Embark on a transformative health journey with us as we uncover the remarkable stories of weight loss successes, the role of bariatric surgery, and the surprising impact of GLP-1 medications. Our latest episode is a heartfelt tableau of personal triumphs, from overcoming genetic predispositions to redefining one’s relationship with food. As our guest candidly shares her inspiring path to a healthier life post-surgery, we unravel the complex emotions and societal judgments that often accompany the decision to undergo such a procedure.
Navigating the world of weight management can be a labyrinth of frustration, especially when faced with insurance hurdles and the daunting prospect of bariatric surgery. Yet, the tales of lifestyle transformation post-operation bring a new perspective to light. Discover how a change in diet, coupled with newfound energy for life’s activities, can redefine your everyday existence. We also dissect the language we use around eating, advocating for a shift towards more positive and empowering terminology, such as “treat” instead of “cheat” to foster a guilt-free, sustainable approach to nutrition.
Finally, our conversation turns scientific, exploring the body’s metabolism as a thermostat with a persistent ‘set point’. We discuss the intricacies of lowering this set point with a mix of strategies, from mindful eating to surgical intervention. Listen as we guide you through the challenges of differentiating between food intolerance and genuine satiety post-surgery, providing insights that aim to smooth the path for anyone on this life-changing journey. Join us for an episode that’s not just about shedding pounds but about gaining a deeper understanding of ourselves and the complexities of our bodies.
Transcript
Zoe:
Okay, here we are, episode 11.
Dr. Weiner:
That’s right.
Zoe:
Welcome back to our podcast. You guys so grateful you’re here Back again. We’ve got another amazing episode lots of scientific backed information to help you on your weight loss journey. What are we gonna talk about today, Dr. Weiner?
Dr. Weiner:
Well, the title of the show is Mounjaro, Second Time’s the Charm. We have a really, really interesting patient story that I think you’re gonna enjoy. And it just shows how powerful bariatric surgery and GLP-1 medications are when we put them together. Before we get into this episode, I also just wanna take a quick note to let anybody out there listening know we are hiring in our practice. So if you’re a nurse practitioner or a physician assistant interested in spending your day taking care of patients who are being successful in their weight loss efforts and really enjoying the positive experience that we see when we’re performing bariatric surgery or helping people with their meds, please reach out. Call our office and ask to talk to Sierra. Also, medical assistants, we are hiring medical assistants as well. Insurance, good salary. Please call the office, ask to speak to Sierra if this is something you’re interested in. So, Zoe, what are we gonna talk about today after my little employment push?
Zoe:
All right. So in this episode we will be discussing an interesting new weight loss technique. Interesting, it’s gonna be interesting, you guys. We have another incredible patient here to share her story and I can’t wait to hear from her. She’s got a lot of really great things to share. And we have, of course, our nutrition segment- Treat versus cheat. Are you using the phrase cheat meal? I don’t know. We’ll have to talk about it. And also, why don’t insurance companies cover weight loss medications? I think that’s a burning question on everybody’s mind.
Dr. Weiner:
Absolutely.
Zoe:
And last but not least, of course, we will be discussing our social media submitted questions: the physiology of weight loss, hunger versus heartburn, as well as strategies to control food cravings.
Dr. Weiner:
All right, yes, another great show. We’re having a really fun time putting these together and, of course, we gotta thank Sierra, who’s staying here behind the scenes and she’s the voice of the questions. Without her, this wouldn’t be happening, absolutely. So in the news, this is Medical News Today, and the title of the news article is, Could a Vibrating Ingestible Capsule Help Treat Obesity? So I think this came out of MIT, of course, and first of all, this is a fascinating idea. It’s a little pill and it vibrates and you swallow it and the vibrations are supposed to trick the stomach into thinking that you’re full by somehow triggering the stretch receptors to fire. They’ve only done this in animal studies, and so they gave animals this pill and the animals decreased their food intake by 40%. A lot. So they ate 40% less when they swallowed a vibrating pill prior to going to eat and I think they used pigs, because pigs like to eat a lot. Yeah, I mean that’s.
Zoe:
Go figure.
Dr. Weiner:
So it turns out that pigs do like to eat a lot and have an appetite that some people think kind of is similar to human beings. So the big question I have when I look at something like this; so there’s always something like this coming out. And I go to our conferences or I read through the journals and I swear every month there’s something new coming out and it makes great water cooler conversation. But the question is, does this sync with the physiology of obesity? And I think that’s the first thing I look at is that we understand how weight loss works. This concept of your set point that we’re gonna talk about a little bit later in the show. And what we need to do is lower your set point. So the big issue is that, if you understand digestion, when you swallow a pill or food, it spends 30 minutes to an hour in your stomach and often less. It may be less- liquids much less. It’s not like things spend six to eight to 10 hours in your stomach. The stomach mechanically disrupts the food and breaks it down and mixes it with acid to prepare it to enter the small intestine and it’s actually the small intestine where it’s absorbed. And the small intestine also regulates appetite, and it’s very possible that the vibrating pill will trigger some receptors in the small intestine as well, so that will also reduce your appetite. But generally within two, three hours this pill is gonna be into the colon. The colon really doesn’t regulate appetite much at all, and so what happens in those two to three hours? So you eat this pill. My guess I wouldn’t be surprised is. My guess is that these animals ate 40% less than they were nauseous. So it’s very likely that this thing just causes you to be nauseous and, in all honesty, any weight loss technique that is designed to induce nausea, it’s just not going to be particularly Interesting to most people. So this could be a pill that you take. It makes you nauseated, but then three hours later it’s passed through your small intestine and your hunger returns with a vengeance Because no longer are you getting these, these changes to the stretch receptors, and so are we going to see an alternative period of nausea and then extreme hunger, in which case we most likely would see very poor tolerance. The second, and I think the more important component, is that the idea that less food is going to drive substantial weight loss may not be true. Right. And correlating food the amount of food you eat with weight loss doesn’t always work out. And we have lots of patients who come to me and they’ll be like I don’t understand, I never eat. And they’ll skip breakfast, they’ll skip lunch, they may be snack on a few hundred calories throughout the day. Have a not great dinner, but it’s a thousand calorie dinner. They’re, They’re not eating a lot, but they’re still struggling and they’re actually often gaining weight. This set point lowering effect of the treatment is what’s going to matter and what’s going to drive permanent, durable weight loss. Reducing food intake alone, we may see that 10% that we see from calorie restriction diets and then essentially a bounce back the second you stop taking the pill. And we may see people having a hard time moderating their food intake throughout the day on this. So it’s important to understand that that physiology drives weight loss. And if something doesn’t work to lower your set point, work to lower that amount that your brain thinks you should weigh, we’re not going to see durable weight loss. This is why GLP-1 meds work. And what’s interesting about GLP-1’s is we’ve had them for a while in either pill format or, in short acting formats. It wasn’t until we got the long-actingformat that lasts a week that we started to see weight loss.
Zoe:
I don’t know this, this vibrating pill seems like a recipe for disaster, if you ask me.
Dr. Weiner:
I think you’re probably gonna be right.
Zoe:
I was like, visualizing. I was like imagine how that would feel like vibrating through your intestines and your colon.
Dr. Weiner:
Do you think you can hear it? You might be able to hear like you’re walking around buzzing. So bizarre, but hey so anyway, I’m gonna bet that somebody’s already Invested a couple million bucks in this thing. That’s my guess.
Zoe:
Well, I mean, leave it to the diet industry.
Dr. Weiner:
Yeah, anyway. All right, so talk to us about our patient story today, Zoe.
Zoe:
All right. Well, we’ve got BJ here. I’m really happy that she came in to share her story. BJ has been a patient of ours for a while, so let’s go ahead and hear from BJ. Well, we want to welcome our incredible patient, BJ. So glad that you are here with us today and going to share your story, so thanks for being here.
BJ:
Of course. Yeah, I’m excited.
Dr. Weiner:
When we decided that we were gonna actually have patients come on the podcast, BJ was like one of the first people who came to my mind because, first of all, she’s done so well. She’s put so much effort into this and her success has not come easy. And her story also, I think, from a medical and physiologic and pharmacologic perspective is also super interesting and very valuable for to a lot of people out there. So, BJ, why don’t you just kind of share your story about your weight gain? And you know some of the things that led you up to before, before we even met?
BJ:
Yeah, of course. Yeah. So, like probably a lot of your patients, I’ve struggled with my weight my entire life. I cannot remember a time when I wasn’t on a diet some sort. It’s genetic in my family. I come from a long line of people who struggled with weight and obesity, including my mother and my, my aunt, her sister. They both really struggled with it and we’re on all the diets growing up. So I watched them and learned that that’s what you do. You just have to keep dieting and keep trying right. So I did all the things. I did weight watchers multiple times. I did Jenny Craig. I did, you know, low fat, low carb, keto fasting I mean, you name it. I did the bacon diet.
Dr. Weiner:
I’ve heard of the bacon diet.
BJ:
Yes, bacon diet. I’ve tried them all. I went to a nutritionist before Zoe, who put me on a bunch of vitamins and told me, like very specific, like you can have this much of this much. The thing I remember the most was like 11 cashews. I could have cashews but only 11 cashews. So, and none of them worked. I mean, well, I would lose like 10% of my weight, yeah, and then it started to plateau. And then it would just come right back on, start to creep up and I’d go off the diet and gain another 20 pounds. So it was just this constant yo-yo spiral, whatever you want to call it. Just constant, constant, constant. So yeah, I just was. I’m sure that’s very common for a lot of you.
Dr. Weiner:
Extremely common. Yeah, I think a lot of people think, oh, bariatric surgery is for people who can’t diet, right? No, bariatric surgery is for people who can’t lose weight from dieting. And that is a concept that has lost on a lot of people. Which is that nutritional therapy is a treatment for the disease of obesity. Like any other medical treatment, for any other medical disease. And sometimes it works and sometimes it doesn’t. Right.
BJ:
And it’s taken me a long time to get to that point of accepting that. And even now I still struggle with about that, a little bit like that emotional piece of like I just didn’t try hard enough. I just wasn’t doing enough. Like it just wasn’t. So I wasn’t until I bought your book, because this book really helped me a lot and I don’t know if your member be bringing this to my first appointment.
Dr. Weiner:
Dog eared and highlighted. First of all, I love that because it’s like, this person is taking this seriously. They are all in. So don’t you know that’s a great sign when I see it. I know it’s not gonna be a 15 minute visit, but it’s a great sign. Yeah, which is fine, I’m fine with that. Okay, so what brought you to our office, like, how’d you finally say, okay, it’s time for me to really seek medical treatment. Because it sounds like you put this off for decades, decades.
BJ:
I did. I mean it was really. I had started developing a lot of comorbidities. So I’d developed diabetes and high triglycerides and cholesterol and I needed it. I’d sleep apnea, I needed a CPAP machine. Like all those pieces, and it just got to the point where I just thought, okay, you know, it’s that definition of insanity you keep doing the same things and you know expecting different results, and that wasn’t working. So, honestly, I can’t remember how I found your office. I know my guess is that I googled it. I actually had gone in, I think it was 2012, into a different office with a different surgeon and had jumped through all the hoops that they asked you to jump through and then, at the last minute, not last minute, but pretty far into the process got denied because they looked at my chart and I had lost like 30 pounds on something a few years before. So they figured, oh, you can, I don’t know what that is, but my, my insurance wasn’t gonna pay for it. And so, even though I had gained all that back plus more by that point. Whatever. So I think I just googled weight loss surgery in Tucson and I can’t remember if I, I remember finding your YouTube videos and your book and all that. And I was like I wanted an appointment with this surgeon and go see him. And so I think that’s how I found you. That’s what I remember.
Zoe:
Do you wanna tell us a little bit about what your nutrition looked like before getting surgery?
BJ:
Sure, um, so I really don’t feel like, I mean again, being on a diet forever. I really feel like I knew a lot of the rules. I know a lot of information about eating, so I don’t feel like it was ever really about overeating or binging or or any of that stuff. I mean I did. I was a Coca-Cola drinker for many years. I love Coca-Cola, full-leaded Coca-Cola. So I know that that was definitely a part of it. Um, but once I got, you know, the diagnosis of diabetes, I stopped drinking that entirely. I was drinking diet soda, which I don’t do any soda now, but anyway, um, but yeah, I don’t know. I don’t feel like I don’t know if it was ever really my nutrition so much as it was just going on. And just, and I mean there were times in my life where it was less than stellar, for sure, you know, when I was grieving or whatever. I would definitely have times where but I don’t again was never like a binge eater or you know nothing.
Dr. Weiner:
I think genetics is one of the hardest factors to overcome when it comes to weight loss. You know when, when, when you have a strong family history it sounds like you do. My hunch is before surgery you line your mother, your aunt up. You guys were shaped the same, looked the same. And and you know, when that’s in your medical history, when your family history it’s really tough. Yeah, it makes the playing field very unfair.
BJ:
Well, it’s like the nutrition piece. You said like yeah, I mean you. I followed my points on Weight Watchers. I did all those things that people told me to do and it just didn’t make a difference.
Zoe:
Yeah. I also think your point about you know going on and off all these different diets and that weight yo-yoing. You know that losing that 10%, gaining it back and all of that just, you know, it goes to show the the longer you go on that cycle, the harder it is. Yeah, for sure and also the comorbidities.
Dr. Weiner:
The longer you have diabetes, the longer you have sleep apnea. The longer you have high cholesterol, high blood pressure, the more damage it does over time. Yeah, and so when we first started, we, that was right when Mounjaro was coming out. You were probably one of our first patients we put on Mounjaro. You’re probably getting the $25 coupon, is that right? Yeah, yeah. So, so that was right when Mounjaro came out. So we were like, hey, you’re diabetic, this is a great drug for you. Talk to us about your first experience with Mounjaro in that pre-op period.
BJ:
So I was really excited because I thought, oh, maybe I don’t need to have surgery. I was nervous about having surgery, as anyone would. Yeah, of course. And this is starting to sound like there’s this new miracle drug on the on the market and and so I started taking it and I it actually really helped with my blood sugar pretty quickly. Yeah got them, you know, really evened out, but I did not lose much weight at all. I think I was on it, I want to say, like three or four months, and I think I’d lost around four pounds in that time. So it just I was disappointed, I was really yeah.
Dr. Weiner:
And, and that, you know, that’s unusual, but not everybody responds to Mounjaro. I think the important point there is that you were diabetic at the time I was. You had an elevated hemoglobin A1c and, and diabetics lose less weight when they’re on GLP-1’s. And that’s kind of ironic because these are diabetes meds. Right, but we know across the board, diabetes makes it harder to lose weight. And it’s not just insulin because you weren’t on insulin at the time. It’s the the way that your body metabolizes sugar when you have diabetes somehow interferes with your ability to lose weight. And you know it’s probably high insulin levels, because diabetics, type 2 diabetics, have high insulin levels because essentially it’s like their insulin receptors have earmuffs on, like they can’t hear. So you have to shout louder in order to get the signal to the cells. So you have to release more insulin in order to get it to the cells. And Insulin is a fat storage hormone. So your body was kind of primed to release a lot of this fat storage hormone which worked against any of your efforts to lose weight. Yeah, so the Mounjaro didn’t work and at that point we were like, let’s do it. So how’d you decide on what surgery to have.
BJ:
Oh man, I went back and forth quite a bit. I really originally. Well, back in 2012, I planned to go it, do the, the sleeve. I was really thinking the sleeve at the time. I have a few friends that have had the sleeve and had very good success with it. But sitting down and chatting with you about it, we decided that I mean just the risk, or not maybe risk is not the right word, but the, the chances of regain are a little higher with that. We also know again because my genetic history, that that might not, I might only lose. We were concerned that it might only lose 30 or 40 pounds, which I needed. I wanted to lose more than that. And then also, I’d had GERD issues in the past. I haven’t had one some in a while, but I was concerned about the reflux issue and I was like I’m not doing this twice. Yeah.
Dr. Weiner:
So how was your recovery? You chose the gastric bypass.
BJ:
Yeah, I mean, at first it was hard. I would say the first two or three months were, you know, just getting used to everything, and there was definitely times I think what did I do? Why did I do this?
Dr. Weiner:
Everybody thinks that. Right, I know.
BJ:
So I knew that going into it, that there would be times like that. I remember one of the hardest times was just a few, maybe just a week afterwards and they had my family had ordered takeout from somewhere and I was like, I can’t have anything. And again, like what was I thinking? But within like three months I was feeling really good. Yeah, no problems from there on.
Dr. Weiner:
Let’s talk about your weight loss initially and your diabetes response and everything like that. What did you start at? How much weight did you lose?
BJ:
Sure. Yeah, I started off, my highest weight ever was 223. I think when I started with you as 216, okay, and at this point I’m at 135.
Dr. Weiner:
Okay, yeah, awesome, yeah, that’s really exciting.
BJ:
I know it’s really exciting.
Dr. Weiner:
But it wasn’t a straight shot.
BJ:
It was not a straight shot. Thank you for bringing that up. Yeah so I was, you know, doing pretty well at first. I mean, you have these little stalls as you go along, which is totally to be expected. But around the four or five month mark I really stalled out like a lot a lot. Yeah, I wasn’t going anywhere and I remember, trying not to panic. I was like it’s okay, it’s okay. But again, I had that again from all these years of dieting, oh my gosh, it’s coming back, it’s all coming back, right? Another failure.
Dr. Weiner:
I failed.
BJ:
That’s my thought like I failed. I failed. I failed because that has been the story of my life with diet. It’s a feeling, feeling. So I chatted with you and you recommend me going back on the Mounjaro and I was, really, didn’t want to do it.
Dr. Weiner:
Yeah.
BJ:
I really didn’t want to. I thought, but this was supposed to be the answer, the surgery was supposed to be the answer. But then after another month of really losing nothing maybe like a quarter of a pound. I don’t know. I mean, it was just just really kind of plateaued out, I decided to give another shot. And at that point, that’s when we really started to see the weight loss.
Dr. Weiner:
Yeah, so you tried it before surgery. Uh-huh, didn’t work. Didn’t work. And then you try it after surgery.
BJ:
Yeah, and it worked like a charm. Worked like a charm. And that was well after my diabetes had gone completely into remission.
Dr. Weiner:
Yeah so yeah and, and so that’s the fascinating part of the story. So we know, as we talked about, diabetics lose less weight. Yeah, and the big difference and the reason why Mounjaro was different for you the second time around was because you weren’t a diabetic anymore. And so the gastric bypass corrected your glucose, brought your insulin levels down to a reasonable amount, and then when we put the Mounjaro on board the second time around, it clicked and it worked. And so, that to me, is really it’s fascinating and it shows so many things about it. It shows, first of all, where you are before surgery is not necessarily your story after surgery. And it also demonstrates the power of combining therapies. And I think if there’s one thing our office does better than anywhere in the country, it’s combine the medications and the surgery together to optimize results. And then you see someone losing way above what we would have predicted. In someone who, up until a few years ago, would have probably been on the side of the bell curve you don’t wanna be on. We know there’s an average response and we know there’s variability after surgery. Half the people lose more than average, half the people lose less than average, and you were on track to be less than average. But now here you are. How many years out are you? Two years, one year. You’re still only one year out, okay.
BJ:
Just a little over 13 months.
Dr. Weiner:
Okay, 13 months out and you’re ahead of the curve. So fantastic. Good yeah, yeah.
Zoe:
So why don’t you tell us a little bit more about what your nutrition looks like now, your eating habits? You mentioned your family getting takeout, so do you make room for treats, like, how does that look? Now, I’m just kind of paint the picture for us.
BJ:
Absolutely. So, with the GLP-1’s and learning from you, I’ve learned that I have to eat a small amount several times throughout the day. Like I am not super hungry, but when I am hungry I need to eat a little bit throughout the day. So I really focus in on protein. That’s like my number one. And then vegetables. Yeah, absolutely, with the planned indulgences we actually had takeout yesterday. We had, what’s it called, again, well, whatever. Anyway, a few days ago we had Chinese and I got Mugugai pan and ate a lot of the chicken and broccoli and vegetables and a little bit of the rice, just because it’s mixed in there with the sauce and stuff. But yeah, I really, like I said, I really focus in on that protein. I heard your podcast about meat snack. I’m definitely a meat snack. I love those little chicken skewers from Costco. Those are my friends. String cheese, a lot of cottage cheese, you know that kind of stuff.
Zoe:
Have you noticed any significant change in your relationship with food?
BJ:
Yes, yes and no. I mean yes in that, I’m just not thinking about food very much at all. I mean not that I really, I feel again, like I don’t really feel like that was my biggest issue, but I don’t. Yeah, sometimes I’ll look at the go. Oh my gosh, I haven’t eaten in something at whatever one o’clock in the afternoon or whatever I’m like. I haven’t eaten today. I need to go eat something. But I also I remember you telling me I mean, maybe it was both of you, I don’t know but about how you would crave like fresh food and stuff Like I love, like blueberries or like my favorite now. And as far as like treats and sugar and stuff like I will like if we get ice cream as a family or something I’ll have a bite of like two or three of my kids you know I have three teenage boys. Pray for me everybody but I’ll eat like a bite of each of theirs or something. But that’s good enough, that’s plenty and it’s satisfying. And yeah, it’s really. It’s different. It’s a whole different world, for sure, it’s amazing, yeah.
Dr. Weiner:
Fantastic. All right, BJ. What’s next for you? What are you excited about? What keeps you up at night? You’re, you know, 2024, new year.
BJ:
I’m mostly excited about how good I feel. I just have the energy that I just didn’t expect to have. I remember you say and I don’t know if it’s in the book or somewhere that you’re going to want to move.
Dr. Weiner:
Yeah.
BJ:
And I was like mm-hmm, yeah, right.
Dr. Weiner:
The gastric bypass swagger. Yes, exactly yeah, you just move a little bit more. When you walk, totally, it’s your body burning off calories so that you maintain that weight.
BJ:
Yeah, we were at a wedding last month and I danced all night.
Dr. Weiner:
Yeah, I mean, I really never had to sit down. Exhausting, dancing all night it takes a lot of energy.
BJ:
I’m in my favorite part yo. I know, I know it’s so much fun and I’ve been going to the gym with a good friend of mine. We are doing some weightlifting stuff, love it. Met with a trainer and been doing that and that’s so fun. And yoga, I can do yoga moves, like the child’s pose, like I used to have, like move my body around to get it, but now I can just do it. I mean just that kind of stuff. That’s so exciting for me, that’s so fun. Like I said, I have three teenage boys at home, so just being active with them and doing some fun stuff with them it’s been great. The thing that keeps me up at night. The only thing that I worry about a little bit is just I have several friends now who have seen my success and I just want to make sure that they know that. You know I really do believe in the health at every size movement and that I don’t want to have I don’t want to be that, I don’t want to say the word but shaming of people who are obese, and I just want to make sure that you know people, like I said, they see me and see my success and actually I’ve had two friends that have had surgery now One is a patient of yours and so I just I want to make sure that they are safe and doing it correct. So I know the one that came to you is in good hands. But I just worry a little bit about that responsibility and that.
Dr. Weiner:
I worry a lot about that responsibility. I believe you. I believe you and I think you know that’s part of the thing we’re trying to do with the podcast is making sure that we put out information so that people can get some really solid common-sense advice about how to navigate this very complicated journey and yours has been extremely complicated but also very successful. Sowe’re so happy to see this BJ and you’ve been such a great patient to have in our practice and I consider myself extremely lucky to have you have chosen us and our team for your weight loss journey and I see nothing but really good things ahead for you. Thank you. I appreciate that.
BJ:
Yeah for sure.
Zoe:
OK. So BJ mentioned something about her planned indulgences, which leads me into our nutrition segment. I actually had to correct you earlier, so I want to discuss a concept that so many, a word, a concept, something that so many people have in their vocabulary: Cheat day or cheat meal. I’m sure you’ve used it. I’ve used it before I became a dietitian. So many people use it, but the concept of cheating right yeah, it has a very negative connotation.
Dr. Weiner:
Absolutely.
Zoe:
What do we think of cheating on, tests, partners? Right, it’s so negative. You don’t cheat on yourself. And so having that negative mindset reinforces a poor relationship with food. And so, I always encourage to reframe that vocabulary word from cheat to treat. So how can we implement treats in a way that is aligned with maintaining your weight loss and living a long, happy, sustainable lifestyle aligned with your goals? And that is this concept of planned indulgences, or your planned treat. And that’s where you have your birthday dinner or you have date night or you have brunch with your girlfriends, but it’s not all the time. It’s this thing that you go outside of the house for. You look forward to it, you enjoy it mindfully, slowly, savor it without guilt, no negative self-talk afterwards, and always follow that fun food with a fuel food. So whatever you eat next to be very nourishing, whole, real, unprocessed. And this is how we can reinforce a positive relationship with food, help to decrease that all or nothing mindset that so many people struggle with and to create long-term success.
Dr. Weiner:
I mean, I love so many things about that tip. That is really really fantastic. Like if you think about it, in almost every other space outside of food, we look at these treats as good, positive things. Like I’ve got a vacation planned with my family. So that’s a week I’m not going to be working. Is it my lazy week that we call that? No, we look at that as a treat. I look forward to that too, and so when I’m working really hard, I say hey, but I’ve got this vacation, I’ve got some time set aside. Nobody looks at me as cheating on my job. We recognize that there are times when you need to stop working your butt off and relax a little bit and enjoy yourself. And so you’re really kind of leveraging that the way we look at the world in every other space besides food, and I think that that was super observant. What a great tip. I am not going to use the word cheat again when it comes to dieting. Ok, great Thanks. Or maybe not use the word dieting either. All right on to our Economics of Obesity segment. This is a question that I will field in my office easily a couple times a week, and it’s why doesn’t my insurance company want to cover weight loss medications.
Zoe:
Great question.
Dr. Weiner:
Because we know that obesity is associated with so many comorbid illnesses. We know that we see reductions in cancer rate, reductions in heart attacks and strokes. With weight loss, reductions in hospitalizations, emergency room visits there’s a huge cost savings that comes from treating obesity. The first thing and we talked about this in our last episode is that Medicare is prevented by law from covering obesity medications. Well, thank you so much. You have to look at the timing of this. This came out. It was first voted on 2003. It started in 2006. And this came out, believe it or not, it was not necessarily an obesity bias. It came out as a safety concern, because right around this time was when the whole fen-fen disaster came out, where we recognized that Phen-Phen causes these heart valve abnormalities and a number of people died from Phen-Phen. And so we looked at this and they said, okay, well, you know what? We don’t want Medicare to cover any weight loss medications and so we’re going to make a law against it as a safety measure. I don’t think that law had a lot of foresight to understand that medical treatments evolve. I think the predictability of GLP-1’s for weight loss we all knew at some point someone was going to figure this out. It was just too important of a problem. There’s too much money on the other side of solving this problem that at some point we’re going to figure out how to do it safely. And we’re there. I think the GLP-1’s have continued to prove themselves to be safe options and effective options for treating obesity, but there is a law, and so that’s the first thing is that what Medicare the other commercial payers will often follow the Medicare rules. That’s kind of where they start and they’ll modify from that, and because there’s actually a law preventing it, a lot of commercial payers just follow suit and that’s that. There is, however, the Treat and Reduce Obesity Act, and this is introduced annually, so there’s a group that introduces this into Congress every year and tries to get it pushed through, and they actually do have bipartisan support, and we’re seeing more and more people looking at this act and I think with the GLP-1’s, we’ll see, hey, maybe this is something that does make some sense for Medicare, so this may get passed in the future. Until recently, it hasn’t really been an issue because there hasn’t been any good options. There’s also in 2023,. They successfully got weight loss medication, specifically Wegovy, approved on all federal health benefits. So if you’re a federal employee, you have covered for Wegovy. Zep bound is on the horizon. I don’t think we’re seeing Zep bound covered on these federal health plans, but I would not be surprised if we see that in the near future. And so that’s been something that’s changed, and so that’s often the first step and Medicare can follow from there. So we do see the government paying for obesity treatment for our federal employees, which hopefully we’ll see that extended to Medicare in the future. But when it comes to reducing health care costs and that’s the assumption like oh, these meds are going to reduce health care costs the problem is that when it comes to commercial insurance policies, most people will change their insurance policy every one to two years, so it’s very uncommon that you have the same policy, even if you stay with the same employer.
Sierra:
Right.
Dr. Weiner:
So we’ve had three. We’ve had three insurances. Right, you’ve had three insurances since starting to work for us. Yeah, we started on Blue Cross, switched to United and now we’re back on Blue Cross. And so, if you’re Blue Cross, you’re like well, why am I investing in weight loss medications?
Zoe:
Because you’re just going to switch to United in a year or two, we will reap the benefits of those reduced health care costs.
Dr. Weiner:
Right, and so because these are quarterly traded companies, we don’t see the. There’s not the longevity that you need in order to recoup these costs. Also, if you look at our current prices, which we talked about last week, it would probably cost about a trillion dollars, which is way more than we’re going to see in terms of the reduction of health care costs. It could be around $250 billion, but it’s going to cost a trillion. So right now, because the drugs are so expensive, it just, the math, just doesn’t work out for the you don’t. Even though you get a tremendous reduction, it’s not going to make up for the cost of the medications. We bring those medications down substantially in price and all of a sudden, this starts to make a lot of sense. Okay, so now let’s move on to our questions from social media. Of course, we’ve got Sierra here to read the questions out there. So, Sierra, what’s our first question?
Sierra:
Okay, first question is from Margaret from the website. We’re all working toward the goal of losing weight. When I was younger, I was told the key is in the colon. However, I now know that this is a very small part of the equation. I think it would be helpful for us to know exactly how our bodies are losing weight. Is it possible for you to explain the basic physiological mechanism behind weight loss?
Dr. Weiner:
Yes, it’s. First of all, it’s complicated. I have tons of videos on this on YouTube. We call this whole mechanism your metabolic thermostat. So if you think about a thermostat, a thermostat is designed to keep the temperature in a room stable. If the temperature drops a little bit, the heat turns on to bring it back. If it warms a little bit, the air conditioning turns on to bring it back to that set point. We all have a weight set point and our body uses our food cravings and hunger and our metabolic rate to maintain that weight. So your brain and not the cortex, the part that we can control, the outer part that thinks, but your brain stem, your brain stem, is the most primal, basic part of your brain. It controls your heart rate, it controls your respiratory rate, it controls a lot of our basic physiologic parameters. This works also to control our body weight. So when we reduce our calorie intake, our body fights back against this and it increases our hunger and it slows down our metabolic rate in an effort to reduce the weight loss. Because our body fat is vital and our bodies evolve in an environment of famine and food shortage, and so our body is designed to prevent famine, to prevent food storage, and so any weight loss treatment that is successful must focus on lowering that set point. And there are four ways to lower your set point. The first is nutritional change not eating less but eating different foods. The second is building muscle and using it. The third is medications like we gov, Zepbound, Tirzepatide, semaglutide, the GLP-1’s. And the fourth is bariatric surgery, and so we focus all of our treatments in our practice on those four treatments. Exercise tends to be the least effective of the fours we’ve talked about in the past. We focus on those four treatments. Now, what you’ve alluded to with the colon is this microbiome, and the microbiome is part of our body’s regulation of our body weight. By changing our microbiome we can actually potentially lower our set point, and that’s one of the mechanisms that we think eating more vegetables, eating more fiber, it changes the microbiome so that you can lower your set point, so that nutritional change and actually also the medications and bariatric surgery, all will change that microbiome. But you can’t intentionally change the microbiome by delivering the right bacteria to the colon. It really is something else whether eating differently, taking medications, bariatric surgery that changes the microbiome. So as much as that is play, that does play a role. It’s not an actionable item. It’s something that responds to the other changes that we’ve made.
Zoe:
Yeah, you can’t take a probiotic pill and expect your microbiome and your colon to change, unfortunately not.
Dr. Weiner:
Maybe someday, you know.
Zoe:
Maybe that vibrating pill.
Dr. Weiner:
Maybe we’ll have to go up the other way. Maybe we’ll edit that.
Sierra:
We’ll see Okay. Next question is from Eva Pilsen on episode eight, paging. Dr Lilly. I recently had a gastric sleeve, a little over a month ago. I’m finding it difficult to determine whether what I’m experiencing is food intolerance, heartburn, or if I’m satiated after eating and drinking. How can I differentiate between these three?
Dr. Weiner:
That’s a tough one. I’ll start, but I want to hear your thoughts on this too, Zoe. So you’re a month out from your sleeve. So I think the first thing is is there’s most likely, the least likely thing there is hunger. There’s very little hunger right after surgery, and I’m going to let you talk a lot about mindful eating, because I think there’s so much that you can get from a mindful eating approach, but it’s likely that hunger is not going to be something that you’re experiencing too much of at this point. You can still get hunger, but this kind of ravenous drive for food, that’s not what you’re experiencing. The truth is, whether it’s food intolerance, whether it’s heartburn, whether it’s just abdominal pain or dysphagia is the term we use which is difficulty swallowing, to me is irrelevant what we name it doesn’t matter. It’s how it makes you feel and what it makes you do. That matters, and that’s where the mindful eating is going to come in. But you have to start figuring out what things you’re doing that causes these sensations and then what are you going to do about it. So let’s talk a little bit about mindful eating and how important it is in that first month or so after surgery. It’s important all the time really after surgery.
Zoe:
Right, definitely, and so this is something that we talk a lot about is that you have to learn your new anatomy and if that means that you’re navigating new satiety signals, new hunger signals although, of course, a month out you’re probably not having hunger signals but really being present in your body while you are eating. And I think so many of us are so busy, most of our meals are consumed in front of our work computer, maybe in front of the TV or, at the very minimum, scrolling on the phone, right, and so we are in the habit based on, maybe, the environment that we’ve created is to eat with distraction and mindlessly. So bringing that awareness, that presence back into your body, to eat very slowly, eat without distraction and being acutely aware of when you get that first sign of satisfaction, and stopping there and eating past the point of fullness, which many people do a small handful of times after surgery. But it’s not fun. You don’t want to make a habit out of it, no. So being able to recognize, even if it’s I’m not sure if I’m full, but I’m going to go ahead and stop here just to make sure, and then you can go back to it two or three hours later, that’s normal, that’s expected or even 10 minutes later. Right, Right, Totally. And so I think a concept that I just I want to touch on briefly is how we have been conditioned. Many of us maybe not everybody, but many of us have been conditioned to ignore our body’s natural cues, right Conditioned from an early age, to ignore our satiety signals and finish everything on your plate. And then, maybe, during adulthood and starting a weight loss journey, what are we told? Eat less and exercise more. Right, the news article about eating 40%, the pigs eating 40% less. If we are conditioned to ignore our hunger and chew a piece of gum because they ignore that hunger, you just need to eat less, Well then, of course we’re out of touch with our body. Of course we’re having difficulty recognizing our true hunger and satiety signals. So a mindful eating is a practice that you need to put in. Those repetitions you need to do very intentionally and, yes, over time it will get easier. But this is something everybody can implement, but especially while you are learning your new anatomy immediately after surgery.
Dr. Weiner:
Yeah, and we do have a mindful eating support group through our nutrition support group. So if this is something you want to work on, you can meet with Zoe over Zoom and help develop that. But I think, yeah, what I would recommend is really focusing on mindful eating in this scenario and trying to figure out whatever you name it is irrelevant how it makes you feel, what you can do to eliminate it and how you can structure your diet to minimize it. All right, last question.
Sierra:
Okay, this one is from Rafael, from our website. What is your opinion about making a healthier version of your food craving? Will that lead to more cravings?
Zoe:
Well, I think this is the perfect question. I wonder who picked that. So piggybacking off of our conversation in our nutrition segment earlier about those planned indulgences, there’s kind of two pathways I like to take with this. One is is the food that you’re craving? You want to make a planned indulgence and you want to go enjoy it in moderation every once in a while. That’s a different conversation. If we’re making a healthier version of the food you’re craving, let’s take ice cream or tacos, for example. I was literally on a Zoom session today talking about this with somebody Now figuring out what it is about the food that you are craving. So we use the example of pudding. So, all right, think about the texture it’s smooth, it’s sweet, maybe it’s cold. How can I recreate this in a more nutritious whole foods style? So we discussed okay, we’re going to use Greek yogurt, we’re going to add some unsweetened cocoa powder and raspberries.
Dr. Weiner:
Love it.
Zoe:
And so now you’ve got this like more nutritious version of pudding. Same thing with the taco. She was using these nice romaine boats and she had black beans and veggies and, you know, fresh avocado all that great stuff. So making a healthier version of the food that you are craving, I think, is incredible, and that is actually what gets you excited about what you’re eating, because when you have genuine enjoyment out of preparing and eating a meal that you’ve put thought and intention towards, you’re going to be more likely to do that again. And what better way than to get excited about making a healthier version of your favorite food?
Dr. Weiner:
Yeah, love it. Great, great suggestion. So really, in general, you always want to eat the healthiest version of the food that you can, unless it’s one of those planned indulgences, in which case you just kind of go and for it in a mindful, intentional manner. All right, fantastic.
Zoe:
All right. Well, that wraps up another episode. I think we had a lot of value here and if you found this valuable, we really ask that you share this with your friends, with your relatives, anybody who you think would get value out of it. And, of course, we want to thank our guest, BJ. Thanks so much for being here and we’ll see you in the next one.
Dr. Weiner:
See you next time.
