Evo Terra (Host): What should you know about medical and surgical weight loss? Let's find out with Dr. Philip Ernest, a Surgeon and the Medical Director of General Surgery and the Medical Director of the Metabolic and Bariatric Institute at San Juan Regional Medical Center.

 This is Celebrate Health, from San Juan Regional Medical Center. I'm Evo Terra. Thank you for joining me today, Dr. Ernest.

Philip Ernest, MD, FACS: Thank you so much for having me today, Evo. I appreciate the time.

Host: Now, before we get into the questions about medical and surgical weight loss, tell me a little bit about what is the Metabolic and Bariatric Institute?

Philip Ernest, MD, FACS: Yeah. So, I think some people are confused by that name sometimes because really what we are is a comprehensive weight loss center. So what that means is that we're going to take care of a patient whether they need surgery, whether they need medicine, whether they just need some counseling and help on how to fix their diet so that they can not keep gaining weight.

So really we're there to help the community. And that where the title Metabolic and Bariatric Institute really encapsulates that entire comprehensive weight loss center. So yeah, that's, what we are and that's what we were designed to do.

Host: Excellent. Now, let's get into some nitty gritties about having a doctor assist with their weight loss. Specifically, we've got medical weight loss and we've got surgical weight loss, and those are two different things. Can you talk about the differences?

Philip Ernest, MD, FACS: Sure. I think that weight loss is weight loss, right? So any weight loss is good in our book, but some people are really looking for to get it one way or another. And I think there are definite benefits between one or the other, depending on where you sit on the scale of how much you want to lose.

And that's a really important piece. So when people come to us and they start talking about what their goals are, that starts help us creating an idea of what pathway might be best for them. And what's so great about our center is that we're able to really tailor a plan that fits each patient.

So obviously the surgical side. It's surgery. We do two types of surgeries here. Currently we do the gastric sleeve, which means you're making the stomach much smaller. We remove about 80 percent of the stomach. You kind of turn it into a tube, essentially. And that creates anywhere from 20 to 30 percent body weight loss. We, we typically see somewhere between 25 and 30 percent total body weight loss with that. And then we do the Roux-en-Y gastric bypass, which is little bit more of a complicated surgery. But basically we're rerouting some of the intestines, making the stomach smaller. And people lose anywhere from 25 to 35 percent total body weight loss with that. It's a little bit better than the sleeve. All in all, they're almost the same, little better diabetes control with that. So that's kind of the surgery side.

The medical side we use medications. There are, everyone's heard about Ozempic and Mounjaro. We have those, we use those, we also use other medications, particularly when insurances don't allow approval for those types of medications, and then we also have diet plans, lifestyle management. We have dietician counseling. We have mental health counselors as well. So, we work within a community of providers to really help make sure we're taking care of the complete patient. And on the surgery side, we're doing all those things as well. You know, It's not just like, oh, I got surgery. I don't get all this, or I get medical, I don't get all. It all really comes together. It's just what the ultimate, where the ultimate treatment line is for how we're getting the weight loss.

Host: That's great information. I want to dive in a little bit deeper into the surgery actually. And there's that term bariatric surgery, which is an odd name. Why not just stomach surgery? I'm not really sure. You talk about two things we can do to change things up. Can you go into a little bit more detail about that?

Philip Ernest, MD, FACS: Yeah. And, bariatric surgery can be confusing. A lot of times I tell people, Hey, I'm a bariatric surgeon and a general surgeon, and they look at me like what is bariatric surgery? And, and you know, really for us as bariatric surgeons, we're almost trying to change that name to being a metabolic surgeon.

And that also makes people look at you like, well, what does that mean? But really your metabolism, most people understand, like that's how you process food. Well, oftentimes, as your body gains weight and you move into this place of obesity, your body's metabolism is actually greatly affected. And what bariatric surgery does, yes, we work on the stomach. That's one of the main parts of bariatric surgery, but it's not just changing the stomach. It's also changing the metabolism. And so what you see is that people actually change how they process their food. And that also is part of how the weight loss happens. So we're restricting food by doing the stomach surgery, but there's also a metabolic side where we're changing how the hormones operate in your body that also greatly assists in the weightloss for the patient.

So, a sleeve and a Roux-en-Y gastric bypass, or a bypass, sleeve or bypass, you know, however you want to state them, there's lots of different slang for these surgeries. They both have great results. They're actually some of the most durable weight loss options out there, more so than any other including medications.

So we have the best data when it comes to surgery. So I really do think surgery is a great option for patient, but I also understand not everybody would want to do that.

Host: Right. Yeah. And talk about changing hormones and the way that our body's metabolism, impacts us and the weight, we clearly that's gonna be different from person to person. So how do you do that? How do you personalize a weight loss plan for your patients?

Philip Ernest, MD, FACS: Yeah. I mean, you

know, the surgery is the surgery, right? So from a surgery side, when I do a sleeve gastrectomy, I try and do it and create a similar result in the surgery itself, how I shape the stomach, how I remove it and the size that I'm leaving behind. But you're right. Everybody's body does respond a little differently to the removal of that stomach, which that part of the stomach I remove in a sleeve typically produces ghrelin, which is a hormone that induces hunger.

So when you remove that stomach, a lot of people have significant loss of hunger cues which really helps with the weight loss as well, but not everybody gets that. And that's why there's some variability in all of these surgeries, but the averages are still very high and people tend to do very well with those surgeries.

So, even after the surgery, we look at, Hey, when you made it to six months, where's your weight loss? When you've made it to a year, what's your weight loss at? And then if we need to, we can always try and adjust things. Do we need you to, you know, you're meeting with the dietitian. Do we need to change the diet a little bit?

Do we need to increase some of the exercise? Are we missing some things? So we're we're working with patients throughout this whole process. And that's part of the individual piece is seeing how each step we're taking actually makes changes or not changes for the patient and then trying to go back and change things.

And then, sometimes you have to add medication on top of a surgery to really get what people want for their goal, for their total body weight loss.

Host: You've mentioned uh, dietician, you've mentioned different medications someone could be on. You've mentioned physical therapy type of things. That takes a team of people, right? I mean, you're a brilliant surgeon, I am sure, but you're not those other things as well, so talk about the team approach, and what sort of support patients are going to get when they come through the Institute.

Philip Ernest, MD, FACS: So we have Megan Ritz, who's the assistant medical director. She is a physician assistant and specializes in weight loss medicine and surgery. And we also have Ryan Bazell, who's a nurse practitioner who also does the same. We also have a full time dietitian that works with us.

We have worked with our rehabilitation and physical therapists here at San Juan Regional Medical Center at the hospital. They are used to seeing referrals and working with patients that are working either towards surgery, weight loss, wherever they are in the process. We also have a mental health counselor that we work with that sees all of our patients as well.

So, yeah, it takes a team. This is not, you know, I am not doing it all. And you know, that expectation is, is that it really takes a team. You need the support of more than just one person to do this. And I think people really appreciate that. They like knowing that it's not just one person, that they have numerous people helping and supporting and being a part of this process.

And I think that's really valuable. People like that team effort. And that's just the provider side. We also have support groups and other ways that people can get out in the community and get further support. So yeah, it's a, we really, like I said, try to create this comprehensive program because it's not just the surgery. It's not just the medication that's going to get it. We want to make sure that they have the long term durable results and that's how you do it.

Host: The totality of healthcare. Yeah. that's, I think, a good way to look at it. As we near the end of this, I want to focus a little bit on patients, people listening right now who might be considering using some of the services there. Who's a candidate for this, either for the medical or the surgical weight loss?

Philip Ernest, MD, FACS: It's probably easier to find who's not a candidate than. If your BMI is normal, we really don't have a lot to offer, especially under using insurance because basically, if you're not overweight, we're very limited. Now there's always cash pay options and different things that we can do to work around insurance.

But for the most part, if you're overweight and particular, if you're overweight with a comorbidity, comorbidity, meaning that you have obesity related or overweight related disease. So I'm overweight and I have Type 2 diabetes. I'm overweight and I have obstructive sleep apnea or high blood pressure, something like that.

Well, that opens up a lot of doors right there to either lifestyle, medication, coaching, those types of things. For surgery, typically you have to be obese with or in the BMI of obesity, which is a BMI of 30 or greater. And that opens up some doors for surgery. Insurance companies are kind of changing around this because there's new indications for bariatric surgery.

They've been out for a little over a year now. I guess we're year and a half and seeing we're how insurance companies change that, but typically it's a BMI of 35 with a medically related obesity condition or a BMI over 40 without. And so, but the new indications are even going down to 30 and we've been able to work with some insurance companies giving them this new data and getting approval for surgery as well.

So, there's great things. I would say there's probably no other field right now that is changing on the daily, like, weight loss medicine because there's so much new stuff coming out, so much new data, medications, it's a great time for people to be invested in their health, particularly in weight loss, because there's lots of options.

Host: Yeah, I know with all the new GLP1s out on the marketplace, it seems like everyone's getting on a medical weight loss thing these days. For the surgery aspect of things, I mean, clearly, the benefit of having the surgery is, look, I get it, you've changed the way that the body processes food and the amount of food they can put in it, so they're going to lose weight over time. What's that time look like, and are there any other benefits surgery provides?

Philip Ernest, MD, FACS: Oh yeah, there's tons of benefits that go along with surgery, but let's just talk about timeframe. So like what do people, how, what's that timeframe for weight loss? So we think of most of the weight loss happening in that first year. So at one year, most people have kind of met the majority of their weight loss, but I will tell you, a lot of patients continue to lose weight to out about two years, 18 months, two years, somewhere in there.

And then they hit that kind of stable area, and then we have to work hard to keep the weight maintenance. But the other benefits are remission of those obesity related diseases. So Type 2 diabetes, high blood pressure, obstructive sleep apnea, those things sometimes people lose high blood pressure within the first week after the surgery before you even really lose a pound.

Type 2 diabetes sometimes is gone within that first week. So people are seeing the benefits of the surgery immediately. And I think that is really unique to the surgery piece because you see the effects of the surgery so quickly.

Host: And do you have any success stories you'd like to share with us today?

Philip Ernest, MD, FACS: Yeah, I think that's one of my favorite parts of doing this, is hearing patients tell me stories about how they're able, my favorite ones are when they're talking about their kids. And the goal was to be able to do things with their kids again and hearing them talk about, Hey, I went to the beach with my kids and I was able to play with them in the surf.

And I felt like, Hey, if something happened, I could save them. And I could have fun with them and I could be there for them. Where just a year ago I wasn't able to do that, or I'm able to go out and do a walk, or just these things that oftentimes we take for granted. And you see people, regaining those things that are so valuable and so important for a family unit.

So, those are some of my favorite stories, but they cross lots of different areas and yes, success is awesome to see for our patients.

Host: Yeah, we always consider success, or at least I like to think of success as, very much a what's in it for me, but you're talking about what's in it for the whole family when someone gets healthier through these products and services. That's great.

Philip Ernest, MD, FACS: Yeah. Yeah. I mean, there's also the obvious weight loss in and of itself. And we do really well with that, but yeah, my favorite is always the heartfelt stories about how they feel the difference, not just how they see it.

Host: Very, very good. Anything else you'd like to add, Dr. Ernest?

Philip Ernest, MD, FACS: No, thank you so much for having me on today. It's great to talk about what we're doing here. We're really proud of it. And, we just want to make sure that we're offering a great service to our community.

Host: Thanks again for your time, sir.

Philip Ernest, MD, FACS: Thank you.

Host: Once again, that was Dr. Philip Ernest, a Surgeon, and the Medical Director of General Surgery, and the Medical Director of the Metabolic and Bariatric Institute at San Juan Regional Medical Center. To learn more about the Metabolic and Bariatric Institute, please visit us online at sanjuanregional.com/mbi. If you found this podcast episode helpful, please share it on your social channels, and check out the full podcast library for topics of interest to you. I'm Evo Tera, and this has been Celebrate Health from San Juan Regional Medical Center. Thanks for listening.