Coming up on Atthe Forefront Live, obesity is a verychallenging condition. People struggle with weight, and are often exasperated with a lack of results. Today on At TheForefront Live, we’ll look at bariatricsurgery alternatives, and how this can change lives. Here at UChicago Medicine, bariatric surgery programs are tailored for each individualto get the maximum outcome and benefit. Also today, we’ll meet onepatient “whos lost” over 80 pounds and gained controlover her diabetes. Lynn Yanow has quitea story to tell, and is a different person todaybecause of bariatric surgery. That’s next, on Atthe Forefront Live.[ MUSIC PLAYING] And welcome toUChicago Medicine, At the Forefront Live. This is your chance to askour professionals your questions by typing in thecomments division. We’ll get to as many as possibleover the next half hour. Remember, thisprogram does not take the place of an actualvisit with your specialist. Joining us today, we have two experts in bariatric surgery, Dr.Vivek Prachand and Dr. Mustafa Hussain. Welcome to the program. Thank you. First of all, justtell us a little bit about bariatricsurgery, in general, which is what that entails.I suppose a lot ofpeople, when they think of bariatric surgery, theythink, you’re just cheating, you’re not dieting, you’retaking the easy way out. But that’s really not the case. Thank you for the issues to. Bariatric surgery isbasically surgery– which necessitates manipulationof your parts and your stomachand your intestine– to really change the wayyour torso perceives hunger and when it feels full. It works by changingyour anatomy, but also your physiology, which is thechemical nature of your body’s rapport andunderstanding to food.And it works by mechanismsthat we partially understand, but not fully. And we’re definitelyworking on that. But it’s definitelynot cheating. It is for people who havetried various things before, but actually needadditional the assistance of us, in terms of losing heavines. And it’s really forpeople who are looking to lose 75 or 100 pounds. So, Dr. Prachand, why is it announced obesity or metabolic surgery, instead of weight loss surgery? I think that that’s areally good question, and I think it’ssomething that’s really changed in the fieldover the last 5 to 10 years. So the emphasisused to really be about weight loss in thepast, and so we would really be emphasizing how many poundspeople lost, and so forth. But the AmericanMedical Association, approximately five years ago, recognized obesity as an illness. And one of the thingsthat we’ve always recognized withthese operations is that, in addition to achievingthe weight loss, which is pretty substantialand sustainable, is the impact on the medicalproblems related to obesity. And so the importanceof thinking about obesity andmetabolic surgery is to really keep in mindand emphasize the fact that these operationsalso have the opportunity to impact all the differentmedical conditions that come along with obesity, such as diabetes, high blood pressure, highcholesterol, sleep apnea, severe seam problems.We even realise patients who mightbenefit from transplantation, but are too heavy to qualifyto undergo a transplant. Bariatric surgery canreally make a difference. We spoke to one patient whohad bariatric surgery now at UChicago Medicine, and here’s her story. And that has drasticallychanged my life , not to have totake insulin shots. I feel considerably better. Lynn Yanow was takingfour insulin shots a date. It was the only direction shecould restrict her diabetes. I feel betteremotionally, physically, and I’m particularly, very pleased. Now, Lynn is much lighter, andoff the majority of members of her medications, including thosefour insulin shots. As of today, I’ve lost8 0 pounds in six months. And I’m very excited about that. I would maybe liketo lose another 10, but everyone tells methat I should leave it be.Lynn chose the bariatricprogram at the University of Chicago Medicine, one of the leading programs in the country. She had the gastricbypass procedure, and is very happywith the results. The reason that I choseUniversity of Chicago Medicine is because they had aprogram, Dr. Hussein had a program to goalong with the bypass. You had to go to categorizes, you had to follow up, there was a whole plan. What differentiates usfrom everybody else is, I judge, our experience, our sense, and our comprehensiveevaluation of patients.UChicago Medicine offersmany options for weight loss. Some of those optionsinclude surgery. There’s sleeve gastrectomy, gastric bypass, and a procedure forextremely heavy patients– that is only done at about 1% of the centers in the country– that’s called theduodenal switch. As federal institutions, we areproviding a wide array of options for patients whoare trying to lose weight, whether it’s that 10 pounds youneed to lose after Christmas, or it’s that 200 pounds thatyou’ve accumulated over years.Each of these proceduresrequires a team approach. The patient will workwith several caregivers to assess their challengesand provide solutions. There is also follow-upafter the procedure, to make sure the patienthas the right support to keep the heavines off. So at a singlehospital stay, they will see the surgicalteam, they will see our bariatric dieticians, as well as our psychologist. And so it’s a one-stopshop, if you are able to. Weight loss isn’teasy, and the patients who participate inthe surgical curriculum have fought with theirsituations for years prior. But the positive newsis there is hope, and it can be a lasting change. Despite all of ourbiases, we don’t know why people are overweight.It’s easy to say they eatmore menu than they actually burn off. And while that maybe true, we don’t understand why some cases aremore efficient at burning off meat than others. Obesity is a complex issue. It will deal with yourgenes, what you’re eating, what your habits are, whatyour social behavior is, what your psychologicalsituation is. So it’s a complex issue, so itdoesn’t have just one solution. Surgery happens to bethe most effective way to help peoplelose weight, but we realize it doesn’tfunction in a vacuum.Lynn’s family is happywith her upshot, as well. It has changed herlife, and helped her to a healthier reality. Since I did the surgery, Ifeel much better about myself. I am much more confident, I do much more things. I do double-takes inthe reflect each time I go a window, every time. I perfectly is not believethat I look like this.And I feel very, very good about it. It’s an interesting narrative. And it’s fascinating to hearthe difference in her life, particularly with her diabetes. So to your pointjust a moment ago, it really does make asignificant health difference. And one thing thatyou touched upon in the video, Dr. Prachand– I required you to talkmaybe a little bit more about this– isthat overall proposal. It’s not just surgery, butthere are many different aspects and different things that peoplego through before the surgery and after. Talk to us a little bit abouthow that works, if you will. Sure. So as was alludedto in the video, we really have a truemultidisciplinary program. And what I intend by true, as to report to virtual, is the fact that we literally have ourdieticians and psychologists in health clinics with us. And we take turns seeingthe patients while they’re in the clinic power. And then we discuss andconfer amongst ourselves to really formulatea good game plan. So this takes placewhen patients come in for their initial evaluation.So we identify if there’ssome particular actions or education that we canwork on to really do people ready to besuccessful with surgery. And we also have the sameapproach in the aftercare. And all of thisis really focused on selecting thepatients that we think will have the bestchance of success with surgery, and get the best outcomesthat we can have after surgery. So really havingthat crew coming is I is believed that setsus quite a bit apart. And it really places the patientsup for success in the future. Utterly. So we want to remindour viewers that we are taking yourquestions, so sort them in the comments section. We’ll try to get toas many as possible. Let’s start off talkingabout the different kinds of bariatric surgery available. They were mentionedin the video, but if you could tell us alittle bit about exactly what he, and what they entail.Sure. So there are currently fourapproved bariatric surgeries that are played national. We are one of the onlycenters that actually offers all four different types of surgeries. The most common one beingperformed these days is something calledthe sleeve gastrectomy, or vertical sleeve gastrectomy. Some people call it VSG. This is a procedure that’sdone laparoscopically, which represents surgery throughvery small incisions. So most of the incisions areabout 1/4 of an inch or so. And this can be donewith general anesthesia, and most people actuallywind up leaving the next day. So the sleeve gastrectomyis a procedure which abbreviates thesize of your stomach by permanently removinga portion of it. So I like to tellpeople, if you think of your stomachlike a big handbag that you can stufflots of things into, if you were goingsomewhere over the weekend. By removing a portionof it, you mostly are shaving it down to wherejust the essential points fit in. So some people sayit’s a banana shape, or I like to sayfrom the big handbag, to maybe just like a smallpurse you would take to a party, or something like that.And so that increases thespace where you can fit food, but also we’ve learnedthat actually impacts some hormones in yourbody that are harmful to thirst and how full “youre feeling”. So it’s not that you feelhungry but can’t eat, but it actually changesthe relationship that you have with food. So that’s why it’sone of the reasons that it actually drives betterthan inhibiting yourself on a diet. So that’s currently themost common procedure. Another procedurethat’s accomplished, also laparoscopically, orusing the small incisions, is called the gastric bypass. Sometimes call it peoplecall it the Roux-en-Y. This is a procedure that’s beenperformed actually a long time for weight loss, since like the’ 60 s or something like that.And it has a reallyexcellent track record. Because it’s been around, there are some tales out there maybe that it was notsafe in the past, et cetera. But this is actuallyis not true. It’s a very safeprocedure, likely as safe as all the other procedures. And it has certainadvantages over the sleeve. And sometimes werecommended for parties with severe indigestion or reflux. We are also welcome to recommendit “if youre having” diabetes on insulin, such as the patient that was highlighted earlier. And it can be quite effective ingetting people off the insulin that they’re on. The other procedureis a procedure called the duodenalswitch, which is the procedure thatwe specialize in now at the University of Chicago. Dr. Prachand was actually theperson to perform it firstly, expending the minimally invasivetechniques here in the Midwest. And very few hubs aroundthe country perform it. It is a little bitmore complex procedure, but also has more payoffs. The duodenal switchis a procedure that opens you themost weight loss, particularly if you’re in thecategory of people who may need to lose around 200 pounds.And that’s people whose BMI– which is body mass index– is over 50. And likewise, it’s veryeffective for people who have very severediabetes, that ought to have diabetic for greaterthan 10 times on insulin. And can be a verypowerful course to treat that metabolic illnes, that combination of obesity and diabetes. The last-place procedureis something called the laparoscopicadjustable gastric strip. Technically we dooffer it, but it is a procedure that isbecoming sort of less popular these days, mainlybecause it is a device. It is subject tomoving and separating. And also we’ve seenover the last few years that the weight loss isnot as effective as some of the other procedures.And so it is a procedurethat is approved, but we are actually performingit less frequently, these days. Now, we are gettingquestions from onlookers. I want to get to those, and try to answer as many as we possiblycan during the program. First question, which you pretty much merely refuted but we’ll goahead and throw it at you again, anyway, whenyou were talking about the duodenal switch.This is somebodywho says, do you think a person whose BMI is over5 0 should think about surgery? And I predict, the question wouldbe, then, what types of surgery should they shouldthey first consider? And either one of youcan orbit that one. So you mentioned BMIof greater than 50. So again, BMI standsfor mas mass index. And we get that crowd bycombining summit and weight into a formula, and itgives a pretty good estimate of how much extra solid aperson has for their stature. It’s not a perfectnumber, and you’ll see a lot of news tales anda lot of complaining about BMI. But the reality isthat, unless you’re an NFL linebacker or aprofessional athlete, it actually does a prettydecent occupation of an assessment of this. So time to quicklyreview, a regular BMI is between 20 and 25. And a person is consideredobese if their BMI is greater than 30. And so we talk aboutsurgery for obesity when the BMI is 40 or higher, or if it’s between 35 and 40 and the person has othersignificant medical problems related to their obesity, as we mentioned earlier.So when we’re talking aboutBMI of greater than 50, that’s typically somebody who’s1 50 to 200 pounds overweight. And normally, and frequentlyassociated with that are those other obesity-relatedmedical conditions like diabetes, high bloodpressure, and so on. So in the past, whengastric bypass was the most commonoperation performed, say 15, 20 years ago, whatwas construed quite frequently is that patients who hadBMIs greater than 50 or 60, they frequently failed tolose fairly weight after they had gastric bypass, or they would regain a significant amount of weight. And that’s really whatprompted our interest in performing theduodenal switching, because historically, it seemedto be associated with a greater amount of weight loss. But there is hadnot been any head to honcho studies equating thetwo operations to determine which is actually moreeffective for this very difficult-to-treat group ofpatients with a higher BMI. So we did the first studycomparing is not simply the weight loss, but the impacton diabetes, high-pitched blood pressure, and high cholesterol.And we were the firstto find that there was, in fact, a significantadvantage for cases with higher than a BMI of 50. Now, that doesn’t meanthat every patient with the BMI of greater than 50 should have a duodenal permutation. And I think that one of thekey things that we really try to convey to ourpatients when they come for an evaluation, and what we really take most of their time in ourconversations and the consultations with patients, is figuringout what the right tool is for you, as private individuals. Because there’snot one operation that’s the best for everyonein all circumstances. And so it’s really aboutfinding the title coincide between the operationand the patient, taking to account thefact that each person has a different amount of weightthat they need to lose, each person has differentmedical conditions that are related to theirobesity, different side effects of the operations, and different effectiveness, in terms of weightloss and impact on these medical conditions.And so that conversationthat we have as the surgeon with the patientis really the key. So we’ve talked aboutpeople with the higher BMI. So we have a questionfrom a see, person without that height of BMI. And the question is, for someonestruggling to lose 25 pounds, would surgery be an option? Generally, probably not. Again, we don’t necessarilygo by how much force you’re overweight, but the BMI. So you would have tocalculate your BMI. But the minimum BMIis basically 40, which correlates toroughly around 100 pounds for people whoare normal height. Or an averageheight, I “re saying”. Or if you’re a BMIis over 35 and you have a medical conditionclosely related to obesity, such as diabetes, high bloodpressure, high-pitched cholesterol, or sleep apnea. Generally, if you’re about2 5 pounds overweight, you’re probablyaround a BMI of 30, again, if you’re anaverage meridian individual. And around that BMI, generally, the first recommendation would be intensivelifestyle modification, which is also the firststep for anyone who’s trying to lose weight.So that’s, generally, definition working with a professional, such as a dietician or a medical specialist thatworks with obesity medicine. Or maybe even a therapist or apsychologist that can help you lose weight. But having those regular visitswith professionals truly been shown to affectsuccess with people trying to lose weight. And that’s one of the nicethings about UChicago Medicine. We do offer serviceslike that, as well, so we can cover the whole range. How safe is bariatric surgery? So I think that there is alot of myths and concerns, when it comes to surgicalsafety with these operations. And again, this, I meditate, dates back to 20 years ago, when these operations reallywere considered to be risky.And frankly, there as alot of high-profile contingencies in the newspapers, and so forth, as the operations initially started to become more popular. But over the years, withmodifications and techniques and the managementof these patients, consuming laparoscopicapproaches, instead of the traditionalopen gash, which required apretty gigantic incision lengthening from the breastbonedown to the belly button. By using theseapproaches, and actually the management of theteam, the safety today in centers ofexcellence, such as ours, is very similar to patientswho have gallbladder surgery. Which is to say that it’sa very safe operation. We have more questionscoming from our viewers. I’ve heard hair losscan be a common side effect of bariatric surgery. Is there a behavior toavoid this, and does it taper off on its own? This can happen afterbariatric surgery, but it can happen alsoif you’re losing force with any other means. When you do lose asignificant amount of weight, particularly immediately, it isthe body’s natural response to sort of make sure it’s notwasting sources, if you will.And not that whisker isa litter of water resources, but mostly, itdoes require protein from your body to realize hair. So when you’re in that initialperiod of rapid weight loss, your figure “re saying”, let’sjust see what’s going on. Make sure we haveenough nutrients for essential offices. So it may shut down brand-new hairgrowth for a little bit, and that may come off asseeing that you’re losing hair. Generally, this is temporaryand perfectly recoverable. And it generally is notsignificant to a extent where others wouldnotice, but you may notice that your fuzz is thinning.Our dieticians, who arenutritional professionals that we work with, are verygood at counseling our patients through the said period, and spawning assured that they followed with theappropriate protein and vitamin recommendations that can reallylimit the amount of hair loss that they knowledge, andcertainly help with the mane regrow age. We’ve got a follow-upquestion to that. Let’s talk a little bit aboutthe vitamins and augments and things that parties willtake after a surgery like this. How long does that go on, and how substantial is that? So with all of the operationsthat we do, making vitamins is something that’s necessaryafter surgery forever. Each of the operationsis slightly different, to its implementation of the behavior thatthe body assimilates and manages different nutrients andvitamins, but in all cases, because of thatreduction in appetite and because there’s lessfood being take place within, if you don’t get enough in andif your body’s not assimilating in the way that ithad been previously, you’re at risk ofdeveloping deficiencies.So taking vitamins everyday is an important part of being as successful asyou can be after surgery. I like to tellpatients, you wouldn’t want to get atransplant operation and then not make yourimmune suppression remedy afterwards. And “youve got to” roughly lookat vitamins in the same way, after you have these operations. One of the commoncriticisms that parties will form when they talkabout bariatric surgery is, oh, beings will justgain the value back. Is that true-life? Or what do we do nowto try to prevent that? So if you look at, let’ssay 100 people who’ve had bariatric surgery, themajority of those patients– let’s say 5, 10 years afterwards– will be down from the initialpoint that they had surgery. So let’s say, if theyhad 100 pounds to lose, the majority of them– that’sover 50% of those patients– will be down 60, 70, 80 pounds.It is very normal, though, after the first time or two after the surgery, to regaina little bit of force. I tell my patients it’s kind oflike providing your thermostat. You should think ofsurgery as resetting your body’s thermostat of wherethe normal weight will be. So initially, you willlose a lot of heavines, and your mas will thenfind its brand-new steady state. And everyone is retrieves justa little bit of value back.And then it’s our jobworking with individual patients to make sure that thatlittle bit of force we gain, which is normal, stays at thatlevel, and doesn’t you know skyrocket back so people aregetting undue amounts of weight back. There are some cases thatdo addition a significant amount of force back, typically not tothe degree where they start off at. But if you if they’velost like 80 pounds, they may regain back3 0, 40 pounds, which is not a result that we wanted. And we absolutely workwith them to limit that. A major style to preventthat from happening is close follow-up withus, close follow-up with our dieticians, anda continued understanding that surgery, as wetalked about earlier, is not the easy way out. It is basically a toolto help you continue to do what you know youshould have been doing, which is modifying yourdiet, increasing your physical activity, and the everything else that we normally talkabout with weight loss.So here’s another questionright along those lines from a spectator. For those of us who havehad gastric sleeve surgery– this person was Juneof 2014 — they’ve gained some load back. They require some incitement orsuggestions to kind of get back on track. What would you tell somebody tojumpstart that process again, and how would you help? Sure.So the nature that I wouldbegin with that patient is made to ensure that they goin to see their surgeon, and re-engage with the program. Oftentimes, patientswill sort of drift away because ofjob converts, or they move and so on. And if they can comeback and realize their unit, that first step canhelp significantly. Generally, what we would doin that sort of circumstance is make sure that there’s notany sort of anatomic question that might be contributingto the weight re-gain. And at the same time, wewould have a full assessment by our dieticiansand our psychologists to made to ensure that the diethasn’t wandered or shifted in a negative direction. And genuinely kind of re-educatingand really getting back on track.And to be honest, Ithink that that’s really where the value of thelong-term follow-up comes in. Because the reality isthat nobody can be perfect every single day, multiple times a day for the rest of their lives. We kind of use a ratio of, ifyou do the right thing 80%, 85% of the time, you’regoing to be fine. And being happens. And there’s things that happenwith regards to employment, relationships, and soforth, and stresses that can lead to peoplekind of getting off the road a little bit. And we’re here for ourpatients to really get them redirected and re-engagedand moving forward again. Here’s another observer question. Not sure why thisone is being asked, but I’m going to go go aheadand throw it out anyway.They want to know what formof vitamins would they make. Chewable, gummy, or capsules? That’s actuallya great question. After bariatric surgery, we are, generally, altering the anatomy. So the road some thingsare absorbed or taken up by your person is alittle different. And that’s partiallyhow the surgeries manipulate. So after certainprocedures, we do solicitor our patients to make vitaminsthat are absorbed better. Sometimes the gummyvitamins, those are vitamins that canbasically dissolve in water. You ruminated them inyour saliva or spit, and they dissolve andyou can swallow them. And that’s adequate forsome of the vitamins. But some vitaminsactually are not well absorbed in thatformat, and we may then recommend different combinationsor formulations of vitamins that are better absorbed.Some vitamins, youmay notice, come in a little droplet ofoil, and those may not be good aftercertain procedures. So we and our dieticians comeup with an individualized plan for each patient basedupon the surgery they had, and too, actually, their pre-vitamin stages. You may have noticed inChicago that it’s actually pretty cloudy today, so thatmeans vitamin D heights are low. And actually, most people, actually even before surgery, come in with somelow vitamin ranks. And what we do is we actually, before your surgery, check all those levels, come upwith an individualized plan about what your vitaminregimen should be based on that and the surgery you’ve had.So each patientwill vary somewhat in what they’ll haveto do, and how they’ll have to take it. So here’s aninteresting question. How do you made to ensure that peopledon’t lose too much weight? I don’t know if that’s evera concern with cases, but how would you direct that? Well, I think that itis a realistic concern. I guess patients allhave in their brains sort of what they would considerto be a target or a objective heavines, if you will.And I would saythat the first step is you have the writeoperation to begin with. As I said previously, there’s not one operation that’s best for everyonein all circumstances. And it’s really that initialdetermination and decision that we come together withthe patient about the surgery a choice that willsignificantly determine , not only the risk oflosing too much weight or also not losingenough value. So truly determining thatsweet smudge in between. So are there certainfoods or boozings that will be off limitsafter the surgery? That’s a great question. So again, it sort of dependson the type of procedure you’ve had. In general, numerous people comein thinking that, oh, gosh, I’m going to have to eat babyfood for the rest of my life, or just imbibe liquids.That’s actually not true at all. Our goal is to get you to eatnormal, health meat again. And about three months afterthe surgery, consistency-wise, there’s really no regulation. So you can eat vegetablesagain, you can eat meat again, all those things. But we do counselyou on the different types of foods you should beavoiding, and foods that work against the weight loss. So a high-carbohydratediet, that’s, again, a great deal of starches, flour rice, pasta, potatoes. Anything that has that sortof grey dye and compatibility is generally to be avoided, chiefly for weight loss. Sugars, sugarythings, sweet things. Again, worksagainst weight loss, but sometimes can constitute youfeel complaint after certain types of surgery. So if you eat something that’svery sweet or high concentrated in sugar, that, again, may not agree with you, and also is not goodfor weight loss.Generally, we tell people toavoid carbonated beverages. That’s things likesoda, brew, pa. Again, because as thatgas expands in the stomach that maybe a little smaller, or in your entrail, that can be uncomfortableand not build you feel well. So I would saythings to be avoided are carbonated beverages, high-pitched carbohydrates, and then high-carbohydrate nutrients. We’re about outof experience, but I do want to ask thisone last question, and it’s concerning insurance. Patently, if you’re goingto have a procedure done, there’s always some concernfrom the patient’s position on whether or notsomething like this would be included in guarantee. Can you speak tothat a little bit? Yeah. So I think that there’sa perception out there that these operations arecosmetic, and in many cases, cosmetic operations arenot covered by insurance. But I think it’sreally important to understand that theseobesity and metabolic operations are not cosmetic.As Dr. Hussain alludedto, these things actually vary the physiologyof the body and contribute tothe weight loss, as well as to the improvement inthe medical conditions related to obesity. And because of thatmedical facet, most insurancecompanies actually do cover obesity surgery. Although the individual patienthas to look at their plan to see if it’s a treated benefit. It turns out that, with thereduction in medications and the overall addition andhealth that takes place after these operationsin the long run, it’s actually a costsavings to the health care system for individuals toundergo these operations. That determines excellent impression. Well, gentlemen, thank you very much. That was great. Thank you. Appreciate it. That’s all the time we havefor At the Forefront Live. Thanks to our guestsfor their participation in today’s program, and thanks to you for watching andsubmitting questions. If you require more informationabout bariatric surgery, please visit our websitesite at uchicagomedicine.org, or you can call 888 -8 24 -0 200. Join us for our nextAt the Forefront Live, where we learn aboutminimally invasive robotic cardiac surgery.That’s Monday, February 4th. Likewise check out ourFacebook page for future At the Forefront Livedates and subjects. Thanks for watching, and have a great week.