Joey Wahler (Host): Obesity continues to plague Americans. So when is bariatric weight loss surgery the best option? Our guest, Dr. Brian Lahmann, he's Chief of Bariatric Surgery at Silver Cross Hospital. Welcome to Silver Cross Hospital's iMatter Health Podcast, where medical experts bring you the latest information on health topics that matter most to you and your family. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Lahmann. Thanks for being with us.

Brian Lahmann, M.D.: It's my pleasure. Thanks for having me.

Host: Same here. So, just how much has America's obesity problem really continued growing over the last several years?

Brian Lahmann, M.D.: Well, the obesity epidemic has been going on for several decades. And the data continues to kind of look worse. There's data from the CDC in Atlanta that studies obesity trends. And every year, it seems to be getting worse. There's more and more states that have higher and higher rates of obesity. Currently, there are, last I looked, 22 states that have over 35% obesity in each state. That's a pretty big number and that incorporates obesity and morbid obesity, which are the patients that we often consider for surgery. The nationwide obesity rate, all-comers is about 41%, so it's very prevalent and continues to kind of look worse every year.

Host: What do you attribute those numbers to? Obviously, Americans love to eat. We have a lot of options when it comes to that. But from your experience, any kind of a unique perspective on why this just continues to get worse?

Brian Lahmann, M.D.: Well, it is a multi-factorial disease. It involves environment, it involves genetics, there's a predisposition to obesity. And the way I always explain it to patients that don't understand the disease of obesity, is that everyone knows someone that can eat everything they want and not gain any weight at all, where a lot of our patients that become obese and then morbidly obese are actually the opposite side of that exact same coin. They're doing pretty normal stuff. They're doing what everybody else does, but they're gaining 10 or 15 pounds every year. Suddenly, a decade later, they're a hundred pounds overweight. So, it's not always that they're just eating way too much or way more than everyone else. It's just their body doesn't process things the same way. So, they have to work harder and harder just to not gain weight, let alone lose anything. So, there's modern conveniences. There's an escalator and an elevator everywhere you go. A lot of people, our lives are more sedentary. We're at home streaming everything, which is part of culture. But those changes affect our patients that are predisposed to obesity, even more so. Plus there's the fact that the convenience of foods and often the least expensive foods are the worst for you, are in the highest calories and fat. So, it's kind of a perfect storm why it continues to get worse.

Host: Indeed. Obviously, a lot of different factors at play, some within our control, some not. So before we go any further, we've heard about it. What exactly, in a nutshell, is bariatric surgery for those unfamiliar?

Brian Lahmann, M.D.: So, bariatric surgery, it's also referred to as bariatric and metabolic surgery, is a surgical intervention that enables patients with a tool. And there's several different tools that we have, including sleeve gastrectomy, gastric bypass, things you hear about that enables the patient to, if they use it correctly and have the mindset to use it in diet and exercise that enables them to feel full with much less amount of food and also to help them have less hunger and less cravings in between meals, so they're less likely to snack. But it also is just a part of a program that incorporates significant changes in diet and exercise, things that they may have tried before. But now enabled with this tool, with the operation, it's going to be much easier to sustain those very strict guidelines for longer and hopefully break the cycle of obesity.

Host: And so, the procedure involves doing actually what?

Brian Lahmann, M.D.: So, the most common operations in the United States are, number one, the sleeve gastrectomy and number two is the gastric bypass. So, the sleeve gastrectomy is an operation that's been around for about 20 years where we actually reshape the stomach by removing a portion of it. So, the stomach sort of looks like a small football or a wine sack, you might say. Now, we reshape it by removing a portion. So now, it looks like a plantain or a small banana. So, that, number one, their stomach can only hold so much. So, they only eat so much food and they feel full. But also, there's a metabolic component, because we're removing a portion of the stomach that is one of the centers of the hormonal control of hunger. So, one of the things that a lot of people know about is a hormone called ghrelin and that ghrelin is a hunger hormone. It makes your body like, "Hey, this guy needs some food. Let's get him some food." That part of the stomach we remove is where a lot of that hormone is made. It's much more complicated than that. But in its simplicity, it helps with your hunger as well as making you feel full with less food.

The gastric bypass is an operation that's been around since 1967, and we've been doing it laparoscopically since 1994, which I guess is 30 years ago all of a sudden. We actually divide the stomach away from itself to make a very small pouch. And then, we reroute a portion of the intestine up to the stomach so that some of the calories you take in don't get absorbed by the body. So again, there's two mechanisms, slightly different. There's restriction because you have that small pouch, but you also have malabsorption of calories because some of the calories bypass part of the intestine.

Host: So that being said, why would someone typically consider having surgery to lose weight? Who's a good candidate for this?

Brian Lahmann, M.D.: Well, the criteria have been set forth by the National Institute of Health. The NIH have been relatively the same for decades, and they have to do with body mass index, or BMI, cutoffs. So, BMI of 40 and above, which is the criteria for morbid obesity, those patients automatically should be considered for bariatric surgery, weight loss surgery. And also, BMI of 35 and above that have any of the significant medical comorbidities that come with obesity, such as diabetes, high blood pressure, high cholesterol, sleep apnea, reflux, joint disease, arthritis, back pain. Thirty-five and above with one or more of those medical conditions are patients that the data shows might be best treated with surgery.

Host: So, should other weight loss options like dietary changes, exercising more, taking medication, should those be exhausted first before having surgery?

Brian Lahmann, M.D.: A hundred percent. And part of the criteria are that they have had-- it's not a specific number, but they have to have been in monitored supervised medical weight loss programs before often insurance companies will approve them for surgery. And we take that into consideration for our patients, even if the insurance didn't have that criteria. We make sure that if they haven't, then we start that program with them. So, "All right, this is what we're going to do. Let's see what we can do without stepping into surgery. What can we do, you know, short of that with behavioral changes?" That's absolutely an important component.

Now, the other side of that is all these patients have been struggling with this disease their entire life. And they've certainly given it some shots. They might not have always had the best or the perfect supervision or advice, but they've definitely been trying. And a lot of our patients in the past have lost 40 or 50 even 80 pounds before. But then, it all comes back, you know, and one of the reasons, like I said, it goes back to breaking the cycles. Those patients, I'm always excited to see those patients that have done it before on their own, but then regain the weight, because now they will have the tool to help them keep the weight off. You know, it'll be easier to lose and it'll be easier to maintain now that they have the tool.

Host: So clearly, these procedures, am I right, are not for people that are just, say, 20, 30 pounds overweight typically? We're talking well beyond that, yes?

Brian Lahmann, M.D.: In general. And the body mass index takes into height and weight. Those are the only two criteria that go into the formula for BMI. But in general, for a five-foot-six person, it's probably being 60 plus pounds overweight that you'd get to a BMI of 35. And then if you're, you know, six-foot-six, then you have to be over a hundred pounds overweight to meet the criteria.

Host: Gotcha. Now, how about any weight loss surgery myths that you can dispel here for us? Like, oftentimes we hear that bariatric surgery, accurate or not, is the "easy way out"? Obviously, you disagree with that to say the least, right?

Brian Lahmann, M.D.: Absolutely. And when we implore upon all of our patients that, like I said, surgery is not the cure for obesity. It's definitely a tool. And if you use this correctly, you can have great success. You can have a new life and live longer. But we always tell people, it is going to be work now, it's going to be work a year from now, it's going to be work 10 years from now. And if they're not ready to acknowledge and accept that, then they're not ready. Now, that can be hard to ferret out, you know, if patients really can take that to heart, but we remind them of it almost every time we see them that like, "Look. We could be doing better if we just change these couple of things. And we go over everything about what they're doing with their diet and exercise to make sure that they're using the tool to their best ability. It requires exceptional effort to maintain that for life. But, you know, it can be very successful.

Host: During your 20 years or so in practice, how would you say more so than anything else this surgery has changed for the better?

Brian Lahmann, M.D.: One thing when I started open surgery was actually still a very common practice where we make a long midline incision from the xiphoid of the belly button. And I did my fellowship in laparoscopic and bariatric surgery. So, we almost started doing everything laparoscopic once I started. So, open surgery is definitely gone by the wayside. Everyone remembers the Lap-Band or the gastric band that was popular and starting in about the late '90s or actually 2003. The Lap-Band was a great low-risk option. It was an alternative to gastric bypass. And we did a lot of bands and it did a lot of people a lot of good. But the problem was that it was an implant. It was a foreign object that was implanted around the stomach to help patients, again, feel full after less food. And foreign objects in the body aren't always the best idea. And in the long term, it turned out that we had a similar experience to Europe to 10 or 15 years ahead of us, that they started to cause problems and they started to need to come out or they would flip or move or grow into the stomach. So, a lot of the Lap-Bands that we put in, the estimate is more than half of them have already been taken out nationwide and people have moved on. Now, that decline of the Lap-Band also corresponded with the advent of the sleeve gastrectomy, so that's really kind of where it's taken over. So, one of the big changes seen is the Lap-Band, which was the safe alternative, is now really not done anymore, and we've moved on to the two options of mostly sleeve and gastric bypass.

Host: Just for a little compare and contrast here, lately as you well know, weight loss drugs like Ozempic, recently approved by the FDA, are all the rage. What patients are best suited to take that, and does it really get the promised results?

Brian Lahmann, M.D.: Well, that's a great question. You know, like you said, these are very internet-famous medications and the ones we're talking about are Ozempic and Wegovy, which are actually the same medication. They're just different doses and indications, but it's the same active ingredient. Trulicity, Saxenda, and Mounjaro, which is also ZepBound, those are also the same medication, but one is labeled for obesity, one is labeled for diabetes. So, these are diabetes drugs that the side effect was appetite suppression and weight loss. So, what they did is they tried these medications on non-diabetic patients and titrated the doses up carefully and found a lot of patients could have appetite suppression, but it wouldn't bottom out their sugar like it does for the diabetics. So, they've become very famous and very expensive. But they do have a role in some patients.

And I would say that I still think that if you meet the criteria and your BMI is over 40, medication's probably never going to get you to a weight that you can sustain without the tool being there for life. And these are medications we don't want to use for life unless absolutely necessary. Because just like anything, there are long-term complications that can come with prolonged use of a medication. Then, there are some scary things in there, like thyroid issues and pancreatic issues. So, I think if you're morbidly obese, which is again a BMI of 40 and above, almost always surgery is going to be the first thing to consider unless there's a good reason not to. And, you know, it could be a complicated discussion with each individual patients.

BMI of 35 and below, we're getting a little bit fuzzy, but I think definitely a patient in the low 30s and below that are still obese or they're overweight in the BMI of 25 to 30. Those are patients that I think we should absolutely-- just like you said with diet and exercise, sometimes adding medication is that third variable with diet and exercise. Those patients have a reasonable chance of success if they're motivated to do so. Those patients require close followup. And our program here at BMI Surgery, we actually have monthly visits where they come in and we decide, we talk to the patient about if they're having effects, if they're having good results, if they're having side effects from medication. Because again, those medications require careful titration up to an effect without having side effects. So, close monitoring and close follow up, as well as accountability, is essential if those patients are going to be successful.

Host: Yeah, I was just going to ask you about that. You just talked about some of the ways that you and yours monitor such medications, maybe just punctuate for us a little bit more how important that medical supervision is so that people aren't just running off roughshod kind of self-diagnosing and self-medicating, right?

Brian Lahmann, M.D.: Yeah. And, you know, things with the internet and the availability of medications is a little bit scary. Even on practitioners with the best of intentions, they might not, you know, understand all these things, you know, completely. That's why it's very important to be involved in a program that understands the depths of all these things and how they connect.

So, one of the things, as I talked about non-diabetic patients, but we're using diabetes medications, these are weekly injections, and you do this at home by yourself. But then once a month, you'll come in to visit. Because if you just start off at the maintenance dose where you're going to wind up, you would get all the side effects all at once. And these are things like nausea, vomiting, heartburn, GI upset, or stomach pain, diarrhea. It can also cause hypoglycemia. Remember, they're diabetes medicines, all of a sudden your sugar will drop, which can be extremely dangerous. So, that's why, again, the careful titration and monitoring of all these potential side effects are absolutely crucial.

Host: Couple of other things. If surgery is recommended, what preparation beforehand, what recovery afterwards is involved?

Brian Lahmann, M.D.: We have, again, a very exhaustive program where we've been fine tuning this for the last two decades. We see a lot of each other. I always tell my patients, you'll probably be as sick as seeing my face here. But we come in for a consultation. I actually have a YouTube video. It has an orientation about all the different types of surgery that came about during COVID. It all used to be in-person, but this is the way things are done now and it saves people a lot of time. So, we have an orientation seminar. They come in for their consultation. We talk in detail about what their history, their medical history, their surgical history to determine number one, if it's the right thing to do. And if it's not, then we have other options like we just talked about. But if they are a surgical candidate and surgery is their best chance, then we talk about which operation is best. We submit through the insurance process to make sure. But we also have medical clearances from cardiology, pulmonary, psychology, psychiatry. All those doctors, I value their input to make sure that, again, this is a safe person to perform an elective operation on. After that, those things are all complete. Oftentimes, their insurance will require that they come in for monthly weigh-ins, just like we already have in place, also to keep track and make sure that doing the right things, they understand the basics of what they're going to be doing after surgery well before. They'll come in for consultation and have their operation. And then, we see a lot of each other after surgery as well. Again, because that monitoring close follow-up is absolutely essential to making the tool to its best ability. So, we check them post-operatively one month, three, six, nine, and twelve months. And then, at the very minimum, I see these patients every year on their surgery anniversary for life. We see them a lot.

Host: So, it's the beginning of a long and hopefully fruitful relationship. In summary here, doctor, after surgery, what quality of life improvement can patients typically expect? And if someone is considering it, what's their next step? What's their first step to get rolling?

Brian Lahmann, M.D.: Well, I always tell my friends and family and patients that this is probably one of the most rewarding jobs I could have ever imagined, this field of medicine. Because I actually truly see people get their lives back. I see patients that were in wheelchairs and walkers, all of a sudden they're able to walk around the block with their spouse or they're able to get down on the floor and keep up with their grandkids. I always tell people that the little things that obesity took away from you are often the coolest to get back. You know, some patients can't tie their shoes without getting out of breath. You know, they can't go up a flight of stairs. They can't do all these things. They can't get on a roller coaster or go on an airplane without the seatbelt extender. They can't cross their legs. I see all these patients, yeah, they lose the weight. It looks great on paper and on the scale. But those small things that they're able to do that they weren't, I mean, it's almost brings them to tears sometimes.

The big picture, the most important things, obviously, is they're healthier. I've had patients on hundreds of units of insulin a day that after we do their surgery. A year later, they're taking nothing with a completely normal blood sugar. You know, and that patient's going to live longer. You know, their blood pressure's under better control, their cholesterol, all these things can either disappear get under much better control. And the data shows that the average patient, they live 10 to 15 years longer if they had the bariatric surgery than if they hadn't. So, it's an exciting see these patients in the long term and just see them healthier and happier.

Next steps, our website is actually the best first step to start at and that's bmisurgery.org, like bravo-mary-index surgery.org. And that's a very extensive website that has all sorts of things, not just about surgery, but obesity in general. You can calculate your own BMI from your height and weight. There's a calculator on those things. And there's actually a very easy guideline to start the process with either the medical side, which we're doing with our nurse practitioners. Or if you might be a surgical candidate, or if you're not sure, there's easy ways to just kind of click in there, log in some basic information and we'll email you a link to our YouTube seminar and we'll get the process started.

Host: Well, folks, we trust you're now more familiar with bariatric surgery. Dr. Brian Lahmann says it's exciting and very rewarding work. Keep up the great effort. Doc, thanks so much again.

Brian Lahmann, M.D.: It was my pleasure. Thank you for having me.

Host: Same here. And for more information, please do visit silvercross.org. Again, that's silvercross.org. Now, if you found our chat helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for being part of this edition of Silver Cross Hospital's iMatter Health Podcast.