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In this episode, we discuss the emotional toll of weight bias, the promise of medications like Ozempic, and the urgent need for accessibility and affordability in obesity treatments. We also delve into the inspiring stories of individuals on the path to better health, including Bev, who shares her impressive weight loss and improved mobility story. Plus, get ready to challenge misleading health claims and learn how to make more informed decisions in the grocery aisle. Don't miss this thought-provoking discussion on the economics of obesity and the small steps that lead to a sustainable lifestyle overhaul.

In our first chapter, we dive into Oprah’s special on obesity, where she opens up about her personal struggles and highlights the importance of unbiased storytelling. We explore the effectiveness of weight loss medications and the need for greater accessibility and affordability in obesity treatments. Join us as we unpack the emotional toll of weight bias and the promise of a healthier future.

In the second chapter, we are inspired by Bev’s incredible weight loss journey and her transformation towards improved mobility. We explore the challenges of weight loss, the role of surgical intervention, and the importance of maintaining mobility as we age. Bev’s story highlights the transformative power of shedding pounds and gaining strength, vitality, and a healthier life. Tune in to hear her inspirational journey towards better health and the ongoing goals required for long-term success.

In our final chapter, we take a practical approach to goal-setting within our Smart Support Squad for nutrition. We discuss the importance of setting realistic, measurable, and achievable goals for sustainable habit change. We also shed light on the deceptive nature of health halos and provide tips on how to navigate misleading food labels. Join us as we arm you with the knowledge to make more informed decisions in the grocery aisle and embark on a better weight loss journey.

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Zoe: 0:17

All right. Welcome to episode 18 of the Pound of Cure Weight Loss Podcast. You get Ozempic, you get Ozempic…


Dr. Weiner: 0:21

“Everybody Gets Ozempic.”


Zoe: 0:27

Did you watch Oprah last night?


Dr. Weiner: 0:29

Absolutely. I would never have missed it.


Zoe: 0:30

Yeah, that was a really great special.


Dr. Weiner: 0:33

I thought she did a fantastic job. First of all, Oprah and I go way back. Back when I was in high school. I would come home, and at 4 p.m., I’d watch the Oprah show. And I just always loved her. She was always so human. There was something that really stuck with me. When she showed that TV Guide, it said that she was lumpy, dumpy, and downright.


Zoe: 0:57

Something, yeah, oh my gosh.


Dr. Weiner: 1:00

And that was in 1990. And so here she is, 35 years later, bringing that up. I assure you that she didn’t have to go searching through that. She knew exactly who wrote it and exactly where it was, and it just really shows how hurtful some of these statements can be and how hurtful obesity bias is.


Zoe: 1:19

Well, Oprah Winfrey is such an incredible woman and so accomplished. And the thing that makes headlines over and over again is her weight juggling.


Dr. Weiner: 1:32

Yeah. So I don’t know. I love that show. There was so much good stuff. They talked about SetPoint. I thought they did a pretty good job with the medications. They really kind of sold the medications. Of course, they picked people who had been very successful, and we see, you know, 15%–20% of people are really not able to do it. I also didn’t think that she talked enough about access and the cost.


Zoe: 1:55

Well, I was really excited that they had the VPs of Eli Lilly and Novo Nordisk there. And I was like, “Oh, we’re going to get good,” but it was so disappointing.


Dr. Weiner: 2:04

It was so vanilla: “Oh, we’re just committed to obesity and making billions of dollars, really.” But billions of dollars first, and, you know, obesity after that. If it makes billions, we’re in. I thought that was kind of how they approached it.


Zoe: 2:18

They needed to be up on the stage being hounded much more than they were.


Dr. Weiner: 2:22

Right, now that you have this life-saving treatment, what are you doing? How are you going to serve the public? This is like the polio vaccine to some degree, and so there’s some moral obligation to provide these medications and not necessarily look at them solely as a vehicle for profit. So, anyway, that leads very, very smoothly, coincidentally, into our In the News segment, and so our In the News segment comes off Yahoo, and it’s about Oprah revealing the real reason why she sold her Weight Watchers, her shares. So Oprah owns 10% of Weight Watchers. Weight Watchers, a while ago, bought Sequence Health, which is a telemedicine company that prescribes Ozempic, Wegovy, and Mounjaro, and so Oprah’s been on the board for Weight Watchers for, I think, about a decade now and owns a significant percentage. And she actually didn’t sell them. She donated them to the Smithsonian Museum for African American Studies and African American History, and first of all, I love that she did that.


Zoe: 3:21

She is like: “I’m not making any money for doing this.”


Dr. Weiner: 3:24

But what I really love about that is that Oprah is at her root.


Dr. Weiner: 3:29

She started as a local news journalist, and I think one thing she’s always done so well is tell an honest, unbiased story, and she did that really, really well last night in this episode that she put out, and I think she made a major financial shift in her life just so that she could tell the story and not be criticized for her bias. I really respected that, and I think we’ve talked so much about how much bias there is in the insurance industry and in the pharma industry, and it’s so nice to see someone really taking a stand and saying, “Hey, I’m going to present the most unbiased version of this thing that I can.” So it’s a great news segment and a great special, and I really urge any of you out there who missed it to watch it. You’re going to hear about Setpoint, and you’ll hear about the medications. They have some national leaders in the field as well, and you see, the pharma industry kind of, you know, says whatever their PR people told them to say.


Zoe: 4:25

Yeah, well, exactly. Did you notice that they didn’t even answer Oprah’s question? Did you notice we had to switch spots? Yes, we did.


Dr. Weiner: 4:34

For those of you listening, you won’t have noticed.


Dr. Weiner: 4:38

But if you’re watching, we did switch spots, so our guy who helps us with the video says we should switch. So here we are, on different sides. It’s a little awkward, I’m not going to lie.


Zoe: 4:48

Yeah, changing up what we’re used to.


Dr. Weiner: 4:50

Yeah, all right. So let’s move on to our patient story. We’ve got Bev here. Bev is really an amazing patient. She’s been so successful and has just been driven and determined to make these changes in her life, and what I’ve loved is that she’s really made them kind of step by step, by meaningful step, and we’re going to help her make that final step, the final last step, today. So, anyway, let’s welcome Bev.


Zoe: 5:11

Yeah, well, we have Bev here. I’m super excited to have Bev share her story today. Bev, how are you doing?


Bev: 5:18

Oh, I’m doing great. I’m so happy to be here.


Zoe: 5:20

We’re really happy to have you. Why don’t you just start off by sharing with the listeners a little bit about your story and your background?


Bev: 5:28

Yeah, well, I had surgery on October 31st, 2022. Everybody thought I was crazy for having it on Halloween.


Bev: 5:37

I’m like, no, I just waited. I waited 10 months; I wanted it, so I just got it as soon as I could. And you know, just going back, I’m not a unique bariatric patient. I wasn’t obese as a child, but when I hit puberty, and I hit puberty pretty early, like 11 years old, dieting seemed like a rite of passage then. And you know, I compared myself to my peers, and they were all thin little girls, and I was getting curves, and so that meant I needed to diet. And I didn’t even realize until the last few years that that behavior actually broke something in my metabolism.


Dr. Weiner: 6:16

Yeah, I think dieting and calorie restriction, especially when it’s kind of this crazy crash diet or these extreme diets at a young age, can be really damaging. The backbone of it kind of starts when we’re in utero, but it really is well into adolescence, puberty, and almost your very young adult years that your body kind of settles on: “Hey, am I a fat storage body or am I a fat burning body?” And so I think you really have to be careful with children and the types of diets you put them on.


Bev: 6:49

Yeah, my first diet was the Ayds candies at age 11. They were like little chocolate or caramel candies, and the secret was that you drank them with a cup of hot water. Just get rid of the candy and have the hot water before your meal.


Dr. Weiner: 7:02

And so you ate that before your meal. Was it a laxative?


Bev: 7:06

I don’t recall that side effect, maybe.


Dr. Weiner: 7:11

I’d worry about that.


Bev: 7:12

But that was like the first one. And then it was Weight Watchers, TOPS, the Atkins diet, and all these. You know, they never stuck.


Dr. Weiner: 7:19

So, how old were you when you had surgery?


Bev: 7:22



Dr. Weiner: 7:23



Bev: 7:24

Yeah, I’m going to be 66 next month.


Dr. Weiner: 7:26

So let’s talk about that decision. You’re a nurse, yeah, and so you kind of spent your whole life as a nurse. When did you first start to think about bariatrics?


Bev: 7:35

Actually, when I hit 60, I couldn’t lose any more weight. I think the pandemic… there was, all you know. And then I started having all this ridiculous pain. So I lost a job that I couldn’t do anymore because I couldn’t hardly walk or stand. And you know, that was obviously my illness of obesity.


Bev: 8:05

Isn’t that sad?


Dr. Weiner: 8:06



Bev: 8:06

But what a turnaround!


Dr. Weiner: 8:08

So how’d you decide on the surgery that you ended up having?


Bev: 8:13

The gastric bypass. When I met with you, you had that little wonderful quiz, and I knew I weighed 295 pounds at my height, and I’m five feet—I mean, I’m losing inches. Yeah, I’m like, I don’t want to lose inches this way. But yeah, so five or four. So yeah, it was. Yeah. I said I wanted to take off the most I could.


Dr. Weiner: 8:38

Yeah, okay, so you chose the little bit more aggressive route? Yeah, and what was your experience like after surgery?


Bev: 8:44

It was beautiful. Even in the hospital now. Going into surgery, I could hardly walk across the street. I couldn’t walk without pain.


Bev: 8:53

I walked with a cane, and I remember you giving me kind of a rundown of what I could lose and everything, and you’re like, “The cane could be a problem.” I go; I’m going to do it. I’m a determined person. But yeah, this surgery I couldn’t have done without it. But there’s a lot to do to get there, and I think I did a lot of the right things with you.


Zoe: 9:18

And you did a lot of the right things afterwards as well. I know that we talked all the time.


Bev: 9:20

Oh, we did. You were like a therapist.


Dr. Weiner: 9:24

Zoe’s part dietician, part therapist. I almost said nutritionist.


Bev: 9:36

Oh my God, Don’t say that; that’s a bad word around here. Yeah, you’re like an old soul in a young body, because you’re bright.


Zoe: 9:42

Thank you, Bev, but why don’t you tell us a little bit about some of that turnaround you made with your nutrition choices and maybe your movement, if that hasn’t changed a lot? What you’ve been able to do since surgery.


Bev: 9:54

Well, you know, I’ll start off with the movement from surgery. You know, I got out of bed and I could walk, and I wasn’t even using the cane, and I’m kind of blown away. I’m trying to ask, “How does that happen in an overnight scenario?” and I thought maybe it had something to do with the diet you put me on prior to surgery.


Dr. Weiner: 10:15

Or maybe the surgery itself. So, as you know, weight loss is a very anti-inflammatory state. Obesity, or weight gain, is an inflammatory state, and when you’re in the process of losing weight, that actually reduces the amount of inflammation. And so a combination of the pre-op diet you did and then the surgery, where we really start to see these hormonal changes within hours after surgery, may have started to decrease the inflammation in your systemic joints.


Bev: 10:41

That’s like mind-blowing, miraculous, to be able to move like that and not having been able to do that, so that piece of it, the movement from the get-go, I was walking maybe 10 minutes four times a day, and then I got up to walking like an hour a day.


Dr. Weiner: 10:59

You could barely cross the street before surgery. Yeah, I think that’s another really important lesson. As you age, and I don’t remember you really having a lot of medical illnesses. Did you have a lot of medical illnesses going into surgery?


Bev: 12:01

People would ask, “Do you have diabetes?” I’m like, not yet, because I knew it was all coming. But my cholesterol—no, high blood pressure—was crazy.


Dr. Weiner: 12:12

And so, on one hand, all your numbers and all your blood work looked great, but on the other hand, you know, it just took five seconds to watch you try to walk across the street to realize that there were some health issues. And so, as you age, the number one determinant of how that process goes is mobility. Even more than metabolic health and everything like that, your mobility really drives your health as you get older, and if you can maintain your walking well into your 80s, that generally is a much easier aging process than people who are struggling in their 60s. And so, let’s talk about your mobility. It sounds like it’s changed dramatically since then.


Bev: 12:51

Yeah, yeah, it really has. My primary is at El Rio, here in town. I want to get you guys together because you saved my life. El Rio does a lot of really good things. They have exercise classes that are free to all their patients, and that’s where I started. So they have strength training, and I know from meeting with you and everything that that’s really important to build muscle.


Zoe: 13:13

I see that muscle.


Bev: 13:18

My next thing is, I’m like, I want to find out how to get that surgery to get rid of this. But anyway, we’ll leave that for another time. But yeah, so I started those classes, and I would have to position myself close to a counter so I could get up off the floor. And now I could just get up off the floor.


Dr. Weiner: 13:34

Yeah, yeah, how far can you walk?


Bev: 13:37

Well, let me tell you. I have taken so many vacations since October.


Dr. Weiner: 13:43

Good for you.


Bev: 13:44

Estes Park, nothing but walking—yeah, like hours of walking. We’ve been camping down in Patagonia with an RV. Now, RVs, you know, that’s work. Get up in the RV and do all your stuff. Get down below and do all your stuff, yeah. And we have dogs. So we’re just, you know, taking a lot of walks with the dog; being so active was a gift.


Zoe: 14:11

Completely different lifestyle.


Dr. Weiner: 14:13

What was your starting weight? You said it was 295. Yeah, and we predicted, I think, around 90 pounds for you.


Bev: 14:18

Yeah, I think you told me like 195 or something. Yeah, I’m like, I’m not liking that. I weighed before I came today; I thought he’s going to ask me this. Unfortunately, I have my shoes and everything on, and I don’t weigh either. I just don’t; I don’t even do it.


Bev: 14:37

But with everything on, I was 166. Get out, right? Is that crazy?


Dr. Weiner: 14:43

So you lost 130 pounds. Yeah, and we predicted maybe 100 max. So you knocked it out of the woods. Do you feel like it’s difficult to maintain your current weight?


Bev: 14:54

No, I mean, I’m surprised every day. I really am. And it’s changed what I eat too, right? I mean, I crave fruits and nuts now. I was like putting my cell phone away. I don’t know if you saw, but I have my cashew stuff down.


Zoe: 15:10

The emergency nuts.


Bev: 15:13

I learned well. So I made calabacitas last night.


Dr. Weiner: 15:20

That’s a great dish.


Bev: 15:22

So yeah, just kind of still figuring it out, I do a lot of beans and legumes. When we went camping, my husband said, “I got to have a hot dog; I got to have a hamburger.” I’m like, that’s okay. I’m making my taco soup with all my beans and legumes.


Dr. Weiner: 15:39

So let’s kind of talk about your set point, and I think from the very beginning that idea really resonated with you that your body weight was kind of stuck at 295 pounds, and that’s really where this idea of the disease of obesity comes from. There are some people who, if they just clean up their eating and start exercising, the weight comes off and their body isn’t set at that number; it’s more fluid. There are other people who, no matter what they do, cannot lose weight. When you were 295 pounds, were you able to lose weight—not a pound, no, five pounds—with maximal effort?


Bev: 16:12

My primary school gave me Ozempic back then.


Dr. Weiner: 16:15



Bev: 16:15

Okay, so I had no instructions, just, you know. I think this could help. It’s been helping. So I went home and took it. It made me so nauseated when I went back to see her a month later. She goes, “How did the Olympics go?” Oh, I took it once. I had the side effect of being nauseated. She goes, “Try it again.” That’s the point.


Dr. Weiner: 16:37

I mean, I guess that happens at the beginning. Ideally, that’ll go away with time, but you just were really struggling, and then we did the surgery, and you turned out to be kind of a super responder. You’re someone who just responded much better than we expected.


Bev: 16:55

I am so grateful for that. Being my age and having gone, you know God loves you. You were so calm in the pre-op room, I’m like, well, you know, in case you have to do an open, he goes. I never have to do an open. The nurse in me, you know.


Dr. Weiner: 17:06

Yeah, so what are you working on now? Like, what are your goals? You’re kind of getting toward what we call the end of the honeymoon phase, where the weight is just coming off and it’s just kind of effortless to control your weight, and you’re not losing any more weight now, correct?


Bev: 17:22

No, I’ve been pretty stable.


Dr. Weiner: 17:24

Our goal weight isn’t zero, so at some point you have to stop losing weight. You can’t lose weight forever. So now that you’re kind of at a stable weight, what are you working on? What are your goals?


Bev: 17:35

Two things; I really want to work with Zoe on the metabolic reset because it’s been on my mind. I know I want to do something that’s going to keep me a little cornered in there, focused in there, and then back to the strength training. I’ve been doing so much traveling that, as you know, I haven’t really gotten to work on the bands, the weights, and whatnot.


Zoe: 17:59

Gotta build the strength to lift those bins in the RV.


Dr. Weiner: 18:05

So what’s holding you back on the metabolic reset diet?


Bev: 18:12

In it, it says you know you can’t have cottage cheese and yogurt, and those are proteins. I’m not really a meat person. I’ll do the beans for my one protein and then maybe fish or you know something, but then I really do depend on the cottage cheese and the yogurt. So that’s the thing that’s kind of kept me shying away from it.


Zoe: 18:31

Well, and the thing is that you absolutely can have the Greek yogurt, and, in small amounts, cottage cheese is not going to make or break your success. And the main thing I want to think about is, “How can we find what works for you long-term?” I like to say that the metabolic reset diet embodies both definitions of the diet. Yes, we have the two-week reset diet version, but ultimately it’s this gold standard that we’re trying to work towards—that it’s just our diet, it’s just how we eat—and that incorporates some tweaks and adjustments. That’s going to be different for you than for somebody else who is following the diet. How can we make the metabolic reset diet sustainable for you? And if that includes cottage cheese, perfect.


Bev: 19:14

Wow, see, that goes back to that thing we’ve talked about before with the black-and-white thinking. I see it on paper, and it’s like, “Oh yeah, I can’t do that.” So I am not thinking there are other things.


Zoe: 19:26

So I plan to see you in the nutrition program, maybe one-on-one soon.


Bev: 19:31

I think that’s a great plan. I mean, I will always be with you guys.


Dr. Weiner: 19:35

And we will always be with you. That’s the deal we make once we do your surgery. You’re our patient for life.


Bev: 19:41

I’m grateful because it’s given me my life back. Honestly, I thought two years ago I wouldn’t make it to see 70. Now I’m like 80.


Dr. Weiner: 19:50

Yeah, yeah. Now you’re like 70. I want to take a big trip for my 70th birthday.


Bev: 19:55

Right, I’m already talking. I’m like, okay, family, get ready; we’re going to Greece.


Zoe: 19:59

And I’m your adopted daughter, so I’m coming with you.


Bev: 20:02

Yes, you are. Yes, you are.


Zoe: 20:13

I’m just so proud of you.


Bev: 20:14

Well, I’m just grateful. I’m grateful for you guys and your support, and it’s a great practice.


Dr. Weiner: 20:21

Well, thank you; we appreciate that. We appreciate you being part of our nutrition program as one of our patients. We’re proud of all your success. I think it’s been fantastic.


Zoe: 20:30

And we really appreciate you being here, being vulnerable, and sharing your story.


Bev: 20:34

Well, that part’s easy, and it’s like it’s the good part I’m going to celebrate. I’m going shopping at Chico’s.


Zoe: 20:46

Fantastic, all right. Well, I just love Bev.


Dr. Weiner: 20:49

Oh, she’s the best.


Zoe: 20:49

We’ve had a really special connection since the beginning.


Dr. Weiner: 20:52

We really have the best patients, don’t we? We do.


Sierra: 20:54

We really do, yeah.


Dr. Weiner: 20:55

We really are so lucky with the patients that come to us and that we get to share their stories of success.


Zoe: 21:01

Yeah. So moving on to our nutrition segment, it kind of aligns with what Bev was talking about—having to make those more baby step changes. So a lot of people are not reaching their goals. Do you want to know why? Because they’re too vague. I want to eat healthier. I want to exercise more.


Dr. Weiner: 21:21

I want to lose weight.


Zoe: 21:22

I want to lose weight, exactly. Okay. I’m like, okay, great, but how right? We need to take this vague kind of pipe dream goal and turn it into actionable steps. And so the acronym SMART, which is used in so many capacities, I’m sure so many people can remember using it in school and different things like that. So a SMART goal, for whoever needs a refresher, stands for specific, measurable, achievable, realistic, and time-bound. So that’s how we turn a vague goal into something that you can actually take action on.


Zoe: 21:57

And this is exactly what we do in our Smart Support Squad support group that I just added to the nutrition schedule. So basically, in this group, we take those vague goals and create more actionable, smart goals so that our nutrition members can go and spend the week working on that goal and then come back, check in, and have accountability. But the key is that these SMART goals take into consideration that they are realistic, because the whole point of sustainable habit change is to have a SMART goal that is actually realistic. Work on it, work on it, work on it, work on it until it is a habit.


Dr. Weiner: 22:38



Zoe: 22:39

Then you don’t have to worry about it anymore, and then we set a new goal, and then we keep stacking those habits on top of each other, and that is something that I’m clearly very passionate about, because we want to set our patients up and our listeners up for long-term success, not just try to do all the crazy things all at once and then get frustrated and quit.


Dr. Weiner: 22:57

Yeah, I think that these vague goals aren’t really goals. They’re hopes, they’re wishes, and they’re dreams, and it’s great that we all should have those things. Those are really important. But it’s the smart goals—these small, measurable steps. That’s how you achieve these dreams.


Dr. Weiner: 23:15

No Olympic winner was like, I’m going to be an Olympic champion, and then it just happened. No, it took hours and hours to work toward this thing. Then the next thing: getting their time under 40 seconds—under 38 seconds, you know—and keeping moving and moving down and achieving more and more with more determined work. And I think that’s how nutrition works too. I kind of talk about it like we’re building a wall here, and each SMART goal is a brick in that wall.


Dr. Weiner: 23:41

And, hey, I’m going to fix this, my issue with artificial sweeteners, and I’m going to work on that for a couple of weeks and really dial that in, and maybe I can’t give them all the way up today, but I’m going to go down to twice a week, and then the next week I’m going to go down to once a week, and eventually you kind of work them out of your diet, and then, hey, I’m working on adding the vegetables in, and you build it up, and you build it up, and you get to that metabolic reset diet. You get to that really ideal, optimal diet that you can sustain long-term, and it’s a very systematic and deliberate process. It’s not this kind of simple “I’m going to do it” and then you focus on it for a couple of days and you get there. Unfortunately, it takes a lot more work, but it is achievable. You can see it in Bev; you can see it in a lot of our patients. You can make these changes, but it takes work, it takes accountability, and it takes this deliberate approach to it.


Zoe: 24:32

Right, and if you’re watching on YouTube and you want that accountability to take that first step, comment on what your SMART goal is. So if your vague goal is that I want to exercise more, turn that into a SMART goal: I will go for a five-minute walk after lunch every day during work and comment on it on YouTube, and we want to hold you accountable by seeing those comments.


Dr. Weiner: 24:54

Absolutely All right, that was great. Yeah, goal setting is so critical for this, and I think everybody focuses on, “What should I be eating?” But even before you focus on what you should be eating, you have to almost focus on the process: “How am I going to get there?” Yeah, so if you’re looking for some help with SMART goals, anybody out there can join our nutrition program. It’s on our patients. But if you’re looking for some accountability or some support in achieving your goals, then we’ve got you there.


Dr. Weiner: 25:26

So let’s move into our economics of obesity segment, and so today I’m going to talk a little bit about surgery. Our economics segment usually covers access to the GLP-1 medications, but we certainly see a lot of surgical patients in our practice, and I do a lot of revision surgery. The most common revision surgery I do is converting a sleeve to a gastric bypass for treatment of acid reflux, but we kind of take on everything in terms of surgery gone wrong, and we’re not far from Mexico, so we see a little bit of that. We see patients struggling with abdominal pain or other issues, often from a surgery that they’ve had some problems with, and so when it comes time to getting these surgeries approved, it can be tricky, and so there’s a couple of issues we’ll see. We’ll see patients who don’t even have coverage for bariatric surgery, and maybe that’s why they went down to Mexico in the first place, and so that can sometimes be an obstacle.


Dr. Weiner: 26:16

And then we see really two main indications for having revision surgery. The most common thing that I do in my practice is treat problems like acid reflux, abdominal pain, ulcers, and things along those lines, but we also see patients who are hoping for additional weight loss, and the diagnosis really matters. When it comes to insurance coverage, if you’re trying to lose additional weight, that can be quite challenging. There’s a lot of insurance policies out there that have what’s called a once-per-lifetime clause, which means you can have one surgery the first time, but after that, if the goal is weight loss, no more additional surgery. I don’t love that because I really think these decisions should be made between a doctor and a patient. But I get it because revision surgery is, you know, twice the risk and half the weight loss.


Zoe: 27:02

Right. So it shouldn’t really be for that purpose.


Dr. Weiner: 27:07

You know there’s a lot of discussion about converting a sleeve to something called a SADI procedure or even a gastric bypass for additional weight loss. We’ve talked in the past. We’ve had some patients who’ve had a sleeve revised to a gastric bypass and done really well with weight loss. It’s just not very reliable, and for me, when I’m doing a major surgery, I want reliable results. I don’t like doing a major surgery that works half the time. That’s not great. I don’t think anybody wants to sign up for that either. So that’s my big issue.


Dr. Weiner: 27:34

And even the SADI procedure, which is a more invasive procedure than the gastric bypass and is a little harder to live with—just more malabsorption, more malnutrition afterward—the weight loss from that is modest, sometimes pretty good, sometimes not so good—20, 30, 40, 50 pounds more than the gastric bypass—but still not great weight loss, probably not as much as we’re seeing with the meds, to be honest with you.


Dr. Weiner: 27:59

And so I think if you’re looking at a revision for additional weight loss, I think you’re going to run into a lot of insurance problems, and I think it’s also really important that you have a really good understanding of how much weight you’re expected to lose and what the range is. Not just what the best person that the surgeon’s ever seen is, but what’s the range? What’s the least they’ve ever seen after this procedure? That’s a great question to ask as well. If we’re looking at acid reflux, abdominal pain, or ulcers, we can almost always get these things approved by the insurance company. It can be a little tricky, but in general, when we have a medical problem that we can diagnose and prove with a CAT scan, endoscopy, ultrasound, or some other imaging study, we can typically get it approved. So it’s all about that diagnosis and how you approach it when you’re looking at revision surgery coverage.


Zoe: 28:48

So let’s say somebody is listening, and maybe they’re out of state, or they did get their surgery in Mexico, or something like that. Maybe they want a sleeve revision because they’re experiencing heartburn, or whatever it is. What would your recommendation be to them? We can see them, right?


Dr. Weiner: 29:04

We can see them, for sure. So, yeah, we do see people from all over the country. So I mean, yes, if someone is looking for revision surgery, we have one of the lowest complication rates in the country, and we offer, I think, an unparalleled support program. Absolutely, you can come down to Tucson, and we can help you out with your procedure, all right. So, Sierra, I think it’s time for us to move into our questions from our users out there in social media land.


Sierra: 29:29

Okay. So the first question is from YouTube: What are my options for post-sleeve weight gain? Will a revision work? After bariatric surgery, do you have to take vitamins forever?


Dr. Weiner: 29:42

Okay. So let’s first talk about a revision. I actually mentioned that just a little bit early. So the knee-jerk response for a surgical revision of a sleeve gastrectomy is either conversion to what’s called a SADI procedure, which is where the intestine is divided just past the stomach, so right after the stomach where the small intestine joins, you divide the stomach and then you bring a loop of the fairly distal intestine up and you connect it like a loop, and its cousin is called the duodenal switch, which is instead of a loop, it’s a divided Roux-en-Y anatomy, and honestly, the anatomic differences are not that critical.


Dr. Weiner: 30:22

I think the important thing is that they’re fairly malabsorptive procedures, where with a gastric bypass we might bypass, say, the first third of the intestine; with this, you’re bypassing two thirds. With a duodenal switch, it could be 80% or 90% of the small intestine, and so that really has very different ramifications for patients. And so my knee-jerk response to sleeve weight gain, and keep in mind that I’m a surgeon and I love doing revisions and complicated surgery, yet I still think that the medications are a better option for patients. I think if a family member comes to me and is struggling with weight regain after a sleeve, I’m going to recommend the medications for them, which means I’m going to recommend the medications for my patients as well.


Zoe: 31:06

Unless they have gastric reflux, right?


Dr. Weiner: 31:09

Yes, unless they have gastric reflux.


Dr. Weiner: 31:10

Yeah, so that’s a great point. Yeah, so if they have acid reflux and, you know, not like, oh, I pop a Tums every now and then, but I have pretty miserable acid reflux, then you’re right, we would recommend it. Thank you. Good job, Zoe. Then we would recommend a gastric bypass in that setting, absolutely. And again, that comes down to safety and also this idea that we’re getting some benefit from the surgery, reducing the reflux, and possibly some really good weight loss. Possibly not, in which case we can bring the medications in. But yeah, when the goal is strictly weight loss, then I would start with the meds. Let’s talk about the vitamins and about the nutrition changes that you need to make for weight regain after a sleeve.


Zoe: 31:53

Right, so do I have to take the vitamins forever? When I’m preparing people for surgery, I like to say this is a lifelong commitment. Your anatomy is never going back to pre-surgery, and neither is your absorption, and people who get gastric surgery or weight loss surgery are prone to developing deficiencies. I like to explain for two main reasons. One is, yes, that altered anatomy results in impaired absorption. The other piece of it is that you’re not eating the same volume or the same variety of food after surgery, at least for those first couple years. So, yes, I like to mentally prepare patients that this is a lifelong commitment to take their vitamins. But those first two years are the most critical, and ultimately we are working towards getting back to eating as much variety of fruits, vegetables, and whole foods as possible to get those nutrients in.


Dr. Weiner: 32:47

Yeah, what about nutritionally? I mean, what are we doing nutritionally for weight regain? Someone comes to you. They’ve regained weight after a sleeve. They don’t have access to the medications; they don’t have reflux. They don’t want a SADI procedure; they just want some nutritional help. What should they do?


Zoe: 33:00

Well, I promise you, it’s not going back to shakes to reset their pouch. I can’t tell you how many times I’ve heard that. That’s not the answer. The answer is not trying to fight against your body’s hunger. Chances are, as you’ve regained weight, your natural hunger has increased. The volume of food you can tolerate increases, and I want you to eat more food. It’s just a matter of eating more of the right thing. So I would 1000% recommend the metabolic reset diet as a way to really jumpstart that weight loss, and then from there we can continue making nutrition changes. We actually do have the metabolic reset diet handout, which should be available soon.


Dr. Weiner: 33:43

If it’s not available at the time of listening, it’ll be available very shortly on our website.


Zoe: 33:47

So that’s a great place to start if you’re interested, but ultimately working towards eating as much whole, real, unprocessed food, lots of veggies, not limiting yourself in the volume of food that you’re eating, and not thinking you have to eat the same small amount as you did immediately after surgery.


Dr. Weiner: 34:05

Yeah, yeah, I think yeah. Great points, Zoe. Let’s move on to the next question, Sierra.


Sierra: 34:12

Okay, this one is from the website, from Mary: I’m trying to decide between sleeve and bypass, and my concern is that I have MS and take ibuprofen for pain. Not every day, and sometimes not even every week. Usually, I take one tablet once daily for a couple of days. Would that make me ineligible for a bypass because of the risk of an ulcer?


Dr. Weiner: 34:32

Yeah. So NSAIDs after a gastric bypass are really one of these, I think, fairly misunderstood concerns. And I’ve had patients say, you know, I get a headache once or twice a month, and I have to take some Advil for that. It’s the only thing that works. So I don’t want to have a gastric bypass. And I think with everything, you have to kind of weigh the risks. So what are the risks of taking NSAIDs? That you can develop an ulcer.


Dr. Weiner: 34:57

Do 100% of people who take NSAIDs get an ulcer after a gastric bypass surgery? No, no, they don’t. And so this is even when we’re talking high-dose NSAIDs. I’ll see patients who had a gastric bypass 20 years ago, and they show up and they’re popping Advil like candy, and they’re not having any issues related to an ulcer. And sometimes we even do endoscopies and things like that and show there’s nothing going on. So not 100% of people who take NSAIDs will get an ulcer. So I think it’s important to know that’s where we’re starting from.


Dr. Weiner: 35:26

And then the second thing is that dose matters with NSAIDs. If you take an Advil tablet once a week, that’s very different from taking 800 milligrams of ibuprofen four times a day for that entire week. And so what this person’s describing is fairly low use of NSAIDs. The other question is, What’s it for? If it’s for aches and pains of your joints and you lose a bunch of weight, the weight loss is far more effective than the NSAIDs for reducing joint pain, and so oftentimes that’s a positive shift.


Dr. Weiner: 36:00

Even if you don’t take the NSAIDs, then you’re still going to have less pain, and you can take Tylenol as well. Tylenol for a lot of things isn’t as effective, but I think this is something you’d have to talk to your surgeon about. There is a little bit of wiggle room, though. With the NSAIDs. My recommendation is not to just go for it and take as many NSAIDs as you like. I still tell patients to really avoid them as much as possible. But I think you’ve got to live your life and understand that this is a spectrum, and if you can kind of position yourself on the lower-risk side, most likely you’re going to be fine.


Zoe: 36:29

Just goes back to it’s not so black and white.


Dr. Weiner: 36:31

It’s not so black-and-white. That’s why we have a podcast.


Zoe: 36:35

We had to dig into the details.


Dr. Weiner: 36:37

If we could answer all this stuff with a multiple-choice question, then we wouldn’t need the podcast. Things are complicated. Obesity is complicated. Oprah said that on her show. She talked about what a complicated disease it is. After 15 years, I still see that every day. 


Sierra: 36:59

Okay, the last question is from Nick from the website: Are fruit juice concentrates fine if included in an ingredient list?


Dr. Weiner: 37:03

Health halo alert.


Zoe: 37:05

Right, exactly, fruit juice concentrates. When you see that in an ingredient list, I want you to think: sugar. And ultimately, that’s just a way to add concentrated sweetness to whatever it is. So I’d still recommend, yeah, reading the ingredients list is great, but also looking at the nutrition facts, looking at the added sugar line, and keeping that as close to zero as possible.


Dr. Weiner: 37:30

I think we should start the health halo game. Call it out, right? Every time you see it,.


Zoe: 37:34

Granola bars.


Dr. Weiner: 37:35

There you go, perfect. Yeah, so we should be. If you’re out there on social media and you see something that is a health halo, tag us and share it with us for sure. Yeah, we love seeing them. And I think when you start to identify them and start to look for them, that’s when you really start to understand how much the deck is stacked against us eating healthy. If you look at our current food chain, yeah, this is a total health halo, no question. I agree 100%. This is just sugar. Yeah, you may as well replace it with cane sugar or coconut sugar. There’s a health halo.


Zoe: 38:00

I know, organic sugar. My favorite. Just kidding.


Dr. Weiner: 38:12

All right, episode 18 in the books: “Everyone Gets Ozempic.” We hope it was helpful. If you’re out there looking for some nutritional support, you can always join our support group and reach out to us through our social media channels if you have any questions that you’d like to see answered on the podcast.

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