Melanie Cole, MS (Host): Welcome to the podcast series from the specialists at Penn Medicine. I'm Melanie Cole and today we're exploring bariatric surgery and obesity medicine. Joining me is Dr. Lisa Dobruskin. She's the Medical Director of the Center for Bariatric Surgery and Metabolic Medicine at Penn Medicine, Princeton.

Dr. Dobruskin, thank you so much for joining us today. Tell us a little bit as we get into this topic, which is such a huge topic. I mean, there's so many avenues.

I'd like you to tell us about the Princeton Bariatrics Program, the services and options that patients might expect from the program, and really tell us a little bit about what you're doing there.

Lisa Dobruskin, MD: Sure. Well, first of all, thank you very much for having me, Melanie. It's a pleasure to be here. The goal of our program is to provide multidisciplinary care for patients who are struggling with the disease of obesity.

We know that there are many causes, that it's a very complex disease that involves many organ systems, and affects people for their whole lives. And so we try to address as many of those aspects of the disease as possible and to provide lifelong treatment for patients.

For example, we know that there's a very strong genetic basis to obesity, which leads to a whole host of pathophysiological processes. There's an imbalance in various neurotransmitters and hormones, and it affects various cascades of metabolism.

And so what we offer at our program is certainly state-of-the-art robotic bariatric surgery, including sleeve gastrectomy and Roux-en-Y gastric bypass. We offer endoscopic procedures, including endoscopic sleeve gastroplasties, and revisional procedures. We offer metabolic medicine, where we use a lot of the newer obesity medications.

And then, we also offer nutritional counseling and behavioral health services, because we know that a lot of patients who struggle with obesity also struggle with mood disorders. They need to work on emotional and stress eating, and so we tackle all of those things. And we offer all of these services for the duration of the patient's life. Because we know that these patients need lifetime follow-up to treat this chronic disease. And the disease involves periods of remission where patients are able to maintain a healthy weight, and then they relapse. And so we need to offer them another modality of treatment. So in terms of lifetime follow up, we have a bariatric coordinator nurse navigator who works with a lot of our patients. We have a lot of programs for our patients to help them maintain their weight and to try to get them back when they're struggling.

Host: Well, thank you for that. As a fellowship trained bariatric surgeon and certified in obesity medicine, tell us in what ways those assets better prepare you to care for your patients in a field that's changing dramatically all the time.

Lisa Dobruskin, MD: Certainly one of the things that I've learned from my training and from working with patients who struggle with this disease is that obesity is so much more than just calories in and calories out. Because we know that there's such an imbalance and dysregulation of so many metabolic pathways and pathways that control eating and hunger, it's not just a matter of telling a patient that they have to eat less. We have to help them by treating some of these abnormalities. And so, that's really a lot of what I've learned, in my experience, both in my training and in my subsequent practice, is understanding that obesity is a chronic complex disease.

And it's also there's a spectrum of disease. You know, just like any chronic disease, there are patients who have a milder form of disease, and maybe for those patients, eating a healthy diet and exercising regularly is enough to help them maintain a healthy weight. There are some patients who have maybe a more moderate form of the disease, where they may need medication or surgery.

And then there are patients who have really more severe disease, where they require more than one modality of treatment, including surgery and medication and of course lifestyle modification. And so I think, because I have the bariatric surgery training and the obesity medicine training, I'm able to offer all of those modalities to patients.

And we really focus on that in our program, so that depending on the stage of the disease process for that particular patient, we're able to tailor the treatment to their needs.

Host: Doctor, you have so many tools in your toolbox these days, and speaking of tools, the GLP-1s have broken onto the market and really upended the landscape in many ways. How have these medications changed the landscape as you see it, of bariatric surgery and weight loss in general?

Lisa Dobruskin, MD: Well, I think certainly, nobody will argue about the fact that these medications have really transformed the treatment of obesity. These medications are really the first class of medications that are truly effective in helping patients lose weight. And they're also relatively well tolerated.

However, what I think is important to keep in mind is that as with many other diseases, it's not a one size fits all treatment. And so there are some patients, again, that are going to take this medication and it's going to be sufficient to treat their disease. But there are a lot of other patients who are going to need bariatric surgery, as well, or maybe just bariatric surgery.

In my experience, what I found is that for patients who have a higher body mass index, so certainly patients with a body mass index of 40 or greater, for these patients, the medication alone is not an adequate treatment. It's just not enough to help them get to a healthy weight. But what I have found is that these medications are an excellent adjunct to bariatric surgery. So for patients who have a little bit of weight regain, or who don't lose as much weight as they should lose after surgery, these medications, really work very, very well as an adjunct.

The other thing that I think is important to recognize is that these medications have limitations. So cost is a big factor right now. Even, out of pocket through some of the newer programs that the pharmaceutical companies are offering for patients who don't have insurance coverage, these medications cost, uh, about $500 a month.

And it's important to understand that for most patients, they're going to have to be on these medications for the rest of their lives. So $500 a month, in perpetuity is quite a lot. And because these medications are so expensive, a lot of employers are starting to opt out of covering the cost of these medications for their employees.

And so we're starting to see more and more patients who are unable to afford these medications. Also, these medications are not covered by Medicare at this point or Medicaid, so those patients, again, are excluded. And even for the patients who do have coverage and are able to afford it, what we're seeing, especially in some of the newer studies that are coming out, is that the compliance is not great.

So several, large scale studies have demonstrated that at one year, less than 50% of patients are still on these medications. And for those patients who discontinue medication, the weight loss is really pretty modest. Maybe three and a half to 7% is what the studies are showing. And even in those patients who do continue these medications for up to a year, what we're seeing in real-world studies is that the weight loss results are not as good as the initial studies.

For the initial studies, we saw that semaglutide patients were losing up to 15% of their total body weight. And with tirzepatide, patients were losing up to 20%. In the newer real world studies, it's more like maybe about 13% for semaglutide, and about 18 percent for tirzepatide.

So, you know, somebody who has a significant amount of weight to lose, a hundred plus pounds, these medications alone are not an adequate treatment.

Host: So interesting. What is going on in your field is really fascinating. We know that many people are seeking help for weight loss, outside of normal medical practice. What counsel do you have for primary care providers who are seeing patients using these online sources for weight loss?

Lisa Dobruskin, MD: The basic answer is that patients are not getting the treatment that they feel they need. And that's why they're being forced to go online and to use some of these other resources. And like you said, I think the main reason is that they're unable to afford the prescription medication.

I do see a lot of patients who are turning to some of these online programs, using the compounded GLP-1 medications, because they're desperate to lose weight, which is very unfortunate. Because the problem with the compounded medications is that they are not FDA-regulated.

And so, you essentially you really don't know what you're getting with these medications, both in terms of how they're formulated, in terms of the dosing. Certainly there have been patients who have had serious adverse effects from these medications. And so I'm always very adamant with patients about the fact that using the compounded medications is not safe.

The other issue that I think needs to be addressed is the fact that none of these treatments are magic bullets on their own. So neither bariatric surgery nor a medication on its own is going to really work effectively without lifestyle modification. And so offering patients the resources, the nutritional counseling, the behavioral health, support groups, all of that is very, very crucial to helping patients achieve good results.

And a lot of the online programs really don't do that. They essentially just prescribe these medications and don't offer patients all of the other, really modalities of treatment that they need. So I think primary care physicians really need to counsel their patients very carefully and explain that even though of course it's important for the patient to lose weight, and the patients desperately want this, these alternatives are really not safe and probably not really effective.

Host: As we get ready to wrap up, I'd like you to speak about, when it’s important for primary care providers to  refer a patient to bariatrics. And that multidisciplinary team that's so important for these patients.

Lisa Dobruskin, MD: I think any patient who qualifies for bariatric surgery should be referred for a consultation just to discuss the options. And so, we follow the NIH criteria for a referral, which is any patient with a body mass index of 40 or above qualifies for bariatric surgery or if their body mass index is between 35 and 39.9 and they have an obesity-related disease such as diabetes, sleep apnea, hypertension, those patients will qualify for surgery, as well.

At our program, we offer all the modalities of treatment. So even for patients who don't feel like they're ready for surgery, we may start with medication, see how they do, and then reevaluate regularly and see how are they doing? Are they losing enough weight? Should we maybe reconsider bariatric surgery?

And so, having this multidisciplinary approach really allows us to tailor the treatment to the patient. And so even for patients who don't qualify for bariatric surgery, who struggle with obesity or are overweight, we do have also weight management doctors, obesity management physicians who prescribe medication. And so those patients certainly can be referred as well. And again, they will also benefit from the same multidisciplinary approach that we follow for the bariatric surgery patients.

Host: Thank you so much, Dr. Dobruskin, for joining us today and sharing your expertise. And to refer your patient to Dr. Dobruskin at Penn Medicine in Princeton, please call our 24/7 provider only line at 877-937-PENN. Or you can submit your referral via our secure online referral form by visiting our website@pennmedicine.org/referyourpatient.

That concludes this episode from the specialists at Penn Medicine. I'm Melanie Cole. Thanks so much for joining us today.

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