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Bariatric/Weight Loss Surgery

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SARA LOMAX-REESE: Let's welcome Dr. Donee Patterson; she is a family medicine physician with Einstein and Dr. Ramsey Dallal, bariatric surgeon.  Welcome.


RAMSEY DALLAL, MD: Thanks for having us.

LOMAX-REESE: Absolutely.  Well welcome back I guess is a better way of putting it.  We want to talk about obesity, overweight, weight loss and all of those things, but I know Dr. Dallal, you are a bariatric surgeon.  I want you to explain exactly what that is but first, I know that a lot of people have heard or they might associate bariatric surgery or gastric bypass with Al Roker, because he is probably one of the most visible personalities who has gone through that experience and apparently he lost 115 pounds with the help of the gastric bypass.  So let me start with you Dr. Dallal; tell us what exactly bariatric surgery and a bariatric surgeon is.

DALLAL:  Well, on the basic level, we are surgeons that operate on people who have weight problems and treat them for their weight problems.  On a more global perspective, we are advocates for people with weight problems; we research and study the disease of obesity and how it affects people and research and treat the disease in all its aspects.

LOMAX-REESE: Dr. Patterson, why don't you give us kind of a global overview of the impact of overweight and obesity on the African American community in specific.

PATTERSON:  So we wanted to talk today because I want people to know that we picked these topics very thoughtfully.  We are not just randomly picking them.  We wanted to talk today because we know that weight loss is the number one New Year's resolution for people and then sometimes by the second and third week, they kind of give up on the weight loss; they say it's too hard and they go back to what feels comfortable.  So we haven't even made it throughout one month of the year.  So we picked this topic because we want to explain the real true health benefits of weight loss, even modest weight loss, but we want to talk about the benefits of it and we want to help motivate people to keep going with their efforts.  A lot of times if you lose weight you can actually prevent some medical illnesses; you can alleviate some existing illnesses which I don't think people realize, and you can even, in some cases, cure some medical illnesses and we want to use today's platform to just motivate people to stay on their wish to lose weight for 2013. 

LOMAX-REESE: Dr. Dallal?

DALLAL: From our perspective, we have been able to treat and manage one of the largest populations of African Americans in the country, providing them with bariatric surgery services.  We've researched and published some of that data which is rather unique.  From an African American perspective….one, it gives me great pleasure to offer services to a minority group that may not be able to have access in other places, but they have the same, generally when they come to my office, complaints as everybody.  The quality of life is poor; they can't play with their kids and grand kids like they want to; they can't go on vacations or trips because they feel limited.  It is a daily chore to live with the disease of obesity and that goes across any culture and any race.  The daily trauma of trying to lose weight, of the guilt and cycle of guilt that occurs is really touching to hear and most physicians who don't broach the subject don't hear how much pain a lot of these patients are in. It gives me great pleasure to be able to offer services that actually work quite well for most people.

LOMAX-REESE: But it is a specific population though that is eligible for bariatric surgery, is that correct, because, and I want to talk about what Dr. Donee mentioned in terms of strategies for weight loss and the tremendous impact it can have on overall health and well being, but based on the information I have, the bariatric surgery is really for people who are 100 pounds overweight or more, is that correct?

DALLAL:  Sure, the people who qualify for bariatric surgery are in general 100 pounds over their ideal body weight, you know that number you look at in the chart that you say there is no way this is a real weight that anybody is.  So for instance, a 5'5" female, her ideal body weight may be 120 pounds and so….

LOMAX-REESE: That does not seem culturally specific to me.  I don't care what the insurance chart say that is not culturally relevant.  I reject that.

DALLAL:  You know why you are 100% right?  Because the charts were developed by the Metropolitan Life Company and they tried to determine at what weight do people live the longest and so that is where the number came from in terms of their being able to predict people who would die early and who wouldn't and that weight is who lives the longest.  The problem is, everybody who has life insurance, when they looked at these studies, were in general middle income white men so you are right, there are race specific differences in perhaps ideal body weight.  For instance, Asian communities tend to be more sensitive to the diseases of obesity at a much lower weight.  African Americans tend to be generally less sensitive.  So it may take a great degree of weight to cause hypertension in African American than in Asian, but again, these are generalities and you can't predict with any specific person their sensitivities.

PATTERSON:  I think to his point, he was saying that, I just want to emphasize, there is a range, so I don't look at one number and say this person is obese.  There is a range and the BMI scale will show that there is a range, but I also want to emphasize that people that aren't 100 pounds overweight, but they have what we have comorbidities, so other medical conditions, so diabetes, high blood pressure, they have sleep apnea, those people don't have to be 100 pounds overweight to qualify for a weight loss surgery.  We are not just pushing surgery on people.  I really don't want people to think that today.  We just want people to be the healthiest that they can possibly be and if it means we encourage them to eat differently and change some lifestyle habits like being sedentary, that's what we want to encourage, but for those people that they really cannot get there, they tried all kinds of diets, they tried all kinds of interventions, Dr. Dallal is here to answer those questions.  I think people have real questions about it.  We have someone who has been doing it for many years now and I believe he is a smart, very thoughtful surgeon and if people have questions, I think that this is an awesome time to answer those questions.  But a lot of people who have diabetes, you know Sara, we all know people who have diabetes or high blood pressure and they just cannot lose weight, they can't get those extra pounds off and so sometimes people need this as an option to help improve their life and change their lives quite frankly.

LOMAX-REESE: That's Dr. Donee Patterson and we are also in the studio with Dr. Ramsey Dallal and we are talking about weight loss; we are talking about bariatric surgery.  If you have a question, give us a call at 215-634-8065 or toll free, 866-361-0900.  Now I know with any kind of surgical intervention and it's easy to sit and say something about surgery as like a last resort option, if you are not struggling and have not living with morbid obesity for like many, many years.  But I know that any kind of surgical procedure has its risks and so I wanted to see Dr. Dallal if you can talk about the risks and the benefits.  We talked a little bit about the benefits but what are the risks to this kind of surgical procedure?

DALLAL: And that is absolutely critical.  As a surgeon, before you offer any procedure on a patient you have to balance the risks and the benefits and make sure the benefits significantly outweigh the risks.  So what are the risks of being overweight versus what are the risks of surgery?  Yes, when you look, firstly in the field of bariatric surgery over the last 50 years of us doing this, we have had tremendous improvements in the safety and quality of the care that we have been able to provide.  Yes, people can die from bariatric surgery.  The mortality rate, the death rate, from bariatric surgery nationwide has dropped drastically and is far lower for instances than that of a hip replacement operation.  But I think that the perception is that it is so dangerous because society wants to make you feel badly for being overweight and seeking surgical treatment which may be a "cop out". So the proception is, oh my gosh, it is so dangerous when in fact if you went to your family member and said you needed a hip replacement  because your hip was so bad it hurt so much, nobody would say no.  but if you needed bariatric surgery because your hip  hurts and you have diabetes and your blood pressure is bad and you don't want to go on an airplane to Florida to visit your family, your family would say no way, you are going to die from that surgery.  So in general, the mortality rate from bariatric surgery is less than 1 in 1000, probably around 1 in 1400 at this point.  There are risks and the risks tend to be short term, immediate risks of infection, of bleeding and other surgical complications.  There are minor surgical complications that occur that can generally be managed, but the risks of not doing something are absolutely significant and have to be considered.  For instance, when you compare people who have had surgery to people who haven't and you follow them over almost a decade period of time, those that have had surgery are 40% less likely to have died in that period of time.  That includes the risk of surgery.  The risk of dying of a heart attack or stroke drops by about 56% in those who have had surgery.  The risk of dying from cancer drops by 60% and the risks from dying from diabetes related complications drops by more than 90%.  So yes, you take a short term risk with the surgery, no question about that and I don't want to minimize that, but it is easy to ignore the risks of not doing something and whether you do it with medicine, with diet and exercise alone or surgery, it should give you an insight into how important it is to do something.

PATTERSON:  I think people think that weight loss surgery is elective and for some people it is not quite an elective surgery like we think of as a cosmetic surgery.  It is not cosmetic surgery and I want people to know that, and it really does change some people's lives and it changes their future and extends their lives and it actually improves their quality of their life, even just the emotional effects of being obese is huge for some families.

LOMAX-REESE: One of the things in reading Al Roker's story, he had the bariatric surgery; he lost a lot of weight but he gained a lot of weight after a certain point, so I think there is some confusion about what exactly happens when you get this kind of surgery. I believe it reduces the size of your stomach an d so you can't eat so much?  Explain to us Dr. Dallal.

DALLAL: There are two main operations that provide those changes, and that is the gastric bypass and a somewhat newer sleeve gastrectomy.  They both work in the same way, so it is not important to really differentiate between the two.  They both work most importantly by suppressing hunger.  People, after these operations, because of changes in nerve signals to the brain and hormones, tend to say they just don’t get hungry very much, they don't crave foods very much, they don't feel deprived of foods even though they are only eating a fraction of what they were eating beforehand.  So it really is a brain operation more than a stomach operation.  I can generally operate on somebody who may even be illiterate, they can't follow easily a diet plan like even Weight Watchers, but they do well with the surgery because their body just does the right thing; their brain  changes in terms of how they approach food and hunger.  So that is the number one way the operation works.  It does certainly change the volume of food you can eat, no question about that.  You eat much less volume of food; you feel full much quicker but your cravings to begin with aren't quite there.  If that didn't occur you would just be hungry all the time and would just not be able to satisfy that need.

LOMAX-REESE: Well it is interesting because this article that I found was in Psychology Today was about Al Roker and he was saying that you really have to change your entire relationship with food in order to have success with this surgery because there is a psychological component to it, so it is not jut that you can't physically consume as much, but you have to change how, if you seek comfort from food or if you seek other emotional things from food, that is not necessarily going to go away.  We are going to get your responses to that question on the other side.  We are going to take a quick break.  We are talking with Dr. Donee Patterson and Dr. Ramsey Dallal today form Einstein and we are talking about weight loss and bariatric surgery and what it can do for your health and well being.

LOMAX-REESE: And we are back.  You are listening to Health Quest Live on 900 AM on WURD.  We are talking about weight loss surgery and weight loss in general.  If you have a question, we have a bariatric surgeon in the studio today.  You can give us a call at 215-634-8065 or toll free, 866-361-0900.  We want to hear what your thoughts, your concerns, your questions might be around this particular procedure.  Before we went to break, I was asking about the psychological impact of people's relationship with food and how that needs to be factored in when we are talking about any kind of weight loss, permanent weight loss procedure or experience.  Dr. Donee?

PATTERSON:  I just want to step back and just emphasize that this is not brain surgery, but what he was talking about is it is actually surgery on the stomach and it changes the hormones that give cues for hunger.  I do want to talk about comfort food.  We all know about comfort food and emotional stress and social stress.  There is different ways that we have cues to eat and I want to encourage people to really think about it and retrain themselves.  When we are rewarding our children for instance, we often reward them with food, but if you think ahead and plan ahead you can change that.  Maybe have coloring books for bubbles or $5.00 gift cards to Target or someplace so that you are rewarding your children with other things besides food.  Even for yourself, know when you are stress eating or know when you are trying to celebrate, to not always say we are going to eat, we are going to a restaurant.  Find some other ways to celebrate, whether it is a movie or out having a picnic where you guys are exercising or something, but really think through how you are dealing with food around stress and social times.

LOMAX-REESE: Dr. Dallal?

DALLAL:  I think that certainly the relationship with food is important, even after weight loss surgery.  I can say on average the first month sometimes is an adjustment for patients.  Their behavior is such is that they eat so much prior and now they can't and it causes anxiety.  I don’t want to over-generalize in that some patients, especially over time, do get more hungry and they can slip with their old behaviors and regain some weight and that is why it is important for long term follow up.  That is why having psychologists and dietitians supporting our patients can be helpful.  You are right; it is a lifestyle change which is important to maintain not in the first year or so after surgery because that is kind of automatic but the long term, absolutely.  You are really right; it does.

LOMAX-REESE: How much does this cost?

DALLAL:  Well, luckily in this region insurance covers most of the costs because it is a medical illness, just like if you needed coronary artery bypass surgery or needed your hip replacement.  So insurance covers the cost for qualifying surgeons in many instances, not in all but in most.

LOMAX-REESE: I'm just curious, what is the cost, the real cost for bariatric surgery?

DALLAL: I can tell you in ten years nobody has pulled out a checkbook and had to pay cash for this.

LOMAX-REESE: Somebody is paying for this though.

DALLAL:  Well, we all are paying for it but we are also paying for the disease of obesity which is actually far more expenses. When you look at the numbers in general, insurance companies recoup the cost of surgery by about 2-3 years and decrease medication costs, decrease admissions to the hospital and other medical complications.  It is actually cost effective for surgery versus not having surgery.

LOMAX-REESE: We are going to the phones.  We are talking with Dr. Ramsey Dallal; he is a bariatric surgeon with Einstein and Dr. Donee Patterson, a family medicine physician with the Einstein Department of Medicine.  We are going to go to Thomas, from Southwest Philly.  Welcome to the show Thomas.

THOMAS: Hello.  I was concerned about this surgery, but I wanted to talk about a lot of people can prevent or avoid surgery because of weight gain if they would just change their lifestyle.  A lot of people eat and consume too much red meat and red meat products that are high in saturate fats, and I read a book on this, that omega 3 fatty acid, that is   a polyunsaturated fat, that helps to lower triglyceride levels and cholesterol  levels in your blood stream. Triglyceride levels and cholesterol  levels in the blood stream are lowered because when people increase the intake of their diets because of omega 3 fatty acids is essential and that they say American's do not eat enough fish, fatty fish, like sardines, mackerel, salmon, those are good sources of omega 3 fatty acids and they did a study that and they say that omega 3 fatty acids lower cholesterol and triglyceride levels in the blood steam and I would like to know as a life style change what would they suggest?

LOMAX-REESE: Thank you for your call Thomas; excellent points.  Dr. Donee?

DALLAL:  It was excellent points.  Thank you for calling. I have to tell you, as a family doctor, people come to me first and many, many people struggle with weight loss so we are not here pushing any surgery.  We really just want to be a motivation for people to not give up the two or three weeks into January.  Whatever it takes, whether we are encouraging you to eat more fruits or vegetables, eat half the plate of fruits and vegetables and less meat, is what we are encouraging.  Even a vegetarian style diet; exercise more, be active, put your kids into activities.  Join a zumba class with them.  Whatever it takes we are here hoping to encourage you, to motivate you to do what it takes to even lose modest amounts of weight this year.  We want to encourage you and some people just really can't take the weight off, even though they have tried many, many diets, they can't take the weight off and so they may be candidates for this procedure and we wanted to bring the specialist to you. People may not have access to specialists and here is a way for WURD listeners to have a specialist; ask the questions you have always wanted to ask.  Yes you are absolutely right Thomas, weight loss surgery is not for everyone; we are encouraging other methods.  If you can do it by other methods by all means, Dr. Dallal would agree, but if you are one of those people that just can't do it, then we are here to answer those questions as well.

LOMAX-REESE: We are going to go to our next caller, we have Joe from Sicklerville; welcome to the show Joe.

JOE:   Good afternoon Sarah and good afternoon to your guests.  My question is are there cases of a patient having a gastrIc bypass type surgery and then experiencing microcystic chronic anemia as a result?

LOMAX-REESE: Dr. Dallal?

DALLAL: Yeah, absolutely.  That is one of the most significant nutritional deficiencies after gastric bypass surgery, iron deficient anemia.  When we looked at our patients before surgery, 16% of them, man, woman, whatever, were iron deficient.  When we looked at them two years after surgery, in men, that only went up to 17% and post menopausal women, that went up to 19% but in premenopausal women, it went up to 31%.  So premenopausal women, especially are most likely to develop iron deficiency anemia after a gastric bypass.  The sleeve gastrectomy is a slightly different operation and probably has a lower rate of iron deficiency.  So you are right, there are deficiencies that require follow up by the bariatric surgeon or your family doctor.  There are multivitamins, minerals that are necessary to be taken after these surgeries and these surgeries do have downsides, like you mentioned.  But again, relative to putting diabetes in remission, decreasing the need or eliminating the need of high blood pressure medications, improving breathing, asthma, heartburn, reflux, decreasing the rate of cancer, improving cholesterol and triglycerides, if followed and managed properly, the benefits still outweigh that risk that you mentioned.

LOMAX-REESE: Well we are just about out of time; we have been talking with Dr. Ramsey Dallal, he's a bariatric surgeon at Einstein and Dr. Donee Patterson, a family medicine doctor at Einstein Department of Medicine. As we close out, final thought? What do you want to leave the listeners with?

PATTERSON:  I want to remind people to remember their children because childhood obesity is a massive epidemic.  Obese children often become obese adults and so I want people to remember the climate and the atmosphere in their house.  To have more fruits and vegetables available for them and encourage them to put down the video games and to go out and play and exercise.  Just don't forget your children this year.

LOMAX-REESE: Excellent reminder. Dr. Dallal?

DALLAL:  The food that we have in our society today is chock full of calories.  It is far more than we need and we are led to believe that our current diet that we eat today is normal, and it is quite far from normal.  Be consequence what you eat; learn how to read labels; understand what calories you need to eat everyday and prevent this illness; don’t come see me; prevent it, that's the most important thing.

LOMAX-REESE: I think another thing is when you eat is important too.  I think a lot of times we eat way too late in the day which can also pack on some pounds.  Dr. Donee, gift card action?

DALLAL: As is our tradition, we have questions on Einstein's Facebook page, very easy questions and for the first person who answer it you can go to our Facebook page, Einstein Health and if you answer it correctly you will get a $25.00  gift card to ShopRite, which kinds of leads us into our next….

LOMAX-REESE: Yes, next Tuesday I hope all of our health question live listeners, all our WURD listeners will come out and check us out.  We will be on location broadcasting live from Brown's ShopRite on Cheltenham Avenue, next Tuesday from 12-1 and Dr. Donee will be with me and we will be talking about some healthy food, some healthy nutrition.

DALLAL: Absolutely, we will have a nutritionist there and she will be giving us suggestions, like our caller said about some of the healthy choices when we go grocery shopping.

LOMAX-REESE: So we definitely want you to come on down.  You will be hearing more about that in the coming days.  Next Tuesday, Health Quest live will be broadcasting live from Brown's ShopRite on Cheltenham avenue from 12-1 p.m. next Tuesday.  Thank you both for being here; I appreciate all the information.


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