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
The Future of Weight Loss: Multimodal Therapy
In Episode 55 of the Pound of Cure Weight Loss podcast, Dr. Matthew Weiner explores the complex causes of obesity and shares innovative strategies for achieving lasting weight loss. Drawing from decades of experience as a bariatric surgeon and his deep understanding of physiology, Dr. Weiner delivers actionable insights into weight loss surgery, GLP-1 medications, and the power of healthy food.
Understanding the Root Cause of Obesity
Obesity is not just about overeating or inactivity—it’s deeply tied to our evolutionary biology. While our ancestors thrived with fat-storing mechanisms, modern diets rich in processed foods have disrupted this balance. These diets push our body’s metabolic thermostat to a higher "setpoint," making weight loss increasingly difficult.
The Metabolic Thermostat: A Key to Weight Regulation
Your metabolic thermostat regulates body weight, hunger, and metabolic rate. It aims to maintain a specific "setpoint," making it hard to lose weight with calorie restriction. Efforts to lower calorie intake often backfire as the body slows its metabolism and increases food noise (cravings and hunger).
Why Does the Setpoint Increase?
- Processed Foods: Disrupt hormonal signals and promote fat storage.
- Weight-Gaining Medications: Certain drugs, such as insulin and antidepressants, elevate the setpoint.
- Hormonal Shifts: Pregnancy, menopause, and chronic stress all contribute to weight gain.
Four Proven Ways to Lower Your Setpoint
Dr. Weiner outlines four key strategies for achieving sustainable weight loss:
1. Focus on Healthy Food
Adopting a diet rich in fruits, vegetables, nuts, seeds, beans, and lean protein is more effective than calorie counting. These whole foods support long-term metabolic health and help reset the body’s physiology.
2. Build Muscle
Strength training helps alter fat storage mechanisms and improves overall metabolic health. While not as powerful as other methods, maintaining muscle mass can complement other weight-loss efforts.
3. Leverage GLP-1 Medications
Medications like Wegovy and Zepbound mimic hunger-regulating hormones to reduce food noise and lower the setpoint. These drugs are highly effective when used long-term, achieving up to 25% total body weight loss in some cases.
4. Weight Loss Surgery
Bariatric procedures such as gastric bypass or sleeve gastrectomy lead to hormonal changes that lower the setpoint. When paired with GLP-1 medications, surgery can result in transformative weight loss of up to 50% of total body weight.
The Importance of Combining Treatments
Dr. Weiner emphasizes the power of integrating healthy eating, GLP-1 medications, and weight loss surgery. This approach customizes weight-loss strategies to individual needs, enhances results, and provides durable, long-term weight control.
Support and Community: Keys to Success
Dr. Weiner highlights the value of support networks and peer-led groups. These resources, paired with professional nutritional guidance, help patients stay motivated and achieve their weight loss goals.
Takeaways:
Obesity is a complex condition that requires a multifaceted treatment plan. Combining weight loss surgery, GLP-1 medications, and healthy food provides the best path to success.
For more resources, visit Pound of Cure Weight Loss to join support groups and access expert insights.
What we see. When we start to back out and think about these as individual or combination treatments, we see that the more treatments we apply, the more weight loss we get. Thank you very much for having me here. I've been a bariatric surgeon now for 20 years Seems like a long time ago. I put my first video out on YouTube because I didn't have a dietician at the time and I needed to communicate with patients what my post-operative diet was, and so now I think I just hit 5 million views on YouTube, which is kind of crazy to me. But I really love being a part of this bariatric community and I've loved being a bariatric surgeon and working with everybody and watching your transformation and your success and being a part of helping you change your life and freeing you really from the, quite honestly, the prison of obesity, and so if you've watched any of my videos on YouTube, I think you have a sense that I really take a fairly physiologic perspective on things, and so I'm going to really dig into some of the science behind obesity and talk about how we can apply that to ensure that you have long-term success going forward. So something when I really dig into the physiology, I think the first place I start with is what most people assume is the cause of obesity, which is calorie excess consuming more calories than you burn. And if you could just diet, eat less, exercise more, then the weight would just come off. And there's a fundamental flaw with that assumption, and that flaw is that the calories that you consume and the calories that you burn are not independent variables, meaning when you eat fewer calories, you burn fewer calories, and if you exercise more, you eat more calories, and if you exercise more, you eat more calories. And so this isn't simple arithmetic, this is high order calculus. The math is actually very, very complicated when it comes to obesity, because as you eat differing amounts, it changes your metabolic rate, and so if we don't factor that in, we put ourselves on a path for failure, and I'm sure there's not a person in this room who hasn't put themselves in calorie deficit, found some initial success and then ultimately found that the math and the strategy broke down and they were very quick to regain their weight.
Dr. Weiner:Another point I discuss is if we're going to take this calorie counting and really carry it forward. The assumption is and there's some debate about this but 3,500 calories is about one pound of body fat, and there's different people argue about it. To be honest with you, I don't really see the point in arguing about it, because the fundamental philosophy behind it is flawed. So let's just work through what happens if you were to consume 10 more calories every day than you burn. Let's talk about what 10 calories is. 10 calories is a potato chip. Yeah, it's nothing. 10 calories is an incredibly small amount of food. But if, every single day over a year, we consume 10 more calories than we burned, that would be 3,650 calories, around 3,500. Let's just round it to 3,500. And so you'd gain a pound of fat in a year if you just eat one extra potato chip more.
Dr. Weiner:Is there anybody out here who weighs the same today that they did five years ago? Anybody? Yeah, give or take right. If you weigh the exact same amount that you did five years ago, it would mean over the last five years, you somehow managed to balance your calorie intake and your calorie consumption down to the last crumb. Because, like I pointed out, even 10 calories over five years, you'll gain five pounds.
Dr. Weiner:And so we have to take a step back from this calorie counting and recognize that it's not so simple and that we can't just look at this as striking the right calorie balance to drive weight loss. There has to be something else at play that allows someone to go five years without eating even one crumb extra, over five years, consuming 1,800, 2,000 calories a day. It's really a remarkable feat and it points to the fact that there is regulation at play. Our body regulates our body fat storage, it regulates our hunger, it regulates our metabolic rate. I refer to this as your metabolic thermostat, and what I really mean when I'm talking about this is that if you were to say, put yourself into calorie deprivation, let's go back to that time when you did the math. You put yourself on an 800 or 1,000 calorie a day diet, you ran the calculation based on what your basal metabolic rate was, and you restricted your calorie intake and you lost weight.
Dr. Weiner:Because it works at first, there's no question it works right off the bat. But what happens is your body has a set point, it has a number that it feels comfortable at, it has a number that you always seem to balance back to. And when you stray away from that, when you restrict your calorie intake, when we focus only on calorie restriction and not other different nutritional methods, which we'll talk about in a second. Your body weight drifts down and the thermostat kicks in and it tries to push your weight back up to your set point. It increases the food noise, the hunger, the thoughts about food. We tell ourselves that these are things that are entirely under our control and there certainly are things that we can do to minimize food noise, outside of medications or surgery or any of the other things we're going to talk about. But we also have to understand that this is a basic physiologic drive and ultimately, if we push this thermostat far enough, our ability to resist that physiologic drive will fail. Just like you can train yourself to hold your breath for 20 seconds 30 seconds a minute, but not 20 minutes Nobody can hold their breath for 20 minutes. It just is physiologically impossible. We also see your metabolic rate slow down, and so the math that initially said you should be losing a pound every three or four days it starts to fail and the weight stalls and you may even go up a little bit and you're like how am I gaining weight eating 1200 calories a day? And the answer is your metabolic rate is slowing down below 1,200 calories a day, and so your body responds to decreased food intake. But there's another part of this thermostat that we tend to ignore, but it's critically important and it's what happened to all of you after surgery.
Dr. Weiner:If you put your weight above your set point, then the opposite changes occur. A good example what I usually use for this is New Year's Eve. New Year's Day, right. What do we all do on New Year's Day? I'm going to eat right, I'm going to exercise, I'm going to go to the gym. I'm motivated. Well, what's happened the week or two before New Year's Day? We eat right, we all eat, and so we all push ourselves a little bit above that set point. Food is in abundance, there's a celebration, everybody's around and we eat a little bit more. And our body weight? We gain a few pounds, and so it's easy to ignore food for those first few days because these opposite changes are happening. We're seeing a decrease in our food noise and we want to go to the gym. We're super motivated because we got this extra energy. We're trying to burn off calories, our body is in high metabolic rate mode and we want to burn calories, and so this set point really governs your body weight.
Dr. Weiner:Your body fat is physiologically regulated and it only makes sense because all of us, physiologically, are cave people, and cave people starve to death. There was no buffet line back in the caveman era, and starving to death was a very real threat, and so our physiology evolved to maximize our ability to absorb calories and regulate our body weight. What happened to the caveman who lost 10 pounds and didn't get hungry, didn't develop a desire to eat? That caveman didn't procreate, no, it was the people who were able to make it through those long periods of famine and starvation that inevitably occur if you're a caveman. Those were the ones who were able to move on and procreate and pass on their genes. And the truth is, everybody in this room. If you've had bariatric surgery and you struggle with your weight, you probably would have been a kick-ass cave person. You would have made it through the winters without any problem. You had all the genes that allowed you to make it through periods of food shortage without losing your precious body fat stores, which were there to keep you alive.
Dr. Weiner:And that's the ultimate, ultimate cause of obesity is that we're eating a modern diet and with our paleolithic genes. And so if we're going to drive permanent, durable weight loss, we're going to achieve that not by fighting away from our set point, not by somehow figuring out how to resist our basic and primal physiologic drives, but we're going to do this by somehow lowering that set point. If you're 300 pounds and we could just turn that set point down, adjust the metabolic thermostat to 250 pounds, and so now, all of a sudden, your set point is 250 pounds but your body weight is 300 pounds, your body's going to say, hey, this is like New Year's Day times 10. I have a rapid metabolic rate, my metabolism is not going to slow down and I have zero interest in food, very much like those first few months after surgery Zero interest in food. You could have gone days without eating, no problem. And so that was because that surgery, that rearrangement of your intestines, lowered your set point and put you well on that overfed side of the metabolic thermostat and the weight loss was now happening with your physiology. Your physiology was driving the weight loss and you weren't fighting against it.
Dr. Weiner:And that's the key, because generally, when your set point is low, it's easy to lose weight, and if it's easy to lose weight, that's a good thing, we're taught. You have to try hard, you have to suffer. This is about pain, discomfort and enduring it. That is the secret to weight loss. That is what you've been told your whole life and it's the exact opposite. That's true. It's the easy weight loss that works. The weight loss after surgery is generally pretty easy. You almost can't do anything to stop it. It's happening to you, not necessarily something that you're causing, and that's the secret to durable, long-term weight loss. We have to lower that set point. But before we talk about how to lower your set point, it's also really important that we understand why your set point went up, because these factors right here, these are the causes of obesity and if we're going to be successful at lowering our set point and keeping it low, we have to minimize these as much as possible.
Dr. Weiner:If you've listened to my podcast or watched any of my videos, you've probably seen me talk about weight gaining medications. New York Times just put out a really great article where they reviewed a meta-analysis of patients who were taking SSRI medications Prozac, welbutrin, sertraline, zoloft all those kind of first-line antidepressants and they showed that taking these medications was associated with weight gain about 5% of your total body weight over, I think, six months or a year. That's a lot of weight. There's other, much more powerful weight-gaining medications Depo-Provera, a long-term birth control medication, insulin for the treatment of diabetes, abilify, risperidone a lot of the psychiatric meds cause weight gain, and so if you're going to preserve your lowered set point, you have to avoid medications as much as you absolutely can. If it's vital to your survival, your mental health, you gotta take it, but if it's not, maybe you shouldn't be taking it. Medication-induced weight gain is real and I see it probably as a major factor of weight gain in about a third of the people I see in the office.
Dr. Weiner:Genetics Problem with genetics is we can't do anything about it. Our genetics are our genetics. But you go to a family reunion and everybody's shaped the same way. You know that's what's going to happen, and so, if those are your genetics, fighting that is very, very difficult. It's an uphill battle. Age also unmodifiable Well, it is, but not the way you want to do it. As we age, we tend to store excess fat. Pregnancy, pregnancy, especially at an older age. Pregnancy in your 30s, mid, even late 30s can be a significant weight gaining factor. Menopause I don't need to tell this to anybody who's going through menopause or has been through menopause. Man, it gets a lot harder to lose weight after menopause.
Dr. Weiner:Stress and depression. I think this is really a huge place where mental health comes in, and it's managing this without taking medications that cause weight gain. And this is where all of the things that people discuss the behavioral therapy, the journaling, the meditation, the exercise all of these other factors that can help modify your stress can also help you maintain that lowered set point, because long-term chronic stress or depression raises cortisol levels. Elevated cortisol levels cause your set point to go up. Processed foods and sleep disruption all cause your set point to go up, and so the first step to maintaining your lowered set point is to look at your life, look at any of these factors and say what can I do to minimize these and changing that?
Dr. Weiner:There are four ways to lower your set point, and, in general, at least three of them will often make a lot of sense to people. So the first is nutritional change, and I'll go into each of these in a little bit more detail in a second. Nutritional change is different than dieting. It's eating different food. An analogy I sometimes use is hey, listen, if I moved you to rural China and you had to farm and raise your own food and animals, do you think you'd lose weight? Yeah, you would change the type of food that you ate. That's different from restricting the calories that you consume, which we've already talked about, is not a solid, long-term solution.
Dr. Weiner:Building muscle and using it this is great for the young folks out there, and this is a little different than exercise too Kind of the traditional exercise that we think of is I'm going to get on the treadmill and I'm going to exercise and burn 200, 300, 400 calories. Anybody who's ever tried to track their calorie consumption during exercise understands what a fool's errand this is right. I mean, you ever use those assault bikes. You know the things where you ride like that with a fan. I do that for like all out for a minute, which is it's the longest minute of my day, and I burn 14 calories doing it. You know it's just you can't burn enough calories through regular cardiovascular exercise to maintain weight loss. However, if you can build muscle and then use it vigorously, which is really what's necessary to maintain that muscle Muscle, the presence of skeletal muscle on your body lowers that set point.
Dr. Weiner:It adjusts the way your body looks at your fat stores and tries to store fat, and so in some people, this is totally possible. In some people, this is just something you shouldn't even try because you'll hurt yourself. And you know I say that as a joke, actually, I left it out of the last slide. But one of the other major causes of your set point going up is injury, and so so many times I talk to patients and they're like I was doing great, and then I was in a car accident, I threw out my back and I needed back surgery and as a result of being laid up from my injury, I gained 40 pounds Very, very common. And a lot of that weight gain is from muscle loss, and so whatever you can do to build muscle safely without injuring yourself, you should do.
Dr. Weiner:But of all the four things up here, this is probably the least effective. Like sometimes I joke that exercise works well for women under 30 and men under 40, which is a pretty limited group. I don't know what do? We have probably three people who fit that category in the room right now. I'm definitely not one of them. The third I don't know.
Dr. Weiner:Has anybody here heard that there's some weight loss medicines out there now? Yeah, yeah, now there's some new medications, the GLP-1s. There's really only two of them. They each have three names, so you hear six names flying around, but there's really only two medications worth looking into. And these medications are a really great adjunct and they work extremely similarly to bariatric surgery. These are set point lowering medications by overwhelming your GLP-1 receptors with these medications. And these medications provide a 50-60 increase in your exposure to GLP-1 over what your basic physiology creates. This isn't like a tiny uptick of your GLP-1. This is a massive overwhelming of it. And these medications are set point lowering medications and they work very well in conjunction with bariatric surgery. And to me, they kind of take some of the imperfect things about bariatric surgery and help cover them up, and so I think they're a really critical part of long-term weight loss strategy.
Dr. Weiner:And the fourth one is bariatric surgery. And we all think, oh, surgery works through restriction and malabsorption. That's not really how it works. It's a hormonal surgery. It changes the way your body interfaces with food. It changes the way your intestines and your stomach stretch in response to eating. It changes the way your intestines and your stomach stretch in response to eating and, through neurohormonal access using ghrelin, leptin, insulin, glp-1, other hormones it sends these signals back to your brain and lowers your set point. And that's the essence of how bariatric surgery works, how bariatric surgery works. So what we see when we start to back out and think about these as individual or combination treatments, we see that the more treatments we apply, the more weight loss we get.
Dr. Weiner:And you know lifestyle changes are great and you know there might be people out there who write books about nutrition and talk about how great nutrition is and if you only fix the nutrition, if you just got the nutrition right, you'd finally lose the weight and keep it off. And I think it's time for us to acknowledge that. That's not necessarily an entirely true statement and I am one of those people who have written one of those books but on average, if you really nail the lifestyle changes, it's about 10% total body weight loss. That's not that much. You're 300 pounds. You lose 30 pounds. It's not enough to solve the problem. Now lifestyle changes are going to be critical for all of these other treatments and we have to look at lifestyle changes as something we add on to our other medical treatments, because they really make the medical treatments work much better.
Dr. Weiner:Bariatric surgery without good nutrition afterward doesn't work that well, and the same is true for GLP-1 medications, probably even more so because it's a less powerful treatment. Bariatric surgery is a more effective set point lowering treatment than GLP-1 medications. So now we get into the medications, our current crop. We're seeing 15 to 20% total body weight loss. There is some data, I think about 18 months for Terzepatide, which is Monjaro and Zepbown, which is clearly the better of the two medications, the more effective of the two medications. That shows about 25% total body weight loss. The thing that we're seeing is that whatever they saw in the studies and this is kind of how medicine works whatever we saw in the studies you don't necessarily get quite that much weight loss on average in the real world Because in the study there were no copays and no prior offs. So we're seeing in our practice somewhere around 15 to 20% total body weight loss and so that's better than lifestyle.
Dr. Weiner:We move up to a sleeve.
Dr. Weiner:We're looking at 20 to 25% total body weight loss, a bypass on average, 25 to 30% total body weight loss the real magic that I'm seeing in my practice and that is exciting me. After 20 years of doing this, I'm probably more excited about what we can offer our patients now than I have been at any other point in my career. It's when we combine all these treatments, when we take a sleeve and a bypass and we add the meds in afterward, we're seeing. I see patients coming into my office 400, 450 pounds and we're literally able to cut their weight in half reliably. Not just hey for the billboard right. Some people respond great to these surgeries 10% of people I call them super responders and they don't need any meds, they just their genes are aligned with this surgery and they have a remarkable response and they'll lose 50% of their body weight. But that's not the average, that's the best responders. That's the top part of that bell curve. With these meds we can get everybody at that level 30 to 50% total body weight loss.
Audience :Yeah, but with the meds don't you have to take them forever and they're not like lukewarm.
Dr. Weiner:Yes, yeah, yeah, but they work. Yes, but what? You have to take them forever, because they're lowering your set point, and your set point will go up. But you know what? You might not have to take high blood pressure pills. You might not have to take high cholesterol pills. Your surgery is in you forever. It's not reversed, and so if you're going to achieve long-term, durable weight loss, you need to make long-term changes, and the beauty of surgery is you make that change once and then it just kind of sticks around.
Dr. Weiner:Medications don't work that way. There's strategies, though, and I think what maintenance looks like on these meds is still up for debate and there's new agents coming out and there's variable responses that we see, and so there's a lot to this. And, again, you don't have to take the meds. I'm just explaining to you what's available out there that will allow you to be successful over the long term. So let's talk about lifestyle changes. Again, very rarely the only solution. There are people who can be extremely successful with lifestyle changes, and the thing that you know, people are like oh, dr Weiner, you're like into the veggies and nutrition and everything like that, and that's absolutely true. But I love it when someone comes in eating a lot of McDonald's and drinking a lot of soda. But I love it when someone comes in eating a lot of McDonald's and drinking a lot of soda. I love it because I can make a huge change in that person's diet and a huge change is going to get you huge results. And so that's a really these people. If you have a very poor diet to begin with, you can lose a lot of weight. Now we don't want to go take that diet all the way up to surgery. We want to correct it before surgery or even before we start the meds potentially. But we can see great weight loss. So in every group there's people who are super responders. There's super responders to surgery. There's super responders to medication. There's super responders to lifestyle changes Young people, people who are capable of high-intensity exercise, are able to lose substantial weight through nutrition, and then people who've lost a lot of weight in the past.
Dr. Weiner:So let's talk a little bit about GLP-1 medications. They are a very powerful treatment option. They are expensive and probably will be expensive for at least another five years, possibly ten. Fifteen percent of people don't respond. 10% of people don't tolerate them.
Dr. Weiner:So I'm not telling you these things are perfect. They are not perfect. There is nothing perfect in the weight loss world. Bariatric surgery is not perfect, nutrition and exercise isn't perfect, and GLP-1 meds aren't perfect, but there are people who respond extremely well to them and there's only one way to figure out if you're going to respond or not, and that's to take them. They have to be taken long-term for weight loss and that is the truth. That's how they work. You've got to go in accepting that. The truth is how many people here take a medication I do right how many people ask their doctor when they can stop taking that medication when it was prescribed? So if we're going to talk about expense and I'd need a whole other hour for that these meds are not expensive. They're $5 to make. It's our screwed up healthcare system that makes them so unaffordable and expensive.
Audience :And agreed.
Dr. Weiner:Yes.
Audience :I don't know if you can answer this or not, but what would be the signs of like you don't tolerate?
Dr. Weiner:You'll know yeah.
Audience :Developing skin rash and they say it might be because of this.
Dr. Weiner:So you know these GLP-1 meds. We're seeing the same thing we saw with bariatric surgery, which is when you have bariatric surgery, if you're like I have this headache, everyone's like, oh, it's your surgery, yeah, right, you know. Oh, I broke my leg, yeah, because your surgery. You broke your leg because of your surgery. And so everybody's very quick to blame everything that happens to you after this, and so we really have to take a step back and look at the science. Skin rash isn't something I'm seeing. We see. It's mostly GI side effects. It's heartburn, nausea, vomiting, constipation, diarrhea. Those tend to be modifiable if you dose them carefully and correctly. I think the big problem we have is we're dosing them. All the data, all the studies, the way that we're supposed to dose them is wrong. We're overdosing them, we're escalating the dose too fast and we need to be a little bit more cautious and understand this is a long play. This isn't a race. We're in this mode of fast weight loss lose weight fast. Everybody wants to lose weight fast and we shouldn't be focused on that. We should be focused on losing weight forever, and that requires a different approach. But yes, they are expensive, but over the long run they won't. This is my favorite graph of all expensive, but over the long run they won't. This is my favorite graph of all. This is from the Surmount trial, which is the Terzepatide Monjaro Zepbound long-term use, and it's a busy graph, but I'm just going to kind of go over a couple of things. If you look here, so this is how many people met this body weight reduction target. So, greater than 5%, 10%, 15, 20. So these are the people who lost the most weight. These are the people who lost the least weight. And then the three different bars. Here are the different doses. So this is 5, 10, and 15 milligrams, and then this bar right here is the control group.
Dr. Weiner:I want to point something out. First, I can't see that number. It's like what? 1.5%, I think. Yeah, 1.5% of the control group.
Dr. Weiner:The people who were given a placebo, a saline injection, lost more than 25% of their total body weight. So there was no nutrition. These patients all participated in a comprehensive, detailed nutrition program, so they selected out a few people who were super responders to nutrition. And I think that's a really important point is all these data and that's another, you know, besides the prior auths and the co-pays that get where we don't get the same results as we see in the studies in real life. It's also the nutrition. These patients got really good nutritional support and that's something that we've created in our practice and actually is open to. Anybody in the country who wants to join our support group is welcome to.
Dr. Weiner:But we see, if we look at this, even at the highest dose of 15 milligrams, about 9% of people lost less than 5% of their total body weight. Another thing I like to point out is, if we look down here, what is that number? 9% of people lost less than 5% of their total body weight. Another thing I like to point out is, if we look down here, what is that number? 25? 15.3. At the 5 milligram the low dose 15% of people lost more than 25% of their weight loss. So for some people, just a little smidgen of this stuff and they lose weight like crazy, and so people are going to respond differently and we're going to. You know, there's things that we can do to leverage that. We have to be aware of the fact that some people don't respond. We also have to be aware of the fact that there's some people out there there's 15% of the people in this room would have a crazy good response with a small dose of the medicine so kind of quickly going over, you know sleeve, moving up 20 to 25% of sleeve patients.
Dr. Weiner:It's a simple, safe surgery. I love sleeves, I do them every week. It's a simple, safe surgery. I love sleeves, I do them every week. The one thing we have to know about the sleeve, though, is there is postoperative heartburn and reflux, and I convert almost one patient a week on average to a gastric bypass for treatment of severe acid reflux, and that, really, to me, is proving to be the Achilles heel of the sleeve, along with weight regain, and we see a lot more weight regain in the sleeve patients, and I just our last episode of the podcast, actually this week's episode it's called GLP-1 or BUS.
Dr. Weiner:Do all VSG patients need GLP-1 meds? And the answer is no, but a lot of people will. When you combine a sleeve with the GLP-1 meds, it's an amazing surgery, amazing weight loss. You get that minimally invasive, less surgery, but you get the durable, long-term weight loss results. You'll see more weight loss with a sleeve and the meds than you do with a gastric bypass, and so I think these are the two issues we see with the sleeve, and if you're having those issues.
Dr. Weiner:You have to understand obesity is a chronic, lifelong disease and it will require chronic lifelong treatments. It may require revision to a gastric bypass. It may require GLP-1 meds and if that's what it takes for you to maintain your lowered set point and that is an important thing to you and the fact that all of you are here in this room, taking your time over the weekend instead of relaxing to learn more about obesity, to learn more about the treatments for bariatric surgery, to connect with each other, it means that you're really committed to success and it might take meds, particularly if you're a sleep patient. Gastric bypass it's a little more involved surgery but we're good at it. I do a lot of gastric bypass surgery.
Dr. Weiner:There's lots of rules with a gastric bypass no NSAIDs, no alcohol, no smoking, no dumping syndrome. You follow the rules. It's a great surgery. You don't follow the rules. It's not a good surgery at all and I think you know I talk a lot about alcoholism. I've talked about it on the podcast. I've talked about it on YouTube. Being very careful with alcohol use after the surgery is critically important. You absorb it differently. It's more addictive.
Dr. Weiner:The most powerful approach is combining everything together and it takes away some of the weight regain. It takes away those patients who have not lost as much weight as they hoped. It also adds to the durability, the lifelong nature, of the weight loss. You can take the meds for life. What I also like about this approach is it's adjustable. We can change the dose. You're losing too much weight, you don't like it, you don't feel good, we lower the dose. We want to gain more, we want to lose more weight, we raise the dose. And so this ability to kind of adjust and as we get more and more drugs, better drugs, then we'll see additional. We'll see even more weight loss and even more flexibility and even more ability to kind of tailor and get that weight to the place that you want it. They are expensive. They will be expensive for a while. They'll be less expensive when we fix our healthcare system.
Dr. Weiner:Don't hold your breath. Yeah, a lot of people ask me. Well, what do you think this election is going to do to change this? Nothing, nothing. So if you want to learn more, we've got a lot of resources.
Dr. Weiner:I made my first video 15 years ago. I've got three books. I've got a fourth one on my computer right now working on it. That'll give me a little bit more time on that one and it'll be talking about GLP-1 meds, but my first book is A Pound of Cure, which is a nutritional guide. We've been taught that it's protein, protein protein, and I'm not sure that's the best long-term advice. I think that's great advice in the first six months, but over the long run I'm not sure mega doses of protein are the best thing for you and your weight loss and your health, and so you can guess by the cover what I do think is best. I've got a cookbook and then, particularly if you really want to learn more about this idea of your set point and what causes your set point to go up and how we lower it, I really cover that in detail on how weight loss surgery really works.
Dr. Weiner:We also have an online nutrition program. Our dietician had a family wedding. She couldn't come with us for this trip, but she really is a critical part of our practice and the way we kind of describe it is. I've kind of plotted out the what, what to eat. She helps people with the how, how do you eat it, and that's where cooking strategies and just general life hacks for meal planning and eating come into place. We have peer-led support groups as well. I think that's just such a critical piece that we've put together, where we have our patients leading and everybody here kind of is in this room because they feel the value of community.
Dr. Weiner:And obesity is a terribly. There's a terrible amount of bias around patients who suffer from obesity and you've been pretty much told the wrong things to do and been blamed for your disease. And been blamed for your disease and hopefully at some point met somebody a doctor, surgeon, a nutritionist, a psychologist who helped you understand that maybe the things that you've been told weren't true and the shame and blame that you felt surrounding your disease also weren't necessarily warranted. And so we really try to create that in our support groups and make sure that people are heard and feel like you're not alone in this whole thing. And I go on our support groups as well.
Dr. Weiner:We do have a platinum program for anybody who wants to see us from anywhere in the country. We do a lot of GLP-1 prescriptions. We have worked out some ways to reduce the costs. We call them creative dosing strategies. My attorney has said don't videotape yourself explaining exactly what they are.
Dr. Weiner:But there are some things. It's a little wonky, but it's less wonky than our healthcare system and it's more in line with your needs and priorities than our healthcare system is, and so we're able to reduce the price of these substantially. We can get people on these for 100, 200, maybe 300 bucks a month at the most, and we kind of leverage this idea that the lower dose, that there are people who respond at the lower dose and you get about two thirds or even more of the total body weight loss from that first five milligram dose, and so we do offer that for anybody out, and I think that's my last slide. So you know, thank you to everybody who came here and took time out of your weekend to learn more about your weight loss and weight loss surgery. And I don't know if we have time for questions or if we'll save those for the fireside. Or Okay, does anyone have for questions? Or if we'll save those for the fireside, okay, does anyone have any?
Audience :questions. Sure, okay, in the slide where it is increasing weight with increased treatment you talked about the teeth and iron lines in the patient.
Dr. Weiner:What do you think about DS and?
Audience :SADES with the medication.
Dr. Weiner:So the DS and the SADES are more effective surgeries than the gastric bypass, and so you know. The main issue, I think, with the sleeve is that it really only changes the hormonal state related to your stomach, when with a gastric bypass, a DS or a SADY, we see intestinal changes as well. So we bring in a whole other pathway of hormonal changes.
Audience :I originally had the RNY about eight years ago, and then, of course, many of us struggled with it. So I did a revision from RNY to SADY and I did only a year out. But I stole for the last month and my doctor suggested to start using the ZipBomb. That's why I want you to think about this and I want a year out. Okay, stop losing.
Dr. Weiner:Yeah, I mean, you know I think answering that question requires a lot more detail before I would say yes or no. But you know, obviously I mix the two. Personally, I probably would have just from the R and Y. I mean again, I don't know when it was, because these meds haven't been out forever, but when I see weight regain after a RU and Y, I treat with medications. In general, my approach for revision surgery is if it's for weight loss, I use the meds instead. If it's for pathology like heartburn, that's when you have to do a revision surgery.
Audience :Okay, we're going to do three more questions. This will be my full time. You said that one of the medications was more effective than the other. I didn't hear was more effective than the other one.
Dr. Weiner:I didn't hear uh zep bound terzepatide monjaro for diabetes yeah, the eli lilly um product.
Audience :But yeah, one more question I have. I'm 70 and I'm not. I had my surgery two years ago a bsg. Now I have terrible heart. Yeah, they're probably not going to give me an ovarian.
Dr. Weiner:Why not? Why After 70, we just leave you out to pasture? Is that how we do it here? Yeah, this isn't Europe, but I'm trying for medication but that's going to help my heartburn. So my approach is and I'm in Tucson, I don't know where you are, but people travel for surgery for me and we obviously offer telemedicine my approach is if I have a VSG patient who's regained weight and has heartburn, I'll convert to a gastric bypass because we see, first of all it fixes the heartburn overnight. The heartburn is gone, boom.
Dr. Weiner:It's an extremely effective way to reduce heartburn. Some people have great weight loss, other people not so much. It's very. There's a lot of variability in weight loss from a sleeve to a bypass, and so you know. But you have heartburn, so let's treat that. It's a safe surgery when done by a safe surgeon and we can get people through it even at the age of 70. I've done bypasses up until you know 72, 73. But if it's pathology, we're going to treat it. You know people show up with colon cancer at the age of 88 and they're having surgery. So we accept surgical treatment of other disease. If you're really suffering, why should you spend the rest of your life suffering At 70 years old, you probably have a 3% serious complication rate with that procedure. To me that's a very reasonable risk to take. Thank, you.
Audience :I just was curious. If you have bariatric resets or set point, why would you need to take a medication if you were the tool you were given? I mean I just have time for you without I need to be in my way. I don't take a medication.
Dr. Weiner:I'm just wondering if you were so so that gets back to the slide where I talk about the causes of set point going up. Something that I didn't talk about was that you know, with all surgeries a sleeve, a bypass, a SADY, a duodenal swish there is some failure over time and that set point can creep up. Your body can adjust the effects of the surgery. The set point lowering effects of the surgery can wear off and we kind of think, well, surgery should be perfect and forever. But it's not and it's not. You know, if people have a hip replacement and 15 years later they're like my hip hurts and you hear that they need to have a revision of their hip, nobody's like. What do you mean? It wore out. I thought this thing was like bionic, it should last forever.
Dr. Weiner:We understand like over time things change, surgeries fail, effects wear off and sometimes you have to take another treatment. That really gets back to this idea. This is a chronic disease and it requires long-term treatments and treatments over time. You know the one and done idea. It happens that way for some people, for a lot of people, honestly, but for a lot of people it doesn't happen that way and it's not a statement about your character, it's a statement about the way your body responds to meds, to surgery, to nutrition. That's really the cause of that.
Audience :All right, I think we have one more question over here. Yes, and tomorrow there's a fire set chat and there's going to be a lot of time to ask more questions. If you have a lot of work right now and just keep it on you, and then, once we answer this question, I can put you away, so don't run out of time. Hi, I was wondering if it matters of the results. If you had bariatric surgery five years ago, ten years ago, fifteen, and then you decide you want to add on the medications, would you still get the same results?
Dr. Weiner:Yeah, I think the medications work better after bariatric surgery than they do in people who've never had bariatric surgery. It's for treating regain and for people who've regained that weight and it kind of gets to this idea that there may be some memory to that lowered set point and so if you've had bariatric surgery, regained your weight, then taking this med may kind of wring out some of those memories of that lowered set point. And we've been really really happy, particularly with regain after sleeve, with the impact of GLP-1s. So no, I don't think the time that it matters To me. There might be something. I haven't seen, it anecdotally. There's certainly no evidence to support it Right now. There's not evidence that shows better weight loss after bariatric surgery with these meds. I think there will be at some point. That's something we've really seen in our practice pretty strongly. All right, thank you so much.
Audience :Dr Kahn. One real quick question. I just need to draw back people's notes. They were writing it down asking how do they get it to your support group, or like so our uh.
Dr. Weiner:First of all, we do have a booth. We'd love to to see. We've got you know. You can scan the qr code and we can give you all the information there. But my website is a great place to start. We actually put a ton of energy into our website. Uh, it's pound of cure, weight losscom, um and uh. Honestly, if you google me, if my web guy is doing a good job, I'll show up and starting at our website, there's a nutrition page and you can you can sign right up on the web website.
Dr. Weiner:We're we're in the always in the process. To me, this is my passion project. I want to to have this grow into a really robust community where people can get the support that you're getting in this room right now, every day online. You know the problem with YouTube, facebook and Instagram is you post up some stuff out there and you're gonna get some support and you're gonna get a lot of haters and people don't understand, and we need to make sure that there's a place where you can post things, you can make yourself a little bit vulnerable and know that you're not going to get attacked for it, and unfortunately, there's very few places online where that's true and our goal is really to create that type of space. So thank you.
