

The focus then shifts to the weight regain after GLP-1 medications—a challenge faced by many patients after discontinuing these treatments. Dr. Weiner introduces Revita, a new device that uses duodenal mucosa ablation to help maintain weight loss following the cessation of GLP-1 drugs. Revita recently received FDA breakthrough device designation for its ability to treat patients who experience weight regain after stopping GLP-1 medications for weight loss. Dr. Weiner discusses how this endoscopic device works by ablating (burning) the mucosa in the duodenum, a section of the small intestine, potentially mimicking the effects of gastric bypass surgery. This approach aims to create a bypass-like effect without traditional surgery, helping to address the critical issue of weight regain after GLP-1 medication cessation.

Duodenal Mucosa Ablation - Skepticism and Safety Concerns

While Dr. Weiner expresses some skepticism about the theory behind the duodenal mucosa ablation, he acknowledges the potential of the Revita device, particularly given the high economic burden and ongoing shortages of GLP-1 medications for weight loss. He notes that while the data is promising, safety concerns—such as the risk of perforation and chronic inflammation—must be addressed before widespread adoption of this technology.

In addition to discussing duodenal mucosa ablation and the challenges of weight regain after GLP-1, Dr. Weiner and Zoe offer practical nutritional guidance. They emphasize the importance of long-term dietary changes, including incorporating more whole foods, fruits, and vegetables, especially for patients on GLP-1 medications for weight loss or recovering from weight loss surgery. The podcast underscores that successful weight management requires sustainable habits, from meal planning to making healthier choices amidst busy schedules.

As they wrap up the episode, Dr. Weiner and Zoe reflect on the future of obesity treatment, acknowledging that a combination of GLP-1 medications for weight loss, non-surgical techniques like GLP-1 medications and the duodenal mucosa ablation, and proper nutrition will continue to evolve. While these treatments are not magic solutions, they hold significant promise in tackling the persistent challenge of weight regain after GLP-1 cessation.

Episode 44 provides a valuable perspective on the latest developments in weight management, particularly for those using GLP-1 medications for weight loss or considering alternatives like duodenal mucosa ablation. Dr. Weiner and Zoe's thoughtful discussion offers essential insights for patients navigating the complexities of weight loss surgery, medication, and nutritional strategies for long-term success.

Episode Transcript

Zoe (00:00):
bananas are demonized right Totally.
People fear eating bananas.

Dr. Weiner (00:05):
I think bananas.
You know a lot of people arelike into this liquid IV and
these electrolyte supplements.
To me the answer is water plusa banana.
Episode 44, zoe.

Zoe (00:17):
Here we are.

Dr. Weiner (00:18):
Here we are Gut instincts.
Can endoscopy fix weight regainafter stopping GLP-1 meds?

Zoe (00:25):
Well, that'd be good.

Dr. Weiner (00:26):
I mean this is the million dollar question, right?
I mean the number of times Ihave patients coming in and
they're like I want the meds andI'm like, okay, you know, you
probably have to take them forthe long run.
Oh well, I don't want that.
So I mean everybody out therewants this situation where they
can take the meds, lose theweight and then be done with it.

(00:48):
I don't know that we're goingto get there.

Zoe (00:51):
Yeah, I've heard I've had a couple of people come to me and
say I want to do it for threemonths, see how much weight I
can get off, and then I'm like,yeah, 90% regain.

Dr. Weiner (01:02):
That's what the most of the data is showing us.

Zoe (01:04):
So what do we have for In the News?

Dr. Weiner (01:05):
So our In the News segment is about where the title
comes from, and it's from MSNand it's about this company
called Fractal F-A-R-C-T-Y-L.
They just got FDA breakthroughdevice status for something
called Revita and it wasactually approved for the
purpose of weight lossmaintenance in patients who have

(01:25):
stopped GLP-1 meds.

Zoe (01:27):
Very specific, must have just been very recently emerging
.

Dr. Weiner (01:31):
You know, I think when they put these things
through the FDA, they're alwayslooking for their angle, their
new approach.
And with the economic burden ofGLP-1 meds, the shortage, all
of these things, they've kind ofto some degree created a little
bit of a health crisis, and sowhen you can solve a health
crisis, the barrier for approvalof FDA-approved things is going

(01:56):
to be substantially lower.
We saw this with COVID.
When COVID came out, it waslike it took absolutely nothing
to get any kind of breathingdevice, ventilator, anything
pushed through the FDA, becausethey were like we could need a
million more ventilators that wehave if this is going to work.
And so they were just likewhatever floodgates open, we'll

(02:16):
try anything.
We'll leave it up to anythingthat can help meet this need.
So the FDA definitely looks atour overall health healthcare
system when it's approvingthings.
So my suspicion is someone veryclever kind of saw this as an
opening.
So it's an endoscopic device.
They kind of put you to sleep alittle bit and they put a scope
through your mouth, pass thescope through the esophagus into

(02:39):
the small intestine.
And the thing I didn't likeabout this is they talk about
this overgrown mucosa in theduodenum the duodenum or the
duodenum, depending on how youwant to say it and how fancy you
want to be is the very firstportion of the small intestine,
right after the stomach empties.
It goes right into this andit's a very specialized portion.

(03:00):
It's where your pancreaticenzymes come in, where your bile
comes in, and so they say thatthere's overgrown mucosa, the
lining in that area of theduodenum.
Now I have done 10,000endoscopies on patients pre and
post-op, after surgery, I mean Ithink anyway, I do a lot of

(03:24):
these things.
I've seen the duodenal mucosamany, many times and I've seen
it in patients suffering fromobesity.
I've never really noticed anydifference between those
patients and other patients.
You got celiac disease.
It looks a little different,you can see, but so I don't know
where they're coming from fromthat.
That to me, and on theirwebsite they've got pictures of

(03:45):
like a thick lining versus athin lining in a normal person.
I think they also targeted type2 diabetes.
They said with diabetes you getthis overgrown mucosa.
That is a new one to me and Ifeel like I should know that.

Zoe (03:59):
I was going to ask if you could visually see a difference,
but it sounds like no.

Dr. Weiner (04:03):
I mean the 5,000 times I've looked at it.
I've never noticed that.
But maybe I missed something, Idon't know.
But their data actually isn'tterrible.
So they showed in type 2diabetics and we've talked a lot
diabetes makes it harder tolose weight.
This showed 3.4% total bodyweight loss.
That was maintained andactually increased to 4% at 48

(04:28):
weeks after the treatment.
And they didn't do lifestyleintervention.
So they're just like I'm goingto burn your duodenal mucosa and
we're going to see what happens.
That's amazing.
No diet, yeah, and they lostsome weight.
So you know, you always got towonder about the
industry-sponsored studies andthese things need to be

(04:49):
validated.
But that, to me, caught myattention.
I thought that was prettydecent and I think you know
again, when I'm looking at stuff, I always want to.
It always needs to make senseto me.
When it's totally random andout there, I always doubt it.
Sense to me when it's totallyrandom and out there, I always
doubt it.
So a gastric bypass bypassesthe flow of food through.

(05:10):
We bypass the duodenum and sois it possible that by ablating
that mucosa it kind of createsthat bypass-like effect?

Zoe (05:20):
Right.

Dr. Weiner (05:36):
And so you know, this thing is interesting to me,
and I think the idea of youknow Right, potentially if not
eliminate the need to continueto take meds, at least give
people hey, you're going to geta six-month holiday and then
you'll take them again for a fewmonths, and then that all
sounds really interesting and Iwonder what we're going to come
up with and what treatments willbe available for that.

Zoe (05:56):
Yeah, well, it sounds like you potentially will be learning
a new skill while you'realready down in there.

Dr. Weiner (06:05):
We'll see.
We'll see.
Yeah, I mean I'm not quiteready to sign up for the trial.
Here's my concern.
I have two concerns.
The first is you can perforate,you're burning that mucosa.
It's, you know, the duodenum isthin, it's not a thick structure
.
The stomach is actually prettythick and you know, sometimes
I'll believe me I make holes inthe stomach all day long.

(06:25):
Sometimes it's a little tricky,like you got to try, and it's
thicker.
It takes some time.
The duodenum man.
It doesn't take much to make ahole in that.
It's a much thinner structure.
And so I worry about perforation, and perforation of the
duodenum is a big deal, that'snot.
You know.
You can patch it and there's asurgical solution for it, but

(06:48):
that's not gonna be a fun monthor two for you.
And so that to me is like youknow, you're going into a very
dicey area.
The bile duct's there, theportal vein's there, the hepatic
artery is there, the pancreaticduct is there.
Like that is tiger country whenit comes to surgery, and so
burning that area over and overagain.

(07:10):
The second thing I worry aboutis that this essentially, you
know, could create chronicinflammation or a chronic ulcer
of the duodenum, and that's aproblem, that's a disease state
that we treat, and so I thinkyou know we need to know a lot
more about this before it comesout.
But the data, their initialdata, is good and it's an

(07:31):
interesting concept and the ideaof an endoscopic treatment to
prevent, to allow people to stopGLP-1 meds that worked, man,
that'd be great.

Zoe (07:41):
Well, it'll be interesting to see, as we hopefully get more
research about it.

Dr. Weiner (07:45):
Yeah, for sure, all right.
So what do we have for ournutrition segment, zoe?

Zoe (07:49):
All right, well, we're going to for our nutrition
segment, zoe.
All right, well, we're going to.
The reason why we have thisnutrition segment is because
last week I got my grocerydelivery.
I actually-.

Dr. Weiner (07:59):
You love that delivery.

Zoe (08:00):
Well, it's because I don't have any flipping time to go to
the grocery store.

Dr. Weiner (08:03):
I get it.
I get it.

Zoe (08:07):
So I'm very grateful that that has been a tool that I've
been able to not only helppatients implement.
But I've actually now and Ilove going to the grocery store.

Dr. Weiner (08:16):
Yeah, I love it.
I really do, I love it.

Zoe (08:18):
But it's just not something I've been able to make time for
recently.
So, anyway, I ordered fivebananas.

Dr. Weiner (08:26):
Okay.

Zoe (08:27):
And I got 15.
I got three bunches of fivebananas.

Dr. Weiner (08:31):
Bonus.

Zoe (08:32):
Yeah, I was like all right, well, we're doing a lot of
banana stuff.

Dr. Weiner (08:35):
We're eating bananas , okay.

Zoe (08:40):
So anyway, I wanted to.

Dr. Weiner (08:41):
I thought it would be interesting to talk a little
bit about how bananas aredemonized, right?

Zoe (08:43):
Banana people fear eating bananas.
I, you know, and I get it.
You know there's a there's alot of sugar in bananas, but
it's a natural sugar.
So let's first talk aboutwhat's the difference between
added sugar and natural sugarand I think we've talked about
this before but the main piecesof it is natural sugars from
whole foods.
You're getting a lot of othergood nutrition.

(09:05):
You're getting fiber.
You're getting phytonutrients,vitamins, minerals right.
You're getting otheringredients, if you will, that
your body has a job for right.
Added sugar it's just sugar.
Whatever's extra is going to bestored for later, aka fat.

Dr. Weiner (09:19):
Yeah.

Zoe (09:19):
So, basically, if you're craving sugar or you're craving
desserts, don't completely nothave any sugar, maybe lean more
towards the natural sugar and,in the case of today, let's talk
about ways to use banana.

Dr. Weiner (09:35):
Perfect, you got 15 of them.
You got 10 extra bananas.

Zoe (09:39):
Right, exactly so.
Frozen bananas are always astaple in my freezer.
You can pop them into asmoothie.

Dr. Weiner (09:46):
You peel them first.

Zoe (09:47):
Yes, I've made the mistake one time of just oh, all these
bananas are bad, I'm just goingto pop them in the freezer.

Dr. Weiner (09:53):
Peel doesn't slide off so easily.
Oh no, no no, that was adisaster, and then you melt it
and it's mush, right, it's sogross.
That's a mistake you make once.

Zoe (10:02):
So frozen bananas can go in smoothies or like a little
dessert, like milkshakes with afrozen banana.
Right Cocoa bananas, some cocoapowder, some Greek yogurt,
almond milk, peanut butter.
You got a delicious dessert,but it's also no added sugar.
You're getting protein verynutritious.
You can make nice cream, one ofyour favorite things.

Dr. Weiner (10:22):
One of my favorites.

Zoe (10:24):
I like slicing the.
I shouldn't do that on thetable Slicing bananas first
putting them on a wax paperlined cookie sheet or parchment
paper lined cookie sheet.
Little smear of peanut butter,little dusting of cocoa powder.
Freeze it so that theyindividually freeze and then you
can store it in a gallon sizeZiploc bag.
But just one little.

(10:45):
It's cold, it's creamy, it'schocolatey, it's very satisfying
.

Dr. Weiner (10:49):
When you freeze a banana, it has a texture of ice
cream.

Zoe (10:51):
Oh it's great yeah.
But then also mashed banana cango great in making.
You know like, if you'rewanting to make some sort of
baked good alternative, that isa great way to add sweetness.

Dr. Weiner (11:04):
Yeah, I've seen that a lot.

Zoe (11:05):
You swap that out for the sugar and the oil, because
you're getting the moisture butyou're also getting the
sweetness.
So, anyway, bananas are great.
Don't be afraid of eatingbananas.

Dr. Weiner (11:18):
And if you're given 15 bananas, you're going to be
making a lot of banana stuff.
Yeah, I think bananas you knowa lot of people like into this
liquid IV and these electrolytesupplements.
To me the answer is water plusa banana.
And actually, if you look attennis players are like you know
, tennis players.
They don't get like they got tobring their own food.
People can't bring them stuff.
They don't have a coach there.
They can really have verylimited like when you're playing

(11:39):
tennis you're on your own, yougot to, you carry your own bag
in, right, you know.
And so tennis players arefamous for using bananas as a
snack and they'll bring in abunch of bananas through the
match and they drink water.
They have their electrolytesolutions too.
I mean, listen, if you'replaying tennis in 90 degree heat
for five hours, you can drinkelectrolyte solutions with sugar

(12:02):
.
I'll give everybody permissionto do that but bananas is really
kind of a staple of theirnutritional plan for getting
through the match.

Zoe (12:11):
Electrolytes and quick digesting carbohydrates.
Exactly.

Dr. Weiner (12:14):
Exactly.
All right, let's move into oureconomics of obesity segment,
and this isn't so much aboutobesity, but it does impact all
of us, I think.
And the question I'm going toask is why is it so hard to find
a doctor these days?

Zoe (12:30):
I don't know, but it sure is.

Dr. Weiner (12:32):
I mean, it really is difficult yeah wait list super
long, the wait list.
I mean it's not crazy to call adoctor and be told our next
opening is in six months.

Zoe (12:44):
Right.

Dr. Weiner (12:44):
Right.
So how did we get here?
People criticize Canada becauseoh, the wait list.
We got them now too.
Yeah, we got major wait lists.
We got wait lists for surgeries.
We got wait lists to seedoctors.
You know, I think we've managedin our practice to keep our
appointment time relativelyshort.
We can usually get to peoplewithin a few weeks.

(13:05):
But you know there's a realissue with this.
So we see shortages ofpulmonologists, psychiatrists,
big time.

Zoe (13:15):
Big time.

Dr. Weiner (13:16):
ENT.
I have a friend who's an ENT.
He's booked out for six monthsNeurosurgeon, primary care
doctors.
When I moved to Tucson I'm inthe medical community it took me
three months to get a PCP.
So, rheumatology almostimpossible to get in with a
rheumatologist these days.
Endocrinology, obgyn we havepregnant women looking for a

(13:41):
doctor.
They test positive.
They're like oh my God, I'mgoing to the OB, oh, we can get
you in in three months.
Isn't there something that'ssupposed to happen in these next
three months?
I mean, it's really getting alittle bit crazy.
The question is why what'scaused this change?
And I think there's a littlebit crazy.
The question is why what'scaused this change?
And I think there's a couple ofissues.
I think we've talked a lot aboutinsurance companies.

(14:03):
Unitedhealthcare is the ninthlargest company in the world,
and these insurance companieshave needed to continue to grow,
to grow profits.
If you look at the stock pricesof these companies, it's been
astronomical.
The CEOs bonuses are directlytied to the stock price, and so

(14:25):
there is just a huge push forinsurance companies to continue
to profit.
The problem is it's notunlimited.
You cannot just keep makingmore money on health care.
There's only a certain amountof health care that needs to be
performed.
There's a real pressure toreduce costs.
Employers have kind of hit theend point where they can't

(14:45):
afford to pay more for healthinsurance, and so what we've
seen is that insurance companieshave now worked to try to
reduce rates, and we've seenthis in our own practice.
We have a couple of payers whoare offering us, in all honesty,
less money than I was paid 10years ago for the same
procedures probably 20 or 30%less.
And so, if you look at what'shappening in every business,

(15:11):
costs are increasingdramatically, and so employee
wages are going up, costs ofgoods are going up, rent is
going up, so costs of providingservices have gone up, the
reimbursement has gone down, andwe've kind of hit this tipping
point where doctors are lesswilling to see all these

(15:33):
patients and they're starting toopt out of insurance networks,
and so, you'll see, you mighthave Aetna, cigna, united, and
you've been like, oh, I'vealways been able to see whatever
doctor I wanted, and we're nowstarting to see these physicians
.
If you're booked out for sixmonths and an insurance company
offers you a small amount ofmoney, what are you going to say

(15:55):
?
You're going to say, sorry, Igot plenty of patients.
I don't need your patients.
I can reduce that that actuallyyou're solving a problem now as
opposed to causing one, and soI think that the net result here
, unfortunately, is that we'regoing to see that people will
have a limited choice inphysicians and that your Blue

(16:17):
Cross card, your Aetna card,your United card, which is
uniformly in the past allowedyou to see whatever doctor you
wanted, you may not have thatoption.
You may start calling up andfinding out oh, we don't take
Aetna, we don't take Cigna.
I think we'll see it with Aetnaand Cigna before we see it with
United and Blue Cross, becauseAetna and Cigna, I think we'll
see it with Aetna and Cignabefore we see it with United and
Blue Cross, because Aetna andCigna pay less typically than

(16:40):
Blue Cross and United.
And so I think this is a realproblem because, especially
people will have relationshipswith doctors and they may all of
a sudden, out of the blue, geta letter that says hey, sorry,
we're not taking your insuranceanymore.
And so the question is what canyou do in that setting?
You know, the first thing youshould do is call your insurance

(17:01):
company and complain.
No question, because if youdon't call your insurance
company and complain.
And if you don't call your HRdepartment and complain and say,
hey, listen, I don't knowwhat's going on.
We need to put some pressure onour insurance company in order
to let them know hey, listen,you have to come up with some

(17:21):
more favorable contracts withphysicians so that we can have
more docs in network.
Then the insurance companieswill continue to do what they're
doing.
So there has to be somepressure there.
So that's the first thing.
The second thing, especially ifit's kind of more of a
cognitive specialty, like youjust need an offices, you don't
need a procedure from them, youdon't need a bunch of testing
through their office Then youcan just reach out to the doctor

(17:47):
and get a self-pay price andyou may find especially if
you're an existing patient, it'svery likely you can get a visit
with your doctor for under ahundred dollars and with co-pays
being sometimes 50 or even 75bucks, it's not a huge
difference and you may even beable to receive some
reimbursement back from yourinsurance company as an out of
network payment.
So you may actually get some ofthat money back.

(18:09):
And so I think the first thingis just see what you can do.
There may be an option tocontinue to work with that
physician out of network thingis just see what you can do.
There may be an option tocontinue to work with that
physician out of network.
And especially, you know, mostof these doctors aren't doing it
out of greed but are reallydoing it out of survival, out of
necessity, out of survival, andso I think you'll find that a
lot of doctors will be willingto work with you and come up

(18:30):
with something very fair andreasonable.
It may be more expensive thanyou have paid in the past, but
certainly not astronomicallyhigh.
I think that problem willlikely work its way out and I
think honestly, the more marketforces and the more directly

(18:50):
people pay for their healthcare,the more we'll see a reduction
in healthcare costs.
So to me that doesn't seem likea terrible awful thing to come
from this.
It may actually help put somepressure on insurance companies
to maybe lean up a little bitand direct more of their costs
to patient care.

Zoe (19:07):
So, anyway, another good episode, zoe, yes, yes, Very
good, and we hope you enjoyed it.
If you have any feedback for uson our new podcast style the
shortened episodes please let usknow.

Dr. Weiner (19:18):
Please follow us on social media.
Reach out to us If you havequestions that you'd like to be
answered on the podcast.
Send them over and we'll do ourbest to get to get to them as
soon as possible.

Zoe (19:28):
See you next time.

Dr. Weiner (19:28):
Bye-bye.