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 podcast. We are talking about weight loss before orthopedic surgery, especially before joint replacement surgery. So I have been thinking recently, we are getting, this is episode 97 of the podcast, which I can hardly believe, and I've been thinking what questions have I not yet answered for my patients? And this one dawned on me pretty quickly this topic of weight loss before orthopedic surgery, which a lot of my patients are in this situation where they are trying to lose weight before maybe a knee replacement or a hip replacement, for example. And I realized, oh my gosh, I somehow have never done a podcast on that topic. And a lot of times you can imagine sort of day in and day out, whether it's social media, whether it's conversations with patients, whether it's podcasts, I talk to the media a lot as well for news articles. Sometimes these things run together and I forget sometimes really obvious topics like why have I not yet talked about weight loss before orthopedic surgery? I have no idea because I talk about this all of the time, but because I talk about it all the time, I think I figured I must have done a podcast on it at some point. So here is where I have a favor for you, my audience. If you have been listening to this podcast for a while and you're like, oh my gosh, I cannot believe Dr. Stombaugh has not done an episode on fill in the blank topic, I want you to email me. You can do that, it's info@sarahstombaughmd.com. You can also go to our website, www.sarahstombaughmd.com, and in the contact me section on the bottom, you can fill out a form and that will come to me as well so that we can see what questions you have, what podcast topic recommendations you have, because I think there's a really good chance that maybe I have missed a couple of really big topics. And so if you're like Dr. Stombaugh, you just absolutely have to talk about this topic. Please shoot us an email, fill out the box on my website. I would love to address any holes that you have identified. And furthermore, if you are listening and maybe it's not a major hole, but you just have a question and you're thinking about your own weight loss and health journey, and you're like, gosh, I wish she could just talk about this specific topic because it would be so, so helpful to me, I would love to hear that. And I would love to make a podcast episode just for you. And so if you've been listening and feeling like there is an episode that I really need speaking to me, I would love to do that. So shoot us an email info@sarahstombaughmd.com, fill out the form on my webpage and I would love to record an episode just for you. And with that, let's dive into this episode about weight loss before orthopedic surgery. So this is something that if you are not in a situation or don't know anyone in this situation, I still want you to take a listen because there's a good chance that if you are struggling with your weight, this is something that could be in your future. And it's really important to know and understand this because I have many patients who come to me because they have been having knee arthritis or hip arthritis, they've seen an orthopedic surgery, they've been advised and said, yes, you are a candidate for the surgery. It would be really a good idea to have a joint replacement that is the best treatment for your arthritis at this time. And your weight or your BMI is higher than those cutoff numbers. And so therefore we cannot do the surgery at this time. And this is a situation that a lot of people find themselves in because the body mass index cutoff for joint replacement surgery is often a body mass index of 40. And so what that looks like is that there are a lot of people for whom their body mass index is greater than 40 and they're being told, Hey, you really need a joint replacement and you cannot have one unless you lose weight to bring your body mass index less than 40. Now, this is not a hard and fast rule across the board, but surgeons or hospitals, even surgical centers who are willing to support a patient in having a joint replacement in a patient who does have a BMI of greater than 40, it is really hard to find those people and there's reasons why those guidelines were put into place. And so what I would like to do in the episode today is talk a little bit about why those guidelines even exist in the first place. Talk a little bit about how those may evolve over the future. Does it actually help us if I've been advised to lose weight during or in order to prepare for surgery? Does that actually help me in order to reduce the risk and the complications of surgery? And okay, how do I move forward and can I actually do this? Because a lot of people find themselves in a situation where they have really bad arthritis, let's say in their knees or their hips. This is true for any joint replacement. But typically when we think about joint replacement, we're thinking about knees, we're thinking about hips, we're thinking about shoulders. And so particularly for knees, particularly for hips, when we have severe arthritis in those joints, those are load-bearing or weight-bearing joints, meaning that all day every day when we're up and walking around those knee joints, those hip joints hold up the rest of our body. And so our weight is impacting those. It's maybe one of the reasons that we've had arthritis and developed that over time, but then the arthritis really limits us in our ability to continue to move. And so people who've been able to keep their weight in check through movement and there's someone who walking or running or other forms of exercise that have really helped them to lose weight in the past, they find themselves in this sort of catch 22 where they're told you cannot have joint replacement surgery until you lose weight. And they know that they can't do the things like exercise that have worked really well for them to lose weight in the future. They're less active now because of the pain that comes from having significant arthritis, which can drive even further weight gain. So it becomes this really vicious cycle where patients feel really stuck because they're like, I know I need my joint replacement surgery, but I'm just in so much pain between now and whenever that happens, I don't think that I can lose weight. So I will say, don't worry, there are some solutions that I have to offer. And we can talk a little bit more about what that looks like. But let's take a step and talk about why is it that this even came to be, where did this recommendation come from and how was it useful? Because even though it's super, super frustrating to a lot of people, there is some value in this guideline in that the guideline was set up really to protect patients to say that we know that patients who live in larger bodies, patients who have a body mass index of greater than 40, are at greater risk of postoperative and perioperative complications. So complications during the surgery and in the recovery period compared to patients who have a lower BMI. And so that threshold was set at 40 because we know that as patients have more significant obesity, there may be increased risk of kidney injury after surgery. There is increased risk of heart complications during surgery. We know that there's a lot of risk of anesthesia itself. And so the act of intubating someone putting in the breathing tube can be really challenging when we have excess weight, our body's ability to be extubated. So taking that breathing tube out and to be able to breathe independently after surgery weight can be a really big factor in that when we look at clot risk, for example, so blood clot risk in the legs, those can travel to the heart, deep vein thrombosis, pulmonary embolism, these things are increased as we have increasing weight, the rates of wound healing, we know that obesity may contribute to more poor wound healing. Similarly, risk of infection may also be higher. And so there's a lot of potential risk that can come. So these guidelines were not put in place to hurt anybody. They were put in place really to protect people, but there's just all these people who sort of get caught up in, and I really need the surgery. And so these guidelines came into place in order to protect patients. And there's a lot of patients who fall into this in-between zone where the risk is there and they really would just like to have the surgery anyway. And so unfortunately for a lot of people in our current era, that's not possible because surgeons, because surgical groups, because hospitals, because insurance companies have set this guideline saying, okay, 40 is the cutoff. Now we do know that patients who have lower body weights do have lower risk of complications both during surgery and in that postoperative complication or in that postoperative recovery period, there is a lower risk of complications. But the question is, does losing weight actually decrease those risks? And that's been one of the things that's really, really interesting. And it's not completely clear that it is, but let me break down some of this data for you. So when those guidelines came to be this big question of, okay, we tell patients to have a BMI of 40 or less, if someone has a BMI of greater than 40 and then they're trying to lose weight and they do lose weight before surgery, does that actually help them? Does that actually reduce their complications both during surgery and after surgery? And the answer here, believe it or not, has been really inconclusive. There's some evidence that says yes, it may actually reduce complication risk and other evidence that says, actually, believe it or not, the complication risk is not reduced. We do know for sure that weight loss improves mobility. So when we think about surgery and we think about arthritis, honestly, in general, we do know that losing weight for patients with arthritis will improve mobility. Now, that is true pre-op, so leading up to surgery, and that is also true postoperatively. And in that postoperative recovery period, patients who have lost weight are able to be more mobile. And we see a quake turnaround in mobility when it comes to patients who have lost weight before surgery. The question is though, some of the other things like infections, things like wound healing, for example, there hasn't been a very clear benefit that losing weight is actually helping patients to reduce their complications from surgery. But the interesting thing here is that there were studies that said, okay, patients who lose weight really quickly before surgery, they do not have decreased risk of post-surgical complications compared to patients who have not lost weight. And the interesting thing is, well, they started to question, well, why did the patient lose weight? Did they have metastatic cancer, for example, right? Did they have another process going on in their body that they were losing weight, but it's not like they were just losing weight. They were also having pretty severe health consequences that were happening. And so then they took out patients who inadvertently lost weight and put patients specifically in a weight loss program versus in just sort of standard management. And they looked at those patients and what they found is that losing weight can actually put people at risk for malnutrition. Now, interestingly, even before weight loss, when we look at our patient population across the board, there are many adults in America who are malnourished. And when we look at even patients with obesity, so patients who have excess fat mass that also have clinical signs of malnourishment. And what that could look like is signs of protein insufficiency, vitamin D deficiency, for example, and other micronutrient deficiencies that show us that people, even if their body weight is elevated and they have obesity, may actually still be dealing with clinical malnourishment. And this is where I think the key is because we've started to see more studies that patients lose weight and then stabilize for a period of time actually have better outcomes than patients who just lose weight sort of as quickly as possible. So let me break this down for you a little bit. When we think about the weight loss journey, sometimes you hear calories in versus calories out, and that is the rule of thermodynamics, which is both true and unnecessarily, overly simplified. So when we think about patients losing weight, we think about weight loss in general. We don't want to just starve ourselves, sort of stop eating or cutting calories. In general we want to be really intentional about in our weight loss journey, are we still fueling our body with plenty of protein with plenty of micronutrients? So thinking about vitamins, thinking about minerals, so particularly fruits, vegetables, grains in their whole form. Are we fueling our body with those things such that as we lose weight, we're actually improving our health? Because a lot of times we talk about weight loss, but the reality is you don't really care about weight loss. You've probably heard me say this before, you care about fat mass loss. And when I say that, everybody agrees with me, of course they want to lose fat. But what happens is that if we're not careful in our weight loss journey, we can actually lose muscle mass alongside of our weight loss. And what can happen then is that even though the numbers on the scale may look lower, we actually haven't done anything to improve our metabolic health. So improving metabolic health requires that we're losing fat mass and that we are supporting or even ideally building our muscle mass. So when we think about a group of patients who are preparing for surgery, for people who are having surgery, recovering from surgery is very hard in the body, whether we're talking about a child, an adult, an elderly adult, anyone in between, it takes a lot of nutrition. It takes good nourishment of our body in order to heal from and recover from surgery. And one of the things that happens for adults who are malnourished because they don't have adequate protein, they don't have adequate vitamins and minerals in their diet, is that then they enter a weight loss journey and they become potentially further malnourished depending on what their weight loss journey looked like. Now we give them a surgery, and it's really not surprising that someone who lost weight and is clinically malnourished is not really going to recover well from surgery. So when we think about the risk of infection, we think about the risk of wound, non-healing, having to go back in for surgical intervention because of poor healing outcomes or because of significant infections. All of those will continue to be high in a patient population that is malnourished. And so there's been more data to come out to say, patients who lose weight in a weight loss program and who are able to stabilize their weight actually do better compared to just weight loss goals in general. So let's talk about what that means for you in your weight loss journey or if you know somebody who is preparing for really honestly any surgery, but specifically joint replacement surgery. How can we support patients in losing weight but actually improving their health, improving their nourishment so that their body is as strong as possible going into surgery is as nourished as possible so that we do actually improve those health outcomes? So I think there's a couple of things we really need to be thinking about here. One, we want to be thinking about the food choices that we're making. We want to be thinking about the protein goals that we have. Are we adequately serving our body's protein needs throughout the day? What this will typically look like, sort of a good rule of thumb is at least one gram per kilogram of body weight. So a person who weighs 220 pounds, that is 100 kilograms, that person would need 100 grams of protein per day in order to support their goals. That member may be a little bit higher, maybe a little bit lower. You would want to talk to your personal physician to help set a goal for yourself and your goals. But we really want to make sure that we're getting adequate protein during our weight loss journey in order to support our muscle mass. So any muscle that we already have, we want to do our best to really, really protect that muscle. And while we may be limited in mobility in certain ways, there are certainly still things we can do in order to build our muscle mass. So this may look like using the pool. So warm water therapy, doing aerobic, that's funny, aqua aerobics, I'm just making up waods over here, but aqua aerobics where you're in the water doing an aerobic exercise where the water helps to take gravity off of our joints. So it takes some of that weight bearing pressure off of our joints, but it also gives really good resistance so that as we're doing our aerobics in the water, that resistance is actually helping to support build our muscle mass even further. This can look like doing resistance training in parts of our body that are not bothering us. So if you're having hip and knee problems, can you do things that are supporting your upper body, for example, supporting your core, making sure that you're supporting your strength to the best of your ability and building our muscle mass. We know that getting adequate protein and supporting our muscles through resistance training is one of the best things we can do, honestly for anybody in the weight loss journey. But especially if we think about someone who's going to be rapidly approaching surgery and that that is the goal is that we make sure that we support, support their muscle mass. The other thing is thinking about the rate of weight loss. A lot of people, and if you're on social media these days, you will see people are losing five pounds per week, and it's crazy. Someone's like, oh my gosh, I lost 20 pounds this month. I'm going to tell you, you do not want to lose as much weight as quickly as possible. Doing that is really putting yourself at a high chance that you are going to be malnourished, that you are not getting adequate vitamins, you're not getting adequate minerals, and that you're not getting adequate protein in your diet. So making sure that your weight loss is slow and steady, often targeting about a one to two pound per week rate is a rate that can be very sustainable and allow your body to still be really well fueled with protein, with vegetables, with whole grains, with healthy fat sources such that during your weight loss journey, you're meeting those micronutrient needs alongside your protein goals and alongside your weight loss goals. It is possible to do that, but as we drive our weight loss goals faster and faster, one of the things that happens, especially if we're using weight loss medications or bariatric surgery, is that we just have no appetite for anything. And so patients may be having almost nothing to eat, and that is not helpful. So the number on the scale looks better, but in terms of your nourishment and your actual health, you have not necessarily done anything to improve your health. So thinking about that kind of slow and steady one to two pound per week rate of weight loss. Now, the really interesting thing is that even for people who have moderate or severe arthritis, that losing weight really makes a huge difference in the way that their knees and their hips are perceiving that weight because those are weight bearing joints. As we lose weight, we feel that really significantly in our lower body. And interestingly, sometimes just a 10 or 20 pound weight loss can make a really big difference such that, okay, all of a sudden it's like, okay, I still may be planning for knee replacement or hip replacement surgery, but it doesn't feel so urgent. It feels like, okay, if I had to wait two months, four months, six months, that feels a lot more doable because all of a sudden as I've seen my body lose 10 pounds, or I've seen my body lose 20 pounds, my body is feeling better, I'm not feeling as much pain in my joints. And so that can be really helpful too. So spacing that out over a period of time, making sure that our bodies are feeling really well fueled. Now, the other thing, when we think about breaking down and building up, we think about metabolism. You can think anabolism. So anabolic steroids, for example, anything that is building our body up is anabolic. So when we think about recovering from surgery, that is going to be a process that we want to be anabolic. We want to be fueling our body, getting enough nutrients so that our body is able to build back up, recover after surgery. And we compare that to a catabolic process, which is a breaking down, and we think about losing weight. That is a catabolic process. And simply put, we can't be doing both of those things at the same time. So when we kind of rush weight loss, weight loss, weight loss, okay, boom, I hit my goal, let me go to surgery right away. We haven't really given our body a chance to stabilize and go back then into an anabolic state. So when we're thinking about weight loss, we do know that patients who lose weight and then define themselves at a maintenance weight for a period of time actually do better compared to patients who sort of lost weight and rushed into surgery. So what this looks like can look like a lot of different things. It can look like using medications to support your weight loss goals. It can look like bariatric surgery if that's something that's right for you and would fit your goals. It doesn't have to look like either of those two things, but it can. And so if you're wondering about those, it's great to reach out to a board certified obesity medicine physician, have a conversation with them about how would this support your goals? Is this something worth trying? Have a conversation even with your orthopedic surgeon. Is it something that I should work with someone to lose weight before surgery? And how can I do that? They may have some really great referral sources of physicians in the area who can help support you in weight loss before surgery, but my advice to you is this. We want to lose weight, but we do also want to reduce the risk of complications. We want to reduce that infection risk. We want to reduce that risk of wound healing issues. And so the best way that we can do this is a low, slow sustainable weight loss, one to two pounds per week emphasizing protein, emphasizing our micronutrients with lots of vitamins, lots of minerals coming from fruits, vegetables, whole grains and meats, and making sure that we're getting those so that our body is not just losing weight as quickly as possible, that we're actually nourishing and improving our health. And that goes a really long way in the recovery process. So the surgery, a lot of patients feel amazing after surgery, and we want to support people in really healing quickly from that, and that is absolutely possible. So hopefully this was helpful in learning why are those guidelines even in place and how can I apply some of this information to support my own weight loss journey? One of the things I love doing is supporting patients who are preparing for orthopedic surgery. I've worked with a handful of physicians or orthopedic surgeons in the Charlottesville, Virginia area to help support their patients as they're preparing for orthopedic surgery. And it's really amazing to be able to support someone not just in losing weight, but really improving their health. And I'll be honest, sometimes I'm worried some of the orthopedic surgeons may stop sending patients to me because they lose 10 pounds, they lose 20 pounds, they lose 30 pounds, and they realize that their knees, their hips are feeling so much better, and I'm like, they're going to stop referring if we're losing weight and improving their arthritis. But the fun thing is we can really support patients in optimizing not just the number on the scale, but really optimizing their health, helping them so that going into surgery, it doesn't feel so urgent. They feel like, Hey, I can do this on a timeline that really makes sense for me, that I can prove my health beforehand, that it doesn't feel so dire because my joints, maybe they're still aching, but it's just not quite as bad as it was before I lost some of the weight. And that as I go into surgery, I have not just a great number on this scale, but I've got my health alongside of me so that I know I'm going to put myself at the best chance of recovering from surgery. If you are interested in working with someone to support your weight loss goals during surgery, I love supporting patients in this journey. I see patients in my office in Charlottesville, Virginia, and by telemedicine throughout the state of Virginia and Illinois. And if you are elsewhere and you're like, I just feel frustrated. I want help connecting with a physician, reach out. I am always happy to help connect you with someone who is in your area, send you a resource so that you can feel comfortable in searching for and trying to understand who is going to be a great doctor to support you in your weight loss journey. And if you have made it through this whole episode and you're like, yeah, I don't have any arthritis at all. I was just really wondering about this, but someone in your life who is dealing with arthritis, someone who's dealing with knee arthritis, hip arthritis, even shoulder arthritis, has been told, Hey, it would be a good idea to lose surgery or lose weight before surgery. I would love if you could send this podcast episode to them so that they can understand a little bit more about where those guidelines came from and that they can get started and moving in the direction of their health goals. Thank you so much for joining me for today's episode. We'll see you all next week.