Welcome back to another episode of the podcast. Today, I have another really great interview for you. It's with board certified bariatric surgeon, Dr. Rosen, and I want to say something that's super unique about Dr. Rosen and the reason I brought him on. So he not only practices surgically, but also incorporates the anti obesity medications into his clinic. And this is something where I get asked all the time.
If bariatric surgeons use GLP 1 medications prior to surgery, after surgery, what kind of weight loss can you expect with just the surgery, when do you need to consider adding on more things, there's all these considerations, long term follow up after that, so we really dig into all of it, but I want to say something that particularly struck me here, you know that, yes, we're evidence based, yes, we talk about all the research and things like that, however, I really want you to listen to this
episode and to hear, especially at the end, please make your way all the way to the last minute. If you hear how absolutely filled with compassion Dr. Rosen is to help patients in this area, how much he understands this chronic medical condition, how much he is on your side, how much he's an advocate for you long term having success. The main thing as he was talking, number one, you know, me, I'm a little bit emotional.
I wanted to burst into tears as he was saying those things at the end, but here's the other thing that really struck me. Honestly, all of you, if you do not have doctors that talk this passionately about helping you, you need to keep going until you find someone that has this type of heart because yes, there's surgical skills. Yes, there's medical knowledge, but someone needs to. Be on your side.
You need to feel like when you have weight regain that it's not that you've let them down or it's not an embarrassment. This is just a medical condition. So I really want to encourage you to listen all the way to the end of this, even if you have not had bariatric surgery or are not even considering it. I still think that there's a lot to learn in this episode. Hope you enjoy. Okay. Welcome thank you so much, Dr. Rosen for coming on the podcast.
I know that our audience needs to hear what you're going to say. So can we start out if you can introduce yourself and tell us how you help patients just so that our audience knows. Sure. Dr. Ntia, thank you so much for podcast. It's a real pleasure. My name is Dr. Daniel Rosen and I am a bariatric surgeon and obesity doctor as well as a general surgeon who mostly focuses on hernia repairs. And hernia repairs are really prevalent for people with obesity.
Because the high pressure that builds up in their abdomen can lead to areas bulging out. And that is what's called a hernia. Those three main focuses of my practice. are really complimentary, as a whole. And lately we've seen a big uptick in the number of patients interested in obesity medicine treatment. And that has been very exciting for that one branch of my practice, but not necessarily so exciting for the other branch of my practice.
And, I'm just really happy to be here today and sort of talk to you about. What's been going on in that whole world. This is one of the reasons I brought you on because number one, you have that surgical expertise, but you also do practice a lot of that clinical medicine side as well with obesity care.
I guess I have so many questions related to these areas specifically and one of them being, I think that there definitely is a time and a place for surgery, but I'm wondering what are you seeing as far as trends that. Are we using more of the GLP 1s before surgery, after surgeries? Can you tell me kind of how that landscape has changed?
I think that GLP 1s entry into the toolbox for not just doctors, but for bariatric surgeons specifically is very The medications were really something that was outside of our everyday purview for the vast majority of surgeons because they were so ineffective compared to surgery. You would see weight losses of 80 pounds, 100 pounds with a surgical procedure, and you would see weight losses of 10, 15 pounds with something like Phentermine or Contrave or Qsimia.
It never really... made a huge dent on our radar because the interventions tended to be so modest compared to the big weight losses you would see with surgery. But with GLP ones, you're seeing weight losses of 50 pounds, 70 pounds. That's not unusual. It's really jumped onto our radar as clinicians, especially when you have patients coming in saying that they want that instead of surgery.
It forces you to sort of understand what these medications are, how they work, how effective they can be compared to the more traditional surgical interventions. And we can use them and we do use them, both before surgery, as well as after surgery. For before surgery, they're really effective for a very high BMI, high risk patient to try and lower that. operative risk. So if you to find what that number is, because I think people listening aren't going to know are they in that category or not?
So what BMI number do you tend to see that as? So for me, I want people to lower their weight preoperatively, whatever their weight because there'll be a lower surgical risk at 320 than they are at 340. And there'll be a lower surgical risk at 260 than they would be at 280.
But I would hold off on a surgery if someone is, above 400 pounds, I would really push for them to get below 400 pounds, let's say, as a number where I would potentially hold off on scheduling a surgical date until we can bring their weight, say under 400 pounds. But that's not hard and fast. If someone is 500 pounds, I may set that number at 450.
In my surgical practice, I try not to operate on patients above 450 pounds because I think you really need to have an integrated hospital that deals with the very highest BMI patients, which for me would be over 450 pounds. For some people, they would use a cutoff of, say, 600 pounds, like you see on that TV show, My 600 lb Life. For me personally, it's 450 pounds, but I always try and set realistic, attainable goals for preoperative weight loss, and these medications can be very helpful.
to get people to reach those, sometimes aggressive pre op weight loss goals. Who do you find is someone that should consider surgery? Do you nowadays try to see what the medications, what can happen, or do you know if they're above a certain BMI point? Who are you saying, hey, you are a good surgical candidate? It's really evolving because these medications are so new and how they integrate. And it's not just on my end how they integrate, it's on the patient's end.
You had a patient who comes in and found out that their friend lost 80 pounds on these medications. They may not be willing to even consider surgery, even though from a BMI perspective, they could qualify for surgery, even though their insurance may pay for their surgery, but they won't pay for these medications and it would be an out of pocket expense to them. They, that patient may not be ready for the mental leap.
to, you know, have general anesthesia and undergo a life threatening surgery, but that in many instances is a life saving surgery. And so it's the mindset of the patient as much as my desire for a specific intervention. That has to guide my treatment. Yeah, I really like that you're saying how fluid it is because that's what I saw. I'm on the clinical side, right? But I see that a lot of people, they want to try first the medication. Maybe they're not as successful as they thought they would be.
I find that then they're more open to getting that surgical consult. If we're able to have really, I call it like the college try, right? Like we're, we're really doing all the things. And if it's not getting them fully where they want to go, then they're open to that next step. And can you, can you tell us just, the main procedures, like I think about sleeve and RNY, but feel free to throw whatever else in there.
What. Typical weight loss percentages, like total body weight reduction on average. I know everyone's different, but on average could we expect with these procedures? A lot of times there's different terminology, a lot I'm most comfortable dealing with percent excess weight loss, as opposed to total weight loss. I know with these medications, they tend to, tout total weight loss percentages of in the mid-teens to. Low 20s.
I think that the conversion would be 60% excess weight loss, typically would convert to a high 20s, mid to high 20s of total weight loss. And that's what you would typically see with a sleeve gastrectomy. With a bypass procedure, you could see, weight, total weight losses of about 30% into the low 30s. You're talking about significant weight loss, 80 to 100 pounds is not unusual with a sleeve gastrectomy and that's to their bottom weight.
Now there's some weight regain that we see over time, so that's not necessarily where they'll be 10 years after the sleeve, but that's a one year weight loss of 70 to 80 pounds. With a gastric bypass, it tends to be a little bit more, you know, usually 20% more weight loss with a bypass operation than you would see with a sleeve operation. Other interventions like the lap band have really fallen out of favor in the last five years.
And I believe that these medications are an absolute death knell for balloons. Which was gonna ask you about that because I feel like they're they're hawking this as quick weight loss. So if anyone's listening here, I'm gonna put it simply correct me if I'm wrong, but you put a balloon in and it could be in for a certain period of time again, depending on what's being used, but then it has to come out.
And so it's this sort of maybe if you're trying to need it like a knee replacement in a few months, you've got to quickly get down to BMI, things like that. But otherwise, I'm glad that you brought that up because I feel like they really advertise it a lot trying to get people to do that. I haven't seen that much balloon advertising lately. It's interesting. You know, I put in a lot of balloons and they can be very effective. They can be good for like 30 to 40 pounds of weight loss.
I don't think you typically see more than mid forties. pounds lost with a balloon on average, and that's with the best balloons. There's the kind that you swallow versus the kind that are inserted surgically. The ones that you swallow are smaller, and are air filled typically. Those, to the best of my knowledge, aren't available in the U. S. market right now. They stopped producing during COVID.
The fluid filled balloons go in with an endoscopy and general anesthesia, and then they're inflated in your stomach. And those tend to have the better weight loss in the neighborhood of 30 to 40 pounds. But when they do come out, your hunger comes back, and typically it's hard to keep the weight off. But for me, the parallel would be stopping the medications. It's, it's the same thing.
The same type of signaling disappears, the balloon stretches the walls of the stomach and that stimulates certain hormones and mechanoreceptors that transmit into the brain and stimulate a sensation of fullness, just like GLP 1 works to stimulate a diminishment of appetite and a sensation of fullness. So when that balloon goes up, comes out, then that receptor, then that signaling tends to decrease and without the balloon filling space in the stomach, you're able to eat more and weight comes up.
So it's the same type of challenge. The issue is pound for pound, balloons are gonna be about twice as expensive and they're gonna, and they're gonna require at least general anesthesia to come out, let alone potentially two endoscopies, one to go in and one to come out. So it's hard for me to, to push balloons for my patients.
The only patient that is really appropriate for balloon at this point would be someone who says, I don't want any medication in my body, but I'm okay with a device put into my body. That's a pretty rare patient that would be okay with. One but not the other. Yeah. Thank you for giving more detail on that because I feel like there's we definitely have access to different things in different parts of the country and what our endoscopists are comfortable with things like that.
Getting back for a second to the bariatric surgery? So you mentioned the. A percentage of weight that can be seen to go down. And then you kind of threw in a comment with the regain that we see. And I know, I think this is very common. I catch people 10, 15 years out from these procedures, feeling defeated. Maybe they've put on half the weight or maybe all the weight back. What do we see typically from the data is sort of expected.
When I say long term, I don't know what kind of numbers you can give me. Maybe like 10 years out from a ruined Y, things like that. What do we typically see? Weight regain is normal. Right. No one stays at their low. That's why it's called the low. And it's pretty expected to see weight regain up to 25% of what you've lost. That's what I would call expected weight regain. The numbers of 25 to 50% weight regain would be where I would.
really begin to counsel the patient and look for some sort of intervention to slow that regain or reverse that regain, whether it's intensive nutritional counseling, working with their exercise, involving a personal trainer, perhaps. getting a psychologist involved if there's some disordered eating patterns that have returned. All of those adjunctive measures can help a patient limit their regain or reverse some of their regain.
When you get to regains of 50% and more, that would be where I would think about investigating some sort of revision surgery. The majority of patients are able to keep 50% of their lost weight off. At five to 10 years, I would say, it would be the vast minority that would regain all their weight back. Less than 5%, I would say, would regain all of their way back.
And I would be very curious in those patients to closely investigate how their surgery was done or what surgery was done for the very, very obese patients. A band wouldn't be effective long term, in my experience. I personally, for a long period of time when I was doing more lap bands in my practice, would try to counsel someone who was a BMI of 43 and above to not consider a lap band because it would be less effective than a sleeve.
Along the same lines, For high BMI patients like 50 and above, a sleeve will likely alone not be enough. And there are a lot of surgeons, bariatric surgeons who are comfortable doing sleeves but not comfortable doing more technical operations like gastric bypass or duodenal switch. And for them, they'll pitch sleeve all day, every day to every patient. And it's not the right operation because it's not powerful enough. to get a BMI 50 person to below that BMI 30 threshold.
So for those patients, it's always, I love the sleeve. Let's do the sleeve. Let's see how you do, but know that at least 50% of patients in your BMI category will not lose enough weight with that sleeve to be in a healthy range, a lower thirties or high twenties BMI or out of the obese range. And that we will need to do a bypass operation of some sort on top of that sleep, either converting you to a gastric bypass.
Or to a duodenal switch and the problem is that I see patients all the time who've had sleeves at other practice who were never told that to prepare for that they got their sleeve, they lost 80 pounds, they stalled out and now it's coming back and they feel like they.
that they failed themselves, but really their surgeons failed them by not setting them up with appropriate expectations and not watching them closely so that at that 80 pound mark, when they stalled out and when that weight started to come back on, that's when you hit them with the second stage, planned second stage procedure to restart that weight loss curve and get them to a much lower BMI than they would have.
And to speak to staging things in my practice, I think that's safer for high BMI patients. Because I follow them so closely, to do a sleeve, which is a quicker operation, less complicated operation, a hundred pounds off, and then before they start to regain in any major way, now do a more complicated bypass operation with them at a lower operative risk because of that initial weight loss achieved by the sleeve.
Yeah, I'm really glad that you talked about the part two here because it's exactly what you're saying. I don't see that much coming off of the sleeve. Then they get discouraged. Then they think, well, surgery isn't for me or nothing can work. And it's this whole, blame and shame and all this thing that they take on when really it's just, we need a different surgical approach.
So you bring up something, I'm hearing that you have good followup with your patients, but I hear a lot of patients that have had a surgery. They do maybe, like the. the first post op visit, but they kind of get lost after a year or two. Is that normal? Is that expected or who's supposed to follow this long term how they're doing? It's not expected.
Recommendations are to follow bariatric surgery patients for life, especially with the potential for vitamin deficiencies, the potential for weight regain over time. It's important to establish that relationship from the get go. When I cut you.
You know, we're inextricably linked and I expect to be on this journey with you and I will tell patients like and I have patients who stopped coming for a while and then they come back and I tell them how upset I am that they robbed me of the joy of going on the transformative journey that I find so rewarding that I didn't get a chance to to Witness that with them because they came once or twice after surgery and They hadn't lost the majority of their weight yet, and then they show up two years
later, and I'm like welcome back Yeah, we missed you. I mean, I'm sure to tell you, though, this is not most surgeons because I feel that again that people have these huge lapses in their care. Frankly, it scares me. They'll come to me 10 years after having last seen a doctor. Surgery was 12, 15 years ago. I'm sitting there thinking, what are we going to find on labs? Right? Okay, so people should be following up more consistently is what I'm hearing.
Are there labs that they should be checking that these things are getting monitored? Is there certain lab profile that Everyone needs every year. Is there anything that you've put out there like that? Every surgeon has their own sort of go to lab profiles. In general, you want to be checking on vitamins A, D, E, and K. If someone has had a bypass operation because those are fat soluble vitamins. You want to be checking their lipid profiles.
You want to be checking iron is the big one for any kind of bypass operation because iron is absorbed in the beginning of the intestine and those that's the part that you're bypassing in a bypass operation. So iron is always a big issue for bariatric surgery patients. And then in general it's just making sure their protein is good, their albumin, things of that nature. There's no magic recipe or potion for, for lab monitoring.
And Primary care practitioners are completely capable of tracking bariatric surgery patients. In terms of the loss to follow up, I would say there's two issues at hand. First, there's the disposition of the surgeon. And while as a bariatric surgeon, you should get into this field to be with patients for years and years and years, the other coin of being a surgeon is you're a problem fixer. I can tell you this from my, my hernia repair side of my practice. Someone comes in, nice to meet you.
Here's my hernia. This is how we fix it. We fix it. Your hernia is fixed. Have a great life. Come back and see me if there's any issues. That's very rewarding as a surgeon and and you're not necessarily in that groove of seeing patients every year. That's a little bit more in the primary care practitioner realm. But if you're in love with bariatrics as the procedure, you've got to be in love.
I think it comes up against surgeons natural inclination to sort of do an operation and then be done with a person. And that's obviously not how I approach my bariatric practice. But the other side of it is patient driven. And this is a big deal because patients on the one hand, think that surgery is done The weight loss is coming off whether they wanted to or not in the beginning in the first six months.
So they're lulled into the sense that like, I got this, like whatever the surgeon's been able to do is done and everything else I can manage. There's that piece that the patient is so confident with their success that they don't need to see the doctor anymore. And then other side of that is when they start to regain weight, they're embarrassed.
Yeah, and they are afraid to let the surgeon down and they don't, they choose not to go to follow ups because they feel like they're going to get scolded for gaining weight that they somehow failed the surgeon, which is very backwards way of thinking for me because I'm all about like we're a team and we're working towards a common goal. How can I help you if you don't come and see me? Right. I hear that. I like the, the patient ownership part.
And what I always say is, as a patient, they need to know who's owning this long term follow up, not everyone's as privileged to have an amazing physician like you that follows them long term. So I'm like, okay, no problem. Maybe you're in an area where the surgeon doesn't have the time to take on that follow up, but then who's going to do it. You need to know that. And if not, you need to start to seek them out. It's like a little bit, we have to kind of take that on.
You've hit on so many things that I even had all these other questions here, and you've, you've, you've, you know, gone into all of them as you're talking. Are there certain, real quick, are there certain, like, multivitamins or things that you recommend that they do to help them out? I think that most vitamin formulations are adequate for bariatric surgery patients. I don't have any formal relationships with any companies and I try not to push particular products.
What's important is to follow those vitamin levels. to get those laboratory tests so that you can see what specifically is in need of repletion or replenishment or supplementation. If you're not getting your blood work checked yearly, then you can't see what it is you need to target. Most vitamins I believe are adequate to provide what is necessary for a supplementation standpoint, but not if you're very low in something. And you won't know that unless you're being checked, right?
I think as doctors, we don't have all the answers. And I really believe that patients. have so much valuable information that social media is such a good resource for answering questions based on other patients experiences. You want to know what the best vitamin is. You can get 20 different people giving you 20 different answers. And while that might be overwhelming, you might be able to connect with one or two people whose experience resonates and is valuable for you.
And that can help guide you on. Getting the right products or the right path or treatment or idea. Obviously everything should be discussed with your doctor. I think social media is this incredible resource to get a lot of your everyday questions answered based on other people's real experience. Yeah, I'm glad you bring that up because I feel like on social I think the bariatric community is strong. They never really had a place I think before to really congregate.
And I think before sort of tick tock and things like that took off. I think it was sort of these random Facebook groups that who knew what was really going on. But. Even just them sharing ideas for how to get increased protein with smaller volumes. It's incredible the things you hear, right? I learn a lot. I feel like I consume it to, to be honest, to be in the know, to kind of hear what people are thinking. Is there any other words of wisdom that you think our audience needs to hear?
Anything that you wish that people would hear prior to seeing the bariatric surgeon or know? Yeah, I think it's really important to advocate for yourself, to If you own the fact that you have a disease that you are worthy for treatment, you should not be judged as less than anybody else. And you should be applauded for any proactive steps you take to manage your disease and bariatric surgery is something that has proven to be reliable and effective to manage obesity and it is management.
It is not curative, meaning. That weight regain will come even though you're so excited to be done with surgery and you're in that honeymoon period where the weight's falling off and your clothes fit and getting rid of your old closets worth of extremely oversized now clothes, but it is a disease and we are trying to manage it and it is a chronic disease and some people, get it. Rosacea, some people get ADHD, some people get obesity. We all have our challenges for the obese population.
They have to wear their challenge out front and center for everyone else to judge. And you have to be strong to be someone who deals with obesity and doesn't get swallowed up by it. Forgive, you know, the terrible pun, and I am just so honored and grateful to be part of that community, to be able to help people in that community. It's just one of the greatest honors of my life. So get as much resources as you can.
Never be afraid to advocate for yourself and find the health care providers that see you as a human who's struggling with a disease. rather than judge you as someone who's anything less than anyone else. Yeah, if I could do like a standing ovation right now, I would because you summed it up, right? You summed it up and it and that's it, right? I think people they've been on the yo yo dieting and they're going round and round. They keep thinking they're going to find the answer.
Unfortunately, we don't have the cure. We have treatments. We have tools. We've got ways to make it easier, but. And then yeah, you just describe like it is hard to kind of wear it on the outside because everyone sees what your thing is, but everyone else has got something to and remembering that the more we can internalize like this is something like anything else. I think I find my patients get a lot of relief me personally. And you're like, okay, we keep going.
We keep trying what's there and we move forward. So I just want to thank you so much for coming on. How can people find you on social? How can they find you in your clinic? Can you just tell us how the people can find you? Sure. So my handles are. Dr. Daniel Rosen, that's D. R. Daniel Rosen, and my website is WaitZen. W E I G H T Z E N, and that's all about coming to terms with obesity and being at peace inside and out.
So that's sort of what we try and do in terms of management of the chronic disease of obesity with nutrition, with medication, with surgery. So WeightsEnd. com and yeah, check out our TikToks, check out our Instagram, we're always trying to make exciting new content that engages people, educates people, motivates people, inspires people, just like you.
Yeah. I was gonna say, we're gonna link all your stuff below your stuff is so informative and great and like catchy and you want to watch it and you learn stuff. And I think that's just amazing that you're that you're out here sharing all of this. Just thank you again so much for coming on. Thank you very much. It's an honor. I appreciate you.