Joey Wahler (Host): The CDC says more than 100 million U. S. adults are obese, and more than one fifth of them have severe obesity. So we're discussing weight loss surgery. Our guest is Dr. Alexander Aurora. He's Director of Advanced Minimally Invasive Surgery and Bariatrics at UM Upper Chesapeake Health. Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System.

Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Aurora. Welcome.

Alexander Aurora, MD: Hi there. Nice to see you.

Host: Same here. So first, why is so much of America so overweight?

Alexander Aurora, MD: I think when we look at our history we've made lots of evolution and lots of changes throughout the years. And unfortunately, some of those changes weren't always for the best. We've made life easier on us sometimes. So we're less in need of physical activity to get work done. We depend a lot more on machinery and equipment. Obviously the evolution of bicycles to cars and motor vehicles that get us around so we don't have to do as much labor just to get to work, for example. And then machines that take over our jobs so we do less physical labor. So one is we're less physically active, but two is food has become a major industry and a major moneymaker for lots of companies.

And they've been able to develop products that are very enticing and mimic lots of flavors that may have been natural in the past but are no longer natural. And so we've adopted habits that aren't always the best for us and we don't necessarily know any better. So I think it's a combination of change in our dietary habits and change in our daily physical activity.

Host: And all of that, of course, has led to diets having always been so common in this country, but it seems like most of them fail. Why?

Alexander Aurora, MD: So, that's a good question as well. Diets, I really hate to hear about them. They seem very restrictive and I believe that's the problem is that as human beings, we want to be free and we want to make our own choices and we don't like to be restricted. And it comes back again to what we're drawn in by, meaning the different types of foods and flavors and things that are available. Obviously cost may be a situation sometimes or a problem. And so, why diets don't work, because they are restrictive and essentially what we need to do is go back to making healthier choices and I think choosing a more natural diet rather than a specific only protein, no carbs, low fat, all those things are just temporary, it's not realistic.

Host: I'm glad to hear you say that because I'm sure many joining us were thinking about just that. You can't cut everything out, right? Unless you're a real extremist.

Alexander Aurora, MD: That's right, we're not looking at cutting everything out, it's more so about making the right choices. You could eat, as far as I believe, regular fat dairy, lots of fruit and vegetables, and lots of meat, seafood, protein. Obviously there should be some restriction with respect to the quantity, but that's something we know pretty well that too much of anything is not a good thing.

Host: Indeed. Simply put, what exactly, for those uninitiated, is bariatric surgery? And what makes it different than, say, dieting?

Alexander Aurora, MD: Yeah, so bariatric surgery basically is defined by doing a type of surgical procedure that will assist you in weight loss to get you usually healthier. And there are numerous procedures that have been developed over the years, some that work better, some that don't work so well. Some that may be dangerous but may be more aggressive, and some of them may work different in, in different individuals.

So essentially, the surgical community has developed different procedures to help people lose weight, get their weight under control, and essentially should be, using those procedures to make people healthier.

Host: Now, the goals of weight loss surgery go well beyond shedding those extra pounds, right? We're really talking about a lifestyle change and work to do for the patient, even post surgery. Yes?

Alexander Aurora, MD: 100 percent correct. Pretty much every single patient that comes into my office, I see them individually on an individual basis, case by case basis. I don't do group sessions really very much. The first thing I usually tell them is that this is something that they can actually do on their own. They don't necessarily need surgery, but the problem is a lot of them have gained this weight over more than 10 years. And it would require a great deal of discipline, patience, and dedication to be able to lose that weight in a smaller amount of time.

It's not realistic that they'll ever lose that weight again in even a year. And a lot of people can't last more than a month on some type of diet, as we discussed. So, I always do bring up initially my recommendations for healthy lifestyle habits. And I also tell them that my goal is to get them healthy first, and it takes a while in a bariatric program before you even get to surgery.

We don't just jump on you and operate. We got to make sure that you're healthy, that you have the right lifestyle habits, and that you're safe. Because a lot of people that are obese suffer from different types of heart disease, potentially lung disease, diabetes, and those can lead to complications at the time of surgery. So we have to make sure you're safe first, before we'll do any operating.

Host: And so let me ask you a little bit about a couple of things there, one being post surgery, when we talk about lifestyle changes patients must make, we're obviously talking about the big two. Right? Diet and also exercise or being active. So in a nutshell, what should people expect in the way of change there?

Alexander Aurora, MD: So again, we're talking about lifestyle change, as you said. I think, for myself, these are, I don't think, very demanding or excessively exaggerated changes that people need to make. I think most people recognize that eating an apple is better than a bag of chips. I think they can also recognize that, yeah someone might ask them to do some exercise, but going for a 20 minute walk every day is not super demanding.

I'm not going to tell anyone they need to go to the gym for an hour every day. That's not really necessary, but some minimal physical activity is needed as well as adhering to some good choices. Big things and simple things are drinking water instead of soda or liquid sugars, for example. Getting more fruit and vegetables instead of chips and processed products, and doing a simple daily walk, maybe 20 minutes.

Host: Because the bottom line here really with what you're discussing is that people undergoing this procedure simply can't go back to what they were doing or not doing previously. Or they could wind up back in the same boat, so to speak. Right?

Alexander Aurora, MD: Yeah, that's a good point. So definitely as I was mentioning before, I tell everyone in the beginning that these lifestyle changes are things they need to make for their life, right? I tell people that once you've made those changes, I will see a small amount of weight loss, but something significant still prior to surgery, and that's usually a good sign. And when I see that, I usually tell people I'd say there's a 90 percent chance of success after the procedure. When patients don't make those changes, I can usually tell, and they usually don't lose any weight at all, or maybe a very small amount. And those patients, I usually caution them that even though they may be safe for surgery, they may not be ready for surgery. And in that case, it's usually 50 percent failure. So even if I do the surgery, they may be able to beat the system. And that's a problem, obviously, everyone wants them to succeed and be healthy again.

Host: So you actually wanna see some change even pre surgery.

Alexander Aurora, MD: That's correct, yeah. So usually a typical patient can lose between 10 and 30 pounds prior to surgery just with simple changes. Very often it depends on how bad their habits are and also actually how big they are. Bigger patients tend to lose more easier, smaller patients in the 250 range maybe only lose 10 pounds prior to surgery, but they can be equally successful.

And keeping that weight off is definitely dependent on continuing with those healthy habits that you had before. Pretty much with almost any procedure that we do in bariatric surgery, the patient can beat the system simply by going back to liquid sugars and bad habits.

Host: Another thing that you mentioned earlier that I'd like you to expand on, please, who qualifies for bariatric surgery and who doesn't? Who tends to be the most successful and who is it, what's the profile for someone with perhaps some pre existing conditions, as you had alluded to, where this is not for them for whatever reason.

Alexander Aurora, MD: So the vast majority, I would say, of patients suffering from obesity or morbid obesity as we call it, will qualify for surgery, if their weight, we calculate it by BMI, the body mass index over a BMI of 35 with a pre determined condition like high blood pressure or diabetes or sleep apnea or if even without those conditions their BMI is already over BMI of 40.

So to give you an idea that would be typically almost anyone over 300 pounds would automatically qualify because just the human skeleton shouldn't be carrying 300 pounds basically. Some taller people that may be, you know, six foot two and 250 pounds, they might be on the borderline.

Patients that cannot have surgery or don't qualify for surgery at this time would be patients that are unfortunately undergoing a cancer treatment and still have not been cleared from that. Patients that cannot understand and follow directions because of intellectual disability, for example, or patients that are just unfortunately non compliant, don't show up for appointments and don't follow through on their commitments, those are usually red flags.

Host: Couple of other things here. Once deemed qualified for surgery, when you start a patient on that pre surgery prep that you've discussed, how does your team support that for someone perhaps going through this for the first time and not knowing exactly how to get started?

Alexander Aurora, MD: Right. That's a good question. So initially when they go on our website, they'll see a link to be able to connect to sort of like an online survey. And that allows us to get some information on them. And then someone from my office gets in contact with them. We usually have them answer some basic questions about their health and an idea of their size and weight before bringing them into the office.

When they do come into the office, they usually have their initial visit with myself. In-office we have actually a registered dietitian as well as an exercise therapist who usually meets with them during that same visit. They'll spend about 30 to 40 minutes with me personally discussing their whole past medical surgical history as well as their social situation, dietary, exercise habits, and a little bitty physical exam.

And then usually I go over a list of recommendations for them. I usually print that out for them so they don't have to memorize anything. And it's also available on their medical portal at the University of Maryland. After that, I usually typically like to see the patients back within about two months to see if they're making progress and how they're doing with the recommendations. And then we progress from there. We also have some educational courses that the dietician, exercise therapists run through with the patients. There's about six of them. They usually do one a month and they're about half an hour in duration.

Host: So clearly, from what you're laying out here, this is an extended process, it's not a simple fix, so to speak, it obviously takes some commitment, as you've mentioned. So in summary here, Doctor, I'm sure many are wondering, if I do all that, what's the success rate here, what are the odds that this will help me reach my goal in terms of weight loss and better health? And of course people also wonder how much weight can I lose, right? I'm sure that would be the most popular question you and yours get. Am I right?

Alexander Aurora, MD: Important questions you bring up. So, the first answer sort of comes back to what I was saying before. Those patients that sort of listen to my recommendations and follow them through, and I, again, I don't think they're exaggeratedly demanding. Eating some fruit and vegetables, getting lots of water, doing a daily walk.

I think most of us can do that. If you switch to those habits and you've lost a little bit of weight before surgery and you go through surgery, then typically about 90 percent success. And when I say that, what I mean is, if you have diabetes and high blood pressure and sleep apnea, to be conservative, I would say 50 percent resolution of those problems.

Meaning that if you're taking diabetic medication, at least 50 percent of those patients will resolve their diabetes. Meaning they don't need to take medication anymore for it. Same thing with high blood pressure. And same thing with sleep apnea, but sleep apnea usually takes a bit longer. Some of the diabetic patients stop their diabetic medication within the week.

Some of those with blood pressure stop it within a month. And then sleep apnea, like I said, usually takes maybe up to six months because you have to lose more of the weight before you actually see the difference. With respect to their weight loss, typically what I tell my patients is they will lose between 15 to 20 pounds per month for the first three months, and then after that typically it slows down.

And I usually give them sort of a goal target weight. It's usually not exaggerated because as we get older, typically we're going to weigh a bit more than when we were 20 years old, but we'll discuss the specifics of that on each individual case.

Host: Well, again, we should stress, as you've pointed out, doc, that this isn't just about losing weight. It includes that of course, but it's more about big picture, looking ahead, being healthier and changing things permanently, not just for a fixed period of time. Folks, we trust you're now more familiar with weight loss surgery. Dr. Aurora, valuable information indeed. Thanks so much again.

Alexander Aurora, MD: Thank you. It was good talking to you and I hope everyone was well informed. If you have any questions, don't hesitate to call the program. I'd be happy to talk to you. Have a good night.

Host: Absolutely. And folks, you can find more shows just like this one at umms.org/podcast, as well as on the YouTube channel. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks again for being part of Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System.

We look forward to you joining us again.