[Music] Lakeland Currents, your public affairs program for north central Minnesota.

Closed captioning is made possible by Bemidji Regional Airport, serving the region with daily flights to Minneapolis-St Paul International Airport.

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Welcome to Lakeland Currents.

I'm Todd Haugen.

Our guests on this edition of Lakeland Currents are from Sanford Health in Bemidji.

They are Michael Joannides who is here with us today as is David Faugno-Fusci.

Welcome to our show gentlemen.

Thanks for having us.

Yeah thank you for having us.

Yeah appreciate it.

You are both certified weight loss surgeons at Sanford Health in Bemidji.

Before we get into that too much tell us a little more about yourselves because neither of you have been here that long, right.

Correct.

Yeah, I've been here for two years.

I grew up in Eden Prairie, Minnesota, so just a suburb of the Twin Cities but I did my medical training at St. George's University in Grenada.

Actually where Dave went as well and then I finished my general surgery training over at LSU and then also in Chicago and then I did a weight loss surgery fellowship in Kansas City and then I did a trauma critical care fellowship in Orlando and then looked for jobs and wanted to come back to Minnesota and so I interviewed up here and really enjoyed the area and yeah so it's been two years of good care.

What a change from Grenada to this.

Were you there very long?

So I was there for one year on the island for training and then we do training throughout the United States your third and fourth year and I did my first year in Newcastle, UK.

It was a Global Scholars Program that I was a part of but Dave he was there a little bit longer.

Yeah I spent two years down in Grenada on the island doing my basic sciences and then the majority of my clinical rotations were in the New York area.

Really.

So is this pretty common in your area of specialty to have done this work in Grenada, that just seems a little bit unusual.

Well it's one of the bigger schools that offer doctors in the US so it is kind of gives you a broader experience of global healthcare is the reason why I went into it.

My dad was actually born in London, England and so that gave me a opportunity to see healthcare in the NHS system, the national healthcare system in the UK, so I experienced that for one year, then I got to see the third world aspect in Grenada you see how that works, and then you get choices of going to the United States or the United Kingdom from our school at St George's and I chose the US, just more familiar with it and my plan was to practice in the United States so that was kind of my reasoning for going to St George's.

Yeah there's a big issue around the country right now with a shortage of medical school admission spots and a shortage of doctors subsequently so there are a number of schools located in the Caribbean and actually around the world that train doctors that eventually go on to practice in the United States.

So both of us had to go through the same training that all the United States medical schools do.

We do all the same exams, there's a special commission that certifies us, we're considered foreign graduates, before we can practice in the United States.

And you've each been here between one and two years.

Yeah I moved here last October from Allentown, Pennsylvania where I was doing my bariatric surgery fellowship so it's been a definite change in pace but we've enjoyed it.

Yeah and the care has picked up quite a bit here, we've had a lot of patients referred to our bariatric surgery program and that's actually how we were able to hire Dave this last year.

So I was two years ago and then we had a lot of clientele that needed weight loss surgery and just needed to reestablish care if they've had previous weight loss surgery and so yeah Dave has been a big benefit having him here.

Bariatric surgery, that's the, is that the medical term for what we're calling weight loss surgery?

Correct.

So there's a few procedures that we do here at Sanford Bemidji Medical Center.

The sleeve gastrectomy is probably the most common one for people to lose weight and that's where we remove 80% of the stomach.

There's no damage done or any tissue rearrangement for the intestines so you absorb things the exact same way, it's really just removing that portion of stomach.

There's a hormone at the top part of the stomach called ghrelin that stimulates appetite, so our goal is to remove that top part of the stomach to hopefully reduce the urge to want to eat, but it'll fit because their stomach's a lot smaller and so that's one of the surgeries.

The other is the Roux-en-Y gastric bypass and that one's been around for many years and that is where we reroute the anatomy.

So we create a pouch of stomach, we attach a loop of intestine to that, and you are restricted how much you can eat but it's also malabsorptive.

And then the other one that we do, well , the duodenal switch is another procedure that's done and it's what I like to describe to patients it's a combination.

So we do a sleeve.

So we take out a portion of stomach and we reroute the anatomy, and those are meant for people with much higher BMI's, maybe in the upper 50's, 60's, 70's BMI range and so, yeah, those are essentially the procedures we do.

Well a little more about those in just a few moments because I have a number of questions about those but, what's obesity and why are we concerned about it?

So basically in the last hundred years or so a lot of research has been put into kind of defining obesity and what we call comorbid medical conditions.

These are things like sleep apnea or snoring which is how most people would refer to it, high blood pressure, diabetes, even joint pain, certain cancers that are related to just carrying excess weight and what we've found over the course of the last 100 years or so is the American lifestyle and modern convenience has led to an increased weight for the population as a whole and we really tried to identify some of the reasons why certain people struggle with their weight, others don't.

And so what we found is that essentially there's what we call a homeostatic set point where your body kind of wants to be in terms of its weight and sometimes that doesn't align with a healthy weight for that individual .

So we do kind of base these off of body mass index or BMI, which is a way of calculating a number based on your height and weight essentially.

It's not a perfect number for every individual.

It kind of is better to apply it to, you know, statistically to a broad population but we do see at higher BMI's, higher comorbidities and shorter lifespan.

So ultimately the goal of a bariatric or weight loss operation or medical weight loss is to not only help you to lose weight, but to help you live a longer healthier life.

Some people are just destined to be a little bigger though, right?

Absolutely, yeah, absolutely.

And so certainly we take that into account, but when we're talking about higher BMI's in the 35-40 plus range it's very rare for someone to be at that BMI and still be healthy.

So there's usually excess weight in the form of fat and other issues going on as well.

Sometimes those of us who are naturally slender, and I've discussed this with cardiovascular docs before, I mean sometimes those of us who are slender think that we're real healthy and everything but that isn't always necessarily true.

True yeah.

There is probably a genetic component but yeah there's definitely a multifactorial reason why people become obese.

So it could be genetics, it could be lifestyle, eating, sedentary lifestyle, not being active.

Our goal in our first visit is to talk with the patient, see if what may have caused them to gain weight if it was something like they've always been a bigger child growing up, then it could be more of a genetic role, what kind of foods they were eating as a child.

But then it could be hormone related.

It could be after a pregnancy you gain a bunch of weight for pregnancy and you're unable to get the baby fat off and so that's where I start to talk to patients, see if it's a hormonal reason, if it's a lifestyle reason.

So that first visit we encompass all of that and so we try to gauge what is the reason that may have made you gain weight.

Is it medication induced?

Some certain medications can cause you to gain weight too, so we talk heavily about is there a medication you did in your early years that made you gain a bunch of weight so then we know kind of able to pinpoint maybe what surgical operation is best for them or what weight loss medication would work for them, too.

Does a person need to see a doc to figure out what their BMI, their body mass index is.

So they can pretty much figure it out by plugging in their height and weight into one of the online calculators that are available pretty much anywhere just by searching for a BMI calculator.

National Institute of Health certainly has one that you can trust but for the most part they're pretty accurate when you do search it online.

One of the things we like to emphasize is that our program is kind of designed to be an all-encompassing program for your health.

So it's not about just getting you in with the surgeon and getting you to surgery, it's about dietary visits with a nutritionist, behavioral health, if there's any modification or changes that can help you to make the changes in your lifestyle.

Certainly exercise and nutrition is a big important factor in being able to lose weight and keep it off.

I think sometimes there's a stigma that going through surgery is like a quick or easy fix for a lifestyle or habit issue and we really want to emphasize that it's not necessarily an individual's fault that they, you know, have gained weight or unable to lose weight, it's a lot of hormonal and biological changes that contribute to it.

And so what we're really offering is kind of a program that's going to allow you to have all the tools necessary to be successful, and if surgery is a part of that then we're absolutely happy to provide that service in the community.

When someone is trying to figure out their BMI on their own do those numbers get given to them kind of in a range that's normal for a certain height.

I mean I'm 6'2 and I weigh about 183 so I have to think for somebody my height that you know 183 might be toward the low end and you may be able to weigh up to 205 or whatever to be still of normal BMI for that height.

Yeah absolutely.

So there's some that are just like a straight calculator where you're putting in your height and your weight but otherwise there could be like a chart that you can find and there's usually it's like we'll go from red to orange to green to blue or something like that and you'll see where you fall on the category.

So certainly a BMI below 20 is starting to get into the range of underweight, 20 to 25 is generally considered a healthy weight, 25 and above you start to be considered overweight and then 30 and above is the category of obesity.

Going above 35 and 40 then we're starting to talk about more severe levels of obesity.

I would assume we could maybe talk about BMI for a whole show but is it different for different genders?

So there is not a difference in the BMI calculation but that is one of the things that we talk about with our patients is that the BMI in and of itself isn't the end all be all, certainly there's a lot in terms of body composition.

Men and women tend to carry their weight differently.

For instance men tend to have more intra-abdominal fat inside their belly, if you think of the classic beer belly or barrel chest.

And women often carry it elsewhere.

So certainly there are differences in the genders but generally speaking with broad based strokes, when we're looking at the BMI, when we're at a point where we're discussing surgery and weight loss medications, the nuances are less important as far as like the overall picture of your health.

Yeah where people carry their weight is definitely key and that's something we look at on the first visit, too.

So if you were somebody that was a very active person, played sports, like an athlete, I've operated on people that were previous military and it's they carry more muscle than they do fat but they may have gained a lot of fat after they finished their military training and so we do tend to see that you're probably those type of patients are never going to get to like a normal range because they probably carry more muscle, so they may stay in that 25 to 30 range, which is technically overweight by the BMI scale, but if you look at the patient if they don't have high blood pressure, they don't have diabetes and they're 25 to 30 of a BMI that's normal for them I think that's going to be safe for them.

So our goal is really to focus on the quality of life afterwards, not really focusing on the weight itself.

But if we do see that they carry their weight in a way that looks unhealthy, that's where we try to focus on that.

So in the order for how this goes when you're consulting with a new patient who is concerned about this issue for themselves what would be the order of treatment that you might prescribe.

You basically first want to find out if they have high blood pressure I would assume and a pre-diabetic condition.

Yeah so often times patients are referred to us by their primary care physician because of their weight and their desire to lose weight.

We're also rolling out a new option for patients to kind of self-refer so they can call Sanford in Bemidji, they'll get in touch with one of our bariatric coordinators who can reach out to them, get their kind of vital statistics so that we know that they are at least in a category where they may qualify for some sort of treatment.

Once they're in the office with us we'll usually meet with them, gauge their interests.

Some people have no interest in surgery, some people want to learn about it but maybe want to try medication first, so we're happy to talk about all the options.

Okay then you try something, I mean if they say well I really want to try maybe a diet and exercise and that doesn't work so are medications next?

So for some patients medications can be next.

So obviously the ones that people often ask about are what's this class of glp1 receptor agonists, things like Wegovy, Ozempic that people have heard about from commercials and advertisings, celebrities are using them that sort of thing.

So we do get a lot of requests for those medications and generally speaking we're looking at, you know, where they are in terms of their BMI, what their goals are, if medication is something that could be an adjunct to surgery to help them get to a healthier weight before surgery whether we think that, you know, that we should just be enrolled in the bariatric surgery program and the medication may not even be covered by insurance sometimes so those are all kind of factors that go into the decision of whether we can prescribe a medication and whether it can be covered and all of that.

What about those medications, and there's another one we could probably do a whole show on, are they, you know, are people safe, some people are kind of more or less self-prescribing.

Yeah, no, it's definitely a touchy subject I think.

I like to look at obesity as like a chronic disease process.

So if you have high blood pressure that's a chronic disease, you're on medication for that usually for life until maybe you lose weight and it gets better.

But obesity we've started to notice in literature that if you have a BMI over 35 for more than five years it becomes that chronic disease process and so like Dave was mentioning your body gets used to that weight and so the hormones between your central nervous system and your brain and your gut nervous system aren't communicating well.

So the weight loss meds they do a good job while you're on it but then the problem is once you get off of it how your body's going to respond and so if you think about obesity in a chronic disease process you would almost have to be on that medication for life or until you've lost a bunch of weight where you get off that obesity scale or that BMI less than 30.

So we don't know what things are like once you get off of it for certain patients and the one thing we have noticed is for surgery that has shown long stability for weight loss.

So people will remain, their weight will stay off much longer and as opposed to the weight loss medications we just don't know yet how the weight loss medications are going to factor in.

There have been a lot of studies more recently, obviously a lot of these medications are new, so looking at costs it takes anywhere from a year and a half to two years to essentially be a wash between the cost of like bariatric surgery and the cost of the medications.

Again this is from an insurance standpoint, we're not talking about out-of pocket cost for the patient necessarily, but over the course of, you know, you're thinking 16 to 24 months the medication would have been paid off by a one-time surgery that's going to have a permanent, long lasting effect.

So that's another thing that we might talk to our patients about is do you want to be taking this injection once a week for the rest of your life?

What will you do if you lose your job or lose your insurance and are you okay with the risk of possibly regaining the weight if you're not able to continue on the medication.

Do we know very much and maybe you've already addressed this Mike but do we know very much about the long-term implications of using these medications for virtually years?

Not that I'm aware of because it's so new, so we don't really have a whole lot of 10 or 15 year data on the weight loss meds whereas we have a lot more data for surgery and how that's working.

I know there's a lot more medications starting to come out and so I think over time we may learn more about that of like the chronic effects but I think I can't really say for sure how things are going to look in 10 years with weight loss meds.

For the most part, like five-year data is the longest that we have, everything seems safe, everything seems to be effective.

Even saying that the weight loss surgeries, the sleeve and the gastric bypass, do have a larger excess weight loss over the initial first two years and then longer maintenance of weight loss after completion of the surgery compared to the medications as far as we know at this point.

One more thing before we get back to surgery.

When people are going through a cycle with these types of treatments whether it's diet and exercise or some sort of medication and they use the med for a while and then they say well I don't need it anymore and then they gain the weight back in some cases is there anything wrong with that, is there any special hazard to kind of going up and down?

Well, so, unfortunately what I was mentioning earlier about that kind of set point where your body wants to be that's what I think most people experience when they try to, you know, however they choose to lose weight whether it's diet, exercise, hypnotism, whatever procedure, anything that you can think of people are sometimes able to lose weight maybe even for six months to a year, but it can be really defeating when you see that scale start creeping back up and feeling like you're doing all the right things, you're doing all the same things, and still your weight is going back to where your body kind of wants to be.

The bariatric surgery procedures have been proven to kind of change that set point and get you to a newer lower weight.

Now that's not to say that every patient who undergoes a bariatric surgery is going to be, you know, a BMI of 25 or 22 for the rest of their life, but if you're talking about someone who's in the 45 to 50 range and they're able to be consistently in the 30 to 35 range that's drastically decreasing the risk of developing arthritis in the knees and hips, developing high blood pressure, developing diabetes, developing certain types of cancers which can be more prone in more obesity.

So I mean this is really about, you know, making yourself more healthy for the long term so that you're there for your kids, so that you're there for your grandkids, so that you can be active in your retirement.

We really want to encourage people to, you know, think about how their weight is affecting their daily life and what their life might look like if they're able to lose a significant amount of weight and we're talking about, you know, 50 to 100 to 150 pounds of weight loss depending on what your starting point is.

It's a significant amount of weight loss.

Yeah, surgery's definitely proven to extend life expectancy for sure in patients with those high BMI's.

There's been a lot of research that even the adjustable gastric band, which most surgeons in the United States do not even perform anymore, that didn't have the greatest weight loss but even that weight loss surgery proved to expand and extend their life expectancy for patients with morbid obesity.

So we have much better surgical options now, so I think if you were to redo some of those studies with the sleeve gastrectomy and the Roux-en-Y gastric bypass you'd find even probably better data for that.

Why aren't doctors using the bands anymore?

There's a lot of complications that can occur with it, it also requires a lot of maintenance.

So the band you basically have a balloon that goes around the top part of your stomach and then there's a catheter that feeds to a port underneath the skin, so in order to inflate and deflate the balloon or the band you have to puncture through the skin and that is at risk of getting an infection.

You can do it too tight, it can erode into the stomach, so there's a lot of little tricky things that can occur with the band.

Things that have started to come to be more like in the 15 to 20 years since the original bands were being placed and also from just the type of surgery it's considered a restrictive procedure.

So like earlier when Mike was talking about the sleeve gastrectomy is a restrictive procedure, so it's limiting the size of the stomach, removing that portion of the stomach that creates the hunger hormone and it has better weight loss for longer and better effect on diabetes, blood pressure, all that stuff than the band does.

So if you're looking at two procedures that work in a similar way but one has better weight loss and better outcomes and fewer risks of complications it's kind of a no-brainer why people have started to gravitate to the sleeve from the band.

And the main thing that we look for between the sleeve and a gastric bypass procedure is looking at whether they have diabetes or if they have reflux symptoms.

Reflux plays a huge role in which surgery we choose so we always want to investigate that and talk to our patients.

We will do a scope on a patient where we actually look at the esophagus, stomach and small intestine before we do an operation to make sure we're not missing any kind of severe disease from reflux.

So that's what we talk about in our first visit as well is what surgery is going to be a good option for them and we go through all the risks, the benefits of it.

Yeah and then kind of move on from there.

We also look at whether they have cardiac disease, so we'd send them and refer them to a cardiologist.

If they have any sleep issues we have them see a sleep medicine doctor to help because it could be sleep apnea that is making people have trouble sleeping.

If you don't get good nights of sleep then your hormone levels called cortisol go up and cortisol, if that's in your system and you eat food, it stores every food as fat and so I've seen people lose about 15 to 20 pounds just by being put on a CPAP machine to help with their sleep apnea.

So it is a multifactorial reason why people get obesity and so we try to encompass all of that in that first visit, see what works best for our patients.

Reflux is something that people should take seriously, isn't it.

Absolutely.

Yeah.

Absolutely.

Yeah so we find outside of, you know, just what we call maladaptive eating habits, things that tend to soothe reflux tend to be higher calorie and less filling so people will sometimes eat or drink things that will actually increase your weight and contribute to reflux.

Weight in and of itself can contribute to reflux.

The constant acid washing over the inside of the esophagus can lead to changes in the esophagus called Barrett's which is a precursor to esophageal cancer, so these are all things that, you know, people tend to be stoic and live with acid reflux and there's medications that can help with that, there's surgical treatments that can help with that.

Yeah people call it well it's just a little heartburn but it actually can have some pretty serious implications.

Absolutely.

Yeah.

So you consult with a new patient that's considering surgery and how many different types of surgery might you consider, again?

I think a majority of them it's going to be the sleeve gastrectomy, the Roux-en-Y gastric bypass and then if somebody carries a lot more weight, like a BMI over 60, then we may consider something called a duodenal switch and so the duodenal switch, like I mentioned, was a combination of a sleeve and a bypass.

If you don't really meet that criteria for weight loss surgery I do do a procedure called an endoscopic sleeve gastroplasty and what that is is there's no cuts on the skin, it's a procedure I do through the mouth, and I have a suturing tool that I basically plicate the stomach or roll the stomach on itself to make it smaller and so I reserve that usually for people with a BMI of 30 to 35 and that or have done a whole bunch of weight loss options, haven't quite gotten to where they want to be, but they don't qualify for weight loss surgery and maybe they don't want to try the medication.

That's another option for them.

Which one is easiest to recover from?

So the recovery is going to be very similar.

The way we're performing these procedures here in Bemidji is we have the davinci surgical system so it's a robotic laparoscopic approach, small incisions that go kind of across the abdomen.

We inflate the belly with CO2 gas, we have a camera that's high definition and 3D vision that goes in through one of those incisions and then the robot is actually attached to all of our surgical instruments.

That gives the surgeon, whether it's me or Mike, sitting at a console in the room with the patient, control of all the instruments that are inside the abdomen.

So that's been one of the things that's been a real advance in bariatric surgery over the last 20 or 30 years, the change from open surgery which is, you know, a big incision all hand, you know, by a surgeon putting their hands inside your abdomen, that was back in the 80's and 90's to laparoscopy which came on more in the late 90's, early 2000's, long thin instruments inflating the belly with gas again, using a camera.

All of these advances have allowed us to really refine the techniques, decrease hospital stays.

They were going home much quicker than they were with open.

Decrease pain, and really limit the risk of complications.

Gentlemen we are out of time.

We appreciate you coming in to see us and hopefully you'll hear from some folks soon.

Thanks again for your time today.

Thanks for having us.

Well, thank you.

Yeah, we appreciate it.

Thanks for joining us for Lakeland Currents.