A Deep Dive into Metabolic Surgery Options with Philip Schauer

**Jim Hill:** Welcome to “Weight Loss And…”, where we delve into the world of weight loss. I'm Jim Hill.

**Holly Wyatt:** And I'm Holly Wyatt. We're both dedicated to helping you lose weight, keep it off, and living your best life while you're doing it.

**Jim Hill:** Indeed, we now realize successful weight loss combines the science and art of medicine, knowing what to do and why you will do it.

**Holly Wyatt:** Yes, the “And” allows us to talk about all the other stuff that makes your journey so much bigger, better, and exciting.

**Jim Hill:** Ready for the “And” factor?

**Holly Wyatt:** Let's dive in.

**Jim Hill:** Here we go. Holly, now more than ever, we have so many tools available to manage obesity. The one we're going to talk about today is bariatric surgery. I know we've had a lot of emphasis on the new drugs. We talk a lot about lifestyle, but consistently bariatric surgery has been a viable option for people who really need and want to lose weight. And to help us understand this topic, we have a great guest today, Dr. Philip Schauer. Dr. Schauer is a very prominent figure in the field of metabolic surgery. He holds the Mary Kay and Terrell Brown Chair Professorship at the Pennington Biomedical Research Center of LSU University in Baton Rouge.

rgery and he's performed over: 8000

He earned his medical degree at Baylor College of Medicine and completed his residency at the University of Texas Health Science Center in San Antonio. Welcome, Phil, to Weight Loss And…

**Philip Schauer:** Well, Jim, thank you. Thank you and Holly, this is quite an honor to be on your podcast. Thank you.

**Jim Hill:** Well, we have so many questions about bariatric surgery for you, but first give our listeners sort of the cliff notes version of how you got where you are and what you're doing today.

, you know, back in the early: 1990

And it is phenomenal. Whether the weight loss comes from surgery or from, you know, lifestyle intervention or medications, weight loss is very therapeutic. And so it's led to my interest in understanding how obesity causes diseases like diabetes, high blood pressure, increased cholesterol, heart disease, sleep apnea, and arthritis. I mean, the list goes on and on and on. So it's really been a fascinating journey. And every day I learned something new.

**Jim Hill:** Wow. Must be a real sense of satisfaction when you see some of the weight loss as you do. You know, Holly and I can see life changes in 10, 15% weight loss and you're taking people oftentimes and they lose half their body weight. That's got to be really as a physician satisfying to see that kind of positive change.

**Philip Schauer:** It is. It really is. And I have to say, Jim, it's a team. Of course, the surgeon performs the operation, but there's so much involved on the pre-op side preparing the patients and afterward. It really is a team effort. Often the surgeon gets all the glory, but the whole team deserves recognition.

**Jim Hill:** Well, those surgeons, they love the glory. Come on, Phil.

**Philip Schauer:** Yeah, yeah, exactly.

**Holly Wyatt:** So, Phil, maybe we can start for our listeners by defining bariatric or metabolic surgery for us. I know there are different types of surgery. So maybe explaining a little bit about that.

**Philip Schauer:** Yeah. So what surgeons basically do, Holly, is we alter the anatomy of the gastrointestinal tract: the stomach and the intestines. And that involves making the stomach smaller and or bypassing portions of the intestines. We used to think that the operations worked just by forcing people to eat less because they could not eat more because of the mechanical restriction of a smaller stomach.

And in my career, we've learned that that's not what happens. What's happening is by manipulating the anatomy of the stomach and the intestines, we're altering the signaling from the intestines to the brain that tells us we're hungry or we're satisfied or not satisfied. So these are a number of chemicals, hormones usually created in the gut that go to the brain that regulate appetite. And we're altering those in a dramatic way. And this is frankly the basis of these new modern drugs.

**Jim Hill:** Yeah, exactly. That's what they do.

**Philip Schauer:** Exactly. They do the same thing. And, surgery, we do it in a different way. We may involve a number of different hormones that we alter with surgery, whereas usually with pharmacotherapy, it's usually one agent, in particular, like a GLP1 or sometimes there's more involved. So basically, to answer your question, metabolic surgeons alter the anatomy of the stomach and the intestines to create this reduced state of hunger, to bring it closer to what normal should be. So we have more of a balance between the amount of food a patient desires and what they should actually have so that they're satisfied.

And I tell patients that the challenge with a voluntary diet is a person can voluntarily reduce their calorie intake. But unfortunately, they're often not satisfied. And they're still left hungry. And the signals to the brain are telling them that they're not done eating. And those signals to the brain that you're hungry are very powerful drives that it's almost like the drive to breathe or to drink, you know. You only resist that for so long. You need tools to help you. And surgery is one powerful tool that helps.

**Holly Wyatt:** Yeah. So is there just one type of surgery or can you choose more than one?

which goes back really to the: 1950

And let me explain each one of those. So sleeve gastrectomy is a simpler procedure and it involves essentially reducing the stomach, actually removing two-thirds of the stomach. Now, the stomach is about the size of an NFL football, okay, when it's full of food. And after the sleeve gastrectomy, we downsize it to about the size of a banana. So by removing two-thirds of the stomach, not only are we reducing the stomach volume so that a smaller quantity of food will give a patient a sense of feeling full, we call that satiety. But we also remove part of the stomach that secretes hormones that actually stimulate appetite.

One of those hormones is ghrelin and there are probably many others. So we're affecting the signaling to the brain with that surgery. That's called sleeve gastrectomy. It's done laparoscopic with small incisions.

Patients will usually stay one night in the hospital, sometimes longer, and they're usually back to work or school within about two weeks. Now that surgery usually long-term will yield about, I would say, a weight loss of 50 to 60% of the excess weight. So if a person, let's say a person weighs 270 and should weigh 170 pounds, with the sleeve gastrectomy, they'll probably end up around 210 so losing about 60 pounds.

They're still a little bit above their ideal weight of 170, but they're definitely much better than they're starting with 270. Okay, so that's a sleeve gastrectomy. The other procedure is gastric bypass. Now with that operation, we actually make the stomach even smaller.

We staple the upper part of the stomach and that becomes the new stomach and that's about the size of an egg, an egg, or a golf ball, which is quite a bit smaller than a banana. Okay, and in addition, we're not going to remove the rest of the stomach, we're just going to bypass it. And we also bypass a small portion of the intestines as well. And that bypass, we think, adds some additional weight loss mechanisms that generally create a little bit more weight loss.

So patients who have gastric bypass will often lose 75 to 80% of their excess weight. And so those are the two options. Now, in both of those procedures, patients do need to take vitamin supplements because typical vitamins are not absorbed quite as well.

So we supplement patients with multivitamins, calcium, and vitamin D typically. And that's usually for life. Yeah. So those are the two procedures. There's one other operation too we can talk about later, but those are the two most common procedures. Yeah.

**Jim Hill:** So Phil, who qualifies for metabolic surgery?

**Philip Schauer:** Right. Those qualifications have been modified over the years. Generally, it's for people that have what we call severe obesity and that has been defined as an individual with a body mass index of 35 or greater with a comorbid condition such as diabetes, blood pressure, heart disease, or some other major medical illness that's caused by the obesity, or if they have a BMI of 40 or greater, even if they don't have a comorbid condition. And a BMI of 35 is roughly equivalent to somebody who's 60, 75 pounds overweight, somebody who's relatively average height. A BMI of 40 is roughly somebody who's about 100 pounds. The other thing was that there are certain conditions where we have evidence that suggests we might even lower the BMI to like 30, for example, if somebody has diabetes. And that's some of the work that I have done with colleagues both here at Pennington and also in my former employment at the Cleveland Clinic where these operations have really powerful effects on diabetes. So if you have a BMI of 30 and diabetes particularly if it's not well controlled with medications, you may be a candidate for surgery as well.

**Holly Wyatt:** Yeah. So it sounds like diabetes allows you to think about doing it at an earlier stage when not quite as much weight to lose. Why do you think they do that? Why do they change the BMI based on whether you have diabetes or not?

**Philip Schauer:** Yeah, because it's just so effective that surgery is the only treatment that I know of. There are some exceptions though that can cause actually what we call long-term remission of diabetes.

Now, if someone has diabetes, Holly, as you and Jim will know if they go on a very restricted diet, they can actually go into remission for a period of time. But most of the data suggests that's fairly short-lived, maybe a year, maybe a little bit longer. But studies are showing that patients who have surgery, their diabetes can go into remission for quite a long time, 5, 10, 15 years or so, which is pretty amazing. That means remission is about as close to a cure as you can get. It means your blood sugar is normal and you don't need medication.

**Jim Hill:** If you're looking at metabolic surgery as a tool, we know that it still produces the most weight loss. It can often reverse type 2 diabetes. What are other benefits, Phil, that you've seen in people who undergo metabolic surgery?

**Philip Schauer:** Yeah, so we think much, perhaps most of the benefit is derived from the weight loss. But interestingly, like diabetes, for example, there are additional hormonal effects that positively affect blood sugar metabolism. In other words, the actual secretion of insulin.

We think that diabetes is a disease of the beta cells of the pancreas, which produce insulin. So even apart from the weight loss, patients have improvements in some of these hormones, which we call incretin hormones, that positively affect better insulin secretion. And so even before patients lose much weight, we often see dramatic improvements in diabetes.

That's an example of the non-weight loss benefits of bariatric surgery, but they often are tied together. But all these comorbid conditions, Jim, I mentioned, they generally get better or, in some cases, resolve. So we see improvements in blood pressure after surgery. Lipids, cholesterol, especially triglycerides and HDL cholesterol, improve quite a bit. We see improvements in other cardiovascular risk factors and sleep apnea and conditions that are derived from the actual mechanical bearing on the body like arthritis. Stress on the joints in the back is largely driven by this excess weight that's pounding on the knee joint or the back or hips. So those tend to improve. So there are some 200 medical conditions we know are obesity related that tend to improve or resolve after surgery.

**Holly Wyatt:** So you talked a little bit about how much weight loss. You use terms excess weight like how much or what percentage of excessive weight. It's interesting surgeons use that terminology. Endocrinologists tend to say percent weight loss. We don't talk about it, so it's two different numbers, but a lot of weight loss basically is what we're saying. You get a lot of weight loss. What about weight regain? Do people who have the surgery, do they regain weight or is it a fix completely and they don't even have to worry about that?

**Philip Schauer:** There's nothing in this field that is perfect. There is no diet or pill or surgical procedure that is 100% effective for everybody. And that's an important message everybody should take home. Surgery happens to be, as Jim mentioned, so far the treatment that produces most weight loss, but it's not perfect. And Holly, I would say, majority of the people lose quite a large amount of weight. Over time, some patients can have some weight regain and that often depends on many factors. For example, patients' genetics, their genetic predisposition to obesity, their starting BMI, the larger the patient is at the time of surgery, the more likely they're going to have significant weight regain. In most studies, I would say that it's fair to say 10-15% of patients will have a significant amount of weight gain after the surgery over, say, five years or more. Generally though, despite the weight regain, their weight is generally quite a bit lower than when they started before surgery.

**Jim Hill:** Well, we actually Phil have a lot of long-term data on bariatric surgery. I mean, I keep saying with the new drugs, we have about two years of data, but with metabolic surgery, we have decades of follow-up.

**Philip Schauer:** We do, Jim. Yeah, and that's the beauty, and that's important. And distinction with the medications. And I am thrilled about these new GLP1 agents. They are a game changer. They are amazing, but they have not stood the test of time yet. And I think one important message for your listeners is that obesity is a chronic relapsing condition. And so we have to have therapies that are effective long-term. So we do have some pretty good long-term data with surgery. There are studies that have follow-up more than 20 years. In fact, the SOS study, as both of you know, actually has a 30-year follow-up. And the surgery is holding up pretty well at 30 years.

It's pretty amazing. And what we do know from the studies, probably the biggest benefit of the surgery is not so much, you know, reduced blood pressure or cholesterol, but it's a reduction in heart attacks and strokes and death. These long-term studies enable us to measure the rates of heart attacks, strokes, and deaths and people who got surgery versus those who didn't. And the reduction in overall mortality is pretty high. The SOS study shows, you know, 30-40%. Some studies show as high as a 50% reduction in mortality, which is putting amazing accomplishment.

**Jim Hill:** So you've told us that the operations themselves are getting much simpler and I think very low risk of problems in the surgery itself. A lot of our listeners may be thinking about, they're thinking about the meds, they're thinking about bariatric surgery. What does life look like in someone after the surgery? What are they eating? How much is this going to change their life?

**Philip Schauer:** Right. And before I go into the eating habits, you know, I've talked about all these wonderful things that happen with surgery. But to be fair, these operations have gotten a lot safer, but this is still surgery. And so, many of the listeners may have had surgery before. So there are small risks of complications of surgery that we all are familiar with. Bleeding, fortunately, is very rare. Infections can occur, very rare. Bowel obstruction is very rare. This is where the bowel can be partially kinked. Sometimes it requires surgery, sometimes it doesn't.

Blood clots can happen. Fortunately, during my career, we've seen steady reductions in all of these complications. And then there's the long-term issue, which I alluded to a little bit earlier, and those are nutrition-related in general.

And that's why it's so important that patients continue to get follow up with their doctor or surgeon and get their lab work checked, probably on an annual basis to make sure that their nutrition is good. The most common nutritional abnormalities are anemia and low blood count. This can be due to inadequate iron intake and vitamin B12. And they can also have problems with their skeleton, their bones if they're not taking the proper amount of calcium and vitamin D. And there can be a potential risk many years down the road of having increased risk of fractures of their bones.

But generally, these things can be mitigated or prevented by good nutrition. Now, you asked what it's like to eat. Well, the first month or so, you can imagine after surgery, your stomach's been altered, so you have to go on a fairly restricted diet, usually just liquids for a couple of weeks, and gradually advance to soft foods and then solid foods. And that first month or two, some patients have a little bit of nausea and sort of adaption issues, but those usually subside after a month or two. Then from there what patients me is that they're just a man who's not as hungry. Before, they would take a very large plate of food to fill them up, and they could eat just a fraction of that and feel totally full. They tend to have less snacking between meals, they're just less hungry, and a much smaller amount of food fills them up. That's generally what it feels like.

**Holly Wyatt:** So what kind of long-term follow-up? So I think of this surgery as being, you're really an investment. You're getting a big potential return, but there's an investment. So what kind of long-term follow-up is needed after surgery? And can you also touch on pregnancy? Some of our listeners have talked about, we've talked about the medications in pregnancy, let's talk about surgery and pregnancy.

**Philip Schauer:** Great question, Holly. Yeah, so that first year, most bariatric centers are going to follow the patient pretty closely. So at our center, at Metamor and Baton Rouge, we're going to see a patient a week after the surgery, one month, three months, six months, sometimes nine months, and definitely at the annual visit. Usually by 12 to 18 months, most patients have reached their lowest weight that they're going to get. We call that the nadir weight. And then after that, we recommend like once a year, once a year to get a checkup, get lab work, and generally best to do that for the rest of their life because obesity is a chronic illness. Whether you're getting a lifestyle intervention or medication, it needs constant follow-up.

**Holly Wyatt:** I think that's a really big point. Makes sense, right? It's chronic, so you are going to need a lifetime of follow-up for it.

**Philip Schauer:** And this is important too, Holly. As we said earlier, some people will regain some weight. That is not a failure of the individual, okay? Because there are so many factors that go into that, particularly genetic predisposition, and cultural, and environmental factors. So we counsel our patients if you're having weight regain, come in. Let's talk about it.

Let's figure out what we can do to get you back on track. Sometimes it's altering lifestyle sort of approach. Sometimes it's adding medications. You can have medications after surgery. Sometimes we have to revise the surgery, okay? So it's this chronic illness that we have to monitor. What was the other question you asked? Oh, pregnancy, yeah. Really important, yeah.

Yeah, so this one's interesting. A lot of women who are struggling with their weight probably know that being heavy can sometimes reduce their ability to have children, you know? And they may have other endocrine abnormalities like polycystic ovarian syndrome. So sometimes weight loss can improve their fertility and enable them to have children.

That's often a good thing. Now, on the other hand, we counsel our young women who are having surgery that it's best to hold off on pregnancy for at least about a year to 18 months because there's this rapid weight loss phase. And you can imagine trying to nourish a baby and losing all this weight is not really a good thing. So we recommend holding off for about a year to 18 months. Once you reach your stable weight, then generally it's okay to get pregnant.

That's the recommendation. And usually, you know, mom does much better during pregnancy when she is a healthy body weight. Pregnancy is easier. The less chance for a mom to have problems like high blood pressure and diabetes during pregnancy, which is important. Also, the delivery of the baby is better. Mom is less likely to need a C-section if her weight is lower. And maybe the most important thing is the baby. Babies do much better when mom has a good healthy weight. A baby is much less likely to have diabetes or severe obesity if the mom does not have obesity during pregnancy. Yeah.

**Jim Hill:** Yeah, that's a really important thing to note. Holly, we should probably do a whole podcast on that, that the mother's weight and metabolic situation during pregnancy can very much have lifelong impacts on the offspring.

**Philip Schauer:** Absolutely, Jim. And may I recommend our own Leanne Redman, who I know you know well.

**Jim Hill:** I interact with Leanne all the time. She's fantastic.

**Philip Schauer:** She is a brilliant scientist and she is an expert.

**Jim Hill:** That's a great suggestion. Holly.

**Holly Wyatt:** Oh, I'm writing that one down. Yes, absolutely.

**Jim Hill:** All right. I have to ask you this, Phil. You know, I'm a big believer in the importance of physical activity. How does physical activity play a role in the long-term success of metabolic surgery?

**Philip Schauer:** Oh, yeah. And Jim, thank you for mentioning that because from day one, we meet our patients, you know, and often it takes three to six months or longer to get ready for surgery. So we start talking about, you know, fitness and getting patients in shape, and studies have shown that physical activity prior to surgery can help reduce complications of surgery.

And sometimes just a matter of walking and I'm a big believer in step counting. I know you're practically the father of step-counting. And, you know, I tell them, go get your Fitbit or Apple Watch and start tracking your steps and try to work toward ideally 8,000 and 10,000 steps.

And then we talk about that, of course, after surgery. Every visit, whether they're seeing a surgeon or our obesity medicine physician, or the dietician, there's always a discussion about physical activity. And physical activity studies show that it could be complementary to weight loss. I think the biggest data tells us that weight loss maintenance, those patients who are active physically tend to have better maintenance of weight loss than people who are more sedentary.

**Jim Hill:** Boy, now you're talking my language. We preach that field that if you want to keep your weight off almost regardless of how you lose it, you have to incorporate movement into your life.

you know. I mean, my gosh, in: 2024

**Jim Hill:** So, Phil, talk to our listener out there that maybe would like to lose 50, 60, 70 pounds. And they're saying, gosh, I don't know, should I go and do these new medications? Should I go and get checked for bariatric surgery? How does someone begin to think through those kinds of choices?

**Philip Schauer:** One strategy is a stepwise approach, doing something less invasive first and then working your way up. So first and foremost, if a person hasn't really done a legitimate sort of lifestyle approach, that should be generally tried first. And then depending upon their weight if they're 50 or 60 pounds, I think trying some of these new medications is a very reasonable approach. Just recognizing some of the limitations.

There's limited access. Unfortunately, a lot of insurance doesn't cover these new agents. And we're talking about semaglutide and tirzepatide. Some insurance doesn't cover them. Out-of-pocket costs are pretty high.

I've heard estimates of about almost $10,000 a month for these agents. And then it's important that patients have to take them continuously, not just to lose the weight. But studies have shown when you stop the medication, we tend to see a significant increase in weight toward what the baseline weight was. Nevertheless, this would be a very effective treatment for many people. Then the third approach would be surgery. And again, for surgery, you have to have health insurance that will cover the surgery.

It's getting better all the time. But in my state of Louisiana, there are still many commercial insurance carriers that don't cover bariatric surgery. And we're trying to get that change.

There's actually a bill right now before the state legislature to mandate coverage for all the private insurance companies that do business in Louisiana. Because the data is so strong for surgery. So I think that the stepwise approach is a rational approach.

**Jim Hill:** But I did hear you say that it is possible that people who have had surgery could do the medications. It doesn't preclude that if necessary, maybe if they start regaining weight.

**Philip Schauer:** Absolutely. And that's a new frontier because, you know, Jim, as you and Holly know, it's only been just a few years that we've had powerful weight loss medication. The previous generation was very modest.

**Jim Hill:** We've gone through those of trying to convince someone that they're happy with an eight or nine percent weight loss. That's a tough sell.

**Philip Schauer:** That's a tough sell. That's right.

**Jim Hill:** Okay, Holly. Now it's time.

**Holly Wyatt:** Now it's time. And I have a question. So we always like to do a question that's kind of vulnerable, like, what would you do? Something that's kind of a little bit personal? This kind of flows with the last question. But let's say you had 60 pounds to lose, 70 pounds to lose. You had type two diabetes.

You don't. I'm just saying, maybe this is a loved one. This is a sister, let's say. Hypothetically, yes, totally. But making it personal and to have type 2 diabetes, you've had it for 10 years. They've been struggling with that. No contraindications to surgery or medications. You've tried lifestyle, insurance will cover either one. What would you choose?

**Philip Schauer:** Okay. Well, that's a real story. That's my sister-in-law.

**Holly Wyatt:** Oh.

**Jim Hill:** I love it. I love it.

**Philip Schauer:** That's my sister-in-law who I love dearly. She lives in South Texas. She had a body mass index of 34 for years and she was diagnosed with type two diabetes. Her doctor went through a litany of medication to the point where she was on insulin and a couple of other drugs for diabetes. Her blood sugar was still not in good control. Her A1C was like 8.5, which is way out of control. Unfortunately, her insurance wouldn't cover it. So I brought her up to, at the time I was at the Cleveland Clinic and we did a gastric bypass on her. That was 10 years ago. I have to say her result was an exceptionally good result.

Okay. Not everybody has a dramatic result as my sister-in-law, but for 10 years, she has been off all her diabetes medications with normal blood sugar. Not everybody has that great result, but she has and she's not gone well. She's not had any complications from surgery. Yeah.

**Jim Hill:** Fantastic. Well, Phil, I think you agree with us that having more tools is wonderful. We welcome them. We welcome the new GLP-1 medications and there are a whole slew of other medications in development. But I think what we conclude is that metabolic surgery remains a viable option for some people and it still produces the most weight loss of any of the tools we have. And we welcome more tools. We're going to use them in combination. But I think it's an exciting time for weight management because again, we do have some powerful tools that can help a lot of people now reach or nearly reach their weight goals.

**Philip Schauer:** Yeah. I totally agree, Jim.

**Holly Wyatt:** And there's one more question I forgot to ask. It's a listener question. And I can tell Jim was about to put the pie on the plate where he sums it all up. But this is, I think, a great question to end with.

And it was from Jennifer and I don't want to leave it out. She asked, where's the best place to go to have bariatric surgery or what should you look for in a bariatric surgeon? So she's interested, but she wants to know where to go or what to look for.

**Philip Schauer:** That's easy. She should come to Baton Rouge, Louisiana. She goes to our website, metamorinstitute.org, we're very good, but they're many great places. And she should find a center that is accredited by the American College of Surgeons. Fortunately, there are about 800 centers in the United States that are accredited. And they have to go through fairly rigorous standards, quality standards to meet that accreditation. So if you choose a site that's accredited, then you have a good degree of assurance that you're going to be in good hands.

**Jim Hill:** Wow, 800. That's amazing. I remember when it was a handful, Phil. This field has come a long way. And you have been one of the real leaders moving it forward. So thank you so much for your time and for sharing your expertise.

**Philip Schauer:** It's been a pleasure, Jim. Thank you and Holly very much. I enjoyed the chat.

**Jim Hill:** We'll talk to you next time on Weight Loss And...

**Philip Schauer:** Bye.

**Holly Wyatt:** Bye, everybody.

**Jim Hill:** And that's a wrap for today's episode of Weight Loss And… we hope you enjoy diving into the world of weight loss with us.

**Holly Wyatt:** If you want to stay connected and continue exploring the “Ands” of weight loss, be sure to follow our podcast on your favorite platform.

**Jim Hill:** We'd also love to hear from you. Share your thoughts, questions, or topic suggestions by reaching out at [weightlossand.com](http://weightlossand.com/). Your feedback helps us tailor future episodes to your needs.

**Holly Wyatt:** And remember, the journey doesn't end here. Keep applying the knowledge and strategies you've learned and embrace the power of the “And” in your own weight loss journey.

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