When A Sleeve Isn’t Enough

In Episode 51 of the Pound of Cure Weight Loss Podcast, Dr. Matthew Weiner and dietitian Zoe Schroeder tackle listener questions on NAION vision, mocktail ideas, limited weight loss after a sleeve gastrectomy, and managing the “murky middle” phase after surgery. Here’s a quick recap of the insightful advice and tips offered in this Q&A episode.

Understanding NAION Vision Risks with GLP-1 Medications

The episode kicks off with a question about the connection between GLP-1 medications (like Ozempic and Wegovy) and NAION vision, a rare eye condition that can cause sudden vision loss. Dr. Weiner explains that NAION is often linked to low blood pressure, a risk that can increase with weight loss. He advises patients on GLP-1 medications to monitor for symptoms like dizziness upon standing, as these may indicate hypotension and increased NAION risk. Adjusting blood pressure medications may be necessary as weight drops.

Key Takeaway: If you’re taking GLP-1 medications and blood pressure medicine, monitor your blood pressure closely. Weight loss may require medication adjustments to lower the risk of hypotension and NAION.

Mocktails: A Fun, Alcohol-Free Way to Celebrate After Surgery

The next question dives into mocktails, a perfect option for those who want to celebrate without alcohol after gastric bypass surgery. Zoe shares ideas for tasty, sugar-free mocktails, like mixing sparkling water with hibiscus tea and adding frozen watermelon cubes for flavor. She also encourages listeners to use fancy glasses and creative garnishes to make the drink feel special.

Mocktail Idea: Hibiscus tea with sparkling water and frozen watermelon cubes makes a refreshing, celebratory drink that’s low in sugar and calories.

Key Takeaway: Mocktails can help you enjoy social occasions without alcohol. Use sugar-free ingredients and fun presentation to keep them bariatric-friendly and festive.

Limited Weight Loss After A Sleeve Gastrectomy

A listener who had a sleeve gastrectomy but lost less weight than expected wonders why their experience differs from others. Dr. Weiner explains that weight loss results vary widely, with some patients experiencing more dramatic changes than others. He emphasizes the importance of combining surgery with lifestyle changes and, if necessary, GLP-1 medications to amplify weight loss.

Key Takeaway: Every weight loss journey is unique, and surgery alone may not guarantee specific results. Combining surgery with lifestyle changes and, if needed, GLP-1 medications can enhance weight loss success.

Navigating the Murky Middle Phase of Weight Loss After Surgery

The episode concludes with advice on navigating the “murky middle” phase around six months after surgery. This stage involves adjusting to a slower weight loss rate and a returning appetite. Zoe suggests shifting from a protein-focused diet to one rich in vegetables, fruits, and nutrient-dense foods to avoid the “portion control trap,” where patients eat small portions of high-calorie foods, risking long-term regain.

Key Takeaway: Use the murky middle to build healthy habits with nutrient-dense foods, setting up a foundation for sustainable weight loss and maintenance.

Conclusion: Small Changes for Long-Term Success

In Episode 51, Dr. Weiner and Zoe underscore that bariatric surgery and GLP-1 medications are tools, not quick fixes. By making mindful adjustments and focusing on healthy eating, patients can set themselves up for long-term success.

Chapters

• 0:00 Habit Teaser Clip
• 0:47 Introduction
• 1:21 Does Ozempic Cause NAION?
• 5:48 Our Thoughts on Mocktails
• 9:14 Only 20lb. Weight Loss After A Sleeve
• 16:11 How to Navigate the "Murky Middle"

Transcript

Zoe: 0:17

it's a whole heck of a lot easier to make lasting changes to your habits when you're feeling successful and you are experiencing progress than it is to wait until you're at your weight and you're in maintenance to then okay, now, once I lose all my weight, then I'm going to change my eating habits. Well, you're not getting positive reinforcement from seeing you know those changes as much in your body. So it's something we definitely want to look out for and nip in the bud if you find yourself kind of falling down that trap. Hello, and welcome back to the Pound of Cure weight loss podcast. When a sleeve isn't enough. Yes, today we're talking about our. We're talking through the question and answers that we get from our social media and our website. So before we dig in, if you have a burning question or you have a question, be sure to drop us a line and ask your question so you might be having yours answered on our next episode.

Dr. Weiner: 1:12

Yes, go to our website. It's poundicureweightlosscom slash podcast and there's a form you can drop a question in and we'll be happy to answer it on the next episode. So why don't we hear from our trusty office manager, sierra, what our first question is?

Sierra: 1:28

Our first comment comes from Clark Kent on our YouTube short Will Ozympic Make you Go Blind? I recommend that you watch Docs who Lift podcast, where they interview Dr Bruger, who is an ophthalmologist specialist. He pointed out some very important things for obesity doctors to keep in mind. The top reason for Nyon is low blood pressure at night. In other words, doctors need to monitor closely for low blood pressure. As you lose weight, they likely need to adjust your blood pressure medication. In addition, the doctor may recommend that you take your blood pressure medication in the morning instead of the evening or at bedtime. As always, never change your medical treatment without consulting a doctor.

Dr. Weiner: 2:11

So this question is one of the reasons why I love doing this podcast, because really there's so much insight. This is someone who's clearly doing their research. So first let's review what NION is N-A-I-O-N. This is something we talked about in a past episode. There have been a few case reports and an extremely poorly done study that only demonstrated correlation did not come anywhere even close to proving causation was a highly selective study in a small group of people that did show that there was an increased rate of vision loss or blindness in people who were taking Ozempic, and the disease is NION, which stands for non-arteritic anterior ischemic optic neuropathy. I had to look that up. I'm not an ophthalmologist and certainly not an expert at this, but their comment about hypotension or low blood pressure causing this there's something there. There's a lot of good science behind that.

Dr. Weiner: 3:17

These medications Ozempic, monjaro, zepbam, wegovi, all of them can cause a decrease in your blood pressure. They can cause it either directly or through weight loss. Just entering this weight loss phase can bring your blood pressure down. We see this after bariatric surgery. If someone's on three blood pressure medications and I do bariatric surgery before they've even lost a pound, I stop at least one of those medications, sometimes two, because I know their blood pressure is going to drop very rapidly in those first few weeks after surgery, because that weight loss phase, the act of losing weight, is what causes the blood pressure to drop. And so we're putting patients on these GLP-1 meds and maybe not adjusting their high blood pressure meds, and so the blood pressure is dropping.

Dr. Weiner: 4:06

And again, I'm not an ophthalmologist. I think this is a very good point. If this is what's causing the ION, I could believe it. But again, I would certainly leave this up to someone who studies this disease on a regular basis, on a regular basis. But I think the point is very well taken, which is that if you are on one of these medications and you also take blood pressure pills, that you should pay very close attention to your blood pressure.

Dr. Weiner: 4:28

The classic symptom of being overdosed on your blood pressure medicine is what's called orthostatic hypotension, which means you stand up and you feel dizzy or faint for a few seconds and you can actually pass out from this and that can be quite dangerous. It's the fall, that's the dangerous part. You're not going to faint and go into cardiac arrest or anything like that, it's just you're going to fall and hit yourself, hit your head or something. If you are standing up and you're starting to take one of these medications, or you've had bariatric surgery and you're standing up and you're feeling dizzy or faint, that's certainly something you should be calling and talking to your doctor about and potentially holding off on your blood pressure medication and adjusting that relatively quickly. That's a very good point. Great question.

Zoe: 5:12

Yeah, well, and also it leads me to think, you know, hopefully there's more studies that might be a little bit more robust to show potentially the causation rather than the slight correlation.

Dr. Weiner: 5:24

Yeah, this article came out probably two months ago and there really hasn't been a lot of uptake on it. I don't see anybody kind of talking too much about it. There's not a lot of concern about it. Everybody kind of recognizes hey, that's kind of an interesting point. But we certainly would need a lot more data before we would change our prescribing habits because of all the good things that these medications can do. So all right, sarah, what's our next question?

Sierra: 5:51

Okay, next question comes from our podcast episode how a Gastric Bypass Could Ruin your Life. This question is from Pearl. What do you think about mocktails?

Zoe: 6:03

in your life. This question is from Pearl what do you think about mocktails? Okay, I love this question because I love making mocktails and I love drinking them out of fancy glasses. That's the key is drinking them out of a wine glass or a fancy glass because it makes it feel more special. But we have to be careful with mocktails, especially if you're ordering them out at a restaurant, because they can be very sugary, just like cocktails, right. And so a couple of my favorite combinations for mocktails take sparkling water, right, like a La Croix or whatever, and pairing it with either muddled fruit or some sort of fruit-based herbal tea. And so a combination that I've really enjoyed is Target has this really delicious hibiscus raspberry tea, and the key is because it's so vibrant in color, it's gorgeous and it's naturally sweet. Putting a little bit of that with some sparkling water and like a lime wedge or something like that in a wine glass, and you've got a perfect, refreshing, hydrating mocktail.

Zoe: 7:02

Yeah, something else that I've I can't remember if I've talked about this yet. However, what I love to do this summer was actually freeze watermelon cubes, and then they're. So here's what you do you slice up your watermelon into cubes, but you can't plop them all into a bag and then freeze them, because they'll all clump together and freeze together, right? So putting them on a cookie sheet first, individually freeze them, because they'll all clump together and freeze together, right? So putting them on a cookie sheet first, individually freeze them, and then, once they're frozen, then you put them in the gallon size Ziploc bag and take a couple out, put them in your glass, pour some water or sparkling water over the top, and not only does it keep the drink cold, but that watermelon juice starts to flavor the water as well, and I found that really nice yeah.

Dr. Weiner: 7:49

I think we've associated alcohol with celebration and there's a lot of people out there who are like they have one drink, oh, I'll just have it. Yeah, no, I'll have a drink, I'm going to celebrate. And the truth is that one drink of alcohol probably does very, very little to kind of cause them to feel drunk and really doesn't change the way they feel very much. It's just not a ton of alcohol, but yet they all have a drink, because that's what you do when you celebrate. But it really is that act of having that kind of special drink. You know, with that watermelon ice cube or the lime wedge on the side of the glass or the fancy glass or the fancy ice cubes, you can buy the square block or the special molds. And I think that's a really interesting point is that there's other ways to kind of make a drink special Elevate, elevate, I love that word. There's other ways to elevate a drink besides adding alcohol.

Zoe: 8:45

Absolutely, and also this is something that I talk with people about all the time If they're really struggling to get their hydration in or they don't like water by itself is how can we jazz it up, make it a little bit more exciting, make it a little bit more special? And so definitely love the different cocktail varieties or, I'm sorry, mocktail varieties.

Dr. Weiner: 9:03

Yes, I would share your, your passion for hibiscus, tea. It really is delicious. Yeah, it's is delicious. Yeah, it's kind of that perfect herbal, fresh, little citrus. Absolutely All right, sierra. How about our next question?

Sierra: 9:17

Next question was on our YouTube video, small Weight Loss After Sleeve, bella Donna asks I had my surgery almost two years ago and it almost literally did nothing. I lost 15 pounds on my own with the liquid diet and only 20 pounds after surgery. I have a lot of friends and family that have had the same surgery and were at least twice my size and are all now very thin. But I had a very different experience.

Sierra: 9:45

First off, I was in a lot of pain after surgery and I had been told by almost everyone. First off, I was in a lot of pain after surgery and I had been told by almost everyone that they didn't have any pain afterwards, except for the first couple of days. I experienced no nausea or vomiting, no change to my appetite or cravings, no problems with food going down. It just went a little slower the first couple weeks Nothing. The only thing that happened was I had to have my gallbladder removed shortly after my surgery. Literally nothing changed. I even went in for a follow-up and if it weren't for the pain I felt after surgery and the scars, I would have thought that they never did the surgery.

Dr. Weiner: 10:21

So this is complicated. So I think, first of all, a lot of people look at that pre-op weight loss on the fasting diet and they discount it like, oh, the surgery didn't do that, I did that before surgery. But the truth is they did it through a very low calorie diet. That's what the pre-op diet is, and we know that. What happens if you go on a very low calorie diet, what happens afterward? You lose a lot of weight. You lose a lot of weight and then, if you don't have surgery or do anything else, you gain it all back right. So that way, even though you look at it and say, oh, I'd lost it before the sleeve, you would have gained it all back. So if you still have maintained that weight loss that's I that weight loss belongs to the sleeve it all's bundled up

Dr. Weiner: 11:03

together exactly so. So this person lost 15 pounds before and then lost about 20 pounds after sleep 35 pounds. We don't know what their starting weight is. That's certainly. I don't think. There's not really anybody going into the surgery saying I want to lose 35 pounds, right? Most people have 50, 60, 70 pounds and that's what they're hoping for. We've talked about this over and over again.

Dr. Weiner: 11:24

With the sleeve, there's a lot of variability. There are some people who don't lose a ton of weight and there are other people who lose crazy weight, and that's one of the things that I find sometimes frustrating. The advent of GLP-1s has added that extra buffer where we can add the GLP-1 in and now we can take that kind of modest weight loss and augment it. But to me, this is a patient who is not very happy with their results, and I get it. They didn't lose as much as they wanted. But that's why the pre-op education is important and also why the post-op care is important, like the meeting with the dietician on a regular basis to make sure the nutrition is optimized, staying involved in your bariatric program. If there's an option for getting you started on GLP-1s, you take that option.

Dr. Weiner: 12:19

This is a lifelong struggle. This is not a one and done treatment, and so the idea that you're just going to have a sleeve and then go on with your life and lose tons of weight, it might happen. It also might not, and there's lots and lots of people out there on both sides of that equation. Lots of people have been super successful and super happy with their sleeve, lots of people who are not so happy with their sleeve, and that's what I think separates the you know, an average bariatric program from a great one. A great bariatric program is going to have in place for you the dietician support, the GLP-1 medications, all of the other things. You need to take that half those patients who don't have a great result from their sleeve and help them get that good result.

Dr. Weiner: 13:04

Amplify it up as much as possible. What are you going to do with this patient if they're in your nutrition group?

Zoe: 13:09

So, of course, we would want to make sure that we're optimizing their nutrition. Are we really taking full advantage of the tool? Because the sleeve is still a tool, whether they lost 20 pounds, 35 pounds after or not, it's still a powerful tool that, when combined with the lifestyle modifications, we can potentially amplify it further. Right? So I would see, did it say how long, um, how long ago they had their, their sleeve? I?

Dr. Weiner: 13:40

don't know if they specify that.

Zoe: 13:41

So, depending on how long after those hunger cues coming back, maybe the volume of food tolerated is increasing again. This patient could potentially really benefit from doing the metabolic reset diet or, like I was talking with somebody on a one-on-one today, a modified metabolic reset diet. She had a sleeve about a year and a half ago and we were talking through how to modify the metabolic reset diet so that she could still follow the principles but maybe not push the volume quite as high. So that would be something I would also really want to be interested in. How can we tweak the movement? Do those movement sprinkles Really? Just digging into all of those other lifestyle factors that can, like I said, amplify the effects of the tool?

Dr. Weiner: 14:28

Right, yeah, and I think that's this to me. This, this comment, really shows that it's not just having the surgery and then getting the result.

Zoe: 14:37

Not the easy way out. It's not the quick fix, yeah.

Dr. Weiner: 14:40

This is part of a comprehensive plan and to me, I think that's what's missing is that we haven't put that comprehensive plan in place. There's some people out there who kind of get lucky and it just all falls into place and it's a one and done surgery. We see that certainly more with a gastric bypass than a sleeve, but we see it with a sleeve too. I think this person is also comparing themselves to other people and that generally isn't going to help much. Yeah, your journey is your journey. Recipe for frustration, yeah, and so I think you have to, kind of, instead of looking at what other people's experience has been and saying, why didn't I get that same experience, you have to look at what your experience is and see how you can make your life better.

Dr. Weiner: 15:18

Yeah, because that's your only realistic option right now. Right.

Zoe: 15:20

Yeah, you can't control the outcomes of other people, but you know, even if their bariatric center didn't, doesn't have the nutritional support. Of course, our nutrition program is open to anyone in the country, so if you're in a similar situation and you're struggling post-op, um, or you know you're on a GLP-1 or whatever, I would be happy to have you in our online Zooms and really amplifying that tool through your nutrition changes.

Dr. Weiner: 15:49

And we do have a platinum program. So we'll see people from all over the country through our platinum program and I'll meet with them and we'll try to figure out what happened and what we can do to rescue it. And a lot of times we can get people back on track and get them the weight loss that they'd hoped for originally. It might not be as easy as they thought it was going to be, but it's possible.

Zoe: 16:10

It's a good option to explore.

Dr. Weiner: 16:12

All right. What's our last question, Sierra?

Sierra: 16:14

Okay. Last one is from our YouTube, episode 38, a Dose of Dilemma. Nicole Chip asks I started the Pound of Cure diet six months before my gastric bypass. Eating a pound or more of veggies was no problem back then. In the first few months after surgery, I understood that my nutrition priorities would be different for a while, as I recovered and focused on protein and figuring out which foods I could tolerate. But now, at six months out, my appetite is starting to return a little bit, and so I know I'm nearing the stage you speak about of moving away from protein first to produce first. But so many bariatric resources either assume you are in the first six weeks or that you are several years out from surgery and battling regain. I would love to hear your advice for navigating the murky middle when you're still losing weight, but at a slower pace, and it's not quite the early honeymoon phase anymore, but not quite the new normal either. How do we get from point A to point Z with as few bumps in the road as possible?

Dr. Weiner: 17:16

Zoe, what do you think about the murky middle?

Zoe: 17:19

I think the murky middle can be murky but it's also can be a really great opportunity. Yeah, to almost like practice for maintenance. Right, because maybe that murky middle is when they can start eating a bit more. Their hunger maybe starts to come back and it's like, okay, I've been trained or instilled to prioritize protein and that might feel like a little lackluster at this time, right, and so as I like to describe it?

Zoe: 17:50

Sure, yes, we still want to prioritize protein, but ideally through whole food protein and weaning off of those protein shakes so much. But the key is really adding in that extra volume and filling in the gaps. I always like to say fill in the gaps, anything else that you can eat, with vegetables, with fruit, so that you are still helping with your weight loss, but you're getting that fiber, you're getting that volume, so you feel full and satisfied and kind of helping that yourself through that honeymoon period a bit more, maybe pushing through a plateau or getting that last bit of weight loss during your murky middle honeymoon period, but utilizing that time. It's not that we want to go back and reset the pouch, go back to only shakes. That's always going to backfire, from my experience.

Dr. Weiner: 18:40

Yeah, no, I agree with you. I think the way you put it is exactly right. In those first few months it's like I can barely get in enough. I just got to get in what I can get in so I can survive. And you're worried about your nutritional state and your health. And with being conscientious and thoughtful, we get everybody through it and it tends to be fairly comfortable, but it is some work. But then all of a sudden you get into what we call the murky middle A lot of people call it the honeymoon phase and you can suddenly eat a little bit more. And you're right, what you do? You put in the vegetables and you can eat a little bit more after that more vegetables, more fruit, more nuts and seeds, beans, and so it's going to be a gradual process and understand that that's the journey.

Zoe: 19:24

And that's where also it can fall. People can fall into the portion control trap.

Dr. Weiner: 19:29

Absolutely.

Zoe: 19:30

You know that murky middle can be a dangerous slippery slope, right If you're not viewing it from the lens of. This is my opportunity to capitalize on the honeymoon period with my tool and to instill these eating habits that I know are going to help me maintain the weight loss longer term. But that portion control trap oof, that is a dangerous one. Talk a little bit more about the portion control trap. So the portion control trap is something that I see some people struggle with.

Dr. Weiner: 20:04

It's out there for sure.

Zoe: 20:05

Especially, I'd say, people who maybe come to us in the platinum program experiencing some weight regain after their sleeve let's say likely due to falling into that portion control trap, which is utilizing the portion control aspect, the volume restriction aspect of the surgery, to just eat less and not change how they're eating. So it might be, oh, I'm just going to have half of the slice of pizza and then that turns into a slice and then you know pretty soon eating the same amount as before. But what's really dangerous about it is because, especially during that honeymoon period, when your hormones are working with you as well as the portion control aspect, you're getting that positive reinforcement for negative behavior.

Dr. Weiner: 20:56

No consequences to eating poorly in the murky middle Right there will be down the road, exactly yeah.

Zoe: 21:01

And you know it's a whole heck of a lot easier to make lasting changes to your habits when you're feeling successful and you are experiencing progress than it is to wait until you're at your weight and you're in maintenance to then okay, now I'm once, I lose all my weight, then I'm going to change my eating habits. Well, you're not getting positive reinforcement from seeing you know those changes as much in your body. So it's something we definitely want to look out for and nip in the bud if you find yourself kind of falling down that trap.

Dr. Weiner: 21:31

Yeah, we know that at three months, you can't eat nearly as much as you're going to be able to in a year, and at two years it's going to be even more. We know there's going to be this progression. You will be able to eat more and more and more as you move through the murky middle, and so the question is what are you going to fill it with? Because you are going to fill it, you're going to eat more, and are you going to fill it with a bigger piece of pizza, or are you going to fill it with more fruits, veggies, nuts, seeds and beans?

Zoe: 22:05

If you watching this podcast, I think you know the answer to that one and the other. The last little note I wanted to say on that is don't expect yourself or force yourself to eat that same small amount that you were eating at three months out. When you're a year out I talk to people about that too it's like, oh well, I was only eating this small amount, I should be eating that same amount. And I was like, well, no, because if you're depriving your body of what it of, that, that fuel, and you're just kind of ignoring that hunger, it's going to catch up, it's going to backfire, and then that, could, you know, lead to going down the wrong path.

Dr. Weiner: 22:39

Yeah, all right. Well, thank you for watching or listening. We're on social media TikTok, instagram, youtube. A pound of cure, a pound of cure, and please reach out to us, drop us questions for our next Q&A session. We'd love to hear from you whether things are going well for you, whether you're struggling. Tell us how you're doing.

Zoe: 23:01

Yeah.

Dr. Weiner: 23:02

See you next time.