A new class of obesity medications is revolutionizing obesity care. Will this make bariatric surgery obsolete?
A new class of obesity medications is revolutionizing obesity care. Will this make bariatric surgery obsolete?
Nutrition Diva is hosted by Monica Reinagel. A transcript is available at Simplecast.
Have a nutrition question? Send an email to nutrition@quickanddirtytips.com or leave a voicemail at 443-961-6206.
Find Nutrition Diva on Facebook and Twitter, or subscribe to the newsletter for more diet and nutrition tips.
Nutrition Diva is a part of Quick and Dirty Tips.
Links:
https://www.quickanddirtytips.com/
https://www.quickanddirtytips.com/nutrition-diva-newsletter
https://www.facebook.com/QDTNutrition/
https://twitter.com/NutritionDiva
https://nutritionovereasy.com/
Hello and welcome to the Nutrition Diva podcast. I’m your host, Monica Reinagel. I have a couple of topics to share with you today, one regarding my recent episode on Ozempic and a very thoughtful response I received from someone who treats patients suffering from obesity. I also wanted to respond to a listener question about intermittent fasting, which a lot of people are turning to as a potential weight management or anti-aging strategy.
A couple of episodes ago, I talked about a class of medications called GLP-1 agonists and their emerging role as a game-changer in the treatment of obesity and diabetes. And in that episode, I speculated on how these medications might impact the future of bariatric surgery. Will these drugs eventually make more invasive and riskier treatments like bariatric surgery obsolete?
Within an hour of that episode’s release, I got an email from Dr. Michelle Toder, a long-term listener who is a bariatric surgeon and who had some strong feelings about my statements regarding weight loss surgery. We had a very thoughtful and enlightening exchange and I wanted to share some of the points that she made.
Normally, I would consider bariatric surgery to be outside the scope of this podcast, where I focus on food and nutrition. But, having introduced the subject, even fleetingly, in my previous episode, it feels appropriate to share with you some of the points that Dr. Toder made.
First, she points out that, because the GLP-1 agonists are relatively new, we do not yet have really long-term data on weight maintenance, improvement in other health conditions, and side effects. Bariatric surgery has a much longer track record. So although the preliminary results of these medications are quite impressive, it’ll be several years before we can compare those long-term effects to those of bariatric surgery. That’s a valid point.
She also pointed out that this is not an either/or situation. A treatment plan for someone suffering form obesity may involve both surgery and medication, along with lifestyle modification. According to Dr. Toder, GLP-1 agonists are sometimes very helpful in preventing weight regain after patients have undergone gastric bypass surgery, although they appear to be less useful for other types of bariatric surgery.
In other words, although the results can be dramatic, bariatric surgery does not necessarily address or fix every issue related to the disease of obesity. Bariatric surgery patients generally require ongoing nutritional, behavioral, psychological, and/or medical support in order to manage this chronic condition.
Because of their relatively short track record, Dr. Toder also expresses concerns about prescribing GLP-1 agonists to younger patients as a long term solution. Would these medications be both safe and effective over a lifetime? These medications can have side effects, which have been well documented in the studies to date. But we don’t yet know the side effect profile of very long term use.
Of course, with any new treatment breakthrough, the long term outcomes are yet to be determined. And, although I am not an expert in obesity medicine, it seems to me that one advantage to medication is that it is more readily reversible than surgery. If it doesn’t work, or stops working, or side effects become intolerable, the medication can be stopped and other options can be considered. However, there may certainly be situations in which it makes more sense to start with a surgical solution.
Having just returned from an obesity medical conference at which GLP-1 agonists were a hot topic, Dr. Toder feels that the clearest consensus seems to be around the use of these medications in people who are experiencing a steady increase in body weight, year after year, that they are unable to stem with lifestyle modification. Without some sort of intervention, they are very likely to continue along that trajectory and begin to experience increasing health issues as a result.
In this situation, medication (along with appropriate lifestyle change) is probably going to be more effective than diet and exercise alone and may also be safer than gastric surgery. And, certainly, with any disease process, the earlier we intervene, the less extreme that intervention needs to be and better the results.
Finally, there are patients who don’t qualify for weight loss surgery (and this can be for a variety of reasons) and these new medications offer better options than we had before. But obviously, I may have been a little premature in predicting the obsolescence of bariatric surgery.
I really appreciated Dr.Toder taking the time to share her perspective with me, which gave me an opportunity to share it with you. And I’ll give her the final word on this subject for today:
“I would hope that those of us who treat [patients with obesity] would continue to support all of the potential tools in the tool box and allow patients to work through the options with their physicians to make a choice that is most comfortable for them at the time. I would not want the medical professionals to discourage appropriate patients from considering surgery nor should the surgeons be dissuading patients from considering pharmaceuticals.”
Another long-term listener reached out with a question about intermittent fasting. Barb writes:
“I just heard a podcast discussing intermittent fasting, in particular, its effect on autophagy. I do a daily 13hr fast, just to help keep me from eating all evening. But if going for 17 hours helps my blood pressure and blood sugar and reduces my risk of dementia, I am willing to give it a shot. However, when I Google it, I am not sure that this is good science.”
I share Barb’s skepticism here. Autophagy is a real thing. The word means “self-digesting” and it refers to a process by which our bodies remove and recycle old and damaged cells. And it does appear to be related to senescence, or aging, in that autophagy appears to slow as we age.
Some research (mostly in healthy young men, who are fasting for Ramadan) suggests that the more extended fasting period typically observed during Ramadan (which also involves drinking no water) might promote autophagy.
Based on that, the speculation/hope is that extended fasting windows may slow the aging process. But do you see how many logical leaps there are here?
First of all, what does the effect of fasting in healthy young men tell us about the effects in aging individuals?
How long or how often would you need to fast to get the benefits? (Ramadan goes for about 1 month per year.)
Does the increased autophagy eventually regress to the mean? Meaning, is there a initial bump when you introduce a new fasting schedule which gradually levels off as you adjust to that routine?
All of these are, for now, unanswered questions.
I think in situations like this, you need to ask: How likely are you to experience the promised benefits? But also, how large is the potential benefit that you are likely to experience? You might stand a very good chance of getting a very tiny benefit. Or a small chance of a larger benefit. Or, it might be small chance of a very tiny benefit.
Often, there’s just not enough good data to answer these questions. So your next question might be: What would it cost me to find out? In money, time, effort, or comfort? Could you get the same or nearly the same benefits from less "costly" interventions?
In this case, what additional benefits might Barb get by expanding her daily 13-hour fast to 17 hours? And how would she measure the effect? Measuring the impact on the rate of autophagy isn’t really practical. But she could certainly try a 17-hour fasting window to see whether it had any measurable impact on her blood sugar or blood pressure. And if it did, she could consider whether those benefits were substantial enough to justify whatever it cost her. But I think she’d need to give it at least a month to assess the impact.
For anyone contemplating extended fasting, I'd advise caution: Take care not to become dehydrated and make sure that you're meeting all of your nutritional needs during your short eating window. I'd feel even more comfortable if the person were actually being monitored by their physician for any unintended ill effects (as well as to evaluate any potential benefits).
But my larger purpose in sharing Barb’s question here on the podcast is to suggest a framework that you can use whenever you encounter these sorts of claims or are considering an intervention:
Before I wrap up, I wanted to invite you to join me and other Nutrition Diva listeners for a 30-Day nutrition upgrade, starting November 8th. This is a time of year when health habits often start to fall apart. So if you could use a little boost of accountability and motivation as we head into the holiday season, head over to nutritionovereasy.com/upgrade and register to join us!