Carl Maronich (Host): Welcome to Health Dose, your go-to source for quick and reliable health and wellness news. I'm your host, Carl Maronich. And today, we'll be talking with Dr. Christina Downer and Dr. Jeffrey Bonacci from MyMichigan Health. The topic? Medications Versus Surgery: Choosing the Right Path for Weight Management. Thanks for joining us, Doctors.

Jeffrey L. Bonacci, M.D.: Thank you. It's good to be here.

Christina Downer, D.O.: Thank you for having us.

Host: I'll start by mentioning, Dr. Downer, is a physician specializing in Obesity Medicine, and Dr. Bonacci is a bariatric and general surgeon. So with that introduction, let's get started and maybe we can start by explaining the primary differences between medical and surgical approaches for weight management. Dr. Downer, we'll start with you.

Christina Downer, D.O.: I always think about lifestyle intervention as the foundation for a healthy weight loss journey. I really want the emphasis to be on a more balanced diet, a more active lifestyle. And then, we start to think about whether or not medication or surgical options may be necessary or appropriate based on how much weight that patient may need to lose or what their other medical conditions may be.

In general, weight loss medications can help people lose, on average, between about five and 15-20% of their starting body weight. Whereas surgical options can often help people lose closer to 25, to sometimes 35% of their starting body weight. So certainly, depending on what those individual's needs are, they may want the additional help from medications or surgery.

Host: That's a great segue into the surgical options, Dr. Bonacci.

Jeffrey L. Bonacci, M.D.: Yeah. So, as far as surgery, when I see patients for a consultation, they've often already gone down that road as far as lifestyle medications, even trying various medications as well. So when it comes time for discussions for a surgery, patients have to be prepared for that because it is an alteration to their normal anatomy to achieve those goals.

But many patients that do undertake the risk of surgery do find that their success with it is quite significant. But no matter what option patients end up choosing, one of the things that we'll explain to them over and over again is that these are tools for patients to use as part of their journey towards success with weight loss.

Host: As Dr. Downer mentioned, a lot of lifestyle and other things that factor into it as well. There's no one thing that's going to fix all issues. Maybe we could talk a little bit and go back to medications and what medications for weight loss typically work and what results might patients expect. And I know there's probably a range of that depending on the patient.

Christina Downer, D.O.: Sure. There are several medication options FDA approved for weight loss. One is called Orlistat, and that's available even as an over-the-counter medication ally. It works by decreasing the body's absorption of fats, which can help to reduce calorie intake and promote weight loss. It's not a very popular choice because it tends to have pretty significant GI side effects, but it is an option.

There are other options, pill medications, for example, Contrave and Qsymia. Both of those medications work primarily by affecting the hunger hormones in the brain, the neurotransmitters that regulate appetite and hunger. Those medications are popular choices, because they are once or twice daily pill medications, generally well tolerated. Our ability to use those medications may be impacted by a patient's underlying health, their age, their other medical conditions, but those are being increasingly used. Because they tend to be more flexible and more affordable than some of the even newer options.

Currently, the most popular and the most effective medications for weight loss are in that GLP-1 family. Those are once weekly injectable medications for weight loss. They work on the gut hormone GLP-1, which helps to regulate fullness and hunger. And it also decreases how quickly the stomach empties. So, it keeps people feeling fuller longer. They get full more quickly when they're eating and it tends to really help to reduce cravings so that they feel like they have less food noise. They're thinking about food less often. And it really helps to keep them on track with a lower calorie diet.

Host: A lot of these medications have become more popular or there's more talk about them. Are you seeing patients coming in that have heard some things and feel they're well-informed? And that may not always be the case. Are you running into issues like that at all in the office?

Christina Downer, D.O.: We certainly have patients who, you know, with the popularity of some of these medications on social media or now almost everybody knows somebody who's using some of these medications for weight loss. It's not uncommon at all for patients to come in wanting to know more about a particular medication or even asking for a medication by name, wanting to kind of explore those options.

Host: Dr. Bonacci, when we're talking surgical interventions, what are some of the risks associated with that and also the concerns that patients may have that you're able to kind of ease their mind with when they come into the office?

Jeffrey L. Bonacci, M.D.: In the past, for surgical treatments, they were viewed as very extreme and potentially dangerous. As time has gone on, we've gotten more and more advanced and very technically adept at doing surgery. So, the surgeries have become safer and safer. But I always let patients know it's not something that we take lightly. There's risks with any kind of surgery. So, the more you do a surgery, the more efficient and technically adept at that you become. So, I tell patients that these are surgeries that we've done over and over again. And as we do them more and more, we get better and better at doing those surgeries.

So, I let them know as far as common risks for surgery, things such as bleeding and infection will apply to any kind of surgery. For the specific risk of surgery, it depends on the type of surgery that they're having. And there's a number of surgeries that are certainly done to help for weight loss. You can kind of group them into kind of two categories where there is a restrictive component where we are usually altering the anatomy to limit the amount of calories that somebody's able to take in.

And then, there's typically a malabsorption component where changing the anatomy affects how the body actually absorbs those calories. Sometimes the surgeries are just one or the other. Sometimes they incorporate both mechanisms to achieve that. So as far as the risks that are specific to those surgeries, it just depends on what type of surgery somebody has.

The most common surgery that's done nowadays for weight loss is called the laparoscopic sleeve gastrectomy, or also called the vertical sleeve gastrectomy. For this surgery, the stomach is stapled almost like the shape of a banana. So, about 75% of the volume of the stomach is removed. So, the normal continuity of the flow of intestines is preserved with that surgery. But it creates a significant amount of restriction as far as limiting the volume of calories that people take in when they eat a meal.

In contrast, there's another surgery that's been done for years and years called the Roux-en-Y gastric bypass. And that surgery incorporates not only restriction because the upper part of the stomach is stapled into a small pouch. But then, we're also changing or rerouting the intestinal flow when we bring part of the small intestine to connect to that pouch. So, patients have not only some restriction, but also malabsorption because they are bypassing part of the normal body's mechanisms for absorption. So when patients are looking at risk for surgery, those are things that we go through with them in detail to let them know the specific risk for the surgery that they choose.

The good news is that even though surgery is a big undertaking, these are surgeries that are done very frequently and are actually quite safe for patients too. And when we evaluate patients for surgery, we want to make sure that they're going to gain the benefit of undergoing that risk of surgery when they have this. Unfortunately, when patients do go through surgery, the success that they have for the weight loss often outweighs those risks by far.

Host: So, post-surgery, they've got to make sure they're doing the things they should be doing to ensure the success from that.

Jeffrey L. Bonacci, M.D.: Absolutely. So like we had said earlier, as far as using these surgeries as a tool, there's something that patients have to understand. What is kind of interesting is that patients, you know, when we talk about other options for weight loss, the very foundation, like Dr. Downer, had mentioned is, you know, things like lifestyle changes. So, limiting calorie intake, incorporation of exercise. These are things that we mention to patients or reiterate to them as well, that it's important to continue with those things even after these surgeries to be successful in the long run. It's something that kind of goes hand in hand. It's not just one or the other necessarily.

Host: Are there specific types of patients that may benefit from one versus the other that you identify pretty early on, or is it really too many variables to be able to really say that?

Jeffrey L. Bonacci, M.D.: To be honest with you, it usually comes down to patient preference. As far as the surgery they have, there may be some specific patient health issues that might make them a better candidate for one versus another. But ultimately, it usually comes down to their preference. Some of the long-term risks for some of the surgeries can have more of an implication, like, for example, the malabsorption side of the gastric bypass can have some long-term, down-the-road issues, whereas the sleeve may not have those issues. So, that might be why a lot of patients choose that route. But those are things that, again, we kind of encompass with patients when we discuss as far as what options are on the table for surgery.

Host: That makes sense. Dr. Downer, maybe I'll look to you and ask how patients are evaluated for weight loss management options at MyMichigan Health.

Christina Downer, D.O.: Clinical guidelines recommend all patients be screened once a year for obesity using BMI. The recommendations would suggest that anybody who has a BMI over 25 would be counseled on lifestyle changes to help move them back towards a healthy weight. BMI category of 25 to 30 is considered overweight, whereas a BMI over 30 is considered obese, and over 40, considered severely obese.

There's a thought that we should probably be doing a better job of acting a little bit sooner intervening in that overweight-- sometimes thought of as pre-obese range-- so that we can prevent the complications that come from obesity down the road. Guidelines would suggest that patients who have a BMI over 27 and any weight-related medical conditions, we should be considering medications in addition to lifestyle interventions. And the thought is that for patients with a BMI over 30 with weight-related medical conditions, we should be considering medications simultaneously in conjunction with those lifestyle changes. Patients don't need to try and fail diet before kind of considering medications.

Host: Are there comorbidities that would lend and make the patient a better option for medical versus surgical procedure, or is that taken into account at all?

Christina Downer, D.O.: It definitely is. One of the most serious weight-related medical conditions is diabetes, and patients with diabetes tend to do really quite well with weight loss surgeries. They can sometimes see remission of their diabetes from surgery alone. Also, a number of our weight loss medications are also in the diabetes family of medications. So, we can sometimes use both of those.

Host: Dr. Bonacci, any thoughts on that topic?

Jeffrey L. Bonacci, M.D.: I would agree with Dr. Downer that diabetes is for sure one that, fortunately, is a significant improvement, if not complete resolution with weight loss surgery as well. I think that when we're looking at patients for candidates for surgery, it is often based on the patient's BMI and also other health-related conditions. Because insurance often dictates the rules for patients to qualify for surgery, usually, we have to look specifically at somebody's BMI for them to qualify for surgery.

In addition to that, other existing health conditions definitely play into that as well. So for example, if somebody's BMI is 40 or greater, usually, that alone qualifies somebody for weight loss surgery. If their BMI is 35 or higher with other health comorbidities such as diabetes or high blood pressure, that would qualify somebody for surgery. Because of the significant response of diabetes to weight loss surgery, some insurers are even lowering that qualification for a BMI of sometimes either 30 or 32 to qualify patients for surgery too.

Host: And on the medical side, Dr. Downer, what are the insurance implications for patients there?

Christina Downer, D.O.: Some of the weight loss medication are very challenging to work with through the insurance companies. The pill medications are sometimes easier to get covered, whereas the injectable medications for weight loss, those in the GLP-1 family tend to be more challenging to work with more insurers who are restricting those from coverage. Those medications tend to be quite expensive if they're not covered by insurance, and that can be a barrier for a lot of patients. It could be a reason that we choose not to use those medications, even though they may be the most appropriate choice for that patient.

Host: Dr. Bonacci, you kind of mentioned some advancements that have happened in the surgical side. Are there any things that are new or that are coming down the road a bit with regard to this on the surgical side of weight management?

Jeffrey L. Bonacci, M.D.: There actually are some advancements coming down. As time goes on, there's more and more surgeries that get developed too. For the realm of surgery, there's one called the-- it's kind of abbreviated as SADI. It's kind of essentially a single anastomosis duodenal-ileal bypass. That's the long term. So, SADI is much easier to say than that. So, it's very similar in the sense that you're performing a sleeve gastrectomy. And then, you are making a new connection to the small intestine just after the stomach to further down the road of the intestine. Again, it incorporates some restriction and also some malabsorption side as well.

There are some experimental techniques that are being looked at as well. Some radiofrequency ablation therapies to the start of the small intestine as well, where they're believed to have some effect on that change in hormone signaling that can have improvement as well. So, there are a lot of things. And with the epidemic of obesity in our country, I think it's always going to be a hot topic for exploration for further research as time goes on.

Host: Anything else happening or any new medications you're learning of that are coming down the road that can help people in this circumstance?

Christina Downer, D.O.: Yeah. There are a number of clinical trials that are ongoing right now. One is investigating oral semaglutide, you know, a popular GLP-1 medication. But the thought is that this will help patients who maybe don't tolerate the injectable version well, or maybe they're reluctant to use an injectable medication, ease of use in administration. So, that one is being investigated now.

There's also a new medication that's in clinical trials now that is looking really promising. It's called retatrutide, and that is a medication that works on three different Receptors, so GLP-1 receptors, GIP receptors, and also glucagon receptors. So, the thought is that this may be even more effective than tirzepatide, which is our currently most effective GLP-1 medication.

Host: In both cases, patients, which either road they go down, are going to need follow up in some certain way. Maybe, Dr. Bonacci, starting with you to ask, following a surgery, what kind of follow-up or, if you will, or support afterward do you guys provide?

Jeffrey L. Bonacci, M.D.: I believe that regular follow-up is essential for patients to be successful. We, on the front end, let patients know as far as expectations for follow-up too. Kind of a standard follow-up that we have for patients after surgery is they would typically see us for their first post-op visit about one or two weeks after surgery. Then, we typically will see them about a month after surgery. Then, typically, each three months over the first year. After they reach a year out from surgery, we tend to see them each six months. And then, when they're two years out from surgery on an annual basis at that point, going forward. Obviously, that's front loaded because early in the postoperative period, that's when patients need most support. But the follow-up in the long term is also essential, because for patients to continue to be successful, it's helpful for them to see us regularly as well.

Host: Sure. And I'm guessing, Dr. Downer, on the medical side is similar. You want to make sure you're following up with patients. But as Dr. Bonacci said, with surgery, that there are things you definitely want to look at pretty quickly afterward. With regard to the medication, how are you following up and supporting there?

Christina Downer, D.O.: Anytime I start a new medication, I like to kind of follow up in that initial period. Oftentimes once a month for the first three months. And then if things seem to be going well, we will start to space that out a little bit. We want to make sure that there's not medication side effects or complications. We want to make sure that the weight loss is progressing as it should, as we're hoping for. We want to provide that accountability for patients. Sometimes, you know, knowing that they have that appointment coming up, knowing that maybe I've asked them to track their calorie intake or their protein intake helps to provide that accountability that can help with weight loss success as well.

I also, in addition to seeing patients for just who are wanting to lose weight, whether it's through lifestyle or medications, I'll also work closely with the patients who have undergone bariatric surgery, just to help make sure that they're also meeting their weight loss goals and then providing that support long term, maybe even years out from weight loss surgery to make sure that they are maintaining a healthy weight and providing support where we can there.

Host: Dr. Downer, starting with you, if a patient is apprehensive to take a medication in which some people certainly are, how do you counsel them in that regard and kind of allay their fears a bit?

Christina Downer, D.O.: I think that we're fortunate that this is one of the best times in medicine for treating and managing obesity, because we have more medication options than ever. We have more surgical options than ever. I think that sometimes people are reluctant to try medications. Maybe they're concerned about side effects, maybe they're concerned about cost.

I think sometimes patients are they have that feeling that weight loss is something that, you know, we need to do on our own. We need to, you know, kind of just buckle down and maybe if I try a little bit harder. But the reality is that these medications do an excellent job of supporting that healthier lifestyle. They make those diet changes feel a little bit more manageable, a little bit more sustainable, feel like something that could be done forever. And I talk to people about the key to lifelong weight loss, maintaining significant weight loss, is trying to find a way to make those changes that resulted in weight loss to be the new normal, to feel like something that can be done forever. I always think of these medications as a tool, never something that is going to cause weight loss by themselves.

Host: A great way to think of it. Dr. Bonacci, how are you helping those folks work through their concerns?

Jeffrey L. Bonacci, M.D.: Naturally, when you consider surgery, apprehension is very normal. Many patients, they feel that that's maybe a drastic step. They may have heard other friends or family members who have already taken that step and maybe didn't have as much success as they wanted. So, reassuring patients for that is an important step. Realizing that when I see patients for a consultation, again, they've usually gone down that road of trying to diet and exercise, previous medications. And unfortunately, they can have continued to struggle with that.

So what's really interesting for patients, when they make that commitment to undergoing surgery, I think they really feel empowered. They realize that everything I've tried before hasn't gotten me to the success that I want, and I want to take this step. And so, I'm going to do everything I can, realizing that I'm making an alteration to my body's anatomy to achieve it. And so, I'll have patients who never dreamed about, you know, doing several laps around their block. And when they're successful with surgery, 6, 9, 12 months down the road, they're actually running their first 5K. So, patients really take hold of that. And I think it really helps them as far as getting that mindset for being successful too.

Host: And finally, Dr. Bonacci, how can someone take a free weight loss assessment at MyMichigan Health?

Jeffrey L. Bonacci, M.D.: So fortunately, MyMichigan Health, through their website, has a link that you can click on to undergo that assessment. There are many options available there, whether patients are choosing either non-surgical or surgical options as well. So, they will often refer them to the resources that they wish to pursue as far as taking that direction on. Many times their primary care physicians, especially if they're affiliated with MyMichigan Health, may help them as far as leading them down that road as well.

Host: Doctors, thanks so much. A lot of great information provided today. A great resource for weight management.

Christina Downer, D.O.: Thank you so much.

Jeffrey L. Bonacci, M.D.: Thank you very much for having me.

Host: We've had a great conversation today. And I did want to mention that Dr. Downer sees patients in Alma, Mount Pleasant, and Midland; and Dr. Bonacci sees patients in Clare, Mount Pleasant, Houghton Lake, Midland, and Alma. And if you enjoyed this podcast, please share it on your social channels and explore our podcast library for more health-related topics. And this is Health Dose. Thanks for listening.