Bariatric Seminar – Dr. Alfredo Fernandez

Bariatric Seminar – Dr. Alfredo Fernandez


– Good evening, I’m Dr. Fernandez, so I’m the Medical Director
of our program here. We have an old program,
been here for many years, we do a lot of cases, and we
are a Centers of Excellence by two different Centers
of Excellence groups, and that’s super important
because when a hospital makes that commitment to
become a Centers of Excellence, it’s a really big deal, so
it’s a change in the hospital as far as chairs, bathrooms, OR equipment, Radiology equipment, an
incredible amount of things that have to be changed. They then get inspected all the time. So we get inspected to make
sure that all the stuff is done right, as far as the hospital, and the more important thing
when you have your surgery done at a Centers of
Excellence is that they track our results, they track our data. So all of you guys will be in a data pool, and if we’re not doing well, if we’re getting a lot of complications, they can take the Centers
of Excellence away. So that’s very very
important, and that’s good, because it’s how we’re
getting, as you’re gonna see, really low complication
rates, when these otherwise complicated surgeries are
done in places like this. Alright, this is the crux of the matter. You see this number all
the time in the press because it’s very impressive,
and it’s a true number, 65% of the population is overweight, and that’s almost worldwide now. But that’s kind of a, it’s a false number, because all you have to
be is 10 or 15 pounds over what they think that we should weigh, and then you fall into that category. The really important number
is a much smaller number, when this, and we’re gonna
learn all about this BMI, when that number gets to
be above a certain number, and you have a little
cheat sheet in your handout that you can plug in your
height and your weight and you’re gonna get that BMI. Once that BMI gets a certain
number, now the weight is important, because now
it has a health impact. So just being overweight 10 or 15 pounds doesn’t affect your health. Being overweight 70,
80, 90 pounds or above, now it’s a health impact, and that’s really the important number. But, the importance of the 65% is huge because that denotes that
portion of the population that’s susceptible to this disease. So 65% of us carry genes
that make us susceptible to become obese, versus
the other, what I call, the 30 percenters, well we may
have some here in the room, I always like to point ’em out indirectly, that are the people
that eat all they want, we all know them, drink
10 beers, five burgers, and they don’t gain weight. What’s up with that,
what’s that difference? And there is a very big
difference, which is historical, but we’re gonna touch upon that. The main two things that I want you to get out of this lecture
are what causes obesity, and how does this
surgery fix that problem, that’s crucial, and that’s
gonna be our goal tonight, to go over those two things,
so it’s a huge problem because most of us can get this problem, but only when it gets
to be a certain number is it a health impact. So, obviously you’re
gonna see it in the news, all over the place, there
isn’t one of our publications, even in General Surgery, that
doesn’t talk about obesity. And this is something you
gotta be really looking out for when you go out
there and you go through the grocery store and
you see all kinds of ads, whenever you see that big huge companies start to advertise that
they’re removing something from their foods, that’s very important, because usually those items,
like that one in particular, high fructose corn syrup,
is the cheapest sweetener, it’s a binding agent, so
it’s literally in everything, and when they now remove it, and switch to something
a little more expensive, and they spend money
advertising it, it means that there’s something wrong with that, basically that’s what it
is, and for big companies to do that, they usually don’t do that, they usually wait until
there’s some regulation or some big lawsuit, and I
think they’re just preemptively avoiding the big lawsuit against
high fructose corn syrup, alright, and we’re gonna
talk a lot about that. This is all about metabolism. Our metabolism, you hear
metabolism, what does that mean? Metabolism is how much energy
we burn to live, literally, it’s more complicated than that, but for tonight’s talk, that’s what it is. This is so much about
metabolism that we changed the name of our society, it used to be Society of Bariatric
Surgery, now we changed it to Metabolic Bariatric
Surgery because really, that’s what changes
when we do these things, and we’re gonna talk a ton about that. And if one of the biggest
metabolic issues that many many of us have, is
diabetes, we’re gonna talk quite a bit about that,
because this is a target of this surgery, is diabetes,
and you’re gonna see how that is. We don’t have to fight China or Russia or any really big country,
we just have to send them more of our food, more
of our McDonald’s, KFC’s, give ’em time, they will
have so many diabetics and such a high rate of obesity,
that they’ll go bankrupt. Literally, China is worried about this, and they’re actually doing many things in order to hold off on
what they’re noticing, you’re gonna see that. Remember that about 95% of the
food produced in our country is less than 15 companies,
so these are hugemongous companies that produce a ton of the foods that we eat everyday,
and whenever you see them doing all this, pay heed to
that, because that’s important, there’s something wrong with these foods when they’re spending all
this money to get rid of them. Cover of TIME Magazine, National
Geographic full article, it’s a worldwide issue,
not just in our country. What has brought the world’s
attention to this problem, especially the Chinese,
they’re really worried, is how much this problem
costs to any society. The cost is staggering, and
it’s really much more than that because in that is not
figured out the cost related to the diabetes, high blood
pressure, sleep apnea, bad joints, and all that
stuff, which is all related. So the costs are hugemongous,
and that’s why everybody is really paying attention to this, because it could be a
reason for bankruptcy. And we kiddingly say that the
weapons of mass destruction that we export are this,
and that is actually true, and what is it, it’s our diet. And why is it so bad, what
has changed in history? Man has eaten in a certain way forever, from the initial history that
we have, even before that, till about the 1940s and 50s, alright, that’s when we have made
big staggering changes. So in our eras, and in the
eras for sure of our parents, and for sure for sure of our grandparents, there has been a dramatic
change in how man eats. Our grandparents ate stuff
that was around there, food didn’t travel, there
was no refrigeration, you know, you couldn’t preserve stuff, you didn’t go to Publix,
there was no such thing, they went to some store where
they bought a pound of flour, a pound of sugar, some salt,
they bought stuff like that so that they could make the food. Very rarely did they have meat, except when it was very fresh,
because again, in those days in the 30s and 40s, there wasn’t that much refrigeration around, food
didn’t travel very far, so what they ate in the
summer was totally different than what they ate in the winter, and they didn’t eat fruits
all year round like we can because stuff didn’t come
from south of the equator, which is what happens now. So they ate a very limited
diet, everything was very fresh, there was no preservatives
in their diet, zero, they used three things to cook. They used butter, olive oil,
and pork fat, that’s it. There was nothing else, until we invented the vegetable oils. The vegetable oils and
that whole frying industry was in the late 40s, 50s,
we had to come up with oils that would be able to get
really high temperatures, not impart any flavor to the food, cause you don’t want your french fries to take 5 or 10 minutes to cook, you want ’em in a minute or less, that means the oil has to
go over almost 500 degrees, be able to go back down at
night so that it doesn’t spoil, can’t give the food flavor, so how do they come up with that stuff, the same way that now,
I saw an ad yesterday, now we only have to change our oil, if we switch to synthetics,
once a year, wow, it used to be there was an
industry around changing oil every 3000 miles, an industry,
now it’s once a year, why, because scientists sit down in labs and they improve upon
stuff, and that’s exactly how they’ve been doing food. What man has been fighting
all of our life are famines. Since prehistoric times
there’s lack of food, we’re designed for famines, we’re designed to survive famines because that’s what we’ve experienced. Man has always made an
effort to try and produce more food and better food
and food that lasts longer and all that stuff, because
we’ve been fighting famines. And that’s been in the
industry, so to say, since the late 1800s. You know, that man has
tried to feed more people and feed more people, and finally now, we went from a history
of famines to last year, the number one chronic disease of Africa became morbid obesity. Wow, we really did good, we
really knocked off famine, you know, now we’re just
knocking ourselves out in a different way. So in that huge surge to
try and feed more people because people were
starving, now we’ve created, probably a bigger problem,
because it affects the entire 65% of us are
the subjects of that. So what is the big deal
with all of these changes? We used to always think
that these things were bad, because, you know, first
there was the war on fats, I remember everything had
to be fat-free and all that, then more recently the war is on carbs and we’ve always been counting calories, and we’ve been taught these
things since we were kids and as we watch the
population get out of control nobody’s changed that
mantra of diet and exercise. Most of your doctors
today are still thinking that you’re overweight
because you eat too much and you don’t exercise
and that’s how it is. And now we have computers,
oh, it’s the computers and the TV and all that,
and it has nothing to do with that, because how can the skinny guy, actually our cinematographer’s
one of those 30 percenters, how can the skinny guy be
involved in the same exact thing and they don’t have the problem? Alright, here’s the problem. The problem is that we’re
designed for famines. Man is designed so that
when we lose weight, and our body doesn’t know
weight, but our body knows exactly how much fat we have stored because our fat cells
are how we store energy, you gotta look at that, it’s energy, it’s nothing other than that. The body doesn’t look at
it different, so we eat to maintain ourselves alive,
that’s that metabolism, we need a certain amount of
energy depending on our genetics it could be 1200 calories
or 2000 calories a day, and we’re designed that if
we start to lose that amount of fat or that storage of
energy, we trigger something that we all have built into our genes. So, let’s say that 180
pound man now is in a war, or he’s in prison, and
he isn’t given food, and he starts to lose weight,
that’s how it happens, so he goes from 180, 170,
160, when a 180 pound normal man gets to about 140,
he’s lost so much body fat that that triggers a
survival response, automatic, we got it built into us. What does that do? The body now is going to protect itself because it fears that it’s gonna die, so we can alter our metabolism, that’s the difference between us and cars, our car comes with 30 miles
to the gallon, that’s it, can’t do much about it except
coast down hill, right, but when that guy gets to 140,
he releases a ton of hormones and his metabolic rate,
we’ve measured now, can go down to as low
as 400 calories a day, whereas normally maybe he was 2000. So now he can survive
at 400 calories a day, so whatever energy he has left in stores, now it can go a lot further, that’s good, that’s a survival tactic, that’s great. Same thing that, who has
it in the animal kingdom, bears and all those animals
that hibernate, same thing. So they’re designed so that
there’s a point when it’s cold and certain triggers, that
they can go and sit somewhere and live off what they
stored, and it’s a dramatic, and we’re doing a lot
of research to see how, that’s actually how we figured this out, by seeing how we are affected that way when the sudden severe weight drops occur. So we have that mechanism
in, that guy now is 140, but now he’s only burning 400 calories, so now he can live a little
longer, plus he’s given a tremendous drive by
increasing his appetite, his hunger, super hungry, that’s good, that’s a motivation to go find food, and when he finds food, he’s
able to eat and eat and eat and not feel full, another
great characteristic, because now, that’s what the bears use, they can eat and eat and eat
and eat and eat to replenish their energy store. So it’s all about energy,
energy in, energy out. So imagine we have this
phenomenal mechanism that has made man survive
all of these years, and now we get to an era
where we have changed completely what we eat
and what we’re eating, what it’s having an
impact is on the ability to regulate that, to
regulate our metabolism. And so what happens is,
when we eat all these things that we’ve been eating
this since we were born, because anybody that had Enfamil, it has high fructose corn
syrup, and that’s what we export to other countries very
cheap so we get ’em right from the womb and we
start screwing up their brains. So these things affect us,
not because they’re fats or because they’re carbs,
or the caloric content, these things affect us because
they damage the ability of our body to regulate,
right, that’s the key, that these foods have an impact on our central regulatory
mechanisms, and therefore, let’s say us, we’ll take our example. So we’ve been eating all these
things since we were little, we get to a certain point,
some people it happens earlier, now that’s a huge problem that we have now with morbid obesity in
kids and diabetes in kids from morbid obesity, it’s a disaster, so let’s say it didn’t
happen when we were kids, let’s say right after puberty,
or when we went to college, we’ve been eating this stuff
since we were born, right, all this stuff, everything that
we like, and then it starts to have an impact on us,
and usually it happens with some other change
that occurs in our life, some other hormonal change, and now we start to put on weight. We were okay before, but now
we start to put on weight. And now we go from 160,
whatever we were, 170, 200, 250, 300 pounds, we got to 300 pounds. We get to 300 pounds and now, boy, we are, I’m unhappy with this, you’re
gonna do something about it, you’re very serious, and
you go to your doctors right after New Years,
it’s your resolution, you go to your doctor and he
examines you, and he says, yeah, okay we’ll put you on a diet. And the diets are all the same. So the diets are high
protein, low good carb, low good fat, B12, shots,
appetite suppressants, there’s not much variation because there’s nothin’ much to do. And what happens to you? You’re at 300 pounds and
you start losing weight. And you get to 290, 280,
270, you feel awesome, because even 30 pounds
of weight loss is huge. You can run around
better, totally different, now you can tie your shoelaces,
you couldn’t do that before, all those silly things, right,
that we take for granted. But at some point in
that weight loss process, and depends on our genes,
at some point, we do what, we trigger our survival
response, because it’s in us, it’s genetic, and now what happens? So let’s say that you
were at 800 calories, which is really difficult,
you were exercising another hundred calories,
which is really difficult, and then your body went to 500. Pow, overnight, and you’re
really really hungry, which before, you were not so bad. Wow, and now you get on
the scale the next day and you didn’t lose anything. You’re not changing anything. You get on the scale the next day and you’re not losing anything. You get on the scale the next day and you went up a pound, and
you haven’t changed anything. Your metabolism changed. Your car went from 30 miles
to the gallon to a thousand. So with that same amount
of energy, can go anywhere. That’s the problem, that
that’s what happens. That these foods screw up our brains, our brains fail to regulate,
in this case, weight, but we’re gonna talk about
a lot of other things, and then we suffer because
once we reach that weight, wherever we got to it,
that became our new weight. So the body now readjusted
to that, your new thermostat, and now it thinks that’s
the normal weight, and it fights us when we want to change. Our body doesn’t like to change anything. Remember, our blood pressure
has to be within a range, can’t have a blood pressure at 10 or 300, your blood sugar can’t be
20 or 8,000 cause we’d die, everything has to be within a range, weight has to be within a range. That’s how our body likes it. Wherever we end up, you
know, even that skinny person when they eat a tremendous
amount, they’ll gain two or three or four pounds, but then they’ll lose it over the next few days, when,
that’s how we’ve measured it, when they’re asleep
resting, their body realizes that much more energy
came in than it needed, they raise their metabolic
rate, and they burn it off over a few nights, or a week, and they get back to normal. Even us, when we get
to really high weights, usually you get stuck there,
and you’ll go up and down but you really won’t vary much. That’s what the body likes. It doesn’t like dramatic changes. So the problem is caused by
foods that we had no idea are affecting our brain. Not because of the other
things that we’ve been told and we’ve been thinking for so long, and if our brain controls
everything, guess what, other organ systems can go bad. It can affect our blood
pressure, our blood sugar, so we used to think
yep, you’re 300 pounds, so you’re gonna be a diabetic,
no, there’s 500 pound people that have nothing wrong
with them, right, nothing. But there are 250 pound people that have every single disease. Why? Because in that brain,
it affected many more things, and in the other brain, it
just affected a couple things, but it is that effect. We spent, how many years did
we spend looking at this, circling the calories and
the fats, and the potassium, and the sodium, you know, all this stuff, what we really should have been taught is, what’s in the bottom,
what’s in this thing? What is in it? Does it have high fructose corn
syrup, canola oil, palm oil, soybean oil, guar gum, you
know there’s even a bunch of stuff now if you look at the labels, which you’re gonna become
label readers for life, there’s a carnauba wax
that makes stuff shinier, it’s all over the place. That shouldn’t be in our
diet because that’s car wax, but that’s what they do. Remember, this industry is
not very well regulated. As long as something
doesn’t kill you right away, if it kills you in 20 years, you know, it gets snuck in there
because we don’t measure that so easily, right? Classic American breakfast,
absolutely the wrong things we should have in the morning. Alright, but this is convenience. Remember, our grandparents
never bought processed foods. We buy all processed foods, literally. There’s many people who never eat anything that’s not made in a factory. Things that are made in
a factory can’t be made the same as you make it
at home, even a cookie, if you’re gonna make a cookie at home, it’s flour, salt, lard, if
you put chocolate or whatever, and you bake it, and it’s fine. You can’t do that in a
factory where they’re making five billion cookies that
are on conveyor beds, they’re getting suctioned and packaged, because they will all fall apart. So that same cookie, when
it goes to the factory, now has about six or
seven things added to it so that it doesn’t fall
apart on the conveyor belt. Alright, very important,
totally a different product. Our body wants to get proteins mostly, especially in the morning. We haven’t been eating for a while, so our body looks at that, those Circadian rhythms, you
know, so we’ve been sleeping, resting, a bunch of stuff
going on, now the first meal should be protein, just
like what animals do. But no, we get this,
which is completely wrong. And there’s this, all you women that want to kill your husbands, just
give ’em this every day, tell ’em, look hon, this is
heart healthy, it’s perfect. Mr. Quaker, look how great he looks alright, so you give him this
(laughs) every day, every day, every
day, that has every single one of those bad things that we’ve
been kinda talking about, 100% of ’em. Does that mean that oatmeal is bad? No, that’s a great source
of protein and nutrients, but there’s a huge difference
between this and this. This is in a factory,
this is how it starts. So you can get steel cut oatmeal, make it, put honey in it, put berries,
put whatever you want, you got a tremendous food source. You buy it in a box, and it kills you. Puts you in a box, that’s
how we should say it, puts you in a box. These are other things
that shouldn’t even be. Guar gum is from the petroleum industry, it’s what we use to improve fracking, which is to get oil deep from
deposits that are in rocks, makes the water more
hydraulic so it’s able to break it down better. So somebody figured out,
man, this is a lot cheaper than high fructose corn syrup, so you’ll see this guar
gum as a thickening agent. Even some of our good things, like I saw, I think it was a KIND
bar, or one of those bars, you know, everything
looked good until they got the guar gum and all this stuff,
and they put it at the end, so hopefully you won’t read that. Here’s another exercise. If you got a thing that’s big
this big, like a protein bar, any bar, that’s this big, and when you, you notice that they put
all the caloric stuff on the outside, but you have
to flip to see what’s in it, if you lift that up and
there’s writing all around, don’t even read it. That’s too many things. That should have three or four
things, should be this, this, that, and that, but no, it has
literally 15 or 20 products, that’s what we gotta
away with, that’s bad, too many things that we don’t even know how they’re affecting many of us. They can use abbreviations,
that’s allowed, high fructose corn syrup,
they can put a 50 or a 70 next to this and you’d think wow, that’s probably something
good, no, that’s bad. Alright, so we gotta be super careful — at the end, write it down — super careful with what’s in our product, so we teach our patients to
be label readers for life. Luckily in our country,
everything has to be on the label, so that’s good, so they
can’t sneak stuff in. But you gotta be careful, and
we’ll talk a lot about this in the office, cause this
is a whole other thing, this is a real chicken, and
this is how Mark McGwire came into baseball, and then,
in a couple or three years, he got like this and he
was hitting 60 home runs, and that was natural, right,
he was just working out more. B.S., he was on human growth hormone, and back then they didn’t
measure that so we didn’t know, but that’s how you get from this to this. You cannot get, no matter what you do, no matter how much you work out, you’ll see that in body,
they get to a certain point, and depending on their
genetics, that’s it. No matter how much they work
out more, they don’t get more. You gotta put the anabolic steroids to change their metabolism,
change their structure, but then that’s a double edged sword, that’s the problem with those things. So real chicken, Tyson
says he’s okay, right, no. And this is a cute, so
this guy is a reporter, he’s asking the farmer, you
know, so you put all this stuff to make your cows fatter, you don’t think that’s gonna have an
impact on us, of course, we are what we eat, so what
we eat is what we become. So we eat a lot of crap, that’s
what we turn into, right. This is what I alluded
to a little earlier. Many countries don’t report obesity rates, but everybody through the
World Health Organization reports diabetic rates. China went from a 1% diabetic rate about 10 or 15 years ago, to now they’re at 11%. That is staggering change for
as many people as they have. That’s gonna cost them
a ton, so they’re doing some very drastic measures in
order to put controls on that. And we can talk about that. So obesity’s not so simple, you know, the simplistic way of
thinking this is we overeat and we don’t exercise, and
henceforth we have the problem, it’s not correct. That’s why we have the problem,
that it’s not so simple. It’s very complicated,
and it has a lot to do with, when we call the
environment, is what we’re eating, cause that’s what has
changed dramatically, and that’s the cause of it,
and it has a tremendous impact and we could never figure
out why cancer, and all this, we couldn’t figure that out
and it’s because everything is controlled by the brain. So when I used to give this
lecture many years ago, it was without this guy. It was, you take in 5000
calories, you burn 3000, the other 2000 you put in
fat, and that was it, math. And a lot of your doctors
still think that way, they don’t realize that, you know, there is the skinny person that can — and they all know it, but
they haven’t been taught it, because they know that when
they treat a burn victim, for example, or anybody that’s
really stressed from disease, we sometimes have to feed those
people 10,000 calories a day because that’s what they’re
burning in order to heal, and that’s this guy working,
you know that’s very important, so we can be a car that can
go from 30 miles a gallon from the factory to a thousand when there’s not that much gas, or to one mile to the gallon
or less when we pour gas into the car and it’s
too much gas, alright, so the body likes to,
the way it should work, is to alter, or to vary, that
burn so that we don’t change that much weight, that’s
how it should be working, and that’s where these foods
affect all of these methods that the body has to know
how much energy is in us, cause the body doesn’t know weight, but it knows storage of energy,
gets pretty complicated. Classic simple experiment,
we use mice for many many — or rats — for many many
studies, and we figured out the right diet for them
so that they thrive. And this diet is called a mixer act diet, and no matter how much you
put, they autoregulate, they stay about the same
weight, nothing happens. But if we get another group of mice and we force feed them
that same mixer act diet, and get ’em that big, and then put ’em back into the population, over a period of time,
they autoregulate back, and they become normal weight again. But we get another group,
and we force feed them high fructose corn syrup,
canola, and palm oil, just those three things,
and get ’em to that weight, and nothing can make them
lose that weight again, so now they’re stuck,
so even in a rat brain, that effect happens. So it’s dramatic, it’s not just us. That was a great way to demonstrate it and to be able to reproduce this stuff. This is all research that’s very recent, this wasn’t around 10 years ago. BMI, basically it’s a height
and weight relationship and it’s very — it’s not
the best thing, but it works, and so we use it. And when you put that
height and weight in, you’ll get a number, and
put you in categories, that’s mostly for our studies,
but what it translates to, the importance of your BMI
is that once it reaches a certain number, now we
start to die from that, and that’s the key, that
it’s no longer benign, you’re no longer just overweight, now you pay the price
of increased mortality. And once this gets to 50,
that goes above 10 times. This stuff has been super well documented, this is, this one dates back to 1989, so we’ve known this
forever, unfortunately, we weren’t paying enough
attention to this problem back in the day, as much as we are now. And there’s all these,
this is what we got, everybody dies of the
same stuff, we don’t die of some unusual thing, you
don’t die of walking down because you’re 300 pounds,
you keel over and die, no, you die because if you
have 300 pounds, and diabetes, and hypertension, and cholesterol issues, you’re a walking time bomb for
a stroke and all that stuff and if you have that
in your family history, it’s gonna happen. What we could never
understand is these things, and now that we know that
all of this is related to our body’s regulatory
mechanisms being screwed up, so if it’s screwing up
one thing, it can screw up the entire thing, or
just one or two things. So that’s the thing, 65
things that can be affected. And this is one of the myths
that has made this problem not go away so fast, cause
you don’t hear anybody talking about avoiding
those things in your diet when they’re on The Today Show telling you to diet and exercise in
the morning, you know, they’re all skinny nutritionists, they’re not mentioning those items. You know, you can find that in research, and you see McDonald’s and
General Mills pulling it out, but nobody’s actually saying
that, guys you can’t eat that, it’s bad, and giving the
explanation, and I don’t know why that is, because that
information is out there. This is readily available. So you can’t, once you
get to a certain way, you can’t diet and
exercise yourself out of it because you trigger
your survival response, and we’ve been watching this for 20 years in study after study where
we see people losing, in 10 years, 500 pounds,
but ending up being bigger than they were originally,
because you keep triggering your survival response. Very very few people can
lose it successfully. Usually it’s people that
usually lose it so gradually that it almost fools the
body and they lose it, which is very unusual. Alright, and then, you
know, this is another thing that, really what triggered
the research into this was the skinny guy, you know,
how do you explain that, but also, we didn’t quite have
a really good understanding of how the surgery fixed the problem. We used to think that the surgery fixed it because you couldn’t eat
because you had a restriction because of a small (mumbles)
and you didn’t absorb, you had malabsorption, that’s incorrect. Those things, surgeries
that do that don’t work, so we had it wrong, and until
all this research started, we now know how it works, and this is what I was talking about, that if you follow people
long enough, anybody can lose 20 or 30 pounds, it’s when
you need to lose 80, 90, that’s the problem,
that’s where you trigger the survival response, when
you follow those people, they are bigger than they
started, and the actual numbers are these, so in all those
pill diets, they don’t work. They work okay for a
small amount of weights, but not for big amounts of weights. And so, these numbers,
wow that looks great, that’s much better,
yeah that’s much better, but there is no risk in these things, unless they’re giving some
real exotic medicines. So there is no risk in diets,
but the moment you step into an operating room, you can die. That shouldn’t be a
surprise, some people say, oh there’s risk, yeah
of course, any surgery. You’re gonna have a little finger thing, people die from that. You can get a reaction to
a medicine or whatever. So surgery is very dangerous, and so, if surgery is very
dangerous, and you’re going to expose yourself to
something very dangerous, it better be really good,
it better have results, a whole lot better than 50% or even 70, we have abandoned tons
of surgeries in the past, not related to this,
with a 10% failure rate, 15% failure, that’s not enough, you know, it’s gotta be 90, 95, 98,
you know, 1% failure rate, that’s what an operation should lead to, and so this is just a number
placed there to show you that this is not good enough. I’ll talk to you about why I mention that. So we’re gonna talk
about these three things. This stuff has been around forever. So obesity, notice, not
before 1950, because it was really really rare before
then, because we didn’t have all those oils and all that
stuff until about then, so it started like within 10 or 15 years of that introduction of that
stuff, we started to see some people with the issues. So, it should have been obvious back then, but nobody was paying any
attention to all that, they were all thought
as diet and exercise, and everybody was on that bandwagon. But this stuff has been around. That’s important, because many times, we don’t find out about a
failure with an operation or about it’s lack of success, or some weird thing that
happens until 15, 20 years after we’ve been doing it,
now we have enough data we start to collect it, we say, okay well this was not such a good idea. That’s how surgery is,
that’s how medicine is, it’s trial and error, literally. It’s not, we can’t, it’s not
like building an airplane or building a car, no, we
literally gotta try stuff and see what happens long-term. The most important part about
all this is that at some point there in the 90s, we
went from open surgery to laparoscopic surgery. Hundred percent difference,
thousand percent difference. Completely different surgery. So a lot of the old stuff you hear, train wrecks and all
that was open surgery, open surgery and this,
it shouldn’t even be done because the difference in
results are so different. So when we went to laparoscopy,
we made a huge stride forward in reducing the
complication rates and everything, and you’re gonna see those. So that’s the most important thing. Unfortunately, and fortunately,
back in the 80s, 85, 86, our National Institute of
Health in all their intelligence came up with these criteria,
which these are pretty good, so if your BMI’s over 40,
because of that risk that you saw on that chart, alright, now
you’re a candidate for surgery because obviously you’re
gonna die from that. But they also realized,
which was very smart of them, that if your BMI is 35
and you have diabetes, or high blood pressure, sleep
apnea, any of those things, that’s bad, that adds a lot more badness, so you become a candidate, smart. We should have done this at
the number 30 with diabetes, but we’re still struggling. Unfortunately, when this was
done, this was the super era of diet and exercise. They believed that for sure,
you guys are not controlling yourselves, you’re overeating,
you’re doing no exercise, and so you’re obese, so
you must try to lose weight with a diet. And so, unfortunately,
since this was written, almost like Moses, that now
this is the sword they fall on, and about three or four years
ago, the insurance companies now have made this one
of their requirements. That’s one of those things that
she asks you, in that sheet, call the insurance company,
basically the two questions are very simple. Am I covered, yep, what kind
of a diet do I have to do, ask ’em straightforward
like that, because if not, they give you a runaround. But basically, they’re
gonna make you do a three or a six month diet. It’s rare an insurance company
that lets you have this without a diet, it’s rare,
because the NIH wrote this way back then and they
have this in their books as a criteria unfortunately. Now, this is huge. They didn’t realize it
then, how important, because they’d had no clue
as to why this was occurring, but if we have now identified
that the culprit behind this, our foods that we’re eating
that are screwing our brain up, can’t eat those anymore
because you could be 10 years down the road, doing
great, and then introduce, as an example, a soda cracker
and some peanut butter without reading the label. The soda cracker has palm
oil, almost all of ’em, although today, there are many that don’t, but you didn’t read the
label, and you can buy a peanut butter that’s
high fructose corn syrup, canola oil, and peanut butter flavor. There isn’t any peanut
butter in it, but it tastes and looks exactly, it spreads beautifully, it’s the best spreading one. So you’re eating that as a
snack, it has almost no calories, let’s say 30, 40 calories, but
it’s got all those bad oils and it’s got high fructose corn syrup, and if that’s enough,
that could throw you off, and eating one of those
a month could be enough to mess your brain up again to
lose the ability to regulate, and it’s not about calories, it’s about messing your brain up. And so with your 1000 calorie a day diet, if your metabolism goes way down again, or you can’t control it,
you slowly inch back up. So that’s why the lifelong
commitment is to read the labels and avoid those foods forever, period. It’s not that hard. You know, there’s so
many things we can eat. Okay, this is a little Hollywood thing, and then I’m gonna draw the surgery. But this makes it look really pretty. Alright, all of this has to do, the ability to do these
things, and the gastric bypass, still the gold standard worldwide, so everything is measured against that. Laparoscopy, that’s the key,
so we put really little holes, we put these instruments,
that allows us to go inside and with these very
thin small instruments, do whatever we want to do. Basically, we’re fooling the
body into not stressing it by making a big incision,
so it doesn’t really know what we’re doing in there. So with these stapling devices
and everything that we have, we can do this, we can
create a small pouch out of the upper part of the stomach, so the stomach, food never
goes into it anymore, we get the small intestine, we divide it at a very specific spot,
we reconnect this to that, and this gets connected to here. So it’s called a gastric
bypass because food doesn’t go through the stomach, it goes
straight into the small bowel, but your stomach’s still gonna
work, still gonna make acid, bile, pancreatic juices enter
here, so all of that stuff is gonna come and mix with
the food, and you’re gonna absorb everything, because
we haven’t changed anything as far as absorption goes. This wasn’t even originally
done for weight loss originally. So everything, all your juices are there, nothing is removed, everything
mixes and it’s fine. In the case of the band,
we’re gonna talk just a little bit about it, the band was from the days of diet and exercise, so
the band started in the 80s in Europe, it was actually
a product that was done in the 50s for reflux and it
failed miserably for that, and some guy said, let’s
change this, blah blah blah, and they came up with
a bunch of variations until they said, let’s put this thing that we used to put up
there a little lower, since people can’t control their eating, boy now we’re gonna really
control your eating, we’re gonna put a device
there that ain’t gonna let you eat. So food is gonna get stuck. That thing originally wasn’t with this, but after many many variations, they said, no, let’s figure out how we can do this, so we can adjust it, so
that it’s adjustable. So then they figured out
that they can put this port, cause ports were used for
chemotherapy, so all this is just putting together a bunch of stuff that was already around. And so the idea is that
since you can’t stop eating, we’re gonna stop eating for you, almost like sewing your mouth shut, right, a little less radical than that. And then the adjustments
were very important because that’s how we made it
not too loose, not too tight, and I used to do bands,
so we got really good at all this monkey business
of getting it exactly right, so that you wouldn’t — so
some things would go through, and so forth, so you can make that balloon tighter or looser, and that’s
really what it looked like. So food would come in here, the idea was that it would get stuck,
that this would distend, you would feel full,
then food would go down, it would go through the normal process, and I’ll show you why it doesn’t work. Sleeve gastrectomy is the newest surgery. It’s been done a ton,
but it’s only been around for a few years, very important point. We have a huge stomach,
about a liter and a half, and this guy that used to deal with really really big
people was having trouble with bands and gastric
bypass because it’s very hard to do ’em, because the
liver sits on top of this, so he figured, well you know
what, I got these staplers, there’s this thing that used
to be done in the old days, I’m gonna get a stapler, I’m gonna get rid of most of the stomach, make this smaller, since it’s smaller, still thinking that now you’re gonna eat
less because it’s smaller, I’m gonna get the 800 pound
person to 4 or 500 pounds and I’m gonna come back
and do a gastric bypass and that’ll be the success,
but it started to work actually really well, and
so we adopted it officially as a bariatric procedure in
2010-11, so we’re in ’18, so it’s not that long, a
ton of ’em have been done because they replace
bands in Europe way before it’s replaced them here,
so a ton a ton of people are doing them, but
now we have enough data to kind of step back a little
bit, like many times happens after we do something for a long time, so it looks like that. Alright, so how do these things work? Alright, so we’re gonna
now, really explain. Alright, all this has to do — can you get this here — all this has to do with digestion and what happens in digestion. You can’t get a big steak, or that food, whatever we brought, did
they bring ham, and whatever, and you can’t get that stuff
and stick it in the intestine and absorb it, that’s not how it works, so we have to change food and
get it ready for absorption. That happens when you start to chew, so chewing is the first step. We break the food down
into smaller particles, saliva gets mixed in with it,
saliva has a bunch of enzymes, so it starts to break the
food down before it gets into your stomach. Your stomach is like a washing machine, it is not a place where
we absorb a lot of stuff. In your stomach are super powerful acids that work upon the food. The stomach crunches the
food, we have two valves, a really big valve here,
and a little weaker valve up here that should
keep the stuff in there. You know, if it doesn’t work
so hot, we get heartburn, and here we don’t know so
much about what happens when this doesn’t work so hot,
but depending on what we eat that food may sit in there for
30 minutes or a lot longer, even to an hour sometimes
while all that process is getting it ready. While it’s sitting there doing that, we send signals, and remember,
that the way we signal our body is to release hormones, that’s our signaling devices. So in the case of digestion,
the liver starts to make bile and we make about a liter
of bile a day, huge amount, and that bile enters the
small intestine here, right past the stomach. Bile is the opposite of
the acids in our stomach, so it’s an alkali, so it’s
to neutralize the acids. We make a ton of acid,
we make a ton of bile, so now we’re burning
ourselves everywhere, alright. While the food is there,
another organ gets activated, your pancreas, it not only makes insulin for your diabetic, for your sugar control, but in the case of digestion, it makes really powerful enzymes
which break the food down. So now that, you know, I use the example of that beautiful steak
that you paid 30 dollars for at the restaurant, looks
really great on the plate, you cut it, you chewed it
really good, like your mom said, chew it 20 times, now that beautiful steak got into your stomach, gets
acted upon by the acids breaking down, bile comes out,
pancreatic juices comes out, finally the steak gets over here and mixes with all of this stuff,
now it’s the first time that that steak is ready to be absorbed. Now it’s become correct. It doesn’t look like a steak anymore. What does it look like
when it gets down here? It looks like vomit, so remember that when you’re paying the money next time, it all turns to vomit.
(laughs) It’s also the time, the first time, when food gets to this
part of the small intestine that we secrete what? A bunch of hormones that
travel through the bloodstream, and they tell your brain,
you’ve eaten enough, now you start to get full. So the sensation of
fullness is not mediated by any distention of anything, it’s mediated by hormones
being released in the gut. The difference between that,
the sensation of fullness, wow that was really good, and what a guy in a food
eating contest does, is once he gets to a certain point where he distends his
stomach, the very next thing is pain, nausea, and vomiting. Anytime we distend anything in our body, pain, nausea, and vomiting. You got a kidney stone,
a gallstone, a blockage, pain, nausea, and vomiting,
that’s how we’re designed. So distention causes pain,
nausea, and vomiting, hormones make you feel
full, that good sensation. So that person now gets that sensation. But the food isn’t even
near done traveling. So the food is gonna
travel down through 23 feet of small intestine. Next time you go to Home
Depot, get a 25 foot hose, put it in front of you,
that’s how much bowel we have. That’s where we absorb our stuff, that’s how we’re designed,
all of that as it travels through there gets this
absorbed there, absorb — and it’s not just 23 feet,
it goes like this inside, anybody that eats tripe sees
what that looks like inside, very complicated. So that’s where absorption occurs. So it went from the
beautiful steak, to vomit, once it reaches the end, once
it gets to the large bowel, digestion doesn’t quite stop,
but it changes dramatically, and that’s like a whole
lecture, but now it went from that beautiful
steak, to vomit, to what, to diarrhea, and the
function of the large bowel is to absorb the fluid so
we don’t dehydrate ourselves and have diarrhea all
the time, so the colon, which we have 12 feet
of, takes care of that. So 23 feet of small
intestine, remember that, it’s very important. All right, so then when
we do these surgeries, what are we changing, what’s the big deal? Well, remember this time
interval, so in the case of the gastric bypass,
which was originally an operation done mostly
after World War I, when we had thousands and
thousands of injured people with, for the first time,
high velocity machine guns, so all those injured soldiers
had to be taken care of, thousands, we had no idea
how to do it, so they had all their stomach blown
out, they would remove whatever they could, they
tried a bunch of ways of putting them together,
and some French guy came up with the best
idea, which is not to try and put together what was left, but to go to the small intestine to a certain specific
location, pull this up to here, and hook ’em up like that,
and rehook ’em up like this. So it look’s like a Y, so
it’s called a Roux-en-Y cause he was French. Alright, so what’s the big deal, what change can you see
obviously that occurs now? Now food doesn’t spend
30 minutes or 45 minutes in the stomach getting
churned up, food now goes mouth, pouch, and straight
into the small intestine, bam, straight in. So that transit time, is what we call it, went from let’s say 45
minutes, to about 30 seconds. So what’s the first
obvious thing that happens? All those hormones that
got secreted an hour after you ate, now get
secreted immediately, and bam, you feel that sensation
of fullness right away. Victory, because now
with eating much less, you feel the same sensation,
wow, I don’t want anymore, I don’t want to eat anymore. Big difference than I’m not
gonna eat because I’m overweight and I’m tryin’ to diet. Huge difference. You cannot appreciate
it until you feel it. Cause it’s inconceivable. But that’s not enough, because
right there at that point all you’ve done is ate
less, just like a diet. If you lose enough weight you
trigger your survival response and you’re toast. But something very interesting happens when we do this surgery, we had no idea until we started measuring people, now we have half an idea, and no idea why, but we measure it. When you do this surgery,
the day after surgery, when you start to drink
liquids, 17 hormones change. Dramatic change in your hormones. And that leads, in most
people, to an increase in your metabolic rate. Now, that’s the key, because
if before the problem was that you lose weight and you
trigger your survival response that’s mediated by hormones, now those hormones are opposite. In many people, they’re burning
thousands of calories a day, so you get a guy, especially
men that are really big, come at a week and they’ve lost 30 pounds. You can’t lose 30 pounds in a
week if you starve yourself, because within three days,
your body slows down. But they’re not, they’re
like if you’re sitting with your car and your foot on the gas, (motor sound), burning, like a burn victim, probably
burning 7, 8,000 calories a day because their metabolic rate was changed, because the hormones change from the rapid transitive surgery. Had no clue that that’s
how this stuff works, none, until they started to do the
research, how does this work, and started measuring people. And the sleeve works exactly the same way. So all we’re creating is a
tube, the food goes down fast, not as fast, maybe one or two
minutes, and hormonal change but not as dramatic. Five hormones change that
we’ve measured (mumbles). And that’s very very
very very very important. Metabolic rate still goes up, but if you have certain diseases, this makes those diseases go away, and this doesn’t make
those diseases go away and now we know that from tracking people and seeing resolutions (mumbles), resolution of hypertension,
so we have data and numbers about that. So how do we choose? And these are the only
two surgeries that we do. It would be great if we had
more, but that’s all we have. We never do bands anymore,
that was a really dumb idea, cause what are you doing, you’re putting that thing
in there, food gets stuck, if you overeat cause you’re starving, you distend this and
you throw your guts up, finally food goes into the
stomach, where it spends what, same 45 minutes depending on what you ate, finally the food enters the small bowel, finally you get told you’re full, so the only hormone that changes is one of your hunger hormones
is elevated all of the time, so you’re hungry, and you can’t eat, really a bad combination. So that’s why they fail,
because it’s a bad mechanism, it’s like a diet, still
triggers your survi– so you lose a bunch of
weight at first, yeah, because you’re eating
less, cause you can’t eat, but as soon as you get to the
point where you lose enough, you trigger your survival
response and it’s a diet, but now you’re screwed,
because now you got this thing that unless you change what
you eat, doesn’t let you eat. So you’re losing weight and throwing up, really a bad combination,
and that’s what happens. Alright, so the anatomic change
leads to a hormonal change and that leads to the effects. So guess what’s all the research is? These are pharmaceutical companies that, now they know these
things, now they’re trying to figure how they can
give you those hormones without an operation, and at some point, we’ll get pretty good at that,
but it’s very complicated, there’s so many changes. Alright, so gastric bypass, sleeve, and we won’t even talk about the band. And I’ll talk to you about
the balloons in the office, that’s an even dumber idea. (laughs) But anyways, and we mentioned
surgery is very dangerous. No matter what we do, simplest surgery can have complications. So we’re gonna talk about
just two, the big two. Blood clots. Remember
we depend on our body to pump blood to every
organ, and then deliver the nutrients and oxygen,
even to your hair cells that make hair, but we
don’t have a million pumps to pump the blood back, so
we need our venous system and gravity and muscle
movement to get that blood back so we can recycle and recycle. When we are gonna operate
on you, we lay you down and the anesthesiologist
gives you some medicines to paralyze you so they can intubate you. We knock the tone of the vessels out because the muscles get relaxed,
so we slow the blood flow. If we leave you there long
enough, you will get blood clots. It’s like traveling in
an airplane really far with your legs crossed, or
anything with your legs crossed for six hours, you’ll get blood clots. Nothing happens right at that point, it’s later (laughs) right,
it’s later when you — this is short — it’s
later when you get up and start walking around
that they can come loose, they travel back through the
veins, through the heart, and if it’s big enough, when
they go back into the lungs, they can block off a big blood vessel and you can die from that. So, before we put you
to sleep, we put, today, compression devices, not those stockings, that was another dumb idea,
a stocking that’s tied around your thigh. No, there’s a thing at the
bottom that massages your calf so it pumps the blood. We have reduced the
operative times dramatically. These operations are rarely
even an hour, 45 minutes, 50 minutes, very short intervals. And then, once you’re awake,
we get you up and walking, cause movement is the simplest
thing to prevent clots, and then we give you a blood
thinner on top of that. So that has reduced that dramatically. The leaks are what always make
gastric bypass and sleeves more dangerous, because we
didn’t have a really good way of denoting when we had
a leak, so we would wait till the next day after surgery, make the people go down to
X-Ray, drink some chalk, and if they had a leak, they’ve
already had it for 24 hours, so that wasn’t really smart. Now what we can do, plus our equipment has dramatically improved,
now we can put blue dye under pressure while we’re
there, and make the leak occur if there is one, so we
can fix it on the spot, and that has really made leaks
very very low percentage, and you’re gonna see the actual numbers. And the others are band
issues that we’ll talk about, anybody who has a band. Mortality has dropped
dramatically, this is actually in all the Centers of
Excellence, the average, around our country, that’s really good, it’s even less than a
gallbladder, and that’s what you achieve with the
Centers of Excellence push. We even changed, now we’re
starting new protocols that all of you are gonna
be doing, which includes different type of nutrients
that you’re gonna get just before surgery
and the day of surgery, so we’re always coming up with stuff to make this even better. And then when you do this
good, you get good results. So you get good weight loss, you get good resolution of the
diseases, and that’s the key, remember if you have diabetes,
hypotension, hypertension, sleep apnea, and your cholesterol is bad, and we get rid of all those things, your life is now gonna be
normal, that’s the key, it is the diseases that’s the key. Yeah, you’re gonna lose weight,
you’re gonna feel better and all that, but this is the real issue. It’s the metabolics. And so this is what it’s all about, and all of you are gonna
be part of this database. You know, nobody knows who
you are, but your numbers will be there and that’s
how we follow this, through this bowl that’s
a nationwide thing that we’re part of, it’s
actually worldwide now. This is cute. So this kid has two docs, one of them is the best diabetic
treating doc in the world and he controls your
diabetes, but if any of you are diabetics, even
well-controlled, many people progress from Metformin
to bigger Metformin, to Metformin and Victoza, to Metformin and a couple of other things, and eventually you end
up on insulin, right. It’s a disease that progresses. And the other parent can just
take you to the operating room and in 45 minutes, and
you’re done with that, and that’s literally what’s
done across the world for many diabetics today, that’s what they’re gonna do in China. Busy slide, we’ll talk
about this in the office, reflux is bad, a bad thing with sleeves, but we’ll talk about that. So, bariatric surgery works
because it works completely a different mechanism than
other forms of weight loss, that’s the key. So this works by changing
your hormones, simple as that. And look at today’s list, so with a band you get restriction, one of your hunger hormones goes up, sleeve you get fast transit, all these are really good changes, and then a gastric bypass
you get a pile of changes. Some of these, to some
people, they don’t need this. So that’s how we choose one or the other, we are not gonna — we’re
gonna sit down with you, we’re gonna see everything
there is about you, and we’re not gonna do surgery
that you want to have done or because your aunt had
this done, or your cousin, or it’s Wednesday, we’re
gonna tell you which one would be best for you, and
hopefully you’ll agree. You come to the office,
you’re gonna all get a call and you’ll set up an appointment. We’re gonna really go in
detail, there’s many people that don’t need anything
cause they’re very healthy, but there’s many people
that have a bunch of stuff that we’re gonna get the
input of all those doctors so that we can make you
as healthy as possible. We’re gonna teach you
a ton about nutrition, we do a psych eval, we’ve
always thought that’s important, because these are very big
changes in your lifestyle that we want to make
sure you’re ready for, what happens afterwards
is just as important. There is no excuse for follow-up, so you’re gonna be follow-up,
you have a 90 day period where you don’t have to pay for anything, but if your insurance
lapsed or whatever happens, those support groups
are four times a month, so there’s people there
that know, and if not, you come right over here and you ask. So, follow up is crucial,
cause we may discover something a year from now that’s a new
thing that we have to avoid, that could be the important thing in you, so that’s very very important. It’s a team effort, so
there’s a bunch of people you don’t even know today that
are gonna be very important in order to make you successful,
so we use all those people. Turn in your registration
form, which you did, and then you’ll get a call. Call the insurance company,
ask them those two basically, am I covered, and how much
of a diet do I have to do, and we’ll guide you as far as that goes because we used to tell people if they say you have a six month diet,
ask your primary care, and we would get a lot
of people that would come with diets that were no good. Boy, now it’s another six months, so come to the office, we’ll show you how we’re gonna do that. Read all of your stuff. There’s a lot of online
things that you can look at. One of the things that I’m
gonna make you look at, and it’s a really easy thing, it’s a 10 minute YouTube, on YouTube, a thing called, Time To Act on Obesity. Very nice animation, it
explains a lot of what I talked about in a really nice way,
it’s about eight minutes, and there’ll be a link to it, which is The Skinny on Obesity,
which is a much longer, several part series, it’s
a very good doctor talking and other people talking about,
some of it is talking about the sugar industry, the food
industry, tremendous amount of information there. And if you really really
want to get into it, go m. — this is Google —
a.r.s. — you gotta put the dots or you’re gonna get the
planet (laughs), ethicon — you don’t want the planet — ethicon, and those are the people that started this research, Metabolically Applied Research
Study, and they’ve now gone in all kinds of directions,
the industry is funding a lot of this, because once we
discovered this hormonal thing, they’re all over this,
lot of data in there, it’s very very very good. Alright, and, we don’t
want fools with tools. You’re gonna get a super
powerful tool, right, so we want you educated so
you know how this works, and that’s the guy that led
to a lot of this research cause, why, why can he
do that, and we can’t, because, what, his
brain is working better, so he can keep doing that.

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