Caitlin Whyte (Host): Obesity is a medical condition that can lead to other serious health conditions. In the United States, more than 40% of Americans have obesity. Like any medical condition, obesity can be managed medically. Bariatric surgery has long been considered the gold standard for medical weight loss.

In the new age of popular weight loss medications like Ozempic and Wegovy, patients may be wondering which route is better to reach their weight loss and health goals. Today we are hearing from Dr. Anila Chadha, Obesity Medicine Physician with Dignity Health Medical Group, Bakersfield, who will discuss these options and help you determine which might be right for you.

This is Hello Healthy. I'm your host, Caitlin Whyte.

Well, Doctor, as we begin our discussion here today, can you first tell us what should patients know before considering medical weight management options?

Anila Chadha, MD: Patients should know that the goal of medical weight management is to decrease the burden of cardiometabolic health problems and to improve the quality of life. It is not for vanity purposes. And also, patients should not think that the medication can be used as a jumpstart for the weight loss journey. The medications are serious medications. They are long term and should be taken under the supervision of a physician.

Host: And Dr. Chadha as an Obesity Medicine Physician, when should patients consider medical weight management then?

Anila Chadha, MD: When patients have not been able to lose weight with lifestyle changes, and their body mass index is more than 30, or, their body mass index is more than 27 with an obesity related complication like Type 2 diabetes, hypertension, dyslipidemia, or fatty liver disease, obstructive sleep apnea; then medical weight management should be considered.

Host: All right. So can you explain how both bariatric surgery and these weight loss drugs that we're hearing so much about work?

Anila Chadha, MD: Now, bariatric surgery is of many types, but the most common two types are gastric sleeve surgery and Roux-en-Y gastric bypass surgery. Gastric sleeve surgery is a restrictive procedure in which the volume of the stomach is decreased and by virtue of restriction, patients feel full very quickly and that's how they have less caloric intake.

Roux-en-Y gastric bypass procedure is both restrictive and malabsorptive procedure, wherein not only the size of the stomach is reduced, but a small portion of the stomach is attached to the intestine and then there is less absorption of nutrients. And by virtue of that, both restriction and malabsorption, patients are able to lose weight by caloric restriction.

However, the weight loss medications, or the anti obesity medications, these are of two types, oral and injectable. The oral medications usually, they work by decreasing the appetite. But the new highly effective GLP 1 receptor analog medications, they are the GLP 1 analogs, which are mimetics of our own incretins, or fullness hormones.

These go to the brain, tell our brain, Eat less and do less fat storage and that's how they are able to give us about 15 to 20 percent weight loss.

Host: Wow. Well, that brings me to my next question. Just how much weight can people lose with bariatric surgery or weight loss drugs.

Anila Chadha, MD: There two types of bariatric surgery as I mentioned before. Gastric sleeve surgery, which is only the restrictive procedure, usually can give around 20 to 30 percent total body weight loss, averaging at 26%.

The Roux-en-Y gastric bypass procedure can give 35 to 40 percent total body weight loss. It is more effective. Still, to this time, bariatric procedures are the most effective way to treat severe obesity. On the other hand, oral medications can give 7 to 10 percent weight loss. Oral medications are like phentramine or a combination of phentramine and Topamax or a combination of bupropion and naltrexone. These all average at 7 to 10%.

But the new highly effective GLP 1 receptor analogs are like semaglutide can give on an average of 16% weight loss and the dual peptide, that is the newest medication, tirzepatide can give around 21% weight loss. So as we can see, the 21 percent is in close proximity to the bariatric sleeve procedure, so these are almost rivaling to each other.

Host: Well, we should, of course, talk about some risks involved in these surgeries and medications. So first, what are some of the risks associated with bariatric surgery?

Anila Chadha, MD: Now, the risk associated with bariatric procedures are usually overestimated. With the gastric sleeve surgery, the most common complication that can occur later on is heartburn. So it's not meant for people who already struggle with that. The perioperative or long term mortality of the gastric sleeve surgery is actually less than other common surgery like cholecystectomy or gallbladder surgery.

Similarly, with the Roux-en-Y gastric bypass, the long term complication that we do see can be marginal ulcer, ulcer at the place where the stomach was attached to intestine. That's why these patients should not take any of the NSAIDs like ibuprofen, Motrin, Aleve kind of medications. And sometimes we see complications from malabsorption or vitamin deficiencies because nutrients were not absorbed. So those are the two common complications that we see with gastric bypass.

Host: And how about those weight loss medications? What are some risks or side effects to keep in mind there?

Anila Chadha, MD: So, the new highly effective weight loss medications like GLP1 receptor analogs, most commonly we see the side effects like nausea or constipation. These medications are fullness hormones, so if patient takes bigger portion, the nausea is very common. Mild nausea when initiating the medication or increasing the dose of the medication is very common, may last for 1 to 2 days.

But if nausea is lasting for more than a week, then that's not good. This can happen in 16 to 30 percent of people. And sometimes we have to stop the medication. Other common side effects are constipation because these medications slow down the gastric emptying, so constipation is very common. Rare side effects that we have seen are pancreatitis or gastroparesis.

These are rare. If patients do have gallstone, it can flare up gallbladder disease. If patients do have active retinopathy from diabetes, it can also flare up retinopathy. So these are common side effects from GLP 1 receptor analogs. For the oral medications, the common side effects are palpitations, or insomnia from medications like phentramine or phentramine and Topamax. Because of the Topamax component, patients can have foggy brain sometimes. With naltrexone or bupropion as well, patients can have some nausea.

Host: All right, and is it common for bariatric patients to ever regain their weight?

Anila Chadha, MD: Obesity is a chronic, recurring, relapsing health problem. Any form of weight loss that's done, sometimes later on, patients can regain weight. There was one Swedish study done that showed that gastric sleeve surgery patients, out of all those patients, 27 percent of patients can regain their weight at 7 years. For the Roux-en-Y gastric bypass, the study was done, they were followed for 3 years, and 4 percent of the patients regained the weight back. Now, with respect to medications, a recent trial was done called Surmount Trial on patients who were taking tirzepatide. So, in this trial, patients were given tirzepatide for 3 years, and after that, they were randomized to tirzepatide group and placebo group.

Patients in the placebo group, they started regaining weight immediately when the medication was stopped. This further reinforces that obesity is a chronic health problem and it should be treated throughout the lifespan of the patient. Sometimes we have to prescribe medications after patients start regaining weight after bariatric procedure.

So bariatric procedure and weight loss medications are not mutually exclusive. They can be combined to comprehensively treat patients.

Host: Well, as we wrap up, Doctor, how can patients determine which option is better suited for their weight loss goals?

Anila Chadha, MD: Depending on patient's clinical profile, personal choice, coverage of medications, prior surgeries, a decision is made procedure or medication should be used to treat obesity. So if patient has history of pancreatitis or if patient has family history of medullary carcinoma of thyroid or if patient has gastroparesis; then medications like GLP 1 are not preferred.

But if patient does not have insurance coverage for the medication or patient does not want to take medication for rest of their life, then surgery should be considered. Again, surgery should not be considered in patients who also have history of some mental health or eating disorders like binge eating problems.

Then, maybe medications are a better choice along with behavioral therapy. So depending on each situation, it should be decided between patient and clinician which route they should go, and as I said before, sometimes, after the surgery, we have to prescribe patients medication for either insufficient weight loss from the surgery, or to prevent weight regain after surgery.

Host: And after hearing all of this, how should someone get started on their medical weight loss journey? What steps should they take?

Anila Chadha, MD: Patients looking for treatment for obesity, they should make an appointment to the with their primary care provider or with an obesity medicine physician in their area or with an endocrinologist to discuss about weight management for long term basis. They should talk about various options starting from medications, surgery, and what are the resources available for lifestyle like diet counseling or exercise, or physical therapy.

 That's how they should start seeking for the treatment for obesity.

Host: Well, thank you so much doctor for sharing with us and for all of the work that you do. Find out more about us online at dignityhealth.org/bakersfield/weightloss. You can also find more interesting and informative podcasts in our podcast library, and be sure to share them with your loved ones. This has been Hello Healthy, a Dignity Health podcast.

I'm Caitlin Whyte.