Rania Habib, MD, DDS (Host): The National Institutes of Health estimates that 256,000 people will undergo bariatric surgery each year. But surprisingly, this only accounts for 1 percent of the eligible surgical population in the U.S., making it one of the most underutilized treatment options for obesity in modern medicine. Welcome to MDCAST by Tampa General Hospital, a go to listening location for specialized physician to physician content and a valuable learning tool for world class healthcare.

My guest today is Dr. Francesca Dimou, an Associate Professor of Surgery in the Division of Gastrointestinal Surgery at University of South Florida. Today we are going to discuss the current and projected prevalence of obesity in the United States and the current treatment options for obesity to help listeners understand metabolic surgery and to see if it is a good treatment option for your patient. Welcome Dr. Dimou. It's so exciting to have you today.

Francesca Dimou, MD: Thank you for having me. I appreciate the time.

Host: We are really excited about your expertise on this topic. You know, it's a very hot topic in obesity medicine. So to begin, what are the rates of obesity in the U.S. today?

Francesca Dimou, MD: So currently what we sort of state is we look at sort of classifications, right? So you have overweight and then obesity. About 30 percent of people in the United States are considered overweight. However, about 40 percent are considered to have the disease of obesity. And typically we say that's a BMI of 30 or greater, and we'll talk, I'm sure, later on as far as surgical candidacy and things like that for weight loss surgery. But typically we say BMI greater than 30. That's about 40 percent of the population.

Host: Wow. That's a much larger number than I thought.

Francesca Dimou, MD: Yes.

Host: So what are considered to be misconceptions with respect to patients with obesity?

Francesca Dimou, MD: Yes. So I think perhaps the biggest misconception for a lot of our patients or the patients that I see and that I speak with, is that obesity is a choice. And I think what we're learning is that the disease of obesity is much more complicated than we ever thought it would be. And it's multifactorial. And I tell my patients this as well. It's genetics. We see people that say, I've always been heavy all of my life, or you see families with the disease of obesity. We see it's also related to food consumption, yes, but also the dietary choices that we have available, and there's all of these components.

It's hormones we're learning, as well. A lot of hormonal involvement, which is sort of what we're seeing with medications and things like that coming into play. So that's why also the treatment of obesity is multifactorial. It's not just surgery. It's not just diet and exercise. It's a lot of components in order to treat it.

Host: What would you like physicians to know specifically about obesity when you're talking about it as a disease? Because I think in med school we often learn it is a choice, and I know you elaborated on that a little bit, but how much of it is their genetics versus other medical problems?

Francesca Dimou, MD: I think the question becomes which came first, the chicken or the egg as far as medical problems. So, we typically say comorbid conditions associated with obesity, high blood pressure, sleep apnea, diabetes. The likelihood of people having those conditions without obesity is lower than the reverse. I think that what we need to understand is the complexities of patients and where they're coming from. Whether it's, we have patients who have a history of, let's say, trauma or abuse and they look to food for compensation or for comfort. You know, anxiety, depression, all of these also psychosocial aspects that we don't really take into account in our daily lives; a lot of the patients that I care for have experienced that, and that also has a component of how we treat patients with obesity that I think we overlook commonly.

Host: Oh, definitely. I think that's really important to remember. So if a referring physician has a patient who has been diagnosed with the disease of obesity and they're interested in sending them to you, what is involved in your initial workup when you see that first patient?

Francesca Dimou, MD: So the kind of backbone, and this is based on the NIH guidelines back in 1991, oddly enough, and hasn't really changed, but has sort of evolved based on insurance requirements. But typically we see patients with a BMI of 35 or greater. So that qualifies them for weight loss surgery, but they have to have a comorbid condition. So that's usually a high blood pressure, diabetes, sleep apnea.

Now, if their BMI is 40 or greater, they don't necessarily need a comorbid condition. So we make sure based on BMI alone that they qualify for surgery. Then we have to look at other components. We have them see the dietician. We have them see the psychiatrist because of the components not only before surgery, but also the changes after surgery.

We make sure any medical conditions that they do have is optimized prior to that. And also the other thing that we have to gauge is how committed is someone to this change. And I tell patients this often, I can do a surgery and change everything in three hours, but you're going to have to change everything you've done your whole life overnight. And that's hard to do. And so I think understanding that commitment is very important. And that's why typically when a patient first sees me in the clinic, the process is about six months to get them to surgery because of all of the components that are involved in order to get them to that point.

Host: So how do you, as the surgeon, make sure that they're committed to that aftercare?

Francesca Dimou, MD: I think a lot of it is the fact that we see them on a monthly basis, whether it's myself, one of the nurse practitioners or one of the dieticians, we see them at least once a month, and we also are able to see what's happening with their weight. Now, with that being said, weight loss during this six month process does not necessarily equate to success after surgery. However, if we're seeing things like weight gain, or they're not changing certain eating habits and that sort of thing, then that's going to be a different component of the discussion that we have and their commitment to weight loss surgery.

Host: Absolutely. So now that you've identified the patients that are candidates for metabolic surgery, what would you like physicians to know about metabolic surgery?

Francesca Dimou, MD: Yes. So I think the unfortunate reality is that bariatric surgery or metabolic surgery still has this negative connotation, not only within the medical field, but with patients. It's still seen as maybe unsafe, which actually it's very safe. It's as safe, or if not safer than a gallbladder or a hysterectomy, especially now with minimally invasive techniques and robotics and those sorts of things, it's overall safe.

The other thing is, is that a lot of people still have this thought process that, well, I know someone who had this surgery and they gained all of their weight back. Which, this is kind of where we go back into the fact of treatment of morbid obesity, is multiple components. It's not just the surgery, it's not just diet and exercise, it's all of these things comprised in order to be successful. And so it's also important that we ensure follow up with our practice and making sure they're seeing their primary care and those sorts of things in order to ensure that they maximize the benefit of that surgery. And I think a lot of people still have this stigma of, oh, well, it's not going to work, or I've seen people fail, or it's unsafe. Those are the main common theories that I see.

Host: You mentioned success of metabolic surgery. What do you define as success and what is the success rate of metabolic surgery?

Francesca Dimou, MD: So success rates, I think vary, depending on the physicians that you speak with. And I think the thing is, is that when I talk to patients, I ask them, you know, hey, do you have a goal weight? Because sometimes people do. And I kind of try to temper their expectations in the sense of what they're looking for. And we don't want a number. And I think the more I talk to patients, success for me is when a patient comes to me and says, I can play with my kids again, and I don't get tired. Or I can go on an airplane. I was too scared because I couldn't sit in the seat and it's those sorts of things, or young women who couldn't get pregnant before that and then they're able to have a family afterwards.

It's those big successes in life that they felt they couldn't achieve, and then after surgery they're able to achieve that. When you look at numbers now, there's different varying success rates, quote unquote, as far as weight loss, and I think that's what we're seeing in the newer literature. You have anywhere from, let's say, 50 percent and then some people say 70 percent and they say, Oh, well, that's not good.

And I think the thing is, is that for us, as bariatric surgeons, we're learning that again, surgery is not the only component in treatment of obesity. We're seeing that patients afterwards, they have a certain metabolic set point and they're doing all the right things. They're dieting, they're exercising, but for whatever reason, their weight is stagnant where it is.

Or they're having weight recurrence. And so that's where these medications that we're seeing on the market are actually very helpful to our patients. And so that's where I think it's going to be a game changer for us to better treat our patients and take care of them. So then they maintain that, that success and those life obstacles that they once had, that they no longer have.

Host: That's fantastic. So what are the surgical options for obesity? And we'd also love for you to touch on what is considered revisional surgery.

Francesca Dimou, MD: So the three main surgeries that are typically offered in the United States, and I'm going to kind of go with what's common, is number one is a sleeve. So that's probably about 70 to 80 percent of surgeries that are done as far as weight loss surgery. So the sleeve is what we call a restrictive operation. We remove about 70 percent of your stomach. It's completely gone. And so the amount of food that you can consume is significantly less. Number two is the gastric bypass. So gastric bypass has been around for quite some time and I think it's gaining more popularity because it is more effective as far as weight loss and this is where we make the stomach, as you guys know, smaller then reroute the intestine. And so it's restrictive and malabsorptive. And then the third one, which is also gaining popularity, is the duodenal switch, or a variant of that, many people may have heard, the SADI. And so, when I talk to people about that operation, it's kind of a sleeve and a bypass in one. The caveat to this operation, which I do find it a wonderful and powerful operation, is that because the amount of intestine and the malabsorptive component of this operation can result in malnutrition, I'm very selective in the patients that I offer that to.

 So, I tell patients like anything else in life good and bad. So those are the main three. So things that have kind of fallen out of favor is the gastric band. That's not as popular. In many instances, we've seen people gain weight back or have had complications from it. So in most instances, we just remove it.

We're not really placing bands anymore. And then as far as revisional surgery, revisional surgery is really anything that we offer or that we do in a patient who's had prior bariatric surgery. So for example, a patient had a sleeve and they have recurrent reflux. You know, or they have reflux, they never had it before.

Then we discuss with them about converting them to a gastric bypass, because that's an acid reducing operation. Gastric bypass, we've done issues if they have ulcers, we can operate on those sorts of things.

And so anything that has had prior bariatric surgery, we also are able to offer other complexities that potentially other people may not do, which is understandable, it's complex.

Host: Absolutely. Now you mentioned three main surgeries and how different types are gaining popularity. How do you determine which surgery your patient's going to have?

Francesca Dimou, MD: I think a lot of components are, number one, what does the patient feel comfortable with? So most patients know the sleeve because either their friends had it or they see it online. And that's what they're most familiar with, but also they find to be the least invasive. So I always ask patients like why?

Because sometimes they already have something in mind. And I think the sleeve is a great operation in people who don't have heartburn, or who have a certain amount of weight to lose. However, it's also good for let's say, patients who need a heart transplant and they're too sick, and it's a short operation, it's 45 minutes or so.

So, you can get them in the operating room, let them lose weight, and then get them to a safer operation further down the road. The gastric bypass, I think, is also a great operation. It's probably the most common operation that I perform. It is for higher BMI patients, it's for people who have acid reflux, people who have parasophageal or hiatal hernias or something that are large, we offer a gastric bypass.

And then the switch will usually be a BMI of 50 or greater. And again, that is something that I have to talk with patients about as far as malnutrition. They have to be very compliant with vitamins. They also have to take additional vitamins. They have to intake higher protein daily. So those are all of the sorts of things that we look at.

Host: Very complex, obviously to determine which surgery patients are going to have. So what are the main risks and benefits associated with metabolic or bariatric surgery?

Francesca Dimou, MD: I think the major benefit that we see is even as soon as they have surgery, let's say they have diabetes and they're on insulin, that next day, their insulin requirements are significantly less or they're off their insulin. Getting them off of their high blood pressure medications, having decreased pain in their joints, mobility, better breathing, all of those components I think are major benefits to the surgery.

The risks, which some patients ask me about, is things like malnutrition. Let's say in a sleeve or a bypass, the likelihood of that is low. I would say five percent or less. And I think the other risk is understanding that this is going to be a lifelong journey and that it's going to take work. So, let's say, you decide after your surgery you start smoking after your gastric bypass, you're going to be at a risk for an ulcer.

Just those sorts of things that we all talk about patients. And anytime you do an operation, there's always the potential risk of having another operation down the road, a sleeve to a bypass. Those sorts of things. And I always talk about that. I'm very open and honest with my patients because I never want to tell them everything's a hundred percent perfect because that's not life.

And so I think that they understand, they have to know that the benefits of increasing quality of life, prolonging their life, and those sorts of things far outweigh the small risks that we see with surgery.

Host: Absolutely. I would agree with that, especially the small things you talked about, reducing these comorbidities of OSA, of the joint pain, they can mobilize, lowering their blood pressure, and with the diabetes getting off insulin is huge.

So we know that this is a very successful surgery, that it's underutilized, but are there any patients who you would not consider for metabolic surgery?

Francesca Dimou, MD: I think about that often because a lot of patients, when we do info sessions or physicians, the common question is, is am I a candidate? And they list all of these medical conditions they have or surgical history. And it's really hard for me to completely rule out a patient. And I think the thing is, metabolic surgery is still seen as elective, and in most cases, absolutely agree.

However, there are patients who are so sick that in a way, it is a life saving operation, that they need to lose the weight. So, with that being said, the main thing is that if I feel they can't tolerate general anesthesia, their weight is too heavy, those sorts of things, I will have them lose weight just more for safety from a general anesthetic standpoint and that I can get them in and out of surgery safer. The other thing is, is we've operated on patients with LVADs and heart failure, kidney transplants. So the threshold is quite high.

Host: If a referring physician wants to send a patient to you to start this work up for metabolic surgery, how would they do that?

Francesca Dimou, MD: Typically we have them refer the patient to the TGH Bariatric Center, whether that's an order within EPIC or they're able to provide, I usually like providing patients the website. I just tell them, Google, you know, TGH Bariatric Center, because it's very easy, because if I write it down they're not going to remember the link and I get it. And the thing is, is everyone's very savvy. Everyone goes online and looks things up. So, either they can call the office, but other instances is they put in a referral to the TGH Bariatric Center, and then it comes to us, and we're able to work that referral.

And that's probably the most common way, because I think sometimes patients are afraid on their own to seek bariatric surgery. So I think if a physician is open and honest with them, whether it's their primary care physician, their cardiologist, orthopedic surgeon, transplant surgeon, all of these physicians, all of us are seeing patients with obesity in our clinics.

It's just that sometimes we're afraid to say it, or bring it up, or some people still tell patients, you know, you have a BMI of 50, diet and exercise, and although that's great advice, the likelihood of them losing that weight is very low. So we want to be able to bring them into our center and help them one way or another.

Host: Thank you for providing us with such a robust amount of information about bariatric and metabolic surgery. Are there any other take home points that you would like to leave with our audience today?

Francesca Dimou, MD: I think the biggest thing that I keep in mind with patients is that patients with obesity, in a lot of instances when you really talk to them, have felt discriminated against or marginalized because of their weight. And no one really says much about it. And I think that understanding a little bit more of where they're coming from and being open about approaching them with weight loss surgery, and they may be offended in the beginning or they may say absolutely not, not happening, but kind of broaching that topic and being more upfront about it and letting them know that that's a possibility, can open a lot of doors and ultimately help save a lot of these people.

Host: Well, thank you so much for your expertise. We loved having you on the podcast today, Dr. Dimou.

Francesca Dimou, MD: Thank you so much for having me. I greatly appreciate it.

Rania Habib, MD, DDS (Host): Thank you for listening to MDCast by Tampa General Hospital, which is available on all major streaming services for free. To collect your CME, please click on the link in the description. For other CME opportunities, including live webinars, on demand videos, and local events offered to you by Tampa General Hospital, please visit CME.tgh.org. Thank you so much for listening. I'm Dr. Habib, wishing you well.