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Presented by the El Paso County Medical Society and hosted by Kathrin Berg Obesity increases the risk of heart disease, of diabetes and many other medical issues.

For most people, diet and exercise has not always worked.

There is a current trend.

I'm sure everybody's heard about them.

We're going to talk a lot about it tonight the weight loss medications.

But the jury's still out on what the long term effects of that is.

So bariatric surgery might be an option for you.

This evening's program is underwritten by Providence Medical Partners, and we want to say thank you to the El Paso County Medical Society for bringing the show to you for 28 years now.

I'm Kathrin Berg and this is the El Paso physician.

Neither the El Paso County Medical Society, its members, nor PBS El Paso shall be responsible for the views, opinions or facts expressed by the panelists on this television program.

Please consult your doctor.

Thank you for joining us to topic today is slimming down for a stronger heart.

I know that we talk about obesity.

We talk about people who are overweight.

And a lot of times it's like, well, I just would look better.

We're not talking about looking better tonight.

We're talking about how to be healthier, how to slim down for a stronger heart.

So thank you for being here, Doctor Clapp.

We were just talking.

You said this is probably the seventh show you've been on.

And you were with us back when we were at the UTEp studio, and so that's probably like 26 ish years ago.

So thanks for sticking with it.

But we have Doctor Benjamin Clapp here, and he is a general surgeon specializing in weight loss.

But again, you do all kinds of surgeries.

We also have Doctor Ricardo Kosturakis, he says, you know, if you can't really say it's a Costa Rica and just it's a nice feeling in your, in your mind, but you are an interventional cardiologist.

So we're going to talk a lot about prevention and how things go on in the world of cardiology.

But with that being said, Doctor Clapp, again, general surgery.

Yes, we're talking a lot about weight loss today.

How is your all day, every day in the role that you're representing today?

Like what do you do all day?

How often do you see patients, how often do you do surgery, etc..

So I've been in El Paso for a long time, and I, I went to Coronado High School and spent some time even at UTEp, and I went to med school at Texas Tech.

So I've been back in practice for 19 years, and for that 19 years I've been a bariatric surgeon, and also doing general surgery.

So what bariatric surgery is a better term for that is weight loss surgery.

And, I focus on things like gastric bypass, gastric sleeves, revisions and other kinds of operations.

Now in El Paso, you can't really do that full time.

There's not enough volume for that.

So I do general surgery.

I still do for gut hernia, gallbladder.

And my daily life is doing things like that.

Operating operate four days a week.

But, I just became a partner with, Tennant with, there, you know, them at hospitals, Providence and especially the mobile campus.

It's been a real positive change.

I left my private practice after 19 years and started on May 1st.

I'm happier every day.

So, I get to just take care of patients, not have to worry about the business aspect of this.

So I'm really happy to be here.

And, I'd like to talk about obesity.

It's my is one of my chief research interests is when my chief interest in my practice.

And you just can't be a physician in the United States today and not have to deal with it.

So I think it's really important.

I'm really excited to hear what the cardiologist has to say about it, too.

Excellent.

We're going to talk about causes today.

It's not just over eating.

There's a lot of stuff that's involved too.

So, I would love Doctor Kosturakis if you can explain again, you're an interventional cardiologist.

How is that different from a cardiologist?

How is that different from the other types of cardiologists that you hear about out there?

Yeah.

So, general cardiologists, are specialists that do a single specialty or fellowship in cardiology.

And within cardiology, there are multiple specialties like electrophysiology, interventional cardiology, heart failure, cardiology.

And we sub specialize in special more specialize areas within the cardiology field.

Interventional cardiologist perform invasive procedures or angioplasty, traditionally of the heart in the corner arteries but also the peripheral arterial system legs, arms, carotid, mesenteric, vasculature in the in the recent past, interventional cardiology has grown significantly.

And now there's a, sub subspecialty of interventional cardiology called structural interventional cardiology.

Yeah.

So now valve replacement, repair of congenital defects, and implant, different devices to treat different cardiac conditions are done with minimally invasive surgeries or interventions and don't require open heart surgery like they did 20, 30 years ago.

Okay.

So specific tonight, when you're looking at cardiology and then you're looking at people who are and again, we can talk about overweight, obese, morbidly obese, etc..

When does the heart start feeling the stress when it comes to people who are overweight, maybe we can talk about we can introduce BMI.

I think there's a lot of these, words that that are thrown around that people don't really know what they mean, but because we're talking about obesity and cardiology tonight, when does it become an issue?

I think there are I separated in two different problems.

The obesity itself is a problem on its own.

Patients develop volume overload.

They develop increased intra cardiac pressures.

Their chest is bigger, their bellies are heavier.

So it takes extra effort for the heart to do its regular work.

But patients with obesity and morbid obesity are also at risk of developing a lot of risk factors that result in heart disease.

Over time, high blood pressure, high cholesterol, diabetes, sleep apnea, and other problems.

Okay, so it starts affecting patients right away.

Those long term effects of cardiovascular disease, heart failure, blockages in the arteries happen a little later because they're related to those risk factors of the physiological changes in the heart.

And the rest of the body occur immediately And I'm going to talk, think in the back of your head that when we start losing the weight, how things start reversing in the time frame on that, in the meantime, everybody's hearing about this and I want to make sure I say these right.

The GLP's, that is the weight loss drugs that are out there right now.

And, we talked a little bit prior to the program starting that I thought, okay, is this a trend?

Is this going to go away?

And you said they're they're probably here to stay.

Stay.

And at this point, they're not it doesn't seem like research is going to be too negative down the road, but just in general with the role that you play and what you've been seeing and patients that are coming to you and people ask you questions a lot.

What is it that you can say to to folks listening?

Well, I think what we should do is define it first, right?

So it's a glucagon like peptide.

So it's a it's a naturally occurring hormone inside of our body.

A GLP one GLP one receptor agonist is a medication a drug that we've designed to work in that system.

And there's about 14 different kinds right now.

There's three that are generally available on the market right now.

They're all injectables, but they're working very hard on making oral, formulations.

So you can take it by mouth.

So it's something that we see already we learned a lot about these gut hormones and the interactions in between the gut and the brain.

And how that's controlled during bariatric surgery.

Because as we modify the gastrointestinal track, you know, we look at things like GLP one or we look at ghrelin or we look at other hormones that interact with the neural hormonal gut axis.

Right.

So GLP one receptor agonist are a natural byproduct of that.

We did so well with them.

It's actually decreased the numbers of bariatric surgery because they work so well.

But we have to look at the limitations and the side effects and what we think is going to happen with these long term.

They're phenomenal drugs.

I use them myself in my practice either before surgery to get somebody to a save for weight or after surgery if they're gaining a little bit of weight or just if I want to manage their weight just by that, just naturally, because they're eligible to take a GLP one receptor agonist at a BMI of 27, its normal weight would be 25 and 27.

You can start medications like that.

The big issue right now with them, though is the cost right.

And accessibility.

And that's not going to change anytime soon.

But they're they're great.

I guarantee the cardiologists use them too.

They're they're they're phenomenal drugs, very low side effects.

Mostly people will feel nauseated.

Maybe some constipation.

They it can it can be very, hard to tolerate.

So about 7% of people just can't take them.

But the average person on a GLP one receptor agonist will lose 10% of their total body weight.

So for 200 pounds, you can lose 20 pounds.

And, about a quarter of patients, 25% of patients will lose 20% of their total body weight.

That's really good.

That's 40 pounds of something.

That's 200.

So here's a question that in my head I'm begging to ask, right.

You lose the weight.

And then is this a medication that they will be on.

Not forever but for forever.

It is.

It is.

So it really is not.

I'm going to lose the weight.

I'll be fine.

And then and maybe we can talk about how people have been playing with that.

But you know I yeah, for a while.

That's a great point.

You know.

And it is intended to be forever.

Right.

But on the other hand, my cardiologist has put me on two different blood pressure medications I'm going to be on forever.

And I'm okay with that because I don't want I have a stroke.

I want to protect my heart.

Right.

So it's I don't see those as deal breakers.

Now for weight loss surgery.

We have to work out the pathways about postoperatively because we have a tool like weight loss surgery.

But we can add these medications.

Do we need to run a forever?

Can we do a lower dose?

Can we do them every other week.

So those sorts of things need to be figured out.

But but the drug is intended to be used forever.

Okay.

So this leads me to a question for the cardiologist.

So and I love case studies I think case studies are easy for people to understand.

Well, this person this is the situation.

And I'm going to say let's not work with BMI because I think that's hard.

But let's say someone who is 200 pounds and they're five, seven, five, eight, so that is obese.

When is it morbidly obese and when we want to do the calculations.

And the reason I'm asking is if they're able to to lose the 20 pounds.

So they were 200 pounds.

Now they're 180 as a cardio ologist.

When and how does that start helping with the heart you were talking about?

And I love how you said it earlier.

Volume overload.

And that's volume blood.

You're carrying extra stuff around.

Your heart's working a lot harder to just get out of bed, go to the bathroom, walk around the hall, etc.

when does that start decreasing?

And and issues?

You can see changes right away with the first few pounds of weight loss.

Blood pressure is one of those things that you can see linearly decrease as weight decreases.

Every 5 to 10 pounds of weight loss would will result in about five points.

Dropping your systolic blood pressure, in the physiological changes are also linearly with weight loss.

As the weight starts coming down slowly, the patients feel better, they can breathe better, they can exercise more.

Their functional capacity increases their blood.

Their plasma and blood volume starts decreasing right away as well.

And, the the they go.

It's a slow process because weight loss can be slow.

They're not going to lose 20 or 30 pounds in one month, but two, three, 4 pounds per month sustained over a year.

The patient will start feeling much better immediately within the first couple of months.

Okay, so this is perfect.

This is great.

This is like a great volley back and forth.

Going to the doctor.

Clap now.

And let's just say we have a patient that for 20 years has been obese, has tried everything.

Maybe, you know, has tried a little bit of these weight loss drugs too, but they really do need a bigger intervention.

So we're looking at maybe bariatric surgery at this point.

What has been the questions going into the bariatric surgery, the pre-op questions that the prep questions like, you know what.

Let's look at this in six months.

Until then, you know, talk about how and I know everybody's different.

I'm in full respect of that.

But throw out some some things that you guys have dealt with.

So first of all, you said the patient had obesity for for 20 years.

I would like step back and correct that the patient suffered with the disease of obesity for 20 years.

It's a disease okay.

And so what we have to think about is it being a disease just like diabetes, heart disease or hypertension is a disease or hyperlipidemia.

And so when you have this person that has a disease, we have different modalities of therapy.

Right.

And we know if somebody comes into your office and they're diabetic and their blood sugar is out of control and a hemoglobin A1, C a 13 or their sugars 400, you're going to hit them with like really big medications and try to get that out of control.

But they come in and they're you know, they're just a little out of control.

Their hemoglobin A1 C is like 6.7 you know.

Yeah they're a diabetic.

But you're not going to just jump to insulin right.

You're going to start with like a first light therapy like metformin or something like that.

So obesity is kind of the same thing.

Are we going to jump right to surgery.

Right to some, you know, which, you know, some people think is an aggressive therapy, I don't I it's probably because I'm a surgeon, but but not everybody's going to fit into that same pathway.

Right.

So we have to look at where they are in the stage of their disease.

We have to look at how bad the disease is affecting the rest of their body.

And we have to look at our available therapies.

So maybe it will be one of these medications.

Let's try that.

First.

Let's see what happens.

If they're one of those few people that can get a 20% total body weight loss.

That's awesome.

That's great.

So I, I was good at surgery, but it's really good.

And it might be enough for them.

But if they if they're heavier, if they have a further disease progression, it might be better to intervene with something a little more, aggressive.

Again, just like diabetes or just like cancer, you know, just do one thing and that's it.

And you're never gonna do anything again.

If you can't get them control, you're going to add another therapy, right?

So I want people to think of the first of all that obesity as a disease.

It's been recognized as such by the centers for Medicaid and Medicare for since 2012.

And we know enough about it now to to say that confidently.

But we also want to think about progression of disease, escalation of therapy and things like that.

So we don't just jump to one thing, okay.

So when they're coming to see the cardiologists and they're thinking, okay, I, I'm, I'm breathing harder, fine.

Maybe I'm out of shape, maybe it's my heart, maybe it's the obesity, etc..

When is it that you find a time to send the patient over to Doctor Clapp for true intervention?

I think it's important because he probably sees the patients in their later stages of the disease.

I tend to see them at the very beginning.

A lot of times I see patients that have been suffering from obesity for 15, 20 years, and I'm the very first one to address their disease.

They've been seeing doctors for years, but no one has really thought about, hey, let's do something about you being so overweight.

Right?

So I always address their weight through BMI and their obesity, and I always give them the option of lifestyle changes.

I always reinforce how important it is because that's we're probably going to talk about if you go on these medications for two, three, six, 12 months, lose weight and then come off but your lifestyle is the same and you haven't made any changes in your habits, that weight's going to come back.

--Precisely to your point.

So diet exercise are incredibly important.

And they also make patients feel better.

So we've thrown out the word this is my my bad.

We've thrown at BMI a couple of times.

So body mass index.

And Doctor Kosturakis If you could explain what that is and how people like literally that are listening right now, then get on their phone and figure out what their body mass index is.

So explain what that is number one and how they can find out where they are.

It's a patient's weight in relation to their height.

So if you're short and heavy your BMI is going to be bit, higher than if you're tall and slender.

And we use BMI because it's easy to calculate.

And that's what all the studies used to measure the severity of obesity in the later in the last few years, maybe decades, we've we've also been focusing on not just BMI but also abdominal adiposity and abdominal fat.

Oh let's do talk about that.

So waist to hip ratio.

It's also very important to to know.

So with those listening BMI.

So if you want to go to any search engine just put on there "BMI" Or "BMI calculator" Thank you.

And that's a body mass index calculator.

But I think BMI calculator you can get it.

And so you can kind of find out where you fit on that.

And and Doctor Kosturakis I love that you said this.

So there is also waist to hip ratio.

Is that what you said.

So there is because it's not perfect.

It's not a perfect science.

Like I have two kids at the same age.

One was a rock and the other one was a feather, but they looked exactly the same.

They were the same, you know, just this is a whole different thing.

Abdominal weight, abdominal fat.

How is that calculated?

And I and I'm embarrassed because I don't know much about it.

And doctor, clap if you want to throw that ratio for that.

Okay.

I mean you could like literally just what measuring waist hip that's just in inches and ratio.

I mean we can get pretty complex with very simple tools.

Like there's a lot of scales that are commercially available that will tell you your fat free mass, your lean muscle mass, your fat composition.

And most gyms will have a scale like that.

And interestingly enough, when we look at GLP one receptor agonist versus surgery, we see protein loss in both.

We see lean muscle mass loss in both of those, which is why we kind of want to focus on high protein intake when people are in that rapid weight loss period with the medications or the surgery.

And we see a greater effect of that on surgery from surgery than we do for the drugs.

So those are sorts of things we have to address as we start using medications like this.

As far as long term side effects, there's been some reported issues about thyroid cancer, pancreatitis, things like that.

The pancreatitis, I think is a more of a real issue.

I don't know what your experience has been with these medications, with these medications, but they're still very, very small numbers right now.

And it's saying, yeah, if you take people out one year, only about a quarter of them are still on medication at one year.

So there is something going on there that we have to think about, whether it's the injection once a week that they don't like, or maybe just the cost, or maybe they just fall off of it.

So what I would say about these medications is they're first generation.

And as we see the second and third generation come out, the combos come out, I think I think the sky's the limit with these medications and they're great.

I think they're gonna change our society.

I think they're going to put a lot of doctors out of jobs.

I mean, when you look at the downstream effects of obesity and we start using these, our children, you literally are getting rid of coronary artery disease.

You know, diabetes, hyperlipidemia, all these strange effects, effects, alcohol consumption, it decreases alcohol consumption.

So the downstream effects of these medications are going to be astounding.

I think they're going to change our society.

Interesting.

So I can't wait to see what's going on in the next, I don't know, several years.

I will tell you.

I don't even know if this is appropriate to bring up or not.

I'm 58 years old, been through menopause, and women our age just gain the extra 10 pounds and they just kind of hang out there.

And so I do have friends of mine my age, exactly same situation that are taking these weight loss medications in my head.

I'm like, if you just, you know, walk around the block a couple of times, you lose that 10 pounds.

But that's me talking.

And I know that's judgment.

And the reason I'm saying that is because I know I've been judgy you about it.

I thought my my process of thought has changed quite a bit since I first got that.

So when we're looking at bariatric surgery, because before these weight loss drugs came in, that was a judgment, right?

How is it that that enters mentally when patients come to you?

It's like, okay, well, you know, I'm 30 pounds overweight.

I'm not morbidly obese, but I'm obese I'm, I do have my cholesterol, etc., etc., etc.

I would love for you to just go through a conversation with a patient that comes to you and is contemplating whether or not they want bariatric surgery.

Well, so that's a great question because essentially almost everyone that comes to me nowadays has been on one of these medications and has tried it.

Okay.

So they, they've tried it and they didn't have the results they wanted, or they found it expensive or hard to get.

And so it's very, very common that most of my patients have already tried this.

And so I think what we're seeing, again, is, is like, you said, you know, we're seeing the or he said that I'm seeing the extreme or the, the later in the disease process.

So, so for me that that's fine.

I'm very comfortable that the patients tried everything including these new medications.

Now let's go ahead to to the therapy I can offer, which is surgery.

Right.

And again that's not for everybody.

We, actually operate on less than 1% of people that are eligible for it in the United States.

But say that, again, you operate on less than 1% of People who are eligible.

Yeah.

Yeah.

And it's funny because, insurance coverage has gotten better.

About 80% of people are insured for this, but they just there's a lack of access.

There's a lack of understanding about it.

So so it's it's almost comforting that they've tried everything.

And now they're going to come to me.

Now, I don't want to say the surgery is the last resort.

It's not but but I like that the patients have invested time, effort, diet and exercise and now medications.

And then if they need my help, then I can help them.

But if you're 350 pounds and you lose 20% of your total body weight, you're still to 275.

So you may still have health effects from that.

So I'm okay with that.

That's fine.

Try it.

And then even if even in the best case, I might still have to be there to help some people.

So talk a little bit about and I'm going right into it just because you somebody now has had the surgery and there is different life change that they have to do.

There's different ways that they have to eat.

There's different supplements that they have to take.

Talk a little bit about that.

And then I'm going to ask another cardiology question.

But I want to come back into the differences between the gastric sleeve and the bypass surgery.

What has you know, I want to say there is one that was used a lot more before, and now it's been taken over.

Sure I can talk about that.

Yeah.

So after surgery, patients do have to commit to a lifelong change.

Right.

And then it's going to be a lifelong adoption of a new, healthier lifestyle.

Some people will say surgery is last.

The the, an easy way out or it's the last resort.

And I don't want people to think of it that way.

If you needed a I mean, we're seeing less and less cabbages or coronary artery bypass grafts, but when he really thinks that's the best thing for a patient, he's going to send it to them, but they're still going to do it.

Right.

And those patients don't argue, say, well, I don't need a heart bypass.

I can do this on my own.

I just need diet, exercise.

So we need to think of like a gastric bypass, for example, in those kind of terms, you reach a certain point that no matter what medication we give those patients, it's not really going to be enough.

And so at that point, it becomes a life saving effort.

But the patient has to be willing to adopt a new life, healthy lifestyle, a new diet.

They have to be able to diet and exercise, rest their life and take vitamin supplementation rest of their life.

So it's really important.

So here's the ugly question.

When they don't take care of themselves after the surgery, what are what happens is, is this now something that cardiology comes back in.

Well, the most common thing that happens, some of these are great.

If somebody just doesn't it just doesn't want to follow the program.

The most common things are going to gain weight again.

But they can't have things like vitamin deficiencies.

Or they can have things like, very rare but very serious vitamin deficiencies or protein malnutrition generally.

It's going to be weight regain because they're going to go back to their old diet But I have seen other complications like that.

Okay.

So as the cardiologist that comes to be, and I want to stay on bariatric surgery for a little bit still.

So now this is someone who has been through the surgery, maybe we can look at two different individuals, one that is doing everything that they should be doing.

They are a class A patient.

Everything's going right.

And there's one that's not.

So now you are the guy dealing with.

And the reason I say this too, is that people who are listening is like, oh, I'll just get this and I'll be done.

It's not the case, and it's not ever the case.

So I'd love for you to kind of walk us through someone who is doing everything they should be after the surgery and someone who's not, and how that affects their entire cardiology system.

So if they're doing everything they should be after the surgery, they're losing weight, exercising, dieting, their risk profile should decrease over time as their blood pressure comes down and glucose comes down.

Lipid levels, decrease.

But some just don't.

Some lose the weight and and still hypertensive.

They still have high cholesterol.

And just because they lost weight doesn't mean they're risk free.

So I still continue to, you know, check their levels once or twice a year.

Recommend medication if appropriate, to maintain appropriate levels of glucose, cholesterol and blood pressure.

And if the person had surgery.

But they're not following any of the, of the recommended therapies after the surgery.

They're just back at the beginning.

So starting over again, let's talk about your habits, lifestyle, about what you're eating.

Are you exercising?

Are you eating at home?

Eating out?

Let's talk about medications again and just continue to check in.

Cardiology.

We see a lot of, most of my patients.

I continue to see for the rest of their lives.

So I have a long time to continue checking and reinforcing the importance of appropriate lifestyle changes.

Okay.

And when do, if any, and I'm thinking about specifically cholesterol because I feel like statins, there's always medications out there, not the weight loss medications, but medications that help with hypertension, that help with cholesterol, that help with this and that, and the other.

Are those any different in patients who have had bypass surgery and or sleeve surgery?

And again, I have or is that the same for me?

Yeah.

So I mean, to go back to the previous question, I that's the person that's coming off track.

I would put on GLP one again.

Okay.

Because there's no reason not to use it after surgery.

Okay.

But there's no reason to use it.

Not not does it have to be okay okay.

So they've had the surgery.

They can't go on this medication.

Yeah.

But as far as other medications I mean we will generally cut back some medications.

But there's going to be things where the cardiologists will look where we're giving this medication, where maybe a renal protective effect, like a, you know, an Ace inhibitor or something like that.

Or maybe you have this bad family history of hypercholesterolemia.

So we're going to continue to treat your, you know, that you might be able to draw some of those back, but we can't change what's happened in the past.

And we can't we can prevent progression of disease.

But like if somebody's already got a bunch of plaque buildup in their arteries, that's not going away.

So we still need to treat that.

So so what I like to do with my patients is get their doctors involved, you know, let them.

We need to co-manage this because we're going to there's going to be some things that are going to get better and maybe even go to remission.

But there's going to be a lot of stuff we still have to manage.

So I'm going to ask you this question, cuz I know on previous shows that we've done it always fascinates me how you describe, the two different procedures that are most popular the gastric sleeve.

Let's talk about that and then how to talk about the bypass surgery.

So which one do you want to pick first.

Well, the most common operation in the United States is gastric sleeve, ok And so what we do with the gastric sleeve is we respect a portion of the stomach.

So the stomach and the bowel remains in continuity.

But we essentially trim down the stomach through about 80% of it.

So think of a garden hose.

It's about this long and about the thickness of a garden hose.

Great operation.

It's it's a lot safer than the gastric bypass.

But these numbers are really you know, like less than 1% sort of risk factors, from surgery, but but see, people see it as simpler, easier.

So it's become adopted more the gastric bypass, on the other hand, has been around for about 65 years.

And what we do is we make a very small stomach of the upper portion of the stomach, and then we, divide the intestine, bypassing it, the older portion of the stomach.

And we bring that up, creating the new.

And that's the most is or connection to the gastric pouch.

So, so food goes in, but it bypasses the old stomach.

So that's kind of stood the test of time.

We know it's ins and outs.

We've done you know hundreds of thousands these over the years.

It's been around forever.

It's a great operation.

Still it's a couple of other operations that we offer.

There's one called the one that has the most is gastric bypass, where we do the same sort of thing with one connection.

Step two and there's a thing called the duodenal switch procedures, which I do also, which are essentially you bypass the intestine.

So it's more of an intestinal bypass of the gastric bypass.

They're all done with the robot with four little holes.

Five little holes are all about one night in the hospital.

They all have about the same safety profiles of gallbladder surgery, so.

Oh.

So yeah, I love doing them.

Yeah, that was a surgery I was going to ask you about a couple of months ago.

There was somebody that needed their gallbladder out.

Again, general surgery, but also, dealing with weight loss surgery.

So here's, are there are there any patients that have certain conditions?

And again, you do do a full follow up and pre-op and everybody else, there's certain patients that simply should not have bariatric surgery.

Well, there's.

Right.

So that's a great question.

I mean, it's kind of a loaded question.

Yeah.

We do tend to it is.

But I thought, you know, we do tend to I mean, most people we can offer something, but there are a couple of conditions where we really don't want to do surgery.

So, for example, someone's an active substance abuser or whether it's alcohol or any other illegal substances.

That's not a great idea.

People with active psychoses.

Not a great idea.

We shouldn't be doing those.

Okay, medically, I mean, we have to look at that and look at their medical risk and get our colleagues involved.

But, I mean, I've done operations on people on the transplant list to get them to a transplant, you know, so they can safely get, like, a heart.

I mean, not a heart, like a kidney or, or a liver transplant.

So we can do those.

They are higher risk.

But but we very rarely turn people down for medical problems.

It's more for other reasons.

Okay.

That's really good to know.

That's really good to know.

Okay, Doctor Kosturakis, I keep looking at your name, making sure I say it right.

In general, we've been talking.

So again, as an interventional cardiologist, am I right in saying that you're trying to do a lot of prevention of what's happening?

I know you're I know you're intervening in what's happening and going on.

So talk about some of the things bariatric surgery aside that you and let's say also, the medication aside, since that's still kind of new, but just old school.

What are some of the interventions that that you have done?

And when I'm thinking that, it's not necessarily about obesity, but when we're looking at putting stents i maybe it is a little bit because obesity or because of cholesterol, again, I get all these core mobilities that that are together.

What are some of the things that you've had to deal with and kind of specifically in El Paso?

Because I know El Paso, we've seen it.

Unfortunately, we do have a higher obesity right here than many other cities, and we have a very high prevalence of diabetes.

So just kind of on that train of thought.

Right.

So I'm a interventional cardiologist.

So I train interventions, I perform interventions, but I do that once a week.

So 80% of my time I spend in the office seeing patients practicing a combination of general cardiology and interventional cardiology.

So this is something I address on every patient.

And we're talking about, you know, when is a good time to intervene?

I think it's a as soon as we can and as soon as insurance will allow us to, because it's a cumulative effect.

The longer you live with severe obesity and risk factors, the more likely you are to develop heart disease.

So if we intervene early in the disease stage, then the risk of having heart disease and multiple risk factors down the line actually decreases.

As far as cardiac interventions related to obesity, I don't think there's much obesity can definitely complicate my interventions because a lot of the procedures I perform are done from the femoral axis.

And there are patients that are so obese that I cannot perform procedures because the risk of bleeding is exceedingly high.

So we can take that and expand a little bit on that.

And where I'm going with this is, again, the issues that can happen that may not be in play right now, but the issues that can happen to you when you are obese.

And I guess here's the other question.

Sorry, I keep throwing them out.

So you know what?

We have an audience here today.

I'm going to ask one of you guys to pick up your phone and do a BMI, calculate.

Because my question is, once you get past a certain BMI, when you know you're gaining weight and you're gaining weight and you're gaining weight and you're just not able to lose it.

Now all of my risks are what and again, as a cardiologist that follows a patient through and they're just gaining weight every year.

What do you physically see happening in those patients.

So you start seeing their blood pressure go up I think is one of the first changes you start seeing is hypertension.

I think lipid metabolism takes a little longer.

I think the body is and we haven't talked about lipids at all.

I think the body kind of adapts to it in the first stages.

But once all the rest of the metabolic changes start happening, like diabetes and glucose intolerance, then hyperlipidemia starts becoming a problem there.

Triglycerides started going up, and that just turns into a vicious cycle whether they have high glucose, high lipid levels.

They gain more weight then more weight, results in even greater glucose levels and cholesterol levels.

And so for a layman, which is me, I'm thinking, okay, so my cholesterol is fine, but I have high triglycerides.

Why is that a problem?

That's still a problem.

They're all lipids and, triglycerides, LDL cholesterol, total cholesterol, all those result in when in excessive levels, they all result in early atherosclerosis, which is the disease process that results in blockages in all the arteries of the body, not just the heart.

Now, describe what atherosclerosis is.

It's a it's a disease process, where, initially cholesterol and lipids start to deposit in the vessel walls.

And that results in what we called, intermodal injuries, or also known as plaques.

Plaques are deposits of lipids initially and then eventually inflammatory cells and calcium in other and other molecules that lead to blockages.

Okay.

And those events we actually need to pass know and those will eventually get big enough that they start obstructing blood flow inside of the artery, or they rupture and create a heart attack or, an acute lane event or a stroke.

Okay.

And again, where I'm going with this and I feel like I don't feel like I'm running out of questions, but I'm trying to really bring home the point of it's so easy to gain weight, and it's so easy to blow it off until you at a point where all these things, like you said, are now in play.

It's not like plaques just gonna go away tomorrow.

So as an interventional cardiologist, you have to now go in and atherosclerosis, which I say wrong.

Are you going in there and now stenting, are you going in there and trying to take some of that plaque away.

How are you doing that now that this person has an issue by not dealing with their weight for all these years, different severe severities, you can have mild atherosclerosis and be completely asymptomatic.

That's the person that typically receives medical therapy aspirin, cholesterol, glucose control, blood pressure control.

Once the atherosclerosis becomes significant or severe, patients will have some symptoms.

If it's in the heart, they'll have either shortness of breath or fatigue with exercise or chest pain.

If it's in an artery of the leg, they'll have what we call claudication, which is leg pain with exercise because of decreased blood flow.

Or if it's in the brain, they can have TIAs or strokes.

So as a cardiologist, if it happens in the leg I typically do a noninvasive workup, ultrasounds, pressure measurements in the leg.

And if there are signs of severe blockages, then I do an angiogram, which is an invasive procedure where I inject contrast into the RI, and I look under X-ray.

And if the blockage is severe and the patient has symptoms, and the best way to treat it is by opening the blockage and restoring the normal blood flow.

If it's in the leg or the heart or in the brain.

But that's the neurologist that would do that.

The the brain blockages, the arteries, and the effect is almost immediate.

I, I'd imagine if they're symptomatic, their symptoms should go away.

If they're related to the blockage and be 99% of the time, they do.

So when and I've heard about stents, too i like you have a stent that's put in and maybe eight years later it might be time for another stent.

How common is that?

So, the stents have evolved quite a bit in the last 20 or 30 years.

And now we're in the fourth generation of drug eluting stents.

So one of the downsides of stents is that they reach the nose so they form blockages inside of the stent.

And there's two types of risk.

The doses you can have de novo disease the same process the atherosclerosis that affects your native arteries also affects the inside of a stent.

But there's a very small number of patients that develop this hyper this hyper reaction to the stent.

And then you get stenosis within a year or two.

Wow.

That quick.

Yeah.

If it's just regular de novo disease inside of the stent.

We have we called rates of ten years, 50% of the stents should be open.

20 years ago, it was 3 to 4 years, when it happens because of a hyper, hyper response to inflammation, it usually happens within the first couple of years.

Okay, so I tell my patients, getting a stent is not curing them of their disease.

I'm just using Band-Aids.

I don't take the plaque out.

All I do is put a stent in there.

But once they get a stent, now they have to be on a couple of medications to keep that stent from forming blockages.

So I tell them you're tading one disease for another disease that we can control a little better already a little easier.

So since I'm sitting here listening to you, how can you describe to someone who has no idea what a stent is?

What is the stent doing physiologically in your arteries?

So when when the plaque is severe, it the walls of the vessel have three layers.

The most inner layer is called the intima intima.

And it's a very thin layer of tissue.

But it's very active.

It communicates with your blood all the time.

There's a lot of channels there.

There's a lot of cytokines that those cells release that control how your arteries dilate or constrict and responds in different scenarios.

So in patients that have atherosclerosis, they lose that control of their arteries.

And what happens is those plaques can either stabilize over time and form essentially a calcium shell so they can keep growing.

But the risk of those, plaques rupturing goes down when I use the stent In order to open the blockage, I have to dilate the artery before I in order to treat the blockage.

And when I do that, you cause tears in the inside of that artery, which puts the patient at risk of having a heart attack.

So before there were stents,, we were usin a balloon angioplasty 40 years ago.

You would open the blockage with a balloon, and then 2 or 3, four hours later, they would come back with a heart attack because, the vessel just occlude.

So the stent is a scaffold.

I tell my patients, think of it as a spring in a pen Holds everything open.

Yeah, it's a spring In a pen and then it comes loaded in a balloon.

The balloon is expanded inside of the artery The Stent expands and it has memory.

It retains its shape.

So it keeps the artery open and it keeps it from recoiling.

Now, if I remember right and I could be wrong, are there stents now that have medication built into them?

Right.

So now the great majority of the stents that go in the heart have medicine medication around them.

And what is that medication doing.

It prevents that risk to gnosis.

So that's why the risk the gnosis risk went from 50% and one two years now to less than 50% as long as ten, 15 years.

Okay.

All right.

I'm going to go to some lifestyle.

So, I have some questions here just from shows And we joked, these are my notes from literally the last 20 years on when we did anything with bariatric.

But I would like to talk about you mentioned gallbladder earlier.

Somebody has a gallbladder taken out.

Their diet has to change the amount of fat that they are no longer able to consume, etc..

When somebody has, bariatric surgery and I know you had the different processes as well, what is it that they have to change the diet?

I know that we were talking about supplements, and I remember I just read this thing called dumping that we haven't talked about in a long time, and I don't even know if that's a thing anymore.

It is.

So I think that, like, I think that the greatest change will be the volume of food that they can eat.

So either operation or any operation that we do to them, it's going to really, really restrict the amount of food they can eat.

For example, the gastric bypass pouch is about 30 cc's, about an ounce.

For the sleeve it's probably about four ounces.

So if you looked at something like this is probably about 250 cc's.

So it would be about half of this maybe.

So that's all the food that, that they can can get in there with that.

So volume is going to be the main thing.

And if they try to overeat it actually will punish them a little bit.

They can throw off.

They can feel really uncomfortable.

Now as far as kinds of foods, we really need to stay away from ultra processed foods because most of those are slider foods.

Like think of a bag of Cheetos you chew it up, it's going to go down.

I mean, it's not gone.

We haven't invented an operation that will can't be defeated.

But I love this bag of Cheetos.

But but so I would say stay away from ultra processed.

Find Greasy foods would be a very easy thing to kind of avoid.

So here in El Paso, having carnitas might not be as good as having carne asada right.

It'd be better to have that, you can have things like sugars dumping syndrome.

I tell my patients and describe dumping syndrome.

Sure.

So dumping syndrome is when you eat sugars and your your intestines been bypassed, your stomach can bypass.

So you deliver like this high load of sugar that's been unprocessed into, into the small intestine.

It makes your body go a little haywire.

You know, they get sweaty, have diarrhea, maybe some explosive diarrhea, vomiting, cramps.

Just this feeling of doom.

So, avoiding sugars, usually cutting it off around 5 to 7g of sugar.

A serving would keep you under that.

That radar.

And then I like to I like to think of guidelines.

So I think of white foods, foods that are made out of starch and flour, you know, flour tortillas, white bread, pan dulce, donuts, cakes, pretzels, chips.

I mean, those those really aren't great for us.

We shouldn't be spending most of our calories eating those.

But 50% of what Americans consume is comes from ultra processed foods.

It was in the news actually, this morning.

So, so those are just some basic guidelines that I would give the patients.

Okay.

And that's such a great point.

We talked about the world is in an obesity epidemic, especially America.

Some Mexico.

But and a lot of it is the foods that people are eating.

And I want to say that there is some kind of medical rah-rah-ness going out to, some of the food companies, etc.

but there's money.

It's all about money.

It's, I mean, what does Starbucks sell, right?

There is no coffee.

It's all sugar, right?

And what do they make?

They make billions of dollars of profit a year.

It's it's money.

No matter what happens.

That will never change.

So until people start demanding change, corporations will not change.

So just, you know, thinking about a healthy diet, thinking about learning how to prepare food in a healthy way, thinking about food deserts, you know, where where people have a social economic status a little lower, may not be able to get to a, healthy grocery store, that those are going to be issues that we could address on a public health, aspect, but probably will not be addressed.

Okay.

Unfortunately, and I think there is my goodness, there is, Jamie Oliver, I think his name was back when my kids were still in school, was trying to change the school menus because it's cheaper for the school menus to to process food.

Everything, the pizzas, the everything.

It's there.

I would love to talk a little bit about what both of you see in your disciplines in the next ten years that are positive, whether they're treatments, if there's a way to start changing the mindset of Americans.

And again, we love our tortillas here.

I love them, too.

What do you see in the next ten years in your discipline that could be helpful, but that's a loaded question.

Doctor Clapp knows this question, and I think for you surgery is almost easier, not easier.

But there's tools or different ways of doing things.

And you know we're talking about the stent that are now medicated that how much nicer those are now.

And I don't know when those kind of came onto the market was that a decade ago, something like 30 years or so, 30 years or so.

Yeah.

I think a big game changer are the GOP ones.

They not only work for for, obesity and patients that are overweight, but they also decrease cardiovascular risk and cardiovascular mortality, especially the, semaglutide.

So I think about what the semaglutide.

Yeah.

So I see patients where we're talking about people that don't get to hear this stuff all day.

So I have patients in the office that have had a heart attack or have atherosclerosis in their heart or their legs, and they're not diabetic, but they're overweight.

And that's a perfect patient to start this medications on because they have heart disease.

They have obesity.

And the medications are going to help with both.

So, they are I think the indications are going to expand and the availability of the medications is going to increase.

So I think it's going to be a game changer in the next five, ten years.

We're already seeing some trends in the obesity rates in the last five years.

We think it's because of the GLP ones and greater access to all this medications and bariatric surgery and other therapies.

So I'm hoping that it's going to continue to level off and hopefully decrease.

And also very important, we have to start with, with with kids and adolescents.

Absolutely.

There was a huge freakout when they started approving these medications for, for young kids.

And I just can't imagine how you would be upset about approving a medication that results in weight loss and decrease of cardiovascular risk factors, but be okay with a 12 year old having a BMI of 35 or eating five bags of Cheetos at school, right at school?

Bingo at school.

Exactly.

So it has to be policy changes, changes in the medical and health industry and also a lot more self-awareness.

Agree, Doctor Clapp and you that you see on the horizon for you.

But for for me specifically for what you say for weight loss surgery.

It's it's not, you know, done.

I mean, it's going to change.

Like already we see practice patterns emerging where we do higher body mass index.

And you know, patients that are a lot higher than our normal average average up till now has been about a BMI of 42.

It's going into the 50s and 60s now because we're going to see that the medications don't work on a subset of patients.

So it's not going to go away.

I will be doing just kind of more high risk patients and, patients with more severe forms of obesity.

But I don't think we're anywhere near, like, getting rid of surgery for something like that.

And that's okay.

I mean, again, we have to think of obesity as a disease and the continuum of disease is going to require different treatments.

So we'll be around doing that.

There are some promising endoscopic therapies to done, you know, with, through the mouth, not surgical like opening people up or doing laparoscopy or robotic surgery.

Those are kind of promising, too.

But I think that really it's going to be the second and third generation G.O.P.

receptor agonist that are really going to drive, drive this in the future.

So, I don't want to go off script, but I kind of do, because as a general surgeon and you kind of just mentioned some things that are on the horizon that are that are coming about.

And there was a cardiologist.

I know there's a new way of going through the wrist versus the groin on some cardiology things, and that's relatively new.

So I'd love to just this is where I kind of geek out on what's the Star Trek stuff coming up?

Remember when bones would go over this old.

You guys are too young.

I mean, the obvious thing is going to be a genetic.

Yeah.

Genetic therapy.

So when we start looking at it, the genetic factors that make up obesity start targeting therapy to individuals looking at their genome and maybe even their gut physiology, and their gut, genomics, where, you know, you look at how much bacteria is in our gut, it outnumbers our own cells by a factor of like 100 or 1000.

And so when we start looking at how to really interact with with that, and then the genetics of the actual person in modifying the amount of genetic level, I think that's that's the key.

Okay.

So when we let AI go at that problem, that's probably where it's going to fix it.

You know, I mean AI that might be but all surgeons out of business, Johns Hopkins has been training a, an intuitive robot with an AI, and it just did a gallbladder on a pig completely unsupervised by itself.

I actually foresee in the next 5 to 10 years that I'll be a pilot.

And I'll be watching a robot operate, and I'll be there just in case.

Just like the guy that flew you here from Dallas last weekend or wherever you went.

He wasn't flying the plane.

No.

It is operating itself, Yeah, and that's where realistically, we're five years away from that now on an on a level, societal level, being willing to accept that we, we can't even set full driving cars yet I have one love it.

Let it do its thing all the time.

But, that's going to be that could be done with surgery and probably five years.

But I say within ten years we'll be doing that routinely.

So let me ask this.

In the meantime, as you were talking about just gut health in general, and I feel like it's not talked about as much, but ten years ago, it's like probiotics, prebiotics.

Take this, take that.

Then there was some that were not approved and there's some that were approved in general.

Prebiotics, probiotics.

What are both of you feel about that?

Because it does matter how your gut accepts the food that it's being given, right?

So if we're looking at the guy that eats five bags of Cheetos and he's not got any good gut health versus the person that eats all of his vegetables, well, in general, is that is that a hype?

Yeah, it's I think it's a hype.

I mean, the problem is, is that, you know, obviously probiotics work.

You know, and we have to have the healthy bacteria in our gut and back.

And, you know, antibiotics will destroy that.

And it will kind of mess you up for a little while.

Right.

But when you have over 10,000 different species in your body and we don't know what what which one does what, we don't even know how to culture most bacteria that we find in the soil, we can't even figure out how to culture them to grow them.

We don't know that yet.

So, I mean, that's that's why I think that genetics will be a way to to automate, you know, automated DNA sequencing probably will help, but it's still there's just so much data to sift through that I think we're going to have to give that over to systems that use AI and things like that to to just wade through that, because how do we know what's healthy and what's not?

And if you have 10,000 different, you know, species interacting inside your gut.

So, I mean, I, I whenever I try to prescribe probiotics to somebody, I, I really I'm in a quandary because I don't know, first of all, they're not regulated by the government.

Bingo.

Exactly.

It's like, which ones are the good?

So I just kind of go with the big brand names and hopefully that works for it.

Okay, that makes sense.

Anything you want to add on that.

Yeah.

Similar thing.

There's a bunch of different probiotics.

Some you can find in a refrigerator in their lives.

Some you can find in a little packet or a bottle or, or a liquid, and we don't know which ones are the better ones and which ones are the worst ones.

I think a perfect example is in patients we'd see this colitis, which is, commonly caused by by overuse of antibiotics.

Their gut just goes completely crazy.

They have severe pain.

Diarrhea doesn't go away.

10, 15 bowel movements a day for a long time.

We're giving in different antibiotics, probiotic takes what seems to work.

Space is a stool transfer.

So you get a stool transfer transfer so you get stool.

I've never heard of that.

A family member, preferably you get an energy to get stool on your end, you tube and it restores your.

Yeah.

It takes somebody with a, intriguing me.

So someone who's got healthy stool.

Yeah.

You stick their poop in an energy tube and stick it in their nose.

I guess they could eat it, but nobody to.

Okay.

Yeah, you got to be careful.

We could do a whole show like you got to be careful with the blender.

You like in the cafeteria, right?

I mean, it's got to be.

So.

That intrigues me.

In the idea you were talking about antibiotics, right?

And it takes a while for your gut to get back to normal.

So with the idea when somebody is on antibiotics for a good amount of time and their their gut is just messed up for most people with not taking any probiotics or prebiotics, how long does that usually take for your body to be able to then accept food like it used to?

And we were just talking about, you know, getting your poop normal, if we can say that.

I know that's kind of a whole infectious disease conversation.

That would take a long time to go.

Okay.

All right.

So here's here's a question to we're talking about genetics.

Right.

And I think when I think genetics I think about the word of of of of oncology of the BRCA, a gene testing of this and that and the other.

I know that's also in with other areas of the world, but I feel like if a grandmother had breast cancer, her daughter had breast cancer.

Now they're taking genetic tests and see if their children would also have those genes in the other worlds.

And cardiology in general is that's something that is is thrown out there anymore, or is that I know it's focused on oncology, but I feel like there's a lot of genetic testing of what's happening.

And there's there's a lot of genetic testing going on in cardiology.

And they're trying to look for different vocal snips, single nucleotide nucleotide polymorphisms that can result in a higher risk of having atrial fibrillation, heart failure, coronary disease.

We've found some correlation between certain, genetic mutations and and cardiovascular diseases and risk factors.

But there's not a very strong direct correlation, okay.

And there's not really like a, a reason to be tested, so to speak, like with oncology with cancers are is like that right now.

There are some cardiovascular conditions that are known to be genetic, but not really for like risk factors.

It's kind of rare to find like a single gene to cause one thing.

I mean, so I mean, there are things like that, like cystic fibrosis, but those are actually quite rare.

Usually there's it's multifactor.

It's poly genetic.

So that those are really hard to tease out.

And you touched base on AI earlier.

So when I am thinking to a five years in the future, just by doing these programs here and there, the ways of testing what your children may have even in utero, we had a pediatric program on before, too, and there is ways of testing things out that aren't physically able to see, oh my goodness, I can't think of the condition.

But on the program, the doctor said the patient that he had who was a female and she is now reproductive age, was strongly suggested not to have babies because of the heart conditions that she would probably have because of her own heart conditions.

And it's not really a question.

It's just kind of, where do you think all of that's going to be going in the future?

Well, we'll only get better at it.

I mean, you know, as you automate these, these sort of like the grunt work of it with something like AI, it's just going to get better and faster.

I mean, the one thing I does well is it synthesizes data quickly and it codes quickly.

So if you're using, you know, a computer to, to make a program to, to look for a certain genetic defect or something like that, it codes without, without mistake, you know, a million times faster than human.

So when we, we use it, things like that, that that's what it's good at.

And then people are worried about it.

They're scared of the Terminator or whatever.

But it's like, no, I mean, it's just people freaking out about it.

It's going to take a lot of the grunt work out.

It's going to take a lot of repetitive work out, and it's going to make our lives a lot easier in a lot of different ways.

And this is where it is too, I think AI there's, there's a fear, but I think maybe there is a true horizon coming to.

That's all.

That's all good.

Even with our fix system, when I say that our information exchange system that we have now, it's not AI, but it's a whole idea of what's your information?

You have a son, you have a daughter.

All that's in the exchange.

And you can kind of figure out, okay, what are the similarities, what aren't.

And then AI kind of takes over and then starts matching all together again.

It's a Rubik's Cube type thing In that case to analyze the human genome.

If we had a AI 20 years ago, we would be 100 years in the future.

Right when I was, I was at UTEp and I was working in a lab trying to get to med school and we would we would do this by hand.

There was one PCR machine in the entire department.

And you would like literally do this by hand.

And now it's now you can get it with the Covid test.

Right.

COVID test was a PCR that was done immediately.

So we have 4 machines when I went there.

So they're getting very crazy.

Get a little better.

You know but anybody is more interested in about obesity.

I'm going to give my plug for my symposium Oh yes please do.

Yes.

Is we are having an obesity symposium at the Radisson Hotel on October 3rd.

It's for mainly nurses and doctors who can get credit, whether CME or CCU.

And we have a 7.5 hours of CME or CEU, and we cover all topics from pediatrics, obesity, cardiology, orthopedic surgery.

We have a, a pulmonologist talking.

I'll be talking about surgery.

We have a dietician, a psychologist talking.

So I'd like to invite everybody to that.

And I ask your permission.

But the telephone number that you can call to to get to Doctor Klapp's office is (915) 351-6020.

I want to say thank you so much for joining us this evening.

This I love the the twists and the turns of this conversation.

We got into the weeds.

We did we get into the weeds.

Sometimes it's like you just take that through.

But this is called slimming down for a stronger heart.

And if you want to watch this program again or any program that we have aired here with the El Paso physician, there are three different places you can go do that.

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It's actually on that website.

You can see the logo, the El Paso County Medical Society that, acronym is EPCMS.com And that's a.com.

And then YouTube.

Good Old-Fashioned YouTube.

You see your kids playing on YouTube.

You look at why it is because it's been around a long time.

Youtube.com.

And look up the El Paso physician on there.

Thank you so much for joining us.

I'm Catherine Berg and this has been the El Paso physician.

Thank you.

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