Dr. Mike (Host): Welcome to The Pulse at Tallahassee Memorial Healthcare. I'm your host, Dr. Mike. And with me today is Dr. James Parker and Greg Laffitte from Tallahassee Memorial Healthcare. Dr. Parker is a general and bariatric surgeon, well-versed in minimally invasive and robot-assisted procedures, and Greg is a PA at Tallahassee Memorial Healthcare, who takes care of a lot of Dr. Parker's patients.

 We're so happy you're joining us today. The topic is bariatric surgery or GLP-1s, which is right for you? Dr. Parker, I'm going to start with you. GLP-1s, they're everywhere now. They've just taken over the media, commercials. What are the primary benefits and risks associated with bariatric surgery compared to GLP-1 medications in the context of weight loss?

James Parker, MD: Sure. I guess we'll start with just the longevity of how long both have been studied? So, bariatric surgery, we've been doing it since the 1960s. The bypass has been around since around that time. And it stood the test of time, whereas the GLP-1s haven't been studied as long. And so, we are not as sure of all of the risks involved with the medications, the long-term side effects, or even the side effect profiles in the more acute settings. I've seen a lot of very weird side effects with the GLP-1 medications. And so, as far as the safety profile goes, bariatric surgery seems to have set the test of time while GLP-1s haven't.

Host: Yeah. So Greg, I'm going to ask you real quick on that same question, since you are the PA that works a lot more on the medical side of all of this, what is your opinion about the GLP-1 medications?

Greg Laffitte, PA: Okay. I think it's a fantastic question, and the audience that we're speaking with, really, they need to have, I think, a very clear understanding with respect to that risk associated with one versus the other. And so when you get into the whole GLP-1 thing, there's one of these injectable pens. This is going to be your Zepbound, Mounjaro. There's the example of the Ozempic pen. And then, you have another pen over here. This is going to be the Wegovy.

The thing about these medications, those three pens that I just held up, with mass marketing, social media, the population that's interested in this is getting a lot of, I think, not false, not misleading, not lies, but they can walk away with the impression that if they do that drug, that it's going to take everything away that they need to do in order to help them reach a satisfactory weight. The problem that exists with it, as Dr. Parker mentioned, bariatric surgeons been around for quite some time, and there are volumes and there's reams of data that the surgeons can go back to, to say, "Yeah, these are the risks, these are the benefits that are associated with that specific surgery." And because of that history, because of that legacy, we know how we prepare and how we plan to prevent those things from occurring.

On the other side, these medications have not been out that long. And so, you then go to the package insert and one of the first things that I look at is a black box warning for the potential for a cancer. So if a person is of the inclination to think, "Well, I don't really want to have a gastric surgery because I can get an injectable." You then have to go into the real science and say, "How long have they been out? What do we know about these medications and the risk that's associated with this?" Maybe there's an unknown. I don't know how long you're going to have to be on this med. And typically speaking, these are what we would regard as lifelong medications. So, I think the jury must be out to be quite honest. Since 1960, or even maybe earlier, we've got 40, maybe 60, 70 years' worth of medical evidence compared to medications that have only been launched within the last less than a decade. So, there's a lot of unknown to the GLP-1 therapy, and that's my opinion.

Host: That's fantastic. So, Dr. Parker, back to you. How does then the effectiveness of the surgery-- in achieving weight loss, right-- compare to the use of GLP-1s, let's say over one year?

James Parker, MD: Yeah. And this kind of alludes back to the social media and the marketing for the GLP-1s is a lot of times you'll hear that you can lose up to 30%. Of your body weight with these medications. But if you look at the studies, the studies are showing that the average patient is losing about five to 7% of their body weight. And then, when those are compared to the bariatric surgery studies, the bariatric surgery procedures, the sleeve and the bypass patients are losing on average 20-22% of their total body weight. And so, the results are a little misleading based on the way that they're marketing these medications. So, the efficacy is still very much so leaning towards bariatric surgery. And not that the GLP-1s don't have their place in certain situations, but I'd say overall bariatric surgery is a lot more of effective long-term solution for weight loss.

Host: well, let's talk about that with Greg then. If GLP-1s do maybe have a place for some patients, what is that? What does the patient look like for your perspective, Greg, who might be a GLP-1 candidate?

Greg Laffitte, PA: That's a conversation that we could have that would go on for hours. I'll summarize it real simple. When you have an individual that comes to see me and they're curious about their weight loss, and they've described to me that they've done everything they know to do, they've been very sensible with their dietary approaches. They've actually gotten with a personal trainer. So, they give me the history that I can verify or at least say, "Okay, this is a good historian. I believe that what they're telling me is true." If that's the individual that's put all of this effort into it and they're not able to break through that weight loss, and they may be that individual that perhaps-- and this is the constellation of the stresses associated with becoming obese-- what if they had a childhood that was extremely difficult and they've been placed on some specific medications that might lead to weight gain or prevent weight loss? There's one.

Number two, what if they were raised in a house where socially you were told, "You better clean your plate"? What if you were raised in a household where it was never something told to you that six Dr. Peppers a night is not a good thing to do. So, the socialization of specific patients when they walk into this room. And I look at what their history has been, how did they get to where they are today, they may be some people that a GLP-1 might be a good idea with, especially if they happen to be a type 2 diabetic.

So if they've demonstrated to me, and I begin to have to say, "Okay. What have you done? What's been a successful? What has not worked for you?" And they may be deathly afraid of having to undergo a surgery. Then, we could say, possibly, let's take a look at this therapy with a clear, very, very finite understanding that these are not cures. Those drugs are fantastic, but you still have to do your part. If you start taking GLP-1 and you don't continue sound dietary awareness, good protein intake, a number of calories to come in, meet with a dietician, go have a conversation with a counselor, that maybe some of the behaviors you have could be corrected and not contributing to this, and then the bottom line, when it's all said and done, are you watching yourself on the high school track more than you're watching social media and sitting at your house?

So in a summarization, there are those people out there that would possibly, and I be an ideal candidate, but it requires a lot of clinical interface to say, "Hey, let's talk to a warm breathing person in the same room, and not somebody that's on an internet website someplace trying to sell you a compounded medication of which you really have no idea where it came from. And then, at the same time, make sure you're getting sound nutritional guidelines as well as speaking about the physiological requirements to do this because there are those risks that are associated with the GLP-1s. They are not for everybody clearly.

James Parker, MD: And I can add to that, I see patients more in a surgery setting. They're sent to a surgeon. And so, I have, I guess, my own guidelines for who would benefit more for a GLP-1 route as opposed to surgical route. And for me, very busy clinic, I don't talk to patients as long as Greg does. So, he gets all of those socioeconomic factors that could contribute. But for me, the bullet points are you're deathly afraid of surgery, surgery's not going to work for you. GLP-1s, losing weight is going to be beneficial in any regard. Patients who are too sick to undergo surgery. So patients who have severe heart failure, who couldn't tolerate general anesthesia and need to lose weight, GLP-1s could work for them, or patients who are super morbid obese, patients who are BMI 90, 100, My 600-Pound Life patients and some of those patients would benefit from losing weight before we undergo surgery, because it's going to make the surgery easier and safer. And then, we have the patients who have already had bypasses and who have regained a lot of their weight for whatever reason. Those patients don't really have much to offer surgery-wise. Going on a GLP-1 has shown to lose 50% of the regained weight, 5-10% of the overall body weight.

Host: Greg, I want to go back to you real quick. Okay. So, let's say somebody has the bariatric surgery, right? And then, I'm assuming you see a lot of postsurgical patients and follow them, versus somebody who's just doing the medications. And let's not include the morbidly obese group. We're talking about people overweight, obese in that area. What is the difference you see in surgery versus the medication versus other comorbidities like diabetes and lipids and cardiovascular risks, et cetera.

Greg Laffitte, PA: Okay. When a patient comes to me from Dr. Parker, we get their electronic file. I'm able to go in and look at their labs. One of the very first things that I like to go take a look at are those comorbidities that are specifically linked to obesity. Diabetes is going to be up there, high cholesterol. I'm going to go look, not that this is in a lab, but I want to look at their blood pressure history. Also, whether or not they have sleep apnea.

So if these individuals demonstrate metabolic syndrome, they come in with a metabolic syndrome and they're a person that has a BMI of a 35 and a comorbidity, so they fall in the criteria for a gastric surgery, I always-- almost always-- will lean towards this is a patient that should be considered as a gastric surgery candidate. And the reason why, to me it's overwhelming. Next May, I would've been here 10 years, had 11,000 patients that I've been through. I've seen the results of what gastric surgery does. I've also been here long enough now where I watched how the drug manufacturers began to roll the GLP-1s out. Without fail, 99% of the time, the individuals that were put on a GLP-1 compared to gastric surgery don't get anywhere near the kinds of results that they got with gastric surgery. That's one, number one.

Number two, I'm beginning now to see the emerging clinical evidence that these people placed on these GLP-1s are starting to recognize specific lean muscle mass degradation. And probably the most telling part about every bit of this, they never learned to change the habits that more than likely got them to that place in my office or in Dr. Parker's office. So, a dramatic distinction gets drawn between when I see a patient come in that qualifies for a gastric surgery, our workup with them begins extremely specific about the surgery is a tool. You must do all these other things in order to have a long-term success. And I do believe, without trying to sound against the GLP-1, because I'm not opposed to them, but I believe that the efficacy for long-term success is far better on the surgical spectrum than it is with the GLP-1. And to add one more thing to it, a GLP-1 can have its place if that patient is going to adhere to a very structured routine followup. And thus far, I don't really see a whole lot of that long-term.

Host: Understood. Yeah. Real quick, Greg, quick followup, and then I'm moving to Dr. Parker for a second. So, you mentioned with GLP-1, maybe there's a loss of lean muscle mass. Why is that important?

Greg Laffitte, PA: It seems that in terms of the evidence, and I'm only taking what I'm reading, it seems as if this process biochemically through the metabolic pathways seems to go and rob lean muscle mass of energy, so glycogen stores, wherever that is, it's in a very complicated pathway. And we do a body composition on every one of our patients. It's called a Tanita. And when the Tanita comes back, I make a comparison to the preceding three months, and I'll even take it back to the very first time they came here. When I see a patient that's 70 years old that walks with a cane, so he's not able to get out and have a lot of exercise endurance, and I say, "Okay, I'm witnessing here lean muscle mass degradation. Yeah, your diabetes is very well regulated, but we're losing some of that core strength that you need to have as a 70-year-old male." Why it's not panning, it didn't happen before the Mounjaro. It didn't happen before the Zepbound. But we see evidence of that now. So, there is a pathway and emerging science that seems to be correlating that experience.

Host: Dr. Parker, when you look at misconceptions about what you do, bariatric surgery, what are some of the most common ones you hear that you want to, like, clarify for potential patients?

James Parker, MD: I think the biggest misconception is how risky or dangerous it is. It's evolved over the years. It's gone from open surgery to laparoscopic surgery to robotic surgery. There've been many different techniques that have been tried over the past 30, 40 years. But for the past 15 years, we've kind of set on the sleeve and the bypass. There are some outliers from newer techniques that are coming around, but the safety profiles of these surgeries have become very low, where the sleeve has the safety profile of a gallbladder surgery. Nowadays, one in 300 risk of having any sort of life-threatening issue happen in the perioperative period. And so, I think that's the biggest misconception, is that these surgeries are very safe and very well-tolerated.

Host: And so, Dr. Parker, also, you know, adding to this, what about recovery time? How long are patients staying in the hospital now versus ten years ago, five years ago? Is all that getting better?

James Parker, MD: It's becoming standardized nationally. We've got Bariatric Centers of Excellence and the entire idea behind it is to get patients up out of their beds, moving around out of the hospital earlier, back to normal activities earlier. As far as our data, TMH, our average length of stay is like 1.1 days. So, a majority of the patients are going home on postoperative day one. We don't send patients home on pain medications, because the surgery is so pain free. Sorry, I don't want to say pain free, but the surgery is very minimal when it comes to pain, and well-tolerated. And we do a good job with our preoperative workup with Greg and the dieticians and everybody to prepare patients mentally for the stress of the procedure so that when they're leaving the hospital on day one, they're hitting the ground running. And they're excited to start feeling better, start having less fatigue, start sleeping through the night and stop taking so many medications that they take around the clock because their comorbidities improve. So, I'd say all in all, the whole package has been great here.

Host: That's fantastic. And so, this question I'm going to move over to Greg, and it's about insurance. So in the clinical setting, what are you seeing here? How does insurance deal with the surgery now versus these GLP-1s? Are they starting to prefer the medications? What are you seeing?

Greg Laffitte, PA: Without a doubt, insurance companies, and this ends up being probably a conversation that would be really, really good for the national debate, and that is somehow one way or another, the insurance companies oftentimes will look the other direction for gastric surgery or even a GLP-1, unfortunately. What I'm finding is that insurance companies are going to be more willing to pay for gastric surgery almost across the board than they would for a GLP-1. That's Blue Cross Blue Shield, any of your national carriers, and then there can be variations between one state versus the other, depending upon who you work for, who that corporation is in the actual contract that they provide for their patients.

I see companies say up in the Atlanta region that will cover GLP-1 and they'll cover a surgery. But you may come to an area where we live where you don't have industry like that, but your major carrier for the vast majority of folks that are employees in the state of Florida, it won't cover it. And so, what's happening with this, there can be some frustrations with people to where they're trying to go to get what I call the gray market. And since insurance is not going to cover it, they'll go see where there's a small placard on a street corner somewhere that says, "Hey, we compound it, come to this office," or I've had patients that will come in and tell me, "Well, I've got a virtual MD. I don't know where they are, but that's where I'm getting it. And it's a compounded version." So, no insurance companies. If anything, they've gotten to that place where they're not covering it. When it first started, maybe 18 months to 24 months ago, it seemed like there was more coverage at that point. But my witness is now they're backing away from it.

James Parker, MD: One of the issues is when they lose coverage for the GLP-1s, then they stop getting the medication and they immediately start regaining the weight.

Host: Yeah. Real quick, Greg, you have mentioned this before, the compounding pharmacies producing these GLP-1s. Tell us the difference between those in the pharmaceutical version.

Greg Laffitte, PA: So, the pharmaceutical version, you're going to find a pen that's going to be dispensed that looks like this. And these are pens that are going to become professionally, already prefilled syringes. There's the Wegovy, there's the Zepbound, there's the Ozempic. And those are the examples of what's been from the actual manufacturer.

Now, as of late, Eli Lilly, for example, has where you can go to Eli or Lilly Direct, and you can buy the vials of their medication and you supply the syringe and then you draw it up. So when you go through a reputable source like Lilly Direct, you know you're going to get the FDA-approved product. Here in Tallahassee, and I would go maybe a radius from Tallahassee out of a hundred miles, I can probably tell you of three or four places in the community where there are pharmacies that are compounding. And there have been in some doctor's offices where they have been compounding these agents as well. And because of my curiosity and my experience, in my own health of having to use injectable medications as well as a mother who once got hepatitis because there was a pain management clinic here in Tallahassee that was doing some, I think, unsafe practices, let's leave it at that, and the doctor left town. When I call these pharmacies, or I call some of these offices to ask them the nature of who their medical director was and to try to gain some insight in terms of their product, they hang up.

So when you find out that, yeah, up in Marietta, Georgia, for example, an investigation was conducted and they brought these vials in and they subjected them to lab scrutiny and come to find out they were sodium chloride and not an actual agent, that's a concern. These drugs are not off patent. So, the proprietary equation, if you will, that's not available. So, somebody is reverse engineering and coming up with something. So, the way I know about it, people will tell me, and I've had numerous cases, numerous people, and they say, "Well, would you prescribe this compounded medication?"

Host: Absolutely. Dr. Parker, any last words, bariatric surgery, GLP-1s for the listening audience?

James Parker, MD: I'd say, at the end of the day, regardless of what you decide to do, medical weight loss or surgical weight loss, I think the most important things are, one, taking that first step, going to see a physician, and really staying accountable with your weight. And two, is really working on dietary and exercise routines starting now and leading up into it. And either way, with surgery or with medical weight loss and GLP-1s, you're going to have a better, overall weight loss and you're going to lose less muscle mass if you stay in the gym, if you eat healthy, if you cut carbs and increased protein. If we do more than just rely on a injectable medication, I think that you're going to have a better outcome. And so, at the end of the day, I just want to see everybody healthier. You can't go wrong as long as you're just staying on top of your health.

Host: Greg?

Greg Laffitte, PA: Yeah, I love his answer there just then. It's the trade that we are involved in is trying to get people healthy. And i'm really motivated from the point of view of we want to do what we can to make people have longer, healthier lives. So if you consider, and there's a guy by the name of Dr. Peter Attia. He has a book by the name of Outlive and he goes into great detail. So, I'm not stealing or copywriting his comments, but it has to do with how do I get you to be 84, 85 years of age or 90 even, so that you're still out enjoying your life and you've not lost your independence. And so, from the standpoint that we know that obesity is a tragedy in our country right now with extremely high numbers, and I'm seeing those of course, in pediatric kids, the teenagers, and so on.

When you come to my office and you have metabolic syndrome if this has not been addressed, at a minimum, let's have that conversation. Let's take the time to sort out the fact from the fiction. And I've got the resources. I've got a bariatric surgeon right here who today I saw one of his patients, he identified for her in the workup a duodenal carcinoma.

 So in this quest for us to get healthy, we either ignore it or we come in the office and let's take it, sit down and have that hard conversation, and not to shame anybody, but it's to say, how did we get where we are today and how can I then integrate my services? Whether it's a non-surgical, whether we're going to go medical, maybe it's going to be a hybrid, maybe we get a little bit of weight off before we go to surgery.

But if you're not going to do surgery, you're going to use this medication. And I'm going to be very, very specific about, I want you to weigh in, food journals. Make sure you're doing the kinds of things to get you that place where you have that long-term success that keeps you independent, happy, and out of a nursing home. That's ultimately where we want to be. Keep your independence and maintain your health. And that guy's sitting right there, Dr. Parker, doesn't come any better than him.

Host: Awesome. Hey, guys, that was fantastic. Great information. I know the audience got a lot out of this. Thanks for coming on today.

James Parker, MD: Yeah, thanks for having me.

Host: For more information, be sure to visit tmh.org/bariatric to start your weight loss journey. If you enjoyed this podcast, go ahead and share it on your social channels and explore our entire podcast library for topics of interest to you. This has been The Pulse at Tallahassee Memorial Healthcare. I'm Dr. Mike. Thanks for listening.