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Surgical Weight Loss Options in 2009 Webcast

January 13, 2009 Alex Nagle, M.D.

Verlina Ammon Please remember the opinions expressed on Patient Power are not necessarily the views of Northwestern Memorial Hospital, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Introduction

Andrew Schorr: It's no secret that obesity is an epidemic in this country. For some, weight loss is

easy, for others it can be a lifelong battle. If you've tried everything else, how do you know if weight loss surgery is right for you? Hear the answers from a renowned expert next on Patient Power sponsored by Northwestern

Memorial Hospital.

Hello and thank you for joining us once again for Patient Power. I'm Andrew Schorr broadcasting live as we discuss with sponsorship from Northwestern Memorial Hospital every two weeks significant medical topics. Now, if you look around at any

group of people in America now you will see a substantial number of people who are overweight, and some people are very overweight, more than a hundred

pounds, and it may have come over many, many, many years. And they have tried diets, they've tried this, they've tried that, trying to lose the weight. Well, when you get to the point where a reasonable approach is to have surgery, bariatric

weight loss surgery, to once and for all lose the weight and keep it off and maybe give you back the hope of a full life, and what about if you've developed diabetes

can also be an approach to try to get you off a whole range of diabetes treatments. A Patient’s Story

We're going to discuss that tonight with an expert from Northwestern Memorial

Hospital, but as I always like to do, I want you first to meet somebody who has lived this whole situation, and that brings me to Verlina Ammon, who lives about three miles north of Northwestern Memorial Hospital on the north side of Chicago.

She's 50 years old. She's worked at an inner city mission for years, and along the way she struggled with depression. Throughout her lifetime she had yo-yo diets.

She tried several types. She'd lose the weight, she'd regain it. It's really been a lifelong struggle, and nothing was really working. Well, she developed the things that can go along with being overweight, high blood pressure, diabetes, asthma and

sleep apnea. And her weight got up to 363 pounds, so much so that for about four and a half years she was in a wheelchair. She could not stand up very long, no

stamina. It was quite difficult. Well, that led her to Northwestern and a discussion about whether weight loss surgery would be right for her.

Verlina, welcome to Patient Power. It seems like the situation you were in and the frustration you must have had, that was really tough.

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Verlina: Yeah, it was very hard on me, just overall any daily living things that I had to do

were just about impossible at that weight.

Andrew Schorr: Now, I've done some programs on this topic, and when I've talked to people who have found themselves in that situation they'd feel, maybe not with family and

friends but just with people on the street, like they were just sort of fading away, like they were becoming invisible people, so it just makes you more sad. Did you

feel that way? Verlina:

Yeah, I did. People wouldn't look you in the eye. They wouldn't look me in the eye or they would just kind of walk away from you. It was like you weren't even there

anymore. I think a lot of times people don't know how to address overweight people and just realize that we're people like everybody else but we have problems with our eating for various reasons.

Andrew Schorr:

What do you think was at work that had you gain the weight over so many years? Was it depression, anxiety, some frustration about something? What do you think fueled you gaining the weight?

Verlina:

Well, I was never a person that did drugs or anything like that, and I think definitely my depression, I had a lot of losses early on in my life, and I think it was

the way I dealt with things. I just kind of isolated and I would eat, and you know a lot of times we as parents would fix foods to make our kids feel better and I think I kind of picked up from that with my mom. And I think definitely I'm an emotional

eater and I can also be a compulsive overeater, so those are the things that I faced.

Andrew Schorr: All right. Now, someone doesn't go into weight loss surgery lightly, and I know at

Northwestern, at the best programs in the country they really screen people carefully. There's a lot of discussion about is this right for you and what's going on

emotionally, and the surgery is just part of it. Tell us a little bit about what you did with help from various players at Northwestern to try to come to a decision that surgery could help and how you prepared for it.

Verlina:

Well, a lot of it was definitely they have a wonderful team there between the nutritionists you meet with, you take classes to learn how to eat and the things that are important like our proteins and vitamins and things like that. And then also

they have health psychologists on board there that will meet with you and can help you know if you are ready for the surgery psychologically too. Because if you're not

ready to make the drastic changes and the things that you have to do it's kind of


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silly to have surgery. So you have to go to them and actually be cleared for surgery through the psychologist as well. And they do have informational

meetings, and now as a patient who has had the surgery I sit during the informational meetings on a panel up front, and it's all people who have had

surgery and the people that are inquiring can ask any question they want of us, so that's another part of the team.

Andrew Schorr: You had the surgery, and we're going to talk about which type…

Verlina: I had the Roux-en-Y laparoscopic gastric bypass surgery.

Andrew Schorr:

All right. We're going to help people understand what that is. But that was in September of 2007.

Verlina: Yes.

Andrew Schorr: And then almost a year later you had plastic surgery where I think first I think you

had hernia surgery and then you had other surgery maybe getting rid of some skin flaps as well, tummy tuck?

Verlina:

Yes. Andrew Schorr:

So you had that. And let's talk about where you are now. What is your weight now, Verlina?

Verlina: Right now I'm at 169 pounds, so I have a total weight loss to date of 194 pounds.

Andrew Schorr:

Wow. And how do you feel? Verlina:

I feel fabulous.

Andrew Schorr: Let's talk about one other aspect I just want to get to, and then I want you to tell us more about your quality of life. You were in serious, serious diabetes treatment

before. So when your weight was 363 pounds, tell us about the diabetes medicines you took.


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Verlina: At that time point I was on four shots a day, and I was taking 300 units of insulin

per day. I was also taking 2,000 milligrams of Glucophage a day, 1,000 a.m., 1,000 p.m. And then I had also started on Actos. I don't remember the dosage of

that, but that was the diabetes medication. Andrew Schorr:

And now what diabetes medicine do you take?

Verlina: Absolutely nothing.

Andrew Schorr: Wow. We're going to hear more about that. And I interrupted you earlier when

you just talked about generally how you feel and what you can do. Tell us about that.

Verlina: Well, I'm absolutely not using the wheelchair anymore, and I'm able to walk to my

appointments and walk to the bank, and I never could do that before. I couldn't imagine walking to the end of my block, let alone walking all over downtown or, you know, just in my neighborhood, so that in itself has been wonderful. I'm still

not doing a lot of heavy exercise because of the more recent surgery, but I'm slowly working in and building up my stamina. So I'm feeling really good.

Andrew Schorr:

Verlina, I know you had an emotional reason among, you had a number of them but one related to a child that really propelled you to want to get well. Tell us about that child and the time you enjoy with him now.

Verlina:

Well, I have a godson who is six years old and part of the reason, when he was just a couple years old I thought I want to be able to watch Nolan grow up and become a man, and at that point I couldn't go to the park to play with him. I couldn't sit on

the floor to play cards with him. There was so much I couldn't do, and I really wanted to be a part of his life. And since the surgery and I've lost the weight I've

been able to just enjoy time with him and sit on the floor and play with him and do things like that, and that definitely has been a motivator for me.

Andrew Schorr: Sounds like you've been getting your life back.

Verlina: Yes.


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Andrew Schorr: That's a true blessing, and it sounds like Northwestern has been a good resource

for you.

Verlina: Oh, absolutely. I tell people I've taken my life back with a vengeance.

Treating Diabetes with Weight Loss

Andrew Schorr: Good for you. Well, let's meet one of the players who has helped you do that.

And as I introduce him I want to mention that we welcome calls from our listeners and here's the phone number to call. 877-711-5611. And you can send an e-mail

in to me and our producers to nmh as in Northwestern Memorial Hospital, [email protected]. [email protected], and we'll get to your questions along the way.

Now let's meet one of the people who has really helped Verlina, the bariatric

surgeon, Alex Nagle. Dr. Nagle is a GI endocrine surgeon on the medical staff at Northwestern Memorial Hospital, and he is an assistant professor of surgery at Northwestern University's Feinberg School of Medicine. Well, Dr. Nagle, you've

heard Verlina's story and hopefully it's been repeated many times, but it must make you and your team feel terrific.

Dr. Nagle:

Absolutely. Verlina's story is really incredible, and it really does exemplify what bariatric surgery is all about. It really is not about just the weight loss. It really is about treating the medical problems, the diabetes, the hypertension, and improving

the quality of life. And even another issue that wasn't touched on is improving life expectancy. So I think a lot of people may view this as simply weight loss surgery,

but we really realize that it goes well beyond that. Andrew Schorr:

Oh, certainly. And as we rattled off the conditions that Verlina had, high blood pressure, diabetes, sleep apnea, which I know there can be connection with

long-term heart problems, and asthma, all that is really serious. Now, help us understand this connection with diabetes and how losing the weight could resolve the diabetes. That's a new one. I don't think we've discussed that before.

Dr. Nagle:

Yes, this is really exciting news. And it really is interesting that this was really observed, bariatric surgeons even in the 1980s and 1990s were observing that after gastric bypass that the diabetes would resolve. And the thing that was really

fascinating is that the diabetes would resolve within weeks after surgery and it was really almost independent of the weight loss. And we now have a better

understand of diabetes, and we realize that a lot of what's creating the insulin


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resistance is relating to the gut hormones and by altering the anatomy of the GI tract which happens in gastric bypass that's altering the gut hormones which is

improving the insulin resistance without, even without weight loss. And then clearly the weight loss on top of that is going to improve the diabetes as well.

So just as a treatment for diabetes it really is a very effective therapy for diabetes. We see 90 to 95 percent of patients who have diabetes before the surgery, and

then after surgery their diabetes is in remission. And it's really been a really change where traditionally diabetes, everyone talks about controlling diabetes, just

trying to control it, and now we're talking about remission of diabetes. And just to add another point, and that's really been one of our big challenges is educating the public and primary care doctors that this is a very effective therapy for diabetes.

Andrew Schorr:

Wow. It's just amazing. I just want to get a comment from Verlina. Verlina, when your diabetes resolved like this that must have been amazing to you.

Verlina: I've definitely celebrated that. And also with the high blood pressure and

cholesterol I was on three blood pressure medications. I'm off all those as well, and I'm off the cholesterol meds, too.

Andrew Schorr: Whoa, this is just amazing. Go ahead, Dr. Nagle.

Dr. Nagle:

Yeah, I was just going to add diabetes, in spite of the medical advances that we've seen in diabetes over the years it's still the leading cause of blindness and kidney failure requiring dialysis and amputations, so diabetes is a progressive, bad

disease. And this is again a very effective therapy.

Andrew Schorr: All right. We have got many calls.

We're going to take a little break, and when we come back we're going to help understand the different procedures that are available now. Which one Verlina had,

she mentioned that, and is there one procedure that maybe has been studied particularly for people with diabetes. We have loads of calls coming in. I'll give the phone number again. You may have to wait a little bit. We just want to discuss

this and then we'll get to your questions. But the phone number is 877-711-5611. Or send an e-mail to [email protected]. We'll be right back with much more

Patient Power sponsored by Northwestern Memorial Hospital. Andrew Schorr:

Welcome back to our live webcast as we're discussing surgery for weight loss, but we're trying to help you understand it for diabetes, where does it come in, and also

that surgery is just part of it. There's a lot of counseling and evaluation that goes


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on up front. There's a lot of hard work that goes on afterwards and throughout your life. We're going to discuss that. Our expert with us is Dr. Alex Nagle, who is

a gastrointestinal endocrine surgeon on the medical staff at Northwestern Memorial Hospital. He's also part of great team that helped Verlina Ammon as her weight

went down from 363 pounds in October of 2007 to now, nearly 2009, let's see, what did it go down to Verlina? 169 pounds.

Verlina: Yeah, 169.

Andrew Schorr: Yeah, lost a lot of weight. Okay. So, Dr. Nagle, let's just go through some of the

different approaches to surgery. So she mentioned Roux-en-Y. Did I get it right? Is that the name of the surgery that she had?

Dr. Nagle: That's right. Roux-en-Y gastric bypass.

Andrew Schorr:

Okay. And I know that there are aspects of that that relate to helping someone with diabetes. Help us understand what that procedure is, and what is the connection with that as far as diabetes management.

The Procedure

Dr. Nagle:

The gastric bypass surgery involves basically two parts. The first part is to divide the stomach which is normally the size of a football and creating a small, little stomach about the size of a golf ball and then restructuring the small intestine and

connecting the small intestine to the new small stomach so therefore the food will go into the small stomach and then straight into the small intestine and basically

bypass the large stomach. The main mechanism is that it restricts how much you can eat because that little stomach will only hold so much. If you eat too much or too fast it will come right back up.

And then also some of the benefits that we've spoken about as far as altering the

anatomy is really what's beneficial with the diabetes. And one of the big advances over the last seven years has really been that this operation can now be done laparoscopically with small, little incisions which really expedites the recovery, the

amount of pain. Patients come in on Monday and then are usually discharged from the hospital on Wednesday, two days later. So we really have come a long way as

far as our surgical technique and being able to do it safely and with small incisions. Andrew Schorr:

Verlina, how long was the recovery for you?


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Verlina: Well, you're up and moving before you leave the hospital and pretty much off pain

pills after a few days at home, so it was pretty quick overall.

Andrew Schorr: Good for you. Now, there are other kinds of procedures that are advertised, Dr. Nagle. LAP-BAND is I know a brand name, but that's been mentioned a lot, and

there's a competing approach, band REALIZE, made by another company. What are these procedures?

Dr. Nagle: That's right. So in the United States there is really gastric bypass and the

adjustable gastric band are the two procedures being performed. The gastric bypass has been around. It was first performed in the late 60s, so it's been around

for a long time, and we have a great deal of long-term data regarding the gastric bypass. Over the last five, seven years we have seen the adjustable gastric band, and it is a good alternative, and both operations have pluses and minuses. And

that's really one of the most common questions I get is how do I determine which one is going to be best for me.

The LAP-BAND or the REALIZE band are very similar, and what they involve is placing a silastic ring around the stomach, around the top portion of the stomach,

and this ring or band has a special balloon on the inside of it which is attached to a port. And this port sits underneath the skin. The port can then be accessed with a

needle. This can be done in the office, and then we can fill the port or the band with fluid to make the band tighter or we can take some of the fluid out to make

the band loose. And the band works by a similar mechanism in restricting how much one can eat. And by just eating a small amount is creates a sense of fullness. So the band procedure is a safer operation in the sense that we're not

having to cut or divide the intestine. We're not rerouting it. It's less invasive, but in general the band procedure is not going to be as effective on average. So there

really are I think definite pluses and minuses to each. Listener Comments

Andrew Schorr:

I know we're going to talk a lot more about it as we go, but we've gotten a lot of calls. Also I want to tell people you can send an e-mail, and so that's another way to get to us. And the e-mail address is [email protected].

[email protected]. Tracy has been holding on the line quite a long while. Tracy, welcome. Where are you calling from?

Caller: I'm from Chicago. I'm a patient of Dr. Nagle's, and I had mine done August 20th,

2007. And I have lost a total of 102 pounds, and I've dropped from a 24 to almost a ten in about 13 or 14 months.


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Andrew Schorr: Wow. And how are you feeling?

Caller:

I am feeling fabulous, and I wanted to thank Dr. Nagle so much. He is such a wonderful doctor. And Verlina, I'm so happy to hear that you're doing so well.

Verlina: Thank you, Tracy.

Caller: The support groups that I have been going to once a month have really helped.

Andrew Schorr:

Well, let's talk about that with you and Verlina for just a second. I think that in America we like to think, well, you have a medical problem, you take a pill and you get better. Or maybe if there's a surgery, it's kind of like you need your knee

replaced or your hip replaced, and it's going to be fixed and away you go. With weight loss surgery that's not it, right? And the support and ongoing work that you

have to do is not insignificant. Wouldn't you agree, Tracy? Caller:

You have to take it upon yourself, and you have to really work hard at it. And what I've done is I really put my mind to it, and I basically have done everything that Dr.

Nagle has asked me, my nutritionist has asked me. And I wouldn't have been where I am today if it weren't for the surgery.

Andrew Schorr: Right. Plays a key role. We're going to let you go, Tracy.

Caller:

Okay. Andrew Schorr:

Keep listening. We've got other people who are waiting. Thank you so much for being with us.

Caller: Thank you, Dr. Nagle.

Dr. Nagle:

Thank you, Tracy. Thank you for calling. Caller:

You're welcome. Bye-bye.


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Andrew Schorr: They love you, Dr. Nagle. It's life changing. But I know it takes a team. We have

another caller who's holding I think still. Angie is on the line with us. Angie are you there?

Caller: Yes, I'm here.

Andrew Schorr:

Where are you calling from? Caller:

I'm calling from Washington State.

Andrew Schorr: Okay. Well, I'm based in Seattle, too. Where in Washington State are you?

Caller: In Everett, Washington.

Andrew Schorr: Okay. So tell us a little bit about yourself. Why are you interested in weight loss

surgery. Is it something for you that you're thinking about?

Caller: Actually, I'm not, but Verlina is a good friend of mine. I was very overweight as a

child and actually through part of my adulthood, and I can totally see how you can end up having this done, and I'm so excited for her.

Andrew Schorr: Well, let's talk about other ways to lose weight for a second. Verlina, you tried a lot

of diets and they just didn't work for you, right? Verlina:

Yeah when the Cambridge diet came out in the 70s I did that. I've done the cottage and pineapple diet. I've done the Reader's Digest cabbage soup diet. So

I've done a bunch of those, and always I put on that weight plus more again, so. Andrew Schorr:

So here we are at the beginning of the year, and I've been watching Marie Osmond and the parade of people who look mahvelous on TV, you know. And I imagine that

might work for 20 pounds or maybe even 30 pounds, but when you get over 100 pounds something got you there and it's got to be really tough to lose it. Dr. Nagle, help us understand the thinking about medical management of weight

versus surgical, and where is there sort of a crossover. Help us understand that because certainly if you turn on the TV, while there are ads certainly for weight loss

surgery there are lots of ads for weight loss programs.


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Dr. Nagle:

Right, and I think you're exactly right. I think when you are 100 pounds overweight, which is typically what we're talking about as far as the minimum

weight criteria for weight loss surgery, it is very difficult to lose weight. And that's typically when diabetes sets in, which makes it even more difficult to lose weight. Joints problems make it very difficult to exercise, and it become as very vicious

cycle, a downward spiral basically, and it's very hard to break that cycle. The data is very clear that one to two percent of people are able to have long-term sustained

weight loss. So you basically have a 99 percent failure rate with diet and exercise. The typical patient I see, their weights yo-yo. They've tried every diet. They lost a

hundred pounds on a certain diet, but then one year, two years later they've gained the weight back, if not even more weight. So it's very, very difficult, and that's

really the message that we're getting or that people are being told. You just need to eat less, exercise more and you'll be okay, but the reality is that if you need to lose 100 pounds or more that just doesn't work. And that's been one of the

rationales for surgery is nothing else works.

Andrew Schorr: Wow. Well, we're going to talk about this whole picture as we continue. Want to thank Angie, friend of Verlina's for calling in. We do invite your calls, and Debbie

has been standing by. We'll get to her in a little bit. And you can call us again at 877-711-5611. 877-711-5611. Or send us an e-mail as many people have to

[email protected]. We're visiting with Dr. Alex Nagle, bariatric surgeon from Northwestern Memorial Hospital, Chicago, and Verlina Ammon, who has made

tremendous progress. We will be right back. Andrew Schorr:

Welcome back to our live webcast, Patient Power sponsored by Northwestern Memorial Hospital. I'm Andrew Schorr. I want to mention we do programs like this

with Northwestern every two weeks. We've been doing it about two years now. There's a vast library of programs in the ihealth.nmh.org website. So please take a look.

Also in two weeks we're going to have on a plastic surgeon who helps people, you

know, nine months or a year later after weight loss surgery reshape their body. And Verlina had a tummy tuck. We're going to have Dr. Victor Lewis with us. We'll also discuss total body lifts, and some people have these huge flaps of skin

removed. And while that's not a weight loss strategy Dr. Lewis will tell you how that may mean in some people losing another 30 pounds that way. Imagine how

much skin that is. It just doesn't spring back into shape so sometimes it needs to be cut out. But there are cost concerns too because typically insurance doesn't cover it. That's in two weeks from tonight.

Now Debbie is with us on line five. Debbie, thank you for calling in. Where are you

calling from, Debbie?


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Caller: I'm calling from Chicago.

Andrew Schorr:

Okay. Tell me about your connection to this topic. Why are you interested? Caller:

Well, I put on the webcast as I was giving my kids a bath, and I went back to the computer just in time to hear Verlina talk about her godson, Nolan, who is my son.

And so we just wanted to call and tell Verlina how proud we are of her. And Nolan just wants to say something.

Young Caller: I love you, Verlina.

Caller: I love you too, Nolan.

Andrew Schorr:

Oh, that's terrific. Verlina, that's what it's all about, isn't it? Verlina:

Yeah, it is.

Andrew Schorr: Okay. Well, Nolan, thank you. Time for a bath and get ready for school tomorrow.

Now, what grade is Nolan in? Caller:

He's in first grade.

Andrew Schorr: Yeah, okay. Well, I've got a little rug rat running around here too. All the best. And, Debbie, thank you for calling in.

So let's talk about that for a second with you, Verlina. The family and friends

support-- Verlina:

Yes.

Andrew Schorr: --is wonderful, isn't it? I mean you need it to really get through because it's a major change for the person who has now decided to go through surgery, and you

have plastic surgery and you're trying to get your life back. That emotional support makes all the difference, doesn't it?


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Verlina: Oh, it's 100 percent. My sister was here. She just went back to Oregon on

Saturday. She's been here to see me through the two surgeries, and her support has been great. And then my family here at the mission where I live, like Nolan's

family, and the family that I'm involved with here, the Bylock Family, have been very supportive. And Hilda, my friend, has come up and when I had to have with wounds redressed that have opened up after the tummy tuck she came faithfully

twice a day to change my bandages. And I mean just overall the support has been tremendous, and it's definitely a big part of your success.

Surgery Preparation and Education

Andrew Schorr: All right. That's part of it, and a big part it. And then also there are people for

instance at Northwestern. Dr. Nagle, let's talk about this. We're giving you a lot of credit as the surgeon, but there is quite a substantial team related to weight loss surgery, evaluation, recovery. Tell us about the other members of the team. Who

are some of the players? I know dieticians, exercise physiologists. Help us understand what it take to really support people.

Dr. Nagle: Right. Well, unlike a lot of surgeries this is a surgery where we really spend a lot of

time really preparing and educating the patients to really kind of know what they're getting themselves into, and that's really the key is preparing them. And the two

biggest components are the psychological component and the dietary changes that are going to be associated with the surgery. And so that's where the majority of

the time is spent. And then there's also the medical, the routine medical clearance, making sure the

diabetes is in check, the blood pressure, the heart. But really it comes down to preparing for the dietary changes and the psychological changes. And I think the

biggest thing that we really like to stress is that first of all this is not the easy way out. This definitely is very difficult, and it requires really a lifetime of commitment. And surgery is the tool. It would really be a mistake to just rely on the band or to

rely on the surgery as the sole source, and it really is a tool that's combined with diet and exercise, but when it is combined and followed it can be very, very

effective. And I think that's really what we want to stress is that it's a tool. Andrew Schorr:

And it may really lengthen somebody's life, because we talk about people, obesity, morbid obesity I think you can call it, where it shortens somebody's life, whether

it's diabetes or heart problems or all the things that can go with it, stroke, etc. We have a lot more questions. I want to take a couple of e-mail questions and then we'll get back to the phone.

Verlina:

Can I say something really quick, Andrew?


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Andrew Schorr: Oh, Verlina, please. Go ahead.

Verlina:

As far as the life expectancy, at the time of my surgery I was told I would be lucky if I lived another three years.

Andrew Schorr: Oh, wow.

Verlina: With all of my stuff, so at that point the risk of surgery, you know, you could

possibly die in the surgery being overweight and with all the health issues, but I definitely would die in two, three years if I didn't get things taken care of.

Andrew Schorr: Now we have the hope that you're going to dance at Nolan's wedding.

Verlina:

Oh, absolutely. Energy Levels Post-Surgery

Andrew Schorr:

And he's just six. Okay. All right. Let's pose some questions. As we go through these questions and take others on the phone, I want to mention that we can't ask

Dr. Nagle to be somebody's doctor over the internet and on a talk show. That wouldn't be fair to anybody. So you've got to consult with your own doctor. If you're in the Chicago area and you're looking at this certainly I'd urge you to check

out the program at Northwestern, but wherever you may be in the sound of my voice, if you will, you need to have a personal consultation with a qualified

program. Here's a question we got from Omaha, Nebraska from Conner, and Conner is

talking a little bit about the post surgery recovery, Dr. Nagle. He said, "I had gastric bypass surgery just last week, and I'm finding it difficult to be on an all

liquid diet." Maybe you can explain that part of it too. He says, "I feel weak and I tire easily. After I get dressed I'm ready to go back to bed. Is this normal, and is there anything I can do to increase my energy?" Dr. Nagle?

Dr. Nagle:

Well, first regarding the liquid diet, every program is maybe a little bit different as far as how the diet is progressed after surgery, but the key here is after surgery, the first couple days, the first couple weeks, it's very difficult to sometimes even

just get water down. And it's such a drastic change from going from a normal size stomach to such a small, little stomach, and the first couple weeks are very

difficult. So we typically have patients for the first two weeks stay on a pureed


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diet, which is basically everything is blenderized, baby food type of food, and then we gradually over the course of several weeks advance them to more soft food.

And that does get easier every month, but the first couple months are very difficult.

As far as the energy is concerned, that's very common that after any major surgery that even though on the outside you just see little incisions, on the inside there's a lot of healing going on which is taking a lot of energy away from you, and it's very

normal to feel fatigued the first couple months after surgery.

And as far as what you can do to increase the energy, I think the best thing to do is really to get up and walk and exercise. And I think you just do a little bit each time and I think you gradually will build up your stamina, and eventually you're going to

find that you do have more energy. And I really think that's the best thing to do is just to try to get up and walk as much as you can.

Andrew Schorr: Right. The solution is not to get into bed.

Dr. Nagle:

Exactly. Andrew Schorr:

It doesn't help your muscles, help your heart, help anything.

Okay. We have a call on the line. It's Anna who is holding. Anna, thank you for calling in. Anna, where are you calling from?

Caller: From northwest Indiana.

Andrew Schorr:

And, Anna, are you touched by this concern? Are you considering weight loss surgery or tell us your connection.

Caller: I am actually a post op patient from the Northwestern program. Almost five years.

Andrew Schorr: Wow.

Caller:

From April of 2004. And one of the other surgeons did my procedure, and I've have had fabulous results and 178 pounds and have a new life, and it was the best thing I ever did. And it is an ongoing walk. You have to be dedicated to the

nutrition and the supplements and the lifestyle that goes along with it, but I wouldn't change it in the least. It was the best thing ever.


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Andrew Schorr: You mentioned your weight now. What was your weight before the surgery?

Caller:

My highest weight that we know of was 378. Andrew Schorr:

And tell us what it is again now.

Caller: It's 198.

Andrew Schorr: Wow. Okay. And you feel good. So for people who are considering this. You

cannot go into this lightly. Any just tips you'd give people so that hopefully they could be five years out and feeling as positive as you do, as far as considering, how they decide and knowing that it's not easy.

Caller:

It's not a quick fix. Like you said, it's not a quick fix. It's not something that you need to take lightly. You need to be very consistent because it is lifelong change. The medications you're able to take, the food you eat, you have to make that

commitment. Your health depends on it. You have to make a commitment to take the supplements every day, not when you think about it but every day. It has to

be a commitment.

Andrew Schorr: Right. Verlina, you're kind of nodding your head, right?

Verlina: Yeah, yep.

Andrew Schorr: Okay. All right. Let's take another call. I want to thank you, Anna, for calling in.

And we have Andory, if I'm saying it right, who is with us. Am I saying your name correctly?

Caller: Yes.

Andrew Schorr:

Where are you calling from? Caller:

San Jose, California.


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Andrew Schorr: San Jose. And Andory, what's your story connected to this topic?

Caller:

Well, I'm Verlina's aunt. Andrew Schorr:

Aunt Andory.

Caller: I want to let her know how proud we are of her. And I've been saving my money. I've owed her a pair of jeans since 1973, I think. And we at that time were going

to buy her a pair of tight-ass jeans. We couldn't find them. But you come out here, honey, and I'll get you the prettiest pair of tight-ass jeans you ever saw.

Verlina: Okay.

Andrew Schorr:

Okay. Good for you. Caller:

We love you.

Verlina: Love you too.

Dr. Nagle: Verlina, you have quite the fan club.

Verlina:

Yeah. Andrew Schorr:

All right. Verlina, they're going to have you on some commercial there somewhere, strutting around in as your aunt says tight-ass jeans. Okay.

Well, I want to take another break. Ron, we're going to take another break. Ron is our wonderful engineer. He's juggling the calls here tonight. I want to remind

people that if you want to give us a call the phone number is 877-711-5611. 877-711-5611. You can send us an e-mail. We've got a bunch more to go

through, Dr. Nagle, and that e-mail address is [email protected]. We'll be back live with our live talk show on weight loss surgery with our expert from Northwestern right after this.


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Facing Challenges Post-Surgery

Andrew Schorr: Andrew Schorr here as we buzz through the Verlina Ammon fan club, godson, and

your whole support team, Verlina. It's really great. We're going to continue with some e-mail questions we've gotten in for Dr. Nagle. Dr. Nagle, here's one from Anita in Oak Park, Illinois. She says, "Hi, Dr. Nagle. I'm a candidate for weight

loss surgery and I'm considering going forward, but I have certain reservations. What do you think is the one thing that most weight loss candidates are not

prepared for post surgery? What can I do to help with this in advance?" Dr. Nagle:

Well, that's kind of a tough question to know one thing, I would say.

Andrew Schorr: You can give us two or three.

Dr. Nagle: Well, like I said, patients are very well prepared. Most people have been thinking

about this for some time. They've gone through the dietary classes. They've met with the psychologist. They've talked to patients who have had the surgery. Again, most people have gathered a lot of information. And I think it really boils down to

it's almost one of those things, as much information as you can have before you go into it is the best, but until you really go through is I think it's really hard to say

what you're going to experience.

I think the hardest thing is really the dietary changes and just getting used to that new small stomach and trying to know when is too full. If I take one more bite am I going to throw up and figuring that out. And a lot of it is really trial and error,

and everyone is a little bit different as far as some foods may agree with you, some may not, and I think it's just really figuring that out.

Andrew Schorr: Verlina, what was toughest for you?

Verlina:

Well, I'm still learning what I can and can't do. I know like you said, Dr. Nagle said, it's different for every person. And a lot of people do really well with fish, but I have not been able to eat fish and keep it down yet. And like you said, a lot of

times that one more bite will put you over the edge, and if you eat too much or you don't chew well enough you will throw up. So it's kind of a deterrent to that

overeating thing. After you do it a few times you don't want it to happen again. And also one of the big changes is the sugar that you really can't eat sugar. Most

of us who try to eat sugar, even this far down the road you have what's called dumping syndrome where the sugar goes right into your intestine because you

bypass the part of the stomach, I believe, Dr. Nagle, if this is true, that processes


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sugar? So then you can have the dumping syndrome which is almost like an insulin reaction. And you feel nauseous, you can feel nauseous, have a headache,

diarrhea. There's several things. So it's kind of a deterrent it's a part of the tool that keeps you from overeating or eating the sugar stuff.

Dr. Nagle: Right. That's exactly right.

Andrew Schorr:

Well, here I want to talk a little bit about sort of the mental side of it. Let's face it. There might have been various stresses and strains of life that led to somebody compulsively eating, if that was the cause of their weight gain. And Steve wrote in

from St. Louis where he said, "I'm considering weight loss surgery. My doctor puts all his patients on antianxiety, antidepression drugs before surgery. Is this

necessary, and if so why?" I don't know if you have a comment on that, Dr. Nagle. I know there's a whole

evaluation at most clinics that go on. So let's talk about the mental evaluation of it and this idea of mental health drugs being used.

Dr. Nagle: We do not use them routinely, and it sounds like maybe this doctor is using them

routinely. We haven't found that that really is necessary, that someone, every patient routinely needs to be on antianxiety medication or antidepressant

medication. Clearly, we do have a high percentage of patients that do take antidepressive drugs, and I think that that in and of itself is not a contraindication

to the surgery. But clearly things like binge eating or other eating disorders are things that must be addressed before someone would be a candidate for these surgeries. The process can take anywhere from six months to a year, if not longer.

And then some patients go through the process of meeting with the psychologist multiple times and really aren't able to work through those issues and eventually

are not a candidate for surgery. But really the psychologists that we work with are excellent as far as identifying those problems, working with those problems. After surgery continuing the care with the psychologist is very important. So again we

do see a lot of depression, but that's again something that usually can be dealt with. And most of the time that's going to be improved after the surgery.

Verlina: Absolutely.

Andrew Schorr:

Okay. Now, Sharon wrote in from North Barrington, Illinois. She's kind of asking about sort of a two-for-one surgery. She says, "My sister needs to have her gallbladder removed and she's also over 100 pounds overweight. She's considering

gastric bypass at the same time. What are the risks of having gallbladder surgery


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and having the gallbladder removed and the gastric bypass simultaneously? And how long would a typical recovery be if you could have both?" Dr. Nagle, what

about this sort of two-for-one idea?

Dr. Nagle: Clearly, the gallbladder is not going to add too much more to the operation as far as the risks. It may prolong the operative time somewhat, and you may need to

stay in the hospital an extra day, but I think clearly if that can be done at the same time I would definitely do that to try to avoid two operations. There is no reason

why the gallbladder can't be removed at the same time as a gastric bypass operation.

Andrew Schorr: Here's a question we got from Newark, New Jersey from Jane. Jane writes in, "Ever

since my weight loss surgery eight months ago I've been taking advantage of the increase I've felt in energy. Where I used to collapse on the couch as soon as I got home now I feel full of energy most of the time. However, in the past week I've

experienced some more fatigue and tiredness. Could this be attributed to a vitamin deficiency or any other issue? I have had my thyroid checked, and it's fine."

So she was flying high and now she feels tired. What do you do in that situation?

Dr. Nagle: Clearly, the vitamins are something that do need to be followed closely after a

gastric bypass. Since the intestine is rerouted some of the vitamins and minerals are not absorbed, such as iron and calcium. Clearly a deficiency in iron can cause

anemia which will cause fatigue. And again this is one of those things where she should follow up with her doctor, and blood work needs to be checked and really look for these deficiencies.

Andrew Schorr:

All right. Here's a question from Katherine in Chicago. Katherine wrote in, "I had weight loss surgery just a month ago. For the first several weeks my bowel movement was normal for post surgery. However, in the past week or so I have

been constipated. Is it okay to take a stool softener?"

Dr. Nagle: Yes, that's fine to take a stool softener. No problem. No problem with that.

Andrew Schorr: Okay. But it sounds like, and Verlina I'm sure you'd echo this, it's okay to call the

clinic. I mean you've been through a big deal, there's a big change going on and you're on your own personal journey so calling the nurse, calling the clinic and going for checkups, that's part of the deal, right?


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Verlina: Yeah, absolutely. And I actually have e-mail contact with my internist, the internal

medicine doctor and my nutritionist. Like we've e-mailed back and forth this week because I kind of was on doing mostly my protein shakes and eating one meal a

day, and she's helping me to start adding more meals in and giving me different ideas, so we just shoot e-mails back and forth, which is really nice. And, yeah, I do follow up also with Dr. Nagle. I saw him about three weeks ago, I think. So it is

definitely a part.

And, Dr. Nagle, isn't it true, too, if you're not getting enough protein in that could also affect your energy level?

Dr. Nagle: Sure. Absolutely.

Andrew Schorr: All right. I'm just going to go a couple of minutes over the top of the hour so we

get some final comments in.

Now, I want to mention for our listeners what helps us a lot is right on the ihealth.nmh.org website, right on the left side there's a little button to click to take our survey. That helps us a lot. Helps Northwestern understand the benefit of

these programs to you, so I urge you to whether you're listening live or as a replay to click on the survey button and take our survey.

Dr. Nagle, so we've talked about kind of the state of the art now. There's a whole

team. You have some different surgical choices. Looks like we're making progress maybe with people with diabetes. Certainly that's helped Verlina. Where are we headed next, because we continue to have new developments. What's

Northwestern working on and your colleagues at other major centers?

Dr. Nagle: I think really a lot of excitement is relating to the treatment of diabetes, as we talked about. And what we're looking at now is offering the operation to patients

who have lower BMIs. Traditionally, the surgery now is based on indications from 1991. The NIH in 1991 came out with recommendations that if your BMI is 35 and

you have diabetes, then you would be a candidate for surgery. But what we know is that there are millions of people who have a BMI between 30 and 35 who have diabetes, and they don't have a lot of options, and they're not a candidate for

bariatric surgery. And we know that of the benefits that we've seen in patients with BMIs over 30 that these can be applied to patients between 30 and 35, and that's

really where we are now. And at this point there's only small trials that are looking at surgery in patients between BMIs of 30 and 35, but that's really I think where--as we get more and more evidence that that's going to be the next frontier.

And again this would be more considered surgery for diabetes. This is metabolic surgery, not necessarily the surgery for weight loss.


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A Hopeful Future

Andrew Schorr: All right. Well, Northwestern is an academic medical center, and research goes on

in your institution and others, and you and your peers are talking all the time. So wherever you are listening to our program that's a dialogue that you have with your doctor. You can check in with the weight loss surgery program at Northwestern

and find out what's the state of the art in the research then and how does it apply to you. Dr. Nagle, before we let you go, are you encouraged? We hear someone

like Verlina, you've given her her life back. We heard the whole fan club say that was true and others as well. Are you encouraged at the difference you can make for the right patient?

Dr. Nagle:

Absolutely. It is very, very rewarding to see really someone have a whole new life. And I think as far as something that's very important advice that I could give to a lot of listeners as far as people who are considering this operation, we've really

spoken about all the benefits of surgery and we've seen there's great benefits from the surgery, but I think it's important to realize and look at the risks of the surgery.

And that has to be something that everyone has to be very well aware of, what are the risks of the operation.

I think one of the things that I can, as far as advice to someone who is considering having the surgery, is really to go to a center where they do high volume

operations, and that's typically 100 or 150 operations per year as a minimum number. Because that really has been shown to affect outcomes. The good news

is that the surgery does have risks, but it really has never been safer. And when we look at outcomes that are performed at high volume centers the risks are very, are quite small. And that's really my best advice is to really look at these centers

of excellence and have an operation at a place like that.

Andrew Schorr: And I'll echo, and I'll say that of course you've worked hard with your colleagues at Northwestern to be one such center. Dr. Alex Nagle, thank you for being with us,

the work you do, helping us get a very fair and balanced view of what it takes for someone as they consider this. All the best to you. Dr. Alex Nagle, who is GI

endocrine surgeon on the medical staff at Northwestern Memorial Hospital. And as we mentioned, in two weeks we'll have Dr. Victor Lewis with us who is a

plastic surgeon who often sees patients from Dr. Nagle and the other bariatric surgeons there and helps those folks with plastic surgery to help kind of shape up

the body even further when such weight has been lost. And Verlina had surgery like that, a tummy tuck, so now you're going to be in those tight jeans, there, Verlina.

Verlina:

Yeah.


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Andrew Schorr: Verlina, before we let you go, you've lived it. And then you had your friend, a lady

who knows you from the northern part of Indiana, who is five years out. So for somebody listening, they don't go into this lightly, could be a big change. They

need to understand the risks and go to a center that's right for them and where there's the sort of the full meal deal of the whole team that works with you and hopefully have family and friends like you do who are so supportive. Do you feel

pretty optimistic about the future for you?

Verlina: Oh, definitely. I feel a lot more hopeful about my life and just what I can do and what I can be now because I've been able to do so much more than I could in the

past and feel good about it too, so, yes.

Andrew Schorr: Okay. Well, Nolan is probably finished with his bath now, and you can call him afterwards. He was so cute. And our dream, our wish for you is happy times with

your godson, Nolan, and we know that you make a difference in just talking to people as you have tonight. And obviously we'd love to see people not get in this

situation… Verlina:

Yes.

Andrew Schorr: …where they get overweight. So we want to see if we can help people. There are a

whole variety of programs you can listen to that related to that in the ihealth.nmh.org section of the website. So, Verlina, all the best to you, and thank you for joining us tonight.

This is what we do on our Patient Power program sponsored by Northwestern

Memorial every two weeks. So Dr. Victor Lewis talking about plastic surgery for people who have lost a lot of weight in two weeks. Our whole library is there for you. And we always welcome your suggestions. Just send them to

[email protected]. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all. Good night. Please remember the opinions expressed on Patient Power are not necessarily the views of Northwestern Memorial Hospital, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.