Coming up on Atthe Forefront Live,obesity is a verychallenging condition. People struggle with weight,and are often frustratedwith a lack of results. Today on At TheForefront Live, we’lllook at bariatricsurgery options,and how this can change lives. Here at UChicago Medicine,bariatric surgery programsare tailored for each individualto get the maximum outcomeand benefit. Also today, we’ll meet onepatient who lost over 80 poundsand gained controlover her diabetes. Lynn Yanow has quitea story to tell,and is a different person todaybecause of bariatric surgery. That’s next, on Atthe Forefront Live. And welcome toUChicago Medicine,At the Forefront Live. This is your chance to askour experts your questionsby typing in thecomments section. We’ll get to as many as possibleover the next half hour. Remember, thisprogram does not takethe place of an actualvisit with your physician. Joining us today,we have two expertsin bariatric surgery, Dr. Vivek Prachand and Dr. MustafaHussain. Welcome to the program. Thank you. First of all, justtell us a little bitabout bariatricsurgery, in general,what exactly that entails. I think a lot ofpeople, when theythink of bariatric surgery, theythink, you’re just cheating,you’re not dieting, you’retaking the easy way out. But that’s really not the case. Thank you for the question. Bariatric surgery isbasically surgery–which means manipulationof your organsand your stomachand your intestine–to really change the wayyour body perceives hungerand when it feels full. It works by changingyour anatomy, but alsoyour physiology, which is thechemical nature of your body’srelationship andunderstanding to food. And it works by mechanismsthat we partially understand,but not fully. And we’re definitelyworking on that. But it’s definitelynot cheating. It is for people who havetried several things before,but really needadditional help from us,in terms of losing weight. And it’s really forpeople who are lookingto lose 75 or 100 pounds. So, Dr. Prachand,why is it calledobesity or metabolic surgery,instead of weight loss surgery?I think that that’s areally good question,and I think it’ssomething that’sreally changed in the fieldover the last 5 to 10 years. So the emphasisused to really beabout weight loss in thepast, and so we would reallybe emphasizing how many poundspeople lost, and so forth. But the AmericanMedical Association,about five years ago,recognized obesity as a disease. And one of the thingsthat we’ve alwaysrecognized withthese operations isthat, in addition to achievingthe weight loss, whichis pretty substantialand sustainable,is the impact on the medicalproblems related to obesity. And so the importanceof thinkingabout obesity andmetabolic surgeryis to really keep in mindand emphasize the factthat these operationsalso have the opportunityto impact all the differentmedical conditions thatcome along with obesity,such as diabetes, high bloodpressure, highcholesterol, sleepapnea, severe joint problems. We even see patients who mightbenefit from transplantation,but are too heavy to qualifyto undergo a transplant. Bariatric surgery canreally make a difference. We spoke to one patient whohad bariatric surgery hereat UChicago Medicine,and here’s her story. And that has drasticallychanged my life,not to have totake insulin shots. I feel significantly better. Lynn Yanow was takingfour insulin shots a day. It was the only way shecould control her diabetes. I feel betteremotionally, physically,and I’m very, very pleased. Now, Lynn is much lighter, andoff most of her medications,including thosefour insulin shots. As of today, I’ve lost80 pounds in six months. And I’m very excited about that. I would maybe liketo lose another 10,but everyone tells methat I should leave it be. Lynn chose the bariatricprogram at the Universityof Chicago Medicine,one of the leadingprograms in the country. She had the gastricbypass procedure,and is very happywith the results. The reason that I choseUniversity of Chicago Medicineis because they had aprogram, Dr. Husseinhad a program to goalong with the bypass. You had to go to classes,you had to follow up,there was a whole plan. What differentiates usfrom everybody else is,I think, our experience,our judgment,and our comprehensiveevaluation of patients. UChicago Medicine offersmany options for weight loss. Some of those optionsinclude surgery. There’s sleeve gastrectomy,gastric bypass,and a procedure forextremely heavy patients–that is only done at about 1%of the centers in the country–that’s called theduodenal switch. As an institution, we areproviding a wide arrayof options for patients whoare trying to lose weight,whether it’s that 10 pounds youneed to lose after Christmas,or it’s that 200 pounds thatyou’ve accumulated over years. Each of these proceduresrequires a team approach. The patient will workwith several caregiversto assess their challengesand provide solutions. There is also follow-upafter the procedure,to make sure the patienthas the right supportto keep the weight off. So at a singlehospital visit, theywill see the surgicalteam, they willsee our bariatric dieticians,as well as our psychologist. And so it’s a one-stopshop, if you will. Weight loss isn’teasy, and the patientswho participate inthe surgical programhave struggled with theirsituations for years prior. But the positive newsis there is hope,and it can be a lasting change. Despite all of ourbiases, we don’tknow why people are overweight. It’s easy to say they eatmore food than they actuallyburn off. And while that maybe true, we don’tunderstand why some patients aremore efficient at burning offfood than others. Obesity is a complex issue. It has to do with yourgenes, what you’re eating,what your habits are, whatyour social behavior is,what your psychologicalsituation is. So it’s a complex issue, so itdoesn’t have just one solution. Surgery happens to bethe most effective wayto help peoplelose weight, but werealize it doesn’tfunction in a vacuum. Lynn’s family is happywith her outcome, as well. It has changed herlife, and helped herto a healthier existence. Since I did the surgery, Ifeel much better about myself. I am much more confident,I do a lot more things. I do double-takes inthe mirror every time Iwalk a window, every time. I absolutely do not believethat I look like this. And I feel very,very good about it. It’s an interesting story. And it’s fascinating to hearthe difference in her life,particularly with her diabetes. So to your pointjust a moment ago,it really does make asignificant health difference. And one thing thatyou touched uponin the video, Dr. Prachand–I wanted you to talkmaybe a little bit moreabout this– isthat overall plan. It’s not just surgery, butthere are many different aspectsand different things that peoplego through before the surgeryand after. Talk to us a little bit abouthow that works, if you will. Sure. So as was alludedto in the video,we really have a truemultidisciplinary program. And what I mean by true,as opposed to virtual,is that we literally have ourdieticians and psychologistsin the clinic with us. And we take turns seeingthe patients while they’rein the clinic office. And then we discuss andconfer amongst ourselvesto really formulatea good game plan. So this takes placewhen patients come infor their initial evaluation. So we identify if there’ssome particular behaviorsor education that we canwork on to really getpeople ready to besuccessful with surgery. And we also have the sameapproach in the aftercare. And all of thisis really focusedon selecting thepatients that wethink will have the bestchance of success with surgery,and getting the best outcomesthat we can have after surgery. So really havingthat team approachis I think what setsus quite a bit apart. And it really sets the patientsup for success in the future. Absolutely. So we want to remindour viewers that weare taking yourquestions, so type themin the comments section. We’ll try to get toas many as possible. Let’s start off talkingabout the different typesof bariatric surgery available. They were mentionedin the video,but if you could tell us alittle bit about what they are,and what they entail. Sure. So there are currently fourapproved bariatric surgeriesthat are performed nationwide. We are one of the onlycenters that actually offersall four types of surgeries. The most common one beingperformed these daysis something calledthe sleeve gastrectomy,or vertical sleeve gastrectomy. Some people call it VSG. This is a procedure that’sdone laparoscopically,which means surgery throughvery small incisions. So most of the incisions areabout 1/4 of an inch or so. And this can be donewith general anesthesia,and most people actuallywind up leaving the next day. So the sleeve gastrectomyis a procedurewhich reduces thesize of your stomachby permanently removinga portion of it. So I like to tellpeople, if you thinkof your stomachlike a big handbagthat you can stufflots of thingsinto, if you were goingsomewhere over the weekend. By removing a portionof it, you basicallyare trimming it down to wherejust the essentials fit in. So some people sayit’s a banana shape,or I like to sayfrom the big handbag,to maybe just like a smallpurse you would take to a party,or something like that. And so that reduces thespace where you can fit food,but also we’ve learnedthat actually impactssome hormones in yourbody that affect hungerand how full you feel. So it’s not that you feelhungry but can’t eat,but it actually changesthe relationshipthat you have with food. So that’s why it’sone of the reasonsthat it actually works betterthan restricting yourselfon a diet. So that’s currently themost common procedure. Another procedurethat’s performed,also laparoscopically, orusing the small incisions,is called the gastric bypass. Sometimes call it peoplecall it the Roux-en-Y. This is a procedure that’s beenperformed actually the longestfor weight loss, since like the’60s or something like that. And it has a reallyexcellent track record. Because it’s been around,there are some storiesout there maybe that it was notsafe in the past, et cetera. But this is actuallyis not true. It’s a very safeprocedure, likely as safeas all the other procedures. And it has certainadvantages over the sleeve. And sometimes werecommended for peoplewith severe heartburn or reflux. We may also recommendit if you havediabetes on insulin,such as the patient thatwas highlighted earlier. And it can be quite effective ingetting people off the insulinthat they’re on. The other procedureis a procedurecalled the duodenalswitch, whichis the procedure thatwe specialize in hereat the University of Chicago. Dr. Prachand was actually theperson to perform it first,using the minimally invasivetechniques here in the Midwest. And very few centers aroundthe country perform it. It is a little bitmore complex procedure,but also has more rewards. The duodenal switchis a procedurethat affords you themost weight loss,particularly if you’re in thecategory of people who mayneed to lose around 200 pounds. And that’s people whose BMI–which is body mass index–is over 50. And also, it’s veryeffective for peoplewho have very severediabetes, thathave been diabetic for greaterthan 10 years on insulin. And can be a verypowerful way to treatthat metabolic disease,that combination of obesityand diabetes. The last procedureis something calledthe laparoscopicadjustable gastric band. Technically we dooffer it, but itis a procedure that isbecoming sort of less popularthese days, mainlybecause it is a device. It is subject tomoving and breaking. And also we’ve seenover the last few yearsthat the weight loss isnot as effective as someof the other procedures. And so it is a procedurethat is approved,but we are actually performingit less frequently, these days. Now, we are gettingquestions from viewers. I want to get to those,and try to answeras many as we possiblycan during the program. First question,which you pretty muchjust answered but we’ll goahead and throw it at youagain, anyway, whenyou were talkingabout the duodenal switch. This is somebodywho says, do youthink a person whose BMI is over50 should think about surgery?And I guess, the question wouldbe, then, what types of surgeryshould they shouldthey first consider?And either one of youcan field that one. So you mentioned BMIof greater than 50. So again, BMI standsfor body mass index. And we get that number bycombining height and weightinto a formula, and itgives a pretty good estimateof how much extra fat aperson has for their height. It’s not a perfectnumber, and you’llsee a lot of news stories anda lot of complaining about BMI. But the reality isthat, unless you’rean NFL linebacker or aprofessional athlete,it actually does a prettydecent job of estimating this. So just to quicklyreview, a normal BMIis between 20 and 25. And a person is consideredobese if their BMIis greater than 30. And so we talk aboutsurgery for obesitywhen the BMI is 40 or higher,or if it’s between 35 and 40and the person has othersignificant medical problemsrelated to their obesity,as we mentioned earlier. So when we’re talking aboutBMI of greater than 50,that’s typically somebody who’s150 to 200 pounds overweight. And typically, and frequentlyassociated with thatare those other obesity-relatedmedical conditionslike diabetes, high bloodpressure, and so forth. So in the past, whengastric bypass wasthe most commonoperation performed,say 15, 20 years ago, whatwas seen quite frequentlyis that patients who hadBMIs greater than 50 or 60,they frequently failed tolose enough weight after theyhad gastric bypass,or they would regaina significant amount of weight. And that’s really whatprompted our interestin performing theduodenal switch,because historically, it seemedto be associated with a greateramount of weight loss. But there really hadnot been any headto head studies comparing thetwo operations to determinewhich is actually moreeffective for this verydifficult-to-treat group ofpatients with a higher BMI. So we did the first studycomparing not only the weightloss, but the impacton diabetes, high bloodpressure, and high cholesterol. And we were the firstto find that therewas, in fact, a significantadvantage for patientswith greater than a BMI of 50. Now, that doesn’t meanthat every patientwith the BMI of greater than 50should have a duodenal switch. And I think that one of thekey things that we reallytry to convey to ourpatients when they comefor an evaluation,and what we reallytake most of their time in ourconversations and discussionswith patients, is figuringout what the right tool isfor you, as an individual. Because there’snot one operationthat’s the best for everyonein all circumstances. And so it’s really aboutfinding the right matchbetween the operationand the patient,taking to account thefact that each person hasa different amount of weightthat they need to lose,each person has differentmedical conditionsthat are related to theirobesity, different sideeffects of the operations,and different effectiveness,in terms of weightloss and impacton these medical conditions. And so that conversationthat we have as the surgeonwith the patientis really the key. So we’ve talked aboutpeople with the higher BMI. So we have a questionfrom a viewer, somebodywithout that level of BMI. And the question is, for someonestruggling to lose 25 pounds,would surgery be an option?Generally, probably not. Again, we don’t necessarilygo by how much weightyou’re overweight, but the BMI. So you would have tocalculate your BMI. But the minimum BMIis basically 40,which correlates toroughly around 100 poundsfor people whoare normal height. Or an averageheight, I should say. Or if you’re a BMIis over 35 and youhave a medical conditionclosely related to obesity,such as diabetes, high bloodpressure, high cholesterol,or sleep apnea. Generally, if you’re about25 pounds overweight,you’re probablyaround a BMI of 30,again, if you’re anaverage height individual. And around that BMI, generally,the first recommendationwould be intensivelifestyle modification,which is also the firststep for anyone who’strying to lose weight. So that’s, generally,meaning workingwith a professional,such as a dieticianor a medical specialist thatworks with obesity medicine. Or maybe even a therapist or apsychologist that can help youlose weight. But having those regular visitswith professionals reallybeen shown to affectsuccess with peopletrying to lose weight. And that’s one of the nicethings about UChicago Medicine. We do offer serviceslike that, as well,so we can cover the whole range. How safe is bariatric surgery?So I think that there is alot of myths and concerns,when it comes to surgicalsafety with these operations. And again, this, I think,dates back to 20 years ago,when these operations reallywere considered to be risky. And frankly, there as alot of high-profile casesin the newspapers, and so forth,as the operations initiallystarted to become more popular. But over the years, withmodifications and techniquesand the managementof these patients,using laparoscopicapproaches, insteadof the traditionalopen incision,which required apretty large incisionextending from the breastbonedown to the belly button. By using theseapproaches, and reallythe management of theteam, the safety todayin centers ofexcellence, such as ours,is very similar to patientswho have gallbladder surgery. Which is to say that it’sa very safe operation. We have more questionscoming from our viewers. I’ve heard hair losscan be a common sideeffect of bariatric surgery. Is there a way toavoid this, and does ittaper off on its own?This can happen afterbariatric surgery,but it can happen alsoif you’re losing weightwith any other means. When you do lose asignificant amount of weight,particularly quickly, it isthe body’s natural responseto sort of make sure it’s notwasting resources, if you will. And not that hair isa waste of a resource,but basically, itdoes require proteinfrom your body to make hair. So when you’re in that initialperiod of rapid weight loss,your body may say, let’sjust see what’s going on. Make sure we haveenough nutrientsfor essential functions. So it may shut down new hairgrowth for a little bit,and that may come off asseeing that you’re losing hair. Generally, this is temporaryand fully recoverable. And it generally is notsignificant to a pointwhere others wouldnotice, but you may noticethat your hair is thinning. Our dieticians, who arenutritional specialiststhat we work with, are verygood at counseling our patientsthrough this period,and making surethat they keep up with theappropriate protein and vitaminrecommendations that can reallylimit the amount of hair lossthat they experience, andcertainly help with the hairregrow period. We’ve got a follow-upquestion to that. Let’s talk a little bit aboutthe vitamins and supplementsand things that people willtake after a surgery like this. How long does that go on,and how significant is that?So with all of the operationsthat we do, taking vitaminsis something that’s necessaryafter surgery forever. Each of the operationsis slightly different,in terms of the way thatthe body absorbs and handlesdifferent nutrients andvitamins, but in all cases,because of thatreduction in appetiteand because there’s lessfood being taken in,if you don’t get enough in andif your body’s not absorbingin the way that ithad been previously,you’re at risk ofdeveloping deficiencies. So taking vitamins everyday is an important partof being as successful asyou can be after surgery. I like to tellpatients, you wouldn’twant to get atransplant operationand then not take yourimmune suppressionmedication afterwards. And you have to almost lookat vitamins in the same way,after you have these operations. One of the commoncriticisms that peoplewill make when they talkabout bariatric surgeryis, oh, people will justgain the weight back. Is that true?Or what do we do nowto try to prevent that?So if you look at, let’ssay 100 people who’vehad bariatric surgery, themajority of those patients–let’s say 5, 10years afterwards–will be down from the initialpoint that they had surgery. So let’s say, if theyhad 100 pounds to lose,the majority of them– that’sover 50% of those patients–will be down 60, 70, 80 pounds. It is very normal, though,after the first year or twoafter the surgery, to regaina little bit of weight. I tell my patients it’s kind oflike setting your thermostat. You should think ofsurgery as resettingyour body’s thermostat of wherethe normal weight will be. So initially, you willlose a lot of weight,and your body will thenfind its new steady state. And then everybody regains justa little bit of weight back. And then it’s our jobworking with the patientsto make sure that thatlittle bit of weight we gain,which is normal, stays at thatlevel, and doesn’t you knowskyrocket back so people aregetting excessive amountsof weight back. There are some patients thatdo gain a significant amountof weight back, usually not tothe point where they start offat. But if you if they’velost like 80 pounds,they may regain back30, 40 pounds, whichis not a result that we wanted. And we definitely workwith them to limit that. A major way to preventthat from happeningis close follow-up withus, close follow-upwith our dieticians, anda continued understandingthat surgery, as wetalked about earlier,is not the easy way out. It is basically a toolto help you continueto do what you know youshould have been doing, whichis modifying yourdiet, increasingyour physical activity,and the everything elsethat we normally talkabout with weight loss. So here’s another questionright along those linesfrom a viewer. For those of us who havehad gastric sleeve surgery–this person was Juneof 2014– they’vegained some weight back. They want some motivation orsuggestions to kind of get backon track. What would you tell somebody tojumpstart that process again,and how would you help?Sure. So the way that I wouldbegin with that patientis make sure that they goin to see their surgeon,and re-engage with the program. Oftentimes, patientswill sort ofdrift away because ofjob changes, or they moveand so forth. And if they can comeback and see their team,that first step canhelp substantially. Typically, what we would doin that sort of circumstanceis make sure that there’s notany sort of anatomic problemthat might be contributingto the weight re-gain. And at the same time, wewould have a full assessmentby our dieticiansand our psychologiststo make sure that the diethasn’t drifted or shiftedin a negative direction. And really kind of re-educatingand just getting back on track. And to be honest, Ithink that that’s reallywhere the value of thelong-term follow-up comes in. Because the reality isthat nobody can be perfectevery single day,multiple times a dayfor the rest of their lives. We kind of use a ratio of, ifyou do the right thing 80%,85% of the time, you’regoing to be fine. And life happens. And there’s things that happenwith regards to employment,relationships, and soforth, and stressesthat can lead to peoplekind of getting offthe track a little bit. And we’re here for ourpatients to really getthem redirected and re-engagedand moving forward again. Here’s another viewer question. Not sure why thisone is being asked,but I’m going to go go aheadand throw it out anyway. They want to know what formof vitamins would they take. Chewable, gummy, or pills?That’s actuallya great question. After bariatric surgery,we are, generally,altering the anatomy. So the way some thingsare absorbed or taken upby your body is alittle different. And that’s partiallyhow the surgeries work. So after certainprocedures, we do counselour patients to take vitaminsthat are absorbed better. Sometimes the gummyvitamins, thoseare vitamins that canbasically dissolve in water. You chew them inyour saliva or spit,and they dissolve andyou can swallow them. And that’s adequate forsome of the vitamins. But some vitaminsactually are not wellabsorbed in thatformat, and we may thenrecommend different combinationsor formulations of vitaminsthat are better absorbed. Some vitamins, youmay notice, comein a little droplet ofoil, and those may notbe good aftercertain procedures. So we and our dieticians comeup with an individualized planfor each patient basedupon the surgery they had,and also, actually,their pre-vitamin levels. You may have noticed inChicago that it’s actuallypretty cloudy today, so thatmeans vitamin D levels are low. And actually, most people,actually even before surgery,come in with somelow vitamin levels. And what we do is we actually,before your surgery, checkall those levels, come upwith an individualized planabout what your vitaminregimen should be based on thatand the surgery you’ve had. So each patientwill vary somewhatin what they’ll haveto take, and howthey’ll have to take it. So here’s aninteresting question. How do you make sure that peopledon’t lose too much weight?I don’t know if that’s evera concern with patients,but how would you handle that?Well, I think that itis a realistic concern. I think patients allhave in their mindssort of what they would considerto be a target or a goalweight, if you will. And I would saythat the first stepis you have the writeoperation to begin with. As I said earlier,there’s not one operationthat’s best for everyonein all circumstances. And it’s really that initialdetermination and decisionthat we come together withthe patient about the surgerya choice that willsignificantly determine,not only the risk oflosing too much weightor also not losingenough weight. So really finding thatsweet spot in between. So are there certainfoods or drinksthat will be off limitsafter the surgery?That’s a great question. So again, it sort of dependson the type of procedureyou’ve had. In general, many people comein thinking that, oh, gosh,I’m going to have to eat babyfood for the rest of my life,or just drink liquids. That’s actually not true at all. Our goal is to get you to eatnormal, healthy food again. And about three months afterthe surgery, consistency-wise,there’s really no restriction. So you can eat vegetablesagain, you can eat meat again,all those things. But we do counselyou on the typesof foods you should beavoiding, and foods thatwork against the weight loss. So a high-carbohydratediet, that’s,again, a lot of starches,flour rice, pasta, potatoes. Anything that has that sortof white color and consistencyis generally to be avoided,mainly for weight loss. Sugars, sugarythings, sweet things. Again, worksagainst weight loss,but sometimes can make youfeel ill after certain typesof surgery. So if you eat something that’svery sweet or high concentratedin sugar, that, again,may not agree with you,and also is not goodfor weight loss. Generally, we tell people toavoid carbonated beverages. That’s things likesoda, beer, pop. Again, because as thatgas expands in the stomachthat maybe a little smaller,or in your intestine,that can be uncomfortableand not make you feel well. So I would saythings to be avoidedare carbonated beverages,high sugars, and thenhigh-carbohydrate foods. We’re about outof time, but I dowant to ask thisone last question,and it’s concerning insurance. Obviously, if you’re goingto have a procedure done,there’s always some concernfrom the patient’s standpointon whether or notsomething like thiswould be covered by insurance. Can you speak tothat a little bit?Yeah. So I think that there’sa perception out therethat these operations arecosmetic, and in many cases,cosmetic operations arenot covered by insurance. But I think it’sreally importantto understand that theseobesity and metabolic operationsare not cosmetic. As Dr. Hussain alludedto, these things actuallychange the physiologyof the bodyand contribute tothe weight loss,as well as to the improvement inthe medical conditions relatedto obesity. And because of thatmedical aspect,most insurancecompanies actuallydo cover obesity surgery. Although the individual patienthas to look at their plan tosee if it’s a covered benefit. It turns out that, with thereduction in medicationsand the overall gain andhealth that takes placeafter these operationsin the long run,it’s actually a costsavings to the health caresystem for individuals toundergo these operations. That makes perfect sense. Well, gentlemen,thank you very much. That was great. Thank you. Appreciate it. That’s all the time we havefor At the Forefront Live. Thanks to our guestsfor their participationin today‘s program,and thanks to you forwatching andsubmitting questions. If you want more informationabout bariatric surgery,please visit our websitesite at uchicagomedicine. org,or you can call 888-824-0200. Join us for our nextAt the Forefront Live,where we learn aboutminimally invasiverobotic cardiac surgery. That’s Monday, February 4th. Also check out ourFacebook page for futureAt the Forefront Livedates and subjects. Thanks for watching,and have a great week.