POPULARITY
30 episodes with asmbs
2 episodes with asmbs
2 episodes with asmbs
3 episodes with asmbs
2 episodes with asmbs
3 episodes with asmbs
The puree stage after bariatric surgery can feel a bit daunting—especially when you're trying to figure out what to eat, how much, and how to make it enjoyable. That's why we're excited to share insights from Jane Stoltze, an experienced Bariatric Dietitian and member of ANZMOSS and ASMBS, in her latest video dedicated to this critical stage of the journey.In this video, Jane breaks down:What the puree stage actually involvesWhy it's important for your recovery and long-term successTexture tips and food ideas to keep meals safe and satisfyingHow to listen to your body and avoid common mistakesHer go-to suggestions for getting enough protein while still being gentle on the stomachWith over 30 years of experience in nutrition and a passion for supporting bariatric patients, Jane delivers practical advice with warmth and clarity. Whether you're about to start the puree stage or currently navigating it, this video is a must-watch.
Join the Behind the Knife Bariatric Surgery Team as they kick off 2025 with a crucial discussion on pediatric and adolescent bariatric surgery. Drs. Matt Martin, Adrian Dan and Katherine Cironi delve into the latest ASMBS guidelines, comparing long-term outcomes of gastric bypass and sleeve gastrectomy in adolescents versus adults. They explore key comorbidities, including type 2 diabetes, hypertension, and orthopedic issues, and emphasize the importance of early intervention. This episode also tackles the complex ethical considerations surrounding surgery in this vulnerable population, including consent, multidisciplinary care, and the evolving role of medical therapies like GLP-1 agonists. Show Hosts: - Matthew Martin - Adrian Dan - Katherine Cironi Learning Objectives: · Identify the current ASMBS guidelines for pediatric and adolescent bariatric surgery, including BMI thresholds and associated comorbidities. · Describe common comorbidities seen in the pediatric population eligible for bariatric surgery, such as type 2 diabetes, hypertension, and orthopedic issues. · Compare and contrast long-term outcomes of bariatric surgery (gastric bypass and sleeve gastrectomy) in adolescents and adults, including remission rates of comorbidities and reoperation rates. · Discuss the importance of a multidisciplinary approach, including psychological and ethical considerations, when evaluating adolescent patients for bariatric surgery. · Explain the ethical framework used in evaluating adolescents for bariatric surgery, including consent/assent, parental involvement, and addressing potential coercion. · Recognize the evolving role of medical management (e.g., GLP-1 agonists) in conjunction with or as an alternative to bariatric surgery in adolescents. Article #1: Inge 2019 – Five-year outcomes of gastric bypass in adolescents as compared with adults https://pubmed.ncbi.nlm.nih.gov/31461610/ - The cumulative effect of sustained severe obesity (BMI >35) from adolescence into adulthood increases the likelihood of diabetes, hypertension, respiratory conditions, kidney dysfunction, walking limitations, and venous edema in legs/feet (when compared to adults that did not report severe obesity in adolescence) - American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines for adolescents who should be considered for bariatric surgery: BMI is ≥35 with a co-morbidity or if they have a BMI ≥40 (class 3 obesity, 140% of the 95th percentile) - This article utilizes the Teen-Longitudinal Assessment of Bariatric Surgery (TEENS LAB) and LABS (adults) databases to evaluate the outcomes of adolescents vs. adults who underwent bariatric surgery Roux-en-Y gastric bypass (2006-2009) - 161 adolescents (13-19 at the time of surgery) with severe obesity (BMI>35) vs 396 adults (25-50 years old at the time of surgery) who have remained obese (BMI>30) since adolescence - Both groups had the gastric bypass procedure as their primary bariatric operation - Both groups had unadjusted similar demographics, however, BMI was higher in adolescence (54) when compared to adults (51) - Results were analyzed using linear mixed and Poisson mixed models to analyze weight and coexisting conditions - After surgery, adolescents were significantly more likely than adults to have remission of type 2 diabetes and hypertension - Increased likelihood of remission of diabetes due to the shorter duration of diabetes, lower baseline glycated Hgb, less use of medications, and increased baseline C-peptide levels - Increased vascular stiffness in adults along with a longer duration of hypertension make the cessation of hypertension less responsive with surgery in adults - No significant difference in percent weight changes between adolescents and adults 5 years after surgery - Both adults and adolescent groups had decreased rates of hypertriglyceridemia and low HDL levels, albeit not significantly different when comparing the two groups - Of note, the rate of abdominal reoperations was significantly higher among adolescents (20%) than among adults (16%) with cholecystectomy representing nearly half the procedures in both groups - Limitations - At baseline, adults had a high prevalence of both diabetes and hypertension - only 14% of adolescents had diabetes vs 31% of adults - Only 30% of adolescents had hypertension vs 61% of adults Article #2: Ryder 2024 – Ten-year outcomes after bariatric surgery in adolescents https://pubmed.ncbi.nlm.nih.gov/39476348/ - The goal is to discuss the long-term durability of weight loss and remission of coexisting conditions in adolescents after bariatric surgery - This article utilizes the Teen-Longitudinal Assessment of Bariatric Surgery (TEENS LABS) database to evaluate the 10-year outcomes in adolescents who underwent gastric bypass or sleeve gastrectomy - 260 adolescents with an average age of 17 years old at the time of surgery (ages ranged from 13-19 years old) - 161 adolescents underwent gastric bypass, 99 adolescents underwent sleeve gastrectomy - Results were analyzed using propensity score-adjusted linear and generalized mixed models - At 10 years, the average BMI had decreased significantly with both groups experiencing about a 20% change in BMI on average - To assess comorbidities, both groups were analyzed together - 55% of patients who had DM2 at baseline, were in remission at 10 years - 57% of patients who had HTN at baseline, were in remission at 10 years - 54% of patients who had dyslipidemia at baseline, were in remission at 10 years - Limitations - Neither of these studies compare surgery to medical management. GLP-1s have shown promise for weight loss management but we need more data in terms of long-term outcomes in co-morbidities like diabetes, hypertension, dyslipidemia - Highlighted Outcomes - Metabolic bariatric surgery is quite effective in the adolescent population - Adolescents tend to have weight loss that is similar to that of adults and improved resolution of comorbid conditions (DM2, HTN, dyslipidemia) Article #3: Moore 2020 – Development and application of an ethical framework for pediatric metabolic and bariatric surgery evaluation https://pubmed.ncbi.nlm.nih.gov/33191162/ - The purpose of this paper is to describe the ethical framework that supports the use of metabolic & bariatric surgery (MBS) on the principle of justice, and how providers can conduct a thorough evaluation of patients presenting for these surgeries - Highlights adolescents with intellectual and developmental disabilities (IDD) and preadolescent children who pose more ethical questions before considering surgery - This article utilizes the bariatric surgery center at one children's hospital and the institution's ethics consult service to develop an ethical framework to evaluate pediatric patients seeking bariatric surgery – using the national ASMBS guidelines - This ethical framework utilized 4 central ethical questions 1. Should any patients be automatically excluded from evaluation for MBS? 2. How should it be determined that the benefits of MBS outweigh the risks? 3. How do we ensure the patient fully understands and is capable of cooperating with the surgery and follow-up care? 4. How do we make sure the decision to have surgery is truly voluntary, and not coerced by family or others? - Results: this ethical framework was discussed in depth in two case studies - Overview of framework: an ethical question would arise from the bariatric team they would review & apply the ethical framework. The question is either resolved by the bariatric team OR ethics consult, continue pre-operative workup vs no surgery - Case 1: 17M (BMI 42) with a history of autism spectrum disorder, pre-DM, depression with behavior challenges, HTN, dyslipidemia. Testing at school demonstrates intellectual functioning at a fourth-grade level. Pt lives with mom and 11-year-old sister. Mom endorses food insecurity (on supplemental nutrition assistance benefits) and struggles with her son's large intake of food. 1. Co-morbidities should not be exclusionary, but pt should undergo a comprehensive psychosocial evaluation with attention to family dynamics and support and the patient's decision-making capacity 2. Discuss benefits vs risks. Benefits – decreased progression of DM2, HTN, hyperlipidemia, cardiometabolic dx. Risks – gastric leak, infection, bleeding, dumping syndrome, etc. 3. Can assess decision-making capacity with the surgical team or if need be other teams. In this case, the pt had limited decision-making capacity - His level of understanding remained stable during the pre-op visits, and he gave assent to surgery - The mom identified a second source of support (extended family) - The team talked to both the patient and mother alone and then, together, found that the patient developed an independent desire for surgery, and thus moved forward. - Case 2: 8F (BMI 50) with a history of mod OSA, L slipped capital femoral epiphysis s/p surgical stabilization (6 mos prior). The patient is neurotypical & excels in school, and lives with mom & dad. Referred by mom & dad (mom with a recent history of sleeve gastrectomy). 1. An 8-year-old should not be discriminated against based solely on age, but the patient should be offered more conservative/less invasive options before OR. a. In this case, the family had not yet been offered these nonsurgical approaches (structured weight management program, physical support, dietician) 2. Discuss benefits vs risks. Benefits – preventing progression of hip disease, improvement of OSA, decreased risk of cardiometabolic dx. Risks – anatomic/infectious/nutrition risks 3. Decision-making capacity was assessed. Found that the parents were more advocating for the surgery saying she has a poor quality of life physically and socially. When the patient was separated from her parents, she said she could lose weight if she had healthier foods at home and someone to exercise with. The patient had decision-making capacity & did not assent to surgery. 4. When the ethics team interviewed the patient and parents, the parents had a strong preference toward surgery vs patient was scared of surgery and wanted to try other approaches first a. Decided that the child's dissent outweighed the medical necessity for surgery and that there were conservative treatment options still available to try - Highlighted Outcomes - ASMBS guidelines give us good direction on who qualifies for surgery and emphasize an interdisciplinary approach to decision-making. The decision to pursue surgery should always weigh the benefits and risks and should be made collaboratively with the patient, family, and care team ***SPECIALTY TEAM APPLICATION LINK: https://docs.google.com/forms/d/e/1FAIpQLSdX2a_zsiyaz-NwxKuUUa5cUFolWhOw3945ZRFoRcJR1wjZ4w/viewform?usp=sharing Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.
Making the decision to undergo bariatric surgery is life-changing. It requires lots of research, soul-searching, and some hard-core commitment to being ok with learning how to live life differently. Our friend and BariNation Expert Timisha MAlone, LMSW, and her husband Tim recently made the decision to sell their home and travel the US on an RV and we wanted to know how they are adjusting to bari life on the road! Both Timisha and Tim are bariatric patients, are raising two small children, and learning to navigate some newly diagnosed chronic conditions. Timisha's health requires her to live with a Service Animal and their dog Winston is a constant companion as they learn how to live life in new, exciting, and different ways. Even when we onboard treatments for our health, other issues can still appear and this conversation is all about learning how they have all adjusted to a life they never imagined. We hope you leave this episode with some new ideas on how you can keep living aligned with your bariatric goals when life changes course on you. The more we know about other people's stories and journeys, the more open we are to adapting our own life when change happens. In this week's bonus podcast episode, Members of the BariNation Support Community and our Patreon supporters of the BariNation Podcast will get a private look into Natalie's own journey of chronic illness and how she is learning to balance her bariatric life with new treatment protocols. Connect with Timisha in the BariNation Membership Community where she leads weekly General Support and Bariatric Grief Groups and on on Instagram @time_for_a_change_rny About our Guest: Timisha and Tim Malone are bariatric patients who inspire others by sharing their ups and downs as they learn to navigate full-time life on the road. Timisha is a licensed therapist and owner of Time For A Change Wellness, a patient advocate, and a member of the ASMBS. She is also learning to treat her newly diagnosed chronic illness' as a mother, patient, and advocate. About Your Hosts: April, Jason, and Natalie are all bariatric patients who were inspired to create the community and support they needed. BariNation empowers people to treat their disease of obesity in kind, compassionate, and caring ways through the community they founded. As they learn to live the pillars of bariatric success (movement, mindset, metabolic wellness), they share their experiences and “aha” moments with their friends and followers. About BariNation: BariNation is a bariatric educational organization on a mission to empower patients to access and utilize the tools, resources, and education needed to find and maintain personal wellness. We connect patients with the support they need, when and where they need it. BariNation produces an award-winning weekly podcast distributed on all major podcast and video platforms and hosts a support membership community that teams up with credentialed and licensed bariatric experts and clinicians. Follow BariNation on Instagram and TikTok, and visit us online at www.barination.com. You can also connect with each of the hosts personally on Instagram; follow April @actively_april, follow Jason @tha_smithsonian, and follow Natalie @breakingbari_ers. You've got this and we've got you! --- Send in a voice message: https://podcasters.spotify.com/pod/show/barination/message Support this podcast: https://podcasters.spotify.com/pod/show/barination/support
Who is a candidate for metabolic and bariatric surgery and what has changed in the past 30 years? Find out in this review! Journal articles: Bariatric Surgery versus Intensive Medical Therapy for Diabetes – 5 Year Outcomes. https://pubmed.ncbi.nlm.nih.gov/28199805/. Association of Metabolic Surgery with Major Adverse Cardiovascular Outcomes in Patients with Type 2 Diabetes and Obesity. https://pubmed.ncbi.nlm.nih.gov/31475297/. Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. https://pubmed.ncbi.nlm.nih.gov/26544725/. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery. https://pubmed.ncbi.nlm.nih.gov/36336720/. **Specialty team application link - https://forms.gle/DwrRcMYDaP3a3LaQA Please email hello@behindtheknife.org with any questions. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. If you liked this episode, check out other bariatric surgery episodes here: https://behindtheknife.org/podcast/clinical-challenges-in-bariatric-surgery-revisional-bariatric-surgery/
Two of the world's leading authorities on bariatric and metabolic surgery, the American Society of Metabolic and Bariatric surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), have issued new evidence-based clinical guidelines for the first time in 30 years! Listen in to this week's episode of What's Up Wednesday to learn about the new, updated guidelines, and how they will affect patients' access to life-saving and life-altering treatments for obesity and metabolic disease.The 2022 ASMBS and IFSO Updated Guidelines on Indications for Metabolic and Bariatric Surgery by Dan Eisenberg et al. were published October 22, 2022 online in the journals Surgery for Obesity and Related Diseases (SOARD) and Obesity Surgery.HERE is the link to the full report.Support the showThe Gaining Health Podcast will release a new episode monthly, every second Wednesday of the month. Episodes including interviews with obesity experts as well as scientific updates and new guidelines for the management of obesity.If you're a clinician or organization looking to start or optimize an obesity management program, and you want additional support and resources, check out the Gaining Health website! We offer monthly and annual Memberships, which include live group coaching, a community forum to ask questions and post resources, pre-recorded Master Classes, digital resources inlcuding patient education materials and office forms, and much more! We also sell our popular Gaining Health products, including a book on developing an obesity management program, editable forms and templates, and patient education materials in our Gaining Health Shop! If you are loving this podcast, please consider supporting us on Patreon
Kellie and Mel met this week's guest in Dallas at the ASMBS conference. They were thrilled to meet her and knew they had to have her on the podcast. Lora's passion for the last twenty years has been helping bariatric patients move through the headwork that follows bariatric weight loss surgery. She prides herself on learning from her patients and helping them figure out how to adjust to life when a coping mechanism, like emotional eating, is instantly taken away after WLS. She discusses this with Kellie and Mel as they bring up personal experiences and how they would cope before surgery versus after WLS. They talk about the mental hurdles that occur in the first year post-op, being aware of our thoughts and emotions, building skills to better navigate stressors and emotions, planning ahead when we know a situation may be stressful, and codependency. There was a lot to unpack in this episode and part two is already being planned to talk more in-depth about these topics. Lora has been helping the bariatric community for over twenty years. She is a bariatric therapist, coach, and professional speaker for the community. You can find Lora on her website at www.loragrabow.com or on Instagram @bariatric.therapist Lora mentioned a book by Dr. Susan David, PhD called Emotional Agility. Click the link below if you are interested in further reading. https://www.amazon.com/Emotional-Agility-Unstuck-Embrace-Change/dp/1592409490/ref=sr_1_1?crid=3ER7UYT0SQQ4&keywords=dr+susan+david+emotional+agility&qid=1667871471&sprefix=dr+susan+david%2Caps%2C91&sr=8-1 (add this book to your shop and then add the shop link here - delete the one above) OSLP strives to educate and inform the bariatric community and those with predetermined ideas about weight loss surgery. Join our email list on our website at www.oursleevedlifepodcast.com for the latest OSLP updates and follow us on Instagram @oursleevedlifepodcast. Please consider supporting us on www.patreon.com/OSLP and become a Badass Benchie today! OSLP-APPROVED PRODUCTS: www.procarenow.com www.devotionnutrition.com OSLP Amazon Store Front: Portion Perfection and more OR Use these Discount Codes to help support OSLP! @procarenow - OSLP @devotionnutrition - OSLP @modestmixteas - oursleevedlife20 @portionperfection - 150SLPOD @the.t.r.i.b.e.membership - OSLP @hidratespark - OSLP @obvi - OSLP15 @builtbar - OSLP @middaysquares - OSLP15 @mybaribox - OSLP
Kellie and Mel of Our Sleeved Life sat down with Dr. Carl Pesta, DO, FASMBS, a renowned bariatric surgeon in MI and the current president of the ASMBS Foundation (American Society of Metabolic and Bariatric Surgery. He has been practicing bariatric surgery since 2003 and has performed over 5000 surgeries in his career. In this episode, Kellie, Mel, and Dr. Pesta focused their discussion on the disease of obesity, preventative care, education, bringing awareness to the disease, and working towards bariatric surgery becoming more accessible through legislative acts. As the ASMBS Foundation president, Dr. Petsa works with surgeons and researchers to fund grants for studies and advancements in bariatric surgery. The foundation seeks out ways to impact more people and ultimately end the disease of obesity. Join us on the Virtual Walk November 5th @10am PST. You can join the TEAM OSLP https://fundraise.asmbsfoundation.org/team/7220 You can find Dr. Pesta on Instagram @carlpesta or www.surgicalconsultants.net/ If you are interested in learning more about the American Society for Metabolic and Bariatric Surgery (ASMBS) and the ASMBS Foundation, check out their websites! OSLP strives to educate and inform the bariatric community and those with predetermined ideas about weight loss surgery. Join our email list on our website at www.oursleevedlifepodcast.com for the latest OSLP updates and follow us on Instagram @oursleevedlifepodcast. Please consider supporting us on www.patreon.com/OSLP and become a Badass Benchie today! OSLP-APPROVED PRODUCTS: www.procarenow.com www.devotionnutrition.com OSLP Amazon Store Front: Portion Perfection and more OR Use these Discount Codes to help support OSLP! @procarenow - OSLP @devotionnutrition - OSLP @modestmixteas - oursleevedlife20 @portionperfection - 150SLPOD @the.t.r.i.b.e.membership - OSLP @hidratespark - OSLP @obvi - OSLP15 @builtbar - OSLP @middaysquares - OSLP15 @mybaribox - OSLP
Do you know why Vitamin D is so critical? Bariatric Fusion Staff Dietitian Megan fills us in on this important guideline from the ASMBS.
This episode concludes the Psychological Self-assessment Series. I will be referring to an assessment form similar to what my specialist and I went over. If you would like to follow along with a copy I found from the American Society for Metabolic and Bariatric Surgery (ASMBS) you may use this link >> Self-Assessment
Dr. Franchell HamiltonShe recognized that many of her patients needed a more personalized plan to help them maintain their weight loss goals. By addressing the mental, behavioral, medical, and environmental factors that kept them from a meaningful transformation, her patients began to regain control in these areas.Ari Gronich: Hey everyone, welcome back to another episode of create a new tomorrow I am your host or Ari Gronich and today I have with me Dr. Franchell Hamilton. She is a bariatric surgeon with not only several years of medical and surgical training, but chemistry psychology as well, who's now kind of grown a little tired of the system, as it is, and is looking to help support patients in a more holistic way. So I want I wanted to have her on here because she truly is part of who's making medicine, good for tomorrow, helping them activate their vision for a better world through medicine. So wanted to bring her on Dr. Franchell, thank you so much for coming on. Franchell Hamilton: Thank you. Thank you for having me. Ari Gronich: Absolutely. Why don't you tell us a little bit about your background? And what made you go from traditional medicine towards some more holistic approach?Franchell Hamilton: Sure. So I was traditionally trained MD, medicine, went through residency, general surgery, and then I did extra training and bariatric or weight loss surgery, and was in private practice for about 10 years. And it wasn't until I was in private practice, actually, kind of with my own patients doing the things the way I want it. To do that I started realizing the system that I've been trained all this time wasn't really effective. And I have three clinics, right. So we had a pretty large practice. We're in a big Metropolitan Dallas Fort Worth area. And I was probably one of the top geriatric surgeons as far as volume, what I started noticing probably about seven years in actually, that I was doing a lot more revision surgeries, which means they've already had a bariatric surgery, gastric bypass, sleeve, lap band, whatever it is, and they were coming back to get a revision surgery. And I noticed that several years in the practice changed from doing predominantly first time, weight loss, whatever, surgery, medication wellness, I do a lot of things in my clinic that I saw a lot of repeat customers that regained. And I had to ask myself, what am I doing here, like I did all the checkboxes that I was taught to do. All the patients had to go see a nutritionist, they had to go see a psychologist, they had to get their heart checked out. They did all the checkboxes that was required by insurance. And that was required from my training. But patients weren't getting better. They were requiring revisions. And even the ones that were doing just the medical weight loss, they just weren't progressing the way I thought they should be. And I didn't go into medicine just to be busy. Just to be a busy surgeon, I actually wanted to make a difference. I have a heart for people with a lot of medical problems and complicated obesity. And I really wanted them to not just treat their medical problems, but to resolve them. I wanted them to go away. And I felt like in that moment, we I wasn't doing the right thing for them. So I really had to kind of rethink what I was doing revamp and I actually got more education and almost like what we call Eastern medicine or holistic medicine during those years because I was getting burned out with traditional medicine because I felt like I was not helping my patients because they didn't get better. Like I was trained bariatric surgery will not only help them lose weight, but their diabetes and hypertension, cholesterol, all this stuff will resolve. Right. And it did for a brief moment in time. And then the majority of patients were regaining. So that was my turning point for me.Ari Gronich: Awesome. Thank you so much for that and your dedication in general to wanting to find the best results for your patients. Because we all know that that's not happening so much in the industry right now. And one of the questions I wanted to ask you is what's been your, you know, the pushback from the system or from your colleagues, and so forth? Or what's been the adaptation from them where they've said, Oh, yeah, I've seen this too. And I also want to do what's best. So how can I get on board with what you're doing? So how have you seen on both sides of that?Franchell Hamilton: So, believe it or not, I felt like and still feel like I'm almost like a sore thumb in my industry because I will tell you, especially in the surgical industry, a lot of us are them. They're not there yet. Like they just they operate the and to be honest, I don't even know if it's their fault, like we were trained as a surgeon, we see a problem, we fix the problem or take out the problem. And then we move on to the next thing before I started my own private practice, I was with a group that was very much like that I was employed. And I immediately got out of that, because I was like, this is definitely not the way I want to practice medicine. And the only way that I felt like I can even come close was by starting my own practice. So that's kind of how I ended up in my own private practice. But I will tell you, in my own private practice, it was a struggle, like, I felt like I got pushback from all sides, I got pushback from the insurance companies, I got pushback from a lot of my own colleagues, when I surgical colleagues, when I brought up the idea that patients have to do other things to help them with their weight, diabetes, when I talked about positive affirmations, or maybe including meditation or yoga, I got pushed back all the way around to the point where I had said, almost like leave those I'm not a part of a lot of those organizations. And from the insurance standpoint, they did not pay for any of the more holistic things that I wanted to do that I saw worked, I saw this work. And I even wrote a letter saying this is medical necessity, I think they need this, this and this. And it was denied left and right. And I often found patients were almost mad at me or my office because we couldn't get this approved. And I'm like insurance companies will pay for their blood pressure medication. But if I want it to treat their blood pressure in another way that I know would actually benefit them by helping them reduce stress, change their environment, whatever the case, I got pushback, I wasn't paid, the insurance company didn't pay. And a lot of my surgical colleagues thought I was actually kind of crazy. So I literally had to shut everything down and almost start over the way I felt like with my own vision, the way I felt like things that should be it almost gave me an aha moment. On the way healthcare was practice, like everything it was it was almost like a brief down moment for me, because I've been in this system for so long. And I didn't even recognize this was happening until my patients weren't progressing. And then if I was in fight with the insurance to get stuff covered, I felt like my voice really wasn't being heard. On the other side, some of my medical colleagues, medical non-surgical, were very open to that idea. So I had to shift almost to the more holistic or integrative community, where they got it, lifestyle medicine, doctors, integrative medicine, functional medicine, meditation therapist, yoga therapist, so I almost shifted into that community. And that's kind of where I felt more welcomed, because in my traditionally trained community, a lot of us, some of us are jumping over, but a lot of us are still with the typical mindset when it comes to how we should treat health care.Ari Gronich: Right. So, you know, part of this show has always been a lot about the health care industry, because that's where I started. And, you know, I know from my own medical history, having a brain tumor that I was told, I'd be basically gaining weight until I was dead. And I was 342 pounds at one point where I'm just going okay, so I went on to a cleanse, I went on to another cleanse after that I did a 40 day fast, and I did a 10-day water fast. I mean, it was like one after another of just Something's got to give. And but, you know, misdiagnosed and mistreated my entire childhood. It's kind of why I'm in the business to begin with. What I what I saw was that results never seemed to matter. It was procedures and the incentive system is to do more procedures rather than to actually get the good results for the patients. And so, one of this is like the audience here. A lot of them obviously hear me a lot, but to the people that are in what they would say mainstream, I'm considered maybe woo woo because I don't have a doctor degree other than my doctor of metaphysics, right. So, I would be discredited, you know, because of that. So, you're a medical doctor who's in this industry, right? And so how do we get that system to start shifting itself to more of a results-oriented system?Franchell Hamilton: Yeah, and I'm glad you mentioned that because one of the reasons I got into, particularly obesity medicine was because of the labels like I was labeled as a kid, I didn't have the best childhood. And I had all this kind of like negative labels slapped on me. And so, when I got into medicine, I knew I wanted to be in a field, where people felt like either they were defeated, or they're, you know what I'm saying they just have this negative connotation. So that's what drew me to obesity medicine in general, because there's all this negativity around it, that most of it is not true, which a lot of it I also felt growing up. And so I want it to be that kind of voice for my patients and be that advocate truly be that advocate. And that's one of the things when I got into medicine, where over time, I felt like I'm not advocating for them, kind of like what you were saying. It's a procedural driven society. I mean, we can talk about what happened in COVID, when elective surgeries got shut down, like there's so much stuff in the hospitals that got shut down, I think the way to change it is to do stuff like what you're already doing, talking to more people getting the word out what me and you are both doing try to promote, I still have my practice, it's completely changed now. But a lot of my work now is to get the word out on the way this healthcare system is having practiced in it for a decade before my eyes were open. And realizing like this is not the way it needs to be practiced. There are actually several communities of physicians now who also believe this, which is helpful, we are partnering with a lot of people like you like yoga therapists, like other people who years ago, they're just like, oh, they don't know what they're talking about. Yes, they do, because they're also seeing results. So it's a matter of like getting the word out there that these other modalities exist. And I think it has to be a combination of patients, patients now are also getting frustrated with their results, they're getting frustrated, for paying these high insurance premiums, and not having anything covered, and not getting the treatments that they feel like are going to resolve their medical problems. So I think it took everybody being frustrated and wanting to make a change in the system it's starting. And I think it's just the combination of us getting the word out joining together and getting a change in this area.Ari Gronich: Yeah, so one of my questions, then is being that you're in the unique position that you're in, of being in that medical side, and now bridging the gaps. You know, to the western side, my question would be, how do we get some of those organizations that are individual like IFM, FMU, a forum, right? Those are all individual organizations to kind of come together and literally create the next kind of healthcare system. Because, you know, the way I look at it, the battle that we've been having has been about who pays the insurance company bills, right? Whether it's the government paying or whether it's the insurance paying, it's still who's paying, but there's been no talk about how do we make the system more effective so that people are healthier so that it costs us less money in general? And so that's kind of one of the conversations I like to have is, how do we come together in a way that honors and respects all aspects of medicine, minus, of course, the fraud and deceit and all that shit. But that honors the risk and respects all the good that medicine is mixed with all the good that the holistic side has to offer, and come and create a new system that just is outperforming the old system.Franchell Hamilton: I agree. And that's a loaded question. Because as you and I both know, that's going to take a lot. That's going to take a lot of manpower. On all ends, physicians, support staff like you other health care workers like you and patients to kind of come in and say we want this change, I can tell you, I have stayed one of the reasons I've stayed with my foot in medicine, like clinical practice is so I can help dictate and start being the change. There's so many other opportunities, I've had to completely leave medicine and kind of and maybe at some point, I will do that. But right now, I am trying to bridge the gap. There are several people that are trying to bridge the gap with their patients and these organizations. So I sit on a lot of committees on a lot of these organizations that do not see it this way. yet. One of the reasons I started They'll stay on these committees. So I can almost be a voice inside that committee to help create the change that I think is needed. I'm, I still sit on my Council Committee for American College of Surgeons and so I'm over all of North Texas as a bariatric surgeon, I represent that one of the reasons I still stay there is so I can voice some of the changes that need to be made, I think it's going to take people higher up honestly, in these organizations to say something, and then to start kind of weaving, which we already had, we met each other. I've met several people who are on the same playing field, but I would have never met until I kind of started this whole thing. I think there needs to be a movement. That's what I'm talking about on my podcast and shows. That's what you're talking about. There's a lot a lot of us that are talking about it and we need to all come together, believe it or not, we are making some headwing. CMS which is Medicare, Medicaid, they the government insurance is considering at least looking at functional and integrative medicine, as far as coverage, which is huge. I know, it doesn't seem like a lot. But that is a huge thing that in general, we've been trying to push just like coverage for bariatric surgery, right? Like there's a lot of issues with that. There's a lot of these like grass roots going on in these organizations. I'm part of AMA, which is an American Medical Association. We're trying to in these organizations, I know there are several of them. And yes, we need to come together more, but we're trying to get stuff passed. So integrative and functional medicine has gotten a bill to Congress saying this is what needs to happen in order to help treat patients better, they've actually looked at it and are considering approving it. Once Medicare and Medicaid approves the coverage of functional and integrative medicine, which is currently not approved, that will be a ripple effect, and all other insurances will follow. So I think it's steps like that that's like big, it's hard for like the lay person to see it who's not working. And it takes years, it takes years. Like it took about six years for even that to get to Congress, you know what I'm saying? It just takes a long time for this stuff to happen.Ari Gronich: So because it takes a long time, when it's us industry, people that are not lobbyists? What is the thing that we can do with our patients? Like what are what are the things that patients can do to accelerate it within their groups? Because I'll tell you, I look at all of the Facebook groups and you know, people, some complaining and some promoting and some other things, but all of them is like it's disconnected. And it's what I would consider to be frantic, complaining or gathering to complain instead of collaborating to succeed. So, my question is both for the patients and the physicians who are starting to work with their holistic counterparts, right? How can they combine together to create more power in that movement.Franchell Hamilton: So I think in kind of what we're doing, and this has also already started, where we're forming networks, right, and networks among our area, or region. And I think from a patient standpoint, they need to complain to their insurance company for coverage, which a lot of my patients when I was accepting insurance and alert or accept it, but when I was accepting insurance, I was like, you need to talk to your insurance and ask to get a coverage, believe it or not, when you're an insurance physician or practitioner of any sort, there are several people that's not a physician that takes insurance, there's only so much that we can do, believe it or not, insurance don't want to pay us but as the patient and I'm a patient too, you're paying into the system. So the patient has more power when it comes to their insurance than the physician or the provider does. So those complaints need to be directed towards their insurance companies demanding coverage or demand to leave. There's so many other options out there. If everybody pulled away from the insurance companies and just decided to that that's not that's not working from them, they have to make changes, right. This is what happened and financial infant structures. You almost like wherever the money is going. So in my community, we've formed networks with everybody massage therapist, physical therapist, nutritionist where you can either do like a subscription, which a lot of people are doing now, and you pay into this network, a subscription and it will cover whatever visits almost like an insurance But you're cutting out the insurance, you're cutting out the middleman, this is getting provided directly to whatever group that you're with, or you because a lot of us physicians, we just want to treat the patient, most providers just want to treat the patient. And so we will make something that's reasonable, and that they can afford a lot. And I can speak on physicians, and a lot of these holistic practices are no longer or don't accept insurance, and they're doing their own models, but we have to network and collaborate. Because if I can't offer something, I need to be able to refer that patient to other services that are in our cash pay, holistic integrative network that they can go see. And a lot of patients, believe it or not, are leaving insurance companies and only getting what they need in the event of traumatic or event. Yeah, exactly. And they're paying the doctors and the providers that are providing care for a lot cheaper than paying these high premiums in these high deductibles. So I think that's what needs to be done all over. And that movement has already started.Ari Gronich: That's awesome to hear. I'm so glad to hear that that is going on. And we'll have to make sure that people know how to connect into networks like that, when they listen to the show, so we'll have links and stuff for that as well. So here is a, an off the cuff. Right? So let's say you're not taking insurance, right? I'm taking insurance, you're not taking insurance, you're getting results, I'm not getting results. Alright, so we're just taking a scenario that I think happens quite a lot. So we're going in for weight loss, counseling, weight loss care, right? How much is the difference in cost for say, bariatric surgery compared to a functional medicine approach? And, you know, an average cost, right? So a bariatric surgery costs, how much and then the average approach for functional medicine costs How much?Franchell Hamilton: Well, in the other question, I guess we have to ask is the results, right? So okay. So the first part, so average bariatric surgery probably costs about 20 grand between the hospital and the doctor. And usually the doctor's offices provide all the pre care and a lot of the post care. So about $20,000 functional medicine, typical subscription cost, cost about 100 and 100 to 150 a month. And so let's say 13,000, right? Are there I'm sorry, yeah, sorry, 13 100 a month. So 1300 for the year versus $20,000, for bariatric surgery. So that's a huge cost difference.Ari Gronich: Okay, so now we're going to go to vote who results on both sides. Since you were talking earlier about how many people come back, let's just do that how many people come back after bariatric surgery versus how many people do average, see come back, meeting more care or knowledge or whatever, after going through a functional medicine program.Franchell Hamilton: So with the functional medicine program, it's kind of ongoing, which it's a lot of support. And so people may not come back because they have recurrence of their disease, it's more just maintenance, right? So that's a little so we're not adding money into the system, because we're not treating anything per se anymore. We're just maintenance, right? So that taking into account, my bariatric patient population. For me, I felt like it was at least 50% that needed a revision, which is high considering the cost of a bariatric surgery. So I felt like there was a piece missing there.Ari Gronich: So, is the cost of the revision about the same as the cost of the original?Franchell Hamilton: No, it's significantly higher, significantly higher, because it's more complicated. Anytime you have to go and this is not this is all surgery. Anytime you have to do a revision, your complications increase dramatically. And so the length of stay in the hospital increases dramatically. Like your postdoc, potential complications are higher, like everything is more expensive in a revision surgery.Ari Gronich: Okay. Cost of ongoing care for functional medicine since there really isn't any revisions. But what's the ongoing cost? Oh, it's just the 13. Franchell Hamilton: Yes, your monthly fee. Yeah. Ari Gronich: So on top of the monthly fee, for instance, whatever that is, so they're, you know, they're all programs are different costs, right. So then there's obviously supplement costs, food cost, so people are freaking out. Let's gonna cost me so much money to get healthy. So let's talk about those costs a little bit, how they go high and how they go low, comparatively to what other people are doing. So in bariatric surgery, typically there's medicine medications that they're taking, which have a cost, right? What's the average cost of the medications of maintenance for somebody who's going through the surgical route.Franchell Hamilton: So bariatric surgery, you have to have supplements, they all have to have supplements. And there are specific variadic supplements that most bariatric surgeons or nutritionist, or baria-nutritions provide in the office because that's what the ASMBS, the people kind of write the rules say they need this supplement. And so there's an approval process. And so those supplements are usually about $60 a month for your basic supplements, let alone if you actually have some deficiencies, and then you start adding on and those supplements can range up to 60 to $100 additional a month, not to mention before surgery, there's protein drinks and supplements that you have to do. And after surgery for the first six to eight weeks, there's also protein supplements that people have to stay on to make sure they're getting all the protein that they need. And let me also mention to stay healthy. There are certain foods the bariatric patients have to eat, they eat less, but almost the same healthy foods to stay healthy that people in a maintenance program will need. So that's the bariatric cost, functional medicine cost. They don't have some way, if you don't have bariatric surgery, you don't necessarily have some of the deficiencies that bariatric patients get. So you don't necessarily need all of the supplements. Some people do, right? But very extra patients require us because of the way we rerouted you, you are 100% going to have these deficiencies because of the way the surgery was made. Other functional medicine patients that didn't have the surgery may or may not have those deficiencies, but everybody should be on a basic supplemental regimen that could cost anywhere from 40 to $60 a month. Ari Gronich: So what's the cost of obesity without any intervention at all? Do you know about those what those numbers are the statistics for those numbers.Franchell Hamilton: So because obesity, so let me tell you what obesity cost big picture, because they've looked at different sectors. So obesity caused, apparently 40% of less workdays, obesity in general, because you're obese, you have all of these other chronic problems that come about that people don't even realize that they will get you're sicker. So COVID, for example. I mean, there's so many studies showing obesity alone is reason why there was high death and high hospitalizations with a ventilator. Okay, so outside of that, though, people your immune system is down, you have more missed workdays, or missed work days, which is costing the economy money, you have a higher propensity for diabetes, and all of those medications, hypertension, high cholesterol, depression, anxiety, we don't even care enough to get into the emotional and mental side of what obesity can cause. So overall, they were in this was probably several years ago, when that I saw these numbers, the cost of obesity was taking up about 56% of our total healthcare, that's just for obesity, because of all of the other sub-quella that it has with obesity and this, I use that number because that's the number I used back in the day to try to get bariatric surgery covered because it wasn't covered as readily. It's better, but we still have coverage issues. Ari Gronich: Alright, so, I want to do the numbers because I want people to kind of grasp the gravity, not just of the obesity, just of the cost of bad results, right? You think that it's costing you a lot to go into a physician, a doctor who actually gets the job done? Who is not taking maybe insurance, but is really about caring for you and your patients? Right? And then you go, but I can't afford you. I have to go to where the insurances and then you have to go to 15 people, you have streamlet high expenses. I find it fascinating that somebody can go in for an MRI without insurance and it costs $200 and they go in with insurance and it costs 1600 or 2000, or however much they decide to charge because the whole idea of insurance at the very beginning is we all pay into it. Cool, so that they negotiate better rates for us, right so that they are taking care of those kinds of things. And I think that people are in such a cognitive dissonance about what is really happening in the world around them like, well, they wouldn't, you know, choose money over, over my health, right? They wouldn't allow the system of medicine to be about that. And so there's this disbelief, even though we see after we see after we see the evidence that something is shifty is going on, right.Franchell Hamilton: Yeah, yeah, I agree. And just to kind of piggyback on that, a lot of people think that they're there, it's almost like insurance for them as a security blanket of some sort, when it's actually not doing anything for you. I mean, I get it, I was in that boat too, for a while, like, Oh, we have to have just in case just in case, in, we're pouring 1000s of dollars a month into insurance. And over time, it's changed right now, everybody not only has their high monthly premiums, but they have this huge deductible that they have to pay out. So they're paying high monthly premiums. And then when you come see me or whatever, Doctor, you owe me your deductible, so your insurance is not even covering that they don't kick in until after your deductible is met. Even when I had insurance, I got rid of it myself. You're right, that same scenario happened to me, I needed an MRI, because of my neck. And so I was gonna go and pay insurance. And I had to pay my deductible. They're like, Oh, you need to pay a $2500 deductible. And I was like, pin. And then my therapist, my chiropractor, he ordered it. He was like, you know, I just I know a cash place, go pay cash, and don't tell him you have insurance. And I went there those 350. And I'm like, why when I had insurance, I was gonna have to pay $2500 out of pocket with insurance. I go to another place and say no, I don't have insurance. And I paid 350. Like, what is wrong with this picture, we're actually paying more into the system with insurance than without insurance the same way with physicians, my rate to see me is the same rate that insurance charged for a deductible plan. And so they're not only paying me that, that they're paying, they're also paying their monthly fee, you know, so it's, it's crazy.Ari Gronich: Yeah, it's, it's intriguing to me, but it also intrigues me to the level at which I guess our industry just doesn't even pay attention or explain it or talk about it. Because to me, it's so obvious, right? If the only thing you did, as a scientist, as a medical scientist was look at the numbers of diabetes, of rates of autism, of rates of obesity, of rates of heart disease, right? You would say, Well, shit, we have all this new technology. But the results that we're getting are like 10 times worse than we were getting before we had all this technology. So you'd think that there'd be some cognitive awareness of this? So my question is, how do we bring back the cognitive awareness to people in their own profession? I mean, in their own world, so that it's not incumbent on the patients alone, to have to fight for their right to feel good?Franchell Hamilton: Yeah, yeah, I agree. And that was the problem. And I was a part of this, where I was completely clueless. I was completely clueless, because they didn't teach this to me in school. And I don't know if they taught it at the school you went to but believe it or not, in most healthcare, professional fools, they're not talking about this. And why would they talk about this, because, you know, this could potentially bring down insurance companies or whatever, I was just looking while you were talking, the gross domestic product for our first quarter was $22 trillion. And that's for to 2020. It has gone up, but it's gone up every year. And this was my kind of aha moment. So when I was giving you those numbers, this was probably back in 2018, or 19, when it was a little bit less, but it was still in the trillions. And so if you think 56% of OB takes 56% of that obesity takes up this $18 trillion number, how much we are spending because of obesity, and we're not doing anything. I mean, that was kind of my big thing. Like this person just paid $20,000 for the bariatric surgery, and they're back in here two years later, and now it's going to cost them 35 you know, because they have to have an extra hospital stay because now it's more complicated and the insurance are willing to dish this out. But when I requested that they see counseling or therapy or food addicts? You know, they denied that like, this does not make sense to me why as a country are we willing to spend money on stuff that may only band aid the problem, but we're not willing to spend money on things that will actually resolve the problem? I can't answer that, because I was blind to it also, because I didn't see it. And I don't even know what kind of the only reason why it was brought is because I want it better for my patients. Not everybody is like that some people are just happy going to work collecting, they're checking going home. And if that's the mentality, that they we will always have that system where our head is kind of down. And our blinders are on, because they're going to work the collecting their check, regardless of the healthcare profession. And they're not seeing this bigger picture. I think what helped me is because I was in private practice, I wasn't employed. But a lot of this, if you're in a hospital setting, or an employed setting, honestly, in the defensive providers, it's hard to see, because you have a patient who comes in with diabetes, you have 30 minutes to talk about their nutrition, prescribe some type of medication, and your hospital, or your clinic has already scheduled the next patient for you. So they've got to go. And that's all you see. And so awareness has to come from the people that are doing this, but only if they want to, like me and you talking about it can only help hopefully that helps people kind of think twice, especially providers that have been there in those employees conditions where their employer doesn't see this, they may not see this, you know,Ari Gronich: Right, I just, you know, I look back on this last year, and I go, what an amazing amount of opportunity got lost, because we weren't allowed to talk about building your immune system versus treating a disease, right, we weren't allowed to talk about the ways in which we develop a system that is immune to these kinds of things, because we're so healthy, and our healthy immune system takes care of this stuff like, Good, right. And so I'd like what a missed opportunity we had this last year. The positive, I think is that we've gotten the opportunity a little bit to recognize and to start building the numbers for what you were saying a little earlier, which is look at all the medical intervention that did not happen this year. And the deaths by medicine toll, how much that's dropped. And we'll we might if somebody is actually interested in doing this be able to figure out what really is the cost and the toll death toll wise and cost toll of medical intervention that's unnecessary. what's the overages of what we're doing that we should not be doing? And, and so I'm looking forward to seeing if that gets any play in the community, you know?Franchell Hamilton: Yeah, and I think it will. So I and that's one of the things like in my practice, I never did research. And I'm getting physicians, because I'm like, we need the data, the only way that we're going to be able to beat this thing is the data like in bariatric surgery, which is where I was for so many years, we have data on how bariatric surgery causes a decrease in diabetes, a decrease in hypertension, and how this is saving money, how much obesity is costing America and how we treat this right. So we have those numbers. But then that's it, it drops off, it doesn't talk about or show the aftermath, right? We hadn't even and I think part of it is because people don't want to, we did so much to kind of get it approved. And even my own community is not showing the data afterwards. Because once they get the surgery, that's it. There's no prevention, there's no once their diabetes has resolved. And that's what we're missing the boat. And part of that, believe it or not, is insurance, you're healthy, wanna pay for your one wellness visit a year in your lab work, and that's it. And then patients are left having to what do I do now as they're like medical problems and everything else is slowly increasing. We need data on what prevention does in the big picture. But what we do have data on and this is kind of what I'm trying to educate other physicians about is that every medical disease has increased since the beginning of time since 2000. Diabetes has increased, hypertension and cardiovascular disease has increased obesity has increased, yet, we're supposed to have some of the best health care in America. And we have all these technologies and all these great meds that have come out right these $1,000 meds that are treating epilepsy in cancer and heart disease. But yet the incidence is not going down. The incidence is not going down people because we're not doing prevention, because the focus is not on prevention. This is why the incidence is not going down. And I don't understand why anybody else is not seeing this. They do offer grants, which mean one of the companies that I'm working with digital health company, to increase access to kind of ask these questions, I will tell you what the pandemic I think, like you were alluding to help with open eyes, we had way more deaths than we should have, because of the pandemic because people were not healthy. And if we have the best expensive meds that everybody's paying for in the best health care of all these technologies, why do we have so many deaths, we have more deaths than some other underserved countries. So what, like what's going on there? So we need to start focusing on prevention. And I think, as the whole people are starting to see that now, I've seen more of a shift, kind of towards the end of this pandemic than I've seen before. So I think all of us like you like me, all of us who are like advocates of prevention, now is our time to try to make changes, policy changes come together, educate our other so I'm educating as many physicians as I can I host webinars, you know, conferences, I'm speaking at conferences, in order to cut these to get the word out conferences where it normally wasn't spoken about before. I think at this point, we as a medical society, all providers have to look at this and look at what happened this past year, and start scratching our head like something is not right. It shouldn't make everybody open their eyes this past year. Ari Gronich: Yeah, absolutely, I completely agree. Here's goes to the system, but it goes towards the fear side. So, yes, there are a lot of physicians like you who were blinded for a lot of years. But there's also a lot of physicians who have felt threatened. Right. So I'll give two examples. One is just there's approximately 70 plus holistic health practitioners who have been found, murdered, suicide, whatever, in like a very short period of time, it was like in a three year period of time, there was like 70, some odd, holistic health practitioners, many of them working on vaccine stuff, like the research and in vaccines, kind of interesting, because that ended right before COVID. And I didn't actually put that together until just now, but it's just a thing. So that and then the amount of like, we had a gynecologist in Orlando, who I met at a functional medicine training. And she had gotten, basically, her business completely shut down, she had gotten investigated by the AMA, she had gotten shut down by insurance companies, because what they consider to be the standard of care is if you're going into a gynecologist, you have four sessions that you could go in, where you either have to be prescribed a medicine or a procedure, if one of those two things is not done in four sessions, all of a sudden, you're not practicing in the standard of care. And she did that with a lot of her patients, because she was actually treating them holistically for whatever the ailments were that they were having. And so she had to, I mean, lose her entire practice. And so the fear factor, the only way, in my opinion, to alleviate fear is to become bigger than the bully. And the only way to become bigger than the bully is to get loud. And to bring a crowd. That's kind of where I'm looking at what you're wanting to do what I'm wanting to do a little bit. And so I want to talk to you about that. What do you say to those doctors who are doing frontier medicine, that are on the fringes of, of the new frontier? Really, it's frontier medicine for reason. They're doing the things that are getting the results that are currently not in the standard of care,they're afraid. What do you what do we tell them?Franchell Hamilton: So, you know, it's really unfortunate that this is happening. And that has happened to me, I've been under investigation, because I didn't want to practice the way other people were practicing. So I've been through it. And I think one of the things is you have to, from a physician standpoint, data will help you a provider standpoint. So if you can show data that it's working, that will help you in a courtroom, for example, the other thing is, in every provider knows this a consent and making sure your patients understand. So I've gotten sued, and I've gotten investigated, and I've gotten dissolved, like dismissed because I have consents, and I tell them, this is the way we're practicing. And honestly, at this point, I even tell them, if you don't like this practice, you know, there's other people that are practicing other ways. But this is the way we're going to do it in order to get you to your surgery, or in order to get you to your weight loss goal, because this is what I found has worked. And it's not your typical medicine. And so I make sure they all my patients sign a consent. And I have data. So I didn't put it in a research form. But my EMR tracks, right, you can track the bloodwork, you can track the weight, you can track there's so many different ways to track it without doing an official study. And so I didn't do a study. And that's why I'm encouraging my doctors that I kind of talked to, let's all put data together that shows and then publish it. We need to put data together and we need to publish it. And believe it or not, this is the way medicine used to be practiced. You experimented, you experimented. And that's how breakthroughs came. And now stuff is so regulated in the United States. I go to these international conferences, and some of these European countries are so far ahead of us, because it needs to be regulated. Let me not like take that away. But I mean, come on, you know, how do you think polio was discovered the vaccine for polio? I mean, some of these things were through experiments, and as long as you explain to the patient whoever you're treating, this is the way I'm going to do things, you have data showing their cholesterol numbers are going down. Because this I'm treating with tumeric. And I don't want to treat them with a static drug, you know what I'm saying. But I'm still getting the same results as your stat and drug by doing the things that I've, they do yoga twice a week, meditate every day for 10 minutes, and I'm giving them tumeric. And this is their cholesterol numbers, right? That will hold up in any investigation or suit as long as you can keep that data. So that's what I would tell to the doctors who are going through this, or providers, because I've been through it and I had that I had my data, I had consent. And I'm not giving up. If this is something that you're passionate about, then what you need to do is start bringing people in with you grabbing people that you know, that's also practicing this because as he stated, you stated, I mean, we're bigger in numbers. So now, a lot of my colleagues are no longer unfortunately, my surgical colleagues, but they're my colleagues that are practicing very similar to what I do. So guess what, when one of them gets investigated, they're gonna call me or their lawyer can call me as a witness or one of us, and I will write letters on their behalf, I will witness to them on behalf, we are much stronger, like you said, and numbers. That's the only way. I don't even know if we can do it with money, because I know this is completely off the topic, but that whole COVID vaccine thing. There was definitely money involved. I don't Bill Gates, I mean, all of a sudden, you know that some of that stuff seemed a little questionable, to be honest. Um, I there was money involved. We don't A lot of us don't have Bill Gates money, you know what I'm saying? So the only way we can kind of start defeating This is by speaking up, don't feel like don't let investigators, lawyers states, like, close your voice down. Because if you're doing things the right way, they can't do it. I mean, it's frustrating. And it's depressing during the time because I went through it. But if you're doing things the right way, you're getting your consents, you're slogging your data, they can't shut you down. I mean, they can't.Ari Gronich: Yeah, I've never been investigated. But I'm, I'm not a physician. Franchell Hamilton: It's higher among us because, you know, physicians, everybody's like, oh..Ari Gronich: There's more scrutiny, which is part of why I want to talk to that side of medicine, because, you know, I watch Zeedog MD, for instance. And he talks a lot about the moral dilemma that physicians are having, because they're being told to practice in a way that is not equivalent to the reason why they got into business, right, why they got into the industry. And I don't remember the exact term that he calls it the moral, something moral injury, it's moral injury. And knowing that he feels that way, he and I disagree, obviously, on a lot of the vaccine things and what he considers science and what I consider to be clinical evidence are very different. But I like the fact that he's willing to have the conversations and so like, I would want to have a conversation with him. And you. And then maybe Dave Asprey, you know, who knows, like somebody who's completely on the other side of the pie, and has his own science to back up what he's saying. And I'd love to have these kinds of discussions regularly with it, like within view of the world, right, so that people can see the differences, how much more similar they really are than differences, and then how we get to a kind of a consensus for practicing medicine in a way that actually gets the results that we want. Because really, that's at the end of the day, the only thing that matters, right?Franchell Hamilton: Yeah, I agree. And, and to talk about his moral injury, I mean, everybody talks about a kind of in the medical field, burnout, right? Like burnout is all of a sudden, significantly higher than perhaps 20, 30 years ago, you didn't really hear about it that much. I never heard about burnout in med school, like you know, or other people getting burned out. And that is why burnout is so high, because there's this mismatch on what a lot of providers or healthcare workers want to do. And what's happening even in nurses and you've probably talked to some nurses too, like I have worked with so many nurses who are just burnt out. And the reason they're burned out, most nurses are hospital employed, or for some type of facility employed, and that's not what they want it to do. That's not the way they wanted to practice. They truly want to help people. You know what I'm saying? And then you start to see like, we're not getting the results. We're not doing what I wanted to do, and that's where the burnout come, I got burned out because there was this mismatch in what I want it to do and what was happening. And boy did it hit hard. And so that's the reason so many healthcare workers are getting burned out is because we all live in a system where they're saying healthcare is this, and a lot of us are waking up and realizing, but that's not helping, you know. And so if there needs to be a revolution in healthcare, and I'll be the first to talk to whoever will hear me talk about this revolution, because we're not getting the job done. Our medical problems are increasing,and we're not doing anything about them.Ari Gronich: And so for me, I feel like right now we're on a 19, or like an 1890s 1800, steam train. Right, and we're going Chug, chug, chug. And what I'm wanting to see is Ilan Musk's mag train going through the boring tunnels, right? And so bridging the gaps, I'm going to go really far back to where we were at the beginning of that conversation, bridging the gaps between the speed at which change looks like it wants to happen, because of the powers that be, and the possibility of what can happen if we have the movement with a leader that is like an Elan Musk, that is like, somebody who's there going, Okay, we're about to do this thing. Let's go, there's no option no stop in us, you know, like Kennedy saying, we're going to the moon by the end of the decade. There's no question, like, make that happen. Right. So if we were to do that, what do you see the steps are to making that happen faster? If you could, like, if you could imagine a sped-up version of what you thought was gonna happen? And then we could kind of plan that out? What would that look like?Franchell Hamilton: So kind of, like you said, We need somebody who's already well known, already well recognized, to be an ear. And, and to also identify and be on the same page as what this movement is about. And to be honest, I think I think we have a couple candidates. And Amazon, for example, they announced a couple years ago, they're over the way the healthcare is being practiced, and they want it to do their own health care, you model, you know, and so these big corporations, I just saw thing about JP Morgan, they want to do, you need to find these companies, we all need to find these companies who want these big changes and who get it right. And then we need them to help us because they already have the clout, they already have the ear of America, to kind of say, this is what needs to happen. Oprah would be a great person, I'm still working on that, I'm gonna get up, I'm still working on that. So somebody like that, who's like, this is the way we need to change the way healthcare is done. And then she will have this movement of people who was already on board. So I think that's what we need to kind of bridge the gap, somebody who has the power in that can be a listening ear to all of these, our voices to say, and they don't even have to do it, right. There's enough of us on the ground level that can take it where it needs to go. But we need somebody who's going to listen and help kind of drive this force, because right now, you have the providers and all the providers and we're a big force if we work together, but we need somebody bigger, honestly, to be able to kind of compete, because once we do that, and when we do this, we're competing with the big pharma companies. We're competing with insurance companies, we're competing with a lot of Congress and Senate, people who honestly, they all have nice pockets, and they don't want things to change, to be honest. So you have to have somebody who has as much power with the crowd who can come back that because right now we have work competing with pharma, and insurance come billion and trillion dollar companies who likes everything to stand or wraps. If I publish an article or almost like some of those healthcare workers you were talking about, there's people more powerful than us, that can make things disappear. You know, so we need someone or a group of powerful people who understand the way healthcare is who have nothing to lose, and they can compete with those bigger companies. So that's what we need. I'm actively working on getting bigger companies involved when the digital company that I'm working with is talking to Walmart. I just got an email a couple days ago saying JP Morgan is looking for a change. So when we get This is part of the digital health arena, because this is also how we can reach more people, right? So once we see these us on this level need to jump on that, and how do we get at least in the door with their whoever their health and wellness coordinator is right, every major company has one of those, you have to start with that and then maybe move your way up.Ari Gronich: Unfortunately, not every single major company has one of those. You know, that's kind of my part of my bailiwick, like I was 18, starting three of the first corporate wellness programs in the country, because my school backed up to Intel, Nike and Tektronix, in Beaverton, Oregon, and I was like, Oh, well, we need to bring people to our clinic. So let's just bring our clinic to them. I've done a lot of corporate wellness programs, a lot of consulting with companies. And unfortunately, the majority still do not have a corporate wellness program, what they have what they consider to be that is, they have a health fair twice a year, or they have a few booths with vendors, and then they give flu shots. And maybe they have an on-call psychologist, you know, where you call in to psychology department or something. But yeah, the creating a complete culture of wellness and accompany is definitely one of my bailiwick's that I wish I had more companies that would say, yes, easily to that possibility. But I do agree that the company's you know, here's the thing, following the money are the companies tied to the insurance companies in any way other than that, and typically they are through investment. And because the investment is from the insurance companies, it's really hard for them to do anything that's really going to get their employees well, so they could do a lot of treatment stuff, a lot of educational stuff, not a lot of policies in place to make it happen. And that's definitely an area where I would like to see shifted and changed. You know, we were talking a little bit earlier, you said, you know how burnout is I remember going into good Samaritan Hospital back in the late 90s, and early 2000s. And they still were on 30 something hour shifts. So they, you know, if you got a surgery at the 28th hour, and it was a 15 hour surgery, you were on for 40 something hours, I mean, some of the most unhealthy people I ever met. And it was a shame, because there's some of the kindest, most loving, giving people, get treated really poorly. And so that's part of the thing is, if we made the system a little bit better, and people were less sick, then the health care workers would have less moral injury, because they'd be doing the thing that they signed up for. And people would be treating them? Well, because they're not the what I would call the sounding board for the administration, for the insurance companies, they're, you know, like, the physicians, the providers have been the sounding board for all the complaints of their patients instead of who's really at fault, or who's really, you know, at cause. So let's, let's wrap up with, I want some positives in this as well, as far as like, I want, you know, things that the audience can do immediately if, especially if they're physicians, but if they're not, that they could do immediately to shift the way that they're getting health care. And some of those behaviors and mindset more to prevention versus, you know, reaction.Franchell Hamilton: Yeah. And, you know, I'll piggyback to and I'll make sure I answer that, because we are kind of like this digital health company that I'm working with. And I have a couple of investments in a couple of them. And there have been some leeway on that area, because a lot of them want kind of digital health. And they have the way we're pitching it to them. Kind of like what I started earlier is if your employees are healthier, they can give you more work days, they don't have to have as much time off from work they don't have so it's benefits you to kind of implement these wellness programs. And so like I said, we have entered into Walmart which surprisingly their chief health officer is very open to the idea of integrative changes. We're still Working with we're working with them. And then other companies such as share-care, which are kind of in a lot of there are people in there are people making, we're making some leeway. But you're right about the train, right, it's Chugga chugga. But I will say at least it's not stopped, like, we're, we're moving, we're moving along slowly, I think it needs to get implemented much quicker. But because of a lot of the regulations, and the pocket, the insurance has such deep roots with so many companies like you just did it, like they're investing in other companies. And that kind of keeps everything at bay and kind of this vicious cycle. It's gonna take some time, but I think a lot of people's eyes kind of got opened after this pandemic. One of the things for physicians, I would say, in order to shift this mindset, if you feel like remember the reason why you went into medicine, first of all, and if you feel like when you see your patients on a regular basis, they're not improving, you have to consider why what other factors maybe the reasons for them not improving, and honestly, you'll give my information out. But this is kind of one of the things that I do now I help physicians kind of help figure this out, because they're all getting frustrated. And so it's like, let's take a look at how the way your practice is set up. And your assessment as a physician, we need to ask patients more questions, right? Like we I'm over the, what's your chief complaint, family history, medical history? Do you smoke? Like, that's fine, we'll get all that. But we need to truly ask our patients, how are they doing? Like, how are you doing? Like, we need to get a feel of where they are at emotionally, mentally. And to be honest, that takes up a lot of time. So physicians that are employed may not want to do that, then create an assessment that does it create a questionnaire that acts that you'd be surprised if you're seeing diabetic patients. When I switched up my questions the way I asked the questions instead of just prescribing them a regimen. Let's take diabetes, for example. They come in and I'm like, oh, you're diabetic? Here is a med or insulin. And here is your nutrition or diet that you're supposed to be on? I'll see you in two to three weeks, right? You need to start asking, Can they even afford that? To be honest? What do they normally like to eat, you almost need to cater more to the patient and work with them as a partner, not as like a doctor kind of throwing out orders and then you expect them to do it. One of the reasons why our healthcare is not working is because we're putting demands on patients. And then we expect them to do that. And then when they come back the expectations aren't there. And then we were like, Well, why is your numbers not down? or Why didn't you exercise? or Why? And we didn't even ask them? How are they doing? How do can even do what we're asking them to do? That needs to be your question, if you're going to prescribe them some type of treatment plan, and it doesn't even have to be a medication you need to ask your patient, do you think you can do this? What do you think you can do to help bridge the gap? This is my goal for you. And this is where you are. So here are some options as the physician, what are some things that you think you can do for us to help bridge the gap? That needs to be the question you ask not just medical history, here is what the American Heart Association, American Diabetes Association says. And I'll see you in three weeks. So that is what I want to offer to providers in general, nutritionist, therapists, chiropractors, I mean, there's several people, we're all in this trying to defeat this together, show them help them understand they have to understand so many patients don't even understand go to their doctor, and then they don't even know why they're started on this or what medical problem they have. That was always so frustrating for me. Make sure your patient understands what they have. I mean, come on, you know, that's number one, and then make sure they understand what your goal is for them. Right as the physician or provider, what is your goal, and then you guys have to work together to meet in the middle. That's number one. Number two for the patient. Patients need to demand more, you need to demand better. And I have told my patients to like what do you want x? What do you want patient just like the same way physicians need to provide Why did I Why am I in medicine, if it's to collect a check, you're in the wrong field, go to admin. If you're doing patient care, you need to meet in the middle with your patient and for my patients. They're so quick to just go in, get their meds or get their refills and then leave and I'm like you need to demand more. This is your health. This is your body. This is your mind, body soul. What do you want for your mind, body and soul, I always tell my patients health is not absence of disease, you need to be whole healthy whole socially, mentally and in the body. So when you think of you need to think of health that way. And if you feel like you are not getting what you need, you need to start looking for ways to get what you need. So much stuff is done virtually now. So even if your primary care doctor, they provide her meds or whatever, but they're not, but you feel like you're not getting some of the other things that you need. Go online. There's a whole host of integrative you can use integrative medicine, lifestyle, medicine, functional medicine, you can use those terms and find people that you can treat virtually the pandemic has helped people like me treat people all over. So we're not limited now to just I'm not limited to just Dallas Fort Worth, I can treat people all over, you know what I'm saying. And so for patients, if you feel like when you're leaving your physician office, and you're not getting what you want out of that you need to find another physician, you're not married to that physician, and you need to consider if your insurance won't cover it, paying out of pocket long term to pay for your health, your health is an investment, it is the most important investment you will ever make. It is more important than your house, your car, what other people spend on money, your health is more important. So spending an extra 100 or 200 a month is nothing that's groceries or half of groceries for most people, you know what I'm saying? So you need to take time and invest in your health, that's the most important investment. You cannot have joy, peace, happiness, and all these other things that we strive to have or even help others if your health is compromised. So spend the investment. So those were kind of the closing points that I would tell both those patients and physicians.Ari Gronich: One last closing point is what would you say to the system as it is? As it's going away?Franchell Hamilton: That's a good question. Um, I would say that for sure the current system, we, we need to make changes we need what we're doing is not working. And I would be happy to see a transformation in our healthcare system to something that's going to resolve medical problems. So I am happy to see it go away in order to revolutionize healthcare and heal our patients in America. So that's and I feel like our current medical system is actually preventing us from being able to actually heal, not just treat that heal and resolve medical problems and make people truly healthy the definition of health.Ari Gronich: Awesome. Thank you so much for being here. I am so glad to have you on. And I know that the audience has gotten a lot out of this conversation, hopefully enough that they'll start acting upon it. We can all create a new tomorrow and activate our vision for a better world. Thank you so much for being here. I appreciate you having me. Thank you. Got it. Thank you so much. Audience I appreciate you listening in. This is our garage and it&#
Bariatric medicine is medical weight management. Bariatricians specialize in the medical treatment of obesity and related disorders. Bariatricians can often be confused with bariatric surgeons who perform weight-loss surgeries such as Roux-en-Y gastric bypass and sleeve gastrectomy. About Teresa LaMasters, FACS, MD Dr. LaMasters received her medical degree from the University of South Dakota School of Medicine in 2001. She completed her residency in General Surgery at the University of Kansas School of Medicine - Wichita in 2006. She then went on to complete advanced training with a fellowship in Minimally Invasive Surgery with an emphasis in Bariatric and Robotic Surgery in 2007 at Stanford University in California. She also expanded her expertise in medical management of obesity and completed her Board Certification in Obesity Medicine obtaining her DABOM in 2019. She leads a very busy, successful practice with high quality outcomes and has performed over 3000 bariatric surgeries in the past 14+ years. UnityPoint Clinic Weight Loss Specialists in West Des Moines, Iowa and the Iowa Methodist Medical Center is a Comprehensive Accredited Center through the American College of Surgeons MBSAQIP. Dr. LaMasters currently serves as a Secretary Treasurer for the Executive Council for the American Society for Metabolic and Bariatric Surgery (ASMBS) and will proceed on to serve as President elect in June 2021 and then President of ASMBS in 2022. She has previously served as the co-chair for the State Chapter Committee and Access to Care Committees for ASMBS. She is the Executive Council liaison for the Diversity and Inclusion Committee, and Public Education Committee for ASMBS. She is Past President of the Iowa State Chapter of the ASMBS. She lead the efforts to organize the state chapter and served as the first president. She serves on the Standards and Verification committee for the MBSAQIP and the American College of Surgeons. She helps develop the quality standards for the national accreditation program and serves as a site surveyor and coach for quality improvement. She is passionate about high quality outcomes and continuous quality improvement. She is a highly sought after expert speaker for surgical and medical treatment of the disease of obesity around the United States and Internationally as well.
This episode continues the Psychological Self-assessment Series. I will be referring to an assessment form similar to what my specialist and I went over. If you would like to follow along with a copy I found from the American Society for Metabolic and Bariatric Surgery (ASMBS) you may use this link >> Self-Assessment
Resources From Today's Episode: Bariatric Surgery Success with Dr. Susan Mitchell Private Facebook Group FREEBIE: 5 Tips to Packing in Protein Free Samples: ProCare Health FREE Samples Podcasts Mentioned: #31 Does Protein Help Prevent Weight Regain? #29 Should You Go Keto after Bariatric Surgery? #48 Is Pea Protein a Smart Choice After Bariatric Surgery? Protein, protein, protein! Do you feel like your head may explode if you hear that word one more time? I bet you do, for I admit, I talk about it a lot as do most dietitians. There are so many protein powders on the market…egg, soy, whey, pea, collagen. Which is the best one for you after surgery? There are days when no matter what you do, you can’t consume enough protein thru food, right? Maybe it’s a bad day and you’re just not feeling well. Maybe your day was interrupted unexpectedly and the meal plans you had just didn’t work out. Protein powder is an excellent way to help hit your daily protein target when eating enough protein thru food is just not happening. Let’s take a quick look at the most common ones. Soy, eggs, whey, and casein are all complete proteins with a high PDCAA score. The highest score is 100 which all of these have. If you’ve listened to some of the other podcasts where I’m talking about protein, you may recall that PDCAA means Protein Digestibility Corrected Amino Acid score which measures quality of protein. A complete protein contains all nine essential amino acids. It isn’t missing, or low in any one of the nine. Essential amino acid means that it cannot be made by your body and must be taken in thru food. Soy protein, made from ground soybeans is a quality complete protein. It’s a good choice if you prefer a plant based protein. Soy, egg, whey and casein all taste a little different so it comes down to your personal preference. Egg protein comes from the egg white or albumen. It’s also a high quality complete protein and is popular with people who can’t have dairy or just want to change it up. I’m going to spend most of our time together on whey protein powder as it’s so popular. It’s often called the gold standard of protein powders. But remember what we just said…egg and soy protein as equally as good just not as popular. The protein in milk is 80% casein and 20% whey. Whey is a complete protein containing all nine essential amino acids and is digested faster than casein. Just like egg or soy protein powder, it isn’t missing or low in any one of the nine essential amino acids. Science 101 for this week. Whey powder comes in several forms: whey concentrates, whey isolates and whey hydrolysates. In whey concentrate the water has been removed but the remaining product usually still contains lactose, fat and cholesterol which are naturally found in whey. Whey protein isolates usually have a little more protein but less of lactose, fat and cholesterol than whey concentrates. Whey hydrolysates are pre-digested and assimilate into the body more quickly. Isolates and hydrolysates are typically more costly due to processing. Most containers just say whey protein on the front. How do you know what’s what? Look at the ingredient label. The ingredients go in descending order most to least. The first words should be whey protein concentrate or whey protein isolate, the two most common forms. It’s up to you which you purchase. Because whey comes from milk, anyone who is truly allergic to milk proteins should avoid whey. A milk allergy is not the same as lactose intolerance. They’re two different things. Because the lactose level is low in whey concentrate and lower in whey isolate, they often work for lactose intolerance. Casein is also a complete protein in milk. Studies suggest that since casein is absorbed more slowly than whey and releases amino acids over time, it may be beneficial to consume before bed. This will supply protein through the night. A combination of whey and casein works well too. Make sure your whey protein doesn’t have a lot of other added ingredients that you probably don’t need, like herbs, coffee or guarana, and particularly vitamins and minerals which typically are not added in the amounts specific to bariatric surgery. Generally the fewer ingredients the lower the cost too. There are so many brands to choose from. I partner with ProCare Health because many of their products are tested by a third party, are made in the US, and meet or exceed current ASMBS guidelines. That’s important to me and for your care. If you want FREE samples, see the link above in the resources and you can try them out. Let’s move on to pea protein which is an environmentally friendly plant-based option that’s easily digested and most people are not allergic to it. It’s dairy-free for vegans and people with a true dairy allergy. For a lengthy explanation of pea protein be sure and listen to podcast #48 Is Pea Protein a Smart Choice After Bariatric Surgery. The link is above in the resource list. A plant-based protein powder like pea may have all nine of the essential amino acids but be limiting in one or more. Remember this means that the level is not high enough to meet the body’s requirement. Because you had bariatric surgery and your body needs high quality complete protein. Pea protein has a limiting amino acid or one in a very low amount which is methionine. You can add the amino acid methionine to your diet by eating foods such as brown rice, sunflower and pumpkin seeds. Adding these to your diet increases the carb and fat grams too. Some pea protein products add sunflower or pumpkins seeds directly to the pea powder which then pushes up the total calories along with carb grams of a serving of that powder to around 8 grams compared to 1 or 2 in whey protein. When you have a gold standard protein like whey, egg or soy, you can save those carb and fat grams and use them on real food. This is so important to the enjoyment of food when your portions and calories are limited. I’m a fan of protein powder, it certainly mets a need but I’m a bigger fan of eating real food and maximizing the benefits to the body. We can’t wrap up without a mention of the current darling collagen powder. Yes, it’s super popular right now but it does not contain the essential amino acid tryptophan and is low in both the amino acids cysteine and methionine making it an incomplete protein source with a lower PDCAA score and not a great choice for after bariatric surgery regardless of the Internet hype. The nice thing about protein powder is that it can be mixed with water, juice, milk or other beverages. Most protein powder mixes best in warm liquid so mix your powder with a small amount of warm water or other warm beverage and then mix into your cold beverage if that’s what you’re having. Or, do you have a frother? This tool works really well for blending in protein powder. Combined with a warm liquid it’s a win-win. So cut thru all the hype and go straight to the ingredient label to see what’s what. Find a protein powder without all the unnecessary added ingredients that you don’t need and push the price up. Whey protein concentrate is whey protein concentrate. It doesn’t need a bunch of added items. Compare prices and the label and look beyond the hype. Save money. It’s all part of taking care of yourself. Decide what works best for you. You’re worth it!
This is a must-listen episode. We're joined by Dr. Lillian Craggs-Dino, a Co-Author of the 2016 ASMBS nutritional guidelines for bariatric patients.
This is the first episode of 2021, the first in a new series, and the first since March 2019. Yes, it has been a while. This episode continues from the previous episode, First Call. I began to set appointments with my medical team. The first I met with was with the Behavioral Health Specialist. I had to take a self-assessment which is what this series will cover. I will be referring to an assessment form similar to what my specialist and I went over. If you would like to follow along with a copy I found from the American Society for Metabolic and Bariatric Surgery (ASMBS) you may use this link >> Self-Assessment
Today we are joined by a very special guest. Dr. Paul Enochs, President of the ASMBS Foundation. Learn about the foundation & its mission. They are responsible for the Walk From Obesity and have gone digital for the spring with hashtag #KeepWFO. Looking to Support the Foundation? Check out the information below: Follow the Foundation on social media ( Facebook and Instagram) @WalkfromObesity Donate if possible, $35 or more, we will send you our 2020 commemorative WFO t-shirt, as well as other gifts based on donation level LINK: https://fundraise.asmbsfoundation.org/index.cfm?fuseaction=donorDrive.event&eventID=895 AWARE (Awareness, Wellness, Access, Research, Education) Campaign: the monthly giving gift to support the Foundation. For as little as $10/month you can support the Foundation's research for obesity research AWARE LINK: https://asmbsfoundation.org/aware/ Contact Info: American Society for Metabolic and Bariatric Surgery Foundation info@asmbsfoundation.org
HEALTHY LIFESTYLE with Host Lori Anne Casdia with Guest Dr. Dominick Gadaleta, MD. FACS, FASMBS serves as Chair Department of Surgery, Director, Perioperative Services Southside Hospital, and Director, Metabolic and Bariatric Surgery and Robotics Program North Shore University Hospital, Northwell Health. Dr. G has been doing Metabolic and Bariatric Surgery Since 1997 and was a founding member and past president of the New York State Chapter of ASMBS. www.northwell.eduQuotes: "We live in a world with plenty of food and not a lot of physical work."Please email us at HealthyLifestylewithLA@gmail.com and follow us on social media @healthylifestylewithLAOur Goal at Healthy Lifestyle is to inspire, educate and empower you to fulfilling a healthy, emotional, spiritual and physical life, so you can feel empowered to live the life you have always wanted and dreamed. We are here to lift each other up with encouragement and positivity. To serve one another.ABOUT Lori Anne De Iulio CasdiaBusiness & Marketing Strategist, Law of Attraction Practitioner & Master Mindset MentorFounder of LDC StrategiesFounder of Strategies By DesignFounder of Monarch LuminariesFounder of Strategies for Success ProgramMotivational Speaker/Inspirational SpeakerEmcee/ModeratorMaster Mindset MentorLaw of Attraction PractitionerHost of HEALTHY LIFESTYLE (LI News Radio/I Heart Radio/InTune/Sound Cloud/YouTube)Publisher/Owner of Port Lifestyle MagazineCo-host For Podcast Out-Loud Out-FrontPerformer/VocalistColumnist for LIBNCertified Herbalist & AromatherapistAwarded the 50 Top Most Influential Women in 2018Lori Anne’s personal philosophy is “We are all here to serve others and lift each other up. Be the best you because everybody else is taken.”Links Website: LDCStrategies.comLDC Facebook: https://www.facebook.com/LDCStrategies/Strategies By Design Facebook: https://www.facebook.com/Strategiesby...Healthy Lifestyle with Lori Anne Facebook: https://www.facebook.com/HealThyLifes...Instagram: https://www.instagram.com/healthy_lif...You can also Listen to Healthy Lifestyle with Lori Anne on your favorite app: I Heart Media | iTunes (Apple Podcasts) | Google Podcasts | Spotify | Spreaker | Sound Cloud | TuneIn | YouTube
ASMBS President Eric DeMaria, MD, discusses an encouraging new systematic review and meta-analysis from George Washington University, which found that metabolic surgery is significantly more effective than medical management for the treatment of type 2 diabetes in patients with milder forms of obesity. Dr DeMaria also explains the ASMBS’s position on the use of metabolic surgery in patients with a body mass index of 30 to 35 kg/m2, the future of metabolic surgery, and more. For more, visit www.consultant360.com.
Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for the 30th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. I hope everybody enjoyed a fantastic conference. This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery. Nachi: As the obesity epidemic continues to worsen in America, bariatric procedures are becoming more and more common, and this population is one that you will need to be comfortable seeing. Jeff: Thankfully, this month’s author, Dr. Ogunniyi, associate residency director at Harbor-UCLA, is here to help with this month’s evidence-based article. Nachi: And don’t forget Dr. Li of NYU and Dr. Luber of McGovern Medical School, who both played a roll by peer reviewing this article. So let’s dive in, starting with some background. Starting off with some real basics, obesity is defined as a BMI of greater than 30. Jeff: Oh man, already starting with the personal assaults, I see how this is gonna go… Show More v Nachi: Nah! Just some definitions, nothing personal! Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits! Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery. Jeff: Well that’s kind worrisome. Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That’s almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!! Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80’s to 2008, the worldwide prevalence of obesity nearly doubled! Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia. Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark. Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017. Jeff: And while it’s not exactly core EM, we’re going to briefly discuss indications for bariatric surgery, as this is something we don’t often review even in academic training programs. Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group. Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures. Which again reiterates why this is such an important topic for us as EM clinicians to be well-versed in. Nachi: As far as types of procedures go – while there are many, there are 3 major ones being done in the US and these are the lap sleeve gastrectomy, Roux-en-Y gastric bypass, and lap adjustable gastric banding. In 2017, these were performed 60%, 18%, and 3% of the time. Jeff: And sadly, no two procedures were created alike and you must familiarize yourself with not only the procedure but also its associated complications. Nachi: So we have a lot to cover! overall, these surgeries are relatively safe with one 2014 review publishing a 10-17% overall complication rate and a perioperative 30 day mortality of less than 1%. Jeff: Before we get into the ED specific treatment guidelines, I think it’s worth discussing the procedures in more detail first. Understanding the surgeries will make understanding the workup, treatment, and disposition in the ED much easier. Nachi: Bariatric procedures can be classified as either restrictive or malabsorptive, with restrictive procedures essentially limiting intake and malabsorptive procedures limiting nutrient absorption. Not surprisingly, combined restrictive and malabsorptive procedures like the Roux-en-y gastric bypass tend to be the most effective. Jeff: Do note, however that 2013 guidelines do not recommend one procedure over another and leave that decision up to local surgical expertise, patient specific risk factors, and treatment goals. Nachi: That’s certainly an important point for the candidate patient. Let’s start by discussing the lap gastric sleeve. In this restrictive procedure, 80% of the greater curvature of the stomach is excised producing early satiety and weight loss from decreased caloric intake. This has been shown to have both low mortality and a low overall rate of complications. Jeff: Next we have the lap adjustable gastric band. This is also a restrictive procedure in which a plastic band is placed laparoscopically around the fundus leaving behind a small pouch that can change in size as the reservoir is inflated and deflated percutaneously. Nachi: Unfortunately this procedure is associated with a relatively high re-operation rate – one study found 20% of patients required removal or revision. Jeff: Even more shockingly, some series showed a 52% repeat operation rate. Nachi: 20-50% chance of removal, revision, or other cause for return to ER - those are some high numbers. Finally, there is the roux-en-y gastric bypass. As we mentioned previously this is both a restrictive and a malabsorptive procedure. In this procedure, the duodenum is separated from the proximal jejunum, and the jejunum is connected to a small gastric pouch. Food therefore transits from a small stomach to the small bowel. This leads to decreased caloric intake and decreased digestion and absorption. Jeff: Those are the main 3 procedures to know about. For the sake of completeness, just be aware that there is also the biliopancreatic diversion with or without a duodenal switch, as well as a vertical banded gastroplasty. The biliopancreatic diversion is used infrequently but is one of the most effective procedure in treating diabetes, though it does have an increased risk of complications. Expect to see this mostly in those with BMIs over 50. Nachi: Now that you have a sense of the procedures, let’s talk complications, both general and specific. Jeff: Of course, it should go without saying that this population is susceptive to all the typical post-operative complications such as venous thromboembolic disease, atelectasis, pneumonia, UTIs, and wound complications. Nachi: Because of their typical comorbidities, CAD and PE are still the leading causes of mortality, especially within the perioperative period. Jeff: Also, be on the lookout for self-harm emergencies as patients with known psychiatric disorders are at increased risk following bariatric surgery. Nachi: Surgical complications are wide ranging and can be grouped into early and late complications. More on this later… Jeff: Nutritional deficiencies are common enough to warrant pre and postoperative screening. Thiamine deficiency is one of the most common deficiencies. This can manifest within 1-3 months of surgery as beriberi or later as Wernicke encephalopathy. Symptoms of beriberi include peripheral neuropathy, ataxia, muscle weakness, high-output heart failure, LE edema, and respiratory distress. Nachi: All of that being said, each specific procedure has it’s own unique set of complications that we should discuss. Let’s start with the sleeve gastrectomy. Jeff: Early complications of sleeve gastrectomy include staple-line leaks, strictures, and hemorrhage. Leakage from the staple line typically presents within the first week, but can present up to 35 days, usually with fevers, tachycardia, abdominal pain, nausea, vomiting sepsis, or peritonitis. This is one of the most serious and dreaded early complications and represents an important cause of morbidity with an incidence of 3-7%. Nachi: Strictures commonly occur at the incisura angularis of the remnant stomach and are usually due to ischemia, leaks, or twisting of the gastric pouch. Patients with strictures usually have n/v, reflux, and intolerance to oral intake. Jeff: Hemorrhage occurs due to erosions at the staple line, resulting in peritonitis, hematemesis, or melena. Nachi: Late complications of sleeve gastrectomies include reflux, which occurs in up to 25% of patients, and strictures, which lead to epigastric discomfort, nausea, and dysphagia. Jeff: I’m getting reflux and massive heartburn just thinking about all of these complications, or the tacos i just ate…. Next we have the Roux-en-Y bypass. Nachi: Early complications of the Roux-en-Y Gastric Bypass include anastomotic or staple line leaks, hemorrhage, early postoperative obstruction, and dumping syndrome. Jeff: Leak incidence ranges from 1-6%, usually occurring at the gastro-jejunostomy site. Patients typically present within the first 10 days with abdominal pain, nausea, vomiting, and the feeling of impending doom. Some may present with isolated tachycardia while others may present with profound sepsis – tachycardia, hypotension, and fever. Nachi: Similar to the sleeve, hemorrhage can occur both intraperitoneally or intraluminally. This may lead to hematemesis or melena depending on the location of bleeding. Jeff: Early obstructions usually occur at either the gastro-jejunal or jejuno-jejunal junction. Depending on the location, patients typically present either within 2 days or in the first few weeks in the case of the gastro-jejunal site. Nachi: If the obstruction occurs in the jejuno-jejunostomy site, this can cause subsequent dilatation of the excluded stomach and lead to perforation, which portends a very poor prognosis. Jeff: Next, we have dumping syndrome. This has been seen in up to 50% of Roux-en-Y patients. Nachi: Early dumping occurs within 10-30 minutes after ingestion. As food rapidly empties from the stomach, this leads to distention and increased contractility, leading to nausea, abdominal pain, bloating, and diarrhea. This usually resolves within 7-12 weeks. Jeff: Moving on to late complications of the roux-en y - first we have marginal ulcers. Peptic ulcer disease and diabetes are risk factors and tobacco use and NSAIDs appear to increase your risk. In the worse case, they present with hematemesis or melena. Nachi: Internal hernias, intussusception, and SBOs are also seen after Roux-en-y gastric bypass. Patients with internal hernias usually present late in the postoperative period following significant weight loss. Jeff: Most studies cite a rate of 1-3% for internal hernias, with mortality up to 50% if there is strangulation. Nachi: And unfortunately for us on the front lines, diagnosis can be challenging. Presenting symptoms may be vague and CT imaging may be negative when patients are pain free, thus laparoscopy may be needed to definitively exclude an internal hernia. Jeff: Strictures may occur both during the early and late period. Most are minor, but significant strictures may result in obstruction. Nachi: Trocar site hernias and ventral hernias are also late complications, usually found after significant weight loss. Jeff: Cholelithiasis is another very common complication of bypass surgery, occurring in up to one third of patients, usually occurring during a peak incidence period between 6-18 months. Nachi: For this reason, the current recommendation is that patients undergoing bypass be placed on ursodeoxycholic acid for 6 months preventatively. Jeff: Some even go as far as to recommend prophylactic cholecystectomy to prevent complications, but as of 2013, the recommendation was only ‘to consider’ it. Nachi: Nutritional deficiencies are also common complications. Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. Patients typically take vitamins postoperatively to prevent such complications. Jeff: And next we have late dumping syndrome, which is far more rare than the last two complications. In late dumping syndrome, 1-3 hours after a meal, patients suffer hypoglycemia from excessive insulin release following the food bolus entering the GI tract. Symptoms are those typical of hypoglycemia. Nachi: Lastly, let’s talk about complications of lap adjustable gastric band surgery. In the early post op period, you can have esophageal and gastric perforations, which typically occur during balloon placement. Patients present with abd pain, n/v, and peritonitis. These patients often require emergent operative intervention. Jeff: The band can also be overtightened resulting in distention of the proximal gastric pouch. Presenting symptoms include abd pain with food and liquid intolerance and vomiting. Symptoms resolves once the balloon is deflated. The band can also slip, allowing the stomach to move upward and within the band. This occurs in up to 22% of patients and can cause strangulation. Presentation is similar to bowel ischemia. Nachi: Later complications include port site infections due to repeated port access. The infection can spread into connector tubing and the peritoneal cavity causing systemic symptoms. Definitely start antibiotics and touch base with the bariatric surgeon. Jeff: The connector can also dislodge or rupture with time. This can present as an arrest in weight loss. It’s diagnosed by contrast injection into the port. Of note, this complication is less common due to changes in the technique used. Nachi: Much like early band slippage and prolapse, patients can also experience late band slippage and prolapse after weeks or months. In extreme cases, the patients can again have strangulation and symptoms of bowel ischemia. More mild cases will present with arrest in weight loss, reflux, and n/v. Jeff: The band can also erode and migrate into the stomach cavity. If this occurs, it usually happens within 2 years of the initial procedure with an incidence of 4-11%. Presenting symptoms here include epigastric pain, bleeding, and infections. You’ll want to obtain emergent imaging if you are concerned. Nachi: And lastly there are two rare complications worth mentioning from any gastric bypass surgery. These are nephrolithiasis, possibly due to increased urinary oxalate excretion or hypocitraturia, and rhabdomyloysis. Jeff: That was a ton of information but certainly valuable as most EM clinicians, even ones in practice for decades, are unlikely to have that depth of knowledge on bariatric surgery. Nachi: And truthfully these patients are complicated. Aside from the pathologies we just discussed, you also have to still bear in mind other abdominal conditions unrelated to their surgery like appendicitis, diverticulitis, pyelo, colitis, hepatitis, pancreatitis, mesenteric ischemia, and GI bleeds. Jeff: Moving on to my favorite - prehospital care - as always, ABCs first. Consider IV access and early IV fluids in those at risk for dehydration and intra-abdominal infections. In terms of destination, if it’s feasible and the patient is stable consider transport directly to the nearest bariatric center - early efforts up front will really expedite patient care. Nachi: Once in the ED, you will want to continue initial stabilization. Special considerations for the airway include a concern for a difficult airway due to body habitus. Make sure to position appropriately and preoxygenate the patients if time allows. Keep the patient upright for as long as possible as they may desaturate quickly when flat. Jeff: We both routinely raise the head of the bed for all of our intubations. This is ever more important for your obese patients to help maximize your chance of first pass success without significant desaturation. Nachi: And though I’m sure we all remember this from residency, it’s worth repeating: tidal volume settings on the ventilator should be based on ideal body weight, not actual body weight. At 6 to 8 mL/kg. Jeff: Tachycardic patients should make you concerned for hypovolemia 2/2 dehydration, sepsis, leaks, and blood loss. Consider performing a RUSH exam (that is rapid ultrasound for shock and hypotension) to identify the cause. A HR > 120 with abdominal pain should make you concerned enough to discuss urgent ex-lap with the surgeon to evaluate for the post op complications we discussed earlier. Nachi: If possible, obtain a view of the IVC also while doing your ultrasound to assess for volume status. But bear in mind that ultrasound will undoubtedly be more difficult if the patient has a large body habitus, so don’t be disappointed if you’re not getting the best views. Jeff: Resuscitation should be aimed at early fluid replacement with IV crystalloids for hypovolemic patients and packed RBC transfusions for patients presumed to be unstable from hemorrhage. No real surprises there for our listeners. Nachi: Once stabilized, gather a thorough history. In addition to the usual questions, ask about po intolerance, early satiety, hematemesis, and hematochezia. Definitely also gather a thorough surgical history including name of procedure, date, known complications post op, and name of the surgeon. Jeff: You might also run into “medical tourism” or global bariatric care. Patients are traveling overseas to get their bariatric care more and more frequently. Accreditation and oversight is variable in different countries and there isn’t a worldwide standard of care. Just an important phenomenon to be aware of in this population. Nachi: On physical exam, be sure to look directly at the belly, making note of any infections especially near a port-site. Given the reorganized anatomy and extent of soft tissue in obese patients, don’t be reassured by a benign exam. Something awful may be happening deeper. Jeff: This naturally brings us into diagnostic testing. Not surprisingly, labs will be helpful in these patients. Make sure to check abdominal labs and a lipase. Abnormal LFTs or lipase may indicate obstruction of the biliopancreatic limb in bypass patients. Nachi: A lactic acid level will help in suspected cases of hypoperfusion from sepsis or bowel ischemia. Jeff: And as we mentioned earlier, these patients are often at risk for ACS given their comorbidities. Be sure to check a troponin if you suspect cardiac ischemia. Nachi: If concerned for sepsis, draw blood cultures, and if concerned for hemorrhage, be sure to send a type and screen. Urinalysis and urine culture should be considered especially for early post op patients, symptomatic patients, or those with GU complaints. Jeff: And don’t forget the urine pregnancy test for women of childbearing age, especially prior to imaging. Nachi: Check an EKG immediately after arrival for any patient that may be concerning for ACS. A normal ekg of course does not rule out a cardiac cause of their presentation. Jeff: As for imaging, plain radiographs certainly play a role here. For patients with respiratory complaints, check a CXR. In the early postoperative period, there is increased risk for pneumonia. Nachi: Unstable patients with abdominal pain will benefit from an emergent abdominal series, which may show free air under the diaphragm, pneumatosis, air-fluid levels, or even dilated loops of bowel. Jeff: Of course don’t forget that intra abd air may be seen after laparoscopic procedures depending on how recently the operation was performed. Nachi: Plain x-ray can also help diagnose malpositioned or slipped gastric bands. But a negative study doesn’t rule out any of these pathologies definitively, given the generally limited sensitivity and specificity of x-ray. Jeff: You might also consider an upper GI series. Emergent uses include diagnosis of slipped or prolapsed gastric bands as well as gastric or esophageal perforations. Urgent indications include diagnosis of strictures. These can also diagnose gastric band erosions and help identify staple-line or anastomotic leaks in stable patients. Nachi: However, upper GI series might not be easy to obtain in the ED, so it’s often not the first test performed. Jeff: This brings us to the workhorse for diagnostic evaluation. The CT. Depending on suspected pathology, oral and/or IV contrast will be helpful. Oral contrast can help identify gastric band erosions, staple-line leaks, and anastomotic leaks. Leaks can be identified in up 86% of cases with oral contrast. Nachi: CT will also help diagnose internal hernias. You might see the swirl sign on CT, which represents swirling of the mesenteric vessels. This is highly predictive of an internal hernia, with a sensitivity of 78-100% and specificity of 80-90% according to at least two studies. Jeff: While CT is extremely helpful in making this diagnosis, note that it may be falsely negative for internal hernias. A retrospective review showed a sensitivity of 76% and a specificity of 60%. It also showed that 22% of patients with an internal hernia on surgical exploration had a negative CT in the ED. Another study found a false negative rate of 32%. What does all this mean? It likely means that a negative study may still necessitate diagnostic laparoscopy to rule out an internal hernia. Nachi: While talking about CT, we should definitely mention CTA for concern of pulmonary embolism. In order to limit contrast exposure, you might consider doing a CTA chest and CT of the abdomen simultaneously. Jeff: Next up is ultrasound. Ultrasound is still the first-line imaging modality for assessing the gallbladder and for biliary tract disease. And as we mentioned previously, ultrasound should be considered for your RUSH exam and for assessing the IVC. Nachi: We also should discuss endoscopy, which is the test of choice for diagnosing gastric band erosions. Endoscopy is also useful for evaluating marginal ulcers, strictures, leaks, and GI bleeds. Endoscopy additionally can be therapeutic for patients. Jeff: When treating these patients, attempt to contact the bariatric surgeon for guidance as needed. This shouldn’t delay imaging however. Nachi: For septic patients, make sure your choice of antibiotics covers intra-abdominal gram-negative and anaerobic organisms. Port-site infections require gram-positive coverage to cover skin flora. Additionally, give IV fluids, blood products, and antiemetics as appropriate. Jeff: Alright, so this month, we also have 2 special populations to discuss. First up, the kids. Nachi: Recent estimates from 2015-2016 put the prevalence of obesity of those 2 years old to 19 years old at about 19%. As obese children are at higher risk for comorbidities later in life and bariatric surgery remains one of the best modalities for sustained weight loss, these surgical procedures are also being done in children. Jeff: Criteria for bariatric surgery in the adolescent population is similar to that of adults and includes a BMI of 35 and major comorbidities (like diabetes or moderate to severe sleep apnea) or patients with a BMI 40 with other comorbidities associated with long term risks like hypertension, dyslipidemia, insulin resistance and impaired quality of life. Nachi: Despite many adolescents meeting criteria, they should be referred with caution as the long term effects are unclear and the adolescent experience is still in its infancy with few pediatric specific programs. Jeff: Still, the complication rate is low - about 2.3% with generally good clinical outcomes including improved quality of life and reducing or staving off comorbidities. Nachi: Women of childbearing age are the next special population. They are at particular risk because of the unique caloric and nutrient needs of a pregnant mother. Jeff: Pregnant women who have had bariatric surgery have an increased risk of perinatal complications including prematurity, small for gestational age status, NICU admission and low Apgar scores. However, these risks come with benefits as other studies have shown reduced incidence of pre-eclampsia, large for gestational age neonates, and gestational diabetes. Nachi: 2013 guidelines from various organizations recommend avoiding becoming pregnant for at least 12-18 months postoperatively, with ACOG recommending a minimum of 2 years. Bariatric surgery patients who do become pregnant require serial monitoring for fetal growth and higher doses of supplemental folate. Jeff: We also have 2 pretty cool cutting edge techniques to mention this month before getting to disposition. Nachi: Though these are certainly not going to be done in the ED, you should be aware of two new techniques. Recently, the FDA approved 3 new endoscopic gastric balloon procedures in which a balloon is inflated in the stomach as a means of simulating a restrictive procedure. Complications include perforation, ulceration, GI bleeding, and migration with obstruction. As of now, they are only approved as a temporary modality for up to 6 months. Jeff: And we also have the AspireAssist siphon, which was approved in 2016. With the siphon, a g tube is placed in the stomach, and then ⅓ of the stomach contents is drained 20 minutes after meals, thus limiting overall digested intake. Nachi: Pretty cool stuff... Jeff: Yup - In terms of disposition, decisions should often be made in conjunction with the bariatric surgical team. Urgent and occasionally emergent surgery is required for those with hemodynamic instability, anastomotic or staple line leaks, SBO, acute band slippage with dilatation of the gastric pouch, tight gastric bands, and infected port sites with concurrent intra abdominal infections. Nachi: And while general surgeons should be well-versed in these complications should the patient require an emergent surgery, it is often best to stabilize and consider transfer to your local bariatric specialty facility. Jeff: In addition to the need for admission for surgical procedures, admission should also be considered in those with dehydration and electrolyte disturbances, those with persistent vomiting, those with GI bleeding requiring transfusions, those with acute cholecystitis or choledococholithiasis, and those with malnutrition. Nachi: Finally, patients with chronic strictures, marginal ulcers, asymptomatic trocar or ventral hernias, and stable gastric band erosions can usually be safely discharged after an appropriate conversation with the patient’s bariatric surgeon. Jeff: Definitely a great time to do some joint decision making with the patient and their surgeon. Nachi: Exactly. Let’s close out with some Key points and clinical pearls. Jeff: Bariatric surgeries are being performed more frequently due to both their success in sustained weight loss and improvements in associated comorbidities. Nachi: There is an increased risk of postoperative myocardial infarction and pulmonary embolism after bariatric surgery. There is also an increased risk of self-harm emergencies after bariatric surgery, mostly in patients with known psychiatric co-morbidities. Jeff: Nutritional deficiencies can occur following bariatric surgery, with thiamine deficiency being one of the most common. Look for signs of beriberi or even Wernicke encephalopathy. Nachi: Staple-line leaks are an important cause of postoperative morbidity. Patients often present with abdominal pain, vomiting, sepsis, and peritonitis. Jeff: Strictures can also present postoperatively and cause reflux, epigastric discomfort, and vomiting. Nachi: Intraperitoneal or intraluminal hemorrhage is a known complication of bariatric surgery and may present as peritonitis or with hematemesis and melena. Jeff: After significant weight loss, internal hernias with our without features of strangulation are a late complication. Nachi: Late dumping syndrome is a rare complication following Roux-en-Y bypass occurring months to years postoperatively. It presents with hypoglycemia due to excessive insulin release. Jeff: Esophageal or gastric perforation are early complications of adjustable gastric band surgery. These patients require emergent surgical intervention. Nachi: Overtightening of the gastric band results in food and liquid intolerance. This resolves once the balloon is deflated. Jeff: Late complications of gastric band surgery include port-site infections, connector tubing dislodgement or rupture, band slippage or prolapse, and band erosion with intragastric migration. Nachi: Given the myriad of possible bariatric surgeries, emergency clinicians should be cognizant of procedure-specific complications. Jeff: Consider obtaining a lactic acid level for cases of suspected bowel ischemia or sepsis. Nachi: Endoscopy is the best method for diagnosing and treating gastric band erosions. Jeff: Septic patients should be treated with antibiotics that cover gram-negative and anaerobic organisms. Suspected port site or wound infections require gram positive coverage. Nachi: Pregnant patients who previously had bariatric surgery are at risk for complications from their prior surgery as well as pregnancy-related pathology. Jeff: A plain radiograph may be useful in unstable patients to evaluate for free air under the diaphragm, pneumatosis, air-fluid levels, or dilated loops of bowel. Nachi: CT of the abdomen and pelvis is the mainstay for evaluation. Oral and/or IV contrast should be considered depending on the suspected pathology. Jeff: Have a low threshold for emergent surgical consultation for ill-appearing, unstable, or peritonitic patients. Nachi: So that wraps up Episode 30! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And the address for this month’s cme credit is ebmedicine.net/E0719, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References Altieri MS, Wright B, Peredo A, et al. Common weight loss procedures and their complications. Am J Emerg Med. 2018;36(3):475-479. (Review article) Colquitt JL, Pickett K, Loveman E, et al. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014(8):CD003641. (Cochrane review; 22 trials) Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21 Suppl 1:S1-S27. (Society practice guidelines) Phillips BT, Shikora SA. The history of metabolic and bariatric surgery: development of standards for patient safety and efficacy. Metabolism. 2018;79:97-107. (Review article) Contival N, Menahem B, Gautier T, et al. Guiding the nonbariatric surgeon through complications of bariatric surgery. J Visc Surg. 2018;155(1):27-40. (Review article) Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient, 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727-741. (Society practice guidelines) Chousleb E, Chousleb A. Management of post-bariatric surgery emergencies. J Gastrointest Surg. 2017;21(11):1946-1953. (Review article) Goudsmedt F, Deylgat B, Coenegrachts K, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass: a correlation between radiological and operative findings. Obes Surg. 2015;25(4):622-627. (Retrospective review; 7328 patients) Michalsky M, Reichard K, Inge T, et al. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis. 2012;8(1):1-7. (Society practice guidelines)
This week on BTK, we start off with Kevin giving you updates regarding the next steps in BTK future as well as our search for an adjunct member of our team. Check out the application here! https://t.co/ihgTDph6Ex Dr. Samer Mattar (current ASMBS President) discusses and refutes common bariatric myths that many practitioners fall for. It's a great review on current bariatric literature and recommendations! Additionally, we discuss many new "interventions" in the world of weight loss surgery. Tune in to hear these options!
Are you or someone you love interested in bariatric surgery? What do you need to know about the surgery and post-surgery adaptations to nutrition? Is there more to obesity than you actually have control over? How does compassion play a role in how we view others who are dealing with obesity? What are the top 2 food additives that are increasing your food addictions and cravings? How can you work with your physician better as a team in a prescription-happy, "corrupt" medical industry? Learn the answers to these questions and so much more with Kristy Jo's conversation with Dr. Matthew Weiner, Board-Certified General Surgeon specializing in Bariatric Surgery since 2006 in Michigan. If you find this episode helpful, please SHARE it with someone who can also benefit, and be sure to leave a glowing review for the Body Buddies podcast on iTunes and Stitcher Radio. Thank you for being here to better #PowerYourBody! Dr. Weiner's Website: http://drmatthewweiner.com/ Dr. Weiner's YouTube: https://www.youtube.com/user/DrMatthewWeiner Dr. Weiner's Book: Click Here to view on Amazon Dr. Weiner's Bio: Dr. Weiner is a board certified general surgeon and Fellow of the American College of Surgeons. He has been practicing laparoscopic and bariatric surgery since 2006. Dr. Weiner completed his medical degree at the University of Michigan and graduated in the top quarter of his class. He then went on to complete his surgical training at New York University. After finishing his residency, Dr. Weiner was a faculty surgeon at Wayne State University for five years before starting his own private practice. Dr. Weiner performs both general laparoscopic surgery and bariatric (weight loss) surgery. In both fields, he focuses on minimally invasive techniques that result in less pain and a faster recovery. Dr. Weiner’s office is able to provide both surgical and non-surgical care for the treatment of obesity. Rather than focusing on willpower and self control, Dr. Weiner works with his patients to help them understand the reasons behind their weight gain and attempts to work with your physiology to conquer food cravings and avoid weight loss plateaus that sabotage our best intentions. Learn more about Dr. Weiner’s Nutritional Philosophy Dr. Weiner’s weight loss practice has resulted in thousands of patients finally winning their war against obesity. Dr. Weiner has developed a specialized nutritional program that maximizes patient’s weight loss after surgery. His knowledge and passion for nutrition and fitness are contagious and he is dedicated to ensuring that his patients are properly educated and supported throughout their journey. Dr. Weiner is an active member of the American Society of Metabolic and Bariatric Surgeons (ASMBS) and is a past president of the Michigan state chapter of the ASMBS.
ASMBS 2012 Spotlight: Obesity Action Coalition
ASMBS 2012 Spotlight: Celebrate Vitamins
ASMBS 2012 Researcher Spotlight: Dr. Heneghan
ASMBS 2012 Researcher Spotlight: Dr. Dalal
ASMBS 2012 Researcher Spotlight: Dr. Willson
ASMBS 2012 Researcher Spotlight: Dr. Blackstone
ASMBS 2012 Spotlight: Connie Stapleton
ASMBS 2012 Spotlight: Bariatric Advantage
ASMBS 2012 Spotlight: Wellesse
ASMBS 2012 Spotlight: Twin Labs
ASMBS 2012 Spotlight: Building Blocks Vitamins
ASMBS 2012 Spotlight: New Whey Protein
ASMBS 2012 Researcher Spotlight: Dr. Morton
ASMBS 2012 Spotlight: Obesity Help
ASMBS 2012 Spotlight: Calcet Creamy Bites
ASMBS 2012 Spotlight: Post Op and a Doc
ASMBS 2012 Spotlight: BariWare
ASMBS 2012 Spotlight: Ferretts Iron
ASMBS 2012 Spotlight: Vitalady
ASMBS 2012 Researcher Spotlight: Dr. Torquati
In Episode 31 we talk about a few stories on the bariatric news, and them Danielle drops in for a minute to let us know how she's doing. We're also joined by Patrina McBride who bring a Canadian perspective on weight loss surgery. * Steady progress: Mother, daughter lose combined 274 pounds * Binge Eater to Bulimic: How Weight-Loss Surgery Can Trigger Eating Disorders? We were joined this week by McNee and Patrina
In episode 2 of BariatricTV Support Chat Radio we talk about a few things in the news. * Bariatric Surgery Saves Money for Diabetic Patients * EndoBarrier non-surgical therapy continues to show positive results * Weight Loss Drug Pulled From Market We’re also joined by DivaTaunia to talk about her show. As well as Melting Mama to discuss whats going on in her world. Seems she has men posting naked pictures to her. We were also joined by the usual slew of Bariatric Beauties, and McNee and Baka, who are handsome gents as well.
The crew from Building Blocks Vitamins at ASMBS
Susan Marie from BariatricEating at ASMBS
Ben Prince from Isopure at ASMBS
Yvette Szeleczyk from Hormel Health Labs at ASMBS
Shannon Watts from Revival at ASMBS
This week the BTV crew visits the 27th annual meeting of the American Society of Bariatric and Metabolic Surgery (ASMBS) in Las Vegas Nevada. Over the next week we’ll be uploading interviews we’re doing with vendors of bariatric products, as well as key researchers that presented findings at the meeting. So check back often as we’ll be adding content throughout the weekend and next week.
Teresa From Celebrate at ASMBS
Zeke From My Diet Dinnerware at ASMBS
Dr. Jacques from Bariatric Advantage at ASMBS
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