Ever find yourself questioning the moral compass of Big Pharma and their partnerships? Brace yourself as we navigate the intricate relationship between Eli Lilly and a telehealth company, dissecting how this could potentially skew prescription practices. With patient care and the integrity of medical advice at stake, we’re not shying away from challenging the status quo, predicting the medical community’s pushback, and advocating for transparency and patient-focused strategies over profit-driven alliances.
Next we talk with our patient couple Kim and Larry. They open up about their weight loss struggles and how they found success combining nutrition and GLP-1 medication. It’s a candid look into the reliance on support systems, the role of medications like GLP-1 agonists, and the often overlooked emotional journey behind managing eating habits. We’ll pull back the curtain on the stigmatization attached to medication use in weight management and why it’s time to normalize these life-changing aids that can redefine our relationship with food and hunger.
Rounding off, we’re strapping on our sneakers to tackle the economics of obesity treatment and the practicality of weaving movement into our daily lives. From ingenious ‘movement sprinkles’ to the financial burden of medications and surgeries, we’re shedding light on accessibility issues and potential policy impacts. Plus, we won’t leave you hanging on the topic of hiatal hernias post-gastric sleeve surgery, offering insights into when it’s time to consider surgical intervention. Buckle up for a journey through the complexities of health, ethics, and personal well-being.
Transcript
Zoe:
Okay, well, welcome back to the Pound the Cure podcast. We are in 2024.
Dr. Weiner:
Yeah, ball dropped in 2023 and now it’s rolling in 2024. I guess, so how about that? So this is episode eight. What do we title this one?
Zoe:
Paging Dr Lilly.
Dr. Weiner:
Yeah, paging Dr, Lilly.
Zoe:
Dr. Lilly.
Dr. Weiner:
Okay, so we’re really having a good time with the podcast, and it’s now after the new year. In the past we’ve been recording a little bit behind schedule. We’re now pretty close up to date. I am actually. If I’m a little bit unhinged, it’s because last night I was in Houston at the National Championship watching my Wolverines win. Go blue! And so I have been up quite a bit and flew in this morning and then saw an office full of patients and now here we are recording a podcast. So, please again, if I seem a little sleep deprived, well, it’s because I am.
Zoe:
Or if we hear your stomach growling.
Dr. Weiner:
Yeah, or if my voice seems a little hoarse. Any of that, well, you have an excuse for that.
Zoe:
Dr. Weiner needs a nap.
Dr. Weiner:
Totally, totally. All right, so let’s get into the show. Our first segment is about the news, and we have the news article is about Eli Lilly, or it’s called Lilly Direct, and Eli Lilly has. They haven’t bought. Well, it’s unclear what the financial relationship is, but there is some extremely tight relationship with a telehealth medical company, just like Weight Watchers and Ro and Joint Calibrate, and these companies that are out there essentially just selling prescriptions for a monthly fee. So Eli Lilly has partnered with one of these, and so essentially what we have is a pharmaceutical company partnering with a medical group in order to, I would assume, sell their medication. Prescribe their medication, and so I think, I don’t know if it’s just me who thinks this is totally crazy and violates every ethical principle of unbiased healthcare, but I think we have to recognize that if we have a pharmaceutical industry that has a close financial relationship with a medical group, do you think that this medical group is going to be prescribing a lot of Wegovy, which is made by Novo Nordisk? I don’t think so. Do you think this medical group is going to be appropriately referring to bariatric surgery?
Zoe:
Oh my gosh. Well, when I was reading that article, I was like how is this, is this allowed?
Dr. Weiner:
Yeah.
Zoe:
And I noticed there was a line in there that said that they won’t be inclined to prescribe their medication more than the others, and I thought how in the world could they not?
Dr. Weiner:
So, first of all, there’s a ton of science about how drug reps, and there’s a huge cottage industry of these reps and they come to the office and they want to drop off paperwork. I actually today, it had nothing to do with obesity. It had to do with more of my general surgery practice. I got an email from a drug rep saying, “hey, there’s a patient that I think should go on our medication. I just wanted to talk to you about that is crazy. I mean, at this point we’ve got the tail wagging and the dog. And so this whole thing, I think, and I think there is a lot of pushback from it. So I look through it and in every article they try to put a balanced side of things. The supporting content comes from a Harvard professor and they’re part of the Harvard’s medical weight loss program. Interestingly, the chief medical officer from the company that is partnering with Eli Lilly, just take a guess where they come from.
Zoe:
Harvard, harvard.
Dr. Weiner:
Yeah. So I think we have to call foul on this. I think it’s really important for us to reach out and say, “hey, listen, eli Lilly, you did a great job making a drug. You’re going to make billions of dollars on it. Stay in your lane. Obesity is a complicated disease and these medications, they’re complicated. They require, there’s a lot of nuance to prescribing them, and there’s times when Mounjaro and Zepbound is not the best drug for a patient. We have people who we put on Saxenda, which is probably the worst weight loss drug out there. But there’s a reason why we start them on that drug to help them transition and adjust to the medications, and so there’s a lot of nuance to this. There’s also a very appropriate time to refer for bariatric surgery. And when we have a pharmaceutical industry with this deep financial relationship with a medical group that is pushing and promoting their drug, they’ve gone too far. And I think what we’re going to see here is we’re going to see Eli Lilly back this up. And my prediction is within two or three months, and we just got over a New Year’s show with all of our predictions, so I like to make predictions. My prediction is we’re going to see Eli Lilly back this up. And I think this is not something that’s going to last. And I think there’s going to be a lot more backlash, especially within the academic community, because not everybody in the academic community has tight financial relationships with the industry. And there still are ethical standards in the medical industry, despite what you may see out there. But lots of doctors still have very high ethical principles and I think when this comes out and people recognize what’s happening, we’re going to have to backtrack this, and I think that’s a good thing. So, Dr. Lilly, I think it’s time for you to focus more on manufacturing the medications. Maybe instead of working on creating this relationship with a company that will prescribe your medication, maybe start doing some lobbying to get insurance companies to cover it and to get the government to repeal this law that prevents Medicare from covering obesity treatments. Can you spend your money on that, please, because that’s going to help treat patients with obesity. That’s going to improve access to care. It’s not prescribing physicians. There’s enough physicians out there who are willing to prescribe this.
Zoe:
Talk about making it easier to get these medications. We know how hard it is. We don’t need the drug company to try to make it better by having more prescribing physicians. There are so many of those, yeah.
Dr. Weiner:
The problem is not a lack of prescribing physicians. The problem is a lack of insurance coverage and also excessive costs. If you can put some time and energy into reducing the cost of your medication and also, that’s going to go a long way toward improving insurance coverage.
Zoe:
Very exciting. We have Kim and Larry here, our first official guests on the podcast. Welcome, Larry and Kim.
Dr. Weiner:
All right, this is really exciting. We’re here with Larry and Kim. They are our very first patients that we’re going to have on our podcast. In the past, we’ve told a patient story, “hey, this is what happened with this patient. That’s great. But we talked about it, zoe and I, and we said we really should probably be hearing from the patients themselves Nothing like coming from the horse’s mouth. Exactly, Larry and Kim have been enrolled in our non-surgical weight loss program for almost a year, now. Coming up on a year. I think their story is really interesting and actually quite typical. Something we have seen before. Why don’t you guys share with us a little bit about where you were in March of 2023 when you first started working with us and what triggered you to look into seeking some additional care for your weight?
Kim:
I’ve had a lifetime of up and down Since probably as long as I can remember, what happened in March was I actually came here for a consult.
Dr. Weiner:
Okay.
Kim:
I was ready for surgery, lap band. That’s it. I can’t do it anymore. I’ll repeat the story again, but you told me I wasn’t fat enough.
Dr. Weiner:
I didn’t use that word, by the way. I never.
Kim:
However, I was thrilled. I was absolutely thrilled. No one ever told me I wasn’t fat enough. I mean, I was too fat always. Well, in any event. So we went a different route and we went with the GLP- 3, GLP-1. GLP- 1. I’m sorry, part of it was I’m doing with my husband here and we read your book and we went on Zoe’s podcast and at the time Larry was weighing himself on the scale who’s in some sort of program and I was kind of going on the scale as well. But in conjunction with everything, with the medicines, GLP-1’s, and the food, and the pound of vegetables, and the fruit, that’s what happened. So I really am feeling really great.
Dr. Weiner:
at when you started.
Kim:
I was 171.
Dr. Weiner:
How about you, Larry?
Larry:
I think I was 206 when I came here 206.
Dr. Weiner:
And what do you weighing now, Kim? 123. So you lost almost, just shy of, 50 pounds. So we really, if we do the math on that, that’s like 30% of your body weight. And, Larry, how much weight have you lost? I’m at 168 now. And are you willing to share what medication you’re taking?
Larry:
Yeah, we’re both on Osempic. Okay, we take half a milligram a week.
Dr. Weiner:
that is a very low dose. So the first thing I would say is these are atypical results. This is better than we usually see. 0.5 milligrams of Ozempic, losing 50 pounds that’s in a woman, 30% of her total body weight, that is just extreme. That’s as you’re in the top 3% of weight loss in terms of the GLP-1’s, and especially with your age group. Because as you’re younger, you lose more weight. As you get a little bit older. So talk to me about what you felt when you first started taking the medicine. Did you notice it immediately or did it take some time?
Kim:
I think I noticed it pretty quickly. I had no, absolutely no adverse reaction, no nausea. All of a sudden, I didn’t have the desire as much to eat. I mean, I’m eating, I eat well. Okay. I eat the vegetables. I eat protein. I drink. I’m always drinking water. I don’t know. I just started to feel better. I just think I had a little more energy. I also, as I’ve said to you earlier, I don’t have the obsession. Which is the craziest thing ever because, once again, like I said, I’ve been had a weight problem forever and food is my drug. Food is. I think about it, I think about what the next meal is going to be. When I’m making breakfast, I’m thinking about lunch. I truly have been obsessed with food. And I just get that – Past tense, though right. Not too big. Excuse me. Past tense and it’s a miracle. I mean, this stuff is amazing and obviously I’m a little concerned because obviously you know not going to be so easy to get anymore and I don’t quite understand that.
Larry:
When I started taking it, I also started eating a lot slower than I used to. And so I would used to be able to devour cheeseburger and fries easily. Right. Now, I was cutting the hamburger in half and not having the bun, and I was getting full just on having half of it. And so that was a big thing for me that I was getting full much quicker. And, I’m still staying active. And I was weighing myself. I got a little obsessive. I was weighing myself every day.
Dr. Weiner:
Yeah, You’ve got quite a spreadsheet going.
Larry:
And I have a spreadsheet going. I’m an IT guy so I had a spreadsheet going and so I just sort of pounds go off and then over the summer we go to New York for the summer. People immediately, it’s interesting they noticed the weight loss on me sooner than they noticed it on Kim, but in fact Kim had actually lost more weight at that time. Yeah, that’s interesting. One of my friends there is actually an emergency room doc in New York. And I told them that I was on the Ozempic and he was saying how good it was and all the good things he’s heard about it. And you know we just stuck with it. You know, even driving. You know we spoke with you, as you know, saying we’re going to drive to New York and we’re worried about what are we going to eat on the road Because there’s not much decent stuff to eat on the road. We brought a lot of food with us: Nuts, we brought some string cheese, we had water to drink. You know, really following, you know, the program. And I had, just you know, I had lost 40 pounds once before on Weight Watches and it was great. As long as I was on the program. I started my own business. And I started going to early morning breakfast with there’s bagels and Danish. And after hours, there were mixers where they’re were all fried appetizers. And I stopped going to the gym because I was busy working on trying to get my business going and the weight just went back up and that’s why I’ve been since now. I’m 69 years old now, and been through a few hip replacements and back surgery and I’m saying I got to get this weight off. This is crazy.
Dr. Weiner:
Fascinating stuff. First of all, obesity is an environmental disease and that story of you starting your own business. It just flipped your food environment around a little bit where, all of a sudden, breakfast was a lot more processed as opposed to maybe a quick healthy snack in the morning. And all of a sudden, after work, you’re going to build your business. Building your business meant surrounding yourself by fried appetizers.
Larry:
And drinks.
Dr. Weiner:
And drinks, and drinks yeah.
Zoe:
omething I just wanted to loop back around to really quickly is how you mentioned, they are in that top percentile of success stories. And something that you mentioned to me earlier is that of course, these medications are an incredible tool, but you guys have been able to make such significant change to your nutrition. I believe has really helped amplify your success. So how do you kind of view food now as opposed to maybe before you started the ?
Kim:
Well, I read labels. Which I really never did. I have to tell you, in all my years, I mean I’m 65 years old I hardly ever read labels. And now I’m very aware of the ingredients. Is there any sugar in there? I also have been making a very, very conscious effort to stay away from sugar. I’m a little afraid of that. But I do have, I’ve had my planned indulgence, as you call it. Okay, I’ll have a piece of pizza every now and then, so rarely, but that’s reality.
Zoe:
That’s part of navigating real life, and that’s real life.
Kim:
And I don’t want to think that I could never do that, but even this summer, when Larry was talking about how we were eating all the vegetables and all the fruit, I mean, he said we can’t have watermelon. I said Zoe said if you eat more vegetables and fruit, you can have, if I tell you we went through
Larry:
lot of watermelon.
Kim:
I love that a lot and it was great, I mean, and when Larry said he had the morning breakfast and such you have to navigate life. I feel so much better. I really do. I would love to be back here in a year. Put this on the calendar and I pray to God that in a year I’m here with about the same weight. You know, three or four pounds I could do with because I do know the reality of people gaining weight and I’ve been there.
Larry:
When my friends congratulate me, you know. And I say you know, I say They say, “And you. But you know, losing the weight was one thing, maintaining it is a whole other ball game. And you know that’s always been our concern. One of the good things is also is that we’re doing it together. So it’s not that one is seeing the other one losing more weight or less weight or actually losing anyway. You know we are doing it together. I tend to be a little more active. I’m a lot more active than Kim is. But she’s more disciplined, even with the food than I am. I was a real, two things: One is over the summer, you know, went to New York. I had two bagels all summer. New York, That’s where bagels you know a king, and we had two all summer and very little pizza. It was quite an adjustment. And so you know, I just, it’s, it’s watch it, that playing the indulgence is. It’s true. I mean, if I have a bagel one day, I’m not going to have another one for quite a while.
Dr. Weiner:
Yeah, you know you’ve always wanted to eat really well and change your diet. You’ve started and tried and succeeded and then regained so many times over the years. But when you get the medications on board, it just, it just makes it all possible. And here you are, you know, had you lost 50 pounds in the past, you would be ravenous. You would be walking around all day just trying to quiet your hunger and thinking and being obsessed with food, and that’s just a biologic response to weight loss. But with the medications, with that lowering of the set point, you know you’re 120 something pounds and that set point is is is now there. And so I think that makes such a big difference too is that this is now your new weight as long as you take the meds.
Larry:
So how is it, though? It’s because you know of all the commercials you see on TV, they say you know people that are on Ozempic, they can expect this percentage of weight loss, and we’ve far exceeded that.
Dr. Weiner:
Yeah.
Larry:
You know, and so I’m thinking how is that possible? We’re eating properly, but are we eating that much better that it’s like we have such great results? Is that? Is that what it is?
Dr. Weiner:
I think it’s a combination.
Zoe:
Some people are really super responders to the medication, and some maybe eat the exact same way you do and just their bodies don’t respond as well.
Larry:
If we were on a higher dose would we be losing more weight? Or is there a point where you know we’re going to be?
Dr. Weiner:
There is going to be a law of diminishing returns, where the side effects go up because you know your body’s not going to let you. It’s not going to let you get to 102 pounds. Right? You’d look terrible at 102 pounds. You’d be very unhealthy. Yeah, very unhealthy as you, with each successive pound, it gets a little harder and harder to lose that weight. And so I think no, by raising the dose it’s not like all of a sudden you could become malnourished. And the thing about these meds, too, is that it, let’s say you do, you’re not eating enough and you’re starting to really struggle with your weight just hold off on taking them for a little bit. We lower the dose a little bit, we make some adjustments. But you guys have done extremely well at 0.5 milligrams. But we had a story in one of our support groups where you were talking to us about someone who had made a little bit of a snide comment. Oh, a disparaging comment. Yeah, a disparaging comment. So why don’t you share that story with us?
Kim:
Well, you know, my life is not such an open book. And we came back from the summer and I had seen a neighbor and she noticed how much weight we lost. And I just went out and I told her she said, “are you using that miracle drug? And I said, well, you know, I’ve been using Ozempic. She said, “you know, the second you stop, you’re going to gain it back and there may be a bit of truth to it, whether or not there is, but you know it wasn’t nice. And then, of course, I read this article about that Ozempic and the weight, you know the GLP-1’s are similar to like antidepressants in that people don’t want to admit to taking them because there’s a stigma. There is a stigma. You know you can’t. You know it’s like if someone’s depressed or something – you just, just snap out of it. You know, or basically, I mean, I don’t think Larry understands the you know the whole, you know obesity, obesity, living with you know since forever. But as much you know, because there have been times where he has said or other people said, can’t you just stop eating? No, no, I can’t. The answer is no, I can’t. Okay? And so it’s got to, you know, something in the head. And now, all of a sudden, this miracle drug okay, has now stopped me from being so obsessive about food. I’m loving it. I’m really loving it. I’m so happy that I don’t think about it. I mean, you know he’s like, come on what’s for dinner and I’ll say I don’t care. You know, I’m sorry, honey, but you know you are well fed, okay.
Larry:
Obviously I’m well fed.
Kim:
We are. You know we eat well in the house. But I don’t really care so much. I don’t want to think about it so much. And it really frees me. It’s a very freeing way to be and I’m really glad for this. And I got to tell you I’ll get out there with my you know picket signs if I have to, if there’s anything that can be done, I mean I’m there.
Dr. Weiner:
Obesity Action Coalition.
Kim:
Is there such a thing?
Dr. Weiner:
Absolutely. Look them up. Obesity Action Coalition. They do good work. We’ve partnered with them. They’ve been around for a while. We’ve partnered with them extensively in our bariatric surgery society, but now they’re starting to work with the meds. And, you know, I have plenty of issues with the pharma companies. But let me tell you something you don’t think they want these things to be approved? And so the advantage is that we finally have someone with really big bucks who’s going to be pushing this through: Novo Nordisk, Eli Lilly, soon to be some other big companies who have drugs out there. That we’ll see, because again, it comes down to money. And if you’re a $50 billion dollar company with all the lobbying and all the connections, they’re going to be able to make some headway, but it’s going to take some time. So we’re in a little bit of a dark area right now. Something we talked about, too a little bit, is something that may provide a little bit of solace is that we calculated. We did some rough calculations about what would happen if you guys had to completely self-pay and just not even use Medicare. And so with some creativity, and the real advantage is because you’re on a low dose, we could probably, we would increase your cost per year by 30% or 40%, not doubling, tripling, quadrupling. It might not be true for everybody, but I think for you guys we do have some opportunity for you, without a massive financial outlay, to be able to stay on this drug.
Kim:
Well, we’ll figure it out. I actually feel bad for somebody that can’t. This is an issue. I’m going to contact that coalition. I really am, and see what I don’t know. Who knows?
Zoe:
To be continued. Well, this has been so great, and we’re so grateful that you guys took the time. We know that you have to be up early tomorrow morning for your surgery, but, hip surgery. But we just are so excited to be here to celebrate you and thank you so much for sharing your story and being vulnerable. We really appreciate it.
Kim:
Thanks for having us.
Larry:
I’m glad we found you. Yeah, it’s great to you. Thank you. Thanks.
Zoe:
I just love our patients and I’m so grateful that they came into the office. It’s dark outside y’all. It is late. Larry has hip surgery this morning.
Dr. Weiner:
He’s got hip surgery this morning.
Zoe:
They are committed and we’re just so grateful and honored to have them share our story.
Dr. Weiner:
Absolutely. I’m so happy for their success. I mean, they’ve really just done amazingly well. These meds have worked great for them.
Zoe:
Definitely! All right. I’d love to go ahead and now share my nutrition segment. Okay, It’s a little bit more movement, exercise related this week. So I often, in my support groups, share this concept called that I like, that I’ve coined “movement sprinkles and you kind of have to do a little finger you know finger sprinkle when you sit, talk about it. So what a movement sprinkle is, is basically, if you’re busy which we both are, and many, many people are there is this concept that you have to have 30 minutes to exercise and it has to be this structured. And it feels daunting. Right? And so for people who have that barrier to moving or exercising then feels like it has to be this structured time. I encourage movement sprinkles. So that’s, maybe that’s, five minutes two times a day. You get up from your desk and you walk around the office. Or for those people who work from home, you get up every hour and you just walk around your yard. Or if you have to use the bathroom, you go to the other side of the house instead of the one that’s right next to your room. I was working with somebody who has his office on the second level and so we made the deal that anytime you had to go to the bathroom, you had to go downstairs to the first floor bathroom. So this is a way to sprinkle in movement. Guess what, all of that movement adds up. All those steps add up, I like to say, be inefficient with your movement. So if that means taking one grocery bag in from the car at a time, fine. I’m sure we’ve all heard the parking farther away, right. Sprinkling in these movement sprinkles throughout the day, can add up and can be a great way to increase your movement without the daunting task of structured exercise.
Dr. Weiner:
Yeah, non-exercise activity. And I think that’s really what you’re talking about is how can you add, It’s not necessarily exercise. I joke, exercise is something you got to change your clothes to do. So that’s when you go to the gym. You can’t walk into the gym in a three-piece suit, but if you saw somebody walking down the street in a three-piece suit, you wouldn’t think anything weird about it. So it doesn’t have to be 30 minutes cardio, Get your heart rate over a certain amount. I’ve seen articles that show that jogging for a minute actually results in substantial health improvements.
Zoe:
Wow. yeah, and actually one of our patients who I was going to be a guest on the podcast, Hint Hint, she does movement sprinkles in her office. She’s like Zoe. I was in a dress and I went and I did my jogging in place on her Tabata timer on her lunch break. And so, guess what, it doesn’t have to be this huge commitment, just to move your body a little bit more.
Dr. Weiner:
Yeah, no, great tip. Thank you for that, and I think all of you out there sprinkle a little bit of movement into your day today, if you’re listening to this. Okay, so let’s move into our economics of obesity segment. And I think becoming very clear is that if the affordability of these medications, the affordability of bariatric surgery, in fact, the affordability of healthcare in general let’s be honest, this is not just unique to obesity, but affordability is becoming the single most important determinant of whether people start on these medications, whether people are having bariatric surgery. This is now a financial issue. That’s what makes up people’s minds. In our office, we pull everybody’s benefits. We actually have an overseas call center who helps us with this, so that when people come into our office, we have as much financial information as we can possibly obtain so that we can help counsel them, because I can talk to you till I’m blue in the face about the right medication, but if it’s 500 bucks a month, most patients aren’t going to be able to afford it. And so the economics of obesity we’re going to talk more about what Larry and Kim discussed, and it’s not just with Medicare Advantage plans or Medicare plans like Larry and Kim have, but it’s with all commercial plans. So, again, diabetes is a very expensive disease to treat, and so the insurance companies have tried to put as few restrictions as possible to allow patients with diabetes to get on the medications that are going to reduce their blood sugar, because if your diabetes is better controlled, you don’t need hospitalization. And there’s nothing more expensive than hospitalization. A hospitalization is $20,000, $30,000, $40,000 for a short hospital stay. Let alone a heart attack or something that’s two weeks in the hospital and then rehab, and that can be $100,000 for that. So the drug companies have eliminated obstacles to the treatment of diabetes by eliminating prior authorization for the medications that treat diabetes, like Ozempic, like Mounjaro, like Victoza. However, what they recognize is that when you eliminate prior authorization, any physician can prescribe it for any reason. And that’s well within our right as a physician, and it happens all the time that we use medications that may not be intended for one purpose for another. We do that, all I do that all day long, and not with those Ozempic and Mounjaro, with a lot of other medications. And so what’s happened, of course, is that these medications have been prescribed for weight loss, which they don’t want to pay for. They don’t mind paying for diabetes, because diabetes is expensive Obesity it takes much more time for the consequences and the admissions and the excessive health care costs to build up, and so there’s just not the return on investment. And so the insurance companies have caught on to this. They’ve known about it for a while but they weren’t able to change their policy. Insurance company can’t be like you know what? I’m going to change my policy today. Boom, it’s changed. There’s a whole process and it usually works on the calendar year. January 1st comes along and we’re probably going to see millions and millions of patients who have been receiving Ozempic or Mounjaro fully covered, because what the insurance companies also do is they eliminate the copay. So we have patients getting Ozempic or Mounjaro for $0 copay. And all of a sudden the insurance company is like I’m not paying, giving a $0 copay for weight for an obesity drug, when I’m charging $100, $150, $200 copay for Wegovy or Zepbound. And so we’re seeing that that’s all disappearing now. And all of these patients who were previously getting these medications no longer have access to them. They’ve had great success, like Kim and Larry, and really remarkable results, and all of a sudden it’s being taken away. And so how we handle that, this is going to be a real difficult three to six months for a lot of people as we adjust that. But there’s things that you can do and the best thing that you can do is know exactly what the criteria are, know exactly what your medical policy is. Now, if you have zero signs whatsoever of diabetes, you might be out of luck here and you might be either looking at the coverage for obesity Wegovy or or Zep bound. Or you might be looking into the self-pay market, either through Canada or Zep bound has a pretty reasonable coupon still 550 bucks a month. And there’s some things you can do to extend dosing and adjust things so that that price comes down a little bit. But if you have even borderline diabetes, know what your policy says, call the insurance company, get a copy of it in writing. This is a legal argument and if your insurance company requires a hemoglobin A1C of greater than six, you need to have something greater than six. And if you can find some blood work from six months ago, a year ago, you can make an argument that hey, it was high, but now I’m treated for diabetes, so you can’t just deny me treatment, because this is an active treatment. And so understanding what the rules are and putting together an argument that is going to play to those rules is your best bet to overcome some of these denials.
Zoe:
I think that’s going to be really helpful for a lot of people to hear, because so many people are in this boat right now of coverage change, so thanks for explaining that a bit more for our listeners and for me, because I learned a lot as well. So now we’re moving on to our patient and subscriber/f ollower submitted questions. We’ve got our wonderful Sierra here to read our questions, so let’s get them going.
Sierra:
Okay, perfect. First question is from YouTube, from our podcast episode three, and this is from Cindy. Hmm, now I’m wondering if I should have the Roux-en-Y I’m planning for in February. I made the decision to move forward with surgery based on your “should. I have weight loss surgery video. It was incredibly useful. I fit the criteria 100%. I want to lose about 160 pounds. I’ve lost 26 pounds in four months with weight watchers tracking and pound of cure eating, but the weight loss is slowing dramatically. We gov has not been available to me and I’m not diabetic, so, Ozempic was denied. I want to lose all of the weight for life, so I need a video on how to decide between surgery and the new meds coming. Surgery versus Mounjaro, Retatrutide, fiber.
Dr. Weiner:
Okay, so. So we do have a video that kind of addresses that. And I think the way that I approach this is again, our pyramid, and I’ve talked about this multiple times. The base of the pyramid is nutrition. That’s where Zoe comes in. She’s done great right! 26 pounds! That’s great, yeah. I mean four months, yeah. So, so clearly she’s kind of satisfied the base. The next level up is medications, and that’s where we move next. Now she said okay, I, I can’t get coverage for Ozempic, we gov is not available. So the question is, is We govy not available because it’s on shortage, but otherwise she has coverage? In which case I’d say well, wait a couple months, Zep bound will be covered, we gov will come off shortage and you’ll be able to get access to the medications. If you’re really eager to kind of move along, maybe self paying for a few months there may be, there’s some ways that you can do that, so it’s not necessarily going to break the bank. It’s still expensive but it might not totally break. It’s not going to be thousands and thousands of dollars. So if you have the financial means and you can self pay for a few months to bridge the gap, to just kind of keep things moving along while we wait for we gov to become to come off shortage or for Zep bound to come on your formulary. Then going that pathway and trying the meds and seeing how they they work is important. And the reason that that’s so important is because that not only tells you, hey, should I have the meds? But also which surgery should I choose. Cause we’ve talked about the sleeve versus the bypass. The downside of the sleeve is, of course, weight regain. And this is counteracted by, of course, the meds. And so it’s sleeve plus meds. Now, if you start the meds and they don’t work, you don’t like them, they’re way too expensive, then if you go down the pathway of a sleeve, you’re essentially signing yourself up for medication. Now it might kind of kick the can down the road a couple of years when things are more, when the medication is more affordable, but that’s a prediction. We’re predicting that these meds are going to be more affordable in a few years. That’s to be honest with you, even though I do think that’s going to happen. It’s goes in the face of what’s happening to pharmaceutical costs. Right? Anybody’s drugs cheaper now than they used to be. I mean, I remember sometimes you go and it was like two dollars was your pay right? Remember that? Yeah, so I’m saying that without assumption and I do think there’s some reasons why that will be true. There’s going to be increased competition in the market and there’s such demand for this. It’s a much more demand driven economic curve than pharmaceuticals, other pharmaceuticals, which is like someone told me, so I have to take them. Yeah, so we’ll see some demand and some choice in the market and that hopefully will bring down the cost. But again, you need to know if medications are going to work for you, and if you’re going to enjoy being on them, and if you’re willing to be on them for decades and decades if not life. Because if you’re not, then a sleeve may not be your best option and you should consider a gastric bypass. So we do have that, probably in a couple of different videos. We have that content. Now you have an explanation here. So I think again, if I was you right now, I’d figure out how to get on the meds whether it’s through the self- pay or some other options to see what that’s going to be like for you, to see if you’re comfortable. You heard from Larry and Kim how much they like being on those medications. How helpful they were. Their greatest concern right now is having to stop them. And so, if that’s how you feel with the meds, the meds may be may do enough for you. You might lose enough. Or you might be very comfortable having the less invasive option, the sleeve and being on the meds. If you don’t like the meds, if they’re too expensive, then a gastric bypass is going to be a better option.
Sierra:
Okay. Next question is from Rafael from our website. Hi, is it a good idea to do low intensity exercises some days of the week and high intensity on the other days?
Zoe:
I think that sounds like a great idea. If you do every single day, high intensity, that’s not your body is not going to be very happy with you. But you know your cortisol is going to be just so high all the time without that opportunity to be brought back down. And so there’s absolutely a place for low intensity exercise as well as the high intensity exercise, given, you know, tolerance and if you’re able to. Right? I would not recommend trying to do high intensity every single day. So doing it a couple of times a week, sprinkled in with your low intensity days, sounds great. Getting those movements sprinkles and, you know, combining your strength training along with the cardiovascular is a really great approach to helping support your weight loss goals, improving your health, musculature all that great stuff.
Dr. Weiner:
Yeah, what about you know the same type of high-intensity exercise, or different types of high-intensity exercise. Like, should you, let’s say I mean, let’s say, you do CrossFit one day a week or something similar that intensity. Should it be the same exercise all the time, or should you maybe find another high-intensity exercise on another day?
Zoe:
That’s a good question. I think my answer to that really depends on what their goals are right. So if somebody’s goal is to increase their speed. Right, okay. I want to get really fast at running. Then doing two high-intensity days, maybe that looks like sprinting intervals, sure, then yeah, I’m doing the same type of exercise.
Dr. Weiner:
That you want to get better at, yeah, practicing what you want to get better at.
Zoe:
I don’t even know the exercises in CrossFit because I just it like makes me.
Dr. Weiner:
They do the heavy, the you know the.
Zoe:
Olympic lifting the clean and jerk, If you want to get really good at doing that fast and heavy, then you probably want to be doing that more often. But if the goal is to have some variety so you don’t get bored. So you have that enjoyment. And maybe it is just to have that variety and lose weight and, you know, kind of get a nice mixture of different forms of exercise to create a more functional style of training that your body’s just good at doing life, then maybe mixing it up. But if you have a specific goal, whether it’s an increase of strength, increase of speed, increase of power, then doing the same sorts of movements is definitely the better idea.
Dr. Weiner:
Interesting, yeah. So so train for what you want to get good at. If you want to get good at just general fitness? Make it, make it a variety of different exercises. But if there’s one thing that you’re training for, then do that over and over again. That makes a lot of sense.
Sierra:
Okay. Next question is from Lisa from the website. Is there any way to fix a hiatal hernia other than surgery? If not, what are the pros and cons? When do I know the time is right to fix it?
Dr. Weiner:
So a hiatal hernia and I’ve got a video on Heartburn After a Sleeve, where I think we talk and have some drawings of what a hiatal hernia is. But our body has, we have our torso or our chest or our thorax, and then we have our abdomen. And our abdominal organs are supposed to stay in our abdomen and our lungs and heart are supposed to be in our chest. And there’s a muscle, a thin muscular layer called the diaphragm and it really spans the entire extent of our body and this goes up and down and this is what helps us breathe. Now there’s a little hole. There’s a couple of different holes for us because organs pass from the chest to the abdomen, but one of those is the esophagus. So the esophagus comes through the hole and then the stomach is in the abdomen. So you remember some basic anatomy the esophagus is in the chest and the stomach is in the abdomen and it passes through a hole in the diaphragm. Now that hole can stretch out over time and especially if you’re overweight, but all of us have relatively higher intraabdominal pressure, and it can push that stomach up into the chest and that’s called a hiatal hernia. And what happens is the valve between the esophagus and the stomach should normally sit inside the abdomen. So the pressure is very different. When we breathe in, we create this negative pressure and opens up everything and that’s why air rushes in. And so when the valve is in the abdomen the pressure doesn’t fluctuate that much with breathing. But when the valve shifts up with a hiatal hernia into the chest, every time you breathe in that negative pressure opens the valve and allows the acid to reach up into the esophagus and it causes gastroesophageal reflux disease or the symptom of heartburn. Now it’s really important because a hiatal hernia can cause some serious problems. It tends to be in much older people. Actually, I’ve got one on the schedule for Thursday where someone’s stomach is completely flipped up into the chest and it’s turned on itself and is now blocked. And that’s called a periesophageal hernia and there’s a run on them in Tucson because I just repaired another gigantic one two weeks ago, no last week. So this is a surgery I do with some frequency. And when it’s severe you can’t eat or drink because the stomach is essentially blocked and it’s to some degree an emergency. This is a hospitalized thing, like you’re in the hospital for this. But most people who have a hiatal hernia, and they’re super, super common, and obese people about two thirds of obese people have some form of hiatal hernia. We don’t really care about this dramatic thing where the stomach is flipped, because that’s not what we’re seeing. For the overwhelming majority, and I think in this situation, we’re just seeing that there’s a little bit of an opening and it’s sliding up and it’s causing acid reflux. So you don’t necessarily treat the hiatal hernia itself. It’s not like if I do a CAT scan and I say, oh, here’s the hiatal hernia, this needs to be repaired. You don’t need to repair a hiatal hernia. You need to repair it when it’s causing significant symptoms. Your food is getting stuck and hanging in your chest and you’re vomiting or having extreme pain, or it’s limiting your ability to eat. You’re having severe acid reflux, you’re sitting propped up on pillows. At that point it’s time to fix it. Now I’m assuming this person has had a gastric sleeve and because that’s typically the scenario where people are contemplating a hiatal hernia repair as an elective procedure there’s some other scenarios too, but because we’re obesity channel, I’m going to guess that this is someone who’s had a sleeve gastrectomy. And so fixing a hiatal hernia for the treatment of esophageal reflux or heartburn after a sleeve is moderately successful. I’ll do it. There’s a few times when it makes sense. I think it probably makes more sense for food getting stuck or the symptom of dysphagia than it does for acid reflux. But fixing a hiatal hernia alone is often either not effective or not durable.
Zoe:
Like a bandaid kind of.
Dr. Weiner:
A bandaid. You’re kind of kicking the can down the road a little bit. And so I think really what should happen here is that this person should seek out a bariatric surgeon. Someone who does foregut surgery as well as bariatric surgery, and almost all bariatric surgeons will do hiatal hernia repairs. It’s kind of the same turf. It’s certainly something that we have expertise in and experience in. Seeking out someone with that experience and getting some opinion. You need to do an endoscopy. You may need to do a CAT scan or an upper GI. Getting a good sense of the hiatal hernia, looking at what symptoms you want to improve and then getting an honest answer about whether a hiatal hernia is going to relieve those symptoms. So symptoms should really drive this decision; not the size of the hernia, but whether food’s getting stuck or whether you’re having significant heartburn. And then, honestly this is where someone with some experience in repairing them comes in who’s going to give you an honest answer about whether it’s going to help. In general if you have severe esophageal reflux or heartburn, I’m going to favor revision to a gastric bypass as a durable answer as opposed to a hiatal hernia repair. So, again, I think meeting with someone who has experience is going to be helpful in this case.
Sierra:
Okay. Last question. This one is from Amanda, from our YouTube video on avoiding added sugars and artificial sweeteners. I had a bypass. Is Stevia okay? It helped my sugar addiction.
Zoe:
That’s great. If we can decrease the added sugar, I think that’s great. I kind of view it as a spectrum. Right? We’ve got not having any added sugar and no artificial sweeteners or zero calories. That’s the dream. Let’s call it right over here, fruit being that highest level of sweetness in your diet, that’s ideal. That’s kind of like what we’re working towards Over here. We’ve got, I’m gonna envision she’s using this in her coffee. Let’s say, okay, coffee with sugar or an added sugar coffee creamer. And then maybe in the middle we have coffee with unsweetened almond milk and some Stevia. So is this better than this? Yes. Is not putting any, maybe putting vanilla extract and unsweetened almond milk in your coffee better than the Stevia? Yes, but something I work a lot with patients on, are those swaps. Are moving on that spectrum. And so if adding Stevia to her diet has helped her decrease her added sugar intake and doesn’t increase her sugar cravings which we do see in people, Sure, then I think it’s great.
Dr. Weiner:
Yeah.
Zoe:
And I use Stevia and I think personally, out of all of the non-nutritive sweeteners or zero calorie sweeteners, I do prefer Stevia, just because it’s still a white powder, it’s still processed.
Dr. Weiner:
Totally.
Zoe:
Okay, so it’s. However, on that spectrum, do I favor Stevia over Splenda?
Dr. Weiner:
yeah, I think the only reason Stevia is better than the others, is it’s less sweet. So with the non-nutritive sweetener, which means it tastes sweet but it has no calories, that, in essence, is the problem. Because our body’s gonna respond to the sweet taste and not get the carbohydrates that normally follow. And the taste buds are there for a reason. They play a role in digestion. So when you eat something sweet it says hey, guess what carbohydrate is coming down the pike.
Zoe:
Pump out some insulin.
Dr. Weiner:
Pump out some insulin, prepare for digestion. But when no carbohydrate comes, it disrupts this mechanism. And in general, our body’s gonna shift toward fat storage. And that’s why artificial sweeteners are associated with obesity and weight gain. And so it doesn’t matter whether it’s Stevia whether it’s Aspartame whether it’s sucralose, they’re all the same in essence, where there’s a sweet taste and no calories.
Zoe:
I like to view it I explain it, as the boy who cried wolf.
Dr. Weiner:
Yeah, absolutely, that’s exactly what it is. And so Stevia is less sweet than the other sweeteners and so it triggers less of a change. And so, I think, for that reason, it is preferred, but it doesn’t make it okay. But I think your thought about this on a spectrum and moving toward less sweetener, more toward fruit, is really that’s the dream. But not everybody’s there, and I think it’s important just to kind of make those steps moving along.
Zoe:
Yeah, and I also think that for anybody listening, meeting yourself where you’re at and what is that one swap or that one degree in the right direction that you can make, that makes this feel a little bit more manageable. Yeah, do we have our dream scenario, our gold standard? Absolutely, but if meeting yourself where you’re at is, I put a quarter cup of coffee mate in the coffee every day, if we can make that to the almond milk and the Stevia, that’s a great shift in the right direction.
Dr. Weiner:
Yeah, absolutely All right. Well, I think that wraps up our show, so tell people a little bit about where they can find us on social media and contact us with any future questions.
Zoe:
Yeah, definitely so any of your favorite social media platforms: Instagram, tiktok, facebook. We’re at “a pound of cure and also find us over on our website, poundofcureweightloss. com. If you want to learn more about scheduling an appointment, even submitting a question for our podcast, you can join the nutrition program over there. So definitely check us out and we’ll see you in the next one.
Dr. Weiner:
Yep, see you next time.
