Board-certified obesity medicine specialist and brother of Dr. Nathan Fox joins us for today’s episode about weight management and treatment of obesity. Dr. David Fox helps people in his general practice understand the medical implications of obesity and works to destigmatize the societal shame surrounding what, at the end of the day, is a problem that can and should be treated as any other medical risk factor.
“Medical management of Weight Loss” – with Dr. David Fox, aka Brother David!
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Dr. N. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB/GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. David Fox, brother David, thanks for joining me on the podcast today. How are you doing?
Dr. D. Fox: I’m doing great. Thanks for having me.
Dr. N. Fox: This is very exciting. It’s not easy to get our schedules aligned as we’re both doctors, we both have families, we’re in different time zones. But unfortunately for you, and fortunately for me, you’re stuck home with COVID again.
Dr. D. Fox: I have plenty of time on my hands as I’m isolating for five days from COVID. I have the house to myself, no wife and children. They actually went up to our parents’ cabin in Michigan, which was the original plan, and then I got COVID the day before our vacation was scheduled to start. So it works out. This interview couldn’t have been timed better.
Dr. N. Fox: And we were talking about… First of all, for all listeners, David did not get COVID at the Fox wedding a few weeks ago. We’ve confirmed from all… you know. We contacted the CDC, and did strain testing, and contact tracing, and it was not from the wedding and you believe it was from pickup basketball.
Dr. D. Fox: Right, the timeline does not match the wedding. Getting COVID… What your listeners didn’t hear is I also got COVID about two months ago. So I thought I was gonna be in the clear for a little while, which allowed us to come to your daughter’s lovely wedding. We had a great time. I did not get COVID there. The culprit is pickup basketball in the gym. And that’s where I got it the first time as well.
Dr. N. Fox: Yeah. Well, tell our listeners pickup basketball that seems to be…it’s not an airplane. It’s not a wedding. It’s pickup basketball. Be very careful with that. So…
Dr. D. Fox: Very dangerous activity on many fronts.
Dr. N. Fox: Yeah, but I’m glad you sound well. I assume this is just one of those “I have COVID, nothing to do,” but you’re not violently ill.
Dr. D. Fox: Pretty much minimal symptoms. But I’m just doing my due diligence with proper isolation.
Dr. N. Fox: Well, hope your family has fun without you. What are you going to do? I’m sure mom and dad will appreciate seeing your kids even without you, although, as everyone knows, you’re always their favorite. So what are you gonna do?
Dr. D. Fox: Yeah, I’d like to think they’re missing me a little bit, but I do know for a fact they’re having a lot of fun.
Dr. N. Fox: We were planning on doing this anyways, even though, you know, before your schedule allowed for it. And I wanted to have you on, first of all, because I’m going through the family one at a time. And now that dad has made his podcast debut and is a sensation. And you know, “People” magazine is calling him up, and, you know, ESPN is calling him up. And, you know, everyone wants to have him on. I figured, hey, let’s do the same thing for you. But, you know, you have a really interesting medical practice. And for our listeners, David is trained principally in internal medicine, primary care, but you did sort of subspecialty training in weight management or obesity medicine. And I definitely wanted to talk about that with you as well. So maybe just give our listeners a sense of…well, I know who you are, but tell them who you are, sort of where you’re from, what your training was like, and how you decided to sort of get into that niche field?
Dr. D. Fox: Sure. Well, firstly, I’d like to say that I really enjoyed the interviews you did with dad. I really didn’t wanna follow him. This is a very tough act to follow but, you know, it is what it is and I’ll do my best.
Dr. N. Fox: We’re gonna put a lot of podcasts between you two, so don’t worry about it. Won’t be back to that.
Dr. D. Fox: Okay, good. I appreciate that. So I’ve been in practice for about a decade now. I finished my residency training in internal medicine 10 years ago. And then I joined the faculty at what’s now called Northwestern Medicine. Back when I joined it was actually a private practice. I did internal medicine training and my focus was primary care, the care of the adult patient for, you know, their general medical problems. Overweight and obesity afflicts many people in our society, as we all know, and that’s a part of any primary care practice. However, I became interested in the specialty of obesity medicine, probably a few years into practice. Several of my colleagues did it, and one of them retired while I was in my first few years of practice, and I just happened to be downhill and got many of our patients who were looking for a new doctor. So kind of, you know, they were used to getting an obesity doctor manage them, so I kind of fell into it that way.
You know, I realized this is a problem that affects so many people. It’s the root cause of a lot of the other problems we spend so much time treating in primary care like hypertension, diabetes, sleep apnea, and the list goes on. So I thought, “Man, if you can get someone to lose weight, you’re really helping them out.” And the obesity medicine field, there have been a lot of developments around the time I started practice. Weight loss surgery has been around for, I don’t know, two, three decades, but the surgeries were becoming more refined. What really happened was there were some medications that became FDA-approved around 10 years ago. And so now we have some more tools under our belt to treat obesity.
So, you know, for the reasons of just being interested in it, and then also there were actually more things we can do to help people with obesity, I decided to kind of make this my niche, my subspecialty. I also realized there weren’t a lot of doctors who did this. And I just saw an opportunity there. And then I got some special training in obesity medicine. I became board-certified. So now I do primary care and I practice obesity medicine, which means that people make referrals to me to help their patients lose weight, a combination of lifestyle advice, prescription of medications, and then the people who have weight loss surgeries. I’m not a surgeon, I don’t do the surgery, but I do follow them before and afterwards to help with the medical management of these people.
Dr. N. Fox: How does it break down between primary care and obesity medicine?
Dr. D. Fox: Two-thirds of the population is overweight and obese. So the lines are blurred. If you practice primary care, you’re doing obesity medicine. So I’d say the majority of my patients, I’m doing that. The percentage of patients that are specifically referred to me to take care of their obesity, probably 10% to 20%.
Dr. N. Fox: Right. Okay. And it’s interesting. I don’t know if you’re aware of this, but when I was looking at your profile online at Northwestern, you know, and it’s unusual to have this many reviews, you have over 1,100 reviews, and you are highly rated. You’re like a 4.9 out of 5 stars, which is almost unheard of on the internet because again, only typically angry people go there to comment. So you have tremendous respect, at least amongst the 1,100 people who went online and decided to do something and write about you. So strong work there that is unusual, in my experience, and in a good way.
So many people, as you said, have…either they’re overweight or they have obesity, or they’re concerned about their weight, or their doctor is concerned about their weight. Why would someone see a physician, right, come to see you versus let’s say a nutritionist, or going to, like, a weight loss program or something? Like, how do they find their way into your office? Because I don’t think that everyone’s first inclination in society is, “Oh, let me see a doctor about it,” even though maybe it should be that. It isn’t sort of in the culture we live in. How do they find you?
Dr. D. Fox: Most of these patients have tried to lose weight on their own. They’ve done diets, either just self-directed, things they read on the internet, or they’ve been part of guided programs such as weight watchers and many of the others. So these people have made attempts to lose weight on their own, and they haven’t been successful. And this is when they seek the help of a doctor. They might be interested in a medication, they might be interested in a surgery, or they might just be interested in some noble advice. I might have something that they haven’t tried.
Dr. N. Fox: Would you say most of the people, they find you on their own, or is it that they’re referred to by, again, a surgeon, you know, first who sees them and says, “You know what? Before you have surgery, I want you to meet this guy” because you’re gonna follow them before, during, and after?
Dr. D. Fox: Right. I would say a mix. Many people are referred to me by other providers, either internists who are looking for an obesity specialist to help with their patient, or the surgeon who refers them to me because they’re not a surgical candidate, or they are a surgical candidate and they need to see me as part of just the post-surgical process. But many people just do an online search. We all know that the internet is easy to find people nowadays, and they search the Northwestern website, let’s say, and I think they’re able to find me and see that I have a focus on obesity management.
Dr. N. Fox: It’s interesting. One of the things I wanted to talk about before we go into some of the specifics is just from sort of, like, a global perspective, you and I are bouncing back and forth the terms overweight and obesity. And in medicine, this is normal. This is common. Like, we refer to it as, you know, whether it’s a condition, or a status, or whatever it is, but we know that, you know, there are ways we measure these things and there’s risks of certain outcomes, and you can take someone’s weight or body mass index and correlate it with the risk of, like you said, hypertension, diabetes, and whatnot. Meaning it’s not stigmatized in medicine. It’s just, like, okay. It’s like saying someone has whatever. They’re over a certain age, they have certain risk factors, or if they have a family history, something, they have risk factors. It’s just on the list.
But in society, obviously, people’s weights and people’s body types are very sensitive, they’re very stigmatized, for better or worse, right? There’s a lot of that around it. And how do you sort of view the concept of, you know, obesity as a medical issue versus something that sort of produces shame? Because I know that there’s, you know, obviously, this idea that we should respect and love all body types, which might be true. But on the other hand, we also know medically that certain body types might be due to, you know, overweight and obesity, which we know are health issues. And so how do you balance sort of those two potentially competing values? Let’s say.
Dr. D. Fox: Yeah, that’s a great question.
Dr. N. Fox: Thank you. You thought your brother’s just gonna throw softballs at you and say, “Oh, hey, tell us about yourself, Dave.” No, we’re going right in there. It’s like 60 minutes, Dave. We’re going out.
Dr. D. Fox: Right, by a great question I mean a very difficult one. So weight is a very sensitive topic, you know, as we know. And as a physician, you have to approach it very gingerly, you have to be very respectful. And the language you use matters. People may not like it if you say obese. You’re right. It has a lot of stigma attached to it. Now, these are medical terms. As you mentioned, overweight, obesity, this is the medical term. There are definitions based on the body mass index.
So when I’m thinking about it medically, this is how I’m categorizing it in my mind. When I’m talking to a patient, you know, I may not use these words, you know. There’s a lot of debate, how much of obesity is someone’s fault? And I tend to look at it somewhere in the middle. It’s a very complex disease, and it is a disease. In other words, there are chemical changes in our body that make it very difficult to lose weight. I would look at it like smoking, okay? Smoking is it’s very difficult to quit cigarettes. There are chemical changes in your body that fight you. And oftentimes, it takes many attempts before you successfully quit. Obesity has a genetic basis, you know. Once you gain the weight, it’s very difficult to lose for a lot of biological reasons. So obesity is certainly not entirely someone’s own doing.
Now, I do like to also think we do have some control over this. And I’ve seen it, you know, people through lifestyle changes. Certainly medications and surgeries, weight loss is achievable. So I think the main point is when we’re talking to patients with obesity, we should not blame them, we should not imply that it’s entirely their fault and if they would just make the changes they need to make, they can lose the weight. But we also have to be encouraging, and not be defeatists and say, “Well, sorry, you have obesity. You have no chance of losing this weight.” So I kind of try to walk that fine line. And I think that that’s what works for me in my practice.
Dr. N. Fox: And what about the difference between…? You know, some people argue, you know, “My doctor is always focused on the number, right? My weight or my BMI, as opposed to other health measures.” Is that real meaning the doctors shouldn’t focus on the BMI if all their other health measures are normal or healthy? Or is it something like, “Well, that’s kind of, you know, sort of, like, an excuse to not try to lose the weight, which we know is not good for you?” I’m trying to figure out where you fall on that line.
Dr. D. Fox: Yeah, there’s a term in the literature, it’s called the medically healthy obesity, meaning someone just has obesity and they don’t have a lot of the other metabolic complications known to come with it such as high blood pressure, diabetes, etc. So is this person at the same level of risk as someone who doesn’t have obesity? And the short answer is, no, they’re not the same as someone who doesn’t have obesity. So just obesity itself without the other metabolic problems, you’re still at risk for many of the complications of obesity. So, I think someone who has obesity but doesn’t have these other problems, that’s great. I mean, obviously, that’s better than having those problems. But I still view it, you know, as a medical condition that we should work on treating.
Dr. N. Fox: Okay, so someone comes to you, either on their own or they’re sent, and let’s say they’re that person, right? They have sort of a definition of obesity based on their height, their weight, their body mass index, and otherwise, you know, they don’t have hypertension, they don’t have diabetes. What is your initial evaluation of them, like, “the workup?” And then what would be your initial sort of recommendations to them for management or treatment? Again, assuming they’ve done the things that people usually have tried to do, “I tried this diet, I tried that diet. I had a hard time with this. I lost weight with this, but then I gained it back.” Sort of the stories we all have.
Dr. D. Fox: Yeah, a new patient presenting to me with obesity and they’ve tried a number of different things, and they have some result, usually unsustained. In terms of ruling out secondary causes of obesity, yeah, we should definitely have that in mind, but those are rare. You know, I might check their thyroid function. I might physically…you know. I will physically examine them but look for signs of other endocrine disease. Are they on some medications that might cause them to gain weight? So yes, I’m definitely looking into these secondary causes of obesity.
But let’s say they don’t have any of that, which most of them don’t. It depends on the patient. Depends on where they are in their journey of weight loss. Some of them wanna go straight to medications and surgeries. They’ve tried everything else. Great, I kind of focus on that. Some people are not ready for that. They kind of wanna still focus more on lifestyle management. So I focus on that. So I guess what I’m saying is I try to gauge and see where they’re at and make a joint decision with them. But I try to cover lifestyle, you know, management, and then medication options, and surgical options for the appropriate candidates.
Dr. N. Fox: Do you ever have people coming to you who let’s say aren’t obese, they have maybe a little bit of extra weight they wanna lose? You know, obviously, some of it is related to health, but some of it might be, you know, sort of cosmetic body image, they wanna fit in different clothes, they wanna feel better. Do you have people come to you for this? Meaning they’re not “sick,” they don’t have a lot of issues, and if you saw them, you wouldn’t, you know, spend too much time on it with them. But are there people who come to you to try to focus to sort of, you know, get them over the hump, so to speak, with that?
Dr. D. Fox: Yes, I have a lot of patients like that. They’re mildly overweight, and they do not like the way they look. They wanna lose some weight. I work with them, you know. Yeah, it’s individualized. Obviously, they’re not someone I’d send to bariatric surgery, they’re not appropriate candidates. And they may need not even be appropriate candidates for medication. So yeah, of course, I do get those patients and I try to work with them to achieve their goals of weight, assuming we’re doing it in a healthy way and they’re trying to achieve a healthy weight. I get the occasional patient who’s at the lower end of normal weight and wants to lose, and that’s sort of a different problem. I have to have their health in my mind, first and foremost.
Dr. N. Fox: Right, right. No, that makes sense. Okay, so someone comes to you. Let’s say the first person we’re talking about, they qualify as obesity, they don’t have any other medical issues. You’ve done the workup and it’s normal. Let’s go through those stages because you sort of mentioned based on what they’re ready for. So I assume that the first would be lifestyle modification. So what do you normally go through with them? Is it very aggressive, or do you start very sort of gently? You know, “Let’s add a little this, little that.” What have you found to be helpful?
Dr. D. Fox: Yeah, so I’m not a big believer in aggressive diet changes or aggressive exercise, you know. These are changes that I want them to be able to sustain for their entire lives. So I’m not gonna put them on some extremely low-calorie diet they can only do for a few months to lose a lot of weight and then gradually taper off of that. I tend to counsel on, like, a slow and sustained weight loss, you know. They didn’t get there overnight. They’re not gonna lose the weight overnight. But, you know, some sensible dietary changes, maybe certain specific diets. And, you know, I’m trying to get them to lose maybe one to two pounds a week. That’s sort of the pace that I tell them.
We try to focus on… We set a goal of about 5% to 10% weight loss. The studies show that that’s a reasonable goal for most people, the 5% to 10% range. And then if they achieve that, then maybe we try to go for another 5% to 10%. So yeah, basically, counseling on my end, diet, exercise, study changes that they could sustain over time. We may get a dietitian involved at that point as well.
Dr. N. Fox: What diets do you find are the most helpful for this type of slow, steady, weight loss? Obviously, there’s a lot of crash diets out there. So let’s just… The ones that you feel have a lot of sustainability. And obviously, it’ll differ for every person, but just sort of general strokes, what would be the ones that you think are probably top-shelf good diets?
Dr. D. Fox: My favorite is Mediterranean diet. That one probably has the most evidence behind it in terms of not just maintaining healthy weight, just maintaining general health. It’s been studied with heart health and brain health. You know, so eating a lot of plant-based foods, trying to avoid added sugar and refined carbohydrates, so all those things with white flour, you know. Trying to limit red meat intake, you know. You can focus more on fish and poultry, which are a little bit healthier, and eating healthier fats.
Some other diets that people do that I think are reasonable, there’s a lot of variations of the low carbohydrate diet. That works for a lot of people, but it has to be done in a healthy way. Some people get results with intermittent fasting, which I think is also reasonable if done in a healthy way. There are a lot of variations of that. So I would say those are my three, Mediterranean diet being number one, and then the other two I think are reasonable.
Dr. N. Fox: And what about for exercise? Do you have specific ones you like people to do or just anything that gets them, you know, sort of cardiovascularly moving?
Dr. D. Fox: Yeah, yeah, you know what? I’d say many people are not exercising at all. I’m happy to get them to do anything. I’m not gonna be really picky about what exercise they do. I’m trying to get them from not exercising to exercising. I try to set a goal of 150 minutes a week of moderate to higher intensity exercise, which means you’re sweating, you have a hard time holding a conversation. So it’s not just walking your dog, but something where you’re working a little bit harder than that. And I say, “Can you just give me 30 minutes, 5 days a week?” A lot of people can do that.
Now, if it’s less great, I’ll take anything. If you’ve got 20 minutes a week, that’s fine. But I try to set a goal of 150 minutes a week, which most patients if they really take a close look at their schedule, they’re able to fit in. And I say, yeah, get some aerobic, get some strength. Don’t forget about stretching, mobility, and then also step with balance. So I try to have them incorporate those four things.
Dr. N. Fox: Yeah, I mean, I agree even if it’s, like you said, maybe not walking your dog. But if you went on a treadmill and walked at a certain speed at a certain incline you know, like, I’m huffing and puffing a little bit. Okay, and you can do 30 minutes. You can watch TV while you do it. You can listen to a podcast like this one, for example, when you’re doing it, you can listen to music, you can even potentially if you’re with someone else, maybe hold a conversation. If not, you could do it before and after and just go with someone. People usually have that kind of time if they sort of think in advance, you know. All they have to figure out sort of is, “When I’m done, do I need to shower? And where am I gonna do it,” right? Like if I decide I’m gonna exercise on my way to work, you know, instead of taking the bus, I’m gonna, you know, jog there, right? Is there a shower in your work or something like that? Or at home at night or whatever it might be.
Dr. D. Fox: Nowadays, we have so many options for home exercise, as many of us learned during pandemic. So I say, “Look, you don’t have time to go to the gym, I get it,” or, “You don’t wanna go to the gym because of the safety, you could work out at home.” And there’s so many different ways you can do that. If you wanna get machines, or you don’t even need any equipment, you know. There’s some good stuff you could do with hardly any equipment. Apps on the phone. I might give them some recommendations for that. People should be able to make some time for exercise.
Dr. N. Fox: Yeah, and I think that as long as they’re not doing pickup basketball, whatever the hell it is. You play pickup basketball. I mean, COVID-infested gym that you go to every month apparently.
Dr. D. Fox: Pretty much.
Dr. N. Fox: Yeah, I don’t know if it’s helped your practice. But, you know, for people who don’t know what you look like, I mean, you’re pretty fit. I mean, you’re thin, you eat healthy, you exercise, and you’re not like a freak, you know. You’re not, like, crazy about it. You’re not obsessed or anything, but you just, in general, have always been very health-conscious, I would say, or conscientious. And I think that it’s…I don’t know if it works to your advantage or disadvantage when people, you know, take a look at you and they don’t see someone who’s like, you know, “Oh, my God, this is like, you know, ‘The Incredible Hulk’ type of person,” but you’re like, “Wow, that guy’s fit.” You know, he looks like he’s in good shape.
Dr. D. Fox: Hey, well, I appreciate you saying that. Yes, I put a lot of thought and effort into my own health and eating healthy and exercising. My wife is the same way. Thank goodness, she cooks for us and she makes very healthy food. And I actually do think that’s important. You have to set an example for your patients. If you’re telling them to do something but they get the feeling that you’re not practicing what you’re preaching, I think they’re less likely to follow your advice. For example, if your doctor is telling you to quit smoking but they smoke, are you more likely to quit? I think probably not. So oftentimes, patients ask me, “Well, what do you do?” And I tell them, “I think it’s important to set a good example.” And that’s not why I live a healthy lifestyle. I think I would do that anyway, but I do think that that goes a long way for people taking you seriously.
Dr. N. Fox: Yeah, no, I think that makes sense. Now, if someone is trying these things and it’s not working, or you’ve decided from the outset, you know, let’s try medication, so just as a general overview for our listeners because, obviously, everything is gonna be very individualized, what’s out there, and how effective are they medication-wise?
Dr. D. Fox: Yeah. So like I said, over the past decade, a lot of new medications have come out. So there are some that are available in pill form. I would say the average amount of weight loss with most of these is somewhere in the 5% to 10% range. And that’s beyond what you would lose with diet and exercise. So the pill itself will give you a 5% to 10% weight loss. They have some side effects, potentially, and they do have to be taken long-term, which a lot of patients don’t get that initially. They’re like, “Okay, I’ll take the medicine and I’ll lose the weight, and then I’ll discontinue it.” Well, it doesn’t work that way. You tend to regain the weight if you stop it. So we’re talking about a long-term commitment to the medication if you want sustained results.
Over the past five years or so, a new group of medication has come out. It’s actually used to treat diabetes. They’re called GLP-1 receptor agonists. So these are medications that improve blood sugar regulation. But we noticed that they also have tremendous effects on satiety and help people lose weight. And now there are some drugs in that class available just for the purposes of obesity. And one study very recently, the past few months show that one of these drugs helped you lose about 20% of your weight, which is amazing. That’s almost surgical numbers.
So I would say these drugs, probably somewhere between 10% and 20% of your weight. So those are clearly the best. The problem is cost, which is a whole nother topic. For some reason, insurers do not like to cover the medications to treat obesity. Why not? I’m not sure, you know. Insurance is… I don’t quite understand it all. But…
Dr. N. Fox: No one does.
Dr. D. Fox: Right. For some reason, these are not well covered. And, you know, the cost can be hundreds of dollars a month. And then in the case of these newer drugs, it’s $1,000 plus a month. A lot of people, understandably, don’t wanna pay that. So I think cost is a big barrier. But, you know, if the cost can come down, or one day they go to generic, right now, those are the best ones.
Dr. N. Fox: And those medications are injectables, right?
Dr. D. Fox: Correct, injectable. Other newer ones, it’s just a once-weekly injection. It’s subcutaneous, which means under the skin. Not a big deal. You do it at home. You just get a tiny little needle, you just jab it into the skin of your abdomen once a week. So most people are tolerant of that.
Dr. N. Fox: Right. The insurance is odd because, you know, they cover a lot of the surgery, which is also expensive. And the reason the insurance carriers do it is not because they’re magnanimous and wonderful, you know, and care about everyone, it’s because overall, in the long-term, it’s gonna reduce their costs. Because if you, you know, reduce one person from getting diabetes and then they don’t need their leg amputated, you know, it’s like that’s a big deal. And so they sort of look at it as a long-term cost effect. And presumably, with more time, if these things end up being very effective and producing a lot of results, you have to imagine just from a dollar’s perspective they’ll cover it at some point. I mean, who knows when that’ll be? But it does make sense.
Dr. D. Fox: Yeah, I mean, the evidence is there, all these drugs are FDA-approved. I would think that, yeah, it would reduce their costs overall. If you can help someone lose weight, all the costs of managing all these other problems presumably would go down. But yeah, the drugs are expensive. They might be thinking, “Oh, my gosh, you know, 1/3 of the population is eligible for these drugs that cost $1,000 a month. Maybe that’s just too much money to spend upfront,” so whatever their calculations are. But in terms of what’s best for the patient, we need to have these drugs cost less.
Dr. N. Fox: Right. Right. What are your thoughts on surgery? Obviously, people come to you who are planning surgery so you’re not likely to talk them out of it, let’s say. But just from the front end, is it something that you’re supportive of, or something that you, you know, think is a problem that people are getting surgery for weight loss? I know you once mentioned that it’s sort of ironic that, you know, the thing that seems to work the best is removing half of our intestines. I remember you telling me that once. But obviously, people do it and they have a lot of success with it. So I’m curious what your thoughts are.
Dr. D. Fox: I’m a supporter of the surgery, and they are very effective and safe, generally safe. Some people, I actually am convincing them. I’m trying to convince them to do surgery. I think that’s the best choice for them. So it’s not just them asking me about it. There are two main surgeries that are the most popular in our institution. They’re the only two that are offered, the gastric sleeve and the gastric bypass. The sleeve is you remove just the majority of the stomach. And then the bypass you remove majority of the stomach plus you remove some of the small intestine from the circulation. So both of them are done laparoscopic, which means that they make fewer incisions, they go in there and do it with cameras.
And the surgeons who do them primarily specialize in this. So they do whatever, 1,000 per year or whatever the numbers are, which we know matters with surgery, how many times has your surgeon done this? So they’re generally very safe. Anytime you have surgery, there’s a small risk of complications. But the complication rate is no worse than a lot of other surgeries that people have like getting their gallbladder out or their appendix out. And it’s certainly a lower-risk surgery than getting your knees and hips replaced, which might be in your future if you don’t lose the weight. So I think the surgeries are a great tool for those who qualify and who have failed to lose weight with other conservative measures.
Dr. N. Fox: All right, no, that’s good to know. I have often seen people before pregnancy who come to me because, you know, as you know, their weight can be an issue in pregnancy and they ask me sort of my general advice. And there are some people I’m saying, “Listen, you should just get the surgery, wait a year and then get pregnant and all of your pregnancies will be lower risk than if you got pregnant now.” And that sometimes it’s a tough pill for people to swallow, so to speak, you know. People don’t usually think growing up that they’re gonna need surgery to lose weight. And it is tough, like, yeah, that’s hard, but it might be the one thing that’s gonna work. And there’s a lot of evidence that for people who have it and they lose a lot of weight, they are healthier. It’s like the one thing that we have that cures diabetes and hypertension. Cures it, not just manages it, it just takes it away.
Dr. D. Fox: It’s interesting the people who have these surgeries, their diabetes is cured within days. So there’s something to the surgery beyond the weight loss that helps with a lot of these metabolic problems. So, you know, there’s a complex hormonal signaling that goes on and the surgery somehow corrects that. And I’d also like to point out, the people who have the surgery, typically, the results are sustained. Some people gain the weight back, that happens, but usually, they lose about one-third of their weight. And that’s sustained over time, which makes a huge difference in their health in the long term.
Dr. N. Fox: Yeah, I’ve also found that for people who have obesity and they lose their weight, whether it’s from surgery, or from a medication, or they’re fortunate enough to be able to do it over time with diet and exercise, one of the things that happens is, I call the snowball effect. You know, when they first start, you know, just like walking a few miles, you know, that exercise is so hard to do, right?
They’re, you know, so out of breath, and, you know, they have all this weight, and they really don’t feel good about themselves, and then you lose 5 or 10 pounds, and then you’re walking a mile and a half or 2 miles and then you lose another 5 or 10 pounds. And as these things get easier and you start seeing results, both in terms of your weight, your size, and your exercise tolerance, it’s sort of you get that endorphin kick, like, “I love this,” you know, and it really is that positive reinforcement that sometimes they just need to start. And if they start the surgery, and they start losing that weight, they feel so great. A lot of these people become like these avid exercisers and they start, you know, running marathons just because they’re so into it because they keep getting that positive reinforcement from feeling better and healthier every day over the course of several years.
Dr. D. Fox: Yeah, and I think you just hit on a very important point that I’d like to expand on. You asked what are people looking for me when they come see me? They need to get started. They just need to get started. And then yes, I agree with that snowball effect. So I’m just trying to get something going. And, you know, let’s get some exercise started. Let’s make some dietary changes. And the other key is a very frequent follow-up. I wanna see them quarterly. I don’t say, “All right, make some changes, come back in a year.” No, that’s too long. You got to see them regularly, continue to provide them with that reinforcement. If they have a little bit of a setback, you have to be encouraging and, you know, try to get them back on track. And then yeah, they lose 5 pounds, they lose 10 pounds, and then they gain that confidence. And then that allows them to lose more.
Another point I wanna make is, you know, the studies show that exercise doesn’t contribute that much to weight loss. I think my interpretation of that is maybe in of itself it doesn’t, but I think that if you can get someone to exercise, they feel better about themselves. I think they start eating healthier as well, and I think ultimately, it just leads to a healthier mindset that does, you know, play a big role in their ability to lose weight.
Dr. N. Fox: Yeah, I mean, we haven’t even touched upon the whole mental health aspect of this. That is obviously very positive as well, and I think it’s all intertwined. David, thank you so much for coming on the podcast. This is great. I love it. I love talking to you, in general. I don’t get to see you enough. Come to New York more often. I’ll try to get to Chicago from time to time. But really, this is great. I’m sure our listeners will very much appreciate it. If you are in the Chicagoland region, you can look up Dr. David Fox at Northwestern. He looks like me but younger, more handsome, and in better shape. And yeah, you can make an appointment to see him as well. So thank you so much.
Dr. D. Fox: Thank you. It was an honor to be invited on your show. And I always love talking to you about anything.
Dr. N. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcasts, please visit our website at www.healthfulwoman.com. That’s H-E-A-L-T-H-F-U-L W-O-M-A-N.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at email@example.com. Have a great day.
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