Addiction Medicine Made Easy | Fighting back against addiction
Addiction is killing us. Over 100,000 Americans died of drug overdose in the last year, and over 100,000 Americans died from alcohol use in the last year. We need to include addiction medicine as a part of everyone's practice! We take topics in addiction medicine and break them down into digestible nuggets and clinical pearls that you can use at the bedside. We are trying to create an army of health care providers all over the world who want to fight back against addiction - and we hope you will join us.*This podcast was previously the Addiction in Emergency Medicine and Acute Care podcast*
Addiction Medicine Made Easy | Fighting back against addiction
A Bariatric Surgeon Schools Me On Food Addiction and Weight Loss Surgery
Food isn’t just fuel and obesity isn’t just willpower. We sat down with bariatric surgeon Dr. Mark Vierra to unpack what weight-loss surgery really changes, why genetics and hormones can overpower the best intentions, and how a careful program decides who needs a scalpel and who needs a different plan. From GLP‑1 surges and ghrelin drops to PYY’s “brake,” we walk through how surgery reshapes appetite signals and why even modest weight loss can dramatically improve diabetes and cardiovascular risk.
The conversation goes beyond the operating room. Dr. Vierra explains why five of six referrals don’t get surgery, how he and his partner analyze food diaries, depression, and daily constraints, and when medications like bupropion or GLP‑1s make more sense. We explore binge patterns, the messy reality of predicting who will do well after weight loss surgery, and the tough calls around patients who’ve been told their BMI is destiny when their labs and function say otherwise. The story shifts sharply when we talk alcohol: after gastric bypass, blood alcohol rises faster and stays higher, which raises the risk of alcohol use disorder over time. We share practical ways to screen motives for drinking, plan safeguards with families, and use craving meds thoughtfully.
What ties it all together is respect for biology and the person in front of us. Genetics like MC4R variants and syndromes such as Prader–Willi can drive lifelong hyperphagia; ultra‑processed foods and liquid calories amplify the problem; stigma keeps people from care. We push for a different bias—against soda and engineered foods, not against people—and for care that follows patients long after the incisions heal. If you want a grounded, humane guide to obesity treatment, this conversation delivers clarity without blame.
If this resonated, follow the show, share it with a friend, and leave a review so others can find it. Your support helps us keep building informed, stigma‑free conversations about health.
To contact Dr. Grover: ammadeeasy@fastmail.com
Welcome to the Addiction Medicine Made Easy podcast. Hey there, I'm Dr. Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years, I worked in the emergency department, seeing countless patients struggling with addiction. Now, I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started. Today's episode is an interview with Dr. Mark Vieira, who is a bariatric surgeon in my area. He's an exceptionally talented surgeon and a very intelligent and thoughtful person. After I released the Weight Loss Surgery Doesn't Treat Food Addiction episode on my podcast a few weeks ago, I knew that there was more to the story with obesity and weight loss surgery than just my perspective in addiction medicine. So I've worked with Dr. Vieira for several years, so I sent the podcast episode to him, and he told me there is more to the story, and I am really grateful that he offered his time to speak to us about his work in bariatric surgery to clarify what it is that bariatric surgery really does. And we discussed in this episode a few points that I made about my perspective on food addiction and weight loss surgery in that episode that I put out a few weeks ago. So if you haven't listened to that episode, you may want to go back and listen to it just so you know what we are talking about. Now, a few points that I wanted to call out as we get ready to start. First, Dr. Vieira's focus as a bariatric surgeon is on the treatment of obesity regardless of the cause. If someone has binge eating disorder and is developing heart disease and diabetes because of the weight they have gained, he will treat them. His goal is to help people that are overweight and obese for any reason live happier and healthier lives. And you might be surprised that his treatment plan for his patients often does not involve surgery. Second, not everyone who is overweight or obese has a problem with eating. As Dr. Vieira lays out in this episode, there are certain genetic syndromes that predispose people to obesity. And for them, weight loss surgery can be incredibly helpful. Third, some people who are overweight or obese do have a problem with eating, where they might have an addictive behavior towards food. And I was so impressed to hear the work that Dr. Vieira and his surgical partner, Dr. Steve Chang, do to really dig into a person's relationship with food as they treat them and before they consider surgery. And finally, we talk about stigma. And people who are overweight and obese face significant amounts of stigma. And we have talked about on this podcast how much stigma people with addiction face and how much it harms them. People who are overweight and obese face intense stigma as well, and it harms them just as much as it does people with addiction. And with that, let's get started on this episode. All right. Well, I have to say I respect you enormously as a colleague, and I am really excited to learn from you. Why don't we just start by having you tell our audience who you are and what you do?
SPEAKER_04:So my name is Mark Vieira, and I'm a surgeon, and I finished my medical school in 1985. Did a surgical residency at Stanford and I had a circuitous route to get to medical school. I was studying political science, decided that college was a waste of time. I dropped out of college, but one of my professors said, Listen, I really need a research assistant. Would you come work with me for some time? And he was an anthropologist. I took an anthropology class, physical anthropology class, because I couldn't get into the political science class I needed to. I loved it. It was fascinating. And I went to work with him for a while at a research center in the Caribbean where we were studying the biochemistry of affective disorders. And so that actually fascinated me. I actually was going to drop out after my first quarter. He actually let me take graduate seminars for the entire rest of my first year of college. Otherwise, I would have dropped out. I said, This is wonderful, it's fantastic, but it's not real life. I'm going to head off and I'm going to learn something else. He said, Come watch monkeys. I became completely fascinated with what they were doing. It's a group of physical anthropologists and psychiatrists at UCLA and Texas. And we were doing absolutely fascinating work. They were really interested in the way behavior and neurotransmitters interfaced to influence affective disorders. So I actually went back to college, got a degree in biology and biochemistry, also political science, because that's what I was interested in. And I went to medical school only to do research in biochemistry of affective disorders. So I went to become a psychiatrist, basically because they said that to do the kind of work I wanted to do, I really needed an MD degree, not a PhD degree, because I was interested in more the behavioral issues along with that. So I was pretty interested in that. I went to Stanford. They asked me to stay on when I finished my training. And so I stayed on and became a GI surgeon. And at that time, there were no fellowships in bariatric surgery. There were no fellowships in surgical oncology. A lot of those didn't exist back then. I'd always been really interested in nutrition. So I became the person who taught nutrition for the surgical residents and for the medical students. And it that was mostly nutrition of injury, what happens during sepsis, during metabolism, how do you feed people appropriately? But since I was so interested in it, I wound up getting people who were severely malnourished, sometimes from cancer and from radiation injury and things like that. But I also then wound up taking care of all the severely sick anorexic patients. So if you were really sick and had to be hospitalized, I was the one who came in and did the nutritional rehabilitation for those patients. And it was it was an extraordinary experience taking care of these young people who had what legitimately was often a fatal illness. Legitimately often a fatal illness. And so I tried to figure out how to safely refeed them, and it was it was quite an experience. But I became interested in doing that. I also wound up getting, because of my interest in that, I wound up getting referred patients who had had old weight loss operations that prevented people from absorbing calories. So GI bypass and things like that. And some of those people would develop some metabolic problems, had to be reversed. And so they would get sent to me. And I remember standing at the award table one day reversing somebody who had lost from 400 pounds down to 150 pounds. And I remember saying, anyone who does an operation to promote weight loss should be arrested. Okay. A year later, he came back to me at 400 pounds and said, I don't care if I was developing oxalate nephropathy and was going to be on dialysis. I can't live this way. You need to help me. And that was the that was the memorable episode that made me think that maybe I didn't know enough about this and I needed to learn about it. And at the time, there wasn't, there wasn't a lot that you really could learn. It wasn't commonly done. The the cardiologists approached me because they wanted me to do some crazy operations, JI bypasses, for patients with familial hyperlipidemia. These were people who died of heart disease in their early 20s before we had statins. And the only thing that had been shown to help them was this operation. But that was a huge commitment. And it was really hard to give me a bite on. We did one patient, I think, but I, you know, he was, he was at 22, he was the oldest patient, oldest looking patient in his family. So so anyway, so that's how I got interested in weight loss surgery. And then I started slowly doing them and saw that actually, compared to the cancer surgery I was doing, I was actually improving people's lives much more than I was with a lot of the other operations I was doing. And we didn't really know it back then, of my strong census was true, but we didn't really know it back then. But what we went on to learn was that we were dramatically improving people's life expectancy and saving lives by doing this surgery. I mean, this was when it was old surgery, open surgery. The only thing we did was gastric bypass. But a number of studies came out. The first was from Sweden, where they were doing an old operation, which wasn't very effective. But in fact, a number of studies showed that we reduced the risk of death by about 40% for heart disease, diabetes, and interestingly enough, cancer. And this is within six to seven years, because no other intervention that we have, actually, that's an environmental intervention, reduces your risk of cancer in that shorter period of time. It's usually 20 years. But we we keep coming up with the same numbers. So we dramatically, we dramatically decrease that that risk of death from those diseases. Since I was the only one doing it, I got to design the program the way I wanted to. And since I was really interested in patients with eating disorders and anorexia, and also with nutritional disorders, before this was standard, everybody had to see a psychologist or psychiatrist, and everybody had to see a dietitian, then they would spend time with me. And back then, there weren't many people doing it, and we were really selective about the people we operated on. It was a big operation, and we didn't know that it was good as good as it turned out to be back then. And I worried a lot that I was doing an elective operation that I didn't have to do compared to the cancer operations I kind of had to do. So I took it really seriously, and I devoted devoted a decade to doing that and built a program at Stanford, and we've brought in a fellow and that kind of stuff. So I've done this now since the early 1990s, and it has been an absolutely fascinating experience. I have a young partner who is Steve Chang, and he's a fabulous partner for me. Steve was out doing something else, I think, working in his family's business. He actually started volunteering it as Suicide Hotline on that basis, went to medical school to study psychiatry, and wound up being a surgeon. And so he's the perfect, the perfect person for me to work with because he he has amazing instincts about people. He's a great psychiatrist. And so that's kind of what we do.
SPEAKER_00:When you say he's a psychiatrist, do you mean he takes psychiatry and incorporates it into his surgical practice?
SPEAKER_04:Yeah. So he has amazing insights about people. It's so interesting. He was talking to you about a patient he's struggling with and that I was struggling with, and uh, and he said, Well, where's dad? And I said, What do you mean where's dad? He says, Well, you didn't ask them where's dad? I said, No. He says, Stupid. You need to ask them where's dad. These little things that he picks up on that that other people just aren't clear on. We both prescribe psychoactive medications. We both prescribe a lot of different antidepressants and and well-butterine and and you we were prescribing GLP1s. We were advocating for these way before this was common. I have a I have a talk that I used to give and it that I realized I wrote in 2011 where I was talking about how GLP ones were going to become really important. They should become more widely available and they should be first-line therapy for diabetics rather than insulin, for example. So so we both approach it from that, and he's he's a fabulous person for that.
SPEAKER_00:So it sounds like you have to get to know someone's relationship to food in your first visit with them to understand if they might even be a candidate for weight loss surgery.
SPEAKER_04:Sometimes in the first visit, it usually takes more than that. Okay. Sometimes you can tell pretty quickly. I thought about bringing some food diaries in to show you what it's like because it I think you'd be astonished if if you watched me go through a food diary and say, what do you learn from this? Because it would be a really interesting experience. I've probably looked at uh tens of thousands of food diaries now, and it's so interesting what they choose to write down, how they write it down, whether they estimate calories. We spend as much time as we can trying to figure out. It's really hard. It's really hard. And I have some questions for you about how to get to some of these answers better because I really struggle with knowing what actually happens when patients are not in my office, how much I really can gain from them about what they're about what they're doing. I think Steve is actually better at this than I am, but just by repetition, I think I've gotten relatively good at it. So, yeah, we do need to understand what their, what their relationship with with food is. We have them see a dietitian, we have them see a psychologist or a psychiatrist. But Steve and I are much more likely to turn down somebody either for dietary reasons or for psychological reasons than a psychologist or a psychiatrist. We see about 600 new patients per year who come to us who have been referred to us for weight loss surgery. You can see us without a referral, but only on a case-by-case basis. So almost everybody has to be referred by a primary physician. So we see about 600 new patients a year. We do about 120 cases a year. So the vast majority of patients who come in to see us are not going to have surgery. And they won't have surgery for a whole bunch of different reasons. They may be too sick to have surgery. And we take great pride in this. We can usually take somebody who's really sick and get them so that they can tolerate an operation. But sometimes patients will come in and they'll be huffing and puffing, and you're worried they're going to code in your office, and they just say, Well, I'm going to die this way. I'm willing to roll the dice. I'm sorry that that doesn't work. We're willing to work with you. We followed patients. I think the longest I followed some patients who wound up having surgery was seven years before they had surgery. We've had several patients who've lost 150 pounds or more before they had surgery. So we we do that. Sometimes we prescribe medications for them as a trial. Some patients qualify if they come in, their height and their weight, and comoribities are such that most patients qualify, some don't. Some come in thinking that they need surgery because they're overweight and they're going to die because they're overweight and their weight is really dangerous to them. And we sit down with them and we say, listen, you know, the fact is that these BMI tables were never intended to be used to treat individual patients. That's not the way it's supposed to happen. Those are only useful for research purposes and should never apply to an individual. I look at your blood pressure, I look at your lipid profile, I look at your hemoglobin A1C, your liver function tests, all this sort of stuff. And I look at the amount of muscle mass you have and the fat mass. And the best evidence is that you're not going to die early because of being overweight. Now, you may want to lose weight for cosmetic reasons, you may want to lose weight for functional reasons. All those are legitimate. I don't mean to dismiss those. But if your concern is that you're going to die early because you're overweight, I can tell you that there's just no evidence that that is true. And frankly, if it my advice to you would be come to grips with how much you weigh, as long as it isn't too emotionally distressing for you. And I don't mean to dismiss that, but focus on eating a better diet. Just because far more important for your longevity and your health is going to be a healthy diet, not losing weight. So there's that was a conversation yesterday with a woman who's so grateful to hear that, because she didn't want to have surgery. And she's being pushed by all sorts of people and she didn't want to have it, and she doesn't need it. She absolutely doesn't need it. She does need a better diet. Her diet could be so much better. And she was really receptive to a lot of the a lot of those things. But so a lot of people just wind up not getting it.
SPEAKER_00:So, in terms of phenotypes, if you will, of patients and their relationship to food, in my work in addiction medicine, not everyone's relationship to alcohol is the same.
SPEAKER_03:Right.
SPEAKER_00:So not everyone responds to certain medications. And a lot of what I do is I try to get in there and say, what does alcohol do for you? Because if you think about it, my patients spend their time, their money, and they take risks to get their substance. They're clearly invested in getting it. Their brain has an unmet need, and I have to find what that is to know how to help them. So if you had to say if there's a phenotype around a relationship with food, do you see different patterns of behavior around eating?
SPEAKER_04:Oh, absolutely. They're amazingly different patterns. And it's really hard. So I don't like BMI. I actually don't like those labels for food behavior because I think that those are, again, I think they're only useful if you're doing a research project. And I don't think that they are helpful to me when I'm taking care of an individual patient in my office. I have a real hard time understanding, for example, binge eating disorder. So I asked a patient one time, I was going through this, I said, So do you have a binge eating disorder? And they said, You mean like Thanksgiving? And I thought that was an interesting observation. Do I have it? Do I eat to the point that I'm uncomfortable? So, for example, binge eating behavior. Some people have a clear, you know, you're clearly going to put them in that category. But more common and more subtle than that is people who regularly eat to the point that they're really uncomfortable. I put that in that same category functionally for me in terms of outcomes and counseling them and that sort of stuff. And that is a huge number of patients that I take care of who regularly eat to the point that they are really, really, really uncomfortable, may or may not vomit. That's not something common. But I worry about that a lot. And I worry about that a lot. The reason we mostly worry about binge eating disorders is because those patients have way more side effects after surgery. They're much more likely to have side effects after surgery. They're much more likely to come in complaining of having pain after surgery, feeling nausea, vomiting, that kind of stuff, and they don't lose weight well. So that's the concern. Now, the studies looking at this, and there have been several, the studies suggest that actually, they actually don't do that differently than other people in terms of their weight loss. So their weight loss is kind of similar. You can show that that there tends to be an improvement in binging, however you want to define it, for the first couple of years. Some people who didn't have binge disorder may satisfy criteria later, so it may actually appear later, but but it's it's highly variable and it's absolutely not predictable. So one of my most inspirational patients was a woman who came to see me. I saw her just recently 11 years ago, and she weighed 350 pounds, which is a lot for a woman. And her food diary horrified me. I remember one page of it where she, at one sitting, she ate 50 hot chili peppers. And I thought she had this terrible BNG disorder, and I was just really worried about her, but she really needed to lose weight. And I tried a bunch of stuff with her, and we didn't really make much progress. Her food diaries that she'd bring in, they they looked better, they looked good. It looked as though she had controlled it. Do I trust the food diaries or not? But it looked as like it was better. So I did a gastrin bypass on her, and now 11 years later, she comes back and she she comes back every single year, and her labs are perfect. Her vitamin D level is always like 80. She walks nine miles every single day, she weighs 126 pounds, and she's a vegan.
SPEAKER_02:She speaks only Spanish. And I I really had grave reservations about doing that.
SPEAKER_04:And it's one of the best outcomes that I've had. Binge eating is an interesting thing to take care of. So we do a fair amount of well-butrement in those patients. Right. We we do, and I think for some of those people, it it really helps. It really helps. We do a lot of sort of one-on-one counseling. And one of my one of my residents started one of the first pediatric programs in the country, and I helped them set all that up. And it's an academic center, University of Cincinnati. They had a very well-resourced program with lots of psychiatrists and psychologists who are interested in eating disorders in these patients and exercise physiologists and dietitians. And he said, you know, the problem is the only person they'll come back to see is me, the surgeon. They they won't keep their appointments after surgery with those other people that won't come back to see us. And that doesn't surprise me. That doesn't surprise me. And so Steve and I consider it our responsibility to see those patients afterwards. And those conversations have to do with all sorts of things about how their life is going and whether they have time, whether they have the resources to buy good food, how are they how are they organizing their households? A very wise patient once recently told me the thing that they had learned during the course of all this didn't have anything to do with nutrition, it had to do with time management. Because this got something Steve and I sort of focus on about in terms of eating behaviors and and and such. So do you use any naltrexone? So so I have tried naltrexone several times on patients. I I have yet to have anybody benefit from it.
SPEAKER_00:So this is not science. And this is what I say, what I'm about to t tell you is not science. I'm going to give you an example of one patient. As you and I both know, the plural of anecdote is not data. Right. But I took naltrexone to see what would happen. And as I shared with you, I struggled with binge eating, and naltrexone made nothing taste good. Aaron Powell So I think that's fascinating.
SPEAKER_04:And I think that's a really, really good and interesting point. So the data, the with the published experience, says naltrexone doesn't help, right? I mean, there's just no published data saying that that helps. Buproprion, there's there is there's some. I was so interested in how these patients were responding to buproprion. I thought it was just fascinating. The interesting thing to me about it was I'd put people on it and I'd, when they come back, I'd ask them, do you feel any different? They'd say no, but their eating was better. And it was fascinating to me because the family members would say they seem more at peace. They seem less impulsive. So I thought this is fascinating. I took it, I took a single dose of Wellbuchon once to try it. I thought I was gonna crawl out of my skin. It was the most awful dysphoric experience. And so I always warn patients about that because rarely somebody will have that. But it I think it really speaks to the different physiology. When you talk about phenotype, I assumed you were going to talk about something different. I'm going back to when I was going to be a psychopharmacologist, right? It really speaks to how different it is. An an antidepressant, an SSRI in the right substrate is magical. In the wrong substrate, it's awful. So I have no objection to people trying naltrexone. Listen, the surgery that we do is such a big commitment that Steve and I, when the GLP ones first came out and primary care doctors wouldn't prescribe it. We were happy to prescribe it. We were anxious to prescribe it. And the same would be true for lots of these other things, then and Topamax and stuff like that. So we were prescribing it way before anybody else was out there doing it. Because our threshold can compared to surgery made that seem like a a really trivial commitment. You can start, you can stop it, just tell your family members. So I have, and although the studies don't say denaltrexone helps, I don't think that's the way to think about it. Because if you said, well, does penicillin help for infections? And you did a big study and you gave everybody with infections penicillin, you show that penicillin wasn't effective or marginally effective. If you give it to the right person over the right c condition, it's magically effective. And and I I have little doubt that naltrexone for the right person, for let's say you is magical. But I I really hesitate when people generalize from their experience about relationship to weight or obesity to the experience of other people. For example, we've Steve and I have talked about this. If we were going to get a mid-level in an office, we would not choose somebody who's had weight loss surgery because it's so easy for them to generalize from their experience to the experience of other people. And one of my concerns about sometimes some of the dietitians who take care of patients with is that they they tend to generalize from their experiences and assume that it's gonna be the same for everybody. And I just gotta tell you, it's just not. It's just not.
SPEAKER_00:In my world, an addiction, usually what I tell people, and this is my favorite joke, is Dr. Grover, I put mayonnaise on my left ear and I'm sober. I tell them, put mayonnaise on your left ear.
SPEAKER_04:Absolutely.
SPEAKER_00:And so to your point about well-butrin, it's in my world an addiction medicine, we use it for nicotine, cocaine, and amphetamine addiction. And for some people, it's just too stimulating. And for others, they respond very well. I don't know if you use this at all in your practice, but we do pharmacogenomic testing to see which medications people respond well to. This is a company called GeneSight. I have no financial relationship with them, but basically it's a cheek swab, and you get some cheek cells and send it off to the company and actually send you back a profile of their liver metabolism profile, their you know, SIP system, and they'll actually tell you which medications are under-metabolized and over-metabolized. And you can actually make a guess as to which medication a person might respond to in terms of how they metabolize it. And it's interesting because I've had a couple of people and they'll say, man, this med just really doesn't work. And we look and they're an over-metabolizer. Okay. And so that's something I've found. But to your point, I think what I try to do with, again, a person's relationship to a substance, and I have a few patients I treat for binge eating, is I just try to ask them, what does it do for you? And I just try to find out, is it self-soothing, is it numbing PTSD, is it they just have an intense euphoric response? And then I try to think about which medications I can do to match that. And so that's why I was asking about a phenotype in terms of a food behavior. Because presumably some people binge eat because it tastes really good. They've maybe got a genetic predisposition to release more dopamine to sugar than the average person. Then there's the person with anxiety who finds that food is soothing. There might be the person with PTSD who eats because they don't know what to do when they're anxious or restless. So that's kind of where I was going with that question. And I'm curious, now that I frame it better, do you have a different answer?
SPEAKER_04:I have a different paradigm. Please. I have a completely different paradigm. That's why we're here. I have a completely different paradigm. So I actually think that a lot of maladaptive eating behaviors, okay, that's really one way I would put it. Anorexia is interesting and different. One of the biggest mistakes we can make is to do a weight loss operation in a patient who's has a prior history of anorexia because there's a high probability that we will trigger it. It may have been 20, 30, 40 years ago, and there's a very high probability. So that is that is one of the one of the most striking contraindications that we have. You do not do it in a patient. You don't always know, but we worry about it a lot. Kind of counterintuitive. But it makes sense to me.
SPEAKER_00:But I mean, essentially the way I look at it in in my world from addiction is they have some sort of unmet mental health need, and it comes out in their relationship with food. And anorexia, as as I often see it, is you know, body dysmorphia and anxiety and depression, and they control what they're going to control, which is their food intake.
SPEAKER_04:Yeah.
SPEAKER_00:And so it makes perfect sense to me that a change in their body appearance could be very triggering.
SPEAKER_04:Yeah. Yeah. So when we talk about phenotypes, I think about these two people.
SPEAKER_00:Oh yes. I remember when you gave this talk at community hospital. Yeah.
SPEAKER_04:You know, 650 pounds, no comorbidities at all. This is her CT scan, this little tiny person in this amazing amount of subcutaneous fat, and this is a man much smaller who has all the comorbidities. Interesting. They have, they might as well not be the same species. They have essentially nothing to do with each other. And you can't just treat that patient based on their BMI or the fact that they're overweight. It it is so much more complicated than that. And then the biology is really important. So these little mice, so I'm showing a picture right now of two mice. There's a little brown mouse and there's a much bigger yellow mouse, and they're brothers. And they differ from one another basis on on the basis of a single gene which codes for an abnormal protein in the yellow mouse that codes for a protein called the aguti protein. And that circulates and binds to the four melanocortin receptors in the brain. And because of that, this mouse was overweight even when it was drinking milk when it was first born. It will be much fatter than the little brown mouse. It will be much taller, longer than the than the little brown mouse. This color is a consequence of that. And it has very high levels of insulin. And all of those are a consequence of this one little protein circulating in the in the blood. These are brothers. So I'm showing you a picture of two brothers, and one is a very tall, very overweight child, and the other is a very skinny, shorter child. Heavy child is nine, and the brother is 15. And they differ from one another because the the heavy child has a melanocortin four receptor defect. Because of that, this child was overweight when he was breastfeeding. He has extremely high levels of insulin, which will decline as he gets older. He will always be huge. He's gonna be he's gonna be fat. But he also is going to have really big strong bones and a lot of muscle. This is probably half the NFL. Okay? Now this kid is going to be assumed to have an eating disorder, and people are going to be telling him from day one that you need to eat less, you need to control your eating. If this kid doesn't develop an eating disorder on the basis of the social approbation that occurs because of this, it's it's inevitable. Yes. In 2025, there is no drug, there is no naloxone, there is no psychotherapy, there is no amount of counseling or anything that is going to ever make that poor yellow mouse look like the brown mouse. It's not going to happen. He can try all he wants. And when he lives in a society that says, I know this speaks to you, this is a fundamental problem with your soul, that you can't control your weight, that is damaging. That is really damaging. And this kid is going to go to the same school as his as his older brother, right? And he's going to sit in the class and they're going to say, gosh, that was that your brother who came through a while back? And yeah. And because this kid is heavy, the teacher is going to spend less time with him than if he than with his brother. They're going to assume that he's not as smart. They're going to give him poor grades, even if he does the same quality work. And all of that is completely unfair. And we can help this kid partly by accepting him, by understanding what he has. This is actually, by the way, one in 50 severely overweight children. So this is not some huge anomaly. And there are many other conditions that are similar to this, which also account for some of the people who are really heavy. I think you imagine that these addictive behaviors or eating behaviors somehow cause obesity. There's actually very little evidence that that's true. I think what is the case is that obesity can be coincident with or sometimes can cause eating behaviors to be abnormal. So if you live in a world where where you have a biology where your melanocortin IV receptor is blocked, you have a big appetite. You really want to eat. If your melanocortin III receptors is abnormal, you have a binge eating disorder. So that's actually a separate, slightly separate type. They have a marked binge eating disorder if they have a melanocortin III receptor defect. If you happen to have Pratter-Willie syndrome, okay, which is the syndrome where you have extraordinarily high levels of ghrelin, your parents lock the kitchen, they lock the cupboards because you will literally eat yourself to death. And you need to keep the knives hidden because your child may try to kill you in order to get to food. This is not an exaggeration. So these maladapted behaviors, I think sometimes are a consequence of this biology. You talk about GLP1 medicines like they're really good medicines, and I think they are. I think they're fabulous. I'm so grateful that we have them. So I share that enthusiasm. When you do a gastric bypass for a sleeve gastrectomy, your GLP1 levels go really high and they stay high. So the mechanism for this was actually proposed by a surgeon, the first one really to propose this in 1995 when he wrote a paper titled, Who Would Have Thought It the Best Treatment for Type 2 Diabetes is an operation? And he he, I think he was wrong. I think the whole premise of the paper was wrong, but he proposed that there was an incretin, locally secreted hormone, which actually changed insulin secretion and stuff and led to rapid resolution of diabetes. Turns out that was GLP1. And this was proposed back in 1995 by a bariatric surgeon. And I had always believed that these operations were largely hormonal operations. And the reason I believe that is that I do a lot of cancer surgery. And if I take somebody's stomach out for cancer, their entire stomach, I take it out for cancer, and they don't want to lose weight, and they go through chemotherapy and maybe radiation, I can get people through that whole thing, a total gastrectomy, chemotherapy, the whole thing with weight loss of less than 20 pounds. And long term, their weight's gonna be pretty much what it was before. Maybe a little bit less, but not a lot less. Isn't that interesting that you can do that without them dying of starvation, for example? Now, if I do a gastric bypass, which is kind of like a total gastroctomy, and somebody is motivated to lose weight, there's a reasonable possibility that they will lose about a third of their body weight, which is pretty good. We don't have anything that's that's comparable to that right now. GLP ones are not that good, they're very good. And in fact, I I I I'm gonna plug them even a little bit more. My bias is that you get 90% of metabolic benefits for the first 10% of weight loss. So it doesn't have to be a whole lot of weight loss to actually produce dramatic improvements in your diabetes and your lipid profile and all those sorts of things. But I think that the phenotype that causes somebody to be very overweight actually often their their eating behaviors are a consequence of a huge appetite that they have because they have too much ghrelin or because their GLP1 levels are or are off or something like that. If you want to make it about dopamine, I think 10 years from now, I think we're gonna say, yeah, dopamine is important, but it's not as important as as we think. I went through the phase when everything was serotonin, and then I went through the phase where everything was insulin, and I I went through trials where we gave people sandostain to try to decrease that. So I don't mean to discount it, but I'm not as enthusiastic as you are that that's gonna be the full explanation for what happens. And when you have a, for example, a gastro bypass or a sleep gastroctolate, your GLP1 levels go way high, your ghrelin levels go way down. So ghrelin is a hormone that is produced in the stomach. When you fast, ghrelin levels go up. When you lose weight, ghrelin levels go up. When you eat, ghrelin levels go down. And some of my patients refer to it as the gremlin. So is the gremlin going to go away? And so we think that's one of the mechanisms. And of course, ghrelin is one of the things which drives hunger in Pratter Willie's children. So, you know, there's a lot of, there's a lot of interest in actually trying to have a ghrelin blocker, for example. So that that's an effort. There's a hormone called PYY that's secreted in the small intestine. Some people refer to it as the allele break. Food passes into the small intestine faster. That's the hormone that tells you that you're full when you've eaten two slices of bread at dinner in a restaurant, and then the dinner arrives and you're no longer hungry, right? Because that it's had time to do that. So all those things are hormonal consequences of weight loss surgery. One of the things that I was convinced of way before we started using GLP1s was that there was a hormonal effect in gastric bypass patients in particular, which could be really troublesome. So every once in a while, somebody would have severe refractory nausea, which could last for a long, long, long time. And the symptoms are identical to the symptoms that somebody has when they have a bad reaction to a GLP1. The severe nausea, you can't eat, just absolutely miserable. The thing is you can't take it away. And those people could be miserable for months and months and months. And I I I think that that was a GLP response among those people.
SPEAKER_00:Yeah, I I think it's probably in some ways a referral bias, if you will, in that people come to me for addiction. Many of them, when they get off of their substance of choice, are low on dopamine, and so they look to find it in other places, which often goes to nicotine, caffeine, and food. And so I think that probably is why I have my particular perspective around the question that I asked, which is my patients use food as a replacement for their substance, which is why I was digging into the eating behaviors.
SPEAKER_04:Okay, so that would be the biologic basis of addiction transference.
SPEAKER_00:Or cross addiction, I think is another term for it.
SPEAKER_04:Okay. So uh here, I need some help. Okay. I and I sincerely need some help because about the biggest concern Steve and I have is alcohol. That's actually that's actually the the biggest thing that we really struggle with. And I don't really know how to think about it, how to ask about it. So, so if you come into see me for weight loss surgery, in general, you've actually led a more sheltered life, it turns out. You're less likely to see doctors, you're less likely to be partnered, you're less likely to have all those sorts of things. When we look at social attitudes for people who are overweight, they are more negative than they are towards people who have problems with alcohol or drugs. So, so it's a huge problem. So they come in, they actually have a significantly lower risk of alcohol use disorder when they come to see us than the general population. Two years later, they have about one and a half times the incidence of alcohol use disorder compared to the general population. And so obviously, this is addiction transference or whatever, cross-addiction or something like that. But here's the thing: this behavior was first described in Korean men having gastrectomies for cancer. And when you take out the stomach, you take out the alcohol dehydrogenase, right? We know that populations that have baseline low alcohol dehydrogenase, like American Indians, are particularly susceptible to alcohol use disorder. And it's definitely higher in gastric bypass patients or total gastrectomic patients than it is in sleeve patients who do have some preserved stomach. So I think it's a biochemical. Your alcohol levels go up much faster, they stay up longer, you don't metabolize as easily. So I I think of it very naively as kind of like injecting heroin rather than snoring. I don't know. Sure enough. Makes sense. But so that is that is our biggest, our biggest psychological concern. I think where Steve and I have the most anxiety about it. And let me just give you some scenarios. Person who's been abstinent from alcohol for for 10 years may or may not still go to AAA. Can I can I do a gastrobypass patient in them? I think there's a substantial possibility that they're that they're gonna have a problem again. I think there's a really big possibility. Do I make sure they have a sponsor before? I have them come with their family members and talk to them and what what's the plan gonna be if you see them doing this, all this kind of stuff? But I don't think it's enough. And I don't know, should I put them all on Altrexone? You know, should I should I do that? I just don't know what to do. And let me give you another scenario. What do I do about the 25-year-old Hispanic man who comes in and his food diary shows no alcohol, no alcohol, and then on the weekends it's seven drinks in a night. And he says, but I only drink when we have our family parties. We have our family parties and I have seven beers that night, you know, and that's normal. Do I worry about that?
SPEAKER_00:There's a lot to unpack here.
SPEAKER_04:See, because and I I don't know. And I feel I feel like that's one of the places where we do the most serious harm. I really do. That is that is that is one of the areas where I feel we're at risk for producing the most serious harm.
SPEAKER_00:Aaron Powell So my understanding is that after a gastric bypass, the alcohol is absorbed more quickly. Yes. And therefore the levels go up. Aaron Ross Powell More quickly, yes. Yes. And and I just want to make sure we're on the same page here because I I think I may have heard you say something that I I thought I knew differently. Men have alcohol dehydrogenase in the stomach, women do not. Oh, I didn't know that. So that's one of the reasons why, and I educate about this when I go to schools, is you know, my wife, the lovely and intelligent Dr. Red Close. So she's 5'2 and 125 pounds. Yeah. I'm 6'1 and 185 pounds. When I drink a drink, my alcohol starts to get metabolized in my stomach. Hers does not. And so because I'm bigger and she doesn't have alcohol dehydrogenase in her stomach, her alcohol level might be double mine for the same drink-to-drink comparison. So if she and I drink a beer, my alcohol level might be like 0.01 or 0.02, or hers might be 0.04. And so when you actually go to a BAC calculator and you put in the numbers, and I do this when I educated high schools, someone like me versus someone like Reb, as you go through it, it's a much bigger difference in how much the alcohol gets absorbed, drink for drink, men versus women, if there's a big discrepancy in body size.
SPEAKER_04:So I've assumed that that was always body size, is what I assumed. I'm gonna have to look that up because if it if it is, that means that's an important part of gastric physiology that I didn't know and I pride myself on gastric physiology. So so I'm gonna have to think about that. Alcohol is one of the substances which is absorbed in the stomach. Not a lot of medications are not absorbed in the stomach, most are absorbed in the small intestine. Alcohol beta blockers are absorbed in the stomach. It's worth checking that I I thought it was really that they had less alcohol dehydrogenase. So I think there is some decrease in alcohol dehydrogenase compared to men, and and size makes a huge difference. Of course.
SPEAKER_00:I as I tell the kids when they educate, there's physically more of me to dilute out the alcohol as compared to a smaller woman.
SPEAKER_04:And not just that, women have greater percentage of body fat than men. And so if you think about the volume distribution for a hydrophilic molecule like alcohol, the volume of distribution is really only your water weight. It's not the fat weight. So that woman who is, you know, with two-thirds of your size actually has only half of your of your lean body weight, really. So so therefore you'd expect her alcohol level to go up twice as high as yours, just based on just based on that observation alone.
SPEAKER_00:Yeah. So in terms of so of alcohol, again, the way I talk to my patients is I try to find out what does it do for them. When we give people naltrexone for alcohol use disorder, probably about 50% don't notice a difference at all. About 30% notice some difference in cravings, and maybe 20% are just, I'm good, I don't want to drink. And so usually what I do when I'm treating alcohol use disorder is I always put people on more than one medication for cravings. So it might be naltrexone and gabapentin, or naltrexonin topiramate, or naltrexone in a GLP1 or a campersate and gabapentin. Because the meds for alcohol use disorder don't work so well, I use meds from different classes and they have an additive effect. So in my world, somebody comes in and like, I want to quit drinking. And I'm like, okay, well, what does alcohol do for you? And it's maybe I can't sleep, or maybe I have PTSD and I don't know what else to do, or maybe I have very significant comorbid anxiety and I like the downer effect of it. And then there's a certain population that just get more release of dopamine and endorphins than the average person when they drink. And that's largely genetic. About fifty 40 to 60% of addiction is genetic. So, first of all, we'd be happy to see any of your patients in advance of surgery to try to unpack that relationship with alcohol. And yes, to the gentleman you mentioned, who's a young man who doesn't drink throughout the week and then drinks more on the weekend, he probably has a fairly good response in terms of dopamine and endorphins when he does drink to encourage him to go to seven. And he might be a candidate for an oltrexone. But it's everyone's a little bit different. And so I think that's when I say phenotype is I look at like what behaviors lead to drinking. And that's the question that I ask in my standard intake. There's usually two questions that I ask. The first is, why do you want to get sober? And if it's like I'm gonna lose my kids, that's a lot of motivation. If it's my wife is annoying me, that's not so much motivation. And then the second is what does the substance do for you? And then that allows me to figure out what I'm gonna do. And it might just be they really want to focus on behavioral interventions like AA or therapy, or there's really an unmet need. And in in my world, unfortunately, a lot of it is PTSD that's untreated and people just don't know what to do, so they drink. But I was actually gonna see do you counsel patients when you do their weight loss surgery that alcohol might be more pleasurable for them?
SPEAKER_04:Oh, absolutely. Okay. Absolutely. We we uh that's a very explicit part of our conversation. How do people respond? It's actually quite a long conversation, and often when the conversation starts, sometimes they feel defensive about it. And by the time the conversation is done, and I explain that I worry about this in all patients, and this is the physiology, and this is why I worry about it. And and and I tell them that some of the some of the operations I have regretted most in my entire career have been weight loss operations where patients have become alcoholic afterwards. And I just and I just don't want that to happen to you. Yeah. I re and and I know that I know that that seems unimaginable to you that that can be the case. For a long time it seemed unimaginable to me that that could happen to the people sitting in front of me, but I've seen it happen enough times that that it's something that I really do worry about.
SPEAKER_00:Yeah, in terms of the alcohol behavior, so we have alcohol use disorder and we have high-risk drinking and we have binge drinking, there's various patterns. So someone who binge drinks is likely somebody who gets a lot of euphoria from alcohol. I go out with friends, I stop counting, I black out, versus I drink every night because I can't sleep. So I think both of them potentially have a risk when you decide whether or not you're going to do a weight loss surgery on them. The binge drinker might find that the alcohol is even more euphoric and it's even harder to stop at a particular night of drinking. And then the person who has anxiety and can't sleep, their use of alcohol, that alcohol might feel even better because it's more potent as a downer. So I think that would be my recommendation to you is just to try to understand what their relationship with alcohol is. And the one I would be least concerned about is more likely I have one or two here and there, which I don't think you would be concerned about either. I'm concerned about even that. Really?
SPEAKER_04:And actually, you one of the things that concerns me is when they write down whether it's red or white wine. How come? Because there's a there's a permission structure to to drinking it. I know that sounds crazy, but there's a permission structure that occurs you for drinking red wine because you heard that it's good for your heart and all this sort of stuff. So I I uh that absolutely is a is a red flag for me.
SPEAKER_00:Aaron Powell Interesting. The type of alcohol, when we think about this. Yeah, I mean, in terms of which types of alcohol usually result in someone seeing me, it's most often liquor. And you and I both know this, but as doctors, we define the amount of alcohol as a standard drink is 14 grams of alcohol, right? So it's a 5% 12-ounce beer, a five-ounce glass of 12% wine, or a one and a half fluid ounce shot of 40% liquor. And when I educate kids about this, I'm like if someone gives you a drink, take the beer because it's a finite container. And once you drink it, it's done. But if someone hands you a bottle of liquor, there's however many drinks in it. So I I tend to find that when people make their drinks, they don't measure when they're consuming liquor. And so the consumption is easier to go up and up and up, particularly since a 750 of alcohol has what, like 15 drinks in it? I mean, that's a lot of alcohol in a single purchase as composed to a can of beer. So I'd be interested to see, do you notice a difference in what people drink leading to different outcomes after bariatric surgery?
SPEAKER_04:Aaron Powell I can't I can't say that I've ever noticed that, but maybe I just don't pay enough attention to it. I I can't say that I know. But I've had some people who didn't drink before who have problems afterwards.
SPEAKER_00:Aaron Powell Interesting.
SPEAKER_04:Yeah.
SPEAKER_00:How does that come up? Like in in the postoperative visit, or or when does it tend to come up?
SPEAKER_04:It comes up when I get called that they're in the hospital with with hematemesis.
SPEAKER_00:And a perf ulcer. Yeah.
SPEAKER_04:Interesting. Or, you know, something like that. I mean, one of the most devastating calls I ever got was this woman who I did her weight loss operation, and two years later her husband called me and said, by the way, she shortly after the surgery, she started drinking and she doesn't see her children anymore, and she never comes home.
SPEAKER_00:And uh you know, just awful. So if if I may ask, is is it that they don't drink before surgery and they drink after surgery, or they drink a little before surgery and they drink more after surgery?
SPEAKER_04:Supposedly this woman never drank at all before surgery.
SPEAKER_00:Aaron Powell What do you think leads people to drink after surgery?
SPEAKER_04:So uh catching up for lost time. So when when they started doing the the the children's weight loss surgery at university in Cincinnati, one of the things they learned was that when you do a weight loss operation in a young woman, a teenager, there's a 20% risk of having an unplanned pregnancy within two years. And although we we cut major mortality in cancer, diabetes, and heart disease a lot, we do see an increased risk of deaths from suicides, accidents, and overdoses. That that increase is is small by comparison to what we save, but those are the places where we see the where we see the concern. So for Steve and I, who could have just as easily been psychiatrists, to us this is really distressing. But accidents, suicides, drug overdoses. And so what what is behind that? Well, it may be that actually people getting out there and doing adventurous stuff that they couldn't do before. Sure, right? So you know you you can suddenly get on a motorcycle and maybe that's what happens. So maybe that's what happens. It may be that suddenly you're attractive to the opposite sex and you're going out and you're you're more likely to get pregnant. So it could certainly be that.
SPEAKER_00:I'm putting my addiction hat on here again. So let's say you and I were talking about it. Someone is addicted to alcohol and they get sober. They're craving some sort of positive stimulation. So they'll go to alcohol, caffeine, and food. Is if food is less enjoyable after a weight loss surgery, could they be searching for dopamine elsewhere?
SPEAKER_04:Well, I think we're all searching for dopamine. We're rewired to do so. It's just I I think I think it becomes more accessible to them. They couldn't get up, they couldn't get on a ride in the in the amusement park before. Now they can. There are things that they're able to do now that they could not do before. Can date, they can have sex, they can do things that they otherwise couldn't do. Some of it may be making up for lost time.
SPEAKER_00:Is there a time frame after surgery when they begin to drink? Because if it's a biochemical issue, you'd expect that once the surgery is done and they have a different relationship with food, they would go to alcohol or other things fairly quickly. If it's related to their weight, you would expect to see it further down the road.
SPEAKER_04:I think it's further down the road. Interesting. Yeah, I think it's further down the road. You know, I'm trying to think whether we knew anything about that from Korea. There, especially for men drinking hard liquor, is such a common part of the culture that I I they probably just did it pretty quickly. I think there definitely is and some making up for lost time, and sometimes that's maladaptive. Sometimes it's really adaptive. I can't begin to tell you the number of times people have come back to see me and they say, Listen, I want to thank you. I'm doing the same job that I used to do before. I'm not any smarter, I'm not working any harder, but I've gotten three promotions since then. When, you know, our hesitation about doing patients who have serious binge eating disorders, for example, is is partly to protect ourselves because it's it's our impression that they're really more likely to not lose weight well and to and to struggle with a lot of side effects. So we and that's protecting ourselves. A patient that I saw last week came back and said, I just want to let you know Michael is doing so well, you know, he had his he had his operation five years ago and he's doing so well. He's got a daughter, he's working, he's doing great, he's never been this good before. I wouldn't do his weight loss operation because he had a bad binging disorder. I had him see Steve for a second opinion. He said, No way. He went someplace else, had his sleeve, and it's turned his life around.
SPEAKER_02:I I was wrong. I I I was wrong. And and and it wasn't it wasn't fair to him. It wasn't fair to him.
SPEAKER_04:There are other concerns as well, and this is one of my concerns about linking obesity to things like addiction and and things like that. This is one of my concerns. One of the most devastating things that can happen to somebody when they have weight loss surgery is to have the surgery and not lose weight or regain all of it. That is really devastating. I have a close family member who's a very smart, capable person who basically says, I won't do it because I'm afraid it won't work and I would feel so bad about myself if I do that. And my concern if if you link it to something behavioral and it doesn't work, then it's just you need to try harder. You need to exercise more, you need to walk more, you need to go to church more, you need to take this drug. And rather than acknowledging that this is fit, this is part of the biology, you know, the set point of weight, I know you know about that, but it's fascinating. Most people live at a kind of a stable weight, right? And they lose weight and they almost always go back to that. That that set point goes up by about 20 to 30 pounds between the ages of 20 and 50, something like that. But it tends to be stable for most people over time. It can be disrupted by menopause, childbirth medications, some things like that. But in general, that's what it is. And some people have a desirable set point. They can live in a candy shop and eat whatever they want and never get overweight. And other people, they seem to breathe heavily and they gain weight from the atmosphere of photosynthesize. So I I'm a strong believer in that. And I and I am such a believer in that because I've seen people over such a long period of time go through this. And when you look at the studies looking at it, it's just fascinating. So, so a lot of the studies you need to be really careful when you're reading these because they typically report outcomes based on the people who do well. So a lot of the studies, they say of the people who do well, this many did this this well. And they don't report the people who fell out of the program, who didn't do well. But you know, in the past, without without pharmacotherapy, and even for the most part, with until we had the GLPs, the likelihood that you were gonna lose and keep off a substantial amount of weight for more than 10 years was was under 5%. It was it was really under 5%. And it didn't matter whether you went to weight watches, whether you had psychotherapy, didn't matter whether you took fenfen, you know, none of those things mattered. You basically kind of inevitably went back up to the same weight that you're gonna be. And that's that's that's just what the real numbers, that's just what the real numbers with carefully done studies with good follow-up show. Now, your point about the highly processed foods and stuff, I think is a really important one. It's a really important one because for a long time I was gonna argue that the the set point really isn't changing. What we've seen in the last 30 years is that although the median weight hasn't gone up that much, the average weight has gone up, and that's because the people who were at the heavier end of the spectrum are getting much, much, much heavier. So they're getting much heavier. And it does look as though maybe to some degree the set point is is actually broken. And what I don't know is was that set point always broken, and just that our environment has become such that that they can become all they were intended to be, that they now can become 400 pounds when before they just couldn't get above 300 pounds because you had to walk more because food wasn't as available, that kind of stuff. So I think that's true. But it but in general, that set point for most people still kind of holds. I do think that maybe the set point is completely broken for some people. And I can break it with Zyprexa. I could get you 200 pounds with Zyprexa. It's remarkable. It's it's absolutely remarkable. So I think that I think that's partly partly broken by this. As I was listening to you talk about how desirable processed foods have become and the scientific basis by which they do this, and I was thinking, I want him to just play that back to himself. And rather than saying that this is a food company and doing doing this, I want them to imagine it's an Italian grandmother preparing a meal and trying to find the absolute perfect combination of fat, sugar, and salt that is going to make my child happy. Right? Interesting. And it the listen to it again. It's exactly the same thing that we all do. And my wife is fabulous at this. I mean, she can she can make the food absolutely amazing. And so it's not just industry that's doing this. This is true, this is true everywhere and in every way. I do think that the processed foods are a unique harm. I truly, truly, truly believe that. And one of the things I want to ask you about is bias. So, so I give lectures about how unfair I think bias is against people who are overweight. And I think that's it's a useful thing to be careful of. But I actually think that bias can be really helpful if it's done in the proper way. And here's a way to think about it.
SPEAKER_02:We live in California, very few people smoke. Why is that? Compared to Virginia. Why is that? Is there an answer? Well, I have an idea. I have an idea.
SPEAKER_04:And I think and I think I think it's not because maybe we're biased against people smoke, but I think because we're biased against tobacco. The industry. Not just the industry, just the use of tobacco. We're biased against the use of t tobacco. And I want people to be biased against soft drinks. Seven percent of our calories in this country are pure sugar to come from soft drinks. That there no other food provides that percentage of calories as soft drinks in this country. And nobody needs to drink a soft drink. Nobody needs to. And if you're drinking diet, well, the problem there is when you give mice diet soft drinks, it turns out it it pro they actually gain weight. And it's probably because it changes the gut biome, is probably the that's the hypothesis. But so I want people to be biased against fast food. I want people to be biased against soft drinks. So I want that bias to be built in. And I think that's different than being biased against people who have a weight problem. Because every time I think about that, I think about that child with a melanocorpin four receptor defect who's being treated completely unfairly because people don't understand that background.
SPEAKER_00:Yeah, I lecture professionally on stigma, and stigma kills. It is a big problem in healthcare, and stigma casts a very wide net. There's stigma about epilepsy, there's stigma about schizophrenia, there's stigma about urinary incontinence, and there's actually some research that, in particular in patients with obesity, weight stigma, there's an immortality difference associated with it.
SPEAKER_04:Yeah. They don't go to the doctor, they don't yeah, all those sorts of things.
SPEAKER_00:So I I agree with you. Just as there is a bias against fentanyl. Yeah. People view it view it as an enemy, which it is. I 100% agree with you. The way I look at it and the way I teach about it is that the brain only knows one liquid, and that's water, and it does not recognize the calories in non-water drinks. And so a soft drink should be viewed as dessert.
SPEAKER_04:Or poison.
SPEAKER_00:Yeah. Well said. Yeah.
SPEAKER_04:Or poison. So if somebody comes to us and they want weight loss surgery, five of six are going to get turned away. Okay. And some because they don't need it, some because they don't qualify, some because they're too sick and we can't get them ready for it. Some because we're concerned that they're not going to actually be able to use it effectively. And during the course of that, and and when I think about an eating disorder or depression or something like that, I can't take them to surgery until I've got their congestive heart fail under control. And I can't take them to surgery until the diabetes is is under enough control that they can that they can have a safe operation and heal. And I can't take them to surgery until I've got their eating disorder treated. Now, the problem is I don't have a way to cure somebody's eating disorder. I can manage it, I can help them with it, but I can't cure it. And I shouldn't withhold the most effective treatment we have for them. I shouldn't withhold that for them because they happen to have an eating disorder, unless maybe it's uh anorexia. Right. So that's that's that's that's the way I think about it. So don't be mad at a baritage surgeon because they did it that operation. We treat all those things. I had a dietitian come stay with me one day and she was following me around. She was fascinated because this patient came in and they weren't losing weight and such. And and and I walked in, my first question was, are you picking up the mail? Are you cleaning the house? These kind of things. And she wasn't doing any of those things. I said, Well, your problem is depression. We had no conversation about what she was eating, not a thing. The whole conversation was about her depression. She was a couple years post-op, and what happened is that she felt so much better after surgery, she stopped her well butrin. She stopped her well butrine and she got depressed and didn't realize that that's what it was from. And so if I'm trying to prepare somebody for cancer surgery, I have to treat those things. I have to treat their depression. I have to treat all their diabetes, all those kind of things. So Steve and I are kind of like primary care physicians. One of the really cool things about it is that for an underserved population, we actually get to do a lot of primary care because they often don't have primary physicians, but they can always get into our office. So it's kind of fun for us that we get to see that.
SPEAKER_00:What percent of bariatric surgeons approach this the way you and Steve do?
SPEAKER_04:I don't know. A lot do, I think. But I don't, but I don't honestly know.
SPEAKER_00:Well, I mean, this conversation was for you to share your work as a bariatric surgeon.
SPEAKER_03:Yeah.
SPEAKER_00:And I have to say I've learned a lot. I will apologize for being frustrated on my podcast about that particular case. My point I was making in that particular case, it was a very young individual, and there was a lot of mental health issues, and it was very clear that the team managing his weight loss did not recognize his mental health issues, and that was what made me frustrated.
SPEAKER_04:Yeah, and maybe it's because they didn't pay enough attention. Maybe it's because it's actually really hard to know what people are doing. You know, it can be really hard.
SPEAKER_00:Well, and and I just have to compliment you and Steve Chang for taking such a holistic approach, and I'm very thrilled to hear that you are practicing medicine the way you are, because I believe that's what I would think would be the ideal circumstance in weight loss surgery would be to take the whole person into consideration.
SPEAKER_04:Yeah, that's what we try to do. It sounds like you're doing that. That's what we that's what we try to do.
SPEAKER_00:I I I your point is also taken about somebody seeing you and Steve and saying you're not a good candidate and going somewhere else. We'd see in the emergency department, patients who'd been seeing here thought not to be a good candidate would go elsewhere and then kept having complications.
SPEAKER_04:Yeah. And that creates an interesting dilemma because if you know they're going to go have surgery someplace else and you don't think they're an ideal candidate, maybe you should just have it done here because at least that way they're under our umbrella and and maybe we'll do a better job. So there there are those pressures. That's that's always really tricky. One of the things I like to tell people a lot is that if they lose weight and they do well, they're a really good ambassador for people who are overweight. Oftentimes people find that they treat somebody differently because they've lost weight and they learn a lot about themselves when that happens. So if you do well with weight loss surgery, if you lose weight, if you do well, if you don't act crazy, you will change the way people think about people who are overweight because they'll recognize that they had this bias against you and they'll treat other people better. So it's a really important thing that try to be an ambassador for this. But I have a lecture about trying to predict who's going to do well with surgery and who's not. And I go through what the dietitian said, what the psychologist said, what we said. We go through and look at all that, and then how do they do? And we are terrible at predicting. It doesn't matter how much I like you, it doesn't matter how rich you are, it doesn't matter how successful you've been in the rest of your life. It really doesn't. It really doesn't. And one of the objective things that come out of the barrier surgery literature is that we're not very good at it, and that a lot of the stuff that we've tried to do in terms of mental health and stuff like that turns out doesn't actually affect the outcomes. Interesting. It just doesn't affect the outcomes. For a long time, the insurance companies would require that people wait six months or so. And the idea was that it was going to improve outcomes, and it didn't. It didn't improve the outcomes at all. And there used to be programs where they required people to go through very elaborate psychological preparation, stuff like that. Didn't improve the outcomes at all. So I wish we had better ways of assessing these things. We just we just don't. Steve is better at it than I am.
SPEAKER_00:Well, I have to say, Mark, we're both busy people, and I'm sure you have lots to do today. Anything else you wanted to add as we wrap up?
SPEAKER_04:I think that's it. Thank you for having me.
SPEAKER_00:I was gonna say my life goal is to know what I don't know, I don't know, and thank you for helping teach me today.
SPEAKER_04:And, you know, thank you for what you do. We really appreciate it.
SPEAKER_00:Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction. And a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses. To those healthcare providers out there treating patients with addiction, you're doing life-saving work and thank you for what you do. For everyone else tuning in, thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together, we can make it happen. Thanks for listening. And remember, treating addiction saves lives.