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Have you ever lifted weights and felt a surge of accomplishment that goes beyond physical strength? Uncover the transformative power of weightlifting, not just for your body, but also for your mind. Our 19th episode is a celebration of perseverance, unveiling our Weight Regain program tailored for those who’ve faced setbacks after bariatric surgery. We delve into personalized regimens, group support, and the game-changing use of GLP-1 medications, alongside The Metabolic Reset Diet. Plus, we’re bringing you fascinating insights on how weightlifting can be a powerful ally against mental health struggles like anxiety and depression.

Journey with us as Lori recounts the crucial steps she took on her path to gastric bypass surgery, underscoring the importance of ‘head work’ in achieving health goals. Her narrative is a profound look at the transformative shifts in mindset necessary for long-term wellness. Lori’s story isn’t just about the weight she lost; it’s about the determination and reframed perspective that guided her success. We’ll also navigate through the crucial aspects of sleep hygiene and the economics of obesity, providing actionable advice to enhance your overall health and understand how small changes can lead to significant impacts.

Lastly, we’re examining the evolution of pharmacy services, discussing Lilly’s direct pharmacy model and Amazon’s foray into the industry. What could these mean for patient access to essential medications? Moreover, we address listener questions about gut health post-bariatric surgery, emphasizing the importance of a balanced diet for a thriving microbiome. And for those curious about medication safety, we take a firm stance on the risks and ethics of prescribing compounded medications. Tune in for a comprehensive exploration of health, fitness, and the innovative changes sweeping through pharmacy care.

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Zoe: 0:17

Welcome back. Here we are with another episode. Episode 19, Actually. Gosh, we’re getting up there.


Dr. Weiner: 0:24

We are doing it.


Zoe: 0:25

Proud of us. This is “Zepbound Prime.”


Dr. Weiner: 0:27

Yes, we don’t love the title. We’re going to be honest with you.


Zoe: 0:30

If you have a better idea for the title, comment and let us know.


Dr. Weiner: 0:36

We even asked ChatGPT. It didn’t come up with any good suggestions. But anyway, Zoe, we are about to launch our Weight Regain program, and in the past we’ve really limited our practice to Arizona, but we are opening it up to people from anywhere in the country where both you and I will work personally with the patients. And initially, we’re focusing on people who are struggling with weight gain after bariatric surgery, and you know we’ve talked so much about this on the podcast. Over the last few years, we’ve really developed a couple of unique approaches to prescribing GLP-1 medications, our nutrition support program, and our metabolic reset diet, and we’re putting something together where you can sign up for this and work with us together, individually as well as through the group sessions, to get a personalized plan for addressing your weight gain, prescribe the meds, and help you keep the cost low on those meds as well. We’ve got some ways that we’re able to do that, and we’ll work with you together to help you get this weight off and put you on a better path.


Dr. Weiner: 1:41

We’re really deeply committed to, as we say, no bariatric patient left behind, right? So if you feel like your surgery didn’t get what you wanted out of it and are looking for a plan, we’re putting something like that together. I’m not sure what time we’ll have that in place versus when this is going to launch, but it should be fairly soon, and we’ll certainly make a big announcement and describe it on the podcast once it’s officially live. So we’re excited about that. I think that’s a long time coming. We put a lot of energy into that.


Zoe: 2:10

Absolutely, and I think it’s going to be such a valuable resource for people all over the country, podcast listeners who feel aligned and related to what we’re talking about on the podcast but didn’t feel like maybe there was a place for them to join us. So we’re really excited about that.


Dr. Weiner: 2:22

Absolutely. so this is different. Zoe is doing this in the news segment. So, Zoe, why don’t you talk to us about our news article?


Zoe: 2:29

Yeah, so actually, Dr. Weiner sent this to me. I couldn’t open it originally, but we got a screenshot, and I just thought it was so fascinating. So this comes to us from National Geographic. The title of the article is What Weightlifting Does to Your Body and Mind, and so we talk a lot about the benefits of weightlifting, but specifically on musculature and metabolism, and this article does a beautiful job of digging into all of those physical benefits, including the improvement in type 2 diabetes, cardiovascular disease, weight management, and, of course, high quality sleep, but also the benefits that weight training has on your mind and, in fact, a decrease in anxiety and depression.


Zoe: 2:57

And my thought on this is, and I’m sure so many people can relate to this, that when you’re feeling depressed and you’re feeling anxious, the last thing you want to do is get out of bed or go move your body, and in fact, that can be even more powerful than medications at some points. So, taking that as the sign of almost to, this might not be what feels second nature, but going and moving my body and having that positive cognitive benefit can do so much good for the benefit of mental health.


Dr. Weiner: 3:49

Yeah, there’s something too about just pushing that weight around, like, “I’m angry, I’m anxious, I’m frustrated, I’m depressed, whatever it is, and I’m just going to push away,” and you get those endorphin releases, and I mean, I’ll tell you, my wife has figured this out. Both of us are weightlifters. I think you do it a little more successfully than I do, but we both really enjoy weightlifting. And my wife will say to me, “Listen, Matt, you’re driving me crazy. Go lift some weights and go do something.” You know she has been longing for a while. I recognize how it changes my mood. I’ve recognized it as well, and I know, you know, if I have a stressful job, of course, as a surgeon, there are certainly times when I’m stressed out and frustrated. And you never have that same level of frustration, anger, anxiety, or whatever it is when you walk out of the gym as you did when you walked into the gym. It works every time.


Zoe: 4:41

What is the saying? The only workout you regret is the one you didn’t do. Yeah, but we were actually talking about this today in our emotional eating and stress management support group, and so both of the people who were on there were talking about their main trigger from an emotional eating episode over the weekend derived from stress. So we dug deeper into how we can better manage stress, and both of them, unprompted by me, mentioned that exercise helps them with that, and so I think it’s underrated for a lot of people who it doesn’t feel second nature to but think about how you feel after doing the exercise instead of what it is doing for my weight loss, because that shift is huge.


Dr. Weiner: 5:28

Yeah, and I think the important part of this article too is that weightlifting, especially as you age, may actually be more valuable than cardiovascular exercise. Cardiovascular exercise has gotten attention because the science is out there that regular cardiovascular exercise can reduce your risk of heart attacks. But it actually takes a lot. 75 to 150 minutes a week. 150 minutes of cardiovascular exercise is 30 minutes five times a week. That’s quite a bit, and so we’ve always kind of looked at that as the health benefit. But this article is pointing out that there may actually be more health benefits from weightlifting.


Zoe: 6:04

Right, and also because not only strengthening of the muscles but strengthening of the bones to help prevent injury as aging with falls and that sort of thing as well.


Dr. Weiner: 6:14

So this is a perfect segue into our patient story, Lori, who’s really, really embraced exercise and has been incredibly successful, and she’s got something really big planned for in the works. So let’s hear from Lori. Well, we want to welcome Lori to the show. Lori is one of our gastric bypass patients. She comes to us right now from Montana. Right, Lori? Is that where you’re located?


Lori: 6:37

I am in Montana.


Dr. Weiner: 6:39

Yeah, she came down to Tucson for her surgery, and she’s done really remarkably well. So. I’ll tell you my little thoughts about Lori from the beginning. She kind of came down, and she was like, We’re going to do this surgery; we’re going to do a gastric bypass; I have acid reflux; this is what I want done; and how am I going to do this? How’s this going to work? And it was like she was ready for surgery when she came. Is that accurate? Is that where your head was?


Lori: 7:05

That is accurate. Yes, very much so.


Dr. Weiner: 7:07

So what brought you to that moment? So my sense was that you had done a tremendous amount of research before we met. So what was that research? What brought you to the decision that you finally made, and what got you to that spot?


Lori: 7:22

So I had done a lot of research, and I’d also done a lot of work, like head work, and, of course, been on every diet under the sun. But what really happened is that I started having gastric reflux probably six months before I came to see you, and it was really bad. bad enough that I ended up in the emergency room on Christmas Eve before I came to see you. And so then I had an endoscopy, and when the doctor there in Tucson did it, I said to him, “You know, well, what can make this go away?” And he said, “Well, gastric bypass or lose weight.” And I said, Ah, right.


Lori: 8:04

I don’t sit around eating bonbons; I’ve been working out. I’ve been, you know, trying to lose weight. My body will not release any weight. And so then I said, because I thought about, you know, I’d looked into this before. But I always thought to myself that I wasn’t going to do gastric bypass; it’s just another diet. It wasn’t going to be another diet quick fix for Lori. And so when he told me that, I said, Well, who do you recommend? And he gave me your name. So I said all right. So then I of course checked into this more, and then I came to see you, but at that point I was pretty much thinking I’m going to do this. But when I talked to you, I really thought so.


Dr. Weiner: 8:39

Yeah, so you had really severe acid reflux, and I think that’s one of the things, one of the most important decision-making points I look for with patients, because acid reflux is the Achilles heel of the sleeve gastrectomy, and we see, you know, a number of patients developing severe acid reflux. I think this morning I had a clinic. I think I saw two patients who were in the process of converting from a sleeve to a gastric bypass, and a gastric bypass is, without question, the single best treatment for acid reflux. It’s better than the Nissen fundoplication, which is a standard surgery that is designed to treat acid reflux. A gastric bypass, although it was originally designed as an acid reflux surgery, actually hasn’t been used in that, and if someone walked into my office with just acid reflux and not obesity, no insurance company would allow us to perform that surgery. But it works like a charm. I would assume there is zero acid reflux now.


Lori: 9:34

Zero, and that was one of the things. The other thing I had going on was that I also had non-alcoholic fatty liver disease. I was pre-diabetic, and I was, of course, you know, over 100 pounds overweight. And that was one of the big things. When I met with you, you told me you knew the difference between the sleeve and the gastric bypass, and you said, literally overnight, this would probably go away. And I had a hiatal hernia too, and you repaired that. And literally, it went away, and it never, ever came back.


Dr. Weiner: 10:04

So what was your starting weight, and how much do you weigh now?


Lori: 10:07

Starting weight. I think when I came, my highest weight ever was 302. My starting weight when I came to see you was like 192.


Dr. Weiner: 10:16



Lori: 10:16

Now I’m 183.4.


Dr. Weiner: 10:19

So you’re about 120 pounds from your highest weight. You’re about 120 pounds. From your surgical weight, you’re 110 pounds. How much did we predict for you? 


Lori: 10:32

You predicted right around 90 and 100. And at the time, I thought, if I could lose 90 pounds, hallelujah.


Zoe: 10:36

I want to ask you about the head work. You said you did a lot of head work to get to the place where you were ready for that. So talk us through what that head work was and what that process looks like for you.


Lori: 10:49

Okay, so over the years, I mean, I’ve done various programs, and there’s some other things that are out there, and through some of those programs, there’s some really good material. But really, what it comes down to is that in order to change your actions, you really have to start with changing your mind. And I think the biggest thing was all-or-nothing thinking. As far as you know, if I blow this diet, then I’m, you know, oh, here I go, and I’ll start again on Monday all those old diet mindsets, and so starting to break those down and go “no, it’s not all or nothing,” and it starts with, Let’s just change one thing. And so I started doing that. Or, if I catch myself with this thinking, I’ll never be blank, stop, no, let’s reframe that. And so change that thought and say, you know, this might be difficult, but I can do this to get me to blank. those kinds of thoughts.


Dr. Weiner: 11:45

So talk to us about what you’re planning. You’ve got some really interesting plans coming up.


Lori: 11:49

I do so. My son has always been an athlete. He’s 25, and he’s an ultra-trail runner. He does a hundred-mile race in the mountains, and he does it all over the place. Up here. He did one in Arizona, and he’s that person, and I thought, Wesley, you’re crazy. What are you doing? So he’s crazy enough that he’s convinced me of this.


Lori: 12:14

Last year there was a race that’s in the Bighorn Mountains in Wyoming, and you start out at 7,400 feet, it goes up to 8,100 feet, and there are 18 miles; there’s a 32 mile, a 50 mile, and a hundred mile.


Lori: 12:26

Last year, Wesley did the 50-mile race, and he got third place. So a friend of mine and my trainer, my trainer and a doctor up here, both did the 32-mile race last year, and another friend was with him. And so she said, Lori, I saw the people that were doing this 18-mile race; we could do this. And I said, You’re crazy; no, we can’t. And she said, Yes, we could; we don’t have to run it; we can walk it, and we can do this. So she planted the seed a few months ago, and I said, All right, I will do nothing ever to undo my surgery; never. I mean, this is sacred to me. So I said the only way I will even consider doing this is if Dr. Weiner says I can do it.


Dr. Weiner: 13:05

And I said, Hell yeah,  absolutely.” This is why you had the surgery.


Lori: 13:12

Exactly. And then there’s a limited number of spots for these races, so you have to get up at like five in the morning and hop online to register when registration opens. So Wesley had called me. He’s like, mom, registration is like the next day; are you going to sign up for this race? I said. I got to get a hold of Dr. Weiner; I got to make sure, so then I sent you the message. I said, Can I do this? Your response was absolutely. But do not get hurt. And you said that as long as you train for this and can do at least 12 miles before that race, you can do it and not get hurt again.


Lori: 13:50

So I said okay. So we got on bright and early, and my doctor, my trainer, my friend, and myself all got on boom, and we’re doing the 18-mile race. It is June 14th and 15th, so we’ll be the 15th. The hundred-mile race starts on the 14th, but it’s June 15th.


Zoe: 14:57

Wow, yeah, and actually, Lori, you’re one of our peer leaders, so talk to us about how you’ve been using your peer group as a space for race training accountability.


Lori: 15:11

So really, what we’re doing is a lot, and maybe it’s like a magnet. The people that are coming to this to my group are usually people that want to either get exercising, have never exercised and want to start exercising, or they’re there’s a roadblock to what’s preventing them from doing it again, and so it’s kind of like I should call it the squat club, because sometimes I’ll say, okay, let’s do five squats, give me five squats every day, and I want you to text me when you do it.


Lori: 15:42

And so one gal said okay; she said I could do it. And she said, I don’t know what the block is, but I’ll do it. So she did it, and then the next day it was I’m doing 10. And then, pretty soon, within two weeks, she was doing like 30 squats a day.


Zoe: 15:58

I think she does 40 a day right now. I know exactly who you’re talking about.


Lori: 15:59

And I said, Okay, well, let’s add something else to this. How about doing wall push-ups? Let’s just do five of those every day, or it just depends on where somebody’s at. I encourage people because, after my surgery, within a couple of weeks or a week or so, I was training, but I wasn’t training by any athletic means. My training consisted of a can of vegetables and sitting in a chair like this. You know, doing five of those. It counts, and that’s what I try to do with our group. Every little bit matters, and I tell them, believe me, I am living proof of this, absolutely.


Dr. Weiner: 16:38

If anyone out there is listening and kind of really feeling like, you know, overwhelmed by your obesity, overwhelmed by your body, and overwhelmed by your health, it’s important to know it doesn’t have to be that way. Change is possible, and I think right here, Lori, you’re showing that beautifully, and not only that, but you’re supporting other people who are starting to make those changes. So for anybody out there who is in the process of trying to take on a challenge and run an 18-mile race with 700 vertical feet, I love it. But you do not have to do that to join your group. Let’s be clear: it can be a 5K walk. It can be a one-mile fun run; it can be any.


Zoe: 17:19

It can be five squats a day.


Dr. Weiner: 17:21

It can be five squats a day, absolutely,  and so I think you know so, Lori. You’ve really created this great place for people where they can join and participate in these types of activities and find some accountability and motivation from someone who’s been there and done that, and you know, I really love that you do that. I love that you’ve added that to our program. I think it’s so valuable and so unique. Well, Lori, it’s so great to have you in our practice and in our nutrition program. I think our patients are so lucky to have you and have access to this unique resource, and we love working with you. We look forward to continuing this and seeing your success in June when you conquer that mountain.


Lori: 18:04

Oh, I’m so excited. Yeah, you’ll get that video. I did it. I did it.


Zoe: 18:09

Patients and non-patients. Right, we are welcoming anybody who wants to join the nutrition program and join in on your peer group and see you in there, and we’re just really grateful to have you as a part of our team. And thanks for sharing your story, Lori.


Lori: 18:25

Absolutely, thank you. I say thank you to you guys all the time, absolutely.


Zoe: 18:33

I just love her.


Dr. Weiner: 18:34

Oh, she’s amazing.


Zoe: 18:35

Yeah, and I am so grateful that she is one of our peer leaders.


Dr. Weiner: 18:38

Absolutely. I can’t wait to see her pictures from the top of the mountain.


Zoe: 18:41

Yeah, like a Rocky pose on top of the mountain.


Dr. Weiner: 18:44

So anyway, yeah, it’s so good to have Lori.


Zoe: 18:46

So I want to talk today in our nutrition segment. Although it is a nutrition segment, we know that reaching and maintaining a healthy body weight goes so much deeper than just nutrition. Obviously, that’s what this whole thing is about.


Zoe: 19:02

We need to take a holistic approach. A piece of that puzzle is sleep hygiene. We mentioned how, in the National Geographic news article, weightlifting can help with sleep quality, and I know so many people struggle with sleep and getting enough of it and getting enough quality sleep because of so many factors, like stress, our busy lives, screen time, et cetera. So today I did actually want to share just a few quick tips to improve sleep hygiene. So, as we were talking about, weightlifting is one of them, which is great. Another one actually has to do with limiting screen time. So I know, in theory, we’ve heard it. We know it like I get it.


Zoe: 19:45

But thinking about that blue light. So whether you’re looking at your phone, your iPad, or your TV, that blue light is very activating to your brain. It’s telling your brain we’re in information-gathering mode. It’s time to be activated; we are absorbing, and that makes it really challenging. Maybe your eyes feel tired, so I kind of want to close your eyes after staring at a screen, but your brain is awake, and it can really impact your ability to fall asleep. So limiting screen time, ideally longer, but starting with 30 minutes before bed and replacing that activity with something that cues your brain that it’s time for sleeping. So, whether that’s journaling, reading, meditating, maybe a skincare routine, a warm bath, whatever it is, we need to create routine and consistency to give your body that cue that it’s time to go to sleep. One other tip: I have a ton; I’m not going to spill all the beans right now because I can talk for a long time.


Zoe: 20:44

But the other one is not about what you’re doing before bed. It’s about what you’re doing first thing when you wake up and trying to get natural sunlight as soon as you are able to. Sunlight in your eyes when you’re up or when the sun is up helps to reinforce your body’s natural circadian rhythm. So when the sun goes down, your body naturally starts feeling tired.


Dr. Weiner: 21:07

So should you sleep with your blinds open?


Zoe: 21:10

Well, that’s an interesting question, because ideally we’re sleeping in a cold or cool, dark room, and so maybe in the wintertime having the blinds open is fine. But I don’t know. Even with my blinds closed, it is light in my room as soon as that starts coming up.


Zoe: 21:32

So I’ve gotten a sleep mask, actually. I wake up in the middle of the night to go pee, and if I know the sun is going to be up before I want to wake up, I put on that face mask in the middle of the night and go back to sleep, and it works wonders.


Dr. Weiner: 21:44

So get the natural exposure as soon as you wake, but you don’t necessarily need to wake when it gets light up. Another thing I noticed is that just the other night I was trying to go to sleep, and the amount of light you have in your room and the amount… When you go to sleep, it should ideally be pitch black, super dark, but you’ve got your computer on in the corner, and then your phone is in sleep mode, but not quite, and there’s maybe a little light there, and then you’ve got that little nightlight or thing that your outlet has a little orange switch on it that has a light, and so when you look around your room, there’s still so much light, even as we go to sleep. It really takes a conscientious effort to get that room as dark as possible, but I think it’s important to get the room as dark as you can. Yeah, we could probably have a whole episode on sleep.


Zoe: 22:30

Oh, I’m like, yeah, I want to talk about this. I want to talk about this, but I’m going to stop so we can move on to the economics of obesity.


Dr. Weiner: 22:36

Yeah, all right. So this is where our kind of not-so-great title for the show comes from. It comes from Lilly’s Pharmacy. I’ve kind of talked in the past about Lilly Direct, and I have a lot of issues with a pharma company partnering with a medical group. Even if they’re independent, they are still dependent on referrals, and that telehealth group is growing very rapidly. It’s hard to get an appointment with them. Clearly, they have an influx of patients. That has economic value. And so when you have a pharma company providing economic value in any form, whether it’s a contractual relationship where they’re writing a check or it’s just providing something that helps that company or that practice grow, there’s going to be a conflict of interest. Of course they’ll say there’s not; they’ll do their best, but it’s impossible to eliminate that. And so Lilly Direct has another component, which is a pharmacy component. So they’ve partnered with TruePill and now, most recently, Amazon Pharmacy. Now, this is actually not live on March 19th at the time we’re filming this, but they are going to put this out there where you can go through Lilly, and they actually have a pharmacy and a fax line and everything you can send the prescriptions to, and they’ll either parse it out to Amazon or to this company, Truepill, and they can help you get Zepbound. Now, part of me hates this because I really don’t like the pharma industry working outside of their space. There should be pharmacies and there should be pharma companies, and the two should have to negotiate. There should be some independence, and it adds some checks and balances to the whole system. However, I also have to recognize that for a lot of our patients, this is probably a really good thing, and for me, as much as I have this kind of morality and these moral thoughts about healthcare and how we should be unbiased and independent, I also know we serve our patients in the end. Yeah, the patient comes first, and so if this is good for you, we’re going to do it, and we have sent prescriptions over to Lilly Pharmacy. We really, I think, just sent it over a few days ago, and it won’t go through Amazon yet because it’s live, but it will go through Truepill, so we can use this pharmacy.


Dr. Weiner: 24:46

I think there’s some real advantage to this. The first advantage is that we’re not going to have these coupon issues that we’re seeing. There are pharmacies out there that are losing money every time they fill a prescription for Zepbound with the coupon. And so what’s happening is they’re saying, Well, no, I’m sorry, this coupon doesn’t look right to me, and I get it. Who wants to run a business to lose money? So they’re putting a lot of friction and obstacles in the way, preventing people from cashing in their coupons. And okay, I understand where that’s coming from. We’re not going to see that with this Lilly Direct Pharmacy.


Dr. Weiner: 25:23

I also think they’re going to have better control over the stock. With this direct relationship with the pharma industry, my guess is they’ll have stock, more so than your local drugstore, and so, because of all the shortages that we’re seeing, this may be a place where people can reliably get the medication. Now we haven’t seen a ton of shortages with Zepbound. We are seeing it, of course, with Mounjaro, now that they kind of shifted all their production from Mounjaro to Zepbound. So we are seeing shortages in Mounjaro. But this is really focused on Zepbound, the weight-loss version of the drug. So we are looking at this, and I do think it’s a good thing. I like that Amazon is kind of entering into this because they have a lot of pull.


Dr. Weiner: 26:04

You know, why do we love Amazon? We love it for two reasons: first, they’ve mastered shipping. I mean, it’s crazy; you sometimes order something in the morning, and it’s there at night. And the second thing they’ve mastered is prices, right? When you get something on Amazon, how often do you feel like, man, I really got ripped off by Amazon? You never do. You always feel like, Hey, I got a good price; this is a very fair price for what I got, and so Amazon’s kind of mastered that pricing, and there’s so much space for reducing the price.


Dr. Weiner: 26:37

We’ve talked about the PBM sucking 20% to 30%, adding 20% to 30% of the cost, and adding nothing. Amazon will not tolerate that, and they have the clout and the ability to potentially squeeze some of these people out. They’re also not owned by an insurance company, right? So we’ve got Aetna owning CVS and, of course, Caremark and PBM, and so now we have this kind of big group that has a history of keeping prices low, entering into this space. I think this is a good thing. If anybody out there has received a prescription either from Amazon or through Lilly Direct, let us know how that went and share it with others. If we are not kind of sharing our experiences, I think it’s going to be hard for all of us to navigate this space, and it’s only by, you know, a hundred people trying something that we’re going to figure out what the best path is. I do think this may be a good thing. So let’s move into our questions, and we’ve got Sierra on the line here, and she’s going to talk to us about our user questions.


Lori: 27:46

Alright, the first question is from Anna on YouTube, and it’s on the video Eating After Bariatric Surgery: A Guide to the First Month: Is it common to get SIBO with either of these surgeries?


Dr. Weiner: 27:56

Okay, so SIBO stands for small intestinal bacterial overgrowth. SIBO is a bit of a vague space in medicine. It’s not quite as diagnosable as, say, an ulcer or an internal hernia. The symptoms are vague. It’s kind of this abdominal pain, dyspepsia, nausea, or sometimes diarrhea. It’s these GI symptoms. And so the idea is that when you divide from a straight-line anatomy, which is what we’re all born with, to a Y-shaped anatomy, which is like a Roux-en-Y gastric bypass or a duodenal switch, a SADIE is not a Y-shaped anatomy, but there is still some disruption in the flow of food through the GI tract.


Dr. Weiner: 28:43

That bacteria can overgrow. Our microbiome and our small intestine have bacteria in them. That’s normal. We need that bacteria. But it can overgrow.


Dr. Weiner: 28:52

You can get the wrong type, and the idea is that a course of antibiotics can help reduce that bacteria burden and help reverse some of the symptoms. And over the years, I’ve certainly tried this on a number of patients, with some modest success. I mean, you can’t look at an anecdotal success as proof of the disease or proof of the treatment, because sometimes people have symptoms, and sometimes those symptoms go away. Just because you gave an antibiotic doesn’t mean it was the antibiotic that caused those symptoms to go away. So SIBO is not something I really deal with on a regular basis.


Dr. Weiner: 29:23

But it is out there, and it is something that people are concerned about, and it really is unique to Y-shaped anatomy, which is really a gastric bypass or a duodenal switch. But no, it’s not common; it’s not something I’m dealing with. I think it’s probably overstated, and it’s just a way for us to put a label on these kinds of vague symptoms that may come from poor eating, that may come from dysmotility of the intestine, that could come from bacteria we don’t know. But we’re labeling it. But I think, thankfully, it’s not a major problem that a lot of patients are coming to us seeking treatment for.


Dr. Weiner: 29:58

So, Zoe, talk to us about what foods we can eat.


Zoe: 30:01

Well, I want to talk about it, so if we’re trying to cultivate a healthy and beneficial gut microbiome, we not only need to think about and discuss probiotic foods, but also prebiotic foods. So prebiotic foods are basically the food, the fuel for the bacteria. So probiotic foods are good bacteria for our gut. Prebiotic foods are going to be fiber-rich foods. So you don’t need to go out and buy a prebiotic supplement, as many supplement companies have done because they want to capitalize on it. Go eat fruits and vegetables; okay, that’s all you need to do. And then, for probiotic foods, the healthy, good bacteria to help support a productive gut microbiome are going to be things with active live cultures. Greek yogurt’s a great one for this. You can make kombucha, but only as long as you find one that doesn’t have any added sugar. Kimchi’s good for this sauerkraut. So find those fermented foods that have those active life cultures to give your body those good bacteria to support your gut, to support that microbiome.


Dr. Weiner: 31:08

Yeah, I think when you think about fiber, a good example of fiber is cows. So cows eat tons and tons of grass. We can’t eat grass and survive. So how is it that cows are able to survive on grass and we are not? Well, we have to look at what fiber is.


Dr. Weiner: 31:27

So fiber is just a string of carbohydrate molecules, of sugar molecules, essentially strung end to end to end to end, very much like carbs that we kind of want to avoid, like in pasta and bread. The big difference between fiber and the carbs that we see in pasta and bread, like amylose and amylopectin, is the type of bond. So our enzymes have the ability to cleave certain types of bonds but not others, and so fiber is a string of carbohydrate molecules that we can’t cleave; we can’t cut those bonds, so it essentially passes through us undigested. Cows have those enzymes and can break down that fiber into sugar molecules and then use that sugar for life and survival. Bacteria have those same enzymes, and so they can break down that fiber into carbohydrates and then use it for food as well. And so prebiotics are critical—probably more important than probiotics. The bacteria are there, and they’re going to be there.


Zoe: 32:29

And if you give them the right food, then they can.


Dr. Weiner: 32:33

Then they can grow. Yeah, so I think that’s a great point. So if you feel like you’re struggling with SIBO, maybe try some prebiotic foods. Yeah, great, great question.


Sierra: 32:43

All right. The next question is from Stephanie, from our website: Do you prescribe compounded medications?


Dr. Weiner: 32:50

So no, we do not prescribe compounded medications. So let’s first talk about what compounded medications are. So compounded medications are what you typically see, and it’s often on Facebook or Instagram or some other social media channel or something where it’s like, you know, tirzepatide or semaglutide. They always use a generic term, and they say, Oh, if you purchase from us, and it’s usually at a reduced price, it’s only cash. No insurance is ever going to cover this, and so these medications have a fairly sketchy origin, and so I actually wanted, when this came out, to be like, Let’s figure this out; let’s see what’s the deal with these things. Is this something we could offer?


Dr. Weiner: 33:31

This is the early stages of it; we didn’t really know what we were dealing with, and so I kind of reached out and talked to, actually, one of our patients who had found something on Reddit, and she had found some place, and she gave me the information, and I reached out to them, and, honestly, it was like they were trying to sell me Bitcoin. I mean, it was really very sketchy, like, oh, if you make a payment through Alibaba, then I’ll ship it to you. It got really sketchy really quickly, and that’s where these medications are coming from. They are not being manufactured in the United States. They are not being run through the FDA. There is really very little oversight. Now, is it possible that they’re making good medications? It is possible. It’s also possible that there’s no medication in what you’re buying, and it’s possible that there’s something toxic or dangerous in those medications.


Zoe: 34:20

And you have no way of knowing.


Dr. Weiner: 34:21

You have no way of knowing. And also, you could be getting it from one place, and then all of a sudden you don’t know what’s happening there. They could be like, Hey, listen, we’re out of supplies, we don’t have any of these chemicals, and we need to make the medication anymore. So let’s just ship some saline; let’s just dilute it down. So there’s just zero oversight for this. You’re never going to get compounded medications made in the United States because it’s against the patent. A medication factory is a huge thing. It’s a $100 million thing. If you produce something you’re not allowed to produce, you can get sued and lose your whole factory, and it’s very damaging. Anyway, these medications come from a place we don’t know where they’re from.


Dr. Weiner: 35:04

Patient safety is our number-one goal. I’m a surgeon. Surgeons are just. We are indoctrinated in the safety of the patient from the beginning. If it risks a patient’s life, you have to do everything you can to minimize it, and so compound medications don’t work for us as a practice.


Dr. Weiner: 35:18

There’s also a lot of lawsuits out there from Eli Lilly and from Novo Nordisk, where they’re suing the physician practices who are prescribing them or selling them. So we don’t want to get sued by these billion-dollar pharma companies, so we don’t sell them for that reason as well. And then, I think, you also have to recognize that these medications are so popular that the people selling them are profiting quite significantly from them. When we write a prescription for Zepbound or Wegovy, we don’t get a kickback. That’s against the law. We send it to whatever pharmacy you want, and the payment for that medication is between you and the pharmacy. We have no part of it. We don’t get any medication. So you know that you’re getting the drug that we think is best for you, not the one that we make the most money selling.


Zoe: 36:00

Because at the end of the day, we’re a medical practice, not trying to make as much money as possible.


Dr. Weiner: 36:06

Yes, the Hippocratic Oath: first, do no harm. I have found that advice so helpful with so many difficult decisions in my life, and I think when I look at compounded medications, looking at that statement, it’s just, it doesn’t sink, it doesn’t sink. So what do the kids say? It doesn’t track. It doesn’t track. Kids say that, yeah, and probably adults too, yeah, so it doesn’t track, all right? Our last question, Sierra,.


Sierra: 36:37

Okay, this one is from Raphael, from our website. What do you think about monk fruit sweeteners? Also, is a true lemon water enhancer a good option to add to flavor water?


Zoe: 36:48

Okay, well, I’m going to answer the second part of the question first, because it’s pretty simple and absolutely. There’s only one ingredient in true lemon, which is lemons. It’s dehydrated. I don’t know what part of the lemons they use, but it’s fine. It’s great; it’s shelf stable; keep it in your purse; keep it in your bag; add it to your water. Especially if it helps you drink more water, I love it. So let’s talk about monk fruit sweeteners.


Zoe: 37:09

Monk fruit sweeteners are a class of sweeteners known as non-nutritive sweeteners. So artificial sweeteners are non-nutritive sweeteners. But monk fruit and stevia are not necessarily artificial sweeteners because they are derived from a plant. Monk fruit is derived from a Chinese plant. Stevia is derived from the stevia plant, but what you get is not a plant. You still have a form of processed food. Stevia is a white powder that’s processed, whether it comes from a plant or not. Did I tell you that I actually bought a stevia plant? Yeah, it died, so I never got to use it. But the same thing goes for monk fruits, in moderation, just like anything. It’s not black and white, as we’ve talked about before. And if having a little bit of monk fruit every now and then helps you stay away from sugar, Great. I would recommend trying to reduce your reliance on it as much as possible, but ultimately, it’s a non-nutritive sweetener that is potentially better than the artificial sweeteners. What’s your thought?


Dr. Weiner: 38:12

Yeah, no, I agree. I think if you separate the carbohydrate from the sweet taste, then it kind of causes a lot of what you call the boy who cried wolf, right? And so it just really disrupts our ability to metabolize carbohydrates in a normal fashion. And so, whether it comes from monk fruit, whether it comes from stevia, or whether it comes from sucralose, they’re way more similar than they are different. I do agree that these are a little more natural than sucralose, but I don’t know that that makes a huge difference. I think the important thing is, and you’ve talked about this so many times, that there are a lot of more natural options. There’s the spa water that you talk about slicing up fruit and putting it into the water. There’s herbal tea, and these are, I think, probably in my mind, the ideal ways to flavor water if you don’t want to be drinking plain water. All right, another great episode.


Dr. Weiner: 39:02

Yeah, that wraps us up, 19. Next episode, episode 20.


Zoe: 39:06

It’s going to be a big one.


Dr. Weiner: 39:07



Zoe: 39:08

You better come back and listen. Why don’t you just go ahead and share this podcast if it was interesting to you? If there was somebody in your life that you think would benefit from something we talked about, we would be really grateful for you to share the podcast, spread the word, and know that you’re not alone in this fight for weight loss.


Dr. Weiner: 39:26

Absolutely. All right. We’ll see you next time.

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