The Truth About Bariatric Surgery: Fact vs. Fiction

Caitlin Whyte (Host): This is Weekly Dose of Wellness, and I'm your host, Caitlin Whyte. With me is Dr. Bobby Gambhir, a bariatric surgeon from Memorial Care. Today we'll be discussing the ins and outs of weight loss surgery.

To start off our episode, Doctor, can you tell us what do most people get wrong about bariatric surgery and why do these misconceptions persist?

Bobby Gambhir, M.D.: Yeah, so it's a really good question, and I think a lot of it has to do with where a lot of people think that obesity is a willpower problem instead of thinking of it as a chronic disease, which it is.It's funny you asked this question because I get this question quite a bit. We actually see it on a daily basis. Patients obviously ask, and these are things that we come across.

So I actually wrote some of them down. The first of them, bariatric surgery is the easy way out. That's obviously incorrect. I remind all of our patients that we are obviously a tool in their toolbox. And the most important things are, which are the fundamentals are exercising and eating healthy.

So there's no easy way. We do help with the weight loss itself, but you know, there's going to be a lot more work to do even after the surgery itself is done. The second myth that I come across is that it's purely cosmetic, just about the weight loss. And so, you know, that's obviously also false.

We're lucky to live in Southern California. We're around all this fame and fortune. But, everyone wants to look good, feel good, but with weight loss surgery, it's not just about losing the weight, but it's about you know, improving outcomes. Your diabetes, your hypertension, sleep apnea, fatty liver disease, PCOS, infertility, mobility issues, helping increase your lifespan, decreasing your cardiovascular risk.

There's nothing to do with cosmetic and here it's mostly, but not only to improve your weight, but to improve a lot those other, you know, medical conditions. The next is it's dangerous and I kind of chuckle at this one. I've heard this one before.

This takes me back a little bit to my residency days and even prior to that, a lot of people were doing not to age myself in terms of my residency days, but it's just things I heard, obviously. Way back, several decades back, the bariatric surgery during his infancy and there were a lot of procedures that that we no longer do. And that, they had, you know, risks involved.

Now it's one of the most safest abdominal surgeries in the United States. The rates of morbidity mortality are actually very similar to even an elective gallbladder removal, an elective appendectomy. It's the same rates even for as I mentioned, morbidity and mortality. And sometimes they'll even quote less than 1%, and for some risks, even less than 0.1% So, it's extremely, extremely safe.

We are lucky that we do a lot of this and I, you know, that's some reassurance that I give to all of our patients. Safety is always our number one goal. The next myth that I come across is that you'll just gain all the weight back. And while it's true that you can gain some of the weight or you know, a very small percentage of weight regain is possible, that a lot of this weight loss is durable and we've seen with a lot of evidence-based evidence-based medicine and studies that you not only lose the weight now, but you're able to sustain that weight after, the future and keep that weight off. The next one I come across is, it's only for the extremely obese and, you may have watched this Caitlin on the show My 600 Pound Life. But unfortunately that sort of show created this idea that, you have to be that extremely obese to qualify for this sort of surgery, and that's not the case. It's usually for patients with a BMI greater than 35, with any comorbidity or BMI greater than 40. To put into perspective the average American now is between a BMI of 30 to 33.

So, it's not for those who are extremely obese. It causes malnutrition is another myth. And so with the more, you know, obviously that's incorrect with the more common surgeries we now do, including the gastric sleeve, there is no malabsorption component to it. And we are also very careful and cognizant of monitoring any sort of vitamin deficiencies and things like that. And that's something we continue to let our patients know, to continue to take their vitamins and things like that. And then the last one I come across, it's a irreversible lifestyle change. And patients will never, enjoy their food again.

That's you know, completely false as well. Patients can enjoy their food, socialize, live normally. The surgery changes the portion size, but not the joy of food. And, you know, we all love food and we get certain cravings. I, I'm a big, believer in moderation.

So no means am I saying you're going to be on a strict diet and it's mostly everything in moderation, just having a healthy lifestyle. Those are the common myths that I do come across on a daily basis.

Host: And with the rise of GLP1 medications for weight loss, Doctor, why is bariatric surgery still even needed?

Bobby Gambhir, M.D.: So with these GLPs, we have seen it rise throughout the United States. We've seen a lot ofpatients use it and for good value, and we've seen a lot of good outcomes. But I will emphasize, and I emphasize this to everybody, these medications are for a select patient population, and that's for people who have a BMI greater than 27.5 plus a comorbidity or a BMI around 30. I personally, you know, if a patient is trying to go for weight loss and their BMI is around 30, that's something of consideration. But people who are morbidly obese, such as our patients who have a BMI greater than 35, they simply, should not get this medication for several different reasons.

First and foremost is the amount of weight loss needed to get to the healthy BMI range of 25 and below, they would need to lose a lot more weight than what these medications do. These medications have a estimated weight loss of about 10 to 15%, whereas surgery itself has about 50 to 60% is that's what they need.

Unfortunately, a lot of patients will have this where they lose some weight at the start and then they weight plateau. And so that's a very common thing to see. In fact, we are seeing a, you know, we initially saw a decline in patient's coming to see us after the GLPs were introduced.

But now we're seeing a, a rise in these patients because they're taking these medications and not seeing the results that they want to. The second is side effects. No one wants to be nauseous all the time. No one wants to be feeling they need to vomit or even vomiting. That is a big side effect from these medications, including there's other's.

But those are, you know, the most common things that we see. And, next is the costs associated with these medications. So, it may sound like surgery can be all expensive and things like that. And just to reassure our listeners, you know, this is insurance covered. But, moreover, you know, when you look at not only the patient financial burden, but also the healthcare financial burden, there are studies including at the American College of Surgeons that have shown us that long-term weight loss surgery helps not only for decreasing weight and all the things we mentioned, but also financially it's a lot less. And then these GLPs are still in, it's in infancy. We've seen surgery that there is great long-term data of keeping the weight off. And that brings me into my final point of weight recidivism.

Unfortunately, with these medications, the moment you come off of them, the weight recidivism or weight coming back is over 90% chance, and that is quite high. I've seen even higher numbers. To inject yourself every day for that sort of thing, I'm not sure, that is, you know, the correct way to go.

And to have all that weight regained back you know, I would say or counsel, everyone, you want something durable that lasts a long time and then you can start proceeding with, you know, your lifestyle itself.

Host: And for those of us who may not understand how bariatric surgery works medically, can you explain how it actually supports long-term weight loss and metabolic health?

Bobby Gambhir, M.D.: Yeah. How I break it down is surgery and then the hormonal effects of surgery itself and then the behavioral aspects. So with surgery, you know, we have two different types of surgery, that we commonly do now. One is called a gastric sleeve, and the other one is the gastric bypass.

Both of them have a restrictive component, meaning they reduce the size of the stomach itself. So when you eat food, you get fuller. Then with the gastric bypass in particular, there's an absorptive component because you're bypassing some parts of your intestine, not a large portion, but it is some parts and as a result you're not absorbing as many calories or nutrients. But you are getting enough regardless. But it does also help on a hormonal level too. It changes levels in hormone called ghrelin, GLP, these alter appetite cravings, taste preferences.

There's also an improvement in insulin sensitivity and glycemic control. And that's why we see a lot of dramatic improvements in our patient's with Type 2 diabetes. And then, the final thing, which I think is extremely important is the behavioral reset after surgery or even before surgery.

This is a point that we make sure to emphasize, you know, this is a lifestyle change. And so we emphasize to our patients start developing these healthy habits, not only now, but for after surgery. And to foster long-term, habits. Another way I look at for the behavioral reset is, you know, I come from a South Asian background where food is, is at every single, celebration.

My mom, you know, is always asking you to take seconds, take thirds. We get into this,you know, habit of, of taking more than what we should take in terms of nutritional sustenance. So I think the surgery kind of gives us a reset to say, you know, this is what a normal serving size looks like, allows patients to learn those eating habits as well. And then the final thing is that, with behavioral reset is that it creates this cycle of improvement. You know, you're seeing yourself lose weight, you're more motivated to go to the gym, you're more motivated to exercise. And that cycle, which I kind of call a cheat code, that allows patient's to really excel.

Host: And another misconception is that patient's always regain the weight. Now, what does the evidence show about long-term success after surgeries?

Bobby Gambhir, M.D.: Yeah, the long-term research is very clear. People don't regain all the weight. It's very rare for someone to regain all their pre-surgery weight. The data shows us that, you may regain about five to 10%, even a little bit higher, in terms of that weight regain, but for the amount that you've lost, majority of that weight is kept off. And there are a lot of long-term studies to show that. There was a Swedish study that was has 20 year data. There's other studies that have 10 year data and they have shown that you will not only lose the weight early on, but keep that weight off, a majority portion of it. And again, you know the weight and regain, myth and all that stuff; this is where we really emphasize it's important to break away from old habits and to really improve on exercise and the healthy eating component.

Host: Can you talk about the lifestyle changes that happen after surgery and how they contribute to those sustained results?

Bobby Gambhir, M.D.: So surgery gives patients this kind of breathing room to build better habits. And it's the habits that keep the results. There's different aspects to that, and I mentioned already two very important things to me, even three important things so far, but one was the dietary changes or the nutritional intake.

You know, we really emphasize small portions. Single proportion sizes, high protein, you can have carbs, but they are complex carbs, avoiding those calorie dense liquids from high sugar foods, like from Starbucks or, things like that that, they might sound appetizing, but you know, over time those are those empty calories.

The next thing I mentioned is exercise. So not only Cardio, but also weightlifting and things like that where you're actually burning the calories, changing your fat into muscle and developing muscle mass. I tell my mom this every day. If you brush your teeth every day, you, you have to be hitting the gym.

And I say the same thing to all of my patients as well. And so that's just part of the lifestyle change. We also are telling our patients they have to continue to take their vitamins after surgery. It's very important to keep up with your vitamin monitoring. We do have regular clinic visits or follow-up with our patients as well to make sure that we can help in any sort of way.

And the biggest thing I think to sustain the results is going to be that behavioral or that mental health aspect. Having the right support system around you, having a supportive family, having a supportive group of, of people around that, that really help you with through tough times and through emotional aid and to kind of bring you up.

I think those really do help with sustained results as well.

Host: Now, what should someone know before even considering surgery? Are there specific qualifications or any red flags?

Bobby Gambhir, M.D.: So in terms of qualifications for surgery, historically and what we're still using for insurance specific guidelines is BMI greater than 35 with obesity-related comorbidities or a BMI greater than 40. Interestingly enough, our governing body at the American Society of Surgeons for Bariatric Surgeons, they have recently submitted new guidelines where these numbers to change to 30 and 35 respectively is what I mentioned. That is a qualification criteria that we usually use when patient's come to see us, they do have to go through a nutritional assessment, a psychiatric evaluation.

We also have them go to a support class. There's also a visit with their primary care doctor to make sure that they can undergo general anesthesia. It's also a general medication review. So it's a comprehensive evaluation for our patients before surgery as well.

And one thing, again, I emphasize, I know I, I keep bringing back mental health, but it's extremely important. Coming to see us for the first-time, I think is the most important step, making that decision to proceed with surgery thereafter, obviously, it is very important, but saying to yourself, Hey, I'm ready.

I've, tried whether that be GLPs, I've tried exercising, healthy eating. I saw a patient just a few minutes ago and just said, you know, I'm, I'm just sick and tired of this and I'm ready to make a change. So, we're obviously always available for questions and answers, but I think those are some considerations that you have to have before surgery, and that's some considerations we have as well.

And then red flags we look for any sort of underlying or unstable psychiatric illness, or untreated substance abuse, that includes alcohol or drug use. And the other important thing that comes to mind is any sort of medical comorbidity that would make it unsafe for surgery itself.

Practical things to consider for the future. You know, we do give them the full disclosure of life after surgery. You know, it's a one night, one day hospital stay. Most people take a week or two off of work if they're working. And we do help with patients with their disability if they need some sort of paperwork or anything like that for their work purposes.

The only other practicality thing that we bring up as well is that we just request for no heavy lifting for a few weeks after surgery. So they don't develop any sort of hernias. And we also plan for a close follow-up just to make sure that they're doing well. 

Host: And from your experience, Doctor, what are some of the most meaningful outcomes that you've seen?

Bobby Gambhir, M.D.: Yeah, I love this question. You know, I think of it objectively and then subjectively, one for objectively, we see patients that come to us with, you know, a tremendous amount of weight loss. That's great. But objectively as well, when we see their numbers, their hemoglobin A1C, getting to a normal range, their cholesterol improving their, blood pressure improving or, or, being normalized. Having patient's come to us, I've had several of them that come to us with a container of pills that they no longer take. That is extremely, extremely, extremely gratifying. We're not only helping our patients on a weight loss surgery perspective, but from a overall health perspective.

And that is something that motivates us every day. But what also truly motivates me is some of the stuff that I am, I'm available via social media of course, so I get messages, but it's these big wins that I call them our amazing patients, send us, and this includes patients telling me that they have no longer on their CPAP machine.

They're able to move around and they're independent. They can go on a hike with their kids without getting short of breath. I had one lady tell me that she's able to go on the beach with no self-critical concerns. And she's able to run on the beach and she was extremely happy about that.

I had another gentleman tell me that, you know, he was able to go on a rollercoaster ride and not, feel you know, sad and was able to enjoy it very comfortably. Something he enjoyed as a child and very much so. And he was very grateful for that. And similar for being on an airplane. One other thing that I love to hear is improvement in fertility and even pregnancy. We have a lot of patients that come to us with PCOS and our amazing patients are trying to get pregnant. With this weight loss, it allows them to bridge and eventually to get pregnant. So it's extremely, extremely, gratifying to hear that.

Host: I love it. Thank you for sharing. And if a listener is hesitant or scared because of those myths we touched on earlier, what's the one message you want them to take away from this episode?

Bobby Gambhir, M.D.: Yeah. So, I do want to emphasize that it is an insurance approved, extremely safe, evidence-based, procedure that has excellent outcomes. And again, as I mentioned, it is very safe. I don't want anyone to ever think that they're alone, during this process as we are there with them from day one, to even their ten year follow-up.

And always goes back to what is motivating them for surgery. If this has been something that they've had their whole life and they want to conquer, if they're doing this for their family members, with that in mind, I always say, you know, this is what you're doing this for, and just keep that in mind.

Because ultimately you're not only improving your health now, but you're improving your health for the future. And not only for yourself, but for your loved ones and your family members.

Host: And Doctor where can listeners learn more about the surgical weight loss program at Orange Coast Medical Center?

Bobby Gambhir, M.D.: You can always reach me. I'm always available, of course. But our website is memorialcare.org/swl.

Host: Thank you so much for joining us. That was Dr. Bobby Gambhir. For more information, please visit memorialcare.org/swl. If you enjoyed this podcast, please share it on your social channels and check out our entire podcast library for more topics of interest to you. I'm your host, Caitlin Whyte, and This is Weekly Dose of Wellness. Thanks for listening.