This episode reveals the truth behind the costs of GLP-1 medications and the likelihood of accessibility getting worse before it gets better. But don’t despair, we discuss alternatives like nutritional strategies that mimic GLP-1 hormones. We will dig deeper into deciding between a sleeve revision or using GLP-1 medications. We also shed light on the role of these medications in our Pound to Cure program and how iced coffee can fit perfectly into the plan.
A triumphant patient’s story proves that the Pound of Cure approach to eating can cause significant weight loss even when you can’t find Wegovy. As your hosts, we tackle your concerns about maintaining muscle mass and adequate protein in your diet while on medications. We share practical tips about spreading out meals, prioritizing whole foods, and responding to a listener’s query about protein intake.
A healthier lifestyle includes small but significant changes. We discuss the merits of mindful eating and listening to your body’s hunger signals. We talk about hiatal hernia’s and the possibility of recurrence after a sleeve gastrectomy. We provide in-depth information about the SADI procedure, and answer the question, “Is unintentional rapid weight loss a good thing?”
Transcript
Zoe:
I’m Zoe registered dietitian.
Dr. Weiner`:
And I’m Matt Weiner, bariatric surgeon, non-surgical weight loss specialist, and this is episode three of our podcast. We are rolling with this and I’m having a great time planning the episodes and working together with our whole team. We have a new addition here. We have Sierra, our office manager. Say hi, sierra, hi everyone. So I think it’s only fitting that we have Sierra behind the scenes here, because she pretty much is behind the scenes in everything that happens in our office. She really runs the show here, and so when we pick up the phone, when you call which doesn’t happen at every doctor’s office and we run your prior authorization in a timely fashion for your medications, this is all because of the things that Sierra is doing behind the scenes training our employees and making sure that everything runs really smoothly.
Zoe:
Insert Beyonce, irreplaceable here All right.
Dr. Weiner`:
So we have a great show. We’re going to cover a lot of topics. We’re going to address the cost of GLP-1 medications. That’s a really hot topic. I think we’re going to hear a lot more about that. I have some very interesting information and a really fascinating news article. We’re going to talk about a nutritional strategy to mimic GLP-1 hormones. We have a patient who followed rule number one of the Pound to Cure program but not eat a pound of vegetables a day. It’s kind of a hidden rule number one that I’ve established over the years how to eat enough protein on GLP-1 medications. A decision about whether to have a sleeve revision or use GLP-1 medications. How to enjoy your iced coffee on the Pound to Cure program. Hyaluronias, which bring up a lot of questions in our practice Eating frequency, and alcohol and tobacco after surgery.
Zoe:
Lots of great stuff in this episode.
Dr. Weiner`:
All right, so let’s get right into the show and talk about our first news article from the New York Times, and the title of the article is Osempic and we Govee Don’t Cost what you Think they Do.
Zoe:
What they want you to think they do.
Dr. Weiner`:
So this is something that we face every single day. In the office we see tons of patients. Everybody wants to be on these medications. They’re hard to find and they’re ridiculously expensive and a lot of insurances aren’t covering. So the cost of anything in healthcare is like impossible to figure out, right? I think everybody understands that and that’s one of the things that is totally broken about our healthcare system. Without transparent costs, you can’t reduce the cost. So in this article they talk about what the cost is paid by the insurance companies to the pharmacies for the medication. Now if you were to self-pay for these medications, the list prices, I think, around $1,500 a month. Now nobody actually pays that. Most people will use a good Rx coupon which will bring the price down to $1,000 to $1,200 a month. Still a ridiculous amount of money that is outside of the overwhelming majority of our patients budget. So what does the insurance company pay the pharmacy? Well, in this article they talk about $700 for four weeks of WeGoVy. It’s $300 for weeks of Osempic and $215 for four weeks of Monjaro. Now there have been some manufacturer coupons. They’re still available for WeGoVy. They’re no longer available for Monjaro or they’re very limited. We’re having a hard time having our patients get access to these coupons, but this is a markedly reduced price. But if you dig through this article further and you start following the money, we find that there’s actually a lot more to the story. So where does that extra let’s say, osempic’s $300, yougopaycash it’s $1,000, or your insurance company is paying a significant amount of money. Where’s that money going to? It’s going to the insurance companies, it’s going to the pharmacy benefit managers and, of course, it’s going to the farm industry. How much do you think, zoe, these medications cost a manufacturer?
Zoe:
Oh gosh, I don’t even know.
Dr. Weiner`:
You don’t want to know, I don’t want to know. I know About $20 a month. Oh my gosh. Yeah, so we’re taking a medication Now. There’s patenting in all of those things, and I won’t go into my thoughts about drug patents and how they actually decrease access to important medications, rather than they were put in place to make sure that pharma companies have the incentive to develop these medications. But the truth is, these patents probably reduce access to these new medications, and that’s a big part of what we’re seeing right now, and this is going to be incredibly complicated and will probably be studied by anybody who studies healthcare economics in the future as a really interesting story of healthcare economics. But we’re dealing with a $20 a month drug that sells for $1,000 a month, but it’s paid somewhere between $200 to $700 by the insurance companies, and so I think this really brings up this disparity in access to these medications. I don’t think we’re doing a really good job. We’re seeing all of these gray markets, if you will pop up, for these compounded medications, which can potentially introduce safety risks. I don’t like what’s happening in the pharma industry right now and how it’s reducing access to these medications for our patients, and I think we’re just a small operation, but we’re going to do whatever we can to at least shed light on this topic and to help our patients get access to these medications at a price that they can afford, because I think, once we figure this all out, these medications are going to be affordable for everybody and, in all honesty, like we said last time, we’re going to see a significant reduction in the rate of obesity in our country. Once this all gets settled, our thoughts are that it’s going to get worse next year before it gets better, though unfortunately, Well, I mean, it’s kind of like they’ve opened Pandora’s box, right?
Zoe:
We can’t not have access to these medications ever again. I think it’s just going to be this trajectory, like you said, next year getting much more difficult and worse, but eventually, hopefully, knock on wood, right, we have more access and cheaper access and more access to helping more people, like you said, reduce the obesity epidemic in our country.
Dr. Weiner`:
Yeah, yeah, it’s going to be really, really interesting. And then, a couple of years down the road, we’ve got retinotide coming out which is better than any of them. The end of this year we’ve got Monjaro coming out for weight loss and I think everybody, as of 2024, people are going to say, wait, we govie who. I’m going to be taking Monjaro? Because what we’re seeing in our practice is Monjaro is a way better drug, much more effective for weight loss Substantial 20, 30, 40, 50 pounds difference, depending on what your starting weight is. So this is fascinating. We’re going to continue to cover it, probably on a weekly basis, and talk about what we’re seeing in our practice, what you can do so that you can get access to these medications as safely and inexpensively as possible. And it’s really tricky because often those two things start to go against each other and our mission as physicians. Practice is. Safety is first, but I think there’s a way that you can do both, so we’ll be exploring this.
Zoe:
Like we say, do what’s best for the patient.
Dr. Weiner`:
Yeah, absolutely.
Zoe:
All right. Next up we have our nutrition segment and for this week nutrition segment I wanted to bring up an article that actually Dr Weiner just taught my way, so thanks for that. It’s from NPR and it’s actually about utilizing some specific foods to mimic ozempic and wagovi manjaro type hormones, a GLP1 hormones. Does anybody want to guess what that food is? We actually hinted at it last week’s episode when we were discussing fiber. So the reason why fiber can actually increase satisfaction and decrease snacking, like we see with ozempic and the other GLP1 medications, is because of something that we discussed before known as delayed gastric emptying, so slowing down digestion. Think about fiber and you know, if you’re eating a lot of vegetables and fruit and those sorts of things, that takes a while for your body to break down and digest it Like. It’s a lot of work for your digestive system, which is what we want. It’s a good thing. It makes you feel more full and satisfied and less hungry in between meals. So I mean, who doesn’t want research and, you know, scholarly articles to support what we tell our patients on a regular basis? Eat more vegetables and fruit.
Dr. Weiner`:
Yeah, and I think this is great. So you eat more fiber, it triggers a release of GLP1. And you know we’re about to hit 2024. It’s time for us to just kill the calorie. The calorie’s got to die. It’s not a useful measure if you’re looking for weight loss, and I think we’ve known this in bariatric surgery. I’ve been doing bariatric surgery for 15 years and I’ve watched people who’ve struggled with their weight for their entire life all of a sudden lose weight easily and keep it off. And that’s not because of the restrictive component or the malabsorptive component. It’s because of the neurohormonal component. I wrote about this in my first book 12 years ago, so this is certainly not new information. But because bariatric surgery was kind of this kind of fringe space in the medical world, it didn’t quite get out there. But now the GLP1 meds Ozempic, wecovy, monjaro they’re out there. They’re all people are talking about, and I think we’re finally in a position where we can convince people that it’s a hormonal problem and the treatment is hormonal. And so our mission here is that we look at nutrition, we look at GLP1 meds, we look at weight loss surgery pretty much the same way and so this really is evidence of the type of diet that’s going to trigger the neurohormonal shifts the set point, lowering shifts that are going to result in durable, long-term weight loss, as opposed to this kind of starvation diet, which results in almost inevitable weight gain when we focus on calorie intake.
Zoe:
Right, and the way I like to describe the set point to patients is think about it as like that highest weight that your body is trying to push you to get back to. And if you’re doing a very low calorie starvation, just ignoring your hunger cues which I think we talked about this last time your body’s going to win, it’s going to backfire, and so it’s going to keep forcing that set point. And so if we can instead work with your metabolism and your hormones, your hunger cues, to bring down that set point, that’s how you’re able to sustain your new lower weight.
Dr. Weiner`:
Any weight loss attempt that ignores the set point concept is going to fail. It’s going to fail.
Zoe:
You mentioned your book. Tell us a little bit more about where our listeners might be able to get that book.
Dr. Weiner`:
So the book’s on Amazon. It’s called A Pound to Cure. I’ve got a couple of books out there, but I wrote this book 12 years ago and it initially started from my weight loss surgery patients. So I was a fairly new surgeon at that point and I was watching as these people were changing their diets radically and I was kind of a one man show. When I first started I was a dietitian. I wasn’t lucky enough to have a dietitian like I’ve got now and didn’t have nurse practitioners and all of this kind of support staff that we’ve got built into our program now, so I didn’t have that. So I did everything and so it was actually a tremendous opportunity because I got to really talk to my patients, get to know them and I witnessed firsthand what was happening. And they all told me the same thing, which was after surgery their diet shifted. They didn’t like the processed stuff. Greasy food was gross, sweet food was gross. They loved fruit, they loved vegetables and I just kind of listened to their story about what types of foods they enjoyed and I wrote it all down and that kind of became the pound of cure approach and at the same time we saw this was when we started to see all this evidence about set points and the neural hormonal shifts that lower your set point, and that’s why bariatric surgery works so well, and so I kind of put the two together. Hey, it’s the neural hormonal shift that we’re seeing after bariatric surgery that’s causing people to change their food preferences and they’re choosing the diet that’s most likely to drive weight loss, and so that’s where the program came from. And now with GLP One meds, we’re seeing the same neural hormonal shift and we’re seeing in our office that this program, this nutritional program, also works really, really well for GLP One patients. It allows them to eat comfortably and to maximize weight loss. Thanks for the book plug. All right. So the next segment is where we tell a story of a patient who’s in our practice and I don’t know how this comes off on a podcast. But Zoe knows, sierra knows I had times. I speak my mind. I don’t always candy coat things the way maybe probably the you do, and so you know and I choose. This is not how I approach everybody, but anyway, this patient came in. He was 55 years old, 300 pounds. He ate almost 100% process diet. I mean it was fast food for breakfast, fast food for lunch, fast food for dinner and lots of alcohol, not to the point of abuse, but he was just a beer drinking kind of guy, a lot of soda, and he just never really put any effort into eating a better diet. And so he came in and he was really open to everything. It’s like whatever, doc, you know, I just can’t eat this way. He got this blood work and his blood work was terrible. His hemoglobin A1C was through the roof. His cholesterol was terrible, couldn’t fit into his pants anymore. He was like, whatever happens, I’ll do anything. You know surgery, talk to me. Meds, whatever. And he did have coverage for Wee Govey. So we got him a prescription for Wee Govey and but I talked to him because this kind of diet does not work on Wee Govey and you’ll be puking in the bathroom. And this guy did not have the kind of job where his buddies would have been supportive of him puking in the bathroom because he was taking the new designer weight loss drug. So I kind of warned him. So anyway, I talked to him and I try to talk to patients kind of in their own language at times and so please, if you come into my office, I’m not going to say this to you, necessarily, unless it really fits. But I said, listen, you just got to stop eating like an asshole. And he said you know what? You’re right, I do eat like an asshole. And so we kind of talked through and he ended up joining the nutrition program and working with you on this and getting on our metabolic reset diet. So he shows up for his follow-up visit and he lost 22 pounds and I was like man, that wee Gove is good stuff. He goes what are you talking about, doc? I couldn’t get it. It’s on back order. He lost 22 pounds in six weeks just because he stopped eating like an asshole.
Zoe:
World number one.
Dr. Weiner`:
He has actually really following the metabolic reset diet tightly. This was a 180. I was so proud of him and I think this also brings up a really important point. People think like, oh, if I come into the office and they tell Dr Weiner or Zoe that I eat like crap, that they’re going to be unhappy. But I love it, don’t you?
Zoe:
There’s so much room for improvement and we’re also not the food police. We’re here to help you. We’re not going to judge you if you lie to us. They’re not really helping anybody or setting yourself back. So definitely, if you’re on the edge of like gosh, I don’t really want to go because I don’t want to tell them how I’m actually eating. It’s okay, we’re here to help you and to support you through it and we’ll be able to see a lot of great results in not a lot of time. Yeah.
Dr. Weiner`:
Yeah, I think the one thing I can guarantee you is that however you eat, whatever you’re doing, it won’t be the worst that I’ve ever seen or heard of. You know, at this point you’re not going to surprise me with anything. It’s a pretty unusual circumstance where I’m like, oh, I’ve never heard that one before. So anyway, this guy did fantastic. I’m so excited. And he’s really embraced our way of eating. You know, I love that. This approach to eating kind of works for everybody, right, the working man to the kind of professor. It’s a great, it’s an easy to follow approach and if you’re eating a lousy diet and you change to this, you’re going to see great results.
Zoe:
So now we’ve got some questions sent in on our various social media platforms through our website, and because we have the wonderful Sierra here, she is actually going to be the one reading our questions and we’ll we’ll kind of go from there from now on.
Sierra:
Okay, so our first question is from Instagram on our video weight regain after sleeve, and this is from Ichiban, if I’m saying that right. She says thank you for the reassurance. Great video, eight years post-op and experiencing some regain. My concern is how do you get enough protein on the medications? I struggle to get all of my protein without the meds.
Zoe:
That’s a really, really common question. So one of the main things that we discuss in our GLP1 and nutrition support group over with a nutrition program, is a lot about protein. First off, why is protein important? Well, I like to explain it, as protein is what helps to preserve your muscle tissue. So when you’re losing weight, we throw around the phrase weight loss pretty liberally. However, we don’t actually want you to be losing weight from just anywhere. We want the weight that you’re losing to be coming from fat and not from muscle. So that’s why protein is very important, not only after surgery, but also on these medications. So my recommendation, in order to reach your protein goals, whatever that may be, is to try to space it out throughout the day, doing your mini meals. You might not be able to sit down to three square meals a day and get the same volume in because of the volume restriction given the medication. So, by spreading your nutrition out throughout the day, having your little meals, your little mini meals, your little snacks, prioritizing whole food, protein, as well as some fiber and vegetables, fruit, all that good stuff, that is definitely what I recommend. Don’t feel like you have to sit down and eat six. We don’t really want you to be doing this anyway, but sit down and eat six ounces of meat in one sitting, because they are just not going to be able to do that. Now, obviously we do want to be prioritizing whole food protein sources, but the reality is that a lot of people do struggle to reach that protein goal through whole foods alone. So what I recommend is making a smoothie where you can pack in those vegetables and the fruit but maybe you would want to utilize an unflavored way isolate protein powder or whatever kind of protein powder sits best with you, and then that way you can kind of amplify the amount of protein you’re getting. But sometimes sipping on a shake or a smoothie is a little bit better tolerated than sitting down to a meal.
Dr. Weiner`:
You know what’s interesting.
Zoe:
What.
Dr. Weiner`:
If the question was how do I get enough protein after bariatric surgery, you would have given the exact same answer. Yeah yeah, right, totally, and I think that really speaks to the neurohormonal shift that we see with weight loss surgery and with the GLP-1 medications. I think another really interesting point about that is that the diet that causes the most protein loss, the most muscle loss, is a starvation diet, a severe calorie restriction diet, because when you go into calorie restriction mode, your body says I need extra fuel, I got to burn something. And it has two choices it has protein and fat. Well, let’s look at this Fat is your most important source of calories because it’s the most efficient, it’s the most calorie dense. Protein muscle is metabolically active. So if you want to reduce your metabolic rate, guess what? Chew up some of your muscle.
Zoe:
I like to say muscle is more metabolically expensive. Yes, so your body’s trying to save its resources. Got to get rid of the expensive tissue first, yep.
Dr. Weiner`:
Yeah, so I think that’s also important why you need to get enough protein in. And also, my theory is and I don’t think we have the science to support this is that weight loss surgery and GLP-1 meds actually cause less muscle loss than calorie restriction diets.
Zoe:
Hmm.
Dr. Weiner`:
And I think most people think it’s the opposite way. If you’re looking pound for pound weight loss 50 pounds of weight loss from surgery, meds or calorie restriction I think you can see the most muscle loss from calorie restriction.
Zoe:
Hmm, a little aside. You know, if you’re wanting to kind of learn more about the difference in your body composition, because, as we know the scale, it just takes into consideration all of your your body, your, your fat, your muscle, your bones everything in one number. It doesn’t teach you of what your body composition actually is. So you can go to you know a lot of gyms have an in-body scanner or different things like that so you can actually see that difference between how much fat mass versus muscle mass you have. It’s just another measure of progress while you’re on your weight loss journey to see like, okay, am I losing muscle here? Do I need to make any changes nutritionally to preserve that muscle better, and etc.
Dr. Weiner`:
Yeah, I think that’s that’s a great topic for future discussion.
Sierra:
Yeah.
Dr. Weiner`:
All right, see you in our next question.
Sierra:
Okay, so this is also from Instagram. Same video, weight regain after sleeve. And this is from Lisa. Thank you for this. I am in this very position Weight regain after sleeve and I’m starting we go V with the possibility of a revision to bypass. What are your feelings on a revision versus meds only?
Dr. Weiner`:
Yeah, Great question and something we see every day in the office. So this patient’s regained some weight after a sleeve. The truth is, weight regain after a sleeve is extremely common. We’ve got to just get that out there. This is, you know, because otherwise you’re out there suffering in silence and that’s not, that’s not good. And now with the GOP one meds we’ve got some options. So sleeve to bypass for weight loss is a little bit successful. It’s not something that I’m like yeah, this is a great surgery For me. I’m in the patient satisfaction business. You come to me, you’ve got a problem. I’m gonna rearrange your inside somehow Like it. Better work. That’s a lot to do. This is can do it so safely. We’re looking at one, two percent serious complication rates for these surgeries. But nonetheless, surgery is a big deal and you should get a lot out of your surgery and a sleeve to bypass especially if you’ve kind of lost the amount of weight from a sleeve and maybe only regained a few pounds, and then you do a bypass, we’ll see 20, 30 pounds of weight loss off and you get the difference between a sleeve and a bypass. You don’t get to have a bypass all over again because you’ve already had a sleeve, so some of those hormonal shifts have already occurred. You’re only gonna get the incremental difference between them. Now if you’ve regained a lot of weight, you might see more weight loss. So there’s a lot of variability with sleeve to bypass for weight loss. The GLP1 meds, I think, work amazing for weight loss. Now, when a surgeon tells you maybe you should try medications first, Maybe you should try medications first. So if you’re coming into my office, I’m putting you on WeGoV, no questions asked, and at least see where that goes, See how it works for you, Look into the affordability, Look into what the response is and, depending on where you are, you might need both. You might need WeGoV and revision to a bypass. There’s other options too, like the SADI procedure or the duodenal switch. I personally don’t do those procedures, and the reason I don’t do those procedures is because I think they create a few more problems with malnutrition and some longer term issues. My approach to this is I don’t create any disasters. If you come to see me and I’m gonna operate on you, I wanna make sure you get through this okay and I don’t do something to your body that is gonna change your life forever. That’s just kind of my mission statement in life as a surgeon and so the SADI procedure and the duodenal switch. I’ve seen way too many disasters nutritional disasters and partly the patient wasn’t doing everything right. But there’s something about these surgeries that makes you really prone to diarrhea, food intolerance and significant malnutrition. And you might be thinner, but I don’t know that you’re healthier. So I’m personally not a huge fan of those surgeries. I do respect especially the SADI procedure, which is new. Big issue with the SADI procedure is that it’s not covered by most insurance companies, so a lot there to discuss and I hope that was helpful.
Zoe:
Yeah, and I was just gonna say perhaps, if she’s also experiencing GERD, that might kind of tip the scales into what would justify doing a bypass instead. So I think that there are definitely a lot more questions that you would wanna ask if you were to see this patient in office. Absolutely yeah, All right, next question.
Sierra:
Sierra. Okay, so this one is from Facebook. It was a direct message from Diana. I’m determined to find an iced coffee that I enjoy without all of the additives and sugar Anything you would recommend.
Zoe:
Yes, I have many things to recommend. I love this question because I too love an iced coffee. So, first off, I want you to think about the flavors that might trick your brain into thinking you’re having something sweet. Vanilla extract, cinnamon, nutmeg these are all zero added sugar, zero artificial sweetener flavors, but the kind of trigger to your brain oh, I’m drinking something sweet. So I definitely recommend putting that in your iced coffee as well as almond milk. So think about it, of course, unsweetened almond milk. Think about like if you were to be having maybe a cup of coffee and putting some creamer in it before maybe use a couple tablespoons. Almond milk is not the same thickness, you know. It doesn’t have as much oomph to it as maybe creamer, so the proportions are going to be different. So maybe you’ll need to use a half a cup of unsweetened almond milk to kind of get to the same creamy color that you might be after. But here’s my other little trick. So do you have a Nespresso or an espresso maker at all? Yeah, I love my Nespresso, first of all as a game changer, but it comes with a little milk frother. So before I got gifted my Nespresso because my parents didn’t want theirs and I said please don’t give that away, give that to me. I actually bought off of Amazon it was like less than $10, a little stainless steel canister milk manual milk frother. So you’d pour you a little bit of almond milk or whatever in there and then you could froth it up and it adds more volume. It makes it feel a little bit more special. You make yourself your little iced Americano or your iced latte with your flavorings that we already discussed and your frothed up unsweetened almond milk and I think you might enjoy it.
Dr. Weiner`:
That sounds delicious. What about those little ones like the electric ones that kind of vibrate with the coils at the end?
Zoe:
Yeah, yeah, so I have had one of those. It broke pretty quickly, but maybe it’s because I bought a cheap one.
Sierra:
Okay, next question that came from the YouTube video on GERD, and this is what if a hiatal hernia was repaired during the sleeve? Can it come back?
Dr. Weiner`:
So let’s first talk about what a hiatal hernia is. I do cover it in that video. But the way our body is designed is, we’ve got this big, thick muscle and it kind of sits right underneath your ribs and it separates your body into your thorax or your chest and your abdomen, and our abdominal organs are supposed to be in the abdomen and our chest organs are supposed to be in our chest. So your heart and lungs are up above the diaphragm and your stomach and small intestine and large intestine are below. Now what can happen is where the esophagus comes through, because the esophagus is in the chest and then it transitions into the stomach and there’s a little hole in the diaphragm for the esophagus to go through and then the stomach sits in the abdomen. So that hole can stretch over time and I actually just fixed, I just repaired, a pretty big hiatal hernia, honestly, about 45 minutes ago, and that stomach can slide up into the chest and that can disrupt the valve between the stomach and the esophagus. And so what we will do when we perform a sleeve gastrectomy is we’ll pull the stomach back in, we’ll divide some of the attachments and we’ll suture that hole in the diaphragm smaller and that’s a hyal hernia repair. It’s performed probably on a third of all sleeve gastrectomies. We’re much more aggressive doing it on sleeve gastrectomies compared to gastric bypass, because with a sleeve gastrectomy there’s an increased rate of heartburn and hyal hernia repair can help reduce heartburn. So the answer to this question is can it come back? Yes, and it usually does. If you think about it. Now we’ve got this hole and it’s smaller. But guess what? The stomach isn’t this kind of wider shaped organ anymore. It’s a thin tube. So that thin tube can just slide right back up into the chest.
Zoe:
Maybe easier.
Dr. Weiner`:
Easier, easier. So actually, most hyal hernias after a sleeve gastrectomy come back and that’s why in some of the videos I put out recently we talked about how hyal hernia repair after sleeve gastrectomy is probably about 50% effective in reducing heartburn symptoms. So yes, it can come back and it’s actually quite likely to come back. Repairing it again actually has a lower success rate With these surgeries. The more you do it, the harder it gets, the higher the risk is and also the larger the chance of recurrence.
Zoe:
Is there anything like lifestyle factors that somebody can do to reduce their hyal hernia recurrence risk?
Dr. Weiner`:
Weight loss, which, hopefully, is what we see after a sleeve gastrectomy. Yeah, because when you lose weight, the pressure inside your abdominal cavity decreases, and so it’s that pressure. If it’s high pressure, it’s going to push that stomach back up into the chest.
Sierra:
Okay. The next question is from the website. It’s from Kate. She says if I’m not eating grain a modest amount, I get hungry about every two hours. I’m quite active during the day. Are there such time intervals on this diet, such as waiting at least three hours before you eat anything else, or shall I just follow those body hunger signals when I eat? I eat mindfully and I monitor emotional satisfaction and body satisfaction. Emotional satisfaction often comes before body satisfaction, so I consider myself lucky in that regard.
Zoe:
Okay. So if I’m getting the gist of the question, enough is about meal frequency and if there are any specific time intervals we want to be thinking and what stood out to me about your question, kate, was that you mentioned that you’re very active throughout the day. So what I want to speak on about this is how can we time your nutrition around your bouts of activity or your workouts to really not only maximize your energy and your performance during those workouts, but then also post workout to help maximize your recovery and muscle repair and that kind of thing. So I would recommend having some sort of carbohydrate snack, maybe 30 minutes to 60 minutes before, specifically a banana. That’s my favorite go to pre workout snack right, easy, fast energy for that workout and then afterwards, I’d say within about two hours, to have some sort of protein rich snack to help with recovery. It sounds like you’re really good at listening to your body, which I think it probably came with a lot of time and practice and patience, and I think you’re certainly something to somebody to look up to for a lot of our patients and because listening to your body can be really hard, so that’s great. Otherwise, I would say to keep listening to those hunger and satiety signals stop when you feel satisfied and other than that, sounds like you’re doing a pretty good job.
Dr. Weiner`:
Yeah, I think that’s what really struck me about this question is how in touch she already is with her hunger signals, and it really seems to me like she’s doing a great job and probably should just keep doing what she’s doing. And sometimes that’s the question is like am I doing it right? Honestly, Kate, I think you’re probably doing it right.
Sierra:
Yeah. Next question is from YouTube, specifically from the video bypass versus sleeve 2023. And this is from BA Warman. The after surgery you refer in regards to alcohol and smoking, is that forever or just within a year or two?
Dr. Weiner`:
Oh, that’s forever. Yeah, that’s a quick one. Let’s talk about why, though because I think that’s the important thing is like because and I think that’s something we’re really careful about is that and the classic example is like a straw, right? Whatever you do, you could never drink with a straw, and so bariatric surgery patients are like years out and being like I don’t understand what’s going on. I’m not drinking with a straw, I may be eating cheeseburgers on a regular basis, but I’m not using a straw, and so I think we really have to be very careful about the advice we give patients and pick the stuff that’s really important. I make a big deal about alcohol, particularly with my gastric bypass patients, because I unfortunately have seen the adverse effects that alcohol could cause. You change your metabolism of alcohol after surgery. Most patients like it less. That’s great. Alcohol is a major weight gainer, huh.
Zoe:
Yeah.
Dr. Weiner`:
Yeah, so I don’t worry too much about people liking alcohol less after surgery. I worry a ton about the small group about 4% who like alcohol a lot after surgery. My best advice I can give you after a gastric bypass surgery is zero alcohol, and the answer I’m kind of looking for from my patients is okay, no problem. And if you’re like what do you mean? Never, maybe it’s not the right surgery for you. Because you go through this. You drop the diabetes, you fix your blood pressure, you lose 80 pounds, you post your before and afters on Instagram like life is so grand. But behind the scenes you’re an alcoholic and your life is falling apart. You’re losing your job, your marriage is falling apart, you’re not being a proper parent to your child. This wasn’t a good choice for you. The surgery was a huge mistake and it will destroy your life. And so, again, getting back to something I said earlier, I don’t ever want to create a disaster, and so the most common disaster I see after a gastric bypass is not leak in, sepsis and bowel obstruction all the kind of typical complications that we worry about. It’s alcoholism. And for tobacco it’s a little bit different. With tobacco we get ulcers and you become extremely uncomfortable and they can bleed and perforate and essentially, eating feels like every bite of food is gravel. It’s not food, it’s gravel. You lose your enjoyment of food, you become severely anemic, your face looks like you almost have cancer, and these things, if you’re smoking, take months and months and months to heal. It’s not like you quit smoking and they go away two weeks later. It is months and months of healing and a very difficult process, and so tobacco use after a gastric bypass is just a hard. No, vaping is probably a little bit of a softer space. I haven’t seen the same problem. Obviously, there’s a million things wrong with vaping, but again, I try to give my patients accurate advice. Switch from cigarettes to vaping better, better, not my best recommendation, but I’ll take it if I can get it. And so, yeah, those are forever, because you can develop an ulcer at any point in time and you can become an alcoholic at any point in time. So when you make these changes, you’re signing up for permanent lifestyle adjustments.
Zoe:
And I think you’ve said this before that really resonates in terms of the alcoholism. We’re in the business of improving lives, not ruining lives, and that’s one of the cases of it’s just not worth it to ruin your life over. Yeah.
Dr. Weiner`:
I’ve seen that, unfortunately, too many times and I mean it’s really tragic and honestly, I see it in the hospital. That’s where I see it, where I get consulted for a patient with an ulcer or who has malnutrition or liver disease, and they’ve happened to have had a gastric bypass and I can’t tell you how many times I like help them put it together that it was their bypass that triggered their alcoholism. So, leaving that on a somber note, huh, all right. So I think that wraps things up. Episode three in the books In the books. All right, we’re going to keep going with this. I’m into it.
Zoe:
I’m here for it.
Dr. Weiner`:
All right, we will see you next time, as we continue to help you find health and happiness through sustainable weight loss.
