December 12, 2024 • 51 mins
In Episode 55 of the Pound of Cure Weight Loss podcast, Dr. Matthew Weiner explores the complex causes of obesity and shares innovative strategies for achieving lasting weight loss. Drawing from decades of experience as a bariatric surgeon and his deep understanding of physiology, Dr. Weiner delivers actionable insights into weight loss surgery, GLP-1 medications, and the power of healthy food.
Understanding the Root Cause of Obesity
Obesity is not just about overeating or inactivity—it’s deeply tied to our evolutionary biology. While our ancestors thrived with fat-storing mechanisms, modern diets rich in processed foods have disrupted this balance. These diets push our body’s metabolic thermostat to a higher "setpoint," making weight loss increasingly difficult.
The Metabolic Thermostat: A Key to Weight Regulation
Your metabolic thermostat regulates body weight, hunger, and metabolic rate. It aims to maintain a specific "setpoint," making it hard to lose weight with calorie restriction. Efforts to lower calorie intake often backfire as the body slows its metabolism and increases food noise (cravings and hunger).
Why Does the Setpoint Increase?
- Processed Foods: Disrupt hormonal signals and promote fat storage.
- Weight-Gaining Medications: Certain drugs, such as insulin and antidepressants, elevate the setpoint.
- Hormonal Shifts: Pregnancy, menopause, and chronic stress all contribute to weight gain.
Four Proven Ways to Lower Your Setpoint
Dr. Weiner outlines four key strategies for achieving sustainable weight loss:
1. Focus on Healthy Food
Adopting a diet rich in fruits, vegetables, nuts, seeds, beans, and lean protein is more effective than calorie counting. These whole foods support long-term metabolic health and help reset the body’s physiology.
2. Build Muscle
Strength training helps alter fat storage mechanisms and improves overall metabolic health. While not as powerful as other methods, maintaining muscle mass can complement other weight-loss efforts.
3. Leverage GLP-1 Medications
Medications like Wegovy and Zepbound mimic hunger-regulating hormones to reduce food noise and lower the setpoint. These drugs are highly effective when used long-term, achieving up to 25% total body weight loss in some cases.
4. Weight Loss Surgery
Bariatric procedures such as gastric bypass or sleeve gastrectomy lead to hormonal changes that lower the setpoint. When paired with GLP-1 medications, surgery can result in transformative weight loss of up to 50% of total body weight.
The Importance of Combining Treatments
Dr. Weiner emphasizes the power of integrating healthy eating, GLP-1 medications, and weight loss surgery. This approach customizes weight-loss strategies to individual needs, enhances results, and provides durable, long-term weight control.
Support and Community: Keys to Success
Dr. Weiner highlights the value of support networks and peer-led groups. These resources, paired with professional nutritional guidance, help patients stay motivated and achieve their weight loss goals.
Takeaways:
Obesity is a complex condition that requires a multifaceted treatment plan. Combining weight loss surgery, GLP-1 medications, and healthy food provides the best path to success.
For more resources, visit Pound of Cure Weight Loss to join support groups and access expert insights.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Weiner (00:00):
What we see.
When we start to back out andthink about these as individual
or combination treatments, wesee that the more treatments we
apply, the more weight loss weget.
Thank you very much for havingme here.
I've been a bariatric surgeonnow for 20 years Seems like a
(00:22):
long time ago.
I put my first video out onYouTube because I didn't have a
dietician at the time and Ineeded to communicate with
patients what my post-operativediet was, and so now I think I
just hit 5 million views onYouTube, which is kind of crazy
to me.
But I really love being a partof this bariatric community and
(00:44):
I've loved being a bariatricsurgeon and working with
everybody and watching yourtransformation and your success
and being a part of helping youchange your life and freeing you
really from the, quite honestly, the prison of obesity, and so
if you've watched any of myvideos on YouTube, I think you
have a sense that I really takea fairly physiologic perspective
(01:05):
on things, and so I'm going toreally dig into some of the
science behind obesity and talkabout how we can apply that to
ensure that you have long-termsuccess going forward.
So something when I really diginto the physiology, I think the
first place I start with iswhat most people assume is the
(01:26):
cause of obesity, which iscalorie excess consuming more
calories than you burn.
And if you could just diet, eatless, exercise more, then the
weight would just come off.
And there's a fundamental flawwith that assumption, and that
flaw is that the calories thatyou consume and the calories
(01:49):
that you burn are notindependent variables, meaning
when you eat fewer calories, youburn fewer calories, and if you
exercise more, you eat morecalories, and if you exercise
more, you eat more calories.
And so this isn't simplearithmetic, this is high order
calculus.
(02:10):
The math is actually very, verycomplicated when it comes to
obesity, because as you eatdiffering amounts, it changes
your metabolic rate, and so ifwe don't factor that in, we put
ourselves on a path for failure,and I'm sure there's not a
person in this room who hasn'tput themselves in calorie
(02:30):
deficit, found some initialsuccess and then ultimately
found that the math and thestrategy broke down and they
were very quick to regain theirweight.
Another point I discuss is ifwe're going to take this calorie
counting and really carry itforward.
The assumption is and there'ssome debate about this but 3,500
(02:55):
calories is about one pound ofbody fat, and there's different
people argue about it.
To be honest with you, I don'treally see the point in arguing
about it, because thefundamental philosophy behind it
is flawed.
So let's just work through whathappens if you were to consume
(03:15):
10 more calories every day thanyou burn.
Let's talk about what 10calories is.
10 calories is a potato chip.
Yeah, it's nothing.
10 calories is an incrediblysmall amount of food.
But if, every single day over ayear, we consume 10 more
(03:40):
calories than we burned, thatwould be 3,650 calories, around
3,500.
Let's just round it to 3,500.
And so you'd gain a pound offat in a year if you just eat
one extra potato chip more.
Is there anybody out here whoweighs the same today that they
(04:04):
did five years ago?
Anybody?
Yeah, give or take right.
If you weigh the exact sameamount that you did five years
ago, it would mean over the lastfive years, you somehow managed
to balance your calorie intakeand your calorie consumption
(04:26):
down to the last crumb.
Because, like I pointed out,even 10 calories over five years
, you'll gain five pounds.
And so we have to take a stepback from this calorie counting
and recognize that it's not sosimple and that we can't just
look at this as striking theright calorie balance to drive
(04:50):
weight loss.
There has to be something elseat play that allows someone to
go five years without eatingeven one crumb extra, over five
years, consuming 1,800, 2,000calories a day.
It's really a remarkable featand it points to the fact that
(05:11):
there is regulation at play.
Our body regulates our body fatstorage, it regulates our
hunger, it regulates ourmetabolic rate.
I refer to this as yourmetabolic thermostat, and what I
really mean when I'm talkingabout this is that if you were
(05:31):
to say, put yourself intocalorie deprivation, let's go
back to that time when you didthe math.
You put yourself on an 800 or1,000 calorie a day diet, you
ran the calculation based onwhat your basal metabolic rate
was, and you restricted yourcalorie intake and you lost
weight.
Because it works at first,there's no question it works
(05:52):
right off the bat.
But what happens is your bodyhas a set point, it has a number
that it feels comfortable at,it has a number that you always
seem to balance back to.
And when you stray away fromthat, when you restrict your
calorie intake, when we focusonly on calorie restriction and
(06:15):
not other different nutritionalmethods, which we'll talk about
in a second.
Your body weight drifts downand the thermostat kicks in and
it tries to push your weightback up to your set point.
It increases the food noise,the hunger, the thoughts about
food.
(06:35):
We tell ourselves that theseare things that are entirely
under our control and therecertainly are things that we can
do to minimize food noise,outside of medications or
surgery or any of the otherthings we're going to talk about
.
But we also have to understandthat this is a basic physiologic
(06:57):
drive and ultimately, if wepush this thermostat far enough,
our ability to resist thatphysiologic drive will fail.
Just like you can trainyourself to hold your breath for
20 seconds 30 seconds a minute,but not 20 minutes Nobody can
hold their breath for 20 minutes.
It just is physiologicallyimpossible.
(07:20):
We also see your metabolic rateslow down, and so the math that
initially said you should belosing a pound every three or
four days it starts to fail andthe weight stalls and you may
even go up a little bit andyou're like how am I gaining
weight eating 1200 calories aday?
And the answer is yourmetabolic rate is slowing down
(07:44):
below 1,200 calories a day, andso your body responds to
decreased food intake.
But there's another part ofthis thermostat that we tend to
ignore, but it's criticallyimportant and it's what happened
to all of you after surgery.
If you put your weight aboveyour set point, then the
(08:06):
opposite changes occur.
A good example what I usuallyuse for this is New Year's Eve.
New Year's Day, right.
What do we all do on New Year'sDay?
I'm going to eat right, I'mgoing to exercise, I'm going to
go to the gym.
I'm motivated.
Well, what's happened the weekor two before New Year's Day?
We eat right, we all eat, andso we all push ourselves a
(08:33):
little bit above that set point.
Food is in abundance, there's acelebration, everybody's around
and we eat a little bit more.
And our body weight?
We gain a few pounds, and soit's easy to ignore food for
those first few days becausethese opposite changes are
happening.
We're seeing a decrease in ourfood noise and we want to go to
(08:54):
the gym.
We're super motivated becausewe got this extra energy.
We're trying to burn offcalories, our body is in high
metabolic rate mode and we wantto burn calories, and so this
set point really governs yourbody weight.
Your body fat is physiologicallyregulated and it only makes
(09:16):
sense because all of us,physiologically, are cave people
, and cave people starve todeath.
There was no buffet line backin the caveman era, and starving
to death was a very real threat, and so our physiology evolved
(09:37):
to maximize our ability toabsorb calories and regulate our
body weight.
What happened to the cavemanwho lost 10 pounds and didn't
get hungry, didn't develop adesire to eat?
That caveman didn't procreate,no, it was the people who were
able to make it through thoselong periods of famine and
(10:03):
starvation that inevitably occurif you're a caveman.
Those were the ones who wereable to move on and procreate
and pass on their genes.
And the truth is, everybody inthis room.
If you've had bariatric surgeryand you struggle with your
weight, you probably would havebeen a kick-ass cave person.
You would have made it throughthe winters without any problem.
You had all the genes thatallowed you to make it through
(10:26):
periods of food shortage withoutlosing your precious body fat
stores, which were there to keepyou alive.
And that's the ultimate,ultimate cause of obesity is
that we're eating a modern dietand with our paleolithic genes.
And so if we're going to drivepermanent, durable weight loss,
(10:49):
we're going to achieve that notby fighting away from our set
point, not by somehow figuringout how to resist our basic and
primal physiologic drives, butwe're going to do this by
somehow lowering that set point.
If you're 300 pounds and wecould just turn that set point
(11:11):
down, adjust the metabolicthermostat to 250 pounds, and so
now, all of a sudden, your setpoint is 250 pounds but your
body weight is 300 pounds, yourbody's going to say, hey, this
is like New Year's Day times 10.
I have a rapid metabolic rate,my metabolism is not going to
(11:35):
slow down and I have zerointerest in food, very much like
those first few months aftersurgery Zero interest in food.
You could have gone dayswithout eating, no problem.
And so that was because thatsurgery, that rearrangement of
your intestines, lowered yourset point and put you well on
(11:57):
that overfed side of themetabolic thermostat and the
weight loss was now happeningwith your physiology.
Your physiology was driving theweight loss and you weren't
fighting against it.
And that's the key, becausegenerally, when your set point
is low, it's easy to lose weight, and if it's easy to lose
(12:20):
weight, that's a good thing,we're taught.
You have to try hard, you haveto suffer.
This is about pain, discomfortand enduring it.
That is the secret to weightloss.
That is what you've been toldyour whole life and it's the
exact opposite.
That's true.
(12:40):
It's the easy weight loss thatworks.
The weight loss after surgeryis generally pretty easy.
You almost can't do anything tostop it.
It's happening to you, notnecessarily something that
you're causing, and that's thesecret to durable, long-term
weight loss.
We have to lower that set point.
(13:01):
But before we talk about how tolower your set point, it's also
really important that weunderstand why your set point
went up, because these factorsright here, these are the causes
of obesity and if we're goingto be successful at lowering our
(13:22):
set point and keeping it low,we have to minimize these as
much as possible.
If you've listened to my podcastor watched any of my videos,
you've probably seen me talkabout weight gaining medications
.
New York Times just put out areally great article where they
reviewed a meta-analysis ofpatients who were taking SSRI
(13:47):
medications Prozac, welbutrin,sertraline, zoloft all those
kind of first-lineantidepressants and they showed
that taking these medicationswas associated with weight gain
about 5% of your total bodyweight over, I think, six months
or a year.
That's a lot of weight.
There's other, much morepowerful weight-gaining
(14:09):
medications Depo-Provera, along-term birth control
medication, insulin for thetreatment of diabetes, abilify,
risperidone a lot of thepsychiatric meds cause weight
gain, and so if you're going topreserve your lowered set point,
you have to avoid medicationsas much as you absolutely can.
(14:30):
If it's vital to your survival,your mental health, you gotta
take it, but if it's not, maybeyou shouldn't be taking it.
Medication-induced weight gainis real and I see it probably as
a major factor of weight gainin about a third of the people I
see in the office.
Genetics Problem with geneticsis we can't do anything about it
.
Our genetics are our genetics.
(14:52):
But you go to a family reunionand everybody's shaped the same
way.
You know that's what's going tohappen, and so, if those are
your genetics, fighting that isvery, very difficult.
It's an uphill battle.
Age also unmodifiable Well, itis, but not the way you want to
(15:14):
do it.
As we age, we tend to storeexcess fat.
Pregnancy, pregnancy,especially at an older age.
Pregnancy in your 30s, mid,even late 30s can be a
significant weight gainingfactor.
Menopause I don't need to tellthis to anybody who's going
(15:35):
through menopause or has beenthrough menopause.
Man, it gets a lot harder tolose weight after menopause.
Stress and depression.
I think this is really a hugeplace where mental health comes
in, and it's managing thiswithout taking medications that
cause weight gain.
And this is where all of thethings that people discuss the
(15:57):
behavioral therapy, thejournaling, the meditation, the
exercise all of these otherfactors that can help modify
your stress can also help youmaintain that lowered set point,
because long-term chronicstress or depression raises
cortisol levels.
Elevated cortisol levels causeyour set point to go up.
(16:19):
Processed foods and sleepdisruption all cause your set
point to go up, and so the firststep to maintaining your
lowered set point is to look atyour life, look at any of these
factors and say what can I do tominimize these and changing
(16:40):
that?
There are four ways to loweryour set point, and, in general,
at least three of them willoften make a lot of sense to
people.
So the first is nutritionalchange, and I'll go into each of
these in a little bit moredetail in a second.
Nutritional change is differentthan dieting.
(17:01):
It's eating different food.
An analogy I sometimes use ishey, listen, if I moved you to
rural China and you had to farmand raise your own food and
animals, do you think you'd loseweight?
Yeah, you would change the typeof food that you ate.
That's different fromrestricting the calories that
(17:25):
you consume, which we've alreadytalked about, is not a solid,
long-term solution.
Building muscle and using itthis is great for the young
folks out there, and this is alittle different than exercise
too Kind of the traditionalexercise that we think of is I'm
going to get on the treadmilland I'm going to exercise and
(17:48):
burn 200, 300, 400 calories.
Anybody who's ever tried totrack their calorie consumption
during exercise understands whata fool's errand this is right.
I mean, you ever use thoseassault bikes.
You know the things where youride like that with a fan.
I do that for like all out fora minute, which is it's the
(18:09):
longest minute of my day, and Iburn 14 calories doing it.
You know it's just you can'tburn enough calories through
regular cardiovascular exerciseto maintain weight loss.
However, if you can buildmuscle and then use it
vigorously, which is reallywhat's necessary to maintain
(18:32):
that muscle Muscle, the presenceof skeletal muscle on your body
lowers that set point.
It adjusts the way your bodylooks at your fat stores and
tries to store fat, and so insome people, this is totally
possible.
In some people, this is justsomething you shouldn't even try
(18:53):
because you'll hurt yourself.
And you know I say that as ajoke, actually, I left it out of
the last slide.
But one of the other majorcauses of your set point going
up is injury, and so so manytimes I talk to patients and
they're like I was doing great,and then I was in a car accident
(19:14):
, I threw out my back and Ineeded back surgery and as a
result of being laid up from myinjury, I gained 40 pounds Very,
very common.
And a lot of that weight gainis from muscle loss, and so
(19:35):
whatever you can do to buildmuscle safely without injuring
yourself, you should do.
But of all the four things uphere, this is probably the least
effective.
Like sometimes I joke thatexercise works well for women
under 30 and men under 40, whichis a pretty limited group.
I don't know what do?
We have probably three peoplewho fit that category in the
room right now.
I'm definitely not one of them.
(19:58):
The third I don't know.
Has anybody here heard thatthere's some weight loss
medicines out there now?
Yeah, yeah, now there's somenew medications, the GLP-1s.
There's really only two of them.
They each have three names, soyou hear six names flying around
, but there's really only twomedications worth looking into.
And these medications are areally great adjunct and they
(20:23):
work extremely similarly tobariatric surgery.
These are set point loweringmedications by overwhelming your
GLP-1 receptors with thesemedications.
And these medications provide a50-60 increase in your exposure
to GLP-1 over what your basicphysiology creates.
This isn't like a tiny uptickof your GLP-1.
(20:45):
This is a massive overwhelmingof it.
And these medications are setpoint lowering medications and
they work very well inconjunction with bariatric
surgery.
And to me, they kind of takesome of the imperfect things
about bariatric surgery and helpcover them up, and so I think
(21:07):
they're a really critical partof long-term weight loss
strategy.
And the fourth one is bariatricsurgery.
And we all think, oh, surgeryworks through restriction and
malabsorption.
That's not really how it works.
It's a hormonal surgery.
It changes the way your bodyinterfaces with food.
It changes the way yourintestines and your stomach
(21:29):
stretch in response to eating.
It changes the way yourintestines and your stomach
stretch in response to eatingand, through neurohormonal
access using ghrelin, leptin,insulin, glp-1, other hormones
it sends these signals back toyour brain and lowers your set
point.
And that's the essence of howbariatric surgery works, how
(21:55):
bariatric surgery works.
So what we see when we start toback out and think about these
as individual or combinationtreatments, we see that the more
treatments we apply, the moreweight loss we get.
And you know lifestyle changesare great and you know there
might be people out there whowrite books about nutrition and
talk about how great nutritionis and if you only fix the
(22:15):
nutrition, if you just got thenutrition right, you'd finally
lose the weight and keep it off.
And I think it's time for us toacknowledge that.
That's not necessarily anentirely true statement and I am
one of those people who havewritten one of those books but
on average, if you really nailthe lifestyle changes, it's
(22:39):
about 10% total body weight loss.
That's not that much.
You're 300 pounds.
You lose 30 pounds.
It's not enough to solve theproblem.
Now lifestyle changes are goingto be critical for all of these
other treatments and we have tolook at lifestyle changes as
something we add on to our othermedical treatments, because
(23:01):
they really make the medicaltreatments work much better.
Bariatric surgery without goodnutrition afterward doesn't work
that well, and the same is truefor GLP-1 medications, probably
even more so because it's aless powerful treatment.
Bariatric surgery is a moreeffective set point lowering
treatment than GLP-1 medications.
(23:23):
So now we get into themedications, our current crop.
We're seeing 15 to 20% totalbody weight loss.
There is some data, I thinkabout 18 months for Terzepatide,
which is Monjaro and Zepbown,which is clearly the better of
the two medications, the moreeffective of the two medications
.
That shows about 25% total bodyweight loss.
(23:45):
The thing that we're seeing isthat whatever they saw in the
studies and this is kind of howmedicine works whatever we saw
in the studies you don'tnecessarily get quite that much
weight loss on average in thereal world Because in the study
there were no copays and noprior offs.
So we're seeing in our practicesomewhere around 15 to 20%
(24:10):
total body weight loss and sothat's better than lifestyle.
We move up to a sleeve.
We're looking at 20 to 25% totalbody weight loss, a bypass on
average, 25 to 30% total bodyweight loss the real magic that
(24:33):
I'm seeing in my practice andthat is exciting me.
After 20 years of doing this,I'm probably more excited about
what we can offer our patientsnow than I have been at any
other point in my career.
It's when we combine all thesetreatments, when we take a
sleeve and a bypass and we addthe meds in afterward, we're
seeing.
I see patients coming into myoffice 400, 450 pounds and we're
(24:57):
literally able to cut theirweight in half reliably.
Not just hey for the billboardright.
Some people respond great tothese surgeries 10% of people I
call them super responders andthey don't need any meds, they
just their genes are alignedwith this surgery and they have
a remarkable response andthey'll lose 50% of their body
(25:20):
weight.
But that's not the average,that's the best responders.
That's the top part of thatbell curve.
With these meds we can geteverybody at that level 30 to
50% total body weight loss.
Audience (25:33):
Yeah, but with the meds don't you have to take them
forever and they're not likelukewarm.
Dr. Weiner (25:38):
Yes, yeah, yeah, but they work.
Yes, but what?
You have to take them forever,because they're lowering your
set point, and your set pointwill go up.
But you know what?
You might not have to take highblood pressure pills.
You might not have to take highcholesterol pills.
(25:59):
Your surgery is in you forever.
It's not reversed, and so ifyou're going to achieve
long-term, durable weight loss,you need to make long-term
changes, and the beauty ofsurgery is you make that change
once and then it just kind ofsticks around.
Medications don't work that way.
(26:20):
There's strategies, though, andI think what maintenance looks
like on these meds is still upfor debate and there's new
agents coming out and there'svariable responses that we see,
and so there's a lot to this.
And, again, you don't have totake the meds.
I'm just explaining to youwhat's available out there that
(26:43):
will allow you to be successfulover the long term.
So let's talk about lifestylechanges.
Again, very rarely the onlysolution.
There are people who can beextremely successful with
lifestyle changes, and the thingthat you know, people are like
oh, dr Weiner, you're like intothe veggies and nutrition and
(27:04):
everything like that, and that'sabsolutely true.
But I love it when someonecomes in eating a lot of
McDonald's and drinking a lot ofsoda.
But I love it when someonecomes in eating a lot of
McDonald's and drinking a lot ofsoda.
I love it because I can make ahuge change in that person's
diet and a huge change is goingto get you huge results.
And so that's a really thesepeople.
(27:30):
If you have a very poor diet tobegin with, you can lose a lot
of weight.
Now we don't want to go takethat diet all the way up to
surgery.
We want to correct it beforesurgery or even before we start
the meds potentially.
But we can see great weightloss.
So in every group there'speople who are super responders.
There's super responders tosurgery.
There's super responders tomedication.
(27:51):
There's super responders tolifestyle changes Young people,
people who are capable ofhigh-intensity exercise, are
able to lose substantial weightthrough nutrition, and then
people who've lost a lot ofweight in the past.
So let's talk a little bit aboutGLP-1 medications.
They are a very powerfultreatment option.
(28:13):
They are expensive and probablywill be expensive for at least
another five years, possibly ten.
Fifteen percent of people don'trespond.
10% of people don't toleratethem.
So I'm not telling you thesethings are perfect.
They are not perfect.
(28:34):
There is nothing perfect in theweight loss world.
Bariatric surgery is notperfect, nutrition and exercise
isn't perfect, and GLP-1 medsaren't perfect, but there are
people who respond extremelywell to them and there's only
one way to figure out if you'regoing to respond or not, and
that's to take them.
They have to be taken long-termfor weight loss and that is the
(28:58):
truth.
That's how they work.
You've got to go in acceptingthat.
The truth is how many peoplehere take a medication I do
right how many people ask theirdoctor when they can stop taking
that medication when it wasprescribed?
So if we're going to talk aboutexpense and I'd need a whole
(29:21):
other hour for that these medsare not expensive.
They're $5 to make.
It's our screwed up healthcaresystem that makes them so
unaffordable and expensive.
Audience (29:35):
And agreed.
Dr. Weiner (29:37):
Yes.
Audience (29:38):
I don't know if you can answer this or not, but what
would be the signs of like youdon't tolerate?
Dr. Weiner (29:44):
You'll know yeah.
Audience (29:47):
Developing skin rash and they say it might be because
of this.
Dr. Weiner (29:51):
So you know these GLP-1 meds.
We're seeing the same thing wesaw with bariatric surgery,
which is when you have bariatricsurgery, if you're like I have
this headache, everyone's like,oh, it's your surgery, yeah,
right, you know.
Oh, I broke my leg, yeah,because your surgery.
You broke your leg because ofyour surgery.
And so everybody's very quickto blame everything that happens
(30:15):
to you after this, and so wereally have to take a step back
and look at the science.
Skin rash isn't something I'mseeing.
We see.
It's mostly GI side effects.
It's heartburn, nausea,vomiting, constipation, diarrhea
.
Those tend to be modifiable ifyou dose them carefully and
correctly.
I think the big problem we haveis we're dosing them.
All the data, all the studies,the way that we're supposed to
(30:38):
dose them is wrong.
We're overdosing them, we'reescalating the dose too fast and
we need to be a little bit morecautious and understand this is
a long play.
This isn't a race.
We're in this mode of fastweight loss lose weight fast.
Everybody wants to lose weightfast and we shouldn't be focused
on that.
We should be focused on losingweight forever, and that
(31:01):
requires a different approach.
But yes, they are expensive,but over the long run they won't
.
This is my favorite graph ofall expensive, but over the long
run they won't.
This is my favorite graph ofall.
This is from the Surmount trial, which is the Terzepatide
Monjaro Zepbound long-term use,and it's a busy graph, but I'm
just going to kind of go over acouple of things.
(31:22):
If you look here, so this ishow many people met this body
weight reduction target.
So, greater than 5%, 10%, 15,20.
So these are the people wholost the most weight.
These are the people who lostthe least weight.
And then the three differentbars.
Here are the different doses.
So this is 5, 10, and 15milligrams, and then this bar
(31:43):
right here is the control group.
I want to point something out.
First, I can't see that number.
It's like what?
1.5%, I think.
Yeah, 1.5% of the control group.
The people who were given aplacebo, a saline injection,
lost more than 25% of theirtotal body weight.
So there was no nutrition.
These patients all participatedin a comprehensive, detailed
(32:07):
nutrition program, so theyselected out a few people who
were super responders tonutrition.
And I think that's a reallyimportant point is all these
data and that's another, youknow, besides the prior auths
and the co-pays that get wherewe don't get the same results as
we see in the studies in reallife.
It's also the nutrition.
These patients got really goodnutritional support and that's
(32:30):
something that we've created inour practice and actually is
open to.
Anybody in the country whowants to join our support group
is welcome to.
But we see, if we look at this,even at the highest dose of 15
milligrams, about 9% of peoplelost less than 5% of their total
body weight.
(32:50):
Another thing I like to pointout is, if we look down here,
what is that number?
9% of people lost less than 5%of their total body weight.
Another thing I like to pointout is, if we look down here,
what is that number?
25?
15.3.
At the 5 milligram the low dose15% of people lost more than
25% of their weight loss.
So for some people, just alittle smidgen of this stuff and
(33:14):
they lose weight like crazy,and so people are going to
respond differently and we'regoing to.
You know, there's things thatwe can do to leverage that.
We have to be aware of the factthat some people don't respond.
We also have to be aware of thefact that there's some people
out there there's 15% of thepeople in this room would have a
crazy good response with asmall dose of the medicine so
(33:38):
kind of quickly going over, youknow sleeve, moving up 20 to 25%
of sleeve patients.
It's a simple, safe surgery.
I love sleeves, I do them everyweek.
It's a simple, safe surgery.
I love sleeves, I do them everyweek.
The one thing we have to knowabout the sleeve, though, is
there is postoperative heartburnand reflux, and I convert
(34:00):
almost one patient a week onaverage to a gastric bypass for
treatment of severe acid reflux,and that, really, to me, is
proving to be the Achilles heelof the sleeve, along with weight
regain, and we see a lot moreweight regain in the sleeve
patients, and I just our lastepisode of the podcast, actually
this week's episode it's calledGLP-1 or BUS.
(34:23):
Do all VSG patients need GLP-1meds?
And the answer is no, but a lotof people will.
When you combine a sleeve withthe GLP-1 meds, it's an amazing
surgery, amazing weight loss.
You get that minimally invasive, less surgery, but you get the
(34:44):
durable, long-term weight lossresults.
You'll see more weight losswith a sleeve and the meds than
you do with a gastric bypass,and so I think these are the two
issues we see with the sleeve,and if you're having those
issues.
You have to understand obesityis a chronic, lifelong disease
and it will require chroniclifelong treatments.
It may require revision to agastric bypass.
(35:06):
It may require GLP-1 meds andif that's what it takes for you
to maintain your lowered setpoint and that is an important
thing to you and the fact thatall of you are here in this room
, taking your time over theweekend instead of relaxing to
learn more about obesity, tolearn more about the treatments
for bariatric surgery, toconnect with each other, it
(35:28):
means that you're reallycommitted to success and it
might take meds, particularly ifyou're a sleep patient.
Gastric bypass it's a littlemore involved surgery but we're
good at it.
I do a lot of gastric bypasssurgery.
There's lots of rules with agastric bypass no NSAIDs, no
alcohol, no smoking, no dumpingsyndrome.
(35:51):
You follow the rules.
It's a great surgery.
You don't follow the rules.
It's not a good surgery at alland I think you know I talk a
lot about alcoholism.
I've talked about it on thepodcast.
I've talked about it on YouTube.
Being very careful with alcoholuse after the surgery is
critically important.
You absorb it differently.
It's more addictive.
(36:13):
The most powerful approach iscombining everything together
and it takes away some of theweight regain.
It takes away those patientswho have not lost as much weight
as they hoped.
It also adds to the durability,the lifelong nature, of the
weight loss.
You can take the meds for life.
What I also like about thisapproach is it's adjustable.
(36:36):
We can change the dose.
You're losing too much weight,you don't like it, you don't
feel good, we lower the dose.
We want to gain more, we wantto lose more weight, we raise
the dose.
And so this ability to kind ofadjust and as we get more and
more drugs, better drugs, thenwe'll see additional.
(36:59):
We'll see even more weight lossand even more flexibility and
even more ability to kind oftailor and get that weight to
the place that you want it.
They are expensive.
They will be expensive for awhile.
They'll be less expensive whenwe fix our healthcare system.
Don't hold your breath.
Yeah, a lot of people ask me.
(37:22):
Well, what do you think thiselection is going to do to
change this?
Nothing, nothing.
So if you want to learn more,we've got a lot of resources.
I made my first video 15 yearsago.
I've got three books.
I've got a fourth one on mycomputer right now working on it
.
That'll give me a little bitmore time on that one and it'll
(37:45):
be talking about GLP-1 meds, butmy first book is A Pound of
Cure, which is a nutritionalguide.
We've been taught that it'sprotein, protein protein, and
I'm not sure that's the bestlong-term advice.
I think that's great advice inthe first six months, but over
the long run I'm not sure megadoses of protein are the best
(38:06):
thing for you and your weightloss and your health, and so you
can guess by the cover what Ido think is best.
I've got a cookbook and then,particularly if you really want
to learn more about this idea ofyour set point and what causes
your set point to go up and howwe lower it, I really cover that
in detail on how weight losssurgery really works.
(38:28):
We also have an online nutritionprogram.
Our dietician had a familywedding.
She couldn't come with us forthis trip, but she really is a
critical part of our practiceand the way we kind of describe
it is.
I've kind of plotted out thewhat, what to eat.
She helps people with the how,how do you eat it, and that's
(38:52):
where cooking strategies andjust general life hacks for meal
planning and eating come intoplace.
We have peer-led support groupsas well.
I think that's just such acritical piece that we've put
together, where we have ourpatients leading and everybody
here kind of is in this roombecause they feel the value of
(39:14):
community.
And obesity is a terribly.
There's a terrible amount ofbias around patients who suffer
from obesity and you've beenpretty much told the wrong
things to do and been blamed foryour disease.
And been blamed for yourdisease and hopefully at some
point met somebody a doctor,surgeon, a nutritionist, a
(39:40):
psychologist who helped youunderstand that maybe the things
that you've been told weren'ttrue and the shame and blame
that you felt surrounding yourdisease also weren't necessarily
warranted.
And so we really try to createthat in our support groups and
make sure that people are heardand feel like you're not alone
in this whole thing.
And I go on our support groupsas well.
We do have a platinum programfor anybody who wants to see us
(40:03):
from anywhere in the country.
We do a lot of GLP-1prescriptions.
We have worked out some ways toreduce the costs.
We call them creative dosingstrategies.
My attorney has said don'tvideotape yourself explaining
exactly what they are.
But there are some things.
It's a little wonky, but it'sless wonky than our healthcare
(40:24):
system and it's more in linewith your needs and priorities
than our healthcare system is,and so we're able to reduce the
price of these substantially.
We can get people on these for100, 200, maybe 300 bucks a
month at the most, and we kindof leverage this idea that the
lower dose, that there arepeople who respond at the lower
dose and you get about twothirds or even more of the total
(40:47):
body weight loss from thatfirst five milligram dose, and
so we do offer that for anybodyout, and I think that's my last
slide.
So you know, thank you toeverybody who came here and took
time out of your weekend tolearn more about your weight
loss and weight loss surgery.
And I don't know if we havetime for questions or if we'll
(41:08):
save those for the fireside.
Or Okay, does anyone have forquestions?
Or if we'll save those for thefireside, okay, does anyone have
any?
Audience (41:15):
questions.
Sure, okay, in the slide whereit is increasing weight with
increased treatment you talkedabout the teeth and iron lines
in the patient.
Dr. Weiner (41:27):
What do you think about DS and?
Audience (41:28):
SADES with the medication.
Dr. Weiner (41:31):
So the DS and the SADES are more effective
surgeries than the gastricbypass, and so you know.
The main issue, I think, withthe sleeve is that it really
only changes the hormonal staterelated to your stomach, when
with a gastric bypass, a DS or aSADY, we see intestinal changes
(41:54):
as well.
So we bring in a whole otherpathway of hormonal changes.
Audience (41:59):
I originally had the RNY about eight years ago, and
then, of course, many of usstruggled with it.
So I did a revision from RNY toSADY and I did only a year out.
But I stole for the last monthand my doctor suggested to start
using the ZipBomb.
That's why I want you to thinkabout this and I want a year out
(42:20):
.
Okay, stop losing.
Dr. Weiner (42:22):
Yeah, I mean, you know I think answering that
question requires a lot moredetail before I would say yes or
no.
But you know, obviously I mixthe two.
Personally, I probably wouldhave just from the R and Y.
I mean again, I don't know whenit was, because these meds
haven't been out forever, butwhen I see weight regain after a
(42:42):
RU and Y, I treat withmedications.
In general, my approach forrevision surgery is if it's for
weight loss, I use the medsinstead.
If it's for pathology likeheartburn, that's when you have
to do a revision surgery.
Audience (42:56):
Okay, we're going to do three more questions.
This will be my full time.
You said that one of themedications was more effective
than the other.
I didn't hear was moreeffective than the other one.
Dr. Weiner (43:09):
I didn't hear uh zep bound terzepatide monjaro for
diabetes yeah, the eli lilly umproduct.
Audience (43:24):
But yeah, one more question I have.
I'm 70 and I'm not.
I had my surgery two years agoa bsg.
Now I have terrible heart.
Yeah, they're probably notgoing to give me an ovarian.
Dr. Weiner (43:33):
Why not?
Why After 70, we just leave youout to pasture?
Is that how we do it here?
Yeah, this isn't Europe, butI'm trying for medication but
that's going to help myheartburn.
So my approach is and I'm inTucson, I don't know where you
(43:55):
are, but people travel forsurgery for me and we obviously
offer telemedicine my approachis if I have a VSG patient who's
regained weight and hasheartburn, I'll convert to a
gastric bypass because we see,first of all it fixes the
heartburn overnight.
The heartburn is gone, boom.
It's an extremely effective wayto reduce heartburn.
(44:17):
Some people have great weightloss, other people not so much.
It's very.
There's a lot of variability inweight loss from a sleeve to a
bypass, and so you know.
But you have heartburn, solet's treat that.
It's a safe surgery when doneby a safe surgeon and we can get
(44:37):
people through it even at theage of 70.
I've done bypasses up until youknow 72, 73.
But if it's pathology, we'regoing to treat it.
You know people show up withcolon cancer at the age of 88
and they're having surgery.
So we accept surgical treatmentof other disease.
If you're really suffering, whyshould you spend the rest of
(44:58):
your life suffering At 70 yearsold, you probably have a 3%
serious complication rate withthat procedure.
To me that's a very reasonablerisk to take.
Thank, you.
Audience (45:09):
I just was curious.
If you have bariatric resets orset point, why would you need
to take a medication if you werethe tool you were given?
I mean I just have time for youwithout I need to be in my way.
I don't take a medication.
Dr. Weiner (45:23):
I'm just wondering if you were so so that gets back
to the slide where I talk aboutthe causes of set point going
up.
Something that I didn't talkabout was that you know, with
all surgeries a sleeve, a bypass, a SADY, a duodenal swish there
is some failure over time andthat set point can creep up.
(45:48):
Your body can adjust theeffects of the surgery.
The set point lowering effectsof the surgery can wear off and
we kind of think, well, surgeryshould be perfect and forever.
But it's not and it's not.
You know, if people have a hipreplacement and 15 years later
they're like my hip hurts andyou hear that they need to have
a revision of their hip,nobody's like.
(46:10):
What do you mean?
It wore out.
I thought this thing was likebionic, it should last forever.
We understand like over timethings change, surgeries fail,
effects wear off and sometimesyou have to take another
treatment.
That really gets back to thisidea.
This is a chronic disease andit requires long-term treatments
(46:30):
and treatments over time.
You know the one and done idea.
It happens that way for somepeople, for a lot of people,
honestly, but for a lot ofpeople it doesn't happen that
way and it's not a statementabout your character, it's a
statement about the way yourbody responds to meds, to
surgery, to nutrition.
That's really the cause of that.
Audience (46:55):
All right, I think we have one more question over
here.
Yes, and tomorrow there's afire set chat and there's going
to be a lot of time to ask morequestions.
If you have a lot of work rightnow and just keep it on you,
and then, once we answer thisquestion, I can put you away, so
don't run out of time.
Hi, I was wondering if itmatters of the results.
(47:16):
If you had bariatric surgeryfive years ago, ten years ago,
fifteen, and then you decide youwant to add on the medications,
would you still get the sameresults?
Dr. Weiner (47:27):
Yeah, I think the medications work better after
bariatric surgery than they doin people who've never had
bariatric surgery.
It's for treating regain andfor people who've regained that
weight and it kind of gets tothis idea that there may be some
memory to that lowered setpoint and so if you've had
bariatric surgery, regained yourweight, then taking this med
(47:49):
may kind of wring out some ofthose memories of that lowered
set point.
And we've been really reallyhappy, particularly with regain
after sleeve, with the impact ofGLP-1s.
So no, I don't think the timethat it matters To me.
There might be something.
I haven't seen, it anecdotally.
There's certainly no evidenceto support it Right now.
(48:11):
There's not evidence that showsbetter weight loss after
bariatric surgery with thesemeds.
I think there will be at somepoint.
That's something we've reallyseen in our practice pretty
strongly.
All right, thank you so much.
Audience (48:23):
Dr Kahn.
One real quick question.
I just need to draw backpeople's notes.
They were writing it downasking how do they get it to
your support group, or like soour uh.
Dr. Weiner (48:33):
First of all, we do have a booth.
We'd love to to see.
We've got you know.
You can scan the qr code and wecan give you all the
information there.
But my website is a great placeto start.
We actually put a ton of energyinto our website.
Uh, it's pound of cure, weightlosscom, um and uh.
Honestly, if you google me, ifmy web guy is doing a good job,
I'll show up and starting at ourwebsite, there's a nutrition
(48:56):
page and you can you can signright up on the web website.
We're we're in the always in theprocess.
To me, this is my passionproject.
I want to to have this growinto a really robust community
where people can get the supportthat you're getting in this
room right now, every day online.
You know the problem withYouTube, facebook and Instagram
is you post up some stuff outthere and you're gonna get some
(49:17):
support and you're gonna get alot of haters and people don't
understand, and we need to makesure that there's a place where
you can post things, you canmake yourself a little bit
vulnerable and know that you'renot going to get attacked for it
, and unfortunately, there'svery few places online where
that's true and our goal isreally to create that type of
space.
So thank you.
What we see.
When we start to back out andthink about these as individual
or combination treatments, wesee that the more treatments we
apply, the more weight loss weget.
Thank you very much for havingme here.
I've been a bariatric surgeonnow for 20 years Seems like a
(00:22):
long time ago.
I put my first video out onYouTube because I didn't have a
dietician at the time and Ineeded to communicate with
patients what my post-operativediet was, and so now I think I
just hit 5 million views onYouTube, which is kind of crazy
to me.
But I really love being a partof this bariatric community and
(00:44):
I've loved being a bariatricsurgeon and working with
everybody and watching yourtransformation and your success
and being a part of helping youchange your life and freeing you
really from the, quite honestly, the prison of obesity, and so
if you've watched any of myvideos on YouTube, I think you
have a sense that I really takea fairly physiologic perspective
(01:05):
on things, and so I'm going toreally dig into some of the
science behind obesity and talkabout how we can apply that to
ensure that you have long-termsuccess going forward.
So something when I really diginto the physiology, I think the
first place I start with iswhat most people assume is the
(01:26):
cause of obesity, which iscalorie excess consuming more
calories than you burn.
And if you could just diet, eatless, exercise more, then the
weight would just come off.
And there's a fundamental flawwith that assumption, and that
flaw is that the calories thatyou consume and the calories
(01:49):
that you burn are notindependent variables, meaning
when you eat fewer calories, youburn fewer calories, and if you
exercise more, you eat morecalories, and if you exercise
more, you eat more calories.
And so this isn't simplearithmetic, this is high order
calculus.
(02:10):
The math is actually very, verycomplicated when it comes to
obesity, because as you eatdiffering amounts, it changes
your metabolic rate, and so ifwe don't factor that in, we put
ourselves on a path for failure,and I'm sure there's not a
person in this room who hasn'tput themselves in calorie
(02:30):
deficit, found some initialsuccess and then ultimately
found that the math and thestrategy broke down and they
were very quick to regain theirweight.
Another point I discuss is ifwe're going to take this calorie
counting and really carry itforward.
The assumption is and there'ssome debate about this but 3,500
(02:55):
calories is about one pound ofbody fat, and there's different
people argue about it.
To be honest with you, I don'treally see the point in arguing
about it, because thefundamental philosophy behind it
is flawed.
So let's just work through whathappens if you were to consume
(03:15):
10 more calories every day thanyou burn.
Let's talk about what 10calories is.
10 calories is a potato chip.
Yeah, it's nothing.
10 calories is an incrediblysmall amount of food.
But if, every single day over ayear, we consume 10 more
(03:40):
calories than we burned, thatwould be 3,650 calories, around
3,500.
Let's just round it to 3,500.
And so you'd gain a pound offat in a year if you just eat
one extra potato chip more.
Is there anybody out here whoweighs the same today that they
(04:04):
did five years ago?
Anybody?
Yeah, give or take right.
If you weigh the exact sameamount that you did five years
ago, it would mean over the lastfive years, you somehow managed
to balance your calorie intakeand your calorie consumption
(04:26):
down to the last crumb.
Because, like I pointed out,even 10 calories over five years
, you'll gain five pounds.
And so we have to take a stepback from this calorie counting
and recognize that it's not sosimple and that we can't just
look at this as striking theright calorie balance to drive
(04:50):
weight loss.
There has to be something elseat play that allows someone to
go five years without eatingeven one crumb extra, over five
years, consuming 1,800, 2,000calories a day.
It's really a remarkable featand it points to the fact that
(05:11):
there is regulation at play.
Our body regulates our body fatstorage, it regulates our
hunger, it regulates ourmetabolic rate.
I refer to this as yourmetabolic thermostat, and what I
really mean when I'm talkingabout this is that if you were
(05:31):
to say, put yourself intocalorie deprivation, let's go
back to that time when you didthe math.
You put yourself on an 800 or1,000 calorie a day diet, you
ran the calculation based onwhat your basal metabolic rate
was, and you restricted yourcalorie intake and you lost
weight.
Because it works at first,there's no question it works
(05:52):
right off the bat.
But what happens is your bodyhas a set point, it has a number
that it feels comfortable at,it has a number that you always
seem to balance back to.
And when you stray away fromthat, when you restrict your
calorie intake, when we focusonly on calorie restriction and
(06:15):
not other different nutritionalmethods, which we'll talk about
in a second.
Your body weight drifts downand the thermostat kicks in and
it tries to push your weightback up to your set point.
It increases the food noise,the hunger, the thoughts about
food.
(06:35):
We tell ourselves that theseare things that are entirely
under our control and therecertainly are things that we can
do to minimize food noise,outside of medications or
surgery or any of the otherthings we're going to talk about
.
But we also have to understandthat this is a basic physiologic
(06:57):
drive and ultimately, if wepush this thermostat far enough,
our ability to resist thatphysiologic drive will fail.
Just like you can trainyourself to hold your breath for
20 seconds 30 seconds a minute,but not 20 minutes Nobody can
hold their breath for 20 minutes.
It just is physiologicallyimpossible.
(07:20):
We also see your metabolic rateslow down, and so the math that
initially said you should belosing a pound every three or
four days it starts to fail andthe weight stalls and you may
even go up a little bit andyou're like how am I gaining
weight eating 1200 calories aday?
And the answer is yourmetabolic rate is slowing down
(07:44):
below 1,200 calories a day, andso your body responds to
decreased food intake.
But there's another part ofthis thermostat that we tend to
ignore, but it's criticallyimportant and it's what happened
to all of you after surgery.
If you put your weight aboveyour set point, then the
(08:06):
opposite changes occur.
A good example what I usuallyuse for this is New Year's Eve.
New Year's Day, right.
What do we all do on New Year'sDay?
I'm going to eat right, I'mgoing to exercise, I'm going to
go to the gym.
I'm motivated.
Well, what's happened the weekor two before New Year's Day?
We eat right, we all eat, andso we all push ourselves a
(08:33):
little bit above that set point.
Food is in abundance, there's acelebration, everybody's around
and we eat a little bit more.
And our body weight?
We gain a few pounds, and soit's easy to ignore food for
those first few days becausethese opposite changes are
happening.
We're seeing a decrease in ourfood noise and we want to go to
(08:54):
the gym.
We're super motivated becausewe got this extra energy.
We're trying to burn offcalories, our body is in high
metabolic rate mode and we wantto burn calories, and so this
set point really governs yourbody weight.
Your body fat is physiologicallyregulated and it only makes
(09:16):
sense because all of us,physiologically, are cave people
, and cave people starve todeath.
There was no buffet line backin the caveman era, and starving
to death was a very real threat, and so our physiology evolved
(09:37):
to maximize our ability toabsorb calories and regulate our
body weight.
What happened to the cavemanwho lost 10 pounds and didn't
get hungry, didn't develop adesire to eat?
That caveman didn't procreate,no, it was the people who were
able to make it through thoselong periods of famine and
(10:03):
starvation that inevitably occurif you're a caveman.
Those were the ones who wereable to move on and procreate
and pass on their genes.
And the truth is, everybody inthis room.
If you've had bariatric surgeryand you struggle with your
weight, you probably would havebeen a kick-ass cave person.
You would have made it throughthe winters without any problem.
You had all the genes thatallowed you to make it through
(10:26):
periods of food shortage withoutlosing your precious body fat
stores, which were there to keepyou alive.
And that's the ultimate,ultimate cause of obesity is
that we're eating a modern dietand with our paleolithic genes.
And so if we're going to drivepermanent, durable weight loss,
(10:49):
we're going to achieve that notby fighting away from our set
point, not by somehow figuringout how to resist our basic and
primal physiologic drives, butwe're going to do this by
somehow lowering that set point.
If you're 300 pounds and wecould just turn that set point
(11:11):
down, adjust the metabolicthermostat to 250 pounds, and so
now, all of a sudden, your setpoint is 250 pounds but your
body weight is 300 pounds, yourbody's going to say, hey, this
is like New Year's Day times 10.
I have a rapid metabolic rate,my metabolism is not going to
(11:35):
slow down and I have zerointerest in food, very much like
those first few months aftersurgery Zero interest in food.
You could have gone dayswithout eating, no problem.
And so that was because thatsurgery, that rearrangement of
your intestines, lowered yourset point and put you well on
(11:57):
that overfed side of themetabolic thermostat and the
weight loss was now happeningwith your physiology.
Your physiology was driving theweight loss and you weren't
fighting against it.
And that's the key, becausegenerally, when your set point
is low, it's easy to lose weight, and if it's easy to lose
(12:20):
weight, that's a good thing,we're taught.
You have to try hard, you haveto suffer.
This is about pain, discomfortand enduring it.
That is the secret to weightloss.
That is what you've been toldyour whole life and it's the
exact opposite.
That's true.
(12:40):
It's the easy weight loss thatworks.
The weight loss after surgeryis generally pretty easy.
You almost can't do anything tostop it.
It's happening to you, notnecessarily something that
you're causing, and that's thesecret to durable, long-term
weight loss.
We have to lower that set point.
(13:01):
But before we talk about how tolower your set point, it's also
really important that weunderstand why your set point
went up, because these factorsright here, these are the causes
of obesity and if we're goingto be successful at lowering our
(13:22):
set point and keeping it low,we have to minimize these as
much as possible.
If you've listened to my podcastor watched any of my videos,
you've probably seen me talkabout weight gaining medications
.
New York Times just put out areally great article where they
reviewed a meta-analysis ofpatients who were taking SSRI
(13:47):
medications Prozac, welbutrin,sertraline, zoloft all those
kind of first-lineantidepressants and they showed
that taking these medicationswas associated with weight gain
about 5% of your total bodyweight over, I think, six months
or a year.
That's a lot of weight.
There's other, much morepowerful weight-gaining
(14:09):
medications Depo-Provera, along-term birth control
medication, insulin for thetreatment of diabetes, abilify,
risperidone a lot of thepsychiatric meds cause weight
gain, and so if you're going topreserve your lowered set point,
you have to avoid medicationsas much as you absolutely can.
(14:30):
If it's vital to your survival,your mental health, you gotta
take it, but if it's not, maybeyou shouldn't be taking it.
Medication-induced weight gainis real and I see it probably as
a major factor of weight gainin about a third of the people I
see in the office.
Genetics Problem with geneticsis we can't do anything about it
.
Our genetics are our genetics.
(14:52):
But you go to a family reunionand everybody's shaped the same
way.
You know that's what's going tohappen, and so, if those are
your genetics, fighting that isvery, very difficult.
It's an uphill battle.
Age also unmodifiable Well, itis, but not the way you want to
(15:14):
do it.
As we age, we tend to storeexcess fat.
Pregnancy, pregnancy,especially at an older age.
Pregnancy in your 30s, mid,even late 30s can be a
significant weight gainingfactor.
Menopause I don't need to tellthis to anybody who's going
(15:35):
through menopause or has beenthrough menopause.
Man, it gets a lot harder tolose weight after menopause.
Stress and depression.
I think this is really a hugeplace where mental health comes
in, and it's managing thiswithout taking medications that
cause weight gain.
And this is where all of thethings that people discuss the
(15:57):
behavioral therapy, thejournaling, the meditation, the
exercise all of these otherfactors that can help modify
your stress can also help youmaintain that lowered set point,
because long-term chronicstress or depression raises
cortisol levels.
Elevated cortisol levels causeyour set point to go up.
(16:19):
Processed foods and sleepdisruption all cause your set
point to go up, and so the firststep to maintaining your
lowered set point is to look atyour life, look at any of these
factors and say what can I do tominimize these and changing
(16:40):
that?
There are four ways to loweryour set point, and, in general,
at least three of them willoften make a lot of sense to
people.
So the first is nutritionalchange, and I'll go into each of
these in a little bit moredetail in a second.
Nutritional change is differentthan dieting.
(17:01):
It's eating different food.
An analogy I sometimes use ishey, listen, if I moved you to
rural China and you had to farmand raise your own food and
animals, do you think you'd loseweight?
Yeah, you would change the typeof food that you ate.
That's different fromrestricting the calories that
(17:25):
you consume, which we've alreadytalked about, is not a solid,
long-term solution.
Building muscle and using itthis is great for the young
folks out there, and this is alittle different than exercise
too Kind of the traditionalexercise that we think of is I'm
going to get on the treadmilland I'm going to exercise and
(17:48):
burn 200, 300, 400 calories.
Anybody who's ever tried totrack their calorie consumption
during exercise understands whata fool's errand this is right.
I mean, you ever use thoseassault bikes.
You know the things where youride like that with a fan.
I do that for like all out fora minute, which is it's the
(18:09):
longest minute of my day, and Iburn 14 calories doing it.
You know it's just you can'tburn enough calories through
regular cardiovascular exerciseto maintain weight loss.
However, if you can buildmuscle and then use it
vigorously, which is reallywhat's necessary to maintain
(18:32):
that muscle Muscle, the presenceof skeletal muscle on your body
lowers that set point.
It adjusts the way your bodylooks at your fat stores and
tries to store fat, and so insome people, this is totally
possible.
In some people, this is justsomething you shouldn't even try
(18:53):
because you'll hurt yourself.
And you know I say that as ajoke, actually, I left it out of
the last slide.
But one of the other majorcauses of your set point going
up is injury, and so so manytimes I talk to patients and
they're like I was doing great,and then I was in a car accident
(19:14):
, I threw out my back and Ineeded back surgery and as a
result of being laid up from myinjury, I gained 40 pounds Very,
very common.
And a lot of that weight gainis from muscle loss, and so
(19:35):
whatever you can do to buildmuscle safely without injuring
yourself, you should do.
But of all the four things uphere, this is probably the least
effective.
Like sometimes I joke thatexercise works well for women
under 30 and men under 40, whichis a pretty limited group.
I don't know what do?
We have probably three peoplewho fit that category in the
room right now.
I'm definitely not one of them.
(19:58):
The third I don't know.
Has anybody here heard thatthere's some weight loss
medicines out there now?
Yeah, yeah, now there's somenew medications, the GLP-1s.
There's really only two of them.
They each have three names, soyou hear six names flying around
, but there's really only twomedications worth looking into.
And these medications are areally great adjunct and they
(20:23):
work extremely similarly tobariatric surgery.
These are set point loweringmedications by overwhelming your
GLP-1 receptors with thesemedications.
And these medications provide a50-60 increase in your exposure
to GLP-1 over what your basicphysiology creates.
This isn't like a tiny uptickof your GLP-1.
(20:45):
This is a massive overwhelmingof it.
And these medications are setpoint lowering medications and
they work very well inconjunction with bariatric
surgery.
And to me, they kind of takesome of the imperfect things
about bariatric surgery and helpcover them up, and so I think
(21:07):
they're a really critical partof long-term weight loss
strategy.
And the fourth one is bariatricsurgery.
And we all think, oh, surgeryworks through restriction and
malabsorption.
That's not really how it works.
It's a hormonal surgery.
It changes the way your bodyinterfaces with food.
It changes the way yourintestines and your stomach
(21:29):
stretch in response to eating.
It changes the way yourintestines and your stomach
stretch in response to eatingand, through neurohormonal
access using ghrelin, leptin,insulin, glp-1, other hormones
it sends these signals back toyour brain and lowers your set
point.
And that's the essence of howbariatric surgery works, how
(21:55):
bariatric surgery works.
So what we see when we start toback out and think about these
as individual or combinationtreatments, we see that the more
treatments we apply, the moreweight loss we get.
And you know lifestyle changesare great and you know there
might be people out there whowrite books about nutrition and
talk about how great nutritionis and if you only fix the
(22:15):
nutrition, if you just got thenutrition right, you'd finally
lose the weight and keep it off.
And I think it's time for us toacknowledge that.
That's not necessarily anentirely true statement and I am
one of those people who havewritten one of those books but
on average, if you really nailthe lifestyle changes, it's
(22:39):
about 10% total body weight loss.
That's not that much.
You're 300 pounds.
You lose 30 pounds.
It's not enough to solve theproblem.
Now lifestyle changes are goingto be critical for all of these
other treatments and we have tolook at lifestyle changes as
something we add on to our othermedical treatments, because
(23:01):
they really make the medicaltreatments work much better.
Bariatric surgery without goodnutrition afterward doesn't work
that well, and the same is truefor GLP-1 medications, probably
even more so because it's aless powerful treatment.
Bariatric surgery is a moreeffective set point lowering
treatment than GLP-1 medications.
(23:23):
So now we get into themedications, our current crop.
We're seeing 15 to 20% totalbody weight loss.
There is some data, I thinkabout 18 months for Terzepatide,
which is Monjaro and Zepbown,which is clearly the better of
the two medications, the moreeffective of the two medications
.
That shows about 25% total bodyweight loss.
(23:45):
The thing that we're seeing isthat whatever they saw in the
studies and this is kind of howmedicine works whatever we saw
in the studies you don'tnecessarily get quite that much
weight loss on average in thereal world Because in the study
there were no copays and noprior offs.
So we're seeing in our practicesomewhere around 15 to 20%
(24:10):
total body weight loss and sothat's better than lifestyle.
We move up to a sleeve.
We're looking at 20 to 25% totalbody weight loss, a bypass on
average, 25 to 30% total bodyweight loss the real magic that
(24:33):
I'm seeing in my practice andthat is exciting me.
After 20 years of doing this,I'm probably more excited about
what we can offer our patientsnow than I have been at any
other point in my career.
It's when we combine all thesetreatments, when we take a
sleeve and a bypass and we addthe meds in afterward, we're
seeing.
I see patients coming into myoffice 400, 450 pounds and we're
(24:57):
literally able to cut theirweight in half reliably.
Not just hey for the billboardright.
Some people respond great tothese surgeries 10% of people I
call them super responders andthey don't need any meds, they
just their genes are alignedwith this surgery and they have
a remarkable response andthey'll lose 50% of their body
(25:20):
weight.
But that's not the average,that's the best responders.
That's the top part of thatbell curve.
With these meds we can geteverybody at that level 30 to
50% total body weight loss.
Audience (25:33):
Yeah, but with the meds don't you have to take them
forever and they're not likelukewarm.
Dr. Weiner (25:38):
Yes, yeah, yeah, but they work.
Yes, but what?
You have to take them forever,because they're lowering your
set point, and your set pointwill go up.
But you know what?
You might not have to take highblood pressure pills.
You might not have to take highcholesterol pills.
(25:59):
Your surgery is in you forever.
It's not reversed, and so ifyou're going to achieve
long-term, durable weight loss,you need to make long-term
changes, and the beauty ofsurgery is you make that change
once and then it just kind ofsticks around.
Medications don't work that way.
(26:20):
There's strategies, though, andI think what maintenance looks
like on these meds is still upfor debate and there's new
agents coming out and there'svariable responses that we see,
and so there's a lot to this.
And, again, you don't have totake the meds.
I'm just explaining to youwhat's available out there that
(26:43):
will allow you to be successfulover the long term.
So let's talk about lifestylechanges.
Again, very rarely the onlysolution.
There are people who can beextremely successful with
lifestyle changes, and the thingthat you know, people are like
oh, dr Weiner, you're like intothe veggies and nutrition and
(27:04):
everything like that, and that'sabsolutely true.
But I love it when someonecomes in eating a lot of
McDonald's and drinking a lot ofsoda.
But I love it when someonecomes in eating a lot of
McDonald's and drinking a lot ofsoda.
I love it because I can make ahuge change in that person's
diet and a huge change is goingto get you huge results.
And so that's a really thesepeople.
(27:30):
If you have a very poor diet tobegin with, you can lose a lot
of weight.
Now we don't want to go takethat diet all the way up to
surgery.
We want to correct it beforesurgery or even before we start
the meds potentially.
But we can see great weightloss.
So in every group there'speople who are super responders.
There's super responders tosurgery.
There's super responders tomedication.
(27:51):
There's super responders tolifestyle changes Young people,
people who are capable ofhigh-intensity exercise, are
able to lose substantial weightthrough nutrition, and then
people who've lost a lot ofweight in the past.
So let's talk a little bit aboutGLP-1 medications.
They are a very powerfultreatment option.
(28:13):
They are expensive and probablywill be expensive for at least
another five years, possibly ten.
Fifteen percent of people don'trespond.
10% of people don't toleratethem.
So I'm not telling you thesethings are perfect.
They are not perfect.
(28:34):
There is nothing perfect in theweight loss world.
Bariatric surgery is notperfect, nutrition and exercise
isn't perfect, and GLP-1 medsaren't perfect, but there are
people who respond extremelywell to them and there's only
one way to figure out if you'regoing to respond or not, and
that's to take them.
They have to be taken long-termfor weight loss and that is the
(28:58):
truth.
That's how they work.
You've got to go in acceptingthat.
The truth is how many peoplehere take a medication I do
right how many people ask theirdoctor when they can stop taking
that medication when it wasprescribed?
So if we're going to talk aboutexpense and I'd need a whole
(29:21):
other hour for that these medsare not expensive.
They're $5 to make.
It's our screwed up healthcaresystem that makes them so
unaffordable and expensive.
Audience (29:35):
And agreed.
Dr. Weiner (29:37):
Yes.
Audience (29:38):
I don't know if you can answer this or not, but what
would be the signs of like youdon't tolerate?
Dr. Weiner (29:44):
You'll know yeah.
Audience (29:47):
Developing skin rash and they say it might be because
of this.
Dr. Weiner (29:51):
So you know these GLP-1 meds.
We're seeing the same thing wesaw with bariatric surgery,
which is when you have bariatricsurgery, if you're like I have
this headache, everyone's like,oh, it's your surgery, yeah,
right, you know.
Oh, I broke my leg, yeah,because your surgery.
You broke your leg because ofyour surgery.
And so everybody's very quickto blame everything that happens
(30:15):
to you after this, and so wereally have to take a step back
and look at the science.
Skin rash isn't something I'mseeing.
We see.
It's mostly GI side effects.
It's heartburn, nausea,vomiting, constipation, diarrhea
.
Those tend to be modifiable ifyou dose them carefully and
correctly.
I think the big problem we haveis we're dosing them.
All the data, all the studies,the way that we're supposed to
(30:38):
dose them is wrong.
We're overdosing them, we'reescalating the dose too fast and
we need to be a little bit morecautious and understand this is
a long play.
This isn't a race.
We're in this mode of fastweight loss lose weight fast.
Everybody wants to lose weightfast and we shouldn't be focused
on that.
We should be focused on losingweight forever, and that
(31:01):
requires a different approach.
But yes, they are expensive,but over the long run they won't
.
This is my favorite graph ofall expensive, but over the long
run they won't.
This is my favorite graph ofall.
This is from the Surmount trial, which is the Terzepatide
Monjaro Zepbound long-term use,and it's a busy graph, but I'm
just going to kind of go over acouple of things.
(31:22):
If you look here, so this ishow many people met this body
weight reduction target.
So, greater than 5%, 10%, 15,20.
So these are the people wholost the most weight.
These are the people who lostthe least weight.
And then the three differentbars.
Here are the different doses.
So this is 5, 10, and 15milligrams, and then this bar
(31:43):
right here is the control group.
I want to point something out.
First, I can't see that number.
It's like what?
1.5%, I think.
Yeah, 1.5% of the control group.
The people who were given aplacebo, a saline injection,
lost more than 25% of theirtotal body weight.
So there was no nutrition.
These patients all participatedin a comprehensive, detailed
(32:07):
nutrition program, so theyselected out a few people who
were super responders tonutrition.
And I think that's a reallyimportant point is all these
data and that's another, youknow, besides the prior auths
and the co-pays that get wherewe don't get the same results as
we see in the studies in reallife.
It's also the nutrition.
These patients got really goodnutritional support and that's
(32:30):
something that we've created inour practice and actually is
open to.
Anybody in the country whowants to join our support group
is welcome to.
But we see, if we look at this,even at the highest dose of 15
milligrams, about 9% of peoplelost less than 5% of their total
body weight.
(32:50):
Another thing I like to pointout is, if we look down here,
what is that number?
9% of people lost less than 5%of their total body weight.
Another thing I like to pointout is, if we look down here,
what is that number?
25?
15.3.
At the 5 milligram the low dose15% of people lost more than
25% of their weight loss.
So for some people, just alittle smidgen of this stuff and
(33:14):
they lose weight like crazy,and so people are going to
respond differently and we'regoing to.
You know, there's things thatwe can do to leverage that.
We have to be aware of the factthat some people don't respond.
We also have to be aware of thefact that there's some people
out there there's 15% of thepeople in this room would have a
crazy good response with asmall dose of the medicine so
(33:38):
kind of quickly going over, youknow sleeve, moving up 20 to 25%
of sleeve patients.
It's a simple, safe surgery.
I love sleeves, I do them everyweek.
It's a simple, safe surgery.
I love sleeves, I do them everyweek.
The one thing we have to knowabout the sleeve, though, is
there is postoperative heartburnand reflux, and I convert
(34:00):
almost one patient a week onaverage to a gastric bypass for
treatment of severe acid reflux,and that, really, to me, is
proving to be the Achilles heelof the sleeve, along with weight
regain, and we see a lot moreweight regain in the sleeve
patients, and I just our lastepisode of the podcast, actually
this week's episode it's calledGLP-1 or BUS.
(34:23):
Do all VSG patients need GLP-1meds?
And the answer is no, but a lotof people will.
When you combine a sleeve withthe GLP-1 meds, it's an amazing
surgery, amazing weight loss.
You get that minimally invasive, less surgery, but you get the
(34:44):
durable, long-term weight lossresults.
You'll see more weight losswith a sleeve and the meds than
you do with a gastric bypass,and so I think these are the two
issues we see with the sleeve,and if you're having those
issues.
You have to understand obesityis a chronic, lifelong disease
and it will require chroniclifelong treatments.
It may require revision to agastric bypass.
(35:06):
It may require GLP-1 meds andif that's what it takes for you
to maintain your lowered setpoint and that is an important
thing to you and the fact thatall of you are here in this room
, taking your time over theweekend instead of relaxing to
learn more about obesity, tolearn more about the treatments
for bariatric surgery, toconnect with each other, it
(35:28):
means that you're reallycommitted to success and it
might take meds, particularly ifyou're a sleep patient.
Gastric bypass it's a littlemore involved surgery but we're
good at it.
I do a lot of gastric bypasssurgery.
There's lots of rules with agastric bypass no NSAIDs, no
alcohol, no smoking, no dumpingsyndrome.
(35:51):
You follow the rules.
It's a great surgery.
You don't follow the rules.
It's not a good surgery at alland I think you know I talk a
lot about alcoholism.
I've talked about it on thepodcast.
I've talked about it on YouTube.
Being very careful with alcoholuse after the surgery is
critically important.
You absorb it differently.
It's more addictive.
(36:13):
The most powerful approach iscombining everything together
and it takes away some of theweight regain.
It takes away those patientswho have not lost as much weight
as they hoped.
It also adds to the durability,the lifelong nature, of the
weight loss.
You can take the meds for life.
What I also like about thisapproach is it's adjustable.
(36:36):
We can change the dose.
You're losing too much weight,you don't like it, you don't
feel good, we lower the dose.
We want to gain more, we wantto lose more weight, we raise
the dose.
And so this ability to kind ofadjust and as we get more and
more drugs, better drugs, thenwe'll see additional.
(36:59):
We'll see even more weight lossand even more flexibility and
even more ability to kind oftailor and get that weight to
the place that you want it.
They are expensive.
They will be expensive for awhile.
They'll be less expensive whenwe fix our healthcare system.
Don't hold your breath.
Yeah, a lot of people ask me.
(37:22):
Well, what do you think thiselection is going to do to
change this?
Nothing, nothing.
So if you want to learn more,we've got a lot of resources.
I made my first video 15 yearsago.
I've got three books.
I've got a fourth one on mycomputer right now working on it
.
That'll give me a little bitmore time on that one and it'll
(37:45):
be talking about GLP-1 meds, butmy first book is A Pound of
Cure, which is a nutritionalguide.
We've been taught that it'sprotein, protein protein, and
I'm not sure that's the bestlong-term advice.
I think that's great advice inthe first six months, but over
the long run I'm not sure megadoses of protein are the best
(38:06):
thing for you and your weightloss and your health, and so you
can guess by the cover what Ido think is best.
I've got a cookbook and then,particularly if you really want
to learn more about this idea ofyour set point and what causes
your set point to go up and howwe lower it, I really cover that
in detail on how weight losssurgery really works.
(38:28):
We also have an online nutritionprogram.
Our dietician had a familywedding.
She couldn't come with us forthis trip, but she really is a
critical part of our practiceand the way we kind of describe
it is.
I've kind of plotted out thewhat, what to eat.
She helps people with the how,how do you eat it, and that's
(38:52):
where cooking strategies andjust general life hacks for meal
planning and eating come intoplace.
We have peer-led support groupsas well.
I think that's just such acritical piece that we've put
together, where we have ourpatients leading and everybody
here kind of is in this roombecause they feel the value of
(39:14):
community.
And obesity is a terribly.
There's a terrible amount ofbias around patients who suffer
from obesity and you've beenpretty much told the wrong
things to do and been blamed foryour disease.
And been blamed for yourdisease and hopefully at some
point met somebody a doctor,surgeon, a nutritionist, a
(39:40):
psychologist who helped youunderstand that maybe the things
that you've been told weren'ttrue and the shame and blame
that you felt surrounding yourdisease also weren't necessarily
warranted.
And so we really try to createthat in our support groups and
make sure that people are heardand feel like you're not alone
in this whole thing.
And I go on our support groupsas well.
We do have a platinum programfor anybody who wants to see us
(40:03):
from anywhere in the country.
We do a lot of GLP-1prescriptions.
We have worked out some ways toreduce the costs.
We call them creative dosingstrategies.
My attorney has said don'tvideotape yourself explaining
exactly what they are.
But there are some things.
It's a little wonky, but it'sless wonky than our healthcare
(40:24):
system and it's more in linewith your needs and priorities
than our healthcare system is,and so we're able to reduce the
price of these substantially.
We can get people on these for100, 200, maybe 300 bucks a
month at the most, and we kindof leverage this idea that the
lower dose, that there arepeople who respond at the lower
dose and you get about twothirds or even more of the total
(40:47):
body weight loss from thatfirst five milligram dose, and
so we do offer that for anybodyout, and I think that's my last
slide.
So you know, thank you toeverybody who came here and took
time out of your weekend tolearn more about your weight
loss and weight loss surgery.
And I don't know if we havetime for questions or if we'll
(41:08):
save those for the fireside.
Or Okay, does anyone have forquestions?
Or if we'll save those for thefireside, okay, does anyone have
any?
Audience (41:15):
questions.
Sure, okay, in the slide whereit is increasing weight with
increased treatment you talkedabout the teeth and iron lines
in the patient.
Dr. Weiner (41:27):
What do you think about DS and?
Audience (41:28):
SADES with the medication.
Dr. Weiner (41:31):
So the DS and the SADES are more effective
surgeries than the gastricbypass, and so you know.
The main issue, I think, withthe sleeve is that it really
only changes the hormonal staterelated to your stomach, when
with a gastric bypass, a DS or aSADY, we see intestinal changes
(41:54):
as well.
So we bring in a whole otherpathway of hormonal changes.
Audience (41:59):
I originally had the RNY about eight years ago, and
then, of course, many of usstruggled with it.
So I did a revision from RNY toSADY and I did only a year out.
But I stole for the last monthand my doctor suggested to start
using the ZipBomb.
That's why I want you to thinkabout this and I want a year out
(42:20):
.
Okay, stop losing.
Dr. Weiner (42:22):
Yeah, I mean, you know I think answering that
question requires a lot moredetail before I would say yes or
no.
But you know, obviously I mixthe two.
Personally, I probably wouldhave just from the R and Y.
I mean again, I don't know whenit was, because these meds
haven't been out forever, butwhen I see weight regain after a
(42:42):
RU and Y, I treat withmedications.
In general, my approach forrevision surgery is if it's for
weight loss, I use the medsinstead.
If it's for pathology likeheartburn, that's when you have
to do a revision surgery.
Audience (42:56):
Okay, we're going to do three more questions.
This will be my full time.
You said that one of themedications was more effective
than the other.
I didn't hear was moreeffective than the other one.
Dr. Weiner (43:09):
I didn't hear uh zep bound terzepatide monjaro for
diabetes yeah, the eli lilly umproduct.
Audience (43:24):
But yeah, one more question I have.
I'm 70 and I'm not.
I had my surgery two years agoa bsg.
Now I have terrible heart.
Yeah, they're probably notgoing to give me an ovarian.
Dr. Weiner (43:33):
Why not?
Why After 70, we just leave youout to pasture?
Is that how we do it here?
Yeah, this isn't Europe, butI'm trying for medication but
that's going to help myheartburn.
So my approach is and I'm inTucson, I don't know where you
(43:55):
are, but people travel forsurgery for me and we obviously
offer telemedicine my approachis if I have a VSG patient who's
regained weight and hasheartburn, I'll convert to a
gastric bypass because we see,first of all it fixes the
heartburn overnight.
The heartburn is gone, boom.
It's an extremely effective wayto reduce heartburn.
(44:17):
Some people have great weightloss, other people not so much.
It's very.
There's a lot of variability inweight loss from a sleeve to a
bypass, and so you know.
But you have heartburn, solet's treat that.
It's a safe surgery when doneby a safe surgeon and we can get
(44:37):
people through it even at theage of 70.
I've done bypasses up until youknow 72, 73.
But if it's pathology, we'regoing to treat it.
You know people show up withcolon cancer at the age of 88
and they're having surgery.
So we accept surgical treatmentof other disease.
If you're really suffering, whyshould you spend the rest of
(44:58):
your life suffering At 70 yearsold, you probably have a 3%
serious complication rate withthat procedure.
To me that's a very reasonablerisk to take.
Thank, you.
Audience (45:09):
I just was curious.
If you have bariatric resets orset point, why would you need
to take a medication if you werethe tool you were given?
I mean I just have time for youwithout I need to be in my way.
I don't take a medication.
Dr. Weiner (45:23):
I'm just wondering if you were so so that gets back
to the slide where I talk aboutthe causes of set point going
up.
Something that I didn't talkabout was that you know, with
all surgeries a sleeve, a bypass, a SADY, a duodenal swish there
is some failure over time andthat set point can creep up.
(45:48):
Your body can adjust theeffects of the surgery.
The set point lowering effectsof the surgery can wear off and
we kind of think, well, surgeryshould be perfect and forever.
But it's not and it's not.
You know, if people have a hipreplacement and 15 years later
they're like my hip hurts andyou hear that they need to have
a revision of their hip,nobody's like.
(46:10):
What do you mean?
It wore out.
I thought this thing was likebionic, it should last forever.
We understand like over timethings change, surgeries fail,
effects wear off and sometimesyou have to take another
treatment.
That really gets back to thisidea.
This is a chronic disease andit requires long-term treatments
(46:30):
and treatments over time.
You know the one and done idea.
It happens that way for somepeople, for a lot of people,
honestly, but for a lot ofpeople it doesn't happen that
way and it's not a statementabout your character, it's a
statement about the way yourbody responds to meds, to
surgery, to nutrition.
That's really the cause of that.
Audience (46:55):
All right, I think we have one more question over
here.
Yes, and tomorrow there's afire set chat and there's going
to be a lot of time to ask morequestions.
If you have a lot of work rightnow and just keep it on you,
and then, once we answer thisquestion, I can put you away, so
don't run out of time.
Hi, I was wondering if itmatters of the results.
(47:16):
If you had bariatric surgeryfive years ago, ten years ago,
fifteen, and then you decide youwant to add on the medications,
would you still get the sameresults?
Dr. Weiner (47:27):
Yeah, I think the medications work better after
bariatric surgery than they doin people who've never had
bariatric surgery.
It's for treating regain andfor people who've regained that
weight and it kind of gets tothis idea that there may be some
memory to that lowered setpoint and so if you've had
bariatric surgery, regained yourweight, then taking this med
(47:49):
may kind of wring out some ofthose memories of that lowered
set point.
And we've been really reallyhappy, particularly with regain
after sleeve, with the impact ofGLP-1s.
So no, I don't think the timethat it matters To me.
There might be something.
I haven't seen, it anecdotally.
There's certainly no evidenceto support it Right now.
(48:11):
There's not evidence that showsbetter weight loss after
bariatric surgery with thesemeds.
I think there will be at somepoint.
That's something we've reallyseen in our practice pretty
strongly.
All right, thank you so much.
Audience (48:23):
Dr Kahn.
One real quick question.
I just need to draw backpeople's notes.
They were writing it downasking how do they get it to
your support group, or like soour uh.
Dr. Weiner (48:33):
First of all, we do have a booth.
We'd love to to see.
We've got you know.
You can scan the qr code and wecan give you all the
information there.
But my website is a great placeto start.
We actually put a ton of energyinto our website.
Uh, it's pound of cure, weightlosscom, um and uh.
Honestly, if you google me, ifmy web guy is doing a good job,
I'll show up and starting at ourwebsite, there's a nutrition
(48:56):
page and you can you can signright up on the web website.
We're we're in the always in theprocess.
To me, this is my passionproject.
I want to to have this growinto a really robust community
where people can get the supportthat you're getting in this
room right now, every day online.
You know the problem withYouTube, facebook and Instagram
is you post up some stuff outthere and you're gonna get some
(49:17):
support and you're gonna get alot of haters and people don't
understand, and we need to makesure that there's a place where
you can post things, you canmake yourself a little bit
vulnerable and know that you'renot going to get attacked for it
, and unfortunately, there'svery few places online where
that's true and our goal isreally to create that type of
space.
So thank you.
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