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Join Maria Iliakova, a bariatric and general surgeon. In this episode, we’ll explore essential topics in weight management and bariatric surgery. Discover effective ways to start conversations about weight with patients, learn when to refer to a bariatric specialist, and understand the role of anti-obesity medications. Maria will also share success stories from her practice and discuss the importance of addressing mental health, physical activity, and nutrition in overcoming weight management barriers.

Maria Iliakova is a bariatric and general surgeon.

She discusses the KevinMD article, “5 things to know about weight from a bariatric surgeon.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Maria Iliakova. She’s a bariatric and general surgeon. Today’s KevinMD article is titled “5 things to know about weight from a bariatric surgeon.” Maria, welcome back to the show.

Maria Iliakova: Oh, thank you so much Kevin, great to be back.

Kevin Pho: So Maria’s been on the show before. Go to KevinMD.com/podcast, where you can search for Maria’s previous episodes to hear her story. But today let’s jump right into your most recent KevinMD article, “5 things to know about weight from a bariatric surgeon.” Tell us about this article.

Maria Iliakova: You bet. So I am a bariatric surgeon, like you said, and I am completely obsessed with weight and weight management and all things related. So I really thought about, in the past year and a half or so that I’ve been practicing this, I realized there’s a lot of kind of misguidedness, both in general society but even in our own profession in health care, about how to address weight with patients, what’s out there as a treatment, and even how to start that conversation with a patient. So I actually wanted to write this as something that hopefully would help other providers really understand where to get started even with this.

Kevin Pho: That sounds great. So tell us some of these misconceptions.

Maria Iliakova: Yeah. So for a lot of folks, unfortunately, weight is really tied to morality in how we kind of view it as a society. It’s seen as a personal problem, as something that, for a lot of folks, if they become overweight it’s seen as something that they did to themselves. And for a lot of folks who are overweight it’s really, really difficult to get access to care even if it exists, because of bias and stigma and things.

So the way to kind of negotiate this for patients is really to be as informed as we can ourselves as health care providers, and then to figure out how to do it on a patient’s terms. And I can give a couple of examples of how that can happen.

Kevin Pho: Absolutely, go right ahead.

Maria Iliakova: Yeah. So for instance, I actually had one of my patients who’s now a year out from surgery and doing really well. She recently disclosed to me that the absolute worst five minutes of her life were the five minutes spent in my waiting room before her first visit with me. And that statement has kind of haunted me since she said it, a little bit.

Because we dove into with her, why did it feel like the worst five minutes? She is a professional woman, she has three kids that she’s given birth to, she’s been through all kinds of physical and mental difficulties in the past, but yet those five minutes in the waiting room were the hardest part of her life. And to her, how she described it, was it was the lowest low. It was basically saying that there is nothing else that I can do except ask for help from someone, and actually require surgery for it.

I think that feeling of surgery being kind of the extreme treatment and the last resort is something that not only a lot of people believe and patients believe, but a lot of health care providers believe too. And how do we make sure that patients don’t experience the worst five minutes of their life in our waiting rooms? This is not a cancer diagnosis, this is not a loss of function or loss of limb or loss of life situation. In fact it’s an enormous step, for which patients should be congratulated, for really trying to take control of something that isn’t their fault, that is difficult to manage, that is a lifelong management plan. And we as providers I think are really responsible for launching patients on the right track in mindset here.

Kevin Pho: So let’s reframe that. So of course you’re a bariatric surgeon, so how should the public and health care providers think about surgery? And I know you talked about it briefly, but go into more detail about the approach and how we should frame bariatric surgery in your ideal world.

Maria Iliakova: Absolutely. So I think of it kind of like diabetes or high blood pressure or other things. Weight is something that’s complex, it’s multifactorial, right? And so the way that we treat it, luckily there’s medical and surgical forms of treating it, it has to do with physical health and has to do with mental health as well.

So really understanding that all of those options are appropriate for some patients, and to make sure that we’re approaching it in a way that we’re not blaming patients for something that really is much more systemic than one person can control. And understanding that a full evaluation of someone’s weight really is very comprehensive. Even in our program for instance, I have diagnosed breast cancer in a patient because we have people undergo pretty comprehensive screens before they go through these surgeries.

And the surgery really isn’t extreme, it’s not the end point, it’s appropriate for some people, definitely not appropriate for other people, and you can achieve different outcomes based on what modalities you use, and you can even use them together. So those are some real takeaways.

Kevin Pho: So if I have patients in my exam room and we’re talking about weight loss options, and as you can imagine we have so many options, both medical and surgical, and of course we have things like Ozempic, Wegovy, Mounjaro that are very prevalent on social media, that a lot of patients are asking me and I’m sure asking you about. Tell us the approach that primary care can take before we send patients to you.

Maria Iliakova: Yeah, absolutely. So first, I think medications are great. There’s been a lot of debate about what’s the role of medications, does this eradicate the need for surgery or anything like that. Answer is absolutely not. Medications are really, really important, because not everybody qualifies for surgery under the kind of insurance guidelines that we have and restrictions. Also not everyone can really tolerate surgery, this does require some lifelong maintenance and changes. So certainly surgery is not the best option for everyone, and in fact you can even use medications before surgery, and after surgery if that’s needed. So it’s definitely not an either-or approach.

Medications are awesome because there’s technically nine FDA approved medications right now for weight loss. They can help people lose about 20 percent of their excess weight on average, which is quite a bit. They’re less maintenance in some ways than surgical interventions. But they do have some downsides too, and that’s side effects. You’ve probably heard of gastroparesis from the GLP-1s like semaglutide and Mounjaro and Wegovy, and that’s not really a side effect, that’s a mechanism of action. So that definitely can be an issue for patients.

The other issue with these medications is there’s very little insurance coverage of med weight loss, even though it’s FDA approved. So there’s a little bit of catch-up to do in terms of figuring out how to make it affordable for patients. There’s things like phentermine, which is usually under $30 a month but has a lot of side effects to it, and then there’s things like the GLP-1s like Wegovy and semaglutide and Mounjaro that are over a thousand dollars a month on average. So it’s a really wide range.

There are some really great resources out there. In fact, in my own practice I created a guide for med weight loss and shared that with our primary care providers. But what I was really hearing is that very few primary care providers actually have time to monitor these medications for their patients, because these are medications that ideally you’re monitoring every one to three months or so. Because you want to make sure patients aren’t having side effects, that they’re effective, that the costs aren’t getting out of control for your patient, and that they’re not missing out on other options potentially too.

So it’s really important to sort of figure out, one, is your patient a candidate, so do they have excess weight to lose. Two, is it affordable for your patient, and is there a safe medication to actually choose amongst the different side effects these medications have. And then four, not to exclude other options. When we’re talking about med weight loss, we also talk about mental health support for that, nutrition support, and certainly a consideration of surgery if that’s appropriate for a patient.

Kevin Pho: Now, with a lot of these medications, I know with the GLP-1s the weight tends to come back if you stop those medications. So talk about the reframing again, you mentioned this earlier, but it is a big paradigm shift, like you said, even among health care professionals, to considering obesity more like a chronic disease. So talk more about that reframing, about how sometimes with these medications it needs to be almost a lifelong course.

Maria Iliakova: Absolutely. And a lot of these medications, other than the phentermine class of medications, they haven’t been around for very long. Even GLP-1s are fairly new, and certainly new in the use of weight management.

So you’re absolutely right, medications don’t work if you don’t take them, right? It’s the same thing as taking a beta blocker for high blood pressure or something like that. If you stop taking it, well, guess what, your blood pressure is going to start creeping up again, and your heart risks and things like that. So just like any other medication, you do have to take them for a long time for them to work, or for life.

And you’re absolutely right, weight is a chronic problem, or chronic disease, if you will. Certainly weight is not a disease in and of itself for everyone. There’s NFL linebackers that have a BMI over 40 and are healthy people. But there’s also folks with a BMI over 30 that have cardiovascular risks or other impacts on their health that are related to their weight and metabolism, that would certainly benefit from either medications or surgery or combinations.

So you’re absolutely right, it is a paradigm shift, and maybe that’s the most important takeaway. Maybe there’s not five takeaways, there’s just one really, that there’s a spectrum of care for weight and it is lifelong. Even after bariatric surgery, for instance, somewhere upwards of 20 percent of people, somewhere between like 20 and 30 percent of people, regain weight after a gastric sleeve, and somewhere around 10 to 15 percent regain weight after a bypass. And that’s in part, very rarely is that strictly a patient’s fault or a patient did something wrong. Oftentimes their metabolism reset just hasn’t lasted for a lifetime. So medications even have a really important role for weight regain after surgery.

Kevin Pho: Now, do you get pushback from patients and even health care professionals when you say that weight or obesity is a chronic condition?

Maria Iliakova: Oh absolutely. So yes, you definitely get people who are like, it’s in and out, it’s what people are eating and people should just control that, or it’s the amount of exercise people are getting or something like that.

But I really think that we need to reframe how we think about this. It’s hard to do it, but it’s also impossible for 60 percent of our population to be struggling with excess weight and for that to be an individual problem. Those numbers don’t add up.

At the same time, you do see, even when we try all of these modalities, there are people who have metabolisms that are resistant to weight change. And the way that honestly I describe it to patients and even providers is that weight is like a thermostat. It’s related to your metabolism and other internal mechanisms, but it’s kind of like the thermostat in your house, and after gaining to a certain amount or to a certain BMI it’s essentially impossible to reset that thermostat with diet and exercise.

So diet and exercise are really good for maintaining weight, they’re not that great for weight loss. So while it’s important to have a healthy diet, it’s very important to be physically active and overall healthy, those tools are not very effective at helping people to lose weight, especially in a durable way, above certain BMIs and certain weights. So really helping people understand that there are really fantastic tools out there to help people do that, and that it’s not a problem to access them, it’s not the easy way out, it’s not a cheat or a hack or something like that, it’s quite literally essential health care.

Kevin Pho: Now I know there’s a lot of research regarding the genetic predisposition to obesity. So what’s the current thinking about that?

Maria Iliakova: Yeah, actually that’s a really good question. I will say that we’re in the infancy of why some people gain weight more than others, and what the genetic, not even just genetic but I think epigenetic effects are, of how our metabolisms work and how that affects weight.

There are a few different conditions like acromegaly and others that certainly are associated with increased weight gain or increased eating even over time. There are a few medications that target specific genetic conditions. The number of people who are actually affected by them is definitely less than 1 percent of the population, so while I’m really glad we have those modalities for the people that are affected, they’re pretty uncommon in terms of a genetic basis that we know of.

Most likely there’s no easy answer here. I have a feeling that a lot of weight and a lot of metabolism is related to multifactorial causes that are multigenetic, epigenetic, and so forth.

Kevin Pho: Now earlier on you talked about that patient where five minutes before they saw you was the worst five minutes of their lives. So take us into your exam room. If you’re meeting a patient for the first time, what kind of questions do you ask them as you decide whether bariatric surgery is right for them or not?

Maria Iliakova: I love that you’re asking that question, because putting yourself in the patient’s shoes is really a great place to start. When we’re talking about weight management, a lot of times people are coming in in a very vulnerable position. They’re asking for help for something that for a lot of folks is embarrassing or really difficult to address, and yet this is the person who is brave enough and courageous enough to say, I’m going to go and get help, and I’m going to be here even if it feels uncomfortable. So I really try to honor that.

Weight has been something that, I’m a female in the US, I’ve struggled with weight too, I think that’s really common for people. So number one is to put yourself in the patient’s shoes. And how you do that is also to ask, what are your goals? That’s one of my first questions to a patient when I meet them, is what would you like to accomplish out of this, what matters for you in your life?

And the answers that I get are so broad, they’re so fun, because a lot of times it’s something like, I want to be able to get up and off the floor easily, I want to be able to play with my grandkids or my kids, I want to be able to breathe easier at night, I want to be able to have kids. We have actually people coming to us with infertility, because bariatric surgery is a very effective treatment for that, for some sources of infertility. I have people say, I want to be able to travel without needing a seat belt extender, or I want to be able to get off of my diabetes medications.

So it’s really neat to find out what those goals are, because we can also refer to those goals through the process of getting a patient ready for surgery, or even this applies even if they’re on medications, because it helps me understand whether we can even achieve the goals that they’re wanting to achieve through the modality that the patient wants initially. And then certainly refer to those after surgery, because a lot of folks are able to accomplish those goals and even more.

And I basically don’t ask patients about their weight goals, because one, I can’t guarantee a specific weight with any of these modalities, it’s a range and it’s a probability. And then two, the focus on weight, while important for insurance and qualification, and it is an objective vital sign that we can measure on people, for a lot of folks it’s really the non-scale victories that matter a lot more to them in terms of the quality of life.

Kevin Pho: So you mentioned these quality of life goals that makes you decide whether bariatric surgery is right for that particular patient or not. So what are some of the things that you hear that makes them more suitable for say a medical approach versus a surgical approach? What are some answers to your questions that sway you one way or the other?

Maria Iliakova: Yeah, great question. So one, certainly we do talk about, very frankly, cost. The cost of surgery is usually covered, and the preparation for that, the post-op care, those kinds of things, are usually covered better than medication management. So depending on that, that may be a factor.

If patients really want to lose a lot of weight and get off of all of their diabetes medications, blood pressure medications, et cetera, that’s rarely something that can be accomplished with medications alone and usually would require surgery. But that said, there are pretty distinct boundaries for who can get surgery based on insurance policies. These are in some ways made by professional society guidelines, but they’re usually behind.

So for instance, we have a big professional organization, ASMBS/IFSO, which recently came out with guidelines last year that lowered the BMI threshold for surgery to a BMI of 30 for those with comorbidities such as high blood pressure, diabetes, sleep apnea, and a threshold of 35 for all patients. Most insurance companies do not cover at that threshold. They cover at a threshold of 35 with comorbidities, and a BMI 40 and over. So you do also have to be really mindful about what a patient’s insurance health plan will actually cover, because if you recommend surgery to somebody who won’t qualify, you will not be able to ultimately deliver them a surgery in an affordable manner. So there’s things there.

There are other things that make surgery a difficult choice. Certainly if someone’s mental health is undergoing changes or needs some optimization, probably surgery is not the best plan. If somebody’s going through job changes and may not have time off to take after surgery, that’s another consideration.

So it’s really, you’re seeing, I’m not a primary care doctor but I kind of am in a way, and a lot of bariatric surgeons and bariatric practices do approach it that way, because you really have to understand what is the context of your patient. And I understand why a lot of primary care doctors do not want to triage weight for patients, because it really, really requires a comprehensive approach to what the patient wants in terms of goals, what the patient has in terms of access to resources, and ultimately what you can safely deliver to them.

Kevin Pho: We’re talking to Maria Iliakova. She’s a bariatric and general surgeon. Today’s KevinMD article is titled “5 things to know about weight from a bariatric surgeon.” Maria, let’s end with some of your take-home messages that you would like to leave with the KevinMD audience.

Maria Iliakova: Yeah, absolutely. So really important is, when you start a conversation with a patient about weight, consider asking a patient what they want to accomplish out of it. If someone really doesn’t want to talk about it, don’t do it. It doesn’t serve you, doesn’t serve the patient.

Two is, be aware that there’s lots of different treatments, and that surgery by no means is extreme. Surgery is definitely recommended for many folks who have weight management needs, but also medications exist, and in all these modalities we’re also using nutrition therapy and mental health support.

And ultimately, talk to your local bariatric surgeon, or go visit them. They may have some really great resources. And the whole point of this is for all of us to work together. Currently, again, less than 1 percent of patients who are eligible for bariatric care ever get to see a bariatric specialist. Let’s try to make that 2 percent, 3 percent, or even better. And I think that takes a whole community of all of us as providers to accomplish that kind of care for our patients.

Kevin Pho: Maria, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Maria Iliakova: Thank you so much, Kevin. I really enjoyed it.