Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, 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 of the Conquer Weight Podcast. I have a guest with me today, Dr. Jennifer Salluzzo. She is a bariatric surgeon and studied minimally invasive surgery and is working at VCU. She is joining me today to talk a little bit more about bariatric surgery. We had an episode a couple of months ago with Dr. Timothy Snow and you all loved it. We have more questions, learning a little bit more about what life looks like after bariatric surgery, so Dr. Salluzzo is joining us to talk about that. Dr. Salluzzo, thank you so much for being here today. Dr. Jennifer Salluzzo: Thank you for having me. Dr. Sarah Stombaugh: Absolutely. So tell us a little bit more about yourself, how you came to be a surgeon and specializing in this area. Dr. Jennifer Salluzzo: Well, I originally did not know I wanted to be a surgeon. I actually was thinking of doing rural medicine when I was in medical school and then rotated on a general surgery and bariatric surgery service and just fell in love with it. I really enjoy the continuity of care. It's quite unique in this field being able to maintain long-term relationships with patients. I also do some general surgery. I do a lot of hernia repairs and bariatric surgery and hernia repairs often go hand in hand if patients need to lose weight prior to having a complex abdominal wall reconstruction. So at this point in my career, those are really my two passions. Aside from that, I am from the northeast, but I've been in Virginia for eight years and I live here with my husband and my 6-year-old. Dr. Sarah Stombaugh: I love that. Well, thank you so much. We're really excited to learn more. And that piece that you shared about having a more long-term relationship with your patients, I think that is really unique. Certainly there's many areas of medicine where you might have that, but in the surgical space that is unique to bariatric surgery. And so I'd love to hear maybe just as a broad overview, a lot of times people are thinking about leading up to bariatric surgery. There's often a medically supervised weight loss period of time before that, and so there's a lot of conversation around prepping for bariatric surgery and the procedure itself, but I'd love to hear from you, what does it look like from surgery into the future? Dr. Jennifer Salluzzo: That is true. There is a ton of work that goes into getting prepared for surgery, actually having the surgery, but then once patients go home in my practice and the practice at VCU is we see patients consistently in the first year. So we see them at two weeks, three months, six months, 12 months. But then we want patients to come back every year to be evaluated, make sure that they're maintaining a healthy lifestyle. We also check labs to make sure that their vitamins are in the correct range and make sure they're still taking their vitamins. So we try to maintain a yearly relationship with all of our patients over time. Dr. Sarah Stombaugh: I love that. And tell me about what that might look like in terms of dietary recommendations and even vitamin supplementation that a patient might be doing after bariatric surgery. Dr. Jennifer Salluzzo: So a lot of the vitamins that we recommend are actually vitamins that a lot of us should be taking. The big ones are going to be calcium and vitamin D, vitamin B12. Some patients they need to be on iron, but there are multiple different companies that make vitamins that come in the combinations that bariatric patients need so that they're not taking multiple pills a day. And overall they're pretty well tolerated. They're usually chewable, so patients can order them pre-op, have them, and then as long as they maintain taking the vitamins on a regular basis and have routine follow-up, it is rare that they will have a very significant problem with vitamin deficiency that doesn't get identified Dr. Sarah Stombaugh: Well. And part of why vitamin deficiency happens of course, is because the mal absorptive aspect of these surgeries. And so that ongoing piece of vitamin supplementation is so, so important. And so I think understanding that long-term that there is, okay, you're going to be taking vitamins really every day for the rest of your life, that is a commitment. It's not a huge commitment, but it is a commitment that people need to be aware of and willing to follow. Dr. Jennifer Salluzzo: Absolutely. It's a lifestyle change, but this is all about lifestyle change. So I usually feel that patients who have embraced bariatric surgery and the process and the program, most people understand that postoperatively the goal is to maintain a healthy lifestyle and follow the recommendations which include the vitamin supplementation. Dr. Sarah Stombaugh: Yeah, absolutely. Tell me too about some of the sort of funny things that we don't always think about. So for example, during or after surgery, patients need to separate food from liquids. Thinking about protein goals, tell me about some of those things that someone who's considering bariatric surgery and wondering what does the long-term look like? What are some of those things? Dr. Jennifer Salluzzo: So our patients are typically on a six week progression diet after surgery. And that may vary slightly between practices, but it starts out with liquids and protein shakes and then it gets advanced to a pureed diet, a soft diet, and then back to regular food. And the goal is to eliminate added sugar and maintain a higher protein level. We want our patients to get at least 60 grams of protein per day. Initially that's done by taking protein shakes, but as they progress through the diet and get back to regular food, that is obviously going to come from protein sources and food. Dr. Sarah Stombaugh: Absolutely. Okay, excellent. And tell me, I think a lot of people are very afraid of bariatric surgery. Sometimes they have heard a story from extended relative, a friend of a friend who's had complications from bariatric surgery and certainly with any surgery or any procedure there are risks that are there. Tell me a little bit about some of the more common complications and how often do those happen? Dr. Jennifer Salluzzo: Bariatric surgery did get a bad rap for a long time, but this goes back now to its infancy at this point. We are really into an established system of surgeries overall. There are several risks like with any surgery, however, the risk of having a problem is typically going to be less than having your gallbladder out or having some standard surgical procedures that people go into all the time. For instance, having a knee replacement or hip replacement. In general, the most important things that we will notify patients about when we're consenting them for surgery, bleeding, infection, any injury to an intraabdominal structure, and those are kind of generic for any intraabdominal surgery. Overall, the risk is relatively low of any of that happening. And then there are specific risks to each procedure. For instance, in a sleeve gastrectomy, a proportion of can get reflux afterwards, but that would not be a risk factor after a gastric bypass. So all in all, the risk profile of bariatric surgery is really very favorable and not only is the risk profile low, but bariatric surgery in general is going to extend people's longevity. Dr. Sarah Stombaugh: When I think that piece of it, I mean for one I heard it said, I guess we didn't even talk about you were the president of the Virginia Bariatric Society, which is how we came to meet one another and one of the things I heard it said is this is not your grandmother's bariatric surgery. I love it phrased that way because things have changed just as in any aspect of medicine over the beginning of something to over the next few decades, there will be very different results. We'll learn a lot, there'll be a lot of clinical trials and studies and information that's gathered and those risks have really minimized. I mean, people don't really think twice about having their gallbladder out. If you need to have your gallbladder out, you need to have your gallbladder out and you don't do that for fun. But similarly for bariatric surgery, there's so many potential benefits that can come as a result of losing the weight and seeing that change. So that's amazing. Tell me a little bit, so you are a minimally invasive surgeon including with bariatric surgery. What does that mean and how does that improve some of the risk of these complications? Dr. Jennifer Salluzzo: So bariatric surgery in general now is going to be approached from a minimally invasive standpoint, meaning it's either going to be done robotically or laparoscopically. And what that entails is having small incisions and through those small incisions we're able to see into the abdomen and use special instruments in order to complete the surgery. So instead of waking up with a large incision, the patients just have small incisions that have a small bandage or glue on them, and overall the recovery is going to be much better than having a big midline incision. Pain management is easier and return to work is going to be faster. Dr. Sarah Stombaugh: Okay, excellent. Thank you for explaining that. Tell me, when we think about people going back for revisions, for example, so maybe someone who's had bariatric surgery a long time ago or someone for whom maybe they've had something like a sleeve and would like to have additional support with their weight loss goals. What does it mean to have a revision and what would that look like? There might be a few different examples depending on the situation. So you can certainly share some of those different scenarios as they might come up. Dr. Jennifer Salluzzo: Yes, absolutely. We see patients from all over who come in seeking revisions. They're not necessarily our patients, but one thing we do see with sleep gastrectomy is that patients can develop reflux afterwards and if that reflux is refractory to medicine, revising to a bypass be a potential solution. In patients that don't have a contraindication to a gastric bypass, there are some revisions that can be done for weight regain. However, I would say our initial goal is to always see a patient back, make sure they're following the dietary recommendations, exercise recommendations, taking vitamins to see if there's a way to avoid having to have a revision and simply stick with the primary operation and try to get them to a healthier weight that way. A revision is a more complicated operation. It does have a higher risk profile than a primary surgery, but when needed it is a very valuable tool that we use. Dr. Sarah Stombaugh: Absolutely. When I think for my world in medical weight loss, one of the things that's been really neat to see is that certainly even before the GLP medications, which are some of the newer medications in the market that everyone's really hyped and excited about, we have seen the ability of using anti-obesity medicines, these weight loss medications in order to support patients even who have had bariatric surgery before. Dr. Jennifer Salluzzo: Absolutely. We are using the medications as well. We're using them preoperatively to get people to a healthier weight prior to surgery if needed. We are starting to use it for some weight regain. We work closely with our medical weight loss colleagues at BCU who do the primary medical weight loss as opposed to us and often share patients. I think in general we're moving toward a more comprehensive approach to obesity and obesity management. I don't think it's going to be either medical weight loss or surgical weight loss. They're going to have to come together so that each patient is approached with a unique strategy and it's going to include components of both most likely. Dr. Sarah Stombaugh: Yeah, I agree completely and especially as we look at the effectiveness really of some of the newer GLP medications, Zepbound, the tirzepatide products that are targeting both GLP and GIP, their effectiveness is pretty phenomenal starting to cross into the territory of maybe some of the bariatric surgeries, although typically of course bariatric surgery would have more significant weight loss compared to those. So it starts to bring up the question for any individual patient sitting in front of you, do we approach medical weight loss as a bridge to surgical weight loss or these two things done in combination? And I'm sure that's something you guys it sounds like are seeing in your clinic a lot. Dr. Jennifer Salluzzo: We are seeing it a lot. We see that a lot of patients like to start with medical weight loss, which is an option. I think being supportive of whichever direction a patient wants to go is the most important first step and then following whether or not they're successful and at what point they feel they no longer be successful with one avenue. And at that point then we can talk about other alternatives. So for instance, I am often referred patients who have gone to medical weight loss and they have lost some weight but have not gotten to the point they really need to improve their overall health and longevity. And then they come to us for surgical weight loss to get down the rest. There's also the patient who comes who has quite a high body mass index has surgery and with the operation you don't necessarily lose all of the excess weight that you have to lose. So then we could potentially use medical weight loss as a means to get more weight off of the patients. So it's going to be a multifactorial approach in general. I don't think one or the other is the answer. I think for each patient it's going to just be a overall multidisciplinary decision about which is better for them. Dr. Sarah Stombaugh: I love that explanation. And tell me, this might have been a question we could even have thought about earlier on, but when we think about different bariatric surgery procedures and the amount of weight a person would be expected to lose, share a little bit about that data and how you might counsel patients about expectations with their surgery. Dr. Jennifer Salluzzo: That's actually really important. I think that sometimes the expectation with bariatric surgery is that you'll lose all of the excess weight you have. That is not our expectation. It's actually going to be closer to 60% of your excess weight. But the key outcome is the improvement in all of the comorbid conditions and again, the improvement in longevity. So people are going to be surviving longer. You don't necessarily have to lose every pound in order to live longer and healthier. I don't talk to my patients necessarily about a weight loss goal because it's going to be different for everyone. The goal is to get them to a healthier place where they aren't taking multiple medications multiple times a day. They can run around with their grandchildren, they can babysit, they can even try to get pregnant and have children. So I don't think that looking at it from a pound perspective is necessarily important, but if people ask, I usually do tell them it's going to be around 60% of your excess weight. So if you have a hundred pounds to lose, that would be about 60 pounds. Dr. Sarah Stombaugh: Yeah, and I think that explanation too, thinking about what are the other factors in terms of our health, in terms of our life, it's really amazing watching people regardless of the body size that they live in as they lose 10 pounds, 20 pounds, 30 pounds, these are really, sometimes if you think about someone who has a hundred pounds of excess weight, for example, 2030 pounds may not sound that significant, but you go and pick up a bag of dog food or pick up your suitcase and start to see how this is really making a huge difference in terms of my arthritis, in terms of just my energy levels throughout the day. Not to mention things like blood pressure, cholesterol, liver disease, all of these other things we see related to weight. And as we see more and more excess body weight loss, we may see even further improvements in it. But as you said, a lot of my patients, I think the narrative, especially with the weight loss medications right now and some of the use and popularization for patients who don't have clinically significant obesity, they may be able to find themselves in a goal body weight that brings them to BMI of 22, let's say for example, maybe somewhere where they had lived before and had looked at. But for someone who has really clinically significant obesity associated with comorbidities, a lot of times we let them sort of set the goals and pay attention. I often say we know it when we get there. We are looking at all of these other factors, looking at how your body is feeling and how is your body functioning for you? Do you feel strong? Do you feel energetic? Because we want to make sure that we're supporting patients in losing weight in a way that also feels really good, that they're fueling their body with foods that energize them, getting that adequate protein. And so I like that answer quite a bit that you shared. Tell me too, you mentioned the getting pregnant after bariatric surgery and I think a lot of women are scared about what that might look like. So tell me some of the guidelines in terms of how long to wait before getting pregnant and then potentially weight regain. How do you support patients through that? Dr. Jennifer Salluzzo: That's a really great question actually, because I do see women who are childbearing age who have tried to get pregnant, gone through fertility treatments, but due to the excess weight, their fertility is not where it needs to be in order to have a child. And they'll come to me and we have this discussion about it. And typically my recommendation is one to one and a half years from surgery to start thinking about getting pregnant. The reason for that is this way you'll get to some of your really meaningful weight loss. You will also have an established routine, an established lifestyle. Now post-bariatric surgery, we'll be able to make sure your vitamins are all in line and then you have the time to mentally prepare for another big life change. Potentially patients do have increased fertility after surgery and I think sometimes they don't expect it. And we try to avoid any pregnancies that aren't planned that are close to the surgery in terms of weight gain during the pregnancy, obviously we want patients to maintain a healthy pregnancy like anybody else would. So whatever weight gain they are given by the OB is totally acceptable. And then what we do is try to maintain their protein intake, make sure their vitamins are all being taken and we make any adjustments and work with the OB so that the patient doesn't have any kind of micronutrient deficiency during that time. Dr. Sarah Stombaugh: I think that's such an important point because pregnancy is this time where your body is being depleted of so many vitamins and minerals, and it can be really challenging in general for women, but especially with something like bariatric surgery where their fertility has been restored, but we're still in that healing and recovering phase from surgery. And I think that's a really interesting point that you make. And I see this a lot in the medical weight loss world as well, that it can be really challenging because often fertility is desired, a pregnancy is really desired, and when there have been so many years of infertility and this belief that my body cannot get pregnant, it can also be hard to manage needing to be on birth control or using protection during that period of time because hey, we want to make sure that when you do get pregnant, we're doing it in the safest way possible so that you and your baby can have the best health. But yeah, we do see fertility restored with weight loss and it's really phenomenal to be able to support patients in that way. Dr. Jennifer Salluzzo: It is. I've had several patients who are able to have children after bariatric surgery and it's a wonderful feeling. And that goes back to the continuity of care that I'm able to maintain with patients who have the surgery. I think that it's really important to me as a person, but I think it's important to the success of the patients that they have someone they can reach out to over time. Dr. Sarah Stombaugh: Yes, I agree completely. Tell me a little bit about a patient who comes to see you and is really desires to have bariatric surgery, but is kind of afraid about what does the rest of my life look like? Can I really do this? What would you say to that person? Dr. Jennifer Salluzzo: I would say to that person that anything new is going to be difficult to accept initially, but I would also say where is life heading? If you're on the same trajectory you are now, and it's going to be a place where you're not healthy and you don't feel well and you're not going to live as long to do all of the things that you want to do, but if you can accept that there needs to be a change and you can think about that change, then we can move forward. I think that any surgery is scary for anybody, especially for people who aren't in the medical field, and most people think of surgery as something urgent or emergent, and this is elective in the sense that you sign up for it and you get scheduled for it, but it's not really elective in terms of a health condition. Obesity is pathologic and surgery can be the treatment for it. So in that sense, I like to remind them that this is not really elective. They need to do something to get healthier, to live longer, and if they can embrace the idea of a change, then we will work with them to get them through the process to surgery Dr. Sarah Stombaugh: Well, and I think that reframing, this is not elective. Think of all of the major health benefits this will have for you. It's a lot different than something that is fully elective, like a plastic surgery or something like that, which may have a role and certainly does in plenty of ways, but drawing this distinction of what will the surgery do for you and seeing that big outcome, I love that reframing. So this has been great. Let me ask you, Dr. Salluzzo, as we wrap up, is there anything I haven't asked you that you'd love for my audience to know? Dr. Jennifer Salluzzo: I would like them to know that we are available to discuss surgery and having the discussion doesn't necessarily mean you have to have surgery. While you can have that anxiety about it and it may not be the right decision for you, come talk to us. We can go through the risks, we can discuss other avenues. If medical weight loss is the way to start, great. If surgical weight loss is the way to start, great. All in all, we're looking for people to be healthier and happier so that as we age as a society, we're getting better and living longer. So I would say keep an open mind. Don't listen to stories. People are going to tell stories that are memorable and those are either going to be really good or really bad. So I think that if patients can just keep an open mind, have the discussion, then they have the opportunity to learn about a way to change their lives for the better. Dr. Sarah Stombaugh: I think that's such a phenomenal point that if you go in, you have a single appointment, just learn about the process, understand some of these risks and benefits for me specifically, what would that look like? You're not committed to anything. You can walk out that door and never come back if you want to. But having that appointment, getting that information and having that knowledge so that you can really then make the best decision for your health that is so important is being that information gathering stage so that you feel confident if you move forward with surgery or even without surgery that you know what you're saying no to. Dr. Jennifer Salluzzo: Absolutely. And at VCU, we all work really hard with our patients. We have patients that go through the program a couple times and it's just not right for them at that point in time to have the surgery and we always welcome them back. So it's a process just like any kind of change is going to be a process. It's something you have to work through. And we have a great team. It's multidisciplinary and we want people to work through it with us, not just by themselves because it's a group effort and it shouldn't be an isolated struggle. Dr. Sarah Stombaugh: Absolutely. And that support piece is when we look at long-term weight loss success, the support piece is really what is crucial there to making sure that that happens. Well, this has been really fun, Dr. Salluzzo. Thank you for joining us. Let me ask you, if someone is listening to this podcast, they're in the central Virginia area, how can they find you to learn more about with you or potentially even work with you? Dr. Jennifer Salluzzo: This has been great. Thank you so much for having me. If anyone is interested in coming to VCU Health to see me or one of my colleagues, you can simply go to the website and look up bariatric surgery and you'll have all of the information for our clinics. We have several that aren't just downtown, so we have satellite offices to make it a little bit more accessible to some patients as well. Dr. Sarah Stombaugh: Okay, that's wonderful. And we will make sure to include all of that information in the show notes. And so if someone is listening and is interested in learning more, you can certainly search for Dr. Salluzzo though, but just take a peek at those show notes and I'm glad to hear you guys have a few different locations because I know going to a major medical campus can be a little overwhelming at times as well. Dr. Jennifer Salluzzo: Yes, especially downtown. Dr. Sarah Stombaugh: Yes, absolutely. Well, thank you so much and we will see you all next time.