Conquer Your Weight

Dr. Sarah Stombaugh: This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to today's episode. I'm interviewing a bariatric surgeon, Dr. Tim Snow, and we were talking because it is wild to me that I've gotten through this many episodes without having an episode specifically dedicated to bariatric surgery. So that is what we're doing today. We're going to learn all about the different types of surgery, who might be a good candidate and get all of the questions answered. So if you're thinking, is this something I would consider you get some great initial information here. So with that, Dr. Tim Snow, thank you so much for joining me today. I'm really excited to have you here. Dr. Timothy Snow: Thank you so much for inviting me. This is a pleasure to be on your podcast and speak to your listeners and patients about this topic. I think it's a good thing that kind of compliments all the weight loss medication, nutrition that we talk about. I think it's a good option for many of our patients out there for more durable and sustainable weight loss. So I'm happy to get into it with you. Dr. Sarah Stombaugh: Yeah, absolutely. And Dr. Snow, you are local here to the Charlottesville, Virginia area, which is how we've gotten to know each other. But tell me a little bit about your background and how you came to be doing bariatric surgery. Dr. Timothy Snow: Yeah, of course. So I've been in the Charlottesville area for about five years now at Sentara Martha Jefferson. I did my initial medical school training at West Virginia, the osteopathic medical school in Lewisburg. Then did my residency in general surgery at Stony Brook Southhampton up in New York. And then I did a bariatric and minimally invasive surgery fellowship at Duke University and I've been here in Charlottesville ever since then. Dr. Sarah Stombaugh: Great, excellent. Well, thank you so much. Let's dive in and talk about bariatric surgery. So first I want to spend a little bit of time and talk about who is a candidate for bariatric surgery just based on their weight BMI criteria who might be considering this and what are just the general guidelines as well as patients that you see who is going to be a good candidate for this type of procedure? Dr. Timothy Snow: So this is really a good place to start out with because a lot of the numbers have changed and far as the recommendations are a little bit different from what we as surgeons and national societies recommend compared to what the insurance requirements are right now. So in order to be a qualifying patient for bariatric surgery, the current insurance guidelines recommend that you need to have, it's all BMI based, have a body mass index of 35 or higher with an obesity related comorbidity. And usually these mean other medical problems such as high blood pressure, hypertension, high cholesterol, hyperlipidemia, sleep apnea, or diabetes. Those are kind of the big four, although if you have a BMI of 40 or higher, you don't have to have any of those other qualifying obesity related medical problems. If your BMI is 40 or higher, you automatically qualify or a candidate for bariatric surgery. But all that hinges on insurance coverage. So everybody's insurance policy is different and you often need to have specific bariatric coverage in order to proceed with bariatric surgery. There are self-pay options, obviously if you don't have that as part of your policy, but that is the current insurance recommendation. The national societies have been pushing to lower this number just because obesity continues to be a rising epidemic in our society, especially here in the United States. So the current recommendations from a surgical society is that BMI greater than 35 should automatically qualify you for surgery. And then the BMI of 30 with those medical problems, that's the current recommendation that's been published by the American Society of Metabolic and Bariatric Surgeons. Dr. Sarah Stombaugh: Okay. And I think that's a really great point because those recommendations from the societies have just changed in the last few years here, and a lot of times we'll see that those recommendations change and then the insurance companies kind of slowly get on board. So fingers crossed that someone listening to this episode five years in the future will be like, what are you talking about? It's covered now for me. Dr. Timothy Snow: Slow is a generous term too. They lag behind pretty long. And even with obesity in general, the CDC didn't even consider disease until the two early 2000 tens, Dr. Sarah Stombaugh: Right? Yeah, no, exactly. I think that's a great point. And so it may be some time here. I love talking about numbers and thinking about, okay, so what is A BMI of 30 35 40 mean? And so when we look at these for people, let's say someone who is 5'6", a BMI of 30 is going to be about 190 pounds. A BMI of 35 is going to be about 220 pounds, and then BMI of 40 will be about 250 pounds. And then for someone who is six foot tall, so if you're anywhere in between those, you'll have to just do some math. But anyone who's six foot tall, a BMI of 30 is about 225 BMI of 35 is 260 and A BMI of 40 is 300. And so for people who are like, yeah, I try not to pay attention too much to my BMI don't want to think about those overweight, obese, we think about some of the codes that we use in medical diagnostics and things like morbidly obese can be really hard to see written down on a piece of paper. And so if you've been ignoring those BMI numbers, then some of these weight numbers you can certainly look to. So we've got these insurance guidelines and we'll talk to you because that's definitely going to determine what someone's surgical prep looks like. But before we even get to that, tell me a little bit about the different types of bariatric surgery, because a lot of times we hear bariatric surgery and people may have an idea of one specific thing, what that means for them. There's multiple different types of surgery out there. Tell us a little bit about some of the main types of bariatric surgery and a little bit about those procedures. Dr. Timothy Snow: Right. Yeah, this conversation is going on for a while. If we went over all the different ones that existed. Dr. Sarah Stombaugh: Three hours later. Dr. Timothy Snow: But the two most common ones are the sleeve gastrectomy and the gastric bypass. Gastric bypass has kind of been the gold standard old faithful, it's been around for forever. So all the newer procedures that come out are assessed based on how well the patients respond compared to the gastric bypass. But sleeve is still currently number one, and a lot of that is just because of ease of performing the operation. So essentially a sleeve gastrectomy is where we remove a large section of the stomach, approximately 70% of the stomach with a special stapling device. So it essentially changes the stomach from a big purse into a skinny tube or a banana shape. And that works because you're restricting the space, so there's less space for things to go down, but it's also changing the way your body responds to the surgery. It's making metabolic changes. It removes a lot of the hormones and receptors that are in your stomach that send signals to your brain that say, feed me, I'm hungry. So the way you respond to food and liquids is going to change as well. So in that aspect, it's not only restricted, but it does have some metabolic effects as well. Number two is the gastric bypass. That's probably the second most commonly performed surgery in the United States, and it's been around for forever because proven and it has a lot of good results, that procedure doesn't actually remove anything from the body, but it does reroute the intestines around. So I always tell people it's like changing your internal plumbing around a little bit. So instead of stapling across the whole stomach as in a sleeve and removing it, we kind of carve out a tiny pouch of stomach tissue from the top part of the stomach and that'll be separated from the bottom part of the stomach. We then take a piece of the intestines that it is further downstream and attach it to that gastric pouch that we created. So when you eat and drink, everything goes down, not your windpipe but your esophagus, and it goes into that gastric pouch, then directly into that piece of intestines we attach to it. And that part of the intestines bypasses a small segment of the intestines that it would normally go through and get absorbed as well as restricting size. It's also performing metabolic activities by restricting how much of that liquid or food you intake is actually being digested and absorbed. Dr. Sarah Stombaugh: Okay. Excellent. Thank you. And you and I were talking a little bit before we hit the record button and you're like, I wonder if there's going to be pictures. We will absolutely put pictures on social media because I think that's a really valuable thing to see, although I love your descriptions and that kind of purse or banana shape versus the pouch and bypass is because it's bypassing part of the GI system, right? Dr. Timothy Snow: Right. Correct. Dr. Sarah Stombaugh: Tell me about gastric banding because we don't do that as much anymore, but people are still really familiar with it. And tell me a little bit about that. Dr. Timothy Snow: So a gastric band has really fallen out of favor in the bariatric community. It's still reserved for certain circumstances, but it's not something we would routinely consider for patients. And that's because what we found out through the data and literature in the long run is that it's not a really good operation for patients. And the reason being is it's number one, it's a foreign body that's going into your system and that when we put something around the top of the stomach at the base of the esophagus, which is what the gastric band is, we're putting a band in that we can adjust as far as how much liquid we fill with it to give you more or less restriction. But because of that, we're not doing anything to affect metabolism. It's purely restrictive. So you can drink through it as well because if you just focus on liquids, you can drink all your calories. And that doesn't mean you can't get in milkshakes or things that are caloric high carbs or high fat. So in the long run, we've seen that overall weight loss is pretty poor compared to these other surgical operations and the side effects and potential complications. These bands or foreign bodies can slip. They can cause dilation or inflammation of the esophagus, which can lead to further problems such as Barrett's esophagus, which is a complication where the cells of the esophagus start changing because it's been irritated by all this chronic flow of backflow of gastric juices, which causes inflammation. And then the issues with managing the fluid within the band, you have to get a needle stick into a port that sits in your abdominal wall each time you want to adjust the fluid. So they're a little bit high maintenance as well. So really it comes down to them requiring a significant follow-up for appropriate management and that the complications are higher than other bariatric operations. And the overall total body weight loss and comorbidity resolution, how much your other medical problems improve is quite low compared to other options out there? Dr. Sarah Stombaugh: Absolutely. Dr. Timothy Snow: So currently in my practice, I don't put any lap bands in. I have all managed lap bands since the other patients who have lap bands, but often our conversation is talking about, oh, my GERD is really bad. I have bad heartburn or reflux or foods are getting stuck, and that's because the band is not working anymore. It's causing too much backflow and causing too much pressure in that area. And we often either talk about taking fluid out or removing the band completely. Dr. Sarah Stombaugh: Okay. That's really helpful information. And as we get into this conversation about why we might choose different ones and thinking about just the evolution of these procedures over time, that's some great information. So right now, really the type of procedures you're doing are the sleeve and then the gastric bypass. Is that right? Dr. Timothy Snow: Those that are two most common. I also do, there's other procedures that are out there that are less commonly performed, and there's different indications when we think about doing these procedures and reasons why one may be favorable compared to another. There's another procedure I do called the SADI procedure or Single Anastomosis Duodenal Switch or Duodenal Ileostomy, which is a mouthful, but it's a very effective operation for patients who have a higher weight or a higher BMI who need a more aggressive operation because either a sleeve or a bypass is not going to cut it for them. So we can do the best surgery in the world. But I always tell patients that this is not your golden ticket. This is not going to solve everything overall, managing obesity. Obesity is a chronic disease, and surgery right now is currently the most effective thing out there to treat it in a more durable fashion along with using other modalities like the medications and nutrition and exercise, but not operation. It's not a one operation fits all type of thing. So we really cater it to our patients. So that SADI operation is basically a combination of the sleeve and the bypass. That's the easiest way to describe it to people. We do a sleeve just as we described before, but then we're also doing it in another intestinal bypass. But compared to the standard gastric bypass, it happens at a different location. It happens at the duodenum, which is the first part of the intestines, and it's a longer bypass compared to the standard gastric bypass. So the combination of the sleeve and the intestinal bypass are why it's a little bit more effective. But the side effect of that is that you can have a little bit higher risk of nutritional or vitamin deficiencies. The protein requirements after getting that procedure are a little bit higher. That's not a procedure you want to get on somebody who you don't think is going to be reliable and follow up because it is a major operation that does require maintenance to make sure patients are not having problems. So that is an option I do for patients. It's not something I do frequently, but it is a good operation for those higher BMI patients, those with a BMI of 60 or higher for weights of 400 or higher. It's something that's going to give them more significant and durable weight loss and be more effective for them in the long run. Dr. Sarah Stombaugh: Absolutely. So thank you for explaining that and we got a little bit then especially with the SADI into some of the pros and cons and who might be a good fit for that. Tell me, when you're thinking about a sleeve gastrectomy versus a traditional bypass, how are you deciding what are the pros and cons and how do you help a patient to make the best decision for them? Dr. Timothy Snow: So when patients come into our office, we have them fill out a pretty extensive medical questionnaire. So I kind of have an idea of what their history and medical problems are coming into it. So I already have an idea of which operation I think will be appropriate for them, but that doesn't mean that I'm going to sway their decision one way or another. This is a mutual decision between our staff and the patient to do what's right for them and what they also want too. But we try to steer them in the right direction based on what we think is clinically appropriate. So a lot of it comes down to BMI, your weight and what your expected goals are and your other medical problem. So someone with a sleeve sleeve and gastric bypass in the long run, three to five years out from surgery, the weight loss overall is pretty similar, but it does favor the bypass by about five to 10% as far as excess body weight loss or maybe another two to 5% of total body weight loss. If somebody's starting out at a lower BMI in the long run, those percentages don't mean too much. So if you're 200 pounds and getting bariatric surgery, the difference is probably going to be pretty negligible. But if you're 380 pounds and getting a sleeve or a bypass, you're probably going to lose more weight in the long run with a bypass compared to a sleeve just because of those percentages. The heavier you are, the more those percentages eat up more numbers and make a more difference. So weight comes into play. So we talk about that. And then it's really the other medical problems too. If a patient is, when we talk about the blood pressure, cholesterol, diabetes, all that stuff, if they're on three blood pressure medications on a bunch of insulin, I usually push them towards one of the more aggressive operations. It's going to be a little bit more effective. The sleeve can also help you get rid of blood pressure problems and cholesterol meds and come off of those, but you have a little bit higher chance with those other operations. So that's another thing we consider, but then it's reasons why not to do one of those surgeries. What's a reason why it's not right for that patient? So for the sleeve, the big one is really heartburn and reflux. So if a patient has really bad heartburn reflux despite eating and drinking the right things, and even if they're on medications for that heartburn reflux and still having breakthrough symptoms, the sleeve is genic, it promotes heartburn, and that's because when you take that big purse and make it to a skinny pipe, there's less space and the pressure's higher, and there's a muscle at the end of the stomach called the Pylori that creates back pressure, and that's enhanced when you have a sleeve just because there's less space. So oftentimes we have that discussion because a lot of people have heartburn and reflux, so it's a very common thing that we discuss in the office. The caveat to that is that some people have hiatal hernias too, and that's just where you have some of the stomach sliding through your diaphragm up into the chest a little bit, and that can throw off your sphincter at the base of the esophagus, and that can cause heartburn and stuck sensation. So we kind of weigh, is fixing the hernia going to make a difference versus not. But oftentimes the literature recommends that if you have bad heartburn, reflux, the bypass is the way to go because the bypass is a low pressure system because bypassing that pylori muscle at the end of the stomach and you don't have that back pressure anymore as far as the bypass, what's a reason why not to do that? Really any bariatric surgery, we don't want people smoking. And in our program, we have a zero tolerance policy when it comes to that, and that's because it's for patient safety. The risk that we talk about when it comes to surgery are all amplified by five or 10 times the original risk if you weren't smoking, which is a super high number when you start adding it up. But even more so with the bypass, people who continue to use nicotine or smoke or use NSAID medications, Aleve, Advil, naproxen, ibuprofen, things like that, you have a higher chance of developing what's called a marginal ulcer or inflammation of the gastric pouch or the connection between the intestines on the pouch. And that's because the stomach tissue, they're still producing acid and that connection doesn't like that exposure to the acid. And those smoking and NSAID medications really promote that inflammatory state that can lead to ulcers. So that's kind of the dreaded thing we look at at bypasses and probably why some people have bad impressions of the bypass. One of the common things we see that people have a major surgical complication is people develop ulcers and then require surgery to fix it. Thankfully, it's low, it's 5% or less, but it's still kind the one thing that keeps us up at night sometimes. Dr. Sarah Stombaugh: Yeah. Oh, absolutely. When I think you brought up a good point, one of the conversations I have with patients often is that people even who may be appropriate candidates for bariatric surgery may not be interested in bariatric surgery because they have a friend or a family member or a friend of a friend of the neighbors, something who's had complications from bariatric surgery. And certainly one of the things we know, it has been a lot of evolution in the field of bariatric surgery over the last couple of decades such that the bariatric surgery procedures now are very different from the procedures in the past. So when you have someone who's like, well, this family friend had a really significant complication, how do you respond to that question? Dr. Timothy Snow: A good question. So we hear this relatively frequently. I think less so now just because it's more and more and more people are starting to realize that bariatric surgery has great benefits, but we still hear it from now and then, so the big thing I'd tell people is that we don't know what happened. That friend or that family member, for sure, there could have been other medical problems that made that patient a higher risk for surgery. That always comes into play. Certain things like coronary artery disease, certain types of lung disease, obesity itself is a higher risk operation. Having obesity makes it a higher risk operation. But there's certain things that do make it higher risk for certain patients, but that's not the only thing. You are right. We've come a long way with how we do these surgeries, and the literature has constantly showed that as time goes on, they are becoming safer compared to back in the nineties and the early 2000s. So we're doing a better job, there's better training. So everybody's doing either fellowships or have designated teaching for bariatric surgery. There's the society that monitors our success with bariatric surgery. So there's a national database and programs are required to be accredited. It meets certain standards. So that's another reason why surgery has become safer, because we've implemented protocols to make it safer. And then I also tell people as far as the surgery itself, think about it like treatment of diabetes. So if you give somebody, you tell somebody you have diabetes and you tell 'em to go eat appropriately, they're going to fail. A majority is part of the time because that therapy is not super effective. So what's the most effective thing? So we usually go write the medications because it's easy. You can just write a prescription, you'd be on the medication that'll take care of it, wipe your hands, but what if that medication doesn't work? Then you have to go on something else like [inaudible] or then you get an injectable medication. So there's always different tiers of treatment that we try. It's the same thing with obesity. It's a chronic disease. So oftentimes when people come in and their BMI is in the fifties or sixties and they say, oh, nothing's worked. I've tried diets and exercise now this is my last resort. I don't think surgery should always be considered a last resort sometimes for certain patients, that's the number one thing that's going to help those patients out. It has a better resolution of those problems compared to certain meds. I think of it as along a spectrum. All these treatment options are modalities that are complimentary. We can all do 'em together instead of just reserving one as a last ditch resort option. I think we could all start using 'em all together at once. Dr. Sarah Stombaugh: When I think a big question that you and I are probably both answering with our patients on a daily basis is what is the amount of weight required to lose for this to be really clinically significant for a person? So it's great to lose 10 pounds, it's great to lose 20 pounds, but at what point, depending on your height, depending on your starting weight, at what point do you start to see improvement or resolution of high blood pressure and high cholesterol and blood sugar, things like diabetes or pre-diabetes or improvement in arthritis? A lot of times the number that will be different for every person, but that's a big part of the deciding factor even from the get-go, can we support you to getting to the place where your body's really functioning for you in the way that you need it to? Dr. Timothy Snow: Right. So I mean, I have patients right after surgery who I often get rid of or stop their blood pressure medications right away. From a surgery standpoint, those metabolic changes happen pretty quickly. And since they're typically on a liquid type of diet, they're a little bit more prone to having a little bit of, not dehydration, but if they're continuing their blood pressure medications, they have a higher chance of having lower blood pressure. So I usually get rid of it right away if they're only on low doses or only a single agent often, and particularly with diabetes, we cut patients metformin in half, we lower the insulin requirements by a third or a half. A lot of those things go down right away just because your body's going through so many changes at once, and I don't necessarily know if it's related to the poundage that people lose. It's the journey that they go through. So they're learning to eat and drink a little bit differently. People can still, that's I think one thing that people are afraid of after surgery too. We haven't even gotten into that. It's a temporary diet progression after surgery, but people can eat normal food, but we encourage high protein, low carbs and just smaller portions. So you can still eat similar stuff. It's just a much smaller amount compared to before, but those changes happen quickly. And with surgery, obviously weight loss is a little bit more prominent compared to just doing nutrition or exercise. But with these medications now that are becoming more effective with the GLP-1s and the GIPs, weight loss is becoming a little bit more prominent through simply doing medications. So people can lose 10 to 15, 20% of their excess weight loss, and that's a great number. But for somebody who say has a BMI of 55 that may help them get down to a BMI of 47, but they still are struggling with the morbid obesity and it may not get rid of all their medical problems. So that's where I think really surgery comes into play along with doing meds or the diet. I think it's really just they all go hand in hand. And that's really, I know I've probably said that already, but I think that's the moral of the story. We got to have to do a little bit of everything to treat these. Dr. Sarah Stombaugh: Yeah, I agree completely. And even from a medical standpoint and how I'm supporting my patients, sometimes that can be helpful in preparing for bariatric surgery, preparing to lose weight as part of the medically supervised weight loss and helping to reduce liver size, which is often helpful in supporting the surgery. So tell me a little bit about medically supervised weight loss because when someone decides, okay, yep, I'm interested in having bariatric surgery, there is typically both from the program, but primarily insurance is driving, there'll be requirements about someone needs to complete a period of medically supervised weight loss, often about six months or so in order to say, yes, this person is a good candidate for bariatric surgery. So tell me a little bit about what that looks like from the different evaluations, how frequently they're meeting with whom they're meeting weight loss requirements that are often that you'll see so that someone who's saying, okay, what would this look like if I actually did that? What does that period of time look like? Dr. Timothy Snow: Sure. So every program's a little bit different in the order of how they do things. So for us, after we receive a patient's information, a consult will be established between either myself or my cos surgeon, whoever the patient sees, and we evaluate the patient the first time around. So we talk to 'em about what our expectations are for what they need to do. We go over the requirements and talk a lot about proper diet or nutrition when it comes to pre and post-op as well as the different surgical options. We go into a very in-depth conversation at that first initial consult. Then they have to go through this period of medical supervised weight loss, which you mentioned, and that varies as far as a timeframe based again on insurance. So the minimum is usually three months, majority is six months, but there's a few insurances out there that make the people wait 12 months, which is painful and I don't think appropriate, but we do what we have to do to get it covered for patients. But usually the medically supervised weight loss is predominantly done with the dietician, a registered dietician where the patient meets with them on a monthly basis in person or telehealth. We do a lot more telehealth since COVID to make it a little bit easier for patients. And so they meet with them for a half hour to an hour and usually the first visit's a little bit longer. And talk about just nutrition in general, what they're doing, where areas they can improve. A lot of the talk is about how to incorporate more protein, how to be more mindful and really work on your mental approach to obesity, a big part of it. So they have to just meet monthly based on the insurance requirements for how many pre-op months there are. And then there's other requirements that as part of an accredited program that patients need to get through. And usually it's basic lab work and clearance from a primary physician. I typically do an endoscopy and EGD on everybody preoperatively to make sure there's no issues with the anatomy of the esophagus or the stomach really looking for any bad inflammation or a hidal hernia. And that really may sway our decision as far as what surgery is appropriate. And then everybody who does bariatric surgery has to get cleared from the psychological assessment team, and that's an accreditation requirement just to make sure there's no risk factors before moving forward with surgery. So once that's all complete, patients are then booked and scheduled. There's not necessarily at least a weight loss requirement, so people don't have to technically lose weight to maintain their approval or authorization for surgery. But really what I look for is to make sure that they're not gaining weight during the process. That really shows me that no, they're probably not adhering to what we've been telling them, not following the instructions. And that's a risk factor for surgery because if they're not going to comply preoperatively, that increases the risk that they may have a problem after surgery. So that's really what we're looking for. But usually most people when they follow the instructions tend to lose weight preoperatively. So often we see a range from anywhere between 10 pounds even. I've had a couple of people lose a hundred pounds before surgery just by really sticking to the preoperative nutrition plan. Dr. Sarah Stombaugh: Yeah, wow. And then tell me a little bit going into surgery and some of the recovery, what does that look like? Because there's going to be the initial recovery and then there's some major changes that people talk about in terms of kind of alluded to protein requirements and how people are consuming beverages. So tell us a little bit about what that looks like. Dr. Timothy Snow: So surgery, and the way I think about it now is surgery is often a scary thing for patients. They always come in, they're excited, but they're very nervous, and that's like any surgery. But the big thing I try to tell people is that with the changes and improvements we made with time, when it comes to bariatrics, the risk of getting bariatric surgery is similar to somebody getting a gallbladder removed or their hernia fixed. We hear about people, oh, I got to get my hernia fixed. And people don't blink an eye on it. The risks are similar to those types of procedures. Bariatric surgery is not higher as far as risk anymore these days as it used to be in the past. So that often comforts people's minds and makes them think, oh, okay, this is not that big of a deal, but it is still big of a deal. We are changing the way that you're going to be. Life's going to be moving forward for the better. So surgery, depending on what surgery we do, surgery could be 40 minutes, could be 90 minutes, usually come up between the hour and hour, two hour timeframe. But recovery is usually pretty quick. People are in the hospital usually overnight. They often, 70% of people probably leave the next afternoon, and we just kind of make sure that they're tolerating some of their liquids and their protein shakes, making sure they're comfortable. But I'll, oftentimes, people don't have a lot of pain after surgery. They're often surprised by how good they feel. Honestly, the big thing we really look for is just to make sure they're able to maintain their fluid intake because when they go home, that's going to be priority number one is staying hydrated and getting some protein in. So we usually, for every patient, recommend 64 ounces of hydration daily. And that can be broth, clear liquids, Gatorade, zeros, the protein shakes count, and then the protein requirement is about 60 grams of protein per day. And we usually recommend a couple of different brands that are about 30 grams each. So two shakes a day is kind of the goal for the first two weeks before we start doing a gradual diet progression at the first post-op where we start doing soft diet with purees like scrambled eggs, things like that. And then after four weeks after surgery, it's regular bariatric type of food. Solid food. Dr. Sarah Stombaugh: Okay, excellent. Well, and I think that then when you look sort of in long-term in terms of the type of food people may be eating, protein requirements, vitamin supplementation, what does that look like? Dr. Timothy Snow: So after any bariatric surgery, we do recommend lifelong vitamin supplementation. And that's just because the volume of food that patients are going to intake, it's just not going to be what it was beforehand. So all the kind of micronutrients, people often don't meet those daily requirements. So a multivitamin and oftentimes some vitamin, vitamin D or thiamine are often requirements after surgery. So that's something we do tell the patients at the initial consultation that'll be part of their long-term maintenance. But what was the other part of the question? Sorry? Dr. Sarah Stombaugh: In terms of protein goals? Dr. Timothy Snow: Oh, protein, yes. So protein can come in any form. So it doesn't necessarily have to be a meat product. You can keep doing shakes as long as you want. Frankly, by two weeks most people are sick with the shakes and they're ready to move on. But in the long run, the shakes are still great, they're high protein, low volume, low calorie, a great way to get your protein in. But people can eat normal sources of protein too. Chicken, fish, even lean red meats, tofu, Greek yogurt, cottage cheese, things that are high protein, low cal, healthy fats, low carb. So all those things are options for patients. And most people don't have a problem meeting those goals and they can eat things normally, it's just the smaller portions and eating a little bit more frequently throughout the day. The carbs and the sweets, those all taste great, but then an hour later, people are hungry and that's because you're not getting the nutrition that you need. And that's where the protein really comes into play, keep you full for a longer period of time. Dr. Sarah Stombaugh: Excellent. Thank you. Well, this has really been an intense run through. Thank you for everyone probably needs to put their seatbelt on or wish they had put their seatbelt on for this episode. We went through a lot. Dr. Timothy Snow: That was a whirlwind of information. Dr. Sarah Stombaugh: It was a whirlwind. I love it though. Tell me, as we're wrapping up here, is there anything that you think would be really important for my listeners to know that you haven't been able to share with them yet? Dr. Timothy Snow: I think don't be scared by the surgery aspect. Surgery always seems to be a scary word, but I think the majority thing, the of stuff that patients say to me after surgery is, man, I wish I would've done this 10 years ago, 20 years ago, 30 years ago. Because people feel good after surgery and majority of people do well, 80% of people maintain durable, significant weight loss after bariatric surgery. And I just saw a couple of post-ops last week, and they've already lost 20, 30 pounds since pre-op. And they're like, oh my God, I can walk two miles. I can play with my grandkids already without getting winded. Not only the health improvements with coming off meds and losing the weight and just feeling better, people's mental health improves, their emotional wellbeing improves. They're able to do things they weren't able to do before. Oftentimes people come to me because they have to get a knee replacement, but their surgeon won't operate on them because they're too heavy because of the risk that could pose for them. So there's always some other reason why surgery might be helpful for you from a bariatric standpoint, but I think look into it and see if it's something that you want to pursue or at least get some information. Coming in for a bariatric consultation doesn't mean that you're committed a hundred percent, it's just to get your foot in the door and learn more about it. Dr. Sarah Stombaugh: And I think that's always the point that I make is you can have a single appointment with the surgeon, learn about the program, learn about what it would mean, see what your coverage is, and really understand the whole thing. And you might learn great information that decides you to set forward into that pathway. And if you get all that information and decide, okay, it's not for me right now, great, but at least you've gotten information. You know how this may play out for you and you've gotten all of that, so it doesn't commit you to anything. But it's an excellent way to get started and learn a little bit more. So tell me, sorry, Dr. Snow, if people are interested in learning more about you, if they're interested in coming to you for a surgical consultation, where can they do that? Dr. Timothy Snow: Right, so we have a specific website on the Martha Jefferson Sentara website. And often if you do a Google search, Sentara weight loss specialist will come up and usually, depending on your location, if your location settings are turned on, it'll direct you to your local hospital systems that are available. But I can provide you with that specific email and a good phone number to call if you do are interested and want to learn some more about our program or just surgery in general, I'd be happy to provide that. Dr. Sarah Stombaugh: Yes. Excellent. And we'll put all that information in the show notes so anyone who's interested in learning all of that information will be in there. Dr. Snow, thank you so much for us today. This has been really fun. Dr. Timothy Snow: No, thank you so much. I appreciate the invite and if anybody needs bariatrics, you know where to find me. Dr. Sarah Stombaugh: Absolutely. Alright, thank you.