Episode 73: Heartburn, Hypoglycemia & Muscle Loss: Solving the Post-Bariatric Puzzle

In this episode of the Pound of Cure Weight Loss Podcast, Dr. Matthew Weiner and long-time surgical partner Deidre Schodroski dive deep into the real-world challenges bariatric patients face after surgery. From the surge in heartburn after gastric sleeve procedures to long-term PPI use, iron deficiencies, protein shake intolerance, hypoglycemia, and muscle loss—this episode delivers practical, science-backed solutions for every stage of the journey.

They also discuss the synergistic benefits of combining GLP-1 medications with bariatric surgery, how to manage complications, and why technology like the Pound of Cure app and Sage, the AI dietitian, is transforming personalized weight loss care. If you’ve ever felt lost in the complexity of postop life or medications, this conversation offers clarity, direction, and support.

- Discover why PPIs aren't always the enemy
- Learn how to build muscle after surgery
- Understand how meds + surgery = better results
- Get protein shake tips that actually work for your gut
- Start using our free app to optimize your care

Learn more about how POC can help you: https://poundofcureweightloss.com/

Transcript

Matthew Weiner (00:21)
All right. Hello everybody. Welcome to the Pound Acure Weight Loss Podcast. We're back after a few weeks off. We've been working very hard clinically. We've been doing a lot of things in our office. It's not Zoe today. It's Deidre. Anybody who has anything to do with our practice knows Deidre. She and I have been working together for six years.

I was thinking about Deidre, I think we've done about 2000 surgeries together at this point. ⁓ Yeah, no, we've done so many cases together and everybody kind of thinks like, Dr. Weiner, he's a surgeon, but I will tell you without my team, I am worthless. And Deidre is really the backbone of our team in the OR, in the office, everything like that. So ⁓ I'm so glad that she's here on the podcast.

Deidre Schodroski (00:46)
I believe that.

Matthew Weiner (01:07)
And she really is a wealth of knowledge and she and I work as a team to help support our patients. And we're gonna focus a little bit more on surgery this podcast. We've gotten some comments from people suggesting we kind of provide more info about surgery. So we're gonna try to do that. And I think Deidre, because of how many of these cases we've done together and how focused our practice is on surgery, we're gonna talk about that today. So we're taking user questions. So if you have questions, you can put them

⁓ on our website, on YouTube, on Instagram, wherever you're seeing us, send us questions and we'll be sure to answer them in an upcoming episode. ⁓ So Deidre, we got our first question. What is it? Let's hear it.

Deidre Schodroski (01:50)
The first question is about heartburn after a sleeve. I'm six months out from my gastro sleeve surgery and lately I've been having really bad heartburn, burning in my chest after meals and when I lay down at night. I didn't have reflux before surgery. Why is this happening now and what can I do about it?

Matthew Weiner (02:06)
Yeah. Well, let's start before we dive into the surgical treatment. Let's just say someone comes in your office, Deidre, they've had a sleeve and they are having some heartburn. Before we're even talking about surgery, what are you counseling them on that's not surgical in terms of how we can manage this and reduce these symptoms?

Deidre Schodroski (02:27)
Well, the first thing you can do, first thing is diet.

I mean, definitely you want to avoid foods that are high in fats, high in carbohydrates that are going to cause problems after gastric bypass, mindful or after sleep as well. Mindful eating, eating slowly, know, chewing your food, not drinking while you're eating, not eating too late at night. ⁓ And then if those methods don't work, then you then we talk about using medication. And many patients are on Pantorpe Resolve for a limited amount of time after surgery just for a

prophylactic effect to prevent ulcers or to help with inflammation. But if you need to take it for longer to help with heartburn, that is reasonable. The over-the-counter dose is only 20 milligrams, but we usually start patients on a prescription dose, which is 40 milligrams. And if that doesn't work, we can double that twice a day. And there is some medication escalation that you can do before thinking about a surgical option for reflux. But if you had a gastric sleeve and you still have reflux at one to two years out from surgery, it's really two years or.

and more, it's very unlikely that it's going to resolve. And ⁓ if it is interfering with your ability to drink, to eat and drink comfortably, for some people even the ability to drink water causes heartburn, to sleep at night if you're waking up and you're aspirating your reflux, if you're developing respiratory infections from that, ⁓ it really is an indication that we need to look at more, you know, at surgical options that are more permanent than medication.

Matthew Weiner (03:55)
Yeah.

Yeah. I mean, think if you can manage it with a PPI, it's certainly worth it. ⁓ It becomes a really complicated decision. This is something that, you we'll see a couple of patients a week with this, with this issue. It's unfortunately really common. ⁓ And if the PPI is work like the omeprazole, Protonix, those types of drugs, that's great. There's a lot of questions about whether you can be on those long-term. Deidre, what do you think about that? What about long-term PPI use?

Deidre Schodroski (04:22)
But

there were quite a few, there were some studies a few years ago, about two years ago that showed a correlation between chronic PPI use and dementia, ⁓ but not causation. And...

I actually just went to a GI conference at the beginning of the year and in the conference, the gastroenterologist said that newer research is showing that it's really the other long-term medications and issues that come with dementia and chronic PPI use was just kind of a part of that and there was not a causative relationship between the two. However, we do know we can cause hypocalcemia, so low calcium, put you at a higher risk for things like gastric polyps, osteoporosis and osteoporosis.

Matthew Weiner (04:55)
Yeah.

Deidre Schodroski (05:08)
it because of the low calcium and you know after bariatric surgery we monitor all of those things but nobody wants to be on a medication forever you know it's not good to be on any medication forever if you don't have to be and so it would be better if you're on a max dose of a proton pump inhibitor for the last 20 years and it's not controlling your reflux or or even for the last two years you know you there may be you may want look at other options

Matthew Weiner (05:15)
God.

Yeah. mean, a big part of my decision making too is if they want to lose more weight. And secondly, what the endoscopy shows. And so every time you come in, you've got heartburn after a sleeve. Let me just, you know, save you the trouble of what the visits going to be about. We're going to we're going to do an endoscopy that is generally part and parcel of this evaluation. You can't make a decision without doing an endoscopy and and.

Deidre Schodroski (05:43)
Absolutely.

Amen.

Matthew Weiner (05:59)
we really see a huge variety of ⁓ findings on these endoscopies. Sometimes I do it and it looks pretty clean, know, nothing major, not a lot of esophagitis or inflammation ⁓ and no significant hiatal hernia and everything looks okay. And I think in that situation, if you are managing it with medications and diet and all of these kinds of non-surgical things,

I think it's very reasonable to kind of just keep going with that and see how it goes. And it typically does get worse, as you mentioned, Deidre, but not always. Sometimes it does kind of just stay the same. the important thing, though, is if you have reflux, you should get an endoscopy. If we start seeing a lot of esophagitis, even something called Barrett's esophagus, where the lining of the esophagus starts to change from normal esophageal cells to small intestine cells,

That's when we, you know, I'm gonna really push that patient and say, hey, this is time to do something about it. The other thing we look for is a hideal hernia. ⁓ And a hideal hernia, a lot of people will sometimes point to their abdomen and be, no, I've got a hideal hernia. See, look, can you see it? That's not what a hideal hernia is. You can't see a hideal hernia from the outside. The only way you can see is with CAT scan or endoscopy or some type of diagnostic imaging. And it's when the stomach slides up into the chest. Deidre and I fix a lot of these things.

And over the years, we've kind of developed a technique. We're starting to use a very small amount of mesh and we find that that's really helpful in the durability of the response. ⁓ But if you have a large hiatal hernia, the stomach is sliding up. That's really also goes along with those positional changes. You can't lie flat at night just because everything's kind of pooling up above the diaphragm and comes up very easily into the esophagus. The wonderful thing about this though is it's super treatable.

And if we convert the sleeve to a gastric bypass and repair a heidel hernia, if it's sizable, we see almost immediate resolution of heartburn symptoms the next morning after surgery. ⁓ And I think that's the important thing. You know, if you're really struggling, suffering with heartburn, then it is fixable. ⁓ We do, I probably do the surgery once a week, Deidre, would you say? Seems like it. We did two this week. We did two this week, I know.

Deidre Schodroski (08:14)
Maybe more than that. Maybe more than that.

Matthew Weiner (08:19)
⁓ So we do this surgery a lot. ⁓ It's actually quite safe. It's generally not, it's not particularly difficult. If it's a huge hiatal hernia, that can get a little trickier, but for the most part, these are straightforward. The patients do just as well as the ⁓ primary gastric bypass ⁓ with minimal to no ⁓ serious complications. Our serious complication rates at 1 % these days. I'm not even sure it's that high.

Deidre Schodroski (08:46)
Yeah, general patients have very good outcomes

Matthew Weiner (08:48)
Yeah. So

Deidre Schodroski (08:48)
from these surgeries.

Matthew Weiner (08:51)
I think that, you know, this is the real weakness of a sleeve. It's great in that we don't see these metabolic changes. You don't see some of the dumping syndrome or the ulcers or some of the hair loss that we'll see with the gastric bypass, but you do see acid reflux and ⁓ it is treatable, but it does require revision. Another significant surgery. Anything else to add on this question, Deidre?

Deidre Schodroski (09:13)
Right.

So that's something to consider also when you're, if you are thinking about having bariatric surgery and thinking about a sleeve versus a bypass, do you have severe reflux now? Because it can definitely worsen that and that can cause long-term things like barotesophagus and know, both of those oblongitis and things. So, but yeah, just the way the sleeve works. Absolutely.

Matthew Weiner (09:24)
Yeah.

Yeah.

It's also a missed opportunity. know, if someone's really

already struggling with acid reflux, then have a bypass because you fix that too. ⁓ reflux, you know, people who don't have reflux don't understand how miserable it can make you feel. Yeah. Yeah. ⁓ you know, so, so I think if you're out there, you're really struggling with acid reflux, go back to your bariatric surgeon.

Deidre Schodroski (09:44)
Right.

Yes, absolutely.

Matthew Weiner (10:04)
⁓ If you're in Arizona, this is certainly something we take care of a lot. ⁓ And we're having more more patients kind of traveling to see us lately. And so we're happy to see anybody who's kind of struggling with acid reflux after their sleeve. And I think the important message though is it is treatable. I mean, you're not gonna have to live the rest of your life like this. And I think also, yeah, what do you see with the weight loss? You probably are closer to this than I do, because you see more...

Deidre Schodroski (10:26)
Yeah, a lot of people told me when I stopped.

Matthew Weiner (10:33)
more post-op patients than I do. What's the weight loss after this surgery?

Deidre Schodroski (10:34)
Right.

conventional thought is that you only lose about 20 to 30 pounds when you do a revisional surgery and You know, we do see patients that lose a lower amount of weight especially if you have other things going on like your postmenopausal or can't exercise and you know so forth but Have other you know health problems to go along with that But I see more and more patients now that have that lose beyond that

that are able to lose more than 20 or 30 pounds. And sometimes it's just because they're very good responders in the surgery. Again, you know, they just have a good weight loss response. And sometimes it's because we start the monoglp1, which is a very reasonable option if you're thinking about kind of weight loss in the back of your head. The weight loss will be slower because it's not a primary bariatric surgery, but that doesn't mean that you can't surpass that 20 or 30 pounds with, you know, excellent nutrition, whole food diet, staying active, GLP-1 medications, and resolution of your other comorbidities.

once your other core abilities like diabetes or remission that you may not have gotten rid of with your sleeve, weight loss is a little bit better usually.

Matthew Weiner (11:40)
Yeah,

for sure. I think also if you've regained a bunch of weight, you tend to lose more than if you're still at that lowest weight. All right, what's our next question, Dibra?

Deidre Schodroski (11:47)
Yes. Yeah, absolutely.

Okay, the next question

I've been on ⁓ Wigovie for almost a year, but my weight loss has stalled. I've only lost about 20 pounds and my BMI is still over 40. I eat pretty healthy and walk several times a week, but it doesn't seem to be enough. Does this mean the medication isn't working for me? Should I start thinking about weight loss surgery instead or can the two be combined?

Matthew Weiner (12:14)
⁓ What do you think? What's your approach to this, Deidre?

Deidre Schodroski (12:18)
Well, so what we have to remember about GOP1 medications is they're very effective for weight loss, but the individual patient's response to a GOP1 medication is going to be different for every person. It's kind of a bell curve. There are 5 % of people that are super responders that lose 100 pounds on the lowest dose of medications. Those people a lot of times have more side effects, but not always. There are 15 % of people that really don't respond at all, like this patient.

They've been on Wacobi for over a year. They've only lost about 20 pounds. And then everybody else is somewhere in between. ⁓ I think that the most effective path to weight loss and the most durable path for weight loss for long-term weight maintenance over your lifetime is a combination of both. Geopneum medications, bariatric surgery, and then geopneum medications again, if needed. ⁓

There are many studies that have shown that bariatric surgery is still the gold standard of weight loss. You're still going to lose more weight for the average person. We'll lose more weight with bariatric surgery than with the medication. And so you kind of use the medication to get to kind of your max weight loss before you think about the surgery, then use the surgery to kind of get you to your closer to your goal weight. And then if you need to lose another 10 or 20 pounds, go back on the medication or if you experience weight regain. But that's what I think that the best the best path is. And I don't think that it means that you're

failure because you didn't lose the 20, you only lost 20 pounds. I think it means that if you're, you know, if you're eating right and you're exercising and doing the things that you're supposed to be doing on these medications, you might just not be a good responder. And it doesn't mean you're not going a good responder to the surgery. So, yes.

Matthew Weiner (13:53)
It's a comment about your DNA,

not your willpower, discipline or anything like that. you know, I think I've been doing this for a long time. ⁓ And the further I get into this, the more I kind of recognize that this is a metabolic disease and response is generally driven by your DNA. And some people respond really well to surgery and others not as well. Same thing with meds. I kind of look at it like you get a roll of the dice.

Deidre Schodroski (13:59)
Exactly, exactly.

Matthew Weiner (14:22)
And so when you're born, you get a roll of the dice and you're to be born into a processed food environment because that's where we live. So the question is, how does your DNA interface with a processed food environment? You roll the dice, you know, snake eyes, not good. I'm going to gain a lot of weight in this environment. And if you're listening to this podcast, chances are that first roll, the dice didn't go great for you. and so then the next thing, and I think it's becoming really clear is. GLP ones is the.

first line of treatment for patients with obesity. And like Deidre mentioned, there is a small group of people who have crazy good response. And if you are a super responder to meds, you should just take meds and not have surgery. Don't bother with it. And the meds are well tolerated. You can afford them and it works out for you and you have great weight loss. Then you're done. And so you get the second roll of the dice when you take GLP-1s and it's, hey, how am I going to do here? Am I going to respond to GLP-1s or not?

you you might roll, have a great role. And if that's the case, you're a super responder. You might get another, you know, set of snake eyes, in which case you're not a responder. And it sounds to me like this patient isn't a great responder. Well, the good news is there's two other good pieces of ⁓ good news here. The first is that the surgery is a different role to dice, in my opinion. If you don't respond well to meds, you still can respond well to surgery. So you get this new role. And the second is once we do surgery,

it tends to increase your last roll score. So if you didn't respond great to Wegovi, you might respond better after surgery. And we've seen that, that surgery increases your response to GLP-1s. This came as real surprise to me. I thought same pathway, both hormonal. you have surgery, you're not going to respond as well to meds because you've kind of maxed that response. But we see the opposite.

My sense of this is it's the same reason and we covered this in detail way back when on one of my favorite episodes with BJ, it's called Monjaro's Second Time's the Charm. And it was about BJ who didn't respond to Monjaro the first time she took it, then had surgery and then responded incredibly well. And I think that diabetics lose less weight because insulin resistance decreases weight loss, whether it's from GLP-1s or surgery for any reason.

And when you have surgery, you become more insulin sensitive and the monjaro works better. And so I think that's the important piece of this is that, you know, if you're not responding to WeGobi, there's still a lot of options for you.

Deidre Schodroski (17:00)
Absolutely, absolutely. And then again, you produce more G-O-C-O-N-O-H-M-R after surgery too. So the medications after surgery are actually very, very effective, even more so than before surgery. So.

Matthew Weiner (17:09)
Yeah.

That,

you know, surgery's not perfect. And there's a lot of criticism about weight regain. And honestly, that criticism is well deserved, especially with a sleeve. We've talked about that many, many times. There's a lot of criticisms about the meds, side effects, cost, ⁓ not as good a response as you might hope. ⁓ lot of criticisms there. When you put the two together though, there's not a lot of criticisms.

Deidre Schodroski (17:21)
Thank

Matthew Weiner (17:38)
You keep the weight off from the surgery. We can usually use a lower dose, which minimizes side effects. ⁓ And so that really is the sweet spot in my mind is surgery plus the meds. And we're doing more and more of that. I really love that approach. And it really kind of makes a lot of what we do bulletproof, which is exciting. It's really great to kind of know like, hey, every single patient who's coming in to see us, we're going to figure this out for them.

Deidre Schodroski (17:51)
for you.

Absolutely. There's a of options.

Matthew Weiner (18:08)
Yeah,

for sure. All right, what's our next question?

Deidre Schodroski (18:12)
protein shake does your office recommend? I found that Premier Protein Shakes are not lactose friendly and I need a whey isolate. I know I whey isolate because that's the best type of protein.

So protein shakes are really, ⁓ they're a very ⁓ touchy issue after surgery because your taste change so dramatically that many people can't tolerate the pre-made protein shakes, which is the easiest thing to do after surgery. ⁓ They, even if they love them before surgery, many times they feel like they're too sweet or the texture is wrong, the flavors they used to love, they hate now, and they can try, you know, many different kinds of shakes and still does not find one that works for them. And then they're stuck. What do

How do I get my protein in? I can't really eat food or very much food. You can't get enough protein from...

from ⁓ two to three small meals a day, you know? So ⁓ what do they do? Well, the reason why a lot of patients can't tolerate these shakes is because of the arophagous sweetener in them. So the first thing you can do is you can make your own shake. You can either use protein powder or you can use ⁓ whole food sources like Greek yogurt or protein-fortified milk like FairLife that's lactose-free and, you know, add fruits and vegetables. On our app, we have a great AI dietician, Sage, and I use Sage for every patient.

now, you know, I would just type in, need 20 recipes for whole food protein shakes that equal 30 grams and it'll give it to me in 30 seconds, you know, so there are lots and lots of options out there for whole food shakes. Another thing you could do is you could try unflavored protein. You could try ⁓ lactose free protein shakes because that might be an issue too. Lots of bariatric patients, especially gastric bypass patients develop a lactose sensitivity after surgery. ⁓ actually does have a lactose free line now of coffee flavored shakes. ⁓

Matthew Weiner (19:55)
Hmm, that's good.

Deidre Schodroski (19:57)
But there but there are lots of lactose free shakes like the fair life shakes and the core power shakes ⁓ So the first step is to find out why you can't tolerate those shakes. Is it just the taste? Do just need to switch shakes or do you need or is it the artificial sweetener? Do you need to be making your own shakes? Do you need to? Find something that's lactose free ⁓ Or you just not need to use whey isolate at all whey isolate is the best absorbed type of protein However, it's not the only type of protein. You could also use

⁓ Some people who's collagen protein, although that's not as well absorbed, but a lot of people do add that to their diet. Most people go to like a pea protein or a vegetable based protein, soy protein, ⁓ and that's a plant based protein. And so you don't have the same, know, some people do are sensitive to like not lactose, but the whey protein itself. ⁓ And so a pea protein works really well for that or a plant based protein.

Matthew Weiner (20:49)
Yeah, it's trial and error really when it comes down to it.

Deidre Schodroski (20:51)
Yeah,

it really is, especially after bypass. So we just kind of have to work through it until we find something that works.

Matthew Weiner (20:54)
Yeah.

Yeah,

I mean, I think you don't don't get yourself attached to the protein shake that you use for your pre-op diet. ⁓ I generally recommend people buy five or six different types of shakes after surgery, different flavors, different brands, different protein sources and see what works. Try those five. And if those don't work, try another five. ⁓ But yeah, the taste, the taste changes are real and the artificial sweeteners aren't great. Again, the homemade protein shakes, I love it, you know, because I love a whole foods approach. So.

that's always a great option. I've had a lot of patients who that was, if it wasn't for that, they would have been like on intravenous nutrition or something. They had a rough go, but that kind of got them through it. So, all right, what's our next question?

Deidre Schodroski (21:37)
Yeah.

I'm two years

out from my gastric bypass and my doctor says I'm anemic again and need iron infusions. Why do I need that instead of just taking pills? I thought my vitamins were enough. I see this all the time after a bypass or after surgery in general. So one thing that patients don't realize is that after bariatric surgery, you will take a multivitamin for the rest of your life.

Matthew Weiner (21:55)
Yeah.

Yeah.

Deidre Schodroski (22:07)
Even after a sleeve and a lot of sleep patients can get away with taking an over-the-counter multivitamin, but the bypass is not as forgiving and With the bypass especially you have to have iron Now some people before they even have surgery are just not good absorbers of iron You know they and it might not be because of you have a heavy menstrual cycle it might just be because you don't absorb iron very well or be 12 or D and so

Matthew Weiner (22:08)
That's the deal.

Deidre Schodroski (22:32)
you will always need that supplementation. ⁓ And some people need even more than the standard, just a multivitamin with iron.

And a lot of patients 10, 20 years down the road, forget that. And they're either taking a gummy multivitamin that doesn't have iron in it, or they're taking an adult multivitamin or a women's or a 50 plus, but it doesn't have enough iron, or many times they don't have iron, even though you think they do. Or they're not taking anything at all, which happens a lot. And then you become anemic and you kind of go and you get your labs done and your doctor, your primary care physician is like, why is your iron so low? And they want to do iron infusions

cycle where you just do iron infusion after iron infusion, that's no way to live. And really the key is you just have to be consistent with your vitamins and get your labs checked every year. That's really important. A lot of people kind of let that fall off over time.

Matthew Weiner (23:23)
What percent of bypass patients do you think are truly dependent on iron infusions where no matter what vitamin you take, even if they're 100 % compliant, they still need infusions every couple months? What do you think? How often is that? Do you see that? Yeah.

Deidre Schodroski (23:37)
So it's not common at all. The few times

I've seen it were actually because of another pathologic issue. So I had a patient who had Crohn's disease, which affects iron absorption. She had to have iron infusions more often. We did eventually get her on just oral supplementation once we figured out that it was a Crohn's disease. So there are some people that have like a genetic anemia, you know, but it's very rare. So the concept of you can't absorb iron.

Matthew Weiner (23:57)
Yeah.

Yeah, I agree.

Deidre Schodroski (24:06)
If you have not had a resection of your bowel, your body absorbs iron. We just have to find the right dose.

Matthew Weiner (24:14)
Yeah.

What do you think about constipation and iron?

Deidre Schodroski (24:19)
So this is very tricky. I find that people have less constipation if they take iron in multivitamin. However, studies have shown that like a gentle iron or iron bisglycanate causes less constipation than the standard ferrous sulfate that's in your multivitamin or elemental iron. But I don't always see that play out. Sometimes it does. You have to take a little bit more iron bisglycanate if you go that route than a standard elemental iron.

So, but you can do either. mean, there is, there are vegetable based irons and iron bisglycanate and gentle irons, slow absorbing irons that might cause less constipation. Certainly people do experience constipation with iron for sure. And some people are very sensitive to it, but if you have low iron, you know, we have to figure out how to your constipation then. So yeah.

Matthew Weiner (25:03)
Yeah.

Yeah, I think most people do tolerate the chelated iron like the biscolysinate like you talked about ⁓ fairly well. It's the ferrous sulfate that is really rough. mean, probably half the people out there cannot tolerate the ferrous sulfate. ⁓ But I think if you're struggling with constipation from iron, try a different formulation. ⁓ But yeah, with the bypass,

that you signed up for it. You signed up for a lifelong vitamin. And I think it's just, if you're not taking it, it will cause problems. It's not something you should take because, hey, it's good for you. It's something you should take because otherwise you're going to have a bad problem that is going to be difficult to treat and be very annoying. And it's going to happen right at the worst time. ⁓ taking a vitamin is a fairly simple thing to do. Checking your iron once a year. ⁓ You signed up for that too. One

Every year you check your iron. If you're low, you check it twice a year and you adjust as needed. I do think that the overwhelming majority of iron infusions are unnecessary and could be managed just with the right iron protocol. yeah.

Deidre Schodroski (26:16)
Absolutely.

You just, the key is to make sure you're taking your vitamins and being consistent with them and even taking additional iron after your infusions so that you don't, you you maintain your iron levels and don't have to do that again. So, yeah.

Matthew Weiner (26:28)
Absolutely.

Deidre Schodroski (26:30)
I'm about three months out from my gastric bypass. I started feeling awful at night. I think my blood sugar might be too low. My heart races, I get dizzy and sweaty, and then I have to lie down. ⁓ I usually try to drink something or eat something, and then I feel better. But is this normal? Am I doing something wrong? So what this patient is experiencing is hypoglycemia. And after gastric bypass, hypoglycemia is...

Matthew Weiner (26:47)
We've heard this one.

Deidre Schodroski (26:56)
can be a real risk. And that is for a few different reasons. ⁓ One, you probably, may have heard of dumping syndrome, and that is the rapid transit of carbohydrates into your intestine because the intestines are connected to the stomach. So there's, you know, they're not going through the pyloric sphincter that is going right into your intestine. And that rapid transit causes an intense absorption of glucose, which causes a large insulin response. And that can drop your blood sugars really low.

So that's one reason and then the other reason is that because your body actually produces more GOP1 hormone after gastric bypass you actually it causes the Amount of insulin that your pancreas produces to go up. So you actually produce more insulin kind of a hyperinsulin EMEA so because of that patients are very high risk for dropping their blood sugars and There are many ways there are easy ways to treat this. The first thing we always talk about is

⁓ is timing of your meals and what food you're eating.

bypass patients especially, but also see patients to a lesser extent. You know, have to avoid foods that are high in fat sugar or carbohydrates because especially foods that are high in carbohydrates and sugar, you're going to get that, you're going to get dumping syndrome. You're going to get the rapid transit of sugar, high spike in your glucose and then overproduction of insulin, which will drop your blood sugar. And then you don't feel good. You feel nauseous, sweaty, lightheaded, feel like a heart's beating out of your chest. You might vomit. Right. And so avoiding those foods is the first

Matthew Weiner (28:17)
Miserable. Yeah.

Deidre Schodroski (28:23)
thing to do and we talk about that a lot before and after surgery. The other thing in eating a whole food diet also eating lots of lean proteins, lots of plant-based proteins and foods that keep your blood sugars at a nice even level and adding those things to every meal like beans and nuts, greens, avocado, know chickpeas, all of those things keep your blood sugars very steady so adding those foods in can also help counteract that effect of a spike in blood sugar and dropping after eating.

⁓ The other reason that people experience reactor hyperglycemia is when they skip meals. They go too long without eating and their blood sugars can drop very low because also when we bypass the pores in the small intestine, you also don't absorb glucose in between times. And so your blood sugars can get very low. And then when you eat, you get a bigger spike, bigger insulin response, and it drops again. So the treatment for this is two things. One, ⁓

timing your meals so that you're eating every kind three to four hours, at least a snack, preferably something that keeps your blood sugars nice and steady like legumes, beans, nuts.

things that are going to keep your blood sugars very even and not things like bread or candy or juice that are full of carbohydrates or sugar because then they're going to spike your blood sugar and it will drop again and you'll have the same effect. ⁓ The other thing is going to be choosing the right foods. A lot of patients experience hypoglycemia overnight and that's because usually they're eating too early of a dinner and not eating again until breakfast and so if you eat a meal

like around seven or eight o'clock, a snack, something that's a protein and fruit, like cottage cheese and blueberries or like a handful of nuts or something like that, that will help keep your blood sugar steady overnight. So even with these changes, some people...

still continue to experience hyperglycemia, even after they're timing their meals correctly and eating the right things. And then we talk about medication that can help slow the absorption of carbohydrates to help keep your blood sugars more steady and not get those big drops after you eat. The most common one we use is called A-carbose. For most people, it works fairly well. There are other medications too that can slow down insulin production in your pancreas, but most people don't have to get to that level. We can usually control it with diet and eating the right things and timing and A-carbose if we need to.

Matthew Weiner (30:41)
Yeah.

Diet and a carbose works most of the time. What do you think about GLP-1s? There was initially a lot of discussion about that for hypoglycemia. Do think it works?

Deidre Schodroski (30:49)
So GOP wants, yeah.

So studies have shown that it does work for hyperbolicemia. And that is because of the way GOP1s work. They slow the amount of glucose on your liver produces and decrease that. It slows the absorption of carbohydrates in your intestine. It slows the, because of that, the ⁓ spike in glucose is less and it affects the amount of insulin that your pancreas produces and slows the clearance of that. And so yeah, it does work for hyperbolicemia, which is interesting.

Matthew Weiner (30:57)
Yeah.

Yeah, I mean, I've

seen those studies too. I haven't seen it work in real life though. That's been my concern.

Deidre Schodroski (31:27)
I have

once or twice, like when were, when it was epic was still a thing. had one or two patients that did seem to help, but yeah.

Matthew Weiner (31:31)
Have you? Yeah.

I'm wondering if

it's low dose that really is, you know, it's, should, if you get, cause you raise the dose and you're going to decrease your PO intake and that's a problem, right? You just talked about regular, regular eating. And so if you just, if you eat less, you're going to have less sugar coming through and you're going to have more hypoglycemia. So I wonder if it's just, if it's just a touch of Ozempic or Zephone that does the trick. I think that'd be an interesting thing to start to experiment. Do you do that? Do you ever use really low dose Ozempic for this?

Deidre Schodroski (31:44)
Mm-hmm. Right.

Right.

That would make more sense. Yeah.

Not to treat, I haven't really used to treat hypoglycemia. We've done it like once or twice and it was a while ago. It did seem to work. It did seem to help the patient. ⁓ They had already had bariatric surgery. So it could also have been that they were just getting farther off from their bariatric surgery, you know? ⁓ But we talk about this a lot when we talk about GLP-1s as well, because you can also get that same hypoglycemic reaction with GLP-1s, especially if you're just giving meals and eating the wrong things. So.

Matthew Weiner (32:10)
Yeah.

Right.

Yeah.

Totally, Yeah. ⁓

So something that I'll do with patients with hypoglycemia that I think is really exciting is, know, in our app, ⁓ our Poundacure app, you can log your food. We have the whole Caloratio food logging system, which also, if you're looking to see, hey, am I eating a diet that's causing blood sugar spikes, a low Caloratio diet, meaning lots of processed foods, ⁓ that's going to be more hypoglycemic.

causing than a high-calorie ratio diet. just using the calorie ratio scoring system to determine, am I following the rules here is a good strategy. You can even take a picture of your food and log it for you. ⁓ But you can take it one step further. And so what I'll have patients do is also log their episodes. Hey, at 6 PM, I had this episode. At 3 AM, I had this episode. ⁓ And then take that log and

put it into the Sage tool and say, hey, Sage, I've had these three hypoglycemia episodes. Can you look at my food logs and see if there's any foods that are triggering the low blood sugar? And Sage may be able to help you identify those foods that are doing it. putting AI into this, it's a large data set, what you eat, when you have these episodes. AI is great at managing and reviewing large data sets. So I would encourage

Deidre Schodroski (33:53)
Thank you.

Matthew Weiner (33:58)
if you're struggling with this, to give that a shot because a lot of times it's a few foods that do it. I think artificial sweeteners can do this sometimes because they'll trigger insulin release ⁓ and they don't have any carbohydrates. So that just kind of lowers your blood sugar altogether. So I think you got to get creative with this, but it is usually a solvable problem, but not always an easily solved problem.

Deidre Schodroski (34:22)
Yeah, sometimes the same thing, trial and error. ⁓ Okay. The last question

Matthew Weiner (34:23)
All right. Yep. What's our last question, Deidre?

Deidre Schodroski (34:29)
I had a sleeve in 2015 and I lost a lot of lean muscle and I started Monjaro in 2024. I didn't work out and I lost a lot more lean muscle. What can I do to prevent this?

Matthew Weiner (34:41)
All right. So what do you think about muscle loss? Is it preventable? Is it ever possible to lose weight but not lose muscle?

Yeah

Deidre Schodroski (34:58)
have a good base of lean muscle, right? So if you are the kind of person that's going to the gym prior to surgery, prior to starting these medications, and you have been building lean muscle for a long time, it's going to be a lot easier to maintain that amount of lean muscle than if you had never worked out before in your life and you're trying to from the beginning. Now with weight loss becomes muscle loss. It's part of weight loss. And it's because your body needs a lot of energy to lose weight rapidly and way more than people think. And because of that,

your body does use some lean muscle mass. But it is possible to rebuild some of that lean muscle mass and a lot of it comes down to nutrition, eating, you making sure that you're getting enough protein in your diet and whole food protein because that's used much more effectively than things like protein shakes and bars and activating that muscle because you can eat all the protein in the world but if you're not working out and doing weight-bearing exercise and and I don't necessarily mean going to the gym but doing weight-bearing or resistance exercise in any form.

then you're not going to build the muscle, right? So ⁓ I do think that it is possible to still build the muscle even after surgery and these medications. And we have patients that have. mean, one of our patients is a bodybuilder. His picture is on the wall in one of our office rooms, exam rooms. And maybe we have marathon runners in our office. I mean, certainly you can do it with the right nutrition and the right activity regimen, know, exercise routine.

Matthew Weiner (36:23)
Yeah.

Being young helps, I think. But so, you know, essentially there's kind of three ways you can lose weight. There's lifestyle. And I would even kind of break lifestyle into calorie deprivation, low calorie, and just kind of, you know, toughing it out versus changing the type of food you eat. That, that would be in my mind, kind of going from a low calorie, sheo diet to a high calorie ratio diet. And then there's meds and then there's surgery and

Deidre Schodroski (36:27)
Absolutely. Yeah.

Matthew Weiner (36:52)
I actually think that the lifestyle modification causes the most amount of muscle loss. There's just no losing weight without also losing muscle. And especially the calorie deprivation, that's when we see the greatest amount of muscle loss because your body's saying, hey, this is a famine. This is dangerous. And so you got fat, that's your parachute, that's your lifesaver, and you've got muscle. That's what's burning the calories. Muscle is

Deidre Schodroski (37:09)
Right.

Matthew Weiner (37:21)
far more metabolically active than any other tissue. think only your brain is more metabolically active than your skeletal muscle. And so you can break down skeletal muscle, it's protein. That's what skeletal muscle is. You can break it down and then you can convert protein into carbohydrate and use it for fuel. And so that's exactly what your body does in a period of calorie deprivation is it will preferentially break down skeletal muscle.

as opposed to fat because that is your reserve. And only when you finally run out and we've used the least amount of muscle possible, can we get down to burning fat. so that, you know, that I think that's the baseline. That's the important thing to keep in mind ⁓ is that no matter what, you're going to lose some muscle. I think surgery and meds cause less muscle loss than certainly than starvation or low calorie diets.

⁓ and possibly even more than ⁓ lifestyle diets. We're gonna review in a future episode an article that really does demonstrate that. But there is no losing muscle. What do you think about Dexa scans or body composition or that kind of stuff?

Deidre Schodroski (38:16)
Yes.

Yeah,

so I mean they're interesting because they kind of show you the, you know, the comparison between your fat mass and your lean muscle mass. You can definitely see an improvement a lot of times in lean muscle mass. That doesn't always translate into what you look like aesthetically or your weight. So, and patients have a hard time with that, but it is a great non-scale victory to see the lean muscle mass, ⁓ you know, amount go up.

⁓ And people do consider that a ⁓ great success. So they are the most accurate way to measure lean muscle mass versus like a body comp machine or something like that. Yeah.

Matthew Weiner (39:10)
The body comp machines I really don't trust, you know You put your hand on this thing and it seems like like a carnival trick to me almost like and and I'm not saying I know there is you know something to it and it does measure impedance and it can tell what's the fat but I I just like how much sweats on your hand if there's salt on your hands or Things like that are gonna impact it substantially. And so I always worried about those machines and felt like they weren't weren't

Deidre Schodroski (39:12)
Yeah, and the body comes to heels especially. Yeah.

Right. Right.

Matthew Weiner (39:39)
active. I think the other piece of, you know, scans and weight loss and all of this is, you know, how much of this is actionable? Like, ⁓ I'm not going to lose weight because I'll lose muscle. Let me just remain obese and maintain my diabetes and my high blood pressure, right? I mean, nobody's going to do that. That doesn't make any sense. So I think the question is if you're targeting weight loss,

Deidre Schodroski (39:40)
Right.

Right, right.

Mm-hmm.

Matthew Weiner (40:03)
what can you do to maximize your fat loss and minimize your muscle loss? And it gets back to kind of all the old fashioned things that we talk about over and over again, which is weight bearing exercise, lifting weights is critically important. And then also good nutrition, not eating junk food, avoiding calorie deprivation, all of those things I think are really important ⁓ in order to minimize weight.

Deidre Schodroski (40:26)
Mm-hmm.

Matthew Weiner (40:32)
muscle loss and checking Dexa scans and body composition stuff is just a lot of noise in the signal. Like I tell patients like, let's say it shows you're losing muscle. What am I going to tell you? You know, eat a little bit more protein and lift weights. What if it shows you're doing great and you're not losing a lot of muscle? I'm going to tell you the same thing. yeah, so you know, it kind of doesn't matter. ⁓

Deidre Schodroski (40:53)
Same thing, you're right. Yeah, no, you're right.

Matthew Weiner (40:58)
in terms of what you can actually do and what actions you can take. I hear you. think ⁓ I wouldn't look at that as, ⁓ well, I lost too much muscle. You lose weight, you lose muscle. That's the deal. ⁓ There's no preserving ⁓ muscle and losing only fat. That's the dream, but that's just not how it works.

Deidre Schodroski (41:18)
Yeah, yeah, I actually had a patient tell me that the primary care physician did not want to start them on a GOP-1 because of the loss of lean muscle mass. And they said, well, if you lose weight, you're going to lose lean muscle mass no matter what you do. So, yeah.

Matthew Weiner (41:24)
Yeah, yeah.

Absolutely. All right. So

that wraps up our questions. I hope you enjoyed our show. Deidre and I will be filming a few more of these together. I think our next episode will be back with Zoe ⁓ and we'll kind of flip back and forth and probably focus a little bit more on surgery with Deidre and maybe a little bit more on nutrition and meds with Zoe. ⁓ I'll be here every time though, that's for sure. And I think... ⁓

I'd encourage you out there to download our app. Our app's still kind of in beta version, but hopefully in the next month or two, it will be fully out of beta version and we'll be kind of talking more about it and how you can leverage our Cal-O-Ratio food logging system and our AI agent ⁓ and all of our other tools that we've put into this app to really make sure that you're getting the best guidance possible. By whatever means you're losing weight, whether you're trying to do it with lifestyle alone.

with meds, with surgery, with some combination of those three items. The app really is there to kind of support you on that journey. So please download it, take a look, send us any comments you have about it. We're actively working on it, I promise. So we'll see you guys next time.