medications to facilitate weight loss.

Is there still a role or even a need for other non-operative and surgical interventions?

[MUSIC] Stay with us as we talk with bariatric surgeon Doctor Joshua P Steiner about the role of surgery in achieving weight loss.

Next, on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

>> Metabolic syndrome is associated with an increased risk for development of cardiovascular disease, stroke, and diabetes.

It is characterized by having high blood pressure, a high fasting blood sugar level, abdominal obesity, high triglyceride levels, and low HDL cholesterol.

However, the leading cause of metabolic syndrome is excess fat, particularly that within the abdomen, and this linkage has spurred interventions aimed at weight reduction.

These interventions include modifications in lifestyle and diet, surgery, and the development of a class of medications known as GLP one inhibitors.

Diet and lifestyle modification can be effective, but not everyone responds or is able to institute these changes.

The many surgical options control weight by decreasing nutrient absorption, food intake, and altering gastrointestinal hormones.

GLP one inhibitors are a relatively new group of medications that control weight by altering insulin and glucagon release, slowing gastric emptying, and increasing satiety.

If the commercials and GLP one medication sales are any indicators, it seems that many of us have opted for medical treatment over lifestyle changes and surgery.

However, for many reasons, there has been a renewed interest in the surgical option as part of a holistic approach to weight loss.

To discuss this in the prevention of the complications associated with obesity, we have as our guest today, Doctor Joshua P Steiner, Jr.

Doctor Steiner is a graduate of Drexel University College of Medicine in Hahnemann University in Philadelphia, Pennsylvania.

He completed a residency in general surgery at the University of Kentucky, followed by a fellowship in advanced GI minimally invasive surgery at the Cedars-Sinai Medical Center in Los Angeles, California.

He is now an assistant professor in the Department of Surgery, and is the director of bariatric surgery at University of Kentucky Health Care.

Doctor Steiner, Josh, thanks for being with us today.

Thank you.

What is a good California boy doing winding up in bariatric surgery?

Well.

>> Winding up in Kentucky is because I married a Kentucky woman.

Winding up in bariatric surgery.

It was not my choice, actually.

Really?

I trained at the University of Kentucky.

I met a wonderful woman, married her, and took her back to California for my advanced surgical fellowship.

The first day there, our boss said, my boss said, we're going to start a bariatric program.

I had no real experience with bariatric in my residency.

And, you know, bariatric has kind of almost a negative connotation.

Obese patients, obese people are stigmatized in our country.

People don't really want to take care of them or didn't want to then, and they're harder to take care of their sicker.

And it wasn't just it wasn't on my radar.

After the first couple of cases and learning just how amazing it became over the next 3 to 6 months, I realized this was my passion and something I really wanted to do.

When you're a resident, you take care of someone for a month or two and you move on to the service, to the next service.

You know that.

But as a fellow, you take care of those same patients the entire year.

So I really got to see the benefits of taking care of someone and seeing the changes that happen with both surgical and dietary modifications and the whole program associated with that.

Around that same time, my wife was pregnant with our second son.

She and my parents weren't getting along the best.

Now they're now they're wonderful.

And she said, I want to go home.

I want to go back to Kentucky.

Around that time, there was a gentleman here who was starting wanting to start a bariatric program, and none of his partners wanted to help him.

So I cold called him, and the rest is history, so to speak.

And he became a huge passion of mine.

And it's I've been very fortunate and blessed to be able to take care of the people of Kentucky for the last 25 years and first 20 years in private practice, the last five years here at the university and 10,000 cases later, it's been really the most amazing thing that I've done in my career.

>> Such great similarity between Kentucky and California.

I'm sure it was just a very seamless transition for you.

Are we using the right terms when we talk and use the term obesity and excess weight, or are there better terms for obesity?

>> Is the technical term for obesity.

Is someone with a BMI greater than 30?

What's BMI?

BMI is a calculation of your height and weight.

The New York Life Insurance tables came up with this a long time ago.

To get the healthiest person to charge the most or less for their insurance policies, and they came up with this this number when you when you there's a formula you plug in, you put in your height and you put in your weight.

And an obese person usually is the obese person usually about, you know, 70 to 80 pounds over their ideal body weight.

Morbid obesity is the term that you were probably trying to get to, and that is literally killer fat.

It's a person who has a BMI of somewhere over 100 pounds over their ideal body weight, somewhere over 40 BMI, BMI of 35 with co-morbid conditions like you mentioned, of heart disease, hypertension, sleep apnea, diabetes.

Those are those things that if they have high comorbid conditions and an elevated BMI, they would benefit from a weight loss surgery.

>> Does a person being overweight by the numbers you gave, does that imply that they are unhealthy?

I'm thinking, I guess, about these football players or some athletes in these really high strength things.

They tend to be, you know, they're over the they're bigger than the rest of us.

>> They're big humans.

Yeah.

Not necessarily.

Not every big person is unhealthy.

Not every overweight person with an elevated BMI is unhealthy.

And we have different parameters.

We have biometric scales to give you the percentage of body fat, water and the like.

When we when we initially screen someone.

But the comorbid conditions that come with someone.

The the medical problems that come with someone who is obese or more importantly, morbidly obese, with significant comorbid conditions, with significant elevation in their weight.

Those are the ones who really benefit from a weight loss modification, whether it's a GLP one analog or surgery.

>> Are we over concerned with weight, or are we appropriately concerned about things from the patient perspective, and also from the health care provider perspective?

>> I think we're probably under concerned at times because weight is it's not just you want to look great and you it's for your now.

Actually nowadays some of those GLP-1 are used so you can get in your bikini Hollywood body.

But I don't I don't do surgery so patients can have a post-op picture of putting three people in one leg of their pants.

And that's all fun and games.

But it's about getting healthier.

It's about living longer.

And unfortunately, we have that comparison of someone who's overweight might not be as attractive as someone who is an ideal body weight, but really what it comes down to is they're not as healthy.

Often they can't do the things they want to do, they can't work the way they want to work, they can't live the way they want to live.

And unfortunately, they live less years.

There was a study some time ago out of Canada, and Canada has free health care.

It's all wonderful, but dot dot dot and that but is you can have bariatric surgery for free, but you might wait five years to get on that schedule to have your free bariatric surgery.

So of course, there was a study done that a thousand patients who waited in a thousand patients were in the surgery arm, and those patients who waited, they died at an 89% higher rate than those complications from the surgery.

So you had an 89% risk reduction of dying if you went the surgical arm, as opposed to just waiting for the surgery, just being obese.

So being obese and more importantly, being morbidly obese has its health concerns, has its health problems.

It's expensive to take care of obese patients, the medications to take care of the hypertension, the mechanical assistance with sleep apnea or surgery for sleep apnea, the cardiac medications those aren't inexpensive.

And unfortunately, those patients are also much, much more unhealthy and harder to take care of just for all comers.

>> What about mobility issues?

Do the people who tend to be obese, particularly the morbid obese, have more joint problems or other musculoskeletal issues?

>> Absolutely.

We actually partner with our orthopedic partners because we can diminish their risks of their complications of surgery by seeing their patients prior to getting a hip or knee.

And if we can take their weight down to a safer BMI with the surgery, then their joints will last longer, their complications will be less, their infections will be less.

So by all means, we can help all aspects of medicine.

I know earlier you had a neonatologist here, and he was talking about some of the pitfalls of pre-term babies and such.

The gynecologic data is such that less morbidly obese women are less obese.

Women having babies have higher birth weights, less risk of C-section, less risk to mother and baby.

I have we call them berry babies now.

I have like hundreds and hundreds of post-bariatric babies and they have some women couldn't get pregnant because the exogenous estrogens floating around the hormones in the fat.

So that fat acted almost like a birth control pill.

We warn these patients after surgery, you're going to become quite fertile, so take extra forms of protection if that's what you don't want to have.

Is another child at age 45 or or something like that.

But it's been beautiful.

It's been wonderful to see Berry start family berry.

>> I love that term.

But, you know, even the risk of cancers associated with patients being obese.

>> And that's a two fold problem.

One is detection is more challenging.

So it's harder to do that exam.

It's harder to present.

But increased fat has higher risks of female cancers breast uterine cervix, male cancers as well.

Colorectal cancers are higher in the obese population.

>> What are some of the reasons why we're getting bigger now?

>> Well, I think the number one reason we have obese patients is it is a genetic problem.

And then we have constant availability to poorly nutritious, overly processed foods, 24 over seven availability to get whatever you want.

There's no there's no people aren't really going out and doing what they used to do.

They exercise less.

The screens and such people don't do as much activity outside and it has become a global problem.

But especially in the United States, we have an increasing rate of obesity, upwards of 20% obesity in our children, where I vividly remember as a child, we didn't have we didn't have phones, we didn't have.

We were outside and our mom yelled at us to come back for lunch, and our mom yelled at multiple times for us to come back for dinner, and we were just out and doing more things.

I don't think our kids do as much and life is harder for these kids.

I have three boys and they're constantly running around, but it just seems more it seems more of a challenge nowadays and we don't let our kids just ride their bikes to school in fourth grade, walk a mile down the road.

It's just things are different.

>> How does a person get to a bariatric surgeon?

>> My my choice is my preference would be the patient to make the first choice.

An obese person knows they're obese.

They're told they're obese by their doctors.

They might have stigma from their friends or family or persons, but I want those patients to make the first call to our office.

I think they know what's out there.

This is 2026.

They know there's medications, they know there's surgery.

And I want that patient to make the first call.

I don't want, you know, their mother, their brother, their father, their doctor.

I prefer them to make the first phone call.

When we get consultations, we call the patient back and we before we put them on the schedule and let them know what the options are, really surgical medical options.

And then make sure they are a candidate.

And b are interested in pursuing either a medical weight loss journey or surgical or combined.

>> Take me to that algorithm then.

So you're talking to the person and it sounds like you're not saying, okay, come in.

We're going to schedule you for surgery in six weeks, but rather you're going to tell them to do what?

>> Well, absolutely nobody comes in the door.

At least they shouldn't come in the door and get bariatric surgery too soon.

Our process, the patients are actually a little shocked.

Really.

We?

Our process is at least a 3 to 4 month process of monthly meetings with either my nurse practitioner who does the screening, or one of myself or one of my partners who does the initial screening, and then every single patient who has bariatric surgery has a mandatory psychological evaluation to make.

Sure we want to make sure we do surgery for the right reasons.

We want to make sure we're not covering up some underlying problem that if we take away their ability to eat or overeat, we've made them much, much worse.

And that's actually required by Medicare and most insurers that they have a psychological evaluation.

We want to make sure they're medically safe enough to undergo an operation.

I want to make sure they can walk the length of the hallway.

We have a lot of non-ambulatory patients who can't initially have surgery, but we can work with them, work with our dietician, do other things to get them to get the weight down where they can lease, transfer and walk the length of the hallway.

We want to make sure that their surgical history or their medical history doesn't prohibit a bariatric surgery, and then we guide them to the safest surgery, determining what is the best option for them long term, short term, with their underlying medical or non-medical problem.

>> So with the advent of the GLP one inhibitors, it looked like initially the number of patients undergoing bariatric surgery.

Now, I guess that should be specific, not the people, as you said, looking for their Hollywood bikini bodies.

But I'm talking about people who are trying to lose weight for other reasons.

Was their initial time where there was dropping that you were seeing bariatric procedures decreasing because more people were using the GLP one inhibitors.

>> It's not initial.

It's still ongoing.

Okay.

So we are our numbers are down for bariatric surgery.

And that's that's not a horrible thing.

I mean, obviously I'd like to operate more, but the fact that more people are exposing themselves and addressing their obesity problems is a great thing.

But the problem sometimes with the GLP-1 is the main thing is they're extremely expensive.

Despite best scenarios, the insurers often do not cover or pay for them, or only partially cover them.

If you don't have the co-morbid problems of diabetes and some of the underlying medical problems.

So it's expensive.

There are some risk factors and some complications that can result from taking a GLP one.

But as a surgeon, I want to make sure we give the patient all the options a success, sometimes with medical or medical assisted weight loss is not the same thing that I would consider a success really.

So if you tell someone they're going to lose 20% of their excess body weight and they weigh 400 pounds and they're 250 pounds over their ideal body weight, if they lose 20%, they're still going to have hypertension, diabetes, sleep apnea.

They're not going to be as healthy as they want to be.

Some people can do amazing.

But also the the the problem we run into there is those patients don't need to be on those medications for life unless they make some significant dietary and lifestyle changes.

So I think surgery is still the gold standard for permanent durable weight loss.

You have your upfront risks, which we have gotten down to a very lower, never zero, but close to less than 1% mortality rate, extremely low leak rate somewhere around the same.

And these patients invariably do very, very well.

Our length of stay is 1.5 days.

So one and a half days in the hospital after our bypass or our sleeve patients.

>> But you made an interesting point though.

When patients are using medication for weight loss, it has to be part of a lifestyle modification.

Does that not also have to take place when a patient has bariatric surgery, or shouldn't that also be part of what goes on bariatric.

>> 100% mandatory in what we do.

So as a surgeon, you cannot have surgery in my program or most programs that are a center of excellence surgery program like mine, unless you participate with the preoperative dietary modification, lifestyle change, we don't operate on patients whose weights are rising.

We want to at least make sure we don't want them.

We'd love it if they plummeted down there.

Sometimes people do so well.

They don't need a surgical intervention.

They make the changes, they see the changes.

But the biggest problem is if they get, in my opinion, if they get prescribed a medication that, as you mentioned, it slows down your GI tract.

It causes some gastric delayed emptying.

So the stomach doesn't empty as fast, gives signals to the brain that you have early satiety and you're full that they don't combine that with some dietary education.

We have nutritionists, dieticians in our office, bariatric nurses.

We have several practitioners.

We have three partners and a nurse practitioner to help with that.

In my opinion, if you do not combine the dietary and lifestyle changes with the surgery and or with the medicine, you will not be as successful as you could be and it could be potentially dangerous.

Not eating is not a great way to lose weight.

Appropriately.

Eating and guiding them is the best way to lose weight.

And if you don't change your dietary habits, if you don't change your activity and exercise habits and you stop that medication, you will regain most likely all of your weight and then some.

>> In my experience with and I'm as guilty as the next person.

But taking medications long term, you're right at it for that first year.

The second year, you're kind of not as enthused.

And sometimes even by the third year, you're tailing away.

In your experience, have you seen that with some of the other weight loss oral or injectable medications?

>> Right now we just have injectables.

Orals are on the horizon, so there will be a blip in those prescriptions in the very, very near future.

And I think they can be a wonderful adjunct, adjunct to weight loss surgery.

I think the combination of using medications and then doing surgery, or as an adjunct to persons who might have problems after surgery is a wonderful thing.

But I think surgery is still a very important aspect of the weight loss journey.

And as you mentioned, a lot of people don't want to or can't really stay on medications forever.

If you're a diabetic, you're most likely going to have to be on medications for the rest of your life.

Same thing with these injectable medications.

If you stop these medications and don't change anything, you will invariably will regain that weight back.

>> The biggest concern I see with excess weight is getting back to what we talked about before about the metabolic syndrome, which is a very real problem.

Patients who've undergone bariatric surgery do we still have to worry about the metabolic syndrome, or is that, for lack of a better term, removed and omitted?

>> Well, if they are successful, and usually we like to see patients lose upwards of 75% of their excess body weight.

And I think we can help them attain that with a with a really disciplined program.

My patients, I want them to be my patients for life.

I don't want to operate on them and send them on their way.

I think that's bad medicine.

And I and I invariably like to see them.

Initially.

They get seen by us immediately post-op one month, three month, and then in six month intervals.

It helps keep them on on task and helps guide them if they stray.

And we check their laboratory values at all those subsequent visits.

You need to be on vitamins for life after bariatric surgery, especially if you have a gastric bypass, which has some mild malabsorption and some malabsorption of vitamin iron, some vitamins, iron and calcium.

If you don't take those supplements, you will have long term complications.

And those and I don't know, a patient who wouldn't trade, you know, a dollar a day worth of vitamins for the injectable insulin, that really uncomfortable CPAp mask.

They're hypertensive meds.

We can really make people healthier and sustain that long term.

>> What is your big go to procedure for patients coming in for weight loss?

Or is there any or do you have a variety of things for the patients?

>> We offer a purely restrictive procedure, which is called the gastric sleeve or laparoscopic gastric sleeve.

It ends up making your stomach look like a little swoop of a small banana, and it removes about 85% of the stomach.

And that's purely what we call restrictive, where it limits the amount of food you can eat.

It gives feedback to the brain that you're full and you eat less.

And then there's a combination procedure that we do called the Roux en y gastric bypass.

And that creates a small little pouch about the size of an egg, and then a bypass of your small intestine of about 100cm or so.

So you have mild malabsorption with some with restriction either operation I'll offer to my patients unless I think it's wrong medically.

>> What about the banding procedure?

>> Well, I did the band initially 26, 27 years ago.

And then when I started our practice 25 years ago here in Lexington, we elected not to do that.

It we just didn't think it was the best operation.

Then a couple different bands came on the market some years later, and we started doing it, and then I realized why I didn't want to do it.

It is purely restrictive, it is removable, and the band is touted as a removable, reversible bariatric procedure.

But it wasn't touted as the explantation rate.

The removal rate was upwards of 50%.

Yeah, I mean, I took out four bands this this month already or will take out four in the month of February, and I haven't put one in since 2012.

So they're coming from all over, from usually places that have placed them in the last decade or two.

It's putting a piece of artificial material around a mobile object, which is your stomach.

And it's just it was initially a wonderful idea.

It was purely restrictive, and there was too many complications related.

>> To, well, the horse was a wonderful idea for getting around, but I think we've got better things.

Slightly, slightly.

So who's not a candidate for bariatric procedure?

>> A person who doesn't want to follow up or make dietary changes.

So that's not a good candidate for bariatric surgery.

We don't operate on anyone who has any nicotine ingestion within 90 days.

They don't heal.

Right.

They it makes no sense.

If you want to become healthier and you still smoke cigarettes or dip tobacco.

So someone who doesn't want to make the changes right out there, they're not a good candidate.

Yeah.

Medically, we have to individually evaluate who is a good candidate and who is not a good candidate.

You need to have for surgery.

You need to have a BMI over 35, so about 75 pounds over your ideal body weight with co-morbid conditions of heart disease, hypertension, sleep apnea, diabetes or a BMI of 40, which is about 100 pounds over your ideal body weight.

Without comorbid.

Those are surgical candidates.

We want our patients to be ambulatory.

We're operating on Bedbound patients, and Non-ambulatory patients is unsafe.

Their risk of pulmonary embolus and complications outweigh the benefits that we can give them from surgery.

And you have to understand and appreciate what we do, what you need to do.

Like I moved from Los Angeles, Kentucky, and there's a lot of people in this state who are undereducated, impoverished.

They might not been able to go to school, they had to work.

And we have a lot of patients who can't read or write, but they can understand they're intelligent people.

They weren't given those opportunities.

So we can operate on people who might not be able to read or write or, you know, person who might be blind and can't read the pill bottles, but they have to just have some help and understand the changes we need to make.

>> I only have about 30s, so give me a quick yes or no.

Should we be doing these procedures on kids?

>> I think that's.

>> A have you come back and talk about it another day?

>> Well, yes.

Under a multidisciplinary program with a psychologist, with the psychiatrist, because there's a lot more changes above the head, above the shoulders that need to be addressed than below.

>> I sure would like to see us instead of talking about all the stuff we can do, let's prevent them from getting too much weight.

>> That's the worst part.

We have increasing risk of rates of obesity all over our country.

>> Yeah, I think we're missing the boat on something.

>> Well, we got rid of PE in most of our high schools.

That doesn't help.

>> Yeah, that'll do it.

[MUSIC] Josh, thank you very much for being with us.

Thank you for having me.

And thank you for being with us today.

[MUSIC] I hope that you have a better understanding of the importance of a team approach to managing weight loss and the complementary relationship between operative and nonoperative treatments.

If you wish to watch this show again or watch an archived version of past shows, please go to ket.org Amanda Mays Bledsoe.

If you have a question or comment about this or other shows, we can be reached at KY at ket.org.

I look forward to seeing you on the next Kentucky Health.

But in the meantime, please take a look at that plate that you have.

Make sure it's not overflowing with food.

[MUSIC] Make sure you put that donut away.

Put down the remote, get outside, do a little exercise, try to stay healthy, and try to stay away from people like Josh so he doesn't have to cut on you to make you feel better.

Absolutely, absolutely.

Look forward to seeing you again next week on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.