Caitlin Whyte (Host): Welcome to Flushing Hospital Med Talk. I'm Caitlin Whyte. Joining me today is Dr. Darshak Shah, the Director of Bariatric Surgery from MediSys Health Network, Flushing Hospital. Together we'll be exploring the important topic of weight loss versus weight loss surgery.

Now, Doctor, is obesity or being overweight a major health problem in the US would you say?

Darshak Shah, MD: Yes. So currently obesity is one of the greatest disease of our public health crisis right now. The latest statistics says that 40.3% of adults, which translates to close to a hundred million adults are obese in United States. Which is a rise of 2.3% in last decade. In last 10 years, the rate of obesity has grown 2.3%.

Now, when the data was split up to see what age group is particularly affected, it was surprising to see that pretty much every age group is affected and even the children and teenagers are now becoming more and more overweight and obese compared to in the past, but by numbers, the age group of 40 to 60 years is the one that is affected the most with the obesity rate being 46.4%.

Host: Well, when is someone considered overweight or obese? And when should they then seek help from a doctor to manage their weight?

Darshak Shah, MD: There are many different criteria by which one can be classified, depending on their weight, but the one that is most commonly used is called the BMI or the Body Mass Index. It's a number that we derive by dividing the weight in kilograms by height in meter squared. So when we get that number, it's easy to find that online calculators to find one's BMI.

A normal BMI is 18.5 to 25. Anyone from 25 to 30 BMI is considered overweight. Over 30 is obesity, and then over 35 is morbid obesity. These are the numbers that we use when we try to tailor our management, and that is something that the insurances use as well, about whose coverage they will include based on their BMI.

Host: Well, for those who are considered obese or overweight, what health complications are they at-risk for?

Darshak Shah, MD: So obesity has been shown to affect every single organ in our body. The one that is most affected that we commonly see in clinical practice, in real-world that we see when patients come to seek help for obesity, a lot of times they have already incurred one of them. So studies have shown that there is a five to 10 times more risk of diabetes, where the glucose is higher and difficult to control in the blood, high blood pressure requiring medication, sleep apnea, where the the spectrum includes snoring to all the way where they are not breathing adequately or their breathing stops while they are sleeping. Osteoarthritis where they have knee or back or other shoulder pain related to extra weight that the body has to carry or the knees have to carry, an increased risk of cancer. Specifically breast, GYN or colon cancer has been shown to be increased rate with obesity.

Host: Hmm. Well, what are the weight loss options that a doctor may recommend to a person facing these problems?

Darshak Shah, MD: In general, anytime we look at weight loss, we broadly classify into three different kind of management options. The first and foremost and the most important one is the lifestyle modification. So any patient we see, the first thing we do is we ask what they have done and we offer them what options they have for lifestyle modification.

The first and foremost is going to be diet. So we counsel them along with the help of a nutritionist where they discuss and understand what their dietary preferences are, and then counsel them about what they should be eating, how much they should be eating, and when they should be eating. There are many different kind of diet options wherethe calories, depending on their activity, their genetic makeup is recommended. Intermittent fasting has been shown to help with weight loss. It's scientifically proven. So diet is number one.

The second form of lifestyle modification is exercise. So there is enough data in scientific literature that shows that the typical recommendation for most patients is 150 minutes of exercise per week.

That exercise can be broadly divided into either cardio or muscle or HIT exercise that we call it high intensity interval training. And that is something that we counsel about spreading over the week where they can either do 30 minutes a day for five days a week, or 40 minutes a day for four days a week. So the recommendation is 150 minutes of exercise per week. So those two are basically lifestyle modification.

Then we move on to medication. That's the second option. For a very long time, the only medication we had for weight loss were all pills. Phentermine is one popular one that was used. Contrave is another one.

So there are a bunch of medical options that we have, but none of them have been shown to have adequate, sustained long-term weight loss without any side effects. So they never became very popular till the recent uptake of injections. When Ozempic was introduced in the market for management of diabetes, we noticed that patients are also having significant weight loss and slowly it started becoming a mainstream injection for obesity more than the diabetic control. And that's when the medicalweight loss with injection started becoming more and more popular. So currently we have a bunch of options.

I'm going to go over it in a second, what options we have about medical weight loss. And the third is surgery. With surgery it's been the gold standard of weight loss for decades. Before the surgery used to be done with open approach and that used to lead to a fair amount of morbidity or complications.

Over the last 50 years, it has shifted from open approach to laparoscopic or robotic approach where the surgeon uses minimally invasiveapproach to perform these weight loss surgeries.

Host: Well, Doctor, clear up some terminology for us. What is the difference between weight loss surgery and then medical weight loss?

Darshak Shah, MD: Sure. So the second and the third option that I just spoke about in terms of options for weight loss. So medical weight loss does not involve any procedures. It is basically giving medicine or injection, a pill or an injection to help with weight loss. Now, there are two different kind of injections, that are more commonly prescribed these days for weight loss.

So the first one is a GLP1 receptor agonist, which means it's, it promotes the GLP1 named receptors, and Ozempic is one of them. It's a semaglutide that helps with diabetes along with helping patients to lose weight, and hence it became popular as a weight loss medication as well. And in the same drug line we have liraglutide, which is Victoza and Trulicity.

So these all work as a GLP1 receptor agonist. They come as a tiny injection that patients self-administer once a week. And we start off with a very low-dose and slowly progress to a higher dose. The second category of injectables that we have presently is a combination of both GLP1 agonist and a GIP receptor agonist.

Now these have become more popular and mainstream for injectable weight loss medications, the Zep Bound and Mounjaro. These are tirzepatide and these help with more weight loss than seen by the other group of medications. So when we talk about numbers, with these injectables, the clinical trials showed that 15 to 20% of weight over the course of a year was lost by the patients. And in real-world when we actually prescribe them, we see patient's typically losing 10 to 15% of their weight in a year. So if someone comes in and they're 300 pounds, typically we end up seeing they lose 30 to 45 pounds in real-world. So there's a term called excess weight loss.

 So that's the weight that the patient has compared to what they should have for their height and gender and the excess weight loss we see is close to 20 to 30% with these injections. And now the second is the surgical weight loss surgery, which is the bariatric surgery that we talked about. With the bariatric surgery, we have multiple different kind of operations.

The most popular of those is the sleeve gastrectomy. The laparoscopic sleeve gastrectomy where we make tiny incisions on the abdominal wall. We go in using a laparoscope or laparoscopic instruments or robotic instruments, and we free up the stomach and make it significantly smaller. And with that, the patients eat less to feel full.

And also certain hormones called ghrelin are secreted in much less quantity. That leads to decreased appetite, and with that patients lose weight. So when we compare the weight loss compared to the medical weight loss in surgery, we see 30 to 33% of weight loss. With medical we spoke about 10 to 15%, so it's more than double the weight loss we see with surgery.And with excess weight loss, we see 60 to 70% of that excess weight being lost with the surgery.

Host: Well, let's break these down even a little more. Who is a good candidate for weight loss surgery?

Darshak Shah, MD: Any patient we see. There is no one-size-fits-all approach. We speak to the patient. We understand their history, we understand their expectation. We see medically how much weight they need to lose, whether they qualify for surgery or not, whether the insurance covers injections or not.

So there is no clear answer to what fits best for everyone. It's always more individualized, customized plan that we make with the patient depending on their coverage and what they need. But when we look at who is covered for surgery, the revised guidelines from the ASMBS, which is the Society for Metabolic and Bariatric Surgery, which, most of the insurances follow, is anyone with BMI over 30 with a medical problem like high blood pressure, diabetes, sleep apnea, osteoarthritis; they would qualify for surgery as long as they are cleared by the specialist that they need to see.

Host: And on the other side, who then makes a good candidate for medical weight loss?

Darshak Shah, MD: Same thing. So if the BMI is 27.5 with a medical problem and the insurance does cover their management with injectables, then we would offer that to the patient with the clear understanding and expectation of what the injectables would bring forth in terms of side effects and the outcomes, and then along with that discussion with the patient, we decide if we should offer them injections or we should offer them surgery.

Host: Well, we've covered a ton of information today Doctor, and to wrap it all up for us, how can I work with my doctor to determine the best path for my own weight loss and health goals?

Darshak Shah, MD: Excellent question. So in terms of discussion with your medical doctor, you should discuss your weight and calculate your BMI, to understand where you are categorized and whether you would qualify for weight loss medication or a surgery.

Understand the risk of the procedure and the side effects of the injections, and you can start the conversation with the doctor and go ahead with the weight loss journey.

Host: Thank you so much for joining us, Dr. Shah. For more information about the services Flushing Hospital offers, visit our website@flushinghospital.org/podcasts. If you enjoyed this podcast, please share it on your social channels and explore our entire podcast library.

I'm Caitlin Whyte, and this is Flushing Hospital Med Talk.

Thanks for listening.

All content of this podcast is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment. Please consult a medical professional before adopting any of the suggestions discussed on this podcast.