Ready to unlock the secrets behind sustainable weight loss success? Join Zoe Schroeder and Matt Weiner, as we provide a roadmap to long-term victory over the scale. We’re shining a spotlight on regaining weight after bariatric surgery, exploring options like the cutting-edge SADI surgery, and decoding the benefits of the medication like Ozempic alongside a nutritional approach.
Using a science-based approach, we delve into the power of personalized nutrition and the practice of mindful eating. Hear a compelling patient story about the journey from major weight regain following a sleeve gastrectomy to triumph with the help of nutrition and Ozempic. We also discuss a post-holiday grocery strategy, whether bougie size is responsible for weight regain, and unintentional, rapid weight loss 5 years post-op. For those interested in the meat-as-a-snack debate, we’ve got that covered too!
The conversation further extends to the topic of iron supplementation post-surgery and the importance of the right type of iron for patients. We also take the time to address whether or not cottage cheese is a good source of protein. Whether you’ve undergone weight loss surgery, are considering it, or simply want to stay informed about the latest in the field, this episode is chock-full of insights and recommendations. We’re confident that everyone can take away something valuable from our chat. So join us and let’s navigate the path to health and happiness together!
Transcript
Zoe:
Welcome to the Pound of Cure podcast. We are back for another episode. I’m Zoe Schroeder, Registered Dietitian.
Dr. Weiner:
Matt Weiner, bariatric surgeon and non-surgical weight loss specialist, and we’ve got a really great show for you today. We are going to cover a bunch of topics, like we always do. Topics include weight loss surgery versus Ozempic. Our patient story is weight regain after a sleeve and how they were able to find success afterward. Post-vacation groceries tip, stomach size after surgery specifically sleeve gastrectomy, cottage cheese, the SADI procedure, iron supplementation, a question from a patient who has unintentional, rapid weight loss five years after surgery and eating meat as a snack. Meat snack, meat snack. All right, so let’s start with the news. In the news. This comes from an article in The Atlantic and the title of the article is, We’ve Had a Cheaper, More Potent Ozempic Alternative for Decades. And I love this article because it really talked about the neurohormonal shifts of bariatric surgery and GLP-1 medications. And this is something we see. I mean, really, Zoe and I are on the front lines of this. We’re talking to dozens and dozens, if not hundreds, of patients a week about their experience on GLP-1 meds, on bariatric surgery, and we’re seeing so many parallels and I think this article really talks about how bariatric surgery is so safe. And it really is so safe. I sleep well at night my phone doesn’t wake me up at two in the morning with some patient in some amount of trouble. Everybody does great. They all go home the day after surgery and we see almost no complications. I literally go years without having a serious complication in our practice, and so we’re able to do these surgeries so safely. They do drive this incredibly powerful neuro hormonal shift. We talked last week about the cost of these medications and how distorted they are, but anyway, bariatric surgery is relatively expensive and it’s the one and done option here. And we go through this with every patient in our practice. But I actually really love their conclusion at the end, which is that if there is a perfect option or long-term, durable, successful weight loss, it’s maybe not bariatric surgery or medications, but the combination of the two, along with, of course, a good nutritional program.
Zoe:
Right. Something I was just actually thinking about is if somebody were to be, let’s say, self-pay, trying to determine whether it would be a better option to do the meds versus getting surgery. It seems like getting surgery would be the cheapest option, honestly, right.
Dr. Weiner:
At our current price, $1,000 a month? Yes! Our self-pay price for surgery in the US, and we have actually a pretty competitive self-pay price is, I think, $15,000, give or take. These are actually on our website $15,000 for a sleeve, $17,000 for a gastric bypass. So if you’re paying $1,000 a month, which is really, at this point, like right now, that’s what you got to pay if you want to get the real meds.
Zoe:
And that gives you 15 months.
Dr. Weiner:
Yeah, and these surgeries give you a lot of weight loss over a very long period of time. So I think right now we’re seeing that. If we’re talking $20 a month, like we talked about last episode, I think the meds are going to be cheaper. I think both of these are costs that are affordable within our healthcare system if the medications are priced appropriately. I’m hoping within three to five years, this is going to become a decision that people are making about the treatments, not necessarily about the cost. I think right now, unfortunately, it is often a very cost-based decision. But it was great seeing this discussion about obesity as a metabolic disease and the treatment is based in pharmacology and medicine and these neurohormonal shifts. That’s what we’ve been preaching for over a decade now. I love that this is finally coming out into the zeitgeist and being part of the popular press.
Zoe:
Yeah, and also because Ozempic and GLP-1’s are so clickbait-y, buzzworthy right now, it’s important to recognize that we don’t have to always buy into the hype of something and to rely on the science, which is part of why we’re here doing this podcast.
Dr. Weiner:
Who’s the author on this? Let’s give this author a shout out because he or she really did a great job. Yasmin Tayag, and this is in the Atlantic. We’ve had some articles in the past. It was all clickbait and they just pushed the envelope in terms of trying to get you to pay attention to the disasters of this and, really often speaking, with medical inaccuracies. But this was an incredibly well researched, well thought out article that synced very much with what we’re seeing on a daily basis. So good job, Atlantic for putting that article out there. Yeah, Thanks. So this patient had a sleeve gastrectomy 12 years ago in another state and they started weighing almost 375 pounds. They dropped down to 250 pounds after their sleeve, which they were still overweight, but that’s a huge amount. I mean you lose 125 pounds, that’s a life changing amount of weight. And, over time they slowly gained back up to 310 pounds. So there’s still 65 pounds down from where they started. They joined our nutrition program and also were started on Ozempic at the same time and they really had a tremendous weight loss response. So at their last visit they actually weighed 250 pounds. So they lost all of their weight regain and we hadn’t even maxed out the Ozempic. You know we’ll see weight loss, especially with Mounjaro, we’ll see weight loss up to 18 months. It takes 18 months to get the weight off with Mounjaro and the most recent study showed that there’s still substantial weight loss the second year after starting Mounjaro. And so this patient really hadn’t maxed out, we weren’t at the highest dose. And they’re on Ozempic which, as we know in a couple of weeks we’re going to have Mounjaro out as a weight loss option and honestly, at that point I think most people are going to say, who. It’s going to completely replace Wegovy because it’s so much more effective. So because this is a journey right, our weight loss is a journey we’re starting on Ozempic, we’re probably going to move this patient onto Mounjaro and my prediction is we’re going to see weight in the low 200’s as a final stable weight. And I think that this patient really shows two things. The first is this is a long journey and it takes time, and there was a moment, I’m sure, where she said I’m a failure. This didn’t work for me. I’m regaining all my weight. But at this point, nobody has to be a failure. The only time you become a failure is if you give up. And so we’ve got great treatment options. We’ve got a great nutrition program and she really embraced all of this and we’re not done. We’re not done here, and I think we’re going to see they’re going to reach a weight far lower than the lowest postoperative weight and have the tools to maintain it for a long time.
Zoe:
How motivating? Yeah good for them.
Dr. Weiner:
Yeah, yeah, fantastic.
Zoe:
All right. Next we have our nutrition segment. So, because it’s the holidays, I’m sure there’s a lot of travel going on. The last thing I want to do – I’m sure a lot of people can relate to this – the last thing you want to do when , let’s say, Sunday afternoon, you’re getting back in from being gone over the weekend, you have laundry going, you have to unpack this, that and the other, the last thing you want to do is go to the grocery store. Right, I experienced this to myself and patients I talk with all the time. It’s like if you do not go to the grocery store that Sunday or whenever you get back, what happens when you get back to work? Life gets back in the swing of things. It’s hectic, and then you’re more likely to just go ahead and get take out Monday night, and then, “I’ll go to the store tomorrow, and then tomorrow comes and just it’s a snowball that we can actually prevent. So my little nutrition tip actually has to do with ordering your groceries. So what I like to do is, while I’m still away, is actually go on the app or the website or wherever you or you can order your groceries, place your grocery delivery to be dropped off at your house within the hour that you get home, and then it’s one less thing you have to think about. You’re all set up for success for the week. You can get right back into your routine, knowing you have a stocked fridge and pantry with nutritious foods and one less thing that you have to go do.
Dr. Weiner:
Yeah, you also don’t have all the temptations in the grocery store – all the end caps and the Oreos. Have you seen how many different types of Oreos there are?
Zoe:
I know it’s always something new.
Dr. Weiner:
Like 50 different types. It’s crazy. The Thins, the double stuff, the Mints you know, they just got over the pumpkin.
Zoe:
Well, and that kind of goes along with something that I talk about in one of my nutrition classes, about navigating the grocery store. I’m sure you’ve heard the phrase, “in order to eat healthy, you have to eat on the perimeter. That’s hogwash! To be honest, like think about what else is on the perimeter the bakery: the alcohol section, the end caps of bazillion different Oreos. So I get sidetracked. But don’t think that you can only shop on the perimeter in order to eat healthy, nutritious foods.
Dr. Weiner:
Yeah, no, I think they know that.
Zoe:
Oh, people are thinking that they are eating healthy.
Dr. Weiner:
All right, so let’s move into our user questions. As always, we have Sierra here. As always, it was only in the last podcast we started doing this. But we’ve got Sierra here to read us the questions. And these are questions that come to us through social media and a lot of times people pose these questions and we want to be able to answer them, but I just can’t type on the phone and give that kind of answer. So we use this opportunity to reach out and give people an in-depth answer to their questions. So, sierra, why don’t you read the first question for us?
Sierra:
The first question is from YouTube on the video, Why did I regain weight after my gastric band and gastric sleeve RG-HF?
Dr. Weiner:
What up RG.
Sierra:
I lost 70 pounds with my gastric sleeve. Could have afforded to lose another 20 pounds, but I was happy with this amount. Looked and felt great. The first two years were okay. The ghrelin that disappeared comes back in no time. I was able to eat more than I should. Fast forward. I regained everything. I am very unhappy. I think not enough stomach was removed. I was able to eat portions that I shouldn’t have been able to so soon. I never hear MD’s discuss that they were too conservative in sizing the stomach.
Dr. Weiner:
So let’s talk about sleeve gastrectomy and the topic that you’ll hear discussed that kind of goes into this, is bougie size. So bougie is just a plastic tube that, while you’re asleep, this not something you would want placed into your mouth while you were awake or down through your esophagus, but while you’re asleep the anesthesiologist places this plastic tube in and they come in different sizes. So the size is measured in French. I personally use a 34 French. Some people talk about 30 French, being the optimal size, or 36 French. The truth is a French is a third of a millimeter. So if we’re talking about two French, we’re talking about two thirds of a millimeter. It is a negligible difference. But we put this tube into the stomach and essentially kind of go and staple up along this tube. Now you can certainly leave too much stomach behind if you’re an inexperienced surgeon. But the truth is I’ve seen a lot of patients with weight regain and I’ll do endoscopies and we’ll work them up looking for things like this. I have seen a few scenarios where clearly enough stomach was not removed and I believe that that was part of the reason for the lack of weight loss. I don’t necessarily think that’s the case here and the reason is they lost 70 pounds. So they did actually have pretty good weight loss. We don’t get the starting weight – again on our website and I think in previous show notes, we have a calculator that we use and we’ll put it in these show notes as well.
Zoe:
You can also get it on our website, yeah, on the website.
Dr. Weiner:
So we have a calculator that you can use to calculate how much weight you would lose after surgery. And you can put in your starting weight and everything like that and we’ll tell you what you lose at one year out. It factors in your age and diabetes and a couple of other things that influence weight loss. S o you can plug your numbers into this calculator and see. My guess is you’re probably right there, because 70 pounds is pretty decent weight loss after a sleeve. So that to me says we probably didn’t deal with not enough stomach being removed. There’s easy tests – an upper GI can tell you that, where you swallow some barium and then we take some x-rays. That’s probably not the cause. To me this actually sounds like something I see very frequently in the office after a sleeve and something we kind of say in the bariatric groups as surgeons is that the stomach helps you get the weight off, but it’s the intestine that helps keep the weight off. And so that’s why gastric bypass and the SADI procedure has much more durable weight loss compared to the sleeve. I hope you listen to the first segment of this, where we talked about essentially someone who’s exactly in your shoes, but hasn’t started on the GLP-1. So this to me, is again pretty easy. We’re going to put this person on some form of GLP-1 medication, like Wegovy, Ozempic, Mounjaro, something along those lines, and most likely we’ll see substantial amount of weight come off. I wouldn’t be surprised if they can get on the right medication, if we get those last 20 pounds off as well. And my hunch is, this wasn’t related to the bougie size. I think if you had it done by a competent surgeon, they’re going to do it the same way every time. This is not a judgment call. This is a pretty standard thing. You know, when I do a surgery I don’t say you know, maybe this time I’m going to do it this way. It’s the exact same way. Every suture’s cut the same way. My assistant, Deidra, she retracts this way at this point and this way at that point. We have this thing choreographed like a Broadway play. I mean, every single move is – I don’t say anything to my tech, she just hands the instruments to me. She knows exactly what’s next. So most surgeons who do a reasonable volume are going to do their surgery the exact same way every time. That’s how you get repeatable results. So most likely I’d be surprised if that’s what we’re dealing with here.
Zoe:
Yeah, and what you mentioned, like there’s no reason why we wouldn’t be able to see that additional weight loss. And I just want to, mirror something I think we said in the last episode, or maybe it was this one, I can’t remember. You’re not a failure. I know you might be feeling unhappy in your body in this moment, but take this as the opportunity to pause and pivot rather than spiral. You’ve got this.
Sierra:
The next question is from YouTube, from the video why you should avoid refined oil and dairy. This is from Ileana67. What is your opinion on cottage cheese?
Zoe:
Well, cottage cheese is having a moment. I don’t know if you knew that or not.
Dr. Weiner:
I didn’t know that.
Zoe:
Yeah. Well, for whatever reason it has resurfaced. I remember eating cottage cheese growing up. Like it was always served as a side dish along with our salads and that kind of thing. Whatever, it doesn’t matter, it’s just having a moment. I think the reason why is because it is very high in protein. Cottage cheese is one of those protein sources that we actually do recommend in those early stages, post-op, during the soft food phase. I do generally recommend if you are choosing to have cottage cheese, of course we’re trying to limit your overall dairy intake so we don’t want to be eating too much dairy all the time. The reality is that cottage cheese is high in protein. If you’re going with the low fat or no fat, that’s a good option. We talk a lot in our nutrition sessions about the 10- to- 1 ratio for picking out lean protein sources. My take is it’s a great option. It is versatile. I wouldn’t recommend having it all the time, but in a pinch it’s a great easy protein source.
Dr. Weiner:
I totally agree on that one, especially post-surgical, the first few weeks it’s a lifesaver.
Zoe:
Since we’re talking about cottage cheese, I have to share something that I made – well two things that I’ll share. I’ll share both of the things that I’ve made recently with cottage cheese because they’re actually so tasty. The first one being a high protein mac- and- cheese utilizing blended cottage cheese with some paprika and garlic and different stuff and then utilizing chickpea pasta. I actually made it this weekend. Chickpea pasta, with your blended cottage cheese mixture. Put that together. Of course, veggies on the side. But talk about a high protein meal and very filling, because the chickpea pasta is super high fiber. We actually discussed in the last episode the importance of fiber and how it can actually mimic the GLP1 hormone. If you missed that episode, definitely go back and watch it, because we dove a little bit deeper into how fiber can actually mimic the hormones that the Ozempic and the GLP1 medications do. That’s it regardless. It was tasty, yeah.
Dr. Weiner:
I think that chickpea pasta. What’s amazing is, if you put a plate of regular pasta in front of me, it’s like I can almost feel like the drive to eat. That stuff hits your brain and it’s like go, you just can’t get enough. You can’t stop eating and it’s like you almost never feel full and then finally you stop and you’re like, oh, that was a lot! But with the chickpea pasta it’s such a different experience. You don’t get that drive to overeat, you feel very satisfied with it.
Zoe:
And I love it. It’s only one ingredient. When we’re talking about as little processed, little ingredients as possible, ah, they should pay me. I talk about it so much.
Dr. Weiner:
We’ll see if we can set up some advertising for that.
Sierra:
Next question was from the YouTube video gastric sleeve versus gastric bypass what’s the difference? 2023. This is from Fiano. What is your opinion of the Sadi operation? It looks to be the best of both worlds. Love your channel, but I’ve never seen you discuss it.
Dr. Weiner:
The Sadi procedure, which stands for single anastomosis, duodenal ileal bypass, is a procedure where we start with a sleeve and then, just after the stomach, we divide the sleeve and then we bring a very distal segment of the intestine up like a loop. So a duodenal switch is kind of like a gastric bypass where it’s divided like a Y, but this is almost like it just brings it around. We call it an omega loop because it makes an omega shape and we kind of swing up the intestine around and so it offers kind of a partial bypass. So this is a relatively new surgery. The first issue with the Sadi procedure is it’s not covered by a lot of insurance. Getting it approved by insurance companies can be very, very difficult. So that’s the first obstacle we have to face and I think a lot of these processes are complex enough that we start throwing that in there and it just becomes a really difficult decision. The second is that we’re definitely going to see more malnutrition issues, so iron deficiency, vitamin D deficiency, particularly the fat soluble vitamins A, d, e and K. We’re going to see more deficiencies than we see with a gastric bypass. We will see a little bit of extra weight loss, and so you do lose more weight with the Sadi procedure compared to a gastric bypass and I think a lot of this. There was a trend up until very recently to kind of be more and more aggressive as we were able to do these surgeries more and more safely. We can start making these procedures more aggressive and driving more weight loss to counteract the weight regain that we’re seeing. We’re also seeing so much weight regain after a sleeve that this is a great option because the sleeve is already done and you just have to loop up the intestine and it’s a pretty straightforward procedure. Now with the GLP-1 medications my suspicion is we’re going to see us kind of back off on the invasiveness because once you do the surgery you buy yourself all these malnutrition issues. I think the other concern I have for the SADI procedure is we see a lot of heartburn reflux after a sleeve. Now I can solve that problem like that. Convert to a gastric bypass, did it today, 90 minutes, no big deal. Patient goes home tomorrow, heartburn is gone. Now with a SADI, remember we still have a sleeve and so if you develop acid reflux after a SADI procedure because we’ve divided the stomach downstream, we’ve looped this intestine around. It is not a simple 90 minute procedure to convert to a bypass or somehow address this acid reflux. So again, my motto is I don’t create disasters. Or if I do a sleeve and someone has acid reflux, we talked about it up front and I got a fix that I can do safely for you. Nobody wants two surgeries, but if that’s your journey and it ends up working for you, that’s still generally okay for most patients. So reflux after a Sadi does not have a good answer. I don’t see it talked about enough in the literature and we’re definitely going to see it. And so that’s my biggest concern is I like to have every option mapped out when I do these procedures. And I think what I see such great results with is the sleeve plus the GLP-1 medications. They work so well together that if this is my family member, I’m going to start with the sleeve and add the GLP-1s in rather than get really aggressive surgery.
Zoe:
Well and also nutritionally, like you mentioned, more prone to malnutrition, specifically with those fat soluble vitamins like vitamin D, that malabsorption. You can sometimes need to take so much extra vitamin D in order to make up for it. And, of course, getting your labs checked and knowing kind of exactly what your supplementation should look like is important there. But just another thing to keep in mind if we’re trying to improve quality of life, decrease the amount of supplements and medications you’re taking, then this might be one of those places where it would actually increase.
Dr. Weiner:
Yeah. Yeah, certainly it’s a growing procedure, but I don’t know I’m not 100% sold on the future of this one. I tend to be a late adopter to these kind of things. For me it’s about, I just want to do this surgery and have it so dialed than kind of taking on new things and being experimental. I don’t work as part of a university. Honestly, I don’t work with residents, and so I kind of consider myself just a production guy. Like I do a lot of surgery and I do it well and that’s kind of my role in life. So I think there is possibly a role for this. We’re seeing it a little bit more at the academic institutions than we are out in private practice.
Sierra:
Next question is from the website From Jeanine. I understand ferrous bis-glycinate is chelated and is supposed to be well tolerated. Is it okay after a bypass?
Zoe:
Yeah, we actually see our patients tend to tolerate ferrous fiscalinate better and if you’re experiencing the constipation, some of the GI complications that maybe other forms of iron may cause, you, definitely should give the ferrous fiscalinate a try. You can actually order it from our website. We have a couple of really great options there for you, as well as with a discount. So who doesn’t want to save some money? So, yeah, you can definitely head over to poundofcureweightloss. com, click on nutrition, recommended products, and you’ll see all of the vitamin, mineral and other really awesome products that we recommend, all listed on that page.
Dr. Weiner:
I don’t know why anybody sells ferrous sulfate. I mean, ferrous sulfate is really poorly tolerated.
Zoe:
Is it cheaper? Maybe it’s cheaper to make.
Dr. Weiner:
Our ferrous fiscalinate is super cheap. Yeah, it’s really cheap. I mean I can’t imagine it being – I mean we’re talking literally dollars a month in difference. I don’t understand why anybody prescribes or uses ferrous sulfate anymore. I think that really just needs to go away and we need to move to the chelated iron supplements.
Sierra:
Next question is from Instagram – your metabolic thermostat – and this is from Jay Larson. Is it normal for a rapid 20 pound weight loss five years post-bypass?
Dr. Weiner:
No, not at all. There’s no specification as to whether this was intentional weight loss through dieting or not. My suspicion is, based on the question, No, it was not intentional weight loss. I think there’s very few things that are going to get my attention from a patient than unintentional weight loss. When you’re not trying and you lose 20 pounds relatively rapidly, that’s generally a sign that there’s something going on. This is a classic scenario for a marginal ulcer. So a marginal ulcer is where the stomach and the small intestine join. Right on the margin of that connection you can develop an ulcer in the lining of the small intestine. These ulcers are typically caused by NSAID use like Advil, Aleve, Ibuprofen and Aspirin. That’s why we recommend against NSAID use after gastric bypass. It can be caused by alcohol use, and the most common cause is tobacco. So smoking has almost a guarantee that you’re going to develop a marginal ulcer, and these things are pretty miserable. You develop a total food aversion. Food becomes disgusting, it becomes very difficult to eat, you lose your appetite, we see profound iron deficiency, and so this person is going to end up being on a lot of ferrous bisgliscinate, and so I think this is someone who needs to seek medical attention. If you have unintentional weight loss, that is not a lucky bonus for you. That is potentially a sign of something dangerous and I think this person needs to reach out to their bariatric surgeon, their PCP, to whoever they can trust in their healthcare world, to get a little bit more treatment. And the diagnosis for this is an endoscopy, where you put you to sleep and use a camera to look down in your esophagus and look at that ulcer, and they’re typically treated with medications. With medications we’ll usually get them to resolve, but it can take time, especially if you’re currently using tobacco. The other thing is that they can bleed and perforate and if they bleed and perforate that obviously can be a much bigger problem. But thankfully, they’re fairly uncommon. I do not see a lot of marginal ulcers in our practice. I see a couple a year, but it’s certainly not with a lot of frequency.
Zoe:
So it sounds like being really aware of those lifestyle habits and factors that you can do to try to minimize your risk for development.
Dr. Weiner:
Yeah, steroids too. Steroids can cause them if you’re on prednisone or something like that.
Sierra:
Okay. Next question is from our website, from Kate. She says can I eat meat as a snack? Pop an ounce of chicken into my mouth with a few veggies. Is it better to eat three times a day and just get all that meat in at once?
Zoe:
I’m here for the meat snacks. Honestly, I think this is a classic case of nutrition being very individualized. Right, we have our general recommendations on the program and the types of food we want to be eating. But your lifestyle, your preferences, your likes, it’s all very personal. So if you like eating those mini meals maybe a bite of chicken and a few veggies spread throughout the day, versus sitting down and eating several ounces in one sitting, do it. That’s great, yeah, and actually I kind of like the idea of that. You know, kind of steady throughout the day. It helps with managing your blood sugar, helps with having your energy, you know, more stabilized throughout the day. So I support the meat snacks.
Dr. Weiner:
Yeah, I think it gets back to something you talk so much about, which is mindful eating, and if meat works for you, then it works for you. You know we don’t want people eating tons of animal protein. Animal protein is something you should keep to a relative minimum, but if this is something that allows you to feel comfortable and full throughout the day and just follow a pretty good diet that somewhat resembles our metabolic reset diet, go for it.
Zoe:
Yeah, well, I think that pretty much wraps up this episode, so I think we have another great one in the books, as we continue to help you achieve health and happiness through sustainable weight loss.
