Transcription:
COVID and Obesity: Why Weight

Prakash Chandran (Host): This COVID-19 WakeMed Voices podcast was recorded on February 1st, 2021. The COVID scare has caused people to wake up and take stock in their overall health and longevity. Oftentimes, people who truly need to lose weight will think someday, or I'll try this new diet and spend years trying to lose the weight without getting anywhere. Now people are starting to realize that maybe someday needs to be today and that the same diet industry that has failed them so many times, might not be the right answer. It's time to seriously consider the only truly effective weight loss strategy, which is bariatric surgery. It's time to follow the science.

We're going to talk about it today with Dr. Scott Bovard, a Bariatric Surgeon at WakeMed Health and Hospitals. This is WakeMed Voices, the podcast from WakeMed Health and Hospitals. I’m Prakash Chandran. So, Dr. Bovard, it's really great to have you here today. I think all of us have heard about bariatric surgery, but we don't necessarily know what that means. So, can you start by telling us a little bit about it?

Scott A. Bovard, MD (Guest): Well, thank you for having me on Prakash. I appreciate this opportunity. Bariatric surgery is also known as weight loss surgery. It is a suite of three different operations that we can provide patients that's going to give them an ability to be more successful with their weight loss goals. We're basically changing the anatomy around to give them more tools to work with and make weight loss not only possible, but take it a lot farther than they've ever expected to be able to.

Host: So let's talk about who is the right person for bariatric surgery. You know, you said, changing things around and giving them the tools to be more successful. What does that type of person look like? And when should they consider bariatric surgery?

Dr. Bovard: Well, we have criteria that we need to follow for bariatric surgery and it has to do with how much you weigh versus your height. Something called the body mass index or the BMI. And when we're talking about somebody with a BMI of 35 or greater, that's morbid obesity. And I can't give you an actual number on weight because it really does depend on height. But you can assume anywhere from 60 pounds over ideal body weight up to however much. I believe that people should probably be looking towards bariatric surgery much earlier than we do. We have a tendency to continue to try to lose weight and other conventional methods that have been failing over the years and people end up just getting larger and larger as they go. So, the best way to approach it is the sooner, the better. And that's really what we're starting to see nowadays as people start recognizing their overall health based off of the COVID scare that we're in now.

Host: Yeah. And one of the things that we have heard is that when you are obese, it not only increases the severity of COVID-19 if you contract it, but it also increases the susceptibility of you contracting many other diseases. Isn't that correct?

Dr. Bovard: Absolutely correct. You know, if you just look at the numbers of COVID-19, it's obviously the most pressing medical issue we've had in any of our lifetimes, and when we see who's actually affected by this, everybody knows, well, age really comes into play and what we call comorbidities or illnesses, but these illnesses are all brought about by obesity. So, if you actually look at the numbers of people that actually were hospitalized for COVID, it's significantly greater for the obese population. In fact, the larger person is more likely they're going to end up in the hospital, around 113% higher hospitalizations and a 75% higher ICU hospitalizations. And 50% higher death rate, just secondary to obesity. So, I always asked my patients prior to COVID, how long have you been thinking about this, first? And it is oftentimes about two years. People think about bariatric surgery before they say okay, I'm going to get something done. And it's always, well, I think, well, I'll try to lose weight some other way first.

And they spend that two years thinking about it and trying many different modalities and not really getting anywhere. I think with COVID, it's kind of opened up patients' eyes a little bit and put a sense of urgency into this that maybe someday should be today. You know, instead of thinking, well, maybe, maybe I can get it done. You know, there's a whole new thing coming out and another diet or another pill or whatever, and people will keep putting it off. And now maybe we better recognize that health is not something we need to gamble with. It's not something we need to just keep postponing. It's something we need to take care of now. And as far as obesity is concerned, there is no actual way to lose weight other than bariatric surgery, because dieting and exercise, which is the standard thing that everybody tries to do has a less than 1% success rate. And it's putting people in danger.

Host: So, let's talk about that a little bit further. I think one of the things that you mentioned that is familiar to me just cause I have so many friends that are struggling with this, is that they've been thinking about it for two years. And during that time, I think there's a lot of societal pressures around, hey, you could do it yourself. Just go to the gym. Stop eating sugar, stop eating carbohydrates. And you'll lose the weight on your own. One of the things that you mentioned was there's a less than 1% chance that that is going to happen. Is that largely due to physiological reasons or is it just due to the fact that from all of the evidence, it's just hard to stay consistent on a diet that restricts all of the things that I just mentioned.

Dr. Bovard: Everything you said was true. It's not this or that. It's there's physiological messages are going on right there. Diets are difficult to keep up with. I believe in my heart, that diets actually cause obesity, dieting causes obesity. I say that to all my patients, very first time I meet them because when they're coming in, they're giving me their story. It's almost like this attitude of failing. And I explain to them that, you know, the harder you try, the more likely you're going to end up in my hands because the central core dogma of all diets is to eat less and go hungry and skip meals and try to force your body to burn fat in lieu of food.

And if you're doing so, all you're doing is you're making fat more important. It's keeping you alive and you'll never truly be able to get rid of it because your body needs it. There's only two things on the planet more important than fat at that point in time. And that's oxygen and water. But you're not denying yourself that, you're denying yourself food. And so your body has a mechanism that's going to survive. And that is to take what little you eat and it's going to store it. It's going to hold onto it. And the harder you try force that off through eating less and going out and working out harder is only going to make it worse. And so there's a frustration that's involved when people are not losing weight and they're putting all this effort and suffering into it, not to mention the money that they pay for these failing promises. They're being misled. You cannot force fat off like that. You need to do things differently. So, when I talk about bariatric surgery, I'm, you know, I'm just talking about making some physiological changes or some anatomical changes to help people do the right thing.

But the most important thing to do is to do the right thing. It matters more of what patients do than what I do. And so I spend the entirety of the rest of the time that I spent with people is to teach them what that right thing should be. And to be honest with you, it's to eat, you must eat, you have to eat to lose weight. You cannot try to force it. Otherwise, you'll lose that battle every single time. It's just nature.

Host: Yeah, yeah, what you're saying makes so much sense. And even though it sounds counter intuitive, it is something that you need to do rather than depriving yourself. And I think as you mentioned, when you kind of go into this almost starvation mode, it increases all of the stressors in every other aspect of your life. And you always feel like you're failing or you're never able to meet that criteria that you've set on yourself. So, considering something like bariatric surgery that can really help be a force multiplier for how your body processes food, is the right way to do. And doing that sooner than later is going to get you out that success that you want sooner. Isn't it correct?

Dr. Bovard: Yes, absolutely. I mean people are blaming themselves for failure, but that's, it's inevitable. You cannot be successful with that kind of diet plan. And so, what bariatric surgery does amongst other things is it makes the efforts that you put into it actually pay off. You know, I still expect people to do well. I expect people to eat right, and to exercise. Those things do work, but they only work from the platform that they're eating often enough to where fat becomes irrelevant. And then we're going to work on portion control and calories in versus calories out. Those things all do come into play, but they only work in certain settings in the settings have to be that your body's not in the fat storage mode, which is what diets automatically put you into.

So, when you start to do things right, and you start to see the success, the better you do, the harder you try. And then the harder you try, the better you do. It's this very positive cycle that you start getting into after surgery. And I think that's one of the reasons why people become so very successful at it because they finally are recognizing the pay off or something that they've been trying to do for literally for years and just been getting nothing but frustration over it. Now, all of a sudden, they're getting the results that they truly deserve and it's because of what they do. In Making the decision that I'm not going to just go on yet another diet. I'm going to go get something that's actually going to work.

Host: So, Dr. Bovard, let's talk about the mechanics of bariatric surgery. I know you mentioned that it gives them the tool that helps them to be more successful, but what exactly are you doing to the body to help them process that food a little bit better?

Dr. Bovard: Well, that depends on what type of surgery we're doing. Right now, there's three major operations that we perform. The sleeve gastrectomy, the gastric bypass and the duodenal switch. So, the sleeve is just working on the stomach alone. And I'd always tell people it's going to give you three different super powers. Super power number one is you're not hungry. If you're not hungry, you're not stupid because hunger makes us make bad decisions. It's an instinct. We will choose the worst foods when we're hungry. Two, you will feel full after eating like a toddler. You eat the smallest amount of food, you'll physically feel full. And so portion control is not really an issue. Of course, that lightens up over time as it should and then number three, as you feel satisfied a lot sooner because you can have a drive to eat, you could be hungry or just desire to eat and be super full at the same time. It happens all the time. And what ends up happening is your stomach fills up. And once your stomach starts to empty, the food actually leaves the stomach and goes into the small intestine and you start the digestive process. Once that happens, a bunch of hormones kick off to start the digestive process and your brain changes.

And it goes from the ingestion phase of eating, which is where there's a drive, to the digesting phase of eating, which is there's no longer a drive. That's where you look down at the food and you're like, I'm done. I don't, I really don't want it anymore. That comes by a lot sooner with the sleeve because the food spends much less time in the stomach and starts the digestive process sooner. So, you can see just on that one particular instance without doing any malabsorption at all, we're giving people tools that they can use to make better decisions.

The gastric bypass is the one that's been around the longest. It is malabsorptive in the sense that we're bypassing small parts of the small bowel. And it's also restrictive in the sense of the stomach is about the size and shape of an egg. It's not very big, so you don't eat a lot and then you don't absorb everything that you do eat. So, it's, it's kind of a dual measure. So, you're going to get sort of the same effects that you got with the sleeve, but you're going to add to it some malabsorption.

Now finally, the duodenal switch, which is the most aggressive and successful of the operations is a sleeve and a bypass together. We're making a little bit larger sleeve and a little bit longer bypass. So, we're getting more malabsorption, but we're still getting all the effects that we're getting with the sleeve. And that's going to give us the best results as far as weight loss and resolution of all the comorbidities, overall.

Host: Well, I'm sure that people that are listening to this are wondering, well, okay, so if I go through this, one of the three procedures that you mentioned, how much weight can I expect to lose in the immediate term and then over time. So, can you speak to that a little bit?

Dr. Bovard: So, we quote national numbers because we keep all the numbers for all the surgeons in the country. So, we talk about excess weight. We can't say how many pounds somebody's going to lose, because that doesn’t, you can't compare one person to another. Somebody who weighs 200 pounds needs to lose weight needs to lose a lot less than somebody weighs 400 pounds. So, we use excess body weight, which means I figured out how a BMI of 25 for an individual. And then every pound for over a BMI of 25 is a pound overweight. So, for myself, I'm six one, I weigh 195. So, that's a BMI of 25. So, let's say I put on a hundred pounds right now, that's 295 pounds.

That means I'm a hundred pounds over ideal body weight. How much of that hundred pounds can I lose? That's how we figure out results. If we're looking at a sleeve, we recognize that between 60% and 65% is the national average, somewhere in there, it kind of fluctuates a little bit. That's 65 pounds out of that hundred that a person needed to lose. Now that's considered the average. Obviously everything's a bell curve. In my personal group, I think it's a little bit over 70% or 70 pounds out of that a hundred that they need to lose. With a gastric bypass, we look between 65 and 75%. Again, it's a kind of a large range that's considered the average, but that's because it's been around for so very long, and there's been so many different iterations of the gastric bypass that we keep improving the outcomes over time by adjusting lengths and such like that. So, so now you're looking at up to 75% or 75 pounds out of that hundred that we needed to lose.

And then there's the duodenal switch, which is the latest and greatest as it were. This is where we do a sleeve and then we go to the very end of the stomach and we do a bypass to that point. So, we keep the stomach complete length and that one's going to be about 90 to 95% excess body weight loss. And all these numbers are recognized at the one year level I do believe. You're gonna get the majority of those in the first six months. Obviously, you're going to get more than half of what you got to lose altogether in the first six months and the rest of it's over the next year. And then when we talk about, you know, years out, there's going to be a little bit of weight gain overall.

And we'll talk about overall numbers. Some people gained back more than others, and that speaks more to what you do with these powers than what the procedures themselves did. But at 10 years, we're still talking 50% at 10 years and overall so those are substantial numbers compared to people who didn't get the surgery. And what was their weight 10 years later? Are they still at 50% of what they needed to lose? And that was based off of gastric bypass that 10 year number.

Host: Just as we start to close, I just wanted to know if there were any potential side effects that people should be aware of when they're considering getting bariatric surgery.

Dr. Bovard: You know, you look better, you feel better. You're happier. Life is better all around. You make more money. I mean, there's actually studies out there showing people who have normal weight make more money. Are there side effects? Yes, there are some side effects in each one of them separately can cause different kinds of side effects.

So, the sleeve gastrectomy particularly, can cause heartburn. If you don't have heartburn and you develop it, typically we just kind of watch it and see what goes on. Cause it goes away within six months. Some of the old duodenal switches, people could have issues with just some malabsorption, some gas and bloating, that sort of stuff. But if that's the case, let me know. There are things we can do, including medications that will eliminate that issue that day. So, there may be some side effects, but that's why we have follow-up with doctors, with your surgeons, for five years out, but overall the side effect is going to be longevity, a you know, happier, more productive life, less medications. Those are your real side effects.

Host: So, just as we close here, you know, there's going to be a lot of people listening to this that are considering this type of surgery. What is one thing that you would say to them that maybe you wish more people or more potential patients knew before coming to see you?

Dr. Bovard: One thing I wish everybody knew is that this is the most underutilized thing you can possibly do in medicine to make yourself healthier. And only 1% of the people who qualify for bariatric surgery will have it done. And that's unacceptable. There was a study that I read preparing for this. It's interesting that bariatric surgery it's found in a much higher propensity in very rich and elite areas. It seems like when we're talking about medical equity and everything else that bariatrics is being shunned for most people unless you're in that top 1%, and then you're more likely to go get bariatric surgery. In the place in the country that has the highest bariatric per capita is Washington, DC, which also has the highest income per capita and the lowest obesity rate per capita.

So, they have fewer obese people, but they're getting more bariatric surgery. And if you follow the trends, it has to do with the access to this seems to be more about the ability to pay, I guess. And I don't think most people understand that this is covered by insurance. This is, it's available to everybody. And it should not be exclusive in any way. It should be available. And I think if people knew these numbers, not only would they say, well, I want it for me, they'd be demanding action how can it be that only the rich are getting this wonderful life-saving procedure.

That's something I wish more people knew about. The final thought would be it's time to really do something about it and to not spend any more time in the anticipation that someday you'll get in shape. Today's the day you should be getting in shape. Today is the day that you should be taking care of all this, because that someday might not show up.

And there's too many regrets out there about people have put things off to the point where it's caused a problem. And they just wish they would've done this sooner. Another great thing. 1991, there was a study done over in Europe. People who lost a hundred pounds, right. They went to those people that lost a hundred pounds and they said you can keep that weight loss, that loss of a hundred pounds, if you accept another disability, disability being deafness, blindness, heart disease or loss of a limb, or you can have your hundred pounds back, which would you choose? Every single person chose anything else, but gaining that weight back. So, people who do it and they lose the weight, would prefer to live with any other disability than to get that weight back. This is the kind of stuff I see every single day, this thankfulness that people have and they all say, why did I wait?

Why did I wait? Why did I wait? And so, I'm trying to get this out there. So, people understand that they don't have to wait. It's available to you. Let's do it now. And don't waste any more of your life losing weight. Just lose it and then live your life.

Host: Dr. Bovard, I think that is the perfect place to end. Thank you so much for your time today. I truly appreciate it. That's Dr. Scott Bovard, a Bariatric Surgeon at WakeMed Health and Hospitals. It's time to live your healthiest life right now. Why wait? It's time to follow the science. Learn more@wakemed.org. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. This has been WakeMed Voices from WakeMed Health and Hospitals. I'm Prakash Chandran. Thanks so much for listening.