Imagine tipping the scales in favor of weight loss success—our latest episode does just that with a deep dive into the obesity management arena. We discuss the excitement around Zepbound, the new FDA-approved heavyweight in weight loss medications, and consider its potential to outrank Ozempic with fewer side effects. You’ll not only hear about the economics behind obesity but also gain strategies for those paying out-of-pocket for GLP-1 medications. And if that’s not enough, we share a real-life story of a patient’s journey through various bariatric surgeries, and why something as simple as sparkling water could be a game-changer for your nutrition.
Is your diet working in concert with your weight loss medication? We examine the critical role of integrating a nutrient-rich diet with treatments like Zepbound. Get the lowdown on why a balanced plate beats calorie counting any day and how the combination of medication and lifestyle changes can lead to the most significant transformations. Then, we take you through a patient’s story from band to sleeve to gastric bypass, revealing the trials and victories along the way, and punctuate the chapter with a bubbly tip on staying hydrated that will have you rethinking your drink choices.
Lastly, we compare GLP-1 medications + sleeve surgery versus the duodenal switch, responding to burning questions from our listeners about these weight management strategies. Delving into the intriguing world of gut health, we advocate for a more natural approach before resorting to probiotic supplements. Closing the chapter, we navigate the intricacies of GLP-1 medications for both bariatric surgery veterans and newcomers, shedding light on the nuanced treatment journeys of individual patients. Join us as we quench your thirst for knowledge with a robust discussion on the interplay of diet, lifestyle, and medication in the quest for a healthier life.
Transcript
Dr. Weiner:
All right, Zoe, episode five, here we come. Episode five, here we come. We’re recording these actually a couple of weeks ahead, I think. As we get a little further into it we’ll record closer to the date. So this is December 27th that this will drop on. So we’ve got a great show. We got a lot of things that we’re going to cover. We’re going to talk about Zepb ound, which right now is brand new, but six weeks from now, when this drops, it’ll be a little less new. We’re going to talk about the economics of obesity what to do if you’re self-pay for GLP-1 meds. That’s something we face in our practice every day With patient story of band to sleeve to bypass. The trifecta. Is the third time the charm?
Zoe:
Guess, we’ll find out.
Dr. Weiner:
We will. Nutrition tip is sparkling water, and duodenal switch or sleeve gastrectomy plus GLP-1 medications, probiotics for weight loss. The best diet for diabetics, calories after surgery- how much should you have? GLP-1 medications in post-op bariatric patients compared to people who’ve never had surgery and eating and drinking at the same time after weight loss surgery? You’ve never heard of that one before, have you?
Zoe:
No, never.
Dr. Weiner:
Anyway, so a great show. So let’s start off just talking about what’s new in the world of obesity. This is the biggest news that we knew was coming, which is that Zepb ound, which is also known as Mounjaro or Tirzepatide, is now available and FDA approved for weight loss. So we’ve been talking about this for a while. Everybody’s known this was coming, but it finally is. So let’s just quickly review Mounjaro. It is, without question, the best weight loss medication available. Everybody’s talking about Ozempic and We govy. I make a joke that Ozempic is like Napster they were first to the market but nobody uses them anymore. And I think, now that we’ve got Zepb ound available, I think in our practice we’re going to most likely be moving the majority of our patients over to this drug because we see more weight loss. We see 21% total body weight loss and diabetics, versus 9% with Ozempic, and we see 21% total body weight loss in non-diabetics, versus about 15, 16% with Ozempic/ We govy. And then there’s even a recent study that came out – now, this is a little bit of a self-selecting study, but they took people who’d lost 7% of their total body weight from diet alone, which takes a lot of work, and then they put them on Zepb ound and they lost 26% of their total body weight loss. It’s like almost pushing gastric bypass weight loss in that, and so we’re seeing really remarkable weight loss. And I think from a side effect profile, we’re actually seeing less side effects with the Tirzepatide compared to the Ozempic or semaglutide. What do you think about the name Zepb ound?
Zoe:
I don’t know, I think they could have done better.
Dr. Weiner:
I do too. I’d like to make a suggestion. Oh, I’d love to hear your stuff. Yeah, I was thinking about this. Actually, I say I was thinking about this. This is my wife. She’s the clever one in the relationship. I actually asked, what do you think would be a good name? So she came up with Lean In. I think that’s great.
Zoe:
Yeah, how’s it spelled?
Dr. Weiner:
L-E-A-N-I-N, Kind of like Lean In, like you know, take a chance, put yourself out there, but also Lean like thin yeah.
Zoe:
I love it yeah.
Dr. Weiner:
So, I think Eli Lilly, if you’re out there, if it’s not too late, maybe consider switching Zepb ound to Lean In.
Zoe:
I’d love to hear that conversation. Like how did they come up with that name?
Dr. Weiner:
I’m going to drop it in the suggestion box for them. I’m Zepbound for glory. I mean, I don’t know where it comes from, but yeah, they apparently. My guess is they spent a lot of money on this. Maybe you should reach out to my wife next time and see if she’s got any ideas for, you know, the next med that comes out. But anyway, this med is the real deal and I think it’s. You know, until the third generation comes out the triple G agonist come out in about three years this is going to be the dominant medication. There’s a lot of predictions that it’s going to be the best selling medication of all time and I think what we’re seeing in our practice is that there’s going to be a lot of people on these meds and they really sync incredibly well with bariatric surgery and they work the same way. This is a great thing that we’re seeing now and I think it’s going to improve access. Eli Lilly also has, I think, figured out the supply chain a little bit better.
Zoe:
I was going to ask you that what you thought in terms of the shortages on the other medications, what you think with this one now being available.
Dr. Weiner:
We’ve seen a lot less shortages for Mounjaro than we have on Ozempic or Wegovy. Wegovy, forget about it. At some point, somebody in the business world is going to look at Wegovy as the biggest mistake, the most expensive supply chain mistake that’s ever occurred, because everybody wants to be on Wegovy, because that’s what’s out there right now. If you’re getting insurance approved medication for weight loss, it’s Wegovy. Right now that’s your only choice, which is also a Ozempic/ semaglutide, same thing, and they just can’t figure out how to get it out there. And somebody definitely dropped the ball on this one. I don’t know what mistake was made, but I’m pretty certain that something happened, because these medications are just not available and it’s not like I mean there’s a lot of people on it don’t get me wrong, but there’s not as many on it as there are like statins or thyroid medicine. They’re making the delivery on those. Those are never on shortage. So we’re expecting more availability from Mounjaro than we’re seeing from Ozempic, and I think that’s a good thing and I think it’s going to open things up as well, and I think if you’re in our practice and you’re currently taking Wegovy, over the next few months we’ll be looking at what your options are and probably offering to switch you over to Zep bound. Our next segment, I think, is one of the most important ones. It kind of dovetails nicely after our talk about Zep bound and it’s about the economics of obesity. This is a really important component and it’s something that we struggle with, I mean, every single day. If I could, just when I meet with a patient, say, hey, here’s the right medication for you. Everybody would have, you know, crazy weight loss in every single one of our patients. But we fight insurance companies, we have the pharma companies, we have shortages and, quite honestly, there’s a lot of bad behaviors in this whole space. And there’s the whole gray market, compounding drugs, which you know, there’s some things about that that I’m okay with, some things I’m not crazy about, but the economics are really what determine most people’s ability to access this. So we talked in one of our previous episodes about the cost of making these medications like 20, 30 bucks. Well, Zep bound is now available and they do have a coupon on their website where you can get it for 550 bucks a month, which is a lot of money. There are some things you can do to extend that so that that $550 may last longer than a month. It’s something we work very selectively with patients on. It’s also Mounjaro is now available in Canada and they sell it in a vial, which also opens up some opportunity to kind of stretch it. There’s some pros and some cons. This is not something that I think everybody should just jump on. You really have to know what you’re doing. There’s a tiny bit of risk in stretching these medications out. I don’t think they’re life threatening risks, but there are issues with not using the medicine exactly as directed and of course, my official recommendation is to use the medication exactly as directed. It’s what my lawyer would, for sure, want me to say. But I don’t work for the drug companies. I don’t work for the insurance companies. I work for my patients.
Zoe:
It’s always about what’s best for the patients.
Dr. Weiner:
That’s right and that’s one of our core values is doing the right thing for the patient in our practice. So anyway, we’ve got these medications out there. We’re starting to see improved access. I think with these, with some creativity, with some thought, with a practitioner who’s interested in helping you kind of make the most out of your money, we can see people on these meds for $100 to $200 a month, which I think is going to be in a lot of people’s price point for what this offers. I mean, if you don’t have your health, what do you got? Yeah, Right.
Zoe:
And I think also, if it’s the situation of dedicating to making this lifestyle change, that it’s necessary to get the best results when combining with the medication. It’s okay, I’m going to budget for this and I am going to make sure I make the most of that.
Dr. Weiner:
Yeah, again, if you’re putting the money out and we’re always going to be talking about substantial money that’s where the nutrition comes in. Again, zoe, I’m taking Zep bound for the first time. What should I eat?
Zoe:
Well, of course we want protein. Of course we know that. But more importantly than well maybe not more importantly, but protein is important. We know that we want to be getting protein through whole food sources, ideally, but the reality is is that we want the majority of your diet to be still coming from fruits and vegetables, and so I think we probably sound like a broken record. Honestly, it might seem simple, but that is what works and that is how we want to eat, not only to minimize the GI symptoms associated with taking these medications to get the best results, but also to have that transformation within the habits and lifestyle so that you can actually maintain the weight loss.
Dr. Weiner:
Totally, totally. I mean, there’s so much about these meds. You got to understand Number one, all the studies, those numbers I gave you 9%, 16%, 21% those were not just numbers of people who were like, hey, come here, let me give you the drug. No, it was people who also participated in intensive lifestyle counseling. We saw that the people who lost the most weight that 26% lost a lot of weight up front, which means they made a lot of changes in their life before they even took the medication. We also know there’s something called tachyphylaxis, and this also is another way. These medications are very similar to bariatric surgery. Bariatric surgery, those first few months you’re really restricted, you can’t take a lot. That’s when we really push the protein. You’re on at six months a year out from surgery and we switch you over from a protein-based diet to a produce-based diet, and that nutrition is going to be critical to maintain the weight loss, because the medication wears off with time. That’s what tachyphylaxis means. The longer you take it, the less it works, and the higher dose you need or the less effect you get, and that’s where the nutrition is. So we really can’t emphasize enough getting the right dose of these meds is critical, but also the right diet. So our next segment is a patient story. So this is a patient. She came to see our new nurse practitioner, Bether, who’s doing a great job, and she came to her initially because she was like I want to lose some weight and her BMI was 33. And when Bether was going through her history and kind of really digging in, she heard okay, you had a sleeve. She actually had a band about 15 years ago, revised to a sleeve about five years ago, and Bether identified that the patient also had a lot of heartburn and was vomiting frequently and was actually pretty miserable. And we know that one of the number one side effects after a sleeve is heartburn. So she referred her over to me. We had an appointment, we discussed things. I did a pretty thorough workup. I found a good piece – probably a third of her sleeve was up in her chest. Large Hiatal hernia, and she was really having a lot of trouble. She was pretty obstructed. I mean everything she ate just sat there like a rock, and so we ended up taking her to surgery. We fixed this large Hiatal hernia where the stomach was up into the chest, we pulled everything down, closed up the diaphragm around it and then converted to a gastric bypass because otherwise it’s just going to come back. And she’s done exceptionally well the reflex, the difficulty of vomiting, like a light switch gone, woke up from surgery within a few days and really had almost no acid reflux and, to be honest with you, so this patient sounds like she had a band, sleeve, bypass, now.
Zoe:
Third time’s the charm.
Dr. Weiner:
Third time’s the charm. I’ve seen that a lot. Yeah, it’s really unfortunate and I think it’s one of the reasons why we tend to kind of lean a little bit more toward the bypass as the primary surgery, just because of the durability and because less side effects. Less side effects sometimes, you know, over the long run, sometimes less issues as much as it’s a more invasive surgery, sometimes it’s a more comfortable life, and so that’s not to say anything about a sleeve, because I love a sleeve when you combine it with the GLP1 meds. But I think also another important point is that and there’s not a lot of band patients out there, but band to sleeve is not a great surgery. We see a lot of reflux. Having the band in place kind of burns out the stomach so it doesn’t empty or squeeze as well, and also there’s so much scar tissue you can’t make that perfectly smooth sleeve all the time and so you end up with a little bit of a wonky sleeve and that can lead to reflux. So when I see patients and there’s not that many of them out there, because pretty much most band patients have had their band removed at this point there’s not a lot of people putting them in again, which I think is a good thing that I really encourage them to revise to a gastric bypass instead. All right, enough from me, Zoe, let’s talk some nutrition.
Zoe:
All right.
Dr. Weiner:
Yeah, give us a good nutrition tip.
Zoe:
Well, okay. So I got inspired to share this nutrition tip based on our work culture here at our office. So it has to do with sparkling water like LeCroux, Bubbly, all those things. I get the generic brand, it’s fine, but what I love about the sparkling waters is that it’s a little bit of flavor. You can get the lime, the hibiscus I think we have. What is it? The tangerine in there? Here’s the thing there are no artificial sweeteners, there’s no added sugar, it’s not colored, but because it is carbonated, it feels a little bit more special, and so for so many people it actually helps reach your hydration goal because you can get sick of drinking and plain water. You might want something a little bit more special here and there, and so actually utilizing the sparkling waters to aid in your hydration is a really great tip. Also, if you are somebody who is trying to maybe wean off of soda but really like that carbonation, swapping it out for a sparkling water is a really great way to still get that carbonation without all of the artificial ingredients we don’t want from soda. The other thing I wanted to mention about this is that I get a lot of people who’ve had surgery who are under the impression that they can never have the carbonation in sparkling water. And those first couple months after surgery, yes, we don’t want to have the carbonation, because what happens is that carbonation fills up your stomach, you feel full, and so if you’re all filled up on the carbonation, they are less likely to be able to reach their fluid goal and their protein goal. So we don’t want that to happen, but later on down the line, like I just mentioned, it actually does help a lot of patients reach their fluid goal.
Dr. Weiner:
Do they have any of these things with caffeine in them?
Zoe:
Oh yeah, I can’t remember the name. I think it’s maybe AHA.
Dr. Weiner:
Yeah, yeah, yeah, yeah.
Zoe:
I may have had it a handful of times, and that’s another really wonderful way to wean off of soda because you’re drinking Coke or Dr Pepper, I don’t know Mountain Dew. They have caffeine in it and so we can’t just go cold turkey on the caffeine. So kind of going maybe to switch over to that. Caffeinated sparkling water is a good option.
Dr. Weiner:
Yeah, caffeine addiction is real. You know. I’m an addict. Caffeine, it’s real, and I think a lot of people who are addicted to soda are really probably just addicted to caffeine. So that’s a great tip to help them switch. It goes way back to the very beginning with this whole bariatric thing, when everybody thought that weight loss failure or weight regain was from stretching out the pouch. And we now know and they’ve done this with different studies, upper GI’s or Cat Scans where you can measure the size of the pouch people don’t regain weight because they stretch out their pouch. Because, first of all, if that worked, it would also work to just trim the pouch again and we’d see weight loss. But we don’t really see that much weight loss from that procedure. So the idea was that somehow carbonation would stretch this thing out, which, honestly, if you’ve ever seen a stomach, it’s thick. Yeah, but anyway, yeah. So I don’t think there’s anything real to this whole carbonation thing. You’re right, in the immediate post-op period it should be minimized. But anyway, it’s a great tip, all right, so let’s move on to our social media questions. In this section we look through all of our social media channels and we’re on TikTok, facebook, instagram, youtube, and we’re a pound of cure. A pound of cure on all of them, I think, and we look at the questions that are out there, because people ask us these really sometimes comprehensive and depth questions and I’m on my phone, I can’t type that well.
Zoe:
And you want to give a comprehensive, thoughtful answer, and so we want to use this time so that you can get those answers questioned. Haha. Questions answered, those questions answered.
Dr. Weiner:
So if you’re out there and you have some questions for us, please reach out through your favorite social media channel and drop us a question, and there’s a pretty good chance. I think we’re answering a good chunk of the ones that are coming in. So we have our trusty office manager, Sierra. Say hi to everybody, hi, everyone, and Sierra is going to do the honors of reading the questions for us and then we’ll come take turns responding. So go for it, Sierra.
Sierra:
Okay, first question is for Dr Weiner. This is from YouTube weight regain after sleeve. And this question is from Colleen. She says doctor, how do you feel about Duodenal Switch as opposed to sleeve plus GLP-1’s? Wouldn’t those patients be better off with a surgery that is most curated for type 2?
Dr. Weiner:
First of all, this is one of the things I love about what we’re doing here, because this is a really smart question. Like Colleen, you’ve done your research, you’ve really thought about this and I think you have a great understanding of bariatric surgery because, honestly, this is a tough question to answer and it really is, to some degree, a philosophical question. I’ll give you my thought on it, and my thought is that a duodenal switch is a pretty rough surgery. There’s a major change in the way you’re going to interact with food for the rest of your life and there’s a significant complication rate. When I went to medical school, when I graduated from medical school, we stood up at the end and we all took the Hippocratic Oath, and in that they tell you, “first, do no harm. And I found that to be probably the single best piece of advice I’ve ever received as a doctor. And the next time I have a difficult decision to make, I always lean on that information and say, hey, which way am I going to have the least likelihood of causing harm? And so for that reason, I would steer more toward the VSG plus the GLP-1. I also like to really leave my options open with patients Like as soon as you kind of paint yourself into a corner, and that’s one of the reasons I’ve been slow to adopt the SADY procedures, because there are patients who develop reflux after the SADY and if you’ve got reflux and you’ve had a SADY, there’s not any really good options. I mean, every option is a really difficult thing and then the end, a lot of times these patients are going to kind of live with this reflux, which can be really unpleasant for the rest of their life. If you just have a sleeve. You haven’t had the SADI portion and we can convert to a bypass, like our patient story we talked about. It’s gone like a light switch. And so for me, I would start with a sleeve. I’d add the GLP-1s and I’d see where we go from this. And I’d work with the patients, determine what their insurance coverage was and they’re going to get the same cure for their type 2 diabetes. Whether you get the cure from surgery or medication, I don’t know that that matters and we can kind of tailor it. We’ve got new drugs in the pipeline that might work even better than a duodenal switch, and so all of this to me, I’d lean on the sleeve and work with the patient on the GLP-1s rather than a duodenal switch. Now, every patient is different and I think I would certainly talk to that patient and refer them out to a surgeon who does the duodenal switch. I don’t do it because I don’t like to create messes. I like all my patients to go out and live a good life and be better off from the surgery, and I don’t know that every single patient that has a duodenal switch would say that. And I certainly see a number of patients through hospital consults who I’m not sure would meet that criteria. And so my approach, my philosophy, is less surgery, more medications, just because it’s less risk and less harm. If someone was like, “I just never want to be on medications, medications are not for me. I’d rather have more surgery, less medications. That’s our own personal decision, but I think, like Colleen, who may actually be leaning a little bit in that direction, that’s your personal choice. Colleen, I think you’re thinking about this in a really smart way and, if you’re okay with some surgical complications, if that means no medication use, I think you’re thinking about this right.
Sierra:
All right. Next question is for Zoe. This is from Nick on our website. Can taking probiotic pills reduce your set point?
Zoe:
All right, there’s a lot I want to say about this.
Sierra:
Yeah.
Zoe:
First off, probiotics. Probiotics containing food, such as Greek yogurt, fermented foods like kimchi these are really great for your gut microbiome right, the gut microbiome. There’s so much research lately about how impactful this is on your weight, on your mental health, on all of these things. So we do want to be cultivating a very healthy gut microbiome, but probiotic pills wouldn’t necessarily be the way that I would recommend to do it. We want to take a food first approach, using those probiotic rich foods, and the thing is is that most probiotic pills that you buy at the store, online, whatever it’s kind of a waste of money, honestly, because they are not very good quality and you’ll have to look at the CFUs and all of the different strains of bacteria in there and you don’t know how long they’ve been there. Perhaps they are all dead. So, in terms of reducing your set point, utilizing probiotic foods as a part of a well-balanced, plant rich kind of whole food based diet, sure, we can lower your set point, but taking a probiotic pill would not reduce your set point in my opinion.
Dr. Weiner:
Yeah, to save money. Sometimes I like take just a vitamin and I just roll it around the floor and then I take it. It’s probiotic. It gets a little extra bacteria. What do you think about that, zoey? Is that reasonable?
Zoe:
You can do that, I’ll not.
Dr. Weiner:
I don’t really do that, nor do I recommend that. But in all honesty I think some of the probiotic pills out there are really nothing more are no different from doing something like that. There are some good ones out there. They tend to be pretty expensive but honestly I’m not sure how much they help that much lowering your set point. That’s a stretch. We know the microbiome is important for lowering your set point. We know that eating certain foods like a plant rich diet is going to change your microbiome. We know bariatric surgery changes your microbiome. Probably going to figure out pretty soon that GLP1 has changed your microbiome, especially because we see this ileus and this delayed gastric emptying which is going to change the type of bacteria that are going to grow because it changes the environment. But does that mean that the probiotic pills are going to lower your set point? I think there’s too many TT in that chain. The IF the IF, the IF, the IF. Exactly, exactly. All right, sierra, what’s next?
Sierra:
Okay, this question is for Dr Weiner. This is from Jenny on Facebook. Hi doctor, my husband and I both had sleeve surgery almost four years ago and we’re doing great with our weight loss. However, my husband is now 156 pounds. He runs every day three to seven miles on average. Almost no body fat, but his A1C is still high. He doesn’t want to take any meds, so he’s going on a strict no-carb and sugar diet. Any other suggestions to help? He has been told he has coagulated blood thicker than normal. Does this make a difference?
Dr. Weiner:
All right. Let me start with the easy part. No, the hypercoagulable state or the kind of thicker blood or the tendency to form blood clots does not have any influence on his hemoglobin A1C. This is clearly somebody who’s done great with weight loss and also sounds like he has made a lot of the lifestyle changes and is really now a very lean individual, and he runs three to seven miles a day. That’s a lot. The question is, why is his A1C still high? I think that’s a really interesting question. The disease we call diabetes is probably like 10 or 20 different diseases. We can see diabetics who are severely overweight. We can see people who are really overweight and have zero diabetes, have a lower A1C in the low end of normal. We can see really thin people who have really bad diabetes. Of course, there’s type 1 diabetes too. There’s probably a lot going on here with diabetes. Not every form of diabetes is caused by being overweight. It’s very likely he has some metabolic derangement that is not necessarily causing him to gain weight but is disrupting his blood glucose metabolism, causing the diabetes. What kind of diet can you eat? I think I’m definitely going to lean on Zoe a little bit for this. I would definitely put a plug in for a vegan style diet. Looking at the work of Dean Ornish, Jeff Buherman there’s a lot of people out there who’ve put out this great literature that shows that avoiding animal protein, or probably animal fat, is the best way to normalize your blood sugars and lower your hemoglobin A1C, which is contrary to what all the diabetic teaching is, which is low carb, low sugar. That avoids the spikes in your blood sugar, it’s going to avoid the hyperglycemia, it’s going to avoid sending you to the emergency room, but it’s not necessarily going to reverse the underlying process of diabetes. Zoe, what are your thoughts? What are you telling diabetic patients? What are your thoughts on a vegan diet for diabetes?
Zoe:
I agree with that. I think that would be great. My main thing when I am explaining diabetes and what I would recommend patients eat to manage their blood sugars is to make sure that they have the winning snack formula. That’s going to be fiber plus protein. Fiber coming from fruits, vegetables and the protein. If he’s following a vegan diet, that would mean the beans, the nut, that sort of thing. Even if you don’t do vegan, that could mean having some Greek yogurt or whatever kind of protein you want. By having the fiber with the protein, it allows your blood sugars to gradually increase, stay in that normal range a bit easier longer, decrease slower. Then when you eat again, then that helps bring it up again. But I don’t recommend waiting super long in- between meals when that blood sugar goes super low and then create a spike that way. I would recommend and I would not recommend doing a no carb diet. Yeah, because vegetables have carbohydrates. Fruit have carbohydrates. Beans, nuts, all of these extremely nutritious, great whole food and plant-based foods have carbohydrates. In fact, if he’s running that much you need carbohydrates. I would actually recommend to be very intentional about where you’re placing the carbohydrates. Obviously, there are a lot more questions I would want to ask here, but that means having a banana and some peanut butter an hour before the run, Then afterwards having another thing so that your blood sugars are nice and stable throughout the day. You’re not doing all of these crazy dips and spikes, which is therefore also increasing the A1C, in my opinion.
Dr. Weiner:
Yeah, that’s great advice right there. I think another thing about vegan diet is a lot of times when you’re looking at vegan diets which originated from the animal rights movement, a single bite of meat is murder. But when we’re looking at it from a nutritional perspective, a single bite of meat is irrelevant, right? Whether you have one bite of meat a day or zero bites of meat, probably not a big difference nutritionally, and so that gives you some space there. Like you don’t have to be a real vegan. You’re gonna have some meat every now and then, but just less animal protein, less animal fat, more plants, more beans, more nuts, more fruit, more vegetables.
Zoe:
And I think a lot of times, you know, people try to put themselves in a specific box with boundaries, right? If you want to eat vegan most of the time and then, like you said, have a steak here and there, then that’s fine. Or if you want to create your own combination of, you know, plant-based, maybe you have the fish here and there. So you don’t have to just stick with specific definition of a diet or a way of eating just because you feel like you have to. You can make your own rules.
Dr. Weiner:
Yeah, great point. All right, see you in our next question.
Sierra:
This is from Nicole on our website. I’ve watched your videos and have your book, but I was curious. The handout for your bariatric program has a really low calorie requirement, like 600 calories at three months post-op. I’m three months post-op and eat twice that. Your book also has high calorie recipes. I’m just curious what you actually think would be appropriate for calories around three months post-gastric sleeve.
Zoe:
Okay, so here we come back to calories.
Sierra:
Yeah.
Zoe:
So I don’t care if you’re eating twice that, I don’t care if you’re eating triple that. If your diet is made up of whole foods. You’re eating a lot of vegetables. You’re eating a lot of fruit. You’re reaching your protein goals through healthy, whole food protein options. It does not matter how many calories you’re eating. If you are eating mindfully. You’re stopping when you are satisfied. And it’s more so about those habits long- term. If we give you a specific calorie target and we say, okay, yes, you have to eat 600 calories, and then in your mind, that’s what you have to stick to. It’s not about the foods, it’s about the calories. Yeah, so you can eat 600 calories. Maybe you go to In-N-Out and you have a burger and a side of fries and that’s your 600 calories for the day. Guess what? You are not going to be getting the best results from that, you know, honeymoon period. You’re not going to be feeling the best and you are not setting yourself up to actually maintain that weight loss that you may experience. So I want you to release yourself of the stress and the pressure of hitting a certain amount of calories and, more so, thinking about the quality of your food, how you’re eating and if you are honoring your body satiety.
Dr. Weiner:
Yeah, I’d also like to make a point that I don’t think we have anywhere in our bariatric handout 600 calories.
Zoe:
No, I was.
Dr. Weiner:
We don’t say. We almost never use the word calories with patients. Yeah, Okay, Sierra. Next question.
Sierra:
This question is from Laura on Facebook. Do I really have to take GLP1 medications for the rest of my life? Do you find in your practice the effects of the injections differ between patients who already had bariatric surgery versus patients who didn’t? As in do they tend to be more effective, fewer side effects, better metabolized between the two groups of patients, or is there no observable differences? Not enough data.
Dr. Weiner:
So, first of all, we got zero data on this. There’s nothing. At some point I’m going to be able to give you a really data-driven answer. But I do have a ton of experience because we have a huge non-surgical weight loss program and I prescribe these medications left and right and we have a lot of post-op bariatric patients in that. So I think it’s a complicated answer. The first is if you’ve had bariatric surgery and regained weight, I think you respond better to GLP1 medications than someone who’s never had surgery. There’s something about you’ve had that weight loss, the surgery is still there, there’s still some of those metabolic changes and we’re kind of re-harnessing them with these GLP1 meds and we’ve got a little more flexibility in the set point and the weight is going to move better. I think in patients who have had bariatric surgery but have not had a lot of weight regain, I think they might lose a little less because there is going to be some overlap in these pathways between what we see with the bariatric surgery and GLP1. Glp1, we know, is a hormone that is changed after bariatric surgery and so when we give a medication we may be using a little bit of that same pathway and we may actually, because of that overlap, get a little less weight loss, and so I think that’s probably the biggest difference that I see. But the truth is we don’t know, we don’t have the data, and even if I do have the data, I don’t know about you. The only way we’re going to find out how you’re going to do with these medications is to try them. And they’re generally well tolerated. People do pretty well on these things, and so I think if you are post-bariatric surgery and this is something you’re considering I think it’s a great option. And what we’re seeing is that some of the not so great things about bariatric surgery – the weight regains, the difficulties, this end of the honeymoon period that everybody gets to – the GLP1 medications kind of bring that honeymoon period back and give you control over food and your appetite and your weight again, and so I think we use them a lot in our post-bariatric patients, and I think, if you’re considering it, working with someone who’s experienced not necessarily some wellness spa that’s selling you a compounded medication, but a practice that’s done their research, that’s working with you and is going to help you on the nutrition side as well as on the medication side maybe something worth exploring.
Sierra:
And does Laura have to take them the rest of her life?
Dr. Weiner:
Yeah, we do have a video about this, and in general, the majority of patients will require long-term use. What that looks like, I don’t know that we’ve really figured that out. Does that mean you got to take the same dose every week, week in, week out, or does it mean you can go that twice a month? Or I have some patients who get on the scale once a week and if the scale hits a certain number, they take a dose, and so there is going to be some flexibility in there, and while most patients are going to require them long-term I wouldn’t say all patients will, I think, have to be prepared to take them long-term if you’re going into this.
Sierra:
Next question is from Maya on our website. I am seven years out after Roux- en- Y. I just recently started eating and drinking at the same time again. Is that okay? I have been highly successful with very little regain. I’ve been so strict for so long now that I’m feeling guilty but have to live my life. I haven’t touched a sip of carbon soda pop since my surgery, thank you.
Zoe:
All right. So I think we kind of addressed the soda pop part in the earlier. That was worked out perfectly. So here’s the thing At first, eating and drinking at the same time – It’s a similar concept as why we recommend not having the carbonation – because if you’re eating and drinking at the same time, maybe you’re filling up on one and then you’re not able to reach your hydration goal for the rest of the day, for example, or vice versa. And so if you are not experiencing that and you’re able to reach your fluids still and you’re able to eat the foods that you are eating and it’s not really causing an issue in terms of your comfort level and your ability to reach those fluid goals, I don’t have a problem with it. What are your thoughts?
Dr. Weiner:
No, I agree. I think it’s like everything, it’s individualized. There’s some people they eat and drink and it fills them up and they can’t meet their food and protein requirements. The original thought was that the water washes everything through the pouch and, like the pouch is this vessel, and once the vessel fills up, well then you’re full. But we know that’s not how it works. When you eat, the food goes right through. Does drinking at the same time wash it through and reduce the satiety of the food? Some people might say that it does. After bariatric surgery, I certainly had patients tell me that. I think the majority of people don’t. So this really gets back to what you preach every day, which is mindful eating and recognizing how this impacts you. And if it impacts you in a negative way, don’t do it. If it impacts you in a positive way, do it. All right. Another good episodes Zoe.
Zoe:
Yeah, lots of good questions out there. Like Dr Weiner said earlier, if you have a question, definitely shoot it over to us and we might be able to give you a nice in- depth answer.
Dr. Weiner:
Absolutely, and if you want to meet with us well, face to face, over Zoom, please look into our nutrition program. It’s on our website. I’m on there a couple of times a month. Zoe’s on there every day. So anyway, thank you for listening and we hope you have a great week.
