Celebrate a transformative year with us as we reflect on the birth of an independent healthcare practice dedicated to your wellness journey. Our anniversary isn’t just about looking back; it’s about charging forward with enhancements to your podcast listening, expanding our nutrition program, and fearlessly navigating the insurance battlefield on your behalf. Our commitment is unwavering as we delve into the economic ramifications of obesity bias, demystify the roles of nutritionists versus dietitians, and provide clear answers on supplements like berberine and effective calorie management with GLP-1 treatments.
This episode isn’t all talk; we walk the walk with Stacey’s personal victory in her weight loss quest—a narrative that will fuel your motivation to take on healthy living, no matter the obstacles. As we examine the saga of Eli Lilly and Novo Nordisk’s pharmaceutical tug-of-war, we uncover how past biases inform present triumphs and trials. It’s a tale of resilience, both in the industry and for individuals like Stacey, who illuminate the path to overcoming obesity with the right support and professional guidance.
Your knowledge will expand as we unravel the impact of GLP-1 medications on metabolism, revolutionizing weight management, and clarify the myths surrounding surgical robots. Remember that the surgeon’s expertise trumps the tool they wield. We thrive on your feedback, so as you absorb the wealth of insights from this episode, remember that your voice shapes our future content. Join us for an inspiring, knowledge-packed journey that empowers you to be an advocate for your health.
Transcript
Zoe:
Welcome back to the Pound of Cure Weight Loss podcast. We are on episode 12. So pretty great stuff going on here. What’s the name of our title today?
Dr. Weiner:
Oh, Domo Arig ato, Mr. Roboto. You can’t say it because you didn’t grow up in the 80s and you don’t remember the Stix song. Do you know the Stix song, Mr. Roboto?
Zoe:
Why don’t you give us a little snippet?
Dr. Weiner:
No, that’s not gonna happen. I didn’t ask you to dance, just sing. Stix is actually one of my all-time favorite bands. The, Come Sail Away with Me, is my favorite song of all time. The rule in the OR is when that song comes on, we have to turn up the volume. And everybody knows it, that if we’re playing Come Sail Away with me, also by Stix who sang and wrote Mr. Roboto we turn the volume up. So yeah.
Zoe:
And so that’s how we have the title of the podcast today. So, actually, another exciting announcement is that we have officially celebrated our one-year anniversary as a practice.
Dr. Weiner:
Yes, it’s been a little bit of a rough road. So we’ve been working together for a little over two years now, I believe.
Zoe:
Yeah, two and a half years.
Dr. Weiner:
Two and a half years. Yeah, so I’m on my third practice in Tucson and this time I said you know what I’m doing, this one alone. I’m not partnering with anybody else, because it’s been a little bit of a rocky road since I’ve come to Tucson. I’m not gonna lie to you, but I’m really excited. We have an amazing team here and it’s great to work with Zoe and Sierra and all the members of our team, so we really have a lot in store coming up this year. So, Zoe, so we’ll talk a little bit about what are our plans for this year. We’re actually very intentional as a group and we sit down and we map things out and we set goals and we hold ourselves accountable to these things. You know, just like when we work with patients, about holding them accountable, setting goals, all that stuff. We do this ourselves in our practice too. So what are our goals for 2024? What are we aiming for here?
Zoe:
Yeah, so we’re really excited about bringing more podcasts and really working to improve this experience for all of our patients and non-patients. So growing the nutrition program and then also partnering or potentially going head to head with insurance companies. You wanna tell us a little bit more about what we mean about that?
Dr. Weiner:
Yeah, I think you know we’re really very much on the front lines of healthcare. We are one of the few private practices, truly a small private practice. For the most part, private practices have been bought up by hospitals, by large groups, by venture capital companies even, but not us. We’re still independent. We’re doing this on our own. If we were in a large group practice, we’d probably have to run every single one of these episodes by some HR person to make sure we didn’t say anything wrong. I’m quite certain, most likely, some of the things that I’m about to say might not make it through the cut. But you know, the insurance companies are really, at this point, destroying our healthcare system. And they’re sucking way too much money out of it without adding the value in, and my goal is to hold them accountable, at least as it pertains to our patients. And so I’ve already had two conversations this year with chief medical officers of health insurance companies and we’re working to hold them accountable and make sure that they’re following their policies and make sure that you guys know what’s happening in healthcare, because I’m not really happy with it. I think I’ve been in practice for 15 years now and I’ve never seen it more predatory than it is today. The patient, what’s best for the patient has absolutely nothing to do with how most of their healthcare system is working for you. And I, you know, I’m gonna stay in private practice and I’m gonna go toe to toe and I’m gonna call people on this and maybe they’ll listen to me. Maybe they won’t. Most likely they won’t. They haven’t so far for 15 years but I’m gonna keep that up.
Zoe:
Well, I think it’s really comforting for our patients and just anybody who’s listening to, know that you and us, and potentially a lot of other doctors out there, are advocating for what’s best for the patient. And it’s not a us and the insurance against the patient. It’s us, with the patient trying to navigate the insurance.
Dr. Weiner:
Yeah, if you hate your health insurance company, then you’ve got an ally in us, cause Cause chances are we don’t like them either very much. At least a lot of the decisions that they’re making right now, and we don’t think that they have the best interests of their patients. We think that the majority of them are quarterly traded and gigantic billion dollar companies, and that’s what they’re interested in is making more money, and your healthcare is really just the vehicle that they use in order to get more money.
Zoe:
Well, we have another packed full episode today, so we’re going to be discussing how obesity bias cost Eli Lilly billions.
Stacy:
Yes.
Zoe:
A patient’s story. She’s gonna be in here in our, I was gonna say kitchen. It is our kitchen, but our studio kitchen, also functional kitchen, to explain a bit more about her success with the revision surgery. I’m going to dive a little bit deeper into the difference between nutritionist and dietitian. Which is which?
Dr. Weiner:
There is a difference.
Zoe:
I’ve even been called a nutritionalist, which isn’t a word, but that’s okay. The economics of obesity how to get insurance coverage for your GLP-1’s.
Dr. Weiner:
Nope, nobody’s really thinking much about that, are they? No, do we get that questions here very often? No, I don’t, yeah, so we’ll address that.
Zoe:
And then we also have our listener and patient submitted questions. We’ve got nature’s Ozempic, also known as berberine. We’ll discuss that a little bit further. What your calorie needs should be if you’re taking a GLP-1 and then robotic versus laparoscopic surgery.
Dr. Weiner:
That’s where our title comes from, our Domo arigato, Mr. Roboto. But I’m gonna talk about the difference between the two and whether there’s an advantage to one over the other. So let’s start with our news segment. So in the news we’re gonna talk about, this is an article out of from Bloomberg and it talks about how Eli Lilly has known for 30 years that GLP-1 medications cause weight loss in non-diabetics. So this researcher named Richard DiMarchi started at Eli Lilly. He ended up getting a patent and I think he used straight up GLP-1. It wasn’t one of the analogs. So none of the medications are actually the hormone GLP-1, a glucagon like peptide. They’re an analog that triggers the same receptors but are different. And the advantage is GLP-1 is metabolized very quickly, as most hormones are, so that you can have this kind of rapid change. But when we take a medicine, we don’t want it to be rapidly metabolized, we want it to last for a longer time. So they did an infusion of GLP-1 and they saw weight loss in humans and they said this is gonna be great. And the Eli Lilly brass said you know what? No one would ever stick themselves with a needle in order to lose weight. Who would ever think that someone would do that right? So he ended up leaving the company and he started several biotech companies. Guess who he sold two out of three of those biotech companies to. Novo Nordisk, who ended up creating Wegovy and Saxenda, and they were really the first to market. So Eli Lilly had this 30 years ago. It dropped the ball. Totally dropped the ball.
Zoe:
They’re trying to make money. They could have been 30 years ahead of this thing.
Dr. Weiner:
You know, certainly 20 years ahead of this thing. We could have had these medications 10, 15 years ago, but because, and a lot of this really comes from obesity bias. Obesity isn’t a disease. People just need to get their eating on track. It’s not about their metabolism. And so we just have to, why would you give them a medicine? You just have to button your lip right. We’ve all heard this before, but in the end, losing out on the several years and the advantage, they’ve lost billions and billions of dollars over this. So there’s really an interesting history between Eli Lilly and Novo Nordisk. So it dates back 100 years. And it actually goes back to one of the first expensive drugs, insulin. And so Initially, Eli Lilly kind of pioneered the distribution of insulin in the US. Novo Nordisk in Europe. And they really battled it over insulin. Before this, though, having diabetes was a death sentence. You were diagnosed with diabetes, especially type one diabetes 100 years ago is pretty much what we were seeing. There wasn’t nearly as much type two diabetes as we have now, but it was a death sentence. And so insulin changed that so that diabetics could live a somewhat normal life. So now we’ve got these two companies still battling over the diabetes medicines of Ozempic and Mounjaro and now obesity with Wegovy and Zepbound. And so these are the next front lines and Wegovy certainly is out ahead and they got the lead. And Ozempic is kind of the medication that everybody thinks of when they think about weight loss. But Eli Lilly has the better drug. More weight loss and right now they’ve got the better distribution plan and they’re able to deliver the medicine. We’re not seeing a ton of shortages of Zepbound or Mounjaro in the US. In Canada we are, but not in the US and so this is going to be a really interesting battle. I’m sure the business schools are going to play this out for years to come and we’re seeing this is all kind of is playing out because of some bad decisions Eli Lilly made 30 years ago.
Zoe:
Very interesting. All right, so now we’re going to have our patient, Stacey, come in, and you know Stacey, like so many of our patients, has had a lot of obstacles.
Dr. Weiner:
A lot.
Zoe:
Right. She really came in and she committed to completely changing her like she has done a complete 180. She does every single thing that you and I guide her on and ask her to do and I just I think she’s,
Dr. Weiner:
she’s incredible and a model patient, really. A complete model patient. I mean one of our best patients from from a compliance perspective, and and I think what she shows is that that it’s possible for anybody. You know, there’s so many people who have, have struggles some of the struggles that Stacey is going to share with us and look at it and say this is never going to happen. Never going to happen for me. But Stacey wanted this. She made it happen. She dug her heels in and she told the world hey, this is what’s going to happen and this we’re going to do this, and she really deserves a lot of credit. So, let’s, let’s welcome Stacey here today. All right. So we’d like to welcome Stacey. Stacey comes to us from Buoy, which I had to ask where Buoy was because I’m not a native Arizonian. And so I’m a native Arizonian and I didn’t know where it was. But it turns out it’s 30 minutes past Wilcox. So you drove two hours to come up here. And and we really appreciate that you know, in rush hour traffic that’s a lot, so so thank you for coming, Stacey, we’re really glad to have you here. I just wanted to ask you some questions about about your story. You’ve struggled with your weight for most of your life, correct? Yes, since since I was probably six. Six years old. So, as a child, did you have a lot of family obesity in your family?
Stacy:
My whole family is overweight.
Dr. Weiner:
Your whole family is overweight. And so were there any moments in time where you’re able to be successful with your weight loss efforts in the past.
Stacy:
I did the gastric sleeve in 2018. I lost probably 55 pounds. Okay, what? What did you weigh?
Dr. Weiner:
before that? 365. 365. And so you lost 55 pounds with a gastric sleeve. Was that in line with what you expected? Did you think you’d lose more? I thought I’d lose more. Yeah, and what was your experience like? I didn’t do your initial gastric sleeve. No, what was your experience like? What? Like what kind of education did you have leading up to it? What kind of support did you have after? What were your dietary philosophies? You know, how’d that all go for you?
Stacy:
Well, I didn’t have any support afterwards. There was not a lot of support leading to it as well. He was just kind of, this is what you’ll eat, this is where we’ll go, this is what it will look like. And I did have to do minimal amount of work to get there, like I had to lose the 30 pounds. After my surgery. I wasn’t able to eat the diet at all. Okay, you struggled. I struggled. I couldn’t eat basically anything, really. No vegetables. No chicken especially. Yeah, for how long?
Dr. Weiner:
Forever. You were never be able to eat chicken after your sleeve.
Stacy:
No, Chicken period. Chicken period, and vegetables was difficult. Even water was hard. I would go to him and I would tell him and he would come and holler at me and then he finally said your failure, you don’t want to follow my rules. Get out of my office. I don’t want to see you again.
Dr. Weiner:
That’s terrible, so I left. How’d that make you feel I mean defeated?
Stacy:
I didn’t know what to do.
Dr. Weiner:
I just can’t believe a doctor would say that to a patient. I’m not doubting you, I know that they did say that. I just can’t believe that a doctor would say that to a patient.
Zoe:
Yeah, it’s crazy.
Dr. Weiner:
Yeah, so you basically got booted to the curb by a bariatric surgeon.
Stacy:
Yeah, I never saw him again. And you couldn’t eat. Or anybody in this practice.
Dr. Weiner:
I think for those of you listening at home, it’s not normal to not be able to eat after bariatric surgery. You should be able to eat comfortably. In that first few weeks after surgery there’s certainly some adjustments to make, but after you get through that, after about a month out, repetitive vomiting is pathologic. There’s something causing it most of the time. After gastric bypass it can be a stricture or narrowing. We do see some patients where that vomiting extends out, but by two months, three months it should be getting much, much better. And so if you’re not able to eat, no matter how hard you try and after what? Five years you lived like this.
Stacy:
Yeah, it was bad. It was five years and I still couldn’t eat. I couldn’t eat chicken at all. Yeah, for five years. I never ate chicken. So if I did, it was not good.
Dr. Weiner:
It was not good. Yeah, that symptom is called dysphagia, or difficulty swallowing. Where you eat and it feels like it’s getting stuck. It sits like a rock in there. Is that what you were experiencing? Yeah, and then it would come up. And then come up. So you’d vomit and the food would come up. So that’s also unusual. There’s a lot of kind of foamy, the foamy, as they call them right? This kind of dry-heave or non-productive vomiting. That is different than productive vomiting.
Stacy:
Well with chicken and like salad, it was productive.
Dr. Weiner:
It was productive, so you’d eat, and that food would come back up. So eventually you started to have some heartburn as well, correct?
Stacy:
A lot of GERD, really bad. And, like nobody would believe me. It was like volcanic lava, yeah.
Dr. Weiner:
A lot of people say, oh, you know, I have a sleeve and again, I’m not poo-pooing the sleeve. Not everybody’s experience with a sleeve is like this and we have some really successful sleeve patients. And pairing sleeves with a GLP-1 medication also works really, really well, and so we do plenty of sleeves. I don’t want people listening to say, oh, the sleeve is a disaster. But we do talk about two symptoms: Dysphagia, difficulty swallowing, and heartburn after a sleeve. And a lot of times people are like, yeah, whatever, I’ll deal with it. But it’s very different when you’re going through it. So talk to us about what some of your heartburn symptoms were like.
Stacy:
Well, it would be like, like it was right here and it was like it would just hurt so bad. It was like a lump of coal would be there and then, when you lay down, it would be like the volcano would explode. Explode. Did you regurgitate food?
Dr. Weiner:
Yes, a lot. Like mouthfuls of it.
Stacy:
Mouthfuls. Did it ever come out your nose. Yes, up your nose and out your nose.
Dr. Weiner:
My general rule is when food’s coming out your nose, it’s time for a revision.
Stacy:
And they don’t understand that your regular PCP is like. What do you mean?
Dr. Weiner:
Yeah, because it’s very unusual. Very few people experience this degree of symptoms and that’s why it’s important you see someone who does these surgeries regularly. And you know patient comes to me and says I’m regurgitating. Every time I lie flat it comes up. I wake up in the middle of the night. I’m coughing, gasping for air because it’s going into your lungs, it comes out my nose. I don’t doubt them for a second. Right. Because I’ve heard that story over and over again.
Stacy:
I cried when he read that. Well, he didn’t read it, but he said it and he was like oh, I have a video on this and I’m like, could you send it to me? He’s like it’s in your portal already. I have to show this to my sister.
Dr. Weiner:
So, you know, did the heartburn start right away or did it come a little bit later? It came along and it got worse, hasn’t it? Yeah, that’s another thing we see. A lot is that the GERD symptoms, once they start to come, once they get in a bad, you could take all the medication in all of Tucson, all of Southern Arizona.
Stacy:
It didn’t touch it. Didn’t touch it and I was on like five, four or five.
Dr. Weiner:
Yeah, and once the symptoms come, they normally don’t go away. They don’t go away, they get worse over time. So you came to see me and we decided to do a gastric bypass. You quit smoking, you jumped through all the hoops and we got you approved for gastric bypass. How was that surgery? Was that a difficult surgery to go through?
Stacy:
Yes, was it. Yes, it’s a mind game.
Dr. Weiner:
What was difficult about it? Was it physically difficult or emotionally difficult?
Stacy:
Both. Emotional all the way through, but physically after. I was like hmm. I don’t like this.
Dr. Weiner:
Yeah, how was it different than a sleeve? You worry more after. You worry more. Yeah, because you think, oh, this is a bypass.
Stacy:
Yeah and I broke my mine. Well, I don’t know if I broke it, but it broke. My sleep, so maybe I was more worried that I would break this. Maybe a little PTSD about it.
Dr. Weiner:
I don’t think that your sleeve broke. I just think it was probably too tight from the very beginning. That’s my sense of it. And that’s why you had the heartburn. That’s why you had the difficulty swallowing. You know that’s, this is something we see in 5% of sleep patients. And it’s pretty brutal. Is the heartburn gone? Yes, gone. Totally gone. Totally gone.
Stacy:
Can you eat chicken? Yeah, I eat chicken all the time.
Zoe:
What about veggies?
Stacy:
Yes, I was like I don’t know veggies. I’m like I already did.
Dr. Weiner:
They need seven pounds, so we just can’t. So we talked a lot about weight loss, and one thing I talk about with patients who’ve had acid reflux is this converting a sleeve to a bypass works great for the acid reflux. And here you are, you can eat chicken, your heartburn is gone. But we talk about the weight loss, and often it’s not going to be as much as we predict. And so I kind of gave you a range. Do you remember how much I predicted you’d lose in terms of weight?
Stacy:
You said maybe you can lose 30 before the surgery, so you can have it. And I’ll get you maybe 20 more after, so we’ll get you around 300 pounds.
Dr. Weiner:
What do you weigh now?
Stacy:
257. 257.
Dr. Weiner:
So you beat what I was kind of hoping for by 40 pounds.
Stacy:
Yeah, I almost doubled. And it’s only been what four months?
Zoe:
or something.
Stacy:
Yeah, I met him August 8th. I did my surgery November 8th and now it’s like yeah.
Dr. Weiner:
I like to under promise over deliver. I’m just gonna tell you that? That’s kinda my motto in life is that I don’t want to tell somebody something’s gonna happen and then have it not happen. I’d rather not tell them it’s not gonna happen and then have it happen and then be happy about it. So we see variable weight loss, and one of the weird things about you, and again this is something that doesn’t always make a lot of sense, is if someone’s regained a bunch of weight after their sleeve, then they tend to respond a little bit better for weight loss with the gastric bypass. Whereas if you just kind of didn’t lose a lot in the first place, and that was a little bit more of your scenario, you just didn’t lose that much from a sleeve, then we don’t typically see a lot of weight loss. But I think we’re at 80 pounds or something for you.
Stacy:
I have lost 95 pounds.
Zoe:
Wow.
Dr. Weiner:
That’s for a bypass? A sleeve to a bypass revision. That’s amazing. But Zoe why don’t to you tell why you think that Stacey’s lost a lot of weight, because I think, of anybody in the practice, you guys probably know each other the best.
Zoe:
Yeah, I mean I was telling the doctor Weiner earlier that you, literally, are the model patient because you do every everything that we talk about. You run everything by me. We went and looked at a menu together before you knew you were gonna be out of town. So every single thing you’ve just done so perfectly and I’m just so proud of that, like the commitment that you’ve made to changing your life.
Stacy:
It’s really, she said don’t eat anything in Safford out, there is nothing. Go to Safeway.
Dr. Weiner:
That’s probably true. So so you know, Stacey, a lot of times we hear from patients like I can’t afford to eat healthy. I’m on a budget. You’ve got some financial limitations in your life correct, and yet you’ve managed to make all of these changes. So so what’s been your secret? How’d you make that happen? You know, if someone else is out there listening and say I can’t afford to eat healthy, what should they be doing? What are some tricks that have worked for you?
Stacy:
We take that cigarette money and you buy apples. Yeah, you have to do that. But, um, you just have to do it and you have to prioritize that money. But, um, yeah, I have a lot of financial, I live on social security. I have food stamps. You have to do it and you have to, I don’t know. Bargain shop.
Dr. Weiner:
Just give us two or three inexpensive, healthy choices that you make a lot. I don’t know I have to, I just buy. More vegetables. Do you buy frozen or fresh?
Stacy:
I buy frozen because you can get frozen fruit on sale a lot more than you can on fresh. So I buy a lot of frozen on sale. How about best and safely? Do you do a lot of beans? You didn’t get beans on sale too, and you get beans through commodities. Okay, two commodities. What tells about that?
Dr. Weiner:
What are commodities?
Stacy:
commodities. Come on the for us the first Thursday of every month and you almost always get a can of beans and a can of tomatoes. Okay, and most of the time the tomatoes are good. You can eat the tomatoes, yeah. So yeah, you can do it.
Zoe:
Well, we have a kind of a little gift we wanted to give to you and that is an entire year of the nutrition membership program for free, because we know how much you show up for yourself and we just we really want to reward those efforts. And we think that you know, we want you to keep showing up and we know it’s important.
Dr. Weiner:
Thank you. We want you to use that nutrition membership money for some healthy food. Yeah now that, now that you burned through the cigarette money, use that nutrition money. We want to make sure you stay part of our community because you’re really really valuable part of our community. We always know, anytime we log into our support group, we know we’re gonna see Stacy in there and you’ve helped a lot of other patients as well. And your story, there’s a lot of people like you out there who are struggling with their weight and they look at their life history, their financial limitations, all the things that have kind of come their way, that that have been difficult and made it really hard to lose weight, and we want to make sure people know you know it is possible. You can do this. You can be a model patient and and we want to make sure that you’re out there telling your story to other people. Thank you.
Zoe:
Well, thanks so much for making that long trip and coming here, and we get to see you in person.
Stacy:
Yes, First time ever. I’ve seen you in person.
Zoe:
Stacy and I have had our entire relationship over zoom. You did amazing. Thank you. Hearing from Stacy is just so inspiring and I hope that knowing the the challenges that she had to overcome Inspires at least one or a small handful of whoever’s listening to, to maybe who are thinking oh my gosh, the road is so far, the mountain is too steep. You can do it and you can absolutely make the changes, just like Stacy did, in order to see your life change.
Dr. Weiner:
Yeah, All right, Zoe, it’s, it’s your time, now. Let’s talk about the nutrition segment. This is something you and I have discussed at length, and I think it’s important for everybody to know. We’re gonna talk about the difference between a dietitian which is you and a nutritionist.
Zoe:
Yes, well, I. I think the first thing is that education is key, because we’re who not like. How are we supposed to know these things? Right, I didn’t know these things before I was a dietitian and and our patients certainly don’t, so hopefully we learned something new. And the difference between a nutritionist and a dietitian is huge. Actually, somebody could read a nutrition article, or just like nutrition, and then call themselves a nutritionist. A dietitian, however, has to have a Bachelor’s of Science, complete a year long unpaid internship yeah, you have to pay to do it, okay, and then sit for the national board exam to become a registered dietitian. And then, of course, continuing education credits to maintain that certification. Now, dietitians are now actually also required to have a master’s degree. Huh, yeah, I am grandfathered in, but that’s why I got my masters when I did, because I wanted to be kind of, you know, ahead of the curve of all of these newer dietitians coming in with masters. So, anyway, if you’re speaking to a dietitian and you call them a nutritionist, we’re going to politely correct you, but please, from now on, hopefully, you know. And? But also the biggest piece of it here, and of course, I don’t really care. I’m here to help serve our patients right, but I just hope that somebody listening that you can be a little bit more discerning of especially online social media. Everybody and their mother are calling themselves nutritionists and it’s just really, really important that you listen to a dietitian that you trust and not just a nutritionist with a million followers on Instagram.
Dr. Weiner:
Right, absolutely. I think this that’s really to me. The take home point is that a registered dietitian goes through a licensing process. There’s continuing education that has to happen. There’s a very high bar to becoming a registered dietitian. Anybody can dole out nutrition advice. Anyone can call themselves a nutritionist. There is no licensing around that term. There is no expectations or criteria to say you’re a nutritionist to some degree. It would be the same thing as like a doctor and a wellness coach. Right. To become a doctor, there’s a lot of things you have to do to get there. And then there’s a lot of ways that you have to behave once you are a physician, or they’ll strip all that away from you rightfully so. And a wellness coach? Anybody can be a wellness coach. You just hey, guess what? Today I’m a wellness coach. And so most people understand the difference between a doctor and a wellness coach. But I think it’s important to understand that this exists in other fields as well. It exists in psychology. It exists in nutrition, and so it’s important for you to understand that licensing matters. Education matters and, beyond just the knowledge base, it’s also the standards that are set for your behavior. If you started doling out kind of crazy advice like hey, I want to put you on the McDonald’s diet. The board could come after you and say Zoe, what are you doing? You can’t be telling everybody to eat a ton of McDonald’s. That’s not appropriate. And you might be sanctioned and potentially could even lose your license. If you’re a nutritionist, you can say whatever you want and there’s no recourse. Okay, so we’re going to move into our next segment, the economics of obesity. And again, if you, it doesn’t matter how great a treatment is, if you can’t afford it, you’re not going to get it. And we see this all the time, right now with the GLP-1 Meds. So I’m going to talk to you about some step-by-step approaches you can take to determine whether you have insurance coverage and then, once you do, what you can do to increase your chances of getting it. So the first thing is is you have to know whether or not your insurance covers these medications. Now there’s a bunch of different ways that you can do it. First, in our, our, our electronic medical record software does have some very limited functionality where it can connect to a database and pull some of this data. A lot of people think, well, I can pull every single last thing. I can’t. I get very, very basic information, but sometimes I can take an educated guess about whether and a medication is covered or not. There’s other ways that you can figure this out, though. A lot of people will have apps through their insurance company with the with the formulary on it. And you can go on those apps and look up your medications Wegovy and Zepbound. Important to know the difference between the diabetic versions, which are almost always covered, and the weight loss versions. If you don’t have diabetes in 2024, it’s really hard to get the not the diabetes medicines. So you can look through the apps for the weight loss versions for Wegovy and Zepbound, unless you have diabetes, in which case you can look at the Ozempic and the Mounjaro the diabetes version. And then the other thing you do is call your insurance company. On our website, we actually have a tool that will guide you through that conversation. And so it tells you what questions to ask and at the end, it’ll send you an email with a nice digest of what the, what the criteria are and what your chances are and what your best medications that you can have.
Zoe:
That’s a really helpful tool.
Dr. Weiner:
Yeah. So your best weapon is to know your policy. So just it being covered is not enough. There’s something called prior authorization. Prior authorization means that we have to submit forms to your insurance company and then it’s reviewed by somebody who determines whether they’re going to pay for it or not. And prior authorization has a strict set of rules; you must be over a certain BMI, you must have tried this medication first. Providing these rules is the key to obtaining insurance coverage, because you want to make sure that you address all of those things in the prior authorization. Again, people think the doctor’s office has the ability to look all those up. Oh, let me just pop on and log in and get all that information. If you can get it. It’s often wrong. Honestly, the only way that we have found to reliably get that information is to submit a prior authorization, have it denied and with the denial will come the criteria that are required for that. And it’s this kind of redundant process where we apply, get denied. Figure out what we need to do. Do it and then reapply and get it approved. So if you can come to your doctor’s office with that information, you’re going to have a much better chance of getting approved. What you can also do is ask for a copy of your medical policy, and that will specify exactly what those criteria are. The more research you do, the better position you’ll be in. You should know what your hemoglobin A1C is. That’s the most common blood value we use to measure diabetes and if you know what your hemoglobin A1C is, you may be in a position to get the diabetes version of these medications. You also should have a list of the other medications you’ve tried for obesity. Have you tried Phentermine or Qsymia or Xenical or any other medications in the past and what did you tolerate, them or not? Also very important, a lot of patients will say but doesn’t the insurance company understand how much this would help me and how much I need this medication? Yeah, they do. They just don’t care. That’s really important to understand. It’s a harsh reality, but I have had hundreds of conversations with physicians, with nurses, who work for insurance companies and they do not care about you. You must approach this like a lawyer, not a patient. Know what your contract says, be able to prove and defend it and then put the prior authorization together. Put forth the argument that supports the medical policy and, unless you look at it that way, your chances of getting approved are very small.
Zoe:
That’s a good tip to think about it like a lawyer, not a patient. And it’s hard to get out of that patient mindset, but I think having those steps that you outlined is going to be really helpful.
Dr. Weiner:
I think the other thing to keep in mind is this is your money that’s being paid. When we, for instance, you, receive some stipend from our practice for your health insurance. Every employee does, for the most part. That’s actually salary that we’re paying to you. If you didn’t get that, we could talk. If we never had to pay that, you would get a raise. And so, whether it’s Medicare, whether it’s coming through a state agency, whether it’s coming through a commercial plan, there is money being paid to this company on your behalf for your health care and it’s being denied to you for a bunch of different reasons.
Zoe:
Because they want to keep their money. All right. Moving on to our listeners submitted questions. We’ve got Sierra here.
Sierra:
Take it away, Sierra. Okay, First question is from YouTube, from our podcast Episode 10, Why Your Meds Cost so Much. And this is from Angela. I’ve actually experimented with using berberine in the last couple of weeks and it seems to be helping. Could you maybe give berberine some attention and explain how it works?
Dr. Weiner:
So you want to start with this one. I think this is probably something both you and I can chime in on.
Zoe:
Yeah, definitely so I think we’ve. Maybe you’ve heard this before. Berberine called nature Ozempic. You know just kind of. You’ll talk a little bit more about the mechanism of action and that kind of thing, what it’s supposed to do. But the biggest thing I want to comment on first is about supplement safety. Anybody and their brother could go outside in the parking lot, scoop up some dirt, slap a label on it and say, here, buy my supplement. Literally there’s no, there are no regulations. So when you’re picking out a supplement, first off we want to make sure that it’s third party tested and approved. I think I’ve probably mentioned this before, but just a refresher for those who maybe forgot or haven’t heard before. You want to find a supplement that has that seal. So that could be USP, that could be Informed Choice, that can be NSF certified for sport. That means that this supplement has been sent off, tested, that third party testing has said, yep, what you say is in there, is in there and it’s safe. So that’s the first step whenever you’re looking at taking a supplement.
Dr. Weiner:
Yeah, so so berberine’s interesting because there actually is a tiny bit of data on this. But this is something that we see quite frequently with nutritional supplements. And I see this a lot too, with a lot of people who make some kind of crazy claims like, hey, you know, beans and other things with lecithin are dangerous and you shouldn’t be, shouldn’t be eating them. Berberine does have a few good effects. It will change your gut microbiome, so the bacteria that are in your GI tract will change a little bit with berberine. It can lower your lipid levels a little bit. And both of these things are interesting because, well, we all know, hey, your gut microbiome is good for your weight loss and your health, but that doesn’t really show that if we change the gut microbiome with berberine, that we actually improve your health. Same thing with lipid levels. What do we care about our lipid levels? We care that they can be associated with heart attacks and strokes. Does berberine reduce your risk of heart attacks and strokes? We don’t have that data. That’s never been proven. My suspicion is it’s not been proven because it’s not true.
Zoe:
Yeah Well, I just I think it’s also very important to keep in mind. It is more important to work on your nutrition changes than try to like bulldose through it with all sorts of supplements. Right, you can’t out-supplement a bad diet. And so those, those maybe maybe not very significant or insignificant improvements that the research shows Burbe Berberine, how much more significant of changes could you make with your nutrition and lifestyle?
Dr. Weiner:
That’s a great point. I mean, Berberine is very similar in makeup and function to Metformin. Which is a medication that every now and then pops up, and I think we’ve talked about it in the past and how it’s really not particularly effective. And I think your point is great is that everyone’s well. What’s the harm? The harm is the opportunity cost. So if you’re focusing your energy on using Berberine, you’re not focusing your energy on nutrition. And there’s no question nutrition is going to be a much more valuable change than adding Berberine as a supplement.
Sierra:
Okay. Next question is from Facebook, from Anna. My dietician says my calorie intake is too low to lose weight and that using Semaglutide is just slowing down my metabolism even further. I average about 1000 calories and 45 to 60 grams of protein daily. I’ve gained 40 pounds since my sleeve seven years ago. I’m at a loss.
Zoe:
All right. Well, I actually really like this question because that phrase starvation mode, I’m sure you’ve heard it, kind of gets thrown around a lot. If someone came to me and they did not have a history of weight loss surgery and they were not on GLP-1’s and they were eating 1000 calories and 45 grams of protein, I’d say that’s not enough. And your metabolism is likely maladapting to accommodate for that significant like that significantly lower amount of calories. However, that’s not where we’re at with this question. Right, being on a GLP-1 medication, very similarly to post-op, is that it impacts your hormones and puts your metabolism in your body in weight loss mode. I like to kind of explain that, as it’s almost like tricking your brain a bit, in that you can eat 1000 calories and something that is not enough for most adults who are not experiencing these hormonal changes, and so we are actually able to kind of bypass that metabolism adaptation, that’s, slowing down, and help reduce that set point or that kind of body’s comfortable weight. But I would recommend bumping up your protein intake a bit. You know, if you’re on the GLP-1’s right now and you have had this history of weight loss surgery, if you can make 60 or new kind of bottom end of that range and try to get 60 to 80, I think that would, that would be great, especially if you are seeing weight loss. We want to make sure that that muscle is protected and so GLP-1’s actually have that protective effect on your metabolism instead of that starvation mode that a significantly lower calorie intake would normally put your body into, that kind of famine mindset. So the GLP-1’s protect your metabolism so that when you’re getting that 1000 calories, that is what your metabolism recognizes as what it needs. Whereas if you’re not on the GLP-1, 1000 calories triggers that famine or starvation mode mindset that we want to avoid.
Sierra:
Okay. Next question is from one of our YouTube shorts on Wegovy reducing the risk of heart attacks. Is it better to get the surgery done with assisted robotics? I have read patients heal better with it.
Dr. Weiner:
So you’ve probably read that from the company Da Vinci that makes the robot, and they’ll definitely make that argument. The surgical robot is this, I mean, this thing is huge. It’s like, you know, eight feet tall and eight feet around and it’s got all these arms and you put them into the patient and then you sit at a little console kind of you know off to the side and you control everything. So the advantage of the robot is that suturing laparoscopically. So laparoscopically means we make these small incisions and we just put these plastic tubes in and use these longer instruments, and that’s actually the way I do the surgery. Suturing laparoscopically is difficult. I trained before the robot was really a thing and so I learned how to tie knots and suture and went through this fairly difficult and time consuming laparoscopic process of education and so I can suture and tie from with laparoscopy, no problem. Not every surgeon can do that. The robotics makes it much easier. It gives you more angulation and more articulation, so that suturing is a little bit easier. You should think of the robot as a tool. And nobody really is going to ask the surgeon hey, listen, what kind of grasper do you use? What kind of stapler do you use. These aren’t questions that anybody’s ever asked me, because it’s really kind of the nuance of surgery. When I talk to other surgeons, we talk about that stuff all the time, but patients don’t need to know that stuff. That’s really left to the surgeon. In the end, you should pick a surgeon with exceptional outcomes. All of our outcomes are tracked. My surgical complication rate for gastric bypass and for sleep gastrectomy is in the lowest 10% in the country. Every bariatric surgeon has their outcomes tracked. We actually have a third party. This is a nurse who doesn’t even live in Tucson and she just reads through the charts on every single patient that I operate on. She calls them up, she looks through them to make sure that they got through the surgery safely. Anytime something happens that we don’t want to happen, they track it. They put it into a national database and I get compared against my peers every quarter. And I get a report that says, hey, here’s how your safety record looks. Our safety record is in the top 10% in the country for both gastric bypass and gastric sleep. We have one of the lowest complication rates, the lowest hospital readmission rate, the lowest re-operation rate in the country and we do the surgery laparoscopically. There are other surgeons in that top decile, the best 10% in the country who do the surgery robotically and are able to achieve those same outcomes. You shouldn’t be asking about robotics or laparoscopy. You should be asking about the surgeon’s outcome. The robot is not going to improve your recovery any more than a stapler would or a needle holder would or any of the other instruments we use. The robots cost several million dollars and on top of it, there’s a huge contract that the hospitals must pay to keep this thing going. The Da Vinci stock has been going through the roof. They’ve been making tons of money and they’re really pushing and promoting this. Hospitals have invested a lot of money in it. They want to make sure that it’s out there and they look at it as a marketing ploy. That’s really what a robot is. It’s a good thing that you can market and say, hey, look how advanced we are. We use a robot instead of laparoscopically. The truth is, it doesn’t matter. Outcomes are what matter. Know your surgeon’s outcomes. Choose a surgeon who has a low complication rate, not one who uses a certain tool or instrument.
Zoe:
That wraps up our show. If you haven’t already, please write and review us on wherever you’re listening to this podcast. We’re really excited about continuing to bring these episodes to you, but we want to know what you think and we want to know how to continually make them better. Make sure you do that if you haven’t already, and submit a question, because we’d love to hear from you as well. We’ll talk to you next week.
Dr. Weiner:
See you next time.
