Scott Webb (Host): Many of us either want to lose weight or based on our BMI really need to lose weight. But deciding between medications like GLP-1s or bariatric surgery or possibly both, really requires the expertise of someone like my guest today, and I'm joined today by Dr. Igor Wanko, Board Certified Bariatric Surgeon with Franciscan Health.

 This is the Franciscan Health Doc Pod. I'm Scott Webb.

Doctor it's nice to have you here today. We're going to talk about weight loss and understanding GLP-1s, bariatric surgery. We're going to cover a wide gamut of things today, but before we get there, you know, I know obesity's on the rise and we hear a lot about weight loss in the news. So we want to maybe talk about the differences between medical weight loss, drugs, and surgery.

So if we start with the GLP-1 drugs, maybe you could explain how these medications help patients lose weight.

Igor Wanko Mboumi, MD, FACS: The biggest thing I think for patients to remember is that, the sort of discussion around weight loss and the systems through which we go about losing weight is a multimodal system. You know, the key is to ensure that we're have a comprehensive approach where you're doing exercise, your diet, eating healthy, having healthy lifestyle and exercising. And medications and surgery actually go hand in hand. I think that for a lot of patients, they think of it as one versus the other, but the key is to remember that they can work in unison.

Now, surgery's not for everybody. The GLP-1s, are also, you know, good options for people who, either don't qualify for surgery or, don't need the surgery or simply don't want to have it. They basically work on the GLP-1 receptors, most of them. The one that Lily has, works on the GIP receptor, it's a double receptor and there's, there's more coming and they, they work by, inhibiting appetite.

They work on the hypothalamus. And really increase satiety and, work on some of the hormones that are actually the ones that bariatric surgery has been found to work on. And, and this is sort of how they help patients lose weight.

Host: Sure. Yeah, maybe you could tell us then, like or describe if you will, the type of patient that would be a good candidate for weight loss medications.

Igor Wanko Mboumi, MD, FACS: Most patients who fall under the umbrella of, you know, BMI over 27 or, BMI is the body mass index, body mass index over 31, uh, will generally be reasonable candidates for the surgery. I mean, we, we do know that there are multiple sort of benefits that go beyond simply losing weight that can help really with the overall. But the key is, you know, patients with comorbidities, patients with diabetes, patients with heart failure or heart disease in general. There's more studies coming out with patients with fatty liver disease and the improvement in, in those patients, even patients who, you know, would qualify for surgery and may need some sort of, start that can sort of enable some initial weight loss prior to undergoing surgery.

Keep going back to the, you know, thinking about the GLP-1s as an to weight loss overall, not as the answer. So one has to exercise, one has to make sure they're eating the right food. And then some have to also consider surgery Now, you know, there's data showing that patients who just start on that medication and do nothing else and, stop it abruptly either for, for insurance purposes or tolerability or simply because of, you know, they just simply can't afford it.

Like, those patients end up gaining significant weight and, and gain even more than they did prior to starting the medication. So, it's definitely not an answer. It has to be combined with medication and, and dietary changes and for those who stop and continue dietary and exercise and, proper lifestyle, they can actually maintain a significant amount of the weight off, and keep some of that, that weight loss off even after stopping medication.

Host: Sure. Yeah. So as you say, there's some responsibility on the patients themselves to you know, eat better, eat right, maintain their fitness, you know, working out, that sort of thing. So you give sense there that, there are advantages to GLP-1s beyond just weight loss, but are there some disadvantages as well?

Igor Wanko Mboumi, MD, FACS: Yeah. You know, as we know, there's just advantages to everything that, that we do. And even if the, the things that are very good for us can also have some bad aspects. Now, there's recent data regarding semaglutide, with, uh, optic nerve neuritis or ischemia, which has caused some blindness in a few patients.

But this is, you know, far and few between. I mean, but, uh, nevertheless, it's a very, very serious side effect to keep in mind. You know, for some patients who may sort of have severe response to the medication, can have, you know, dehydration and, and dehydration can lead to acute kidney injury and, and, and certain things.

A few of my patients though just can't tolerate the medications, who are non-responders. The notion is if, if you lose less than 5% of your total weight in around three to six months, most likely you're non-responders and those medications do not work for you.

It's better to seek probably a consultation with maybe a bariatric surgeon to see if there's another avenue for you. Another thing is tolerance, some patients do tolerate it, but if they start at A BMI of 50, and, and the medication helps them get down to a BMI of 40, they're still at risk for a lot of the comorbidities that anybody with a BMI of 40 would be. So even those patients that may lose significant weight, may lose a hundred pounds, but if they end up with a BMI of 40, that's still a patient that I would definitely still consider someone who needs, you know, sort of aggressive care to help with their overall obesity.

Host: Yeah, as you said, like the drugs just may not be enough, right?

Igor Wanko Mboumi, MD, FACS: Yeah. And, and the biggest management, one of the things for patients who can tolerate and, and patients who do well is cost. And then the perils that come about if you want a way to stop medication. Right. Is, you know, a lot of weight regain and, cost you have to basically be on it for the rest of your life, right?

And that's one thing we, do know in terms of maintaining the same amount of weight off. You basically have to be on it chronically for a very long time. Now, there's some notion that, some of the pharmas that are at the forefront of weight loss are actually coming out with different maintenance regimens.

And then there's studies looking at whether those patients can maintain their weight, without you know, having to take the same intense regimen long term.

Host: Okay. Yeah. And as you say that a patient may lose a significant amount of weight but still have a BMI well over 31. Right. So let's talk then about bariatric surgery as you being a bariatric surgeon, right? Like which type of patient may be, you know, is it a better fit for when we start talking about weight loss drugs, either alone or weight loss drugs with surgery as a combination? Who's a good fit for bariatric surgery?

Igor Wanko Mboumi, MD, FACS: I would say, you know, definitely some of the patients that this is a fit for, is patients who have a higher BMI. Anybody with a BMI of 40 for sure should be a candidate for potentially at least considering surgery. Anybody with a BMI of 35 and two significant obesity comorbidities such as, you know, heartburn or chronic GERD or diabetes especially.

Bariatric surgery is, especially gastric bypass or, or a sleeve can cure diabetes as long as it's a Type 2 diabetic, it can help patients get off their medications for the rest of their life. Some patients also may not necessarily have the money financially.

So although we think of bariatric surgery as, you know, costly, if you do a comparison, it's a lot cheaper for patients to have a surgery and not have to be on a medication that's pretty costly for, for long, long periods of time. So, it's something that every patient should really have, to know as part of their armamentarium, even if you know the medications work. I think in terms of getting patients back to their close to as normal weight as possible, or BMI body mass index of 25, there's really been nothing that has been shown to have the same amount of success as bariatric surgery.

Host: Right. Yeah. And until the popularity, if you will, of the GLP-1s, you know, gastric sleeve, gastric bypass was the gold standard. And, in many cases it may still be for folks who have a, you know, significant amount of weight to lose or keep off. So, let's do that. Let, let's like kind of go through the two.

Maybe you can tell us the differences between the two. We sort of use them interchangeably, but obviously they're a little bit different. So what are the differences between the two surgeries?

Igor Wanko Mboumi, MD, FACS: The gastric sleeve is mostly restrictive surgery where we basically take away 80% of on average, 80% of the stomach. We use a calibrating tool to make sure that we leave the stomach at a particular size. And, and this can, help patients lose a lot of weight. The surgery is thought of as restrictive, but we look at the data and, some of the, uh, scientific research shows that it also is a, a hormonal procedure where, a lot of the hormones, for example, Ghrelin hormone is produced within the fundus of the stomach which is a part of the stomach that we take out. And Ghrelin hormone makes people hungry and, and increases appetite, makes people crave different foods. So when we take away that part of the stomach, patients get a, a hormonal effect that also modifies behavior. So it's not simply a restriction surgery, it's also a hormonal surgery.

Bypass is not only restrictive surgery also because we, we make the stomach much smaller, but we also do a malabsorption procedure with a bypass, the gastric bypass where we're bypassing approximately 150 centimeters of bowel. So, patients are basically undergoing a malabsorptive procedure that is done on purpose and we give them supplementations so what they ingest with their mouth isn't necessarily what the body is able to fully retain.

So, this leads to a significant amount of weight loss for patients. And, you know, part of it is patient preference. Some patients want one or the other. They've had a family member who I had a, who's had a bypass and succeed with one, or they've had another one who's had a sleeve and they, they want that.

But bypass has been around for a very long time. It's a very successful surgery. Patients do exquisitely well, and the way our program works at Franciscan, we basically get the patients home the next day. And for some cases for sleeves, those can be done as outpatient.

You know, the most common thing that I hear from patients in terms of bariatric surgery is that they wish they would've done it sooner. My advice is don't wait too long and, and just get to inquire about these things early, as early as one is physically able to and mentally able to.

Host: Just makes me wonder, even though they are the gold standard, the surgical options; generally speaking, are there some advantages we need to know about besides weight loss? And or are there some disadvantages that you'd like to make folks aware of?

Igor Wanko Mboumi, MD, FACS: Here's a, an interesting thing. So when you, uh, hear about the research that the pharmaceutical companies are doing that show improvement in high blood pressure, diabetes, heart failure, these are all research, that are basically being replicated.

They were previously done for bariatric surgery. So bariatric surgery over the years has proven to cure all those things in terms of heart failure, heart disease, decrease the rates of uterine cancer, decrease the risk of esophageal cancer with the bypass. So all those things were actually findings that were found for bariatric surgery research.

This is a playbook or the sort of the guide that the pharma companies are using to then replicate that same study with their medication. Because the underlying, cure is weight loss. It, it, is not necessarily about how you go about the weight loss.

So that's the biggest advantage. Another thing I would say is of all the modalities of weight loss, exercise, dietary, medication, they all help patients lose weight, but they, all of them, by and large, decrease your metabolism, make your metabolism slower, because your body's response to all of it is to try to get you to regain some weight.

Works in an oxymoron kind of fashion. But you know, the only exception is, is weight loss surgery. Weight loss surgery not only helps you lose weight, but it also actually increases. We found that it increases metabolism in patients and really helps them reset. It really helps them actually, not only lose weight, but also increase their metabolism.

So they process food faster. Why that happens is not a hundred percent you know, well known, but there's theories, that it's again, that hormonal process of the actual surgery that's, that is beyond just the physical, visual, aspect of the surgery itself.

Host: Okay. Yeah, it's, really interesting. Whem we think about doctor, a person, a candidate, a patient that might be good, a good fit for both weight loss drugs and bariatric surgery, who is that patient per se?

Igor Wanko Mboumi, MD, FACS: Obesity is a chronic disease. And it is a lifetime struggle. You can have surgery and just forget about everything and even patients who've had surgery still, you know, after two or three years have a chance of weight regain. And we know that, we know that that happens not just with medicine, not just with diet and exercise. That happens even with surgery eventually with time. There's always a chance of weight regain.

In terms of the patient who qualify or who would be a candidate for both, you know, we have a patient that starts off with a higher BMI, who's open to having surgery, who maybe needs to start the process of losing weight prior to even having surgery. And then that can go into the surgery, have the surgery, lose more weight, and then, once they get down to hopefully a BMI that's considered, quote unquote, you know, normal; maybe continue on with that medication to help them with maintenance, if they start noticing that there's any sort of weight regain. And sometimes it's one of those things where, you know, you start the program and, maybe you consider medication and you see how you respond.

And if the response is not, what, you know, one hopes or enough to get a patient down to a healthy weight to curtail a lot of the comorbidities, you know, that's a patient that could, should potentially consider surgery. So, it definitely does not have to be all or nothing. One can do both safely too.

Host: That's great. I'll give you a chance here as we finish up. What advice would you give to someone who's struggling with losing amount of weight? You talked about obesity is a, you know, is an epidemic really in America. So what's your best advice?

Igor Wanko Mboumi, MD, FACS: You know, I see too many patients who put off getting help because they have young kids at home, because they have a job, they're busy working, you know, there's always a reason to wait. There's always a reason not to, you know.

But you know, we all have the same struggle. The sooner we address it the better. You know, even when you are older, when you're older, there can be, so still some benefits to losing weight. Just because one is in their fifties doesn't mean they can't have an enjoyable life and extend their life expectancy by another 20, 30 year.

Host: Right.

Igor Wanko Mboumi, MD, FACS: By the same token, just because one is, uh, 28, and has no comorbidities, it doesn't mean that the obesity that they have won't affect them and cause significant amounts of chronic illness as they get older.

 I think ideally it's better to live our best years, to be in the best possible health, you know, in our younger years as well as in our older years, to prevent readmission to the hospital, and all, everything that comes with it. So, don't wait too long and reach out for help.

Host: Yeah, that's great advice. As I'm taking from you, it's never too early necessarily and it's never too late. Help is out there, a wide range of things as we've talked about today, the weight loss drugs, the GLP-1s, the surgical options, combination of the two. So good stuff. Thank you so much.

Igor Wanko Mboumi, MD, FACS: My pleasure. Yes, sir. Thank you.

Host: And visit Franciscan health.org/bariatricservices to download a free guide or to schedule an appointment.

 And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.