
The Pound of Cure Weight Loss Podcast
Hosted by obesity specialist Matthew Weiner, MD and dietitian Zoe Schroeder, RD, The Pound of Cure Weight Loss Podcast provides a comprehensive approach to weight loss. We cover nutrition, the new GLP-1 medications, and Bariatric Surgery in depth and answer tons of questions from our audience every week. Check out our website for video versions of the podcast: www.poundofcureweightloss.com/podcast
The Pound of Cure Weight Loss Podcast
Gut Instincts: Can an Endoscopy Fix Weight Regain After Stopping GLP-1 meds?
Episode 44 of the Pound of Cure Weight Loss podcast offers a deep dive into cutting-edge treatments and strategies for long-term weight management, focusing on GLP-1 medications for weight loss, the emerging technology of duodenal mucosa ablation, and the issue of weight regain after GLP-1 treatment cessation. Hosted by Dr. Matthew Weiner, bariatric surgeon, and Zoe Schroeder, registered dietitian, this episode explores innovative methods to combat weight regain while delivering practical nutritional advice for sustained success.
The episode begins with a light conversation about nutrition, as Zoe highlights how bananas are often unfairly demonized. Dr. Weiner suggests a simple hydration solution—water and a banana—as a healthier alternative to processed electrolyte supplements, setting the tone for the podcast’s emphasis on whole, unprocessed foods.
Weight Regain After GLP-1 Medications
The focus then shifts to the weight regain after GLP-1 medications—a challenge faced by many patients after discontinuing these treatments. Dr. Weiner introduces Revita, a new device that uses duodenal mucosa ablation to help maintain weight loss following the cessation of GLP-1 drugs. Revita recently received FDA breakthrough device designation for its ability to treat patients who experience weight regain after stopping GLP-1 medications for weight loss. Dr. Weiner discusses how this endoscopic device works by ablating (burning) the mucosa in the duodenum, a section of the small intestine, potentially mimicking the effects of gastric bypass surgery. This approach aims to create a bypass-like effect without traditional surgery, helping to address the critical issue of weight regain after GLP-1 medication cessation.
Duodenal Mucosa Ablation - Skepticism and Safety Concerns
While Dr. Weiner expresses some skepticism about the theory behind the duodenal mucosa ablation, he acknowledges the potential of the Revita device, particularly given the high economic burden and ongoing shortages of GLP-1 medications for weight loss. He notes that while the data is promising, safety concerns—such as the risk of perforation and chronic inflammation—must be addressed before widespread adoption of this technology.
In addition to discussing duodenal mucosa ablation and the challenges of weight regain after GLP-1, Dr. Weiner and Zoe offer practical nutritional guidance. They emphasize the importance of long-term dietary changes, including incorporating more whole foods, fruits, and vegetables, especially for patients on GLP-1 medications for weight loss or recovering from weight loss surgery. The podcast underscores that successful weight management requires sustainable habits, from meal planning to making healthier choices amidst busy schedules.
As they wrap up the episode, Dr. Weiner and Zoe reflect on the future of obesity treatment, acknowledging that a combination of GLP-1 medications for weight loss, non-surgical techniques like GLP-1 medications and the duodenal mucosa ablation, and proper nutrition will continue to evolve. While these treatments are not magic solutions, they hold significant promise in tackling the persistent challenge of weight regain after GLP-1 cessation.
Episode 44 provides a valuable perspective on the latest developments in weight management, particularly for those using GLP-1 medications for weight loss or considering alternatives like duodenal mucosa ablation. Dr. Weiner and Zoe's thoughtful discussion offers essential insights for patients navigating the complexities of weight loss surgery, medication, and nutritional strategies for long-term success.
bananas are demonized right Totally. People fear eating bananas.
Dr. Weiner:I think bananas. You know a lot of people are like into this liquid IV and these electrolyte supplements. To me the answer is water plus a banana. Episode 44, zoe.
Zoe:Here we are.
Dr. Weiner:Here we are Gut instincts. Can endoscopy fix weight regain after stopping GLP-1 meds?
Zoe:Well, that'd be good.
Dr. Weiner:I mean this is the million dollar question, right? I mean the number of times I have patients coming in and they're like I want the meds and I'm like, okay, you know, you probably have to take them for the long run. Oh well, I don't want that. So I mean everybody out there wants this situation where they can take the meds, lose the weight and then be done with it. I don't know that we're going to get there.
Zoe:Yeah, I've heard I've had a couple of people come to me and say I want to do it for three months, see how much weight I can get off, and then I'm like, yeah, 90% regain.
Dr. Weiner:That's what the most of the data is showing us.
Zoe:So what do we have for In the News?
Dr. Weiner:So our In the News segment is about where the title comes from, and it's from MSN and it's about this company called Fractal F-A-R-C-T-Y-L. They just got FDA breakthrough device status for something called Revita and it was actually approved for the purpose of weight loss maintenance in patients who have stopped GLP-1 meds.
Zoe:Very specific, must have just been very recently emerging.
Dr. Weiner:You know, I think when they put these things through the FDA, they're always looking for their angle, their new approach. And with the economic burden of GLP-1 meds, the shortage, all of these things, they've kind of to some degree created a little bit of a health crisis, and so when you can solve a health crisis, the barrier for approval of FDA-approved things is going to be substantially lower. We saw this with COVID. When COVID came out, it was like it took absolutely nothing to get any kind of breathing device, ventilator, anything pushed through the FDA, because they were like we could need a million more ventilators that we have if this is going to work. And so they were just like whatever floodgates open, we'll try anything. We'll leave it up to anything that can help meet this need. So the FDA definitely looks at our overall health healthcare system when it's approving things.
Dr. Weiner:So my suspicion is someone very clever kind of saw this as an opening. So it's an endoscopic device. They kind of put you to sleep a little bit and they put a scope through your mouth, pass the scope through the esophagus into the small intestine. And the thing I didn't like about this is they talk about this overgrown mucosa in the duodenum the duodenum or the duodenum, depending on how you want to say it and how fancy you want to be is the very first portion of the small intestine, right after the stomach empties. It goes right into this and it's a very specialized portion. It's where your pancreatic enzymes come in, where your bile comes in, and so they say that there's overgrown mucosa, the lining in that area of the duodenum.
Dr. Weiner:Now I have done 10,000 endoscopies on patients pre and post-op, after surgery, I mean I think anyway, I do a lot of these things. I've seen the duodenal mucosa many, many times and I've seen it in patients suffering from obesity. I've never really noticed any difference between those patients and other patients. You got celiac disease. It looks a little different, you can see, but so I don't know where they're coming from from that. That to me, and on their website they've got pictures of like a thick lining versus a thin lining in a normal person. I think they also targeted type 2 diabetes. They said with diabetes you get this overgrown mucosa. That is a new one to me and I feel like I should know that.
Zoe:I was going to ask if you could visually see a difference, but it sounds like no.
Dr. Weiner:I mean the 5,000 times I've looked at it. I've never noticed that. But maybe I missed something, I don't know. But their data actually isn't terrible. So they showed in type 2 diabetics and we've talked a lot diabetes makes it harder to lose weight. This showed 3.4% total body weight loss. That was maintained and actually increased to 4% at 48 weeks after the treatment. And they didn't do lifestyle intervention. So they're just like I'm going to burn your duodenal mucosa and we're going to see what happens. That's amazing. No diet, yeah, and they lost some weight.
Dr. Weiner:So you know, you always got to wonder about the industry-sponsored studies and these things need to be validated. But that, to me, caught my attention. I thought that was pretty decent and I think you know again, when I'm looking at stuff, I always want to. It always needs to make sense to me. When it's totally random and out there, I always doubt it. Sense to me when it's totally random and out there, I always doubt it. So a gastric bypass bypasses the flow of food through. We bypass the duodenum and so is it possible that by ablating that mucosa it kind of creates that bypass-like effect?
Zoe:Right.
Dr. Weiner:And so you know, this thing is interesting to me, and I think the idea of you know Right, potentially if not eliminate the need to continue to take meds, at least give people hey, you're going to get a six-month holiday and then you'll take them again for a few months, and then that all sounds really interesting and I wonder what we're going to come up with and what treatments will be available for that.
Zoe:Yeah, well, it sounds like you potentially will be learning a new skill while you're already down in there.
Dr. Weiner:We'll see. We'll see. Yeah, I mean I'm not quite ready to sign up for the trial. Here's my concern. I have two concerns. The first is you can perforate, you're burning that mucosa.
Dr. Weiner:It's, you know, the duodenum is thin, it's not a thick structure. The stomach is actually pretty thick and you know, sometimes I'll believe me I make holes in the stomach all day long. Sometimes it's a little tricky, like you got to try, and it's thicker. It takes some time. The duodenum man. It doesn't take much to make a hole in that. It's a much thinner structure.
Dr. Weiner:And so I worry about perforation, and perforation of the duodenum is a big deal, that's not. You know. You can patch it and there's a surgical solution for it, but that's not gonna be a fun month or two for you. And so that to me is like you know, you're going into a very dicey area. The bile duct's there, the portal vein's there, the hepatic artery is there, the pancreatic duct is there. Like that is tiger country when it comes to surgery, and so burning that area over and over again. The second thing I worry about is that this essentially, you know, could create chronic inflammation or a chronic ulcer of the duodenum, and that's a problem, that's a disease state that we treat, and so I think you know we need to know a lot more about this before it comes out. But the data, their initial data, is good and it's an interesting concept and the idea of an endoscopic treatment to prevent, to allow people to stop GLP-1 meds that worked, man, that'd be great.
Zoe:Well, it'll be interesting to see, as we hopefully get more research about it.
Dr. Weiner:Yeah, for sure, all right. So what do we have for our nutrition segment, zoe?
Zoe:All right, well, we're going to for our nutrition segment, zoe. All right, well, we're going to. The reason why we have this nutrition segment is because last week I got my grocery delivery. I actually-.
Dr. Weiner:You love that delivery.
Zoe:Well, it's because I don't have any flipping time to go to the grocery store.
Dr. Weiner:I get it. I get it.
Zoe:So I'm very grateful that that has been a tool that I've been able to not only help patients implement. But I've actually now and I love going to the grocery store.
Dr. Weiner:Yeah, I love it. I really do, I love it.
Zoe:But it's just not something I've been able to make time for recently. So, anyway, I ordered five bananas.
Dr. Weiner:Okay.
Zoe:And I got 15. I got three bunches of five bananas.
Dr. Weiner:Bonus.
Zoe:Yeah, I was like all right, well, we're doing a lot of banana stuff.
Dr. Weiner:We're eating bananas, okay.
Zoe:So anyway, I wanted to.
Dr. Weiner:I thought it would be interesting to talk a little bit about how bananas are demonized, right?
Zoe:Banana people fear eating bananas. I, you know, and I get it. You know there's a there's a lot of sugar in bananas, but it's a natural sugar. So let's first talk about what's the difference between added sugar and natural sugar and I think we've talked about this before but the main pieces of it is natural sugars from whole foods. You're getting a lot of other good nutrition. You're getting fiber. You're getting phytonutrients, vitamins, minerals right. You're getting other ingredients, if you will, that your body has a job for right. Added sugar it's just sugar. Whatever's extra is going to be stored for later, aka fat.
Dr. Weiner:Yeah.
Zoe:So, basically, if you're craving sugar or you're craving desserts, don't completely not have any sugar, maybe lean more towards the natural sugar and, in the case of today, let's talk about ways to use banana.
Dr. Weiner:Perfect, you got 15 of them. You got 10 extra bananas.
Zoe:Right, exactly so. Frozen bananas are always a staple in my freezer. You can pop them into a smoothie.
Dr. Weiner:You peel them first.
Zoe:Yes, I've made the mistake one time of just oh, all these bananas are bad, I'm just going to pop them in the freezer.
Dr. Weiner:Peel doesn't slide off so easily. Oh no, no no, that was a disaster, and then you melt it and it's mush, right, it's so gross. That's a mistake you make once.
Zoe:So frozen bananas can go in smoothies or like a little dessert, like milkshakes with a frozen banana. Right Cocoa bananas, some cocoa powder, some Greek yogurt, almond milk, peanut butter. You got a delicious dessert, but it's also no added sugar. You're getting protein very nutritious. You can make nice cream, one of your favorite things.
Dr. Weiner:One of my favorites.
Zoe:I like slicing the. I shouldn't do that on the table Slicing bananas first putting them on a wax paper lined cookie sheet or parchment paper lined cookie sheet. Little smear of peanut butter, little dusting of cocoa powder. Freeze it so that they individually freeze and then you can store it in a gallon size Ziploc bag. But just one little. It's cold, it's creamy, it's chocolatey, it's very satisfying.
Dr. Weiner:When you freeze a banana, it has a texture of ice cream.
Zoe:Oh it's great yeah. But then also mashed banana can go great in making. You know like, if you're wanting to make some sort of baked good alternative, that is a great way to add sweetness.
Dr. Weiner:Yeah, I've seen that a lot.
Zoe:You swap that out for the sugar and the oil, because you're getting the moisture but you're also getting the sweetness. So, anyway, bananas are great. Don't be afraid of eating bananas.
Dr. Weiner:And if you're given 15 bananas, you're going to be making a lot of banana stuff. Yeah, I think bananas you know a lot of people like into this liquid IV and these electrolyte supplements. To me the answer is water plus a banana. And actually, if you look at tennis players are like you know, tennis players. They don't get like they got to bring their own food. People can't bring them stuff. They don't have a coach there. They can really have very limited like when you're playing tennis you're on your own, you got to, you carry your own bag in, right, you know. And so tennis players are famous for using bananas as a snack and they'll bring in a bunch of bananas through the match and they drink water. They have their electrolyte solutions too. I mean, listen, if you're playing tennis in 90 degree heat for five hours, you can drink electrolyte solutions with sugar. I'll give everybody permission to do that but bananas is really kind of a staple of their nutritional plan for getting through the match.
Zoe:Electrolytes and quick digesting carbohydrates. Exactly.
Dr. Weiner:Exactly. All right, let's move into our economics of obesity segment, and this isn't so much about obesity, but it does impact all of us, I think. And the question I'm going to ask is why is it so hard to find a doctor these days?
Zoe:I don't know, but it sure is.
Dr. Weiner:I mean, it really is difficult yeah wait list super long, the wait list. I mean it's not crazy to call a doctor and be told our next opening is in six months.
Zoe:Right.
Dr. Weiner:Right. So how did we get here? People criticize Canada because oh, the wait list. We got them now too. Yeah, we got major wait lists. We got wait lists for surgeries. We got wait lists to see doctors. You know, I think we've managed in our practice to keep our appointment time relatively short. We can usually get to people within a few weeks. But you know there's a real issue with this. So we see shortages of pulmonologists, psychiatrists, big time.
Zoe:Big time.
Dr. Weiner:ENT. I have a friend who's an ENT. He's booked out for six months Neurosurgeon, primary care doctors. When I moved to Tucson I'm in the medical community it took me three months to get a PCP. So, rheumatology almost impossible to get in with a rheumatologist these days. Endocrinology, obgyn we have pregnant women looking for a doctor. They test positive. They're like oh my God, I'm going to the OB, oh, we can get you in in three months. Isn't there something that's supposed to happen in these next three months? I mean, it's really getting a little bit crazy. The question is why what's caused this change? And I think there's a little bit crazy. The question is why what's caused this change? And I think there's a couple of issues.
Dr. Weiner:I think we've talked a lot about insurance companies. Unitedhealthcare is the ninth largest company in the world, and these insurance companies have needed to continue to grow, to grow profits. If you look at the stock prices of these companies, it's been astronomical. The CEOs bonuses are directly tied to the stock price, and so there is just a huge push for insurance companies to continue to profit. The problem is it's not unlimited. You cannot just keep making more money on health care. There's only a certain amount of health care that needs to be performed. There's a real pressure to reduce costs.
Dr. Weiner:Employers have kind of hit the end point where they can't afford to pay more for health insurance, and so what we've seen is that insurance companies have now worked to try to reduce rates, and we've seen this in our own practice. We have a couple of payers who are offering us, in all honesty, less money than I was paid 10 years ago for the same procedures probably 20 or 30% less. And so, if you look at what's happening in every business, costs are increasing dramatically, and so employee wages are going up, costs of goods are going up, rent is going up, so costs of providing services have gone up, the reimbursement has gone down, and we've kind of hit this tipping point where doctors are less willing to see all these patients and they're starting to opt out of insurance networks, and so, you'll see, you might have Aetna, cigna, united, and you've been like, oh, I've always been able to see whatever doctor I wanted, and we're now starting to see these physicians. If you're booked out for six months and an insurance company offers you a small amount of money, what are you going to say? You're going to say, sorry, I got plenty of patients. I don't need your patients. I can reduce that that actually you're solving a problem now as opposed to causing one, and so I think that the net result here, unfortunately, is that we're going to see that people will have a limited choice in physicians and that your Blue Cross card, your Aetna card, your United card, which is uniformly in the past allowed you to see whatever doctor you wanted, you may not have that option. You may start calling up and finding out oh, we don't take Aetna, we don't take Cigna. I think we'll see it with Aetna and Cigna before we see it with United and Blue Cross, because Aetna and Cigna, I think we'll see it with Aetna and Cigna before we see it with United and Blue Cross, because Aetna and Cigna pay less typically than Blue Cross and United. And so I think this is a real problem because, especially people will have relationships with doctors and they may all of a sudden, out of the blue, get a letter that says hey, sorry, we're not taking your insurance anymore.
Dr. Weiner:And so the question is what can you do in that setting? You know, the first thing you should do is call your insurance company and complain. No question, because if you don't call your insurance company and complain. And if you don't call your HR department and complain and say, hey, listen, I don't know what's going on. We need to put some pressure on our insurance company in order to let them know hey, listen, you have to come up with some more favorable contracts with physicians so that we can have more docs in network. Then the insurance companies will continue to do what they're doing. So there has to be some pressure there.
Dr. Weiner:So that's the first thing. The second thing, especially if it's kind of more of a cognitive specialty, like you just need an offices, you don't need a procedure from them, you don't need a bunch of testing through their office Then you can just reach out to the doctor and get a self-pay price and you may find especially if you're an existing patient, it's very likely you can get a visit with your doctor for under a hundred dollars and with co-pays being sometimes 50 or even 75 bucks, it's not a huge difference and you may even be able to receive some reimbursement back from your insurance company as an out of network payment. So you may actually get some of that money back. And so I think the first thing is just see what you can do. There may be an option to continue to work with that physician out of network thing is just see what you can do. There may be an option to continue to work with that physician out of network.
Dr. Weiner:And especially, you know, most of these doctors aren't doing it out of greed but are really doing it out of survival, out of necessity, out of survival, and so I think you'll find that a lot of doctors will be willing to work with you and come up with something very fair and reasonable. It may be more expensive than you have paid in the past, but certainly not astronomically high. I think that problem will likely work its way out and I think honestly, the more market forces and the more directly people pay for their healthcare, the more we'll see a reduction in healthcare costs. So to me that doesn't seem like a terrible awful thing to come from this. It may actually help put some pressure on insurance companies to maybe lean up a little bit and direct more of their costs to patient care.
Zoe:So, anyway, another good episode, zoe, yes, yes, Very good, and we hope you enjoyed it. If you have any feedback for us on our new podcast style the shortened episodes please let us know.
Dr. Weiner:Please follow us on social media. Reach out to us If you have questions that you'd like to be answered on the podcast. Send them over and we'll do our best to get to get to them as soon as possible.
Zoe:See you next time.
Dr. Weiner:Bye-bye.