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Announcer: The University of Florida, College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida, College of Medicine Designates this enduring material for a maximum of 0.25 AMA PRA category one credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.

Melanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole. And today we're discussing weight loss, surgery and transdermal vitamin patches. Joining me is Dr. Jeffrey Friedman. He's an Assistant Professor in the Division of Gastrointestinal Surgery at the University of Florida College of Medicine and the Director of UF Health Shands Hospital Bariatric Surgery Center. Dr. Friedman, it's such a pleasure to have you join us today. As we get into the topic of weight loss surgery, and transdermal vitamin patches, I'd like you to define obesity for other providers and the comorbid conditions that can arise from it and other diseases that either are exacerbated by it or contribute to it.

Jeffrey Friedman, M.D., FACS (Guest): Well, thank you for having me, Melanie. Obesity is a problem that the entire world faces. It's epidemic. It costs our country billions of dollars in healthcare related expenses and cuts people's lives short, by up to 20 years. Obesity is calculated by body mass index, which is your weight in kilograms, divided by your height in meters squared. That's difficult to calculate for a lot of people, and you can just simply Google body mass calculator and input your height in feet and inches and weight in pounds. And it'll calculate your body mass index.

For patients to qualify for surgery, their body mass index has to be over 35 with associated co-morbidities. Some of the comorbidities associated with obesity, migraine headaches, pseudotumor cerebri, hypertension, hyperlipidemia, sleep apnea, Pickwickian syndrome, which is a hypoventilation syndrome, gastroesophageal reflux disease, diabetes, hypothyroidism, low back pain, urinary stress incontinence, menstrual irregularities, infertility, peripheral edema, joint pain. Your risk of developing multiple different cancers go up and your life expectancy goes down by as much as 20 years, when you're morbidly obese. When you are morbidly obese and your body mass index is 40 or greater, the patients referred don't necessarily need to have the co-morbidities listed, but, by the time they hit 40, a lot of patients, as you guys know, do have some of those comorbidities.

Host: Thank you, Dr. Friedman. So, as you're telling us about clinical criteria for bariatrics and letting other providers know who can qualify, as they're working with their patients, along with the things that they must do; I'd like you to speak a little bit about your program and how you work with the patients on things that you'd like them to do in advance of the surgery, whether it's weight loss, exercise, starting an exercise program, prehab. So please let other providers know your clinical criteria for your program and what they can expect from the program.

Dr. Friedman: So there are two sets of criteria that we work with really. The criteria that we put our patients through, and then there is also the criteria that the insurance company will require to qualify or be approved for surgery. So, the patients basically have to satisfy both requirements, our requirements and the insurance company requirements in order to get approved for surgery.

The insurance companies are policy dependent. So, not all insurance policies will provide coverage for weight loss surgery, number one. Number two, a lot of companies who do provide coverage will require their patients have what's called a six months supervised weight loss trial and what that involves is six months of documentation of weight loss attempts with a physician. These do not have any value. They've been proven to not have any value in terms of weight loss or predictive factors, in terms of success after weight loss surgery. But they are a roadblock for patients.

They have to see their primary care doctor for the determined amount of time without missing a month, also to have these things documented. That can be the rate limiting step in this process for patients. And if a patient is interested in pursuing this and has a weight loss trial, it is helpful for them to go ahead and get the weight loss trial initiated.

Once they come and see us, we'll order a full panel of blood work, including multiple vitamin levels. We typically order an upper GI swallow study. Some patients may require an endoscopy. All patients who are in need of a colonoscopy should have an up-to-date colonoscopy. We have our own dietician with our program dedicated to our bariatric patients and all patients have to see and get approved by our dietician. And also our psychologist as well. Some insurance companies will have some other requirements, that is policy dependent and can be different from insurance policy to insurance policy.

Host: Thank you so much. So, this is such important information. Now tell us about the options for weight loss surgery that you're doing there at your program at UF Shand's Hospital. Because that's changed over the years, right? There are things we used to do that we're not doing now.

Dr. Friedman: Correct. Surgery evolves over time and bariatric or metabolic surgery is no different. We had mentioned the lap band. You and I had talked about the lap band briefly. The lap band has grown largely out of favor and is not done much anymore. Certainly, I don't do the lap band and haven't done the lap band in over 10 years. We remove lap bands and in some cases with patients with lap bands, convert that to a different procedure if indicated. We've seen a big increase in the number of sleeve gastrectomies that we do these days. The sleeve gastrectomy has been around for approximately 15 years now. There's good long-term data available. It is a good standalone procedure for weight loss. Patients can expect on average to lose about 50 to 60% of their excess weight following surgery. This involves dividing the stomach and removing three quarters of the stomach. The patients are left with a banana shaped stomach. This is mostly restrictive procedure, meaning it restricts the amount patients can eat or drink. It has beneficial effects on diabetes and high blood pressure and hyperlipidemia and all the other comorbidities associated with obesity as well.

The gastric bypass has been around for 80 years. It's been modified as time has gone by, and the mortality rate with a gastric bypass is less than that of having your gallbladder out after 30 days. In the United States. People are surprised to hear that. I do a gastric bypass through five small incisions. Patients stay in the hospital overnight. This offers better weight loss than the sleeve gastrectomy. And on average, people lose about 60 to 70% of their excess weight. This involves, dividing the stomach into a small pouch that's about the size of an egg and dividing the small bowel. The distal aspect of the small bowel gets attached to the new little stomach and the remnant stomach and the duodenum drain through the proximal end of the small bowel, which gets connected further downstream.

As a result, you can't eat as much and what you do eat, doesn't mix with the digestive juices until further down in your small bowel so you don't absorb as much of what you eat. This operation offers a better weight loss on average than the sleeve, and also better control or amelioration of comorbidities, such as diabetes, high blood pressure and high cholesterol.

And then a Type 2 or non-insulin dependent diabetic, who has had that diagnosis for less than seven years, they have about an 80% chance of the diabetes going into remission following this procedure. The numbers are fairly similar with high blood pressure and high cholesterol following a gastric bypass.

We also offer a newer procedure called the single anastomosis duodenal switch or the SADI procedure. This is a hybrid procedure where we perform a sleeve, and then divide the pylorus and do a distal bypass, a single anastomosis distal bypass to the small bowel at the pylorus. This offers very, very good weight loss in the order of 90 plus percent excess weight loss, and very, very good improvement or amelioration or remission of certain co-morbidities such as diabetes, high blood pressure and hyperlipidemia. We also offer revisional and corrective procedures here. Those are difficult to generalize about. That is a case by case, procedure.

Host: Well, that was an excellent, comprehensive answer about the options available at UF Health Shands Hospital. And thank you for telling us about restrictive malabsorption or a combination of the two. So as we're talking about that, what about right after surgery? Speak about patient lives after these kinds of surgery and their nutrition requirements. I'd like you to tell us about transdermal vitamin patches. Is there data to support their efficiency? Tell us a little bit about that.

Dr. Friedman: So these procedures are restrictive and some are malabsorptive as well. Restrictive, meaning they can't eat or drink as much as what they could before. It restricts the amount they can eat or drink. And initially after surgery in the, especially in the first two to three weeks, when there's inflammation and swelling, dehydration is a very, very common complication. And it's something we fight, and educate our patients to avoid. That being said, our patients are educated to focus on liquids, their liquid intake, following the weight loss operation of their choice. They meet with our dietician and know how much liquids they should be taking as well as how much protein they should be taking as well.

They also have to take multivitamins, calcium and vitamin B12. Every bariatric patient should take that. That's recommended by the American Society of Metabolic and Bariatric Surgery. It's very difficult for some of these patients to maintain their hydration status and nutritional status and get their pills and vitamins in. And that's where these vitamin patches are such a good product for patients, especially in the initial post-op phase. The patches can be put on transdermally like any patch. They are absorbed through the skin. And that takes care of the vitamin requirements. That avoids the necessity for two multivitamins a day, three to four different calcium pills and whichever route they're taking the B12 through. So up to six, seven pills a day less through these patches. With any of these surgeries, there is a risk for vitamin deficiencies and whichever route the patient chooses to do their vitamins, it's important that their vitamin panels and vitamin levels be followed after surgery and with our patients who choose or elect to use the patch post-operatively, we check their vitamin levels at three months after surgery and every three months after.

We've found that this really helps patients avoid problems with dehydration, which can cause nausea and headaches and cause patients to need to go to the emergency room in that initial post-operative phase. This has helped them avoid that, while still getting their vitamins, in the initial postoperative phase.

Host: Now I'd like you to speak, you touched on it a little bit before, about the nutritionist and dietician. How important is multidisciplinary management for these patients? As you're letting other providers know what they can expect from your program, who all will be working with them? And how does it work as far as follow-up as well?

Dr. Friedman: Right. So, we believe that obesity is a very complicated disease. It's multifactorial, it's genetically related. It's related to the environment. It's complicated and it requires a lot of different providers, to treat successfully the disease. And here we have a multidisciplinary team, GI doctors and medicine doctors, and endocrinologists and surgeons and our nutritionists and psychologists, respiratory doctors as well, who all weigh in and will help evaluate and teach and prepare the patient for their life after surgery. In terms of our followup, well, we believe, and it's been well-documented, that the followup of these patients is very important and is directly related to their postoperative success and their long-term success in terms of maintaining weight loss.

We tell our patients that we expect to see them for the rest of their life. We see them in our practice after surgery, two weeks after surgery, six weeks after surgery, three months after surgery, six months after surgery and every six months after that, and we check our post-op vitamin levels on our patients very frequently as well.

Host: What a comprehensive program that is. Dr. Friedman, as we wrap up, what would you like to summarize for other providers about the program at UF Health Shands Hospital, bariatric surgery options, nutrition requirements, and transdermal patches, and how all of this really fits into the practice of care for obesity.

Dr. Friedman: Well, again, I think that obesity is a very severe health problem that not just America, but the world faces. We have hundreds of thousands, if not millions of people who are morbidly obese. This is now effecting our kids. The average life expectancy of Americans is decreasing instead of increasing. Certainly obesity is playing a major role in that. It is costing our country, billions of dollars in healthcare related expenses. Rates of heart disease and diabetes and sleep apnea are skyrocketing and will continue to skyrocket and unless we reverse this trend. I think that it's very important to talk to patients about options for obesity. Surgery's not the first step in the treatment. Certainly diet and exercise and other methods of weight loss need to be tried, but we know that diet and exercise is only successful roughly one to 2% of the time in people with obesity in terms of long-term sustained weight loss. When patients fail to maintain successful weight loss, that's when they should be considered for surgery. Surgery is safe. It's effective. It offers sustained weight loss for patients with obesity and can also get rid of some of the co-morbidities related to obesity as well, and ultimately will make the provider, the primary care doctor's job easier in managing these patients in your practice.

Host: Certainly is an exciting time to be in your field, Dr. Friedman, and thank you for joining us and sharing your expertise on weight loss and obesity and the surgical options available. To refer your patient or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. And that concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please also remember to subscribe, rate and review this podcast and all the other UF health Shands Hospital podcasts. I'm Melanie Cole.