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December 21, 2023 30 mins
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(00:02):
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at okkillct dot org. Now here'syour host for Pulse of the Region,

(00:49):
Kate Balman. Hello, Hello,and welcome to Pulse of the Region,
the show where we highlight the topicsimpacting our region and impacting our state of
Connecticut. I'm your host, KateBalm and thrilled to have you here with
us today. Tuning in, weappreciate it as always to combat this disease.
I am thrilled to have two ofour guests joining us here today to

(01:11):
help dive in on the conversation.Our first guest joining the show is he
is with Greenwich Hospital. He isthe director of bariatric Surgery, Doctor Neil
Flock. Doctor Neil Flock, Welcometo the show. Thank you so much
for being here. Hello, andthank you so much for giving me the
opportunity to speak today on the show. Of course, no, thank you

(01:32):
so much for being here. Andour second guest is she is with Stanford
Health. She is the director ofthe Medical Weight Loss Program at Stanford Health.
Doctor Maria asnas So, Doctor MariaAsnis Welcome to the show. Thanks
so much for having me. Thisis such an important topic to be discussing
it truly is so appreciate both ofyour time today and certainly you know,

(01:56):
thrilled that we're able to have thisconversation because certainly, I think the top
go of obesity has been in thenews so much recently and a lot of
the treatments surrounding that, so Ithink it's so important to really dive in
on the facts today. So firstthing, first before we do that,
though, I would love to givesome brief introductions for each of you,
So why not, Doctor Flatch willput you on the hot seat first,

(02:16):
so we say, and would loveif you could describe the bariatrics program and
also your role is the director ofbariatric Surgery for Greenwich Hospital and Yale.
I'm just going to say, I'msorry, it's Flock. Okay, you
all right? So hi, SoI'm sorry. So I am the director

(02:43):
of bariatric Surgery at Greenwich Hospital andan associate professor at the Yale School of
Medicine. And my role here cominginto Greenwich is to really build up a
comprehensive bariatric surgery program in Greenwich.And what that means is not just the
bariatric surgery, but all the componentsof it, meaning the exercise, the

(03:08):
nutrition, the psychological component as wellas the surgery component. Okay, so
many different aspects there. So excitedto dive deeper into that, doctor Flock.
But first, doctor Asnis, ifyou could describe your role as the
director of the medical weight loss programat Stanford Health, that'd be fantastic.

(03:29):
Sure. So, Neil and Iare both people who have done this before
the buzz on TikTok and social media. So we're I'm so happy that you
have us both here to talk aboutthis important topic. So, just as
a background, I'm an endochronologist,that's my training and obt B Medicine certified,

(03:52):
so that's a separate certification in weightmedicine. So I've always been interested
in helping people with excess weight ina scientific, evidence based way and I
wanted to bring that approach here tothe community and Stanford Health in the Stanford
Health System really does serve the entirecommunity. So the Medical Weight Loss Program

(04:16):
was formally started in twenty nineteen.It had been done by me and a
few other undrochronologists in the area fora lot longer than that, but that
was when the formalized. And whatit really is a medical weight loss program
is a place where patients can comeand feel that they won't be judged,

(04:40):
that there's an empathetic approach to whatyou exactly said, the disease of obesity
and all that it brings. Andso we provide really an evidence based approach
both with medications, meal replacement programs, registered dietitians. The collaboration our with

(05:00):
our with our fitness center. Soit really is a multidisciplinary approach to weight.
That's great, and you know it'sso important. Kind of a lot
of things you just touched on there, but you know, one is really
many people do feel I think sometimesobesity is a disease kind of of vanity,
which you know, certainly you knowisn't isn't correct, but you know,

(05:23):
really sometimes people do feel that othersmay choose to have this disease.
And you know, certainly, asyou mentioned, diet exercise play a huge
role in weight loss and gain.But would love if you could kind of
talk a little bit more about thebiological underpinnings of obesity and you know,
namely the science of obesity and reallyhow our appetite is regulated biologically, which

(05:43):
I just think is fascinating. Soit would welcome you to kind of touch
a bit more on that. Sure, I will preface this I thing I
usually do an hour long talk,which is not even enough time. I
know, that's how complex this is. I usually start with two truths when
it comes to weight. So oneis that it's easy to gain weight,

(06:05):
and there's a variety of reasons why, and they're very complicated and I'll talk
about that in a little bit.And the second truth is that once the
weight is acquired, it is exceedinglydifficult to lose it. The body really
fights weight loss. And where isall of this centered. Where does this
all occur in the body. It'sthe whole body. It's the whole body.

(06:30):
So I put up a slide thathas the brain in the middle of
it and arrows going out to severalof the organs of the body, the
stomach, the small intestine, thepancreas, the fat cells. And that's
just a simplistic model. So inthe brain there is a very very very
primitive place. It's that tiny littlespot called the hypothalamus. And even in

(06:55):
that tiny old spot of the brainis a small center that really regulates appetite.
It regulates why we seek food,when we're full, when we're feeling
hungry, et cetera. And interestingly, that's where a lot of other places,
a lot of other things are regulated, like addiction, like mood.

(07:19):
So all of those things are allin the same place. And when you
think about weight and all the thingsthat we talk about when we first do
patients, we have to talk abouteverything because everything goes into it. What's
what I think you're probably alluding tois what's on the news a lot,
which is a gut braid connection.Yes, so all the medicines that everyone's

(07:46):
talking about on social media, andit seems to be on the front page
of every newspaper every day, arethese medicines that target the gut hormones that
are that are produced in the smalland and these are these are hormones that
are that we all produce, butin certain states like excess weight, diabetes,

(08:07):
pre diabetes, influent resistance, there'sa change in how those hormones act.
And those hormones regulate basically how weprocess carbohydrates, but also regulate our
fullness, how we feel full.And interestingly, they really do signal up
to the brain and back signaling appetiteand fullness and hunger. And these are

(08:33):
things that you're born with. Youdidn't try to You didn't try to have
these changes happen. Nothing you did. Maybe these changes happen. They're largely
regulated genetically, and it's really importantwhen we talk to patients to give them
a little bit of us, youknow, not to get into the maybe
gritty of the pathophysiology of how theirbody regulates weight, but to inform them

(08:58):
that cause contrary to what society andeven some some in medicine have told them
that they've they have this extra weightbecause they're lazy or didn't try hard enough
or whatever it is, or they'vefailed in their efforts, that some of
the reasons that they have extra weightis out of their control. It is

(09:18):
biologically controlled. Okay, fascinating.Now that's so interesting, and certainly,
you know, over really kind ofthe last ten years, as there's been
you know, a lot done andlooking at obesity really as a chronic disease,
and doctor Flock, you know,would love for you to chime in
here is you know, ten yearsago the American Medical Association designated obesity a

(09:39):
chronic disease worthy of treatment. Yetreally despite this, obesity coverage hasn't really
kind of kept up with the evolvingof the science. And so would love
if you could kind of describe kindof this obesity stigma and bias how it's
really impacted the coverage for obesity treatments. I think it's so important to highlight
that. Well really talked about thebiology of the disease, which is something

(10:03):
that you know, we all inobesity treatment, study very hard, and
it all becomes and it all startswith education. And if you don't educate
the very people that treat obesity,such as physicians, then they're not going

(10:24):
to be able to teach their patients. And when people don't understand the problem,
they rely on the media, theyrely on the little information that they
know, and that's where the stigmacomes. Everybody thinks, and I think
you said it, unfortunately, well, diet and exercise. Everybody thinks,

(10:45):
diet and exercise. Well, weknow, doctor asma is and I there
is tremendous amount of genetics that controlpeople who have obesity, and there is
an incredible amount of biology. Itis mostly byology and out of most of
our control. When your gut istelling you and sending hormones and messages to

(11:09):
your brain to eat that you're hungry, then you're going to you're going to
want to eat. And I thinkthat there is a hormone that there are
many hormones we're learning about now.G LP one are new medications that we
treat patients with, and I dothat as well. I treat patients with

(11:31):
medication as well, because they're sowonderful and they're such an incredible revolution.
Those medications make you full, butin surgery, there's one hormone called grellin
that makes you hungry. And whenwe do the surgery, we remove that

(11:52):
hormone, and surgery does a tremendousthing, a tremendous helpful thing. And
we really need, we need thegovernment and we need the backing of our
legal system to make surgery more availableto the larger population, both both surgery

(12:18):
and medications. And that just simplyhasn't happened. It hasn't happened in the
state of Connecticut, I'll tell you, because we know that the Obamacare law
does not cover for people to havebariatric surgery in the state of Connecticut.
Okay, very interesting. That's wherethe problem starts in this state from a

(12:43):
legal standpoint, from a coverage standpoint, and what I've been trying to do
and change and advocate for better accessto care for patients in this state.
That's great, now, thank youfor tireing on that. And certainly the
access also, you know, costscomes is a big piece, as you

(13:05):
know, part of this equation.And doctor asnas is you know, if
you could chime in here is youknow, certainly there are a lot of
complications associated with obesity, which youknow certainly can raise the cost of people's
healthcare. And if you could kindof talk a little bit just on what
impact does this have on our healthcaresystem overall, sure, I'd love to.

(13:28):
You know, I think that weightand access weight is the is an
obesity is the chronic condition that touchesall of medicine. It really affects the
whole body. So as an endocrinologist, obviously I have seen diabetes, diabetes
that is uncontrolled, that is aweight related condition, not caused by weight

(13:52):
per se. It's kind of acycle in and of itself that is an
incredible source of cost to the patientand to the health care system. So
diabetes and it's and its and itscomplications like chronic kidney disease leading to dialysis,

(14:13):
cardiovascular issues wading to you know,cardiac cathorizations, heart attacks, cerebra,
vascular disease like stroke, et cetera. Those are enormous, enormously costly
to the patient band to our healthsystem. Those are all really related to
weight. And then there are otherthings too, depression, anxiety, acid

(14:39):
reflux, osteoarthritis, all of thesethings that people seek the healthcare system for.
And if we continue to treat weightas something that's merely cosmetic, we're
going to we're going to incur atremendous amount of of costs to the healthcare

(15:01):
system and to our population. SoI agree with you know wholeheartedly. You
know, the reason why many ofus stay in big health systems is to
serve our community and to increase access. But like for him, and surgeons
and and and cardiologists who have instruments, we can't we can't help people if

(15:26):
we can't use our instruments, ifthey can't access them in an equitable way.
And unfortunately, the access to bothmedications and bariatric surgery has not been
there in the state of Connecticut,as it alluded to, a large payer
Connecticut does not cover these these interventions. And what it's going to mean is

(15:52):
that we are losing out on thepotential benefits to a lot of patients to
prevent them from hospitalizations for the varietyof being heart attack, stroke, et
cetera. Okay, thank you forbringing up those points. And doctor Flock,
you know, it's we're trying tolook at, you know, for
employers and also payers, you know, what can can those groups look to

(16:17):
do, you know, especially asthey look to consider kind of whether to
opt in or to opt out intocomprehensive obesity coverage. So it's a very
it's a very interesting topic. Ithink when we could speak to for about
two hours, we can talk allmorning about that. Yeah, we're looking
at if you look at a nicelittle graph. There's a nice little graph

(16:37):
that came out a picture of theyou know, the length of our lives
and how our mortality and our lengthof life is just dropped for the first
time in the United States. Andwhy is that happening? Well, for
all the reasons doctor as has justmentioned. There are two hundred and twenty
nine medical conditions associated with by andthey're all getting worse. Maybe maybe a

(17:03):
few are getting better. Maybe we'retackling certain cancers better, getting the heart
disease a little bit better, butoverall we are living shorter lives. And
it's the accumulation of all this diseaseand creating problems is what we're doing.
And then we're withdrawing access to carefor the problems further worsens the problem.

(17:27):
So what employers are seeing is theincreased cost of insurance, and that's becoming
a barrier to their business. It'sincreasing their overhead. They have unhealthy employees,
loss of time, decrease, qualityof life, increased depression. You
know, it's not the most upbeatsubject. I'll tell you that what we

(17:49):
want to do is the opposite.We want people to be happy, not
enjoy their job, live long lives, enjoy their family, be able to
exercise and do all those things.We're moving in the wrong direction, and
it all comes down on the waywe look at cost. Unfortunately, Wall
Street looks at profit over one year. If they simply looked and took a

(18:15):
three to five year outlook on theequalities of those qualities that I just mentioned,
they would see that things get betterif they covered for both obesity medications
and for surgery, because we knowthe patients really have to lose just a
little of that amount of weight,you know, five to fifteen percent.

(18:37):
In that range, you start tosee a lot of these medical conditions improve.
And that's a range where medications reallycould make the biggest change. Although
on the surgeon, the medications reallyhave the opportunity to change healthcare in this
country, and that may be abig statement, but I think doctor Asthas

(18:59):
would agree with me when we considerthat seventy three percent of our Americans are
overweight and many of them have thesehealth conditions. So to answer your question,
I think companies really need to investand cover for both medications and surgery
and improve the quality and health oftheir workers so that they will be happier

(19:26):
and better quality workers with less missedtime. And you'd also reduce the costs
for insurance and those people who selfensure their companies as well. Can I
chime in on that, yes,please do so. I agree hardly.
I think that the way we lookat cost is absolute and over what timeline

(19:51):
is absolutely what should be looked at. And what I will say is that
it is true that it's very easyto look at at what the cost is
even in the next three months orsix months or whatever it is, and
it is quite high. But theproof is really in the pudding of how
well people can do with safe,effective and durable intervention. So in practice,

(20:18):
and Emil and I see this allthe time with surgery, with medications,
with the combination of both as wellas you know, great diet,
good diet, exercise, et cetera. Is that people will go from diabetes
that is uncontrolled to normal sugars,someone who has high blood pressure on ever

(20:41):
more medications, four medications to onemedication, and it's over and over and
over and the in. What reallyshows this is that people continue to seek
these treatments because they are so effective. As far as in employers and what
they look at, they have tolook at it in the long term.

(21:04):
When I started the medical weight lossprogram at Stanford Health, I knew that
we needed to have the tools orthis would never be successful. So at
that time, our employee health,our employee health insurance did not cover antiobesity
medications and sometimes didn't cover bariatric surgery. I made a big push at that

(21:26):
time and I said, we needto cover We need to cover the medication.
And since then, our health systemand our employees have had access to
all the medications as well as bariatricsurgery if indicated, and every employee says,
this is an incredible benefit, andemployees will start to look at this

(21:49):
benefit because this issue of obesity touchesso many people. It's thirty percent of
adult population in Connecticut. Okay,obesity, that's an enormous number of workers.
People are going to start looking atthe health insurance, especially the employer
based health insurance is to see whohas this web Thank you so much doctor

(22:11):
Adams for adding that. In soto kind of close out the show,
you know, I pose this questionto both of you. Doctor Flock will
start with you, is really,as we look at the future, what
would you like to see to kindof change, you know, here in
the state of Connecticut, but alsoeven to nationwide in order to really be
able to treat obesity. And Iunderstand that's a big question with not a

(22:33):
ton of time left, but doctorFlock, if you could, you know,
start with your kind of thoughts there. Connecticut, there is already a
law that's passed, okay that saysthat the government has to cover Medicaid services
have to cover for obesity medications,and it's past law, but the government

(22:56):
simply won't implement the law. Andit really is kind of shocking to me.
So when you fight for laws andyou pass them, they have to
follow them. And I think thateverybody is so afraid of the cost of
these medications that they're simply just notfollowing through what they need to do.
So that's number one. From afederal standpoint, there is a law to

(23:21):
change. It's called TROA to Treatand Reduce Obesity Act for Men, there
to cover for obesity medications as well, and that's been worked on for twelve
years now and hopefully Senators Cassidy andWe'll be able to help push that through
at some point. We really needthat. And now Bernie Sanders is doing

(23:45):
a remarkable job bringing up kind ofone of the causes, not the full
cause, but the causes some ofthe causes of obesity, which are the
foods we eat and the process foodand we just simply need to look into
what is in the food we eat. We really don't even have the power
to look at all these processed foods. We used to blame fat, and

(24:08):
then we blame carbohydrates, and nowwe're seeing that processed foods and certain foods
and oils, et cetera are causing. So we need to work on that
as well, and we need toincrease access to both medications and surgery.
And I realized that it can happenovernight because that would create a quick cost

(24:33):
to everybody. It's got to happengradually. But the gradual has to be
over months, two years, notover decades. So we really need to
see that sort of movement in orderto not only treat obesity, but obesity,
which is the cause of many otherchronic diseases, will also help all

(24:56):
of those for most all of thosediseases that it can change itself. So
that's what we need to do.I like it. Well, thank you
for that future look ahead and certainlykind of nice to see to the timelines
that could be of potential benefit too. So doctor Asnaes asked that same question

(25:17):
to you looking at the future,to you know, add on to doctor
Flock kind of what are your thoughtson what we can look to do.
Yeah, so I agree with alot of what he says. I think
the first step is continued at itseducation about at least be as a disease,
as a chronic illness, not assomething that is a failure of will.
That I emphasize over and over becauseit continues to happen that people are

(25:44):
just telling people to try harder.That is an approach that has failed us
and has failed people too. Ithink access the science of intervention now is
really well established. Both pediatric surgeryand many of the medications. The science
is there, the studies are there, the proofs that our patients is there,

(26:07):
but the access really has to improve. This cannot be These interventions cannot
be just for people who know aboutthem, who can afford them. We
have to, because of the enormityof the issue in Connecticut and in the
country, expand access. And Ithink that the future of that really will

(26:30):
have to be legislated. So Iencourage many of my patients who don't have
access to talk to their state senators, to talk to their senators or congressmen.
An example is Medicare. Medicare doesnot cover any obesity that antiobesity medications
Europe. That's been an enormous population. Our population of older people is growing.

(26:55):
They cannot access medications. That hasto be legislated. So I do
encourage my patients to talk to theirto their legislators. And then lastly,
and it's kind of related to whatdoctor Fox spoke about in Foods, et
cetera, is that this is thisis an issue that continues to grow.

(27:19):
And I get that philosophical because Ithink about how did we get here.
I hope there's one day when Idon't have to see so many patients with
access late and all that it brings. And we do really have to look
at things like activity in schools,time, the time kids get to have

(27:41):
lunch, what they're having, whatthey can access in terms of good quality
foods, having access to activity,et cetera, et cetera, et cetera,
et cetera. There's so many thingsthat we have to We can't just
look at the interventions. You know, the interventions are very important, obviously,
but we have to look at howdo we reduce the problem overall.

(28:04):
Fantastic, Well, thank you bothso much for your insight and you know,
for providing ideas and solutions. Reallyappreciate the work they're both doing and
appreciate you taking the time to behere with us today. Thanks so much,
of course, so much. Andlast but not least, would love
if both of you could share wherepeople and listeners could go to get more

(28:25):
information about the work that you're doing. So, doctor Flock, if you
could share first, well, Iencourage patients to go to the Yale website
to look up barrier with surgery inour program and they can find me,
they can sign on, they cansign on to a free webinar and listen
in and learn about both OBC medicationsand surgery and everything we talked about today

(28:48):
and a little more detail. Ialso have a private website Doctorneilflock dot com
which they can visit and contact me. And I'm on Twitter and very passionate
about edition. Uh. It's NeilFlock, MD on the formerly known social
media application called Twitter. Thank you, doctor Black love it and doctor Asnas.

(29:14):
We're best to get more information aboutyour work. Sure, that's Stanford
Health dot org website. Thanks yousearch me. I'm less with it than
Neil. Is that? Yeah?That's okay, Now judgment here got to
do that. But the Stanford Healthwebsite, Maria Asne and the Medical Lightlof
program. Okay, great well,thank you again so much, and thank

(29:37):
you to all of our listeners fortuning in today. For all the details
about today's show, you can visitPulseoftheregion dot com. We'd like to give
a big thank you to our showpartner, Okill, and last but not
least, I'm Kate Bawman. Goout and make today a good day here
in Connecticut.
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