With obesity affecting 40% of the U.S. population, bariatric surgeon Jonathan Carter, MD, reviews the devastating health effects of excess body fat and contends that clinicians can no longer sidestep difficult conversations about weight management. In this upbeat talk, he offers guidance on talking to patients with upwardly creeping BMIs, explains the evaluation process for referred patients at the UCSF Bariatric Surgery Center, reviews the pros and cons of current surgical options, and describes the impressive influence of weight-loss surgery on cancer risk as well as chronic conditions ranging from diabetes to hypertension to sleep apnea.
Well, let's go ahead and jump in. Um We, we have a few people joining, but that's fine. Um It's really nice to meet you all. Um My name is John Carter. I am um over at the Parnassus Campus at U CS F and I'm a general surgeon and a bariatric surgeon. And today I wanted to share an update of what's going on in the world of bariatric surgery a little bit. Um I wanna keep this kind of fun and informal. So if you have any questions at all, just feel free to unmute yourself and chime in and we can discuss. Um Yeah, so all of us are quite familiar how we define obesity and there really hadn't been any major change. Um We all use the body mass index which is your weight and kilograms divided by your height squared. Um Normal is defined as anybody with a body mass index of uh 18.5 to 25. And then um 25 to 30 is considered overweight above 30 is uh obese by definition. And within the realm of obesity, we subdivide into class one, which is 30 to 35. Class two which is 35 to 40 class three, which is greater than 40. Now, um A lot of people have challenged the body mass index because it's not actually measuring what we want to measure. What we wanna measure is the amount of adipose tissue um in our patients. But we use the body mass index because there's a pretty tight uh linear correlation between the body mass index and the body composition, the percent body fat. And you can see on this scatter plot. Um the the lighter grade or is in men and uh the the dark black is women. And you can see that um there's a pretty tight correlation between BM I and body fat for most patients. Um There can be discrepancies though and I don't wanna go too much into detail, but there's such a thing called sarcoptic obesity. And this is a patient who might have a normal body mass index, but they actually have um inappropriately high body fat percentage composition. And uh the reason that the um uh that the body mass index is normal. So there's just not enough muscle. Um and so their overall body weight is not uh is not as much as you would expect. Um On the other end of the spectrum, it's possible to have a lot of muscle and very little body fat. And that also will give you a high BM I. And the classic example is Arnold Schwarzenegger when Arnold Schwarzenegger was competing and when he was Mr Olympia, he had a BM I of 31 but his body fat composition was only about 8% at the time. So um clearly you can see there, there are some shortcomings of body mass index but for the rank and file vast majority of the patients that you and I and see see in our patient in our clinics, uh BM I works great. Now, one of the things if you are uh in your thirties or um late twenties and practicing, you may not realize how new the obesity epidemic is in the United States. If you go back uh 30 years to 1990 this is what our country looked like and uh what the colors are showing you is the prevalence of obesity in the state. And so here we are in California and we had less than 10% prevalence, obesity, meaning uh less than 10% of the population had a BM I less than 30. And as you might expect in the Midwest and deep South, the prevalence of obesity was a little bit higher. The most obese state at that time was Mississippi and that was, that had a 15 to 20% prevalence. Now, five years later, the country had changed dramatically. Out here in California, we were up to 10 to 15% obesity and in the Deep South and Midwest, um they similarly saw an increase in the pre uh obesity prevalence, multiple states reporting 15 to 20%. Now, just five years later, we had to add a new color. 20 to 25% obesity led by Mississippi, deep south and Midwest. And out here in California, our obesity had increased. We, uh, we're now 15 to 20% obese. Now I'm gonna go year by year and just watch what happens. Here's 05. We had to add a new color now. 25 to 30% prevalence. 06, Mississippi, 07 08, 2009. Yeah. 2011. Well, 13, we had to add yet a new color, uh, led by Mississippi. Now, greater than 35% prevalence of obesity. 14, 15, 16, 17, 2018, 2019. And that's our in 2020 which I think is our most recent data. So our demographic has completely shifted over the Colorado and Massachusetts are the least fat places in the US. Colorado and Massachusetts are the least and Colorado has been the, the kind of the holdout they follow the trend, but only five years later. So you and I see this every day in our practices, there's an epidemic of obesity and in the United States today, about 40% of the population has a body mass index above 30 which is obese and another third have a body mass index 25 to 30 which is overweight. And this is a real problem if you're in interested in public health when we do wrong. Yeah, just having fat on your body. You know, you might say what's the harm in that? And the problem is that it is a causative or uh contributes to an a dysfunction of essentially every organ system in the body. A lot of these associations are gonna be familiar. We are all familiar of the association of obesity type two diabetes, uh in dyslipidemia, that's the so-called syndrome X or metabolic syndrome. Um But some of these may not be as familiar to you. Um I tell you, I do a lot of hernia in my practice, almost every patient is clinically obese that I fix hers. Hernia are not seen in thin patients. They just don't get hernia. You really need obesity in order to create the abdominal wall forces to overcome the scar tissue that you give the surgical incision. So, incisional hernia is largely a, a problem of obesity, colon cancer. I don't know if you know this, but uh if you have obesity, you're about uh between two and three times more likely to develop colon cancer in your life. And that's true for a number of other uh cancers, breast cancer, uterine cancer, uh prostate cancer. Um There's a number of cancers that are all uh significantly increased with obesity. And so, um the cumulative effect of all of that is increased mortality in our patients. And if you do the simple experiment, a large group of Americans and stratifying them by their body mass index. And then looking at their, um, survival, essentially, the higher your BM I, the more years of life expectancy you lose. And it's kind of a, a dose response effect when you get, uh, to the patients that I might see in the bariatric surgery clinic. These are people with BM I, 40 plus, we're really talking about +5678 years of life expectancy. And I would venture to say in your practice, that's probably true. How many people in their nineties who are severely obese do you have in your practice? I would, I would, I would guess that you probably can't think of a single one. How many people in their eighties do you have who are severely obese in your practice? Maybe a few, but not that many. Why is that? It's because they die off before they hit their eighties or nineties. Um, and why do they die? It's really two reasons. It's cardiovascular disease. So we're talking about mis strokes, kidney failure, that kind of thing. And then interestingly, cancer, um, is the second reason, um, for this increased mortality. And so that's the reason we all need to get serious about treating obesity. I think the days of not bringing it up with our patients because we're worried about offending them or maybe they won't come back to see me those days are gone. This is a serious disease and it requires all of us to be actively engaged and um treating our patients particularly now that we have effective treatments. Um and we've got even more effective treatments in the pipeline and we're gonna talk a little bit about that. So how do we approach obesity kind of in the year 2023? Um We use the BM I to really strati uh uh stratify our approach to treatment. Um if you're a primary care provider, um it's really important to screen uh for obesity and just taking a heightened weight and calculating BM I is a good way to do it. It's important to bring it up with the patient and we won't go through it today, but there's lots of good um tutorials that you can take and lots of good um advice from, you know, people that do this regularly is like, how do I bring it up with my patient without offending my patient? I realize that's a real issue. Um Every community has community based uh weight loss programs. It might be jazz or size, it might be like a senior um activity type center. Um know what programs you have in your community and refer to them. And when you talk to a patient reinforce healthy eating and exercise. Um Now, once you see the BM I is creeping up. So for patients who have obesity, meaning A BM I greater than 30 or if they have metabolic disease, diabetes, hypertension, hyper cholesterol Leia and A BM I 27. That's when you should really be thinking about making a referral to a specialty weight management program. Um These are clinics typically run by internists who uh have specialized in obesity medicine. There's actually a um uh that, that is a uh it's not a boarded Subspecialty, but it's a um it's a specialty designation. So you, you actually take a test and go through additional training uh for obesity medicine. And what they can offer is, um, a couple of things. Uh, most of these programs have integration with uh psychiatrists, nutritionists, um, nurses and interns and they provide a number of uh supports for the patient, um, anti VC medications like wave or mano um diet replacement therapy, um behavior modification. So, um, a lot of patients can, uh get a lot of benefit uh from specialty weight management. Now, once the weight is above 30 with metabolic disease or above 35 without, that's really when we start looking at surgery as an, as an option for patients. Um, and I'll tell you in terms of the referrals they go every which way. Um, I, I live in the surgery triangle and, you know, I receive referrals from my colleagues in weight management and also uh from primary care and a lot of patients self refer. And so, um, and we trade patients back and forth a lot. And so, um, I think, I think we're all on one same team and we're all interested in being serious and how we uh treat and approach obesity. And um all of these different modalities are complementary and, and frequently we'll use multi mode modal treatment in one patient. Like we'll have patients who start with surgery and then they'll, um, add an anti BC medicine um, afterwards or vice versa. So I want to focus a little bit on surgery. What do we do in surgery? Um, so we are also a multidisciplinary team. We've got three surgeons, we've got a gastroenterologist. We have nutritionists, we have a psychiatrist, we have two pas and we actually have a dedicated pharmacist and we're interested in treating obesity as a longitudinal disease. So, unlike most surgical referrals where a patient has a problem, you refer them, they get their surgery, maybe one or two post op visits and then uh and then they're back to you. Um We're a little bit different. Um We're, we, we believe or we know that obesity is a longitudinal disease and we're interested in treating longitudinal way. And so um when, when we take on a patient and operate on them, it's a longitudinal point, we'll talk a little bit more about that. Uh When a patient comes in and is referred, what do we do? Um We do a surgical H and P um we do some lab work uh routine chemistry, cell counts, but we also check uh micronutrients. Um we screen for diabetes uh about 10% of our patients who have diabetes actually are not diagnosed with diabetes at the time they're referred. And so we occasionally make a diabetes or a hyper cholesterol Leia diagnosis. Um, in Northern California, vitamin D deficiency is rampant. And so it's probably the most common prescription I write is for vitamin D. Um, we then do a cardio pulmonary assessment. Um All of our patients are seen by our nutritionist and uh we also have an embedded psychiatrist who sees our patients and we talk about healthy eating, dietary habits, strength training, we talk about sleep hygiene. Um Sometimes patients have undiagnosed sleep apnea and we'll get them a sleep study and get them started on CPAP. We'll talk about lifestyle, mood and happiness. We'll talk about substance abuse, um community engagement, stress reduction. So all the behavioral uh uh health issues that we know are so important in treating obesity um for smokers, we'll refer them for smoking cessation before. Uh we operate for women in childbearing age. Um We'll do pregnancy contraception counseling and from primary care. Um uh what we really look for at, from you all um is really, we want every patient needs to have primary care established and uh we're really reliant on you to make sure that their health maintenance is up to date, particularly their cancer screenings. Um um So I'm gonna jump into surgery and I wanna, I wanna talk first about the gastric bypass because it's been around longer. And it's also a, um, it's probably the best study procedure in terms of mechanistically and long term results. So this is an operation that was first done in the 19 fifties, but it didn't really catch on until the 19 nineties with the advent of laparoscopy. Um And uh the laparoscopic revolution really opened up the doors to bariatric surgery in the mainstream because you could do, you could all of a sudden you could do these procedures with very, very low morbidity. Um Whereas an open gastric bypass had about a 2% mortality rate. Laparoscopic gastric bypass is down in like the 0.1% you know, kind of range mortality. So it's very, very low. So what do we do? We take, we don't take any tissue out, there's no tissue removed. What we do is we take a stapler and we divide the stomach into two halves. There's a small half here, which is the part that receives food from the esophagus and the bulk of the stomach, the gastric remnant uh remains below. Then we divide the intestines downstream. We bring at one end and we attach it to the small intestines that allows a pathway for food to leave. You still have a remnant stomach and it still makes gastric juice and acid and those juices go down the duodenum and it, you receive bile from your liver and pancreatic juice and all those digestive juices come down where a second anastomosis is made the digestive juices meet with the food stream and normal digestion occurs thereafter. Now, if you look at the results of gastric bypass, um this is uh what we typically see and this, I'll tell you these results I would say are almost universal. This experiment's been done in multiple countries around the world on every continent. Um And uh the results in response to gastric bypass is fairly uh constant across the globe. Um If you look what this plot is showing is um a total body percent weight loss over time. And this study had 12 year follow up and this was a cohort of Americans and at their starting weight. Um What you see is a rapid drop in weight and it's typically about, it's between 30 40% total body weight in this study, it was about 35% with a standard deviation of about eight or so. And that uh patients reach their lowest weight about 1 to 2 years after surgery. After that, there's a little bit of weight regain. If you look six years out, people on average, maintain about 30% total body weight. And if you go 12 years out, it's maintained again, they stay around uh 30% total body weight. So that's the mean and standard deviation. What I really liked about this study was they actually plotted every individual patient and that really gives you a strong sense of the variability we see and it turns out this is true for all obesity interventions. If you look at medications, diet lifestyle interventions, there, there's a huge variability in response that we see from patient to patient. And we all need to be aware of that. Otherwise, we might um mistakenly draw a conclusion about the efficacy of the intervention when in fact, we're just seeing the variation. So you know, there are some patients after gastric bypass that, that lose 40 50 even 60% of their body weight. Those patients are achieving essentially a normal body mass index. So those are great responders. And if you follow them out over time, many of those patients are able to maintain that outstanding response. But on the other end, there are some patients who have um less of a response. You know, you can see patients that only lost 10 or 15 or 20% of their total body weight. And um some of those patients as time goes on experience weight regain such that if you look 12 years out, you know, the majority of patients are doing great have maintained a lot of weight loss, but there's a few patients out there that have uh regained all of their lost weight and are back to zero. Now, I put the 5% threshold here. Um, if you read the medical literature on like medications for weight loss, most studies are powered or designed to try to demonstrate a 5% total body weight loss and that's kind of the goal for medical treatment. And so you see surgical, it's dramatically better than that 5% for the vast majority of patients that undergo it. Now, the weight loss is great. But I'll tell you an anecdote. Um, the reason I got into this is actually nothing to do with weight loss, although it's weight loss surgery. What I thought was so amazing was seeing the improvement in comorbidities um, with the patients. And when I was a resident in surgery, I would come to the Bariatric clinic and I couldn't believe it. I mean, I, I was seeing patients who, you know, they had had the surgery and they lost £100 but their migraines were gone. Their diabetes was complete remission, like no medicines, normal A one c normal fasting blood glucose, their sleep apnea was gone. Their hypertension was better. They, you know, they weren't on Lipitor anymore. I mean, the, the metabolic improvement was really dramatic and that improvement um translated to a reduction in end organ disease. And so if you look at this, uh, paper that was, uh studied a large cohort of patients, um, and was published in Jama. If you look at all cause mortality, uh with bariatric surgery, there's a dramatic survival benefit to having the surgery versus continuing to be obese. Why is that? Because we know obesity puts you on that adverse survival curve. And so if you have the surgery, you get those years back. Um, largely now you might expect the surgery itself has a non-zero mortality rate. And so you can see early on, like in the first 30 days, there's a little more deaths in the search. Those are, those are the very few patients that die from the procedure itself. But the crossover is, you know, within six months and thereafter, there's a strong survival benefit. And why is that, um, half of that benefit is from a reduction in cancers. So we know that bariatric surgery is associated with a reduction of a number of cancers, colon and Omeri brass prostate ovarian. And if you look at all cause cancer incidents, there's a reduction in cancers that are seen. And in this Kaplan Meyer, um the hazard ratio was about 0.58. So the one way to say that is if you have the surgery, you're actually 40% less likely to develop cancer, which is a benefit that I think most of our patients don't really think about. Um, if you think about the patients you've referred, you probably weren't saying you should go see Doctor Carter because you have less chance of uh getting a cancer or dying from cancer. But that's actually one of the, the important benefits of the procedure and for the individual patient, it can really be a, a life changing intervention. Um This is a patient of mine, Patty who uh gave me permission to share her story on this slide but she came to us, um, with a BM I of 44 she had struggled for years. She'd done behavior modification. She'd been on a number of diets. She'd been on, uh, in medically supervised weight management programs. She could lose 30 or £40. But, you know, it seemed like the weight would always come back on after a couple of years. Um, although she was young, I think she was in her early thirties when she came in. Um she was already suffering from obesity related illnesses. She had hypertension migraines. Uh She'd been diagnosed with diabetes recently. She had asthma in a trigo. She had stress urinary incontinence and PC O si would argue every one of these illnesses is a consequence of obesity. Um We did a bypass and followed her and at her two-year appointment, um she was doing awesome. She had just run a half marathon, her BM I was down to 22. Essentially all of her uh obesity related illnesses were resolved or in remission. Um It's pretty cool to see. So how can that work? Why does bariatric surgery work? And in the old days, we used to talk about uh malabsorption and restriction mal absorption means that calories that you put in your mouth and swallow are not absorbed by the body. And it turns out that there's very little mal absorption with modern bariatric procedures. Um The sleeve basically has no mal absorption of macro nutrients the bypass, there's a little bit of fat mal absorption, about 10% fat mal absorption after the bypass. But it's not a significant calorie sink. The restriction means that you just don't have a stomach anymore. So when you swallow, there's just not a volume to put food in. And both uh operations have a little bit of a restriction. But the dominant effect we now know is hormonal. Um when you talk to patients who have had these procedures and you say, hey, why do you think you're losing weight? They'll say doc, I'm just not that hungry, like I'm just never that hungry. And when I, when I do eat, it just takes a small amount of food to make me feel full well. How could that be true? Well, it turns out that we're learning the mechanisms, although there's still a lot to be learned, but we know that uh both of these operations um produce potent changes in gastrointestinal hormones that have downstream effects. Um Let me take a few examples. Um Grein lin is a hormone that is secreted by your stomach and it's uh secreted when your stomach is empty. And so when you eat, it suppresses uh Grein levels and it has receptors in your brain, specifically the hypothalamus. And when the gren is high, it tells your hypothalamus to go um find some food. So it's basically a hunger signal. Uh peptide yy um is uh released by the distal ilium uh, sometimes we call it the ilio break. Um, it's secreted by food, hitting the distal ilium and it goes in the bloodstream. It has receptors in the brain also. And that tells your hypothalamus to stop eating. So that's a satiety hormone. Uh G IP, a GOP one. you're probably more familiar with GOP. One agonists are very, uh popular. I'm sure every one of you has prescribed or has a patient on a GOP one agonist. So when you eat, uh uh the food hits the small bowel and GOP, one is uh secreted into the bloodstream. GOP. One has receptors in the brain in the pancreas, in the um fat mass in the periphery, uh in the liver and in the skeletal muscle. And it has beneficial metabolic effects on every organ system. So to the brain, it tells you to stop eating to the pancreas, it tells the pancreas to crank out insulin. This is why we use it for type two diabetes. Um for the fat cells, it uh reduces leptin release, it increases ain release it, it reduces inflammation. Uh we know that from a measurement of serum inflammatory markers similar in the liver, it reduces glucose production and increases triglyceride clearance. So these are all beneficial effects and um those can have potent effects on, on diabetes which we're all aware of. So what's interesting is both these hormones, um augment the secretion of these G I hormones in a beneficial way. And that's the primary reason that they're working. Um, it's sort of interesting we now have, I mean, for the first time we are starting to see effective anti obesity medicines. Um, some aide which uh uh is uh the generic name is Wave or OIC is a G LP one agony that was originally um used for diabetes and now has an obesity indication and can result in about 15% body weight loss at high doses. Um The newer drug TPI, which is mojo is both a G IP one and the G LP in both the G IP and G LP one agonists. So, dual target, um in obesity trials, it has resulted in up to 20% total body weight loss. So keep in mind, a sleeve is about 30% and a bypass is about 35%. So, so with these medicines, we're getting about half the effect of a bariatric procedure. And so it's, it's kind of exciting to see we're finally unlocking the pharmacology so we can duplicate the effects of the operations um with just a medication hormonal effect. Um There's a new drug in the pipeline that has three targets. It's, it's G IP one or G IP, GOP, one and a third target. And the hope is that will be even more effective, but there's a downside to bariatric surgery and that's the risk of getting a complication. Um If you look at modern uh complication rates from gastric bypass. The risk of dying from the operation is very low. Um, but it's not zero, it's about 0.2%. When you look at all comers, uh, getting a leak from your anastomosis is about 1.6%. There's a small risk of bleeding. 1.2%. There's a small risk of DVT or PE if you add all those up and you say what percentage of patients need some sort of intervention, it's about 3% and about 7% are readmitted. Most of those are for nausea, vomiting, dehydration. Um but some of them for leaks or bleeds or DVTs or something. If you look at long term, there's some long term risks. The first, the major risk is that the ulcer, the operation is an ulcerogenic operation. That's because the gastric pouch still makes acid and the geum that's anna the most to it cannot protect itself from acid. Your small bowel cannot, has no mucosal defense for acid. Um You might say, well, what happens the acid, well, the acid in your stomach or my stomach, it's perfectly titrated by pancreatic alkaline. Such that you're, when you're in the second portion, Duden, there's actually a neutral Ph of the kind. And so when we do a bypass, we short change that so marginal ulcer is a long term complication occurs about 1% per year, but it can occur five years, 10 years, 20 years after your bypass. The other thing is since we're messing around with these intestines. There's a chance for intestinal obstruction that occurs at about 1% per year. But when it occurs, it's almost always surgical. We need to go in and fix the obstruction. So the question is, can we do better? And that's where the sleeve gastrectomy comes in. This operation was invented about 20 years ago. I would say it really started to, to pick up legs maybe 15 years ago. And I would say within the last five years, it's become by far the most popular operation. Um about at U CS F, about 80% of our patients go for the sleeve. And if you look at the whole United States, it's about two thirds um have a sleeve. So why do we like the sleeve so much? If you look at the weight loss over 10 years, it's very similar to bypass. Um This plot is plotting total uh body weight loss as a percentage and um here going up is better. So, uh you can see, you know, bypass in this study resulted in about 30% total body weight loss. Whereas sleeve was a little bit less, like maybe, I don't know, 27 28%. And if you look at the, um you know, these box plots, it's pretty similar at a population level. You could say the bypass is a little bit better than the sleeve. But on an individual, you know, there, there are two Bell curves that are almost perfectly overlapped. And so, you know, if you're looking at an individual patient, are you gonna lose more weight with the sleeve or the bypasses? You have no predictability. They're both very effective and the, and both of them are very effective. Over 10 years. You can see in this study, uh the sleeve cohort at 10 years out had lost about 20% of their body weight and the bypass was a little more like maybe 25%. So, weight loss is very similar. But the main benefit is the safety profile is even better. If you look at risk of death, leak, bleeding, E BT readmission, reintervention, it's about half that of a bypass across the board. The other thing is with the sleeve, you don't have to worry about marginal ulcers and you don't have to worry about intestinal blockages. It really do, it doesn't happen. So you get about the same weight loss, but you get an even safer profile. So that's very appealing for surgeons, right? Because I don't want to wake up at two in the morning to deal with my perforated marginal ulcer in my bice bypass patient, right? Sleep patients don't come to the emergency room in the middle of the night because they don't have, there's nothing that happens to them that occurs emergently. So that's very appealing. There is one Achilles heel of the sleeve though and that's GD, about 30% of patients end up with gird after sleeve. And so those patients um may have to be treated with uh PPIs. And there's a rare patient who actually has to be converted to a bypass for refractory card. A bypass is a very effective antireflux operation. So that's really driven the population to sleeve. And I would say most of the patients that you will see in your practice are gonna be sleeve patients um just driven by the popularity of it. So I have just a couple more slides and then um we can open up for uh questions and I know there's questions in the chat, but I haven't uh looked at those yet. Um So how do we follow patients um after surgery? So the bariatric post op visit goes like this. Um We recommend our patients come see us three months after surgery, six months after surgery. And then every year, we also know despite our best attempts that the attrition rate is pretty high and a lot of patients are followed by you all um primary care. And so, you know, what are the things that we're interested in? So, subjectively, we asked just how you're doing like how are you doing with your dieting? How are you doing with your exercise? How's your sleep hygiene? How's your mood? Um has any alcohol or drug abuse uh slipped in your life? We know after bypass specifically, there's a little uptick in alcoholism. So we want to ask him about that community engagement, stress relief, those sorts of questions in terms of medications, we wanna make sure that they're still taking their Bariatric vitamin. Um, the one that we recommend at U CS F is called Bariatric Pro Care. Um, this is a special multivitamin that's actually manufactured specifically for bariatric patients. And the formulation is um specific to them in addition to their pro care, which covers most of their needs. They should also be taking calcium plus D and we don't care that much. Any calcium, whether it's, uh, you know, calcium citrate or calcium carbonate doesn't really matter. And, you know, we don't care that much how much d whether it's 3 75 or 500,000, whatever, it doesn't matter. We just want them taking calcium plus D two or three times a day. Ideally, it's three times a day, but it's hard for patients to do so, twice a day is better than, uh, than nothing. Um, if they have a bypass, we don't really want them taking, um, in seds at all because we're worried about those marginal ulcers. Um, if they have a sleeve, it's no big deal they can take inside and then, you know, we wanna tie trade or adjust other meds as comorbidities resolve. Um, often we can eliminate, uh, di diabetes meds, hypertension meds, statins, whatever, um, physical exam, there's not much to do. Um, if they have a lot of loose skin, um, you can ask them, if they're interested in seeing a plastic surgeon for body contouring surgeon. I think that's an awesome way um, for patients to feel even better about their bodies. Um, after a lot of weight loss and then, um, we have a, a lab panel here. If you want to take a screenshot, this is exactly what we order uh with our post op visits. Um, you can see it's just basic micronutrients. You know, we check a one C monitor diabetes resolution, we check the lipid panel to monitor their uh cholesterol resolution. Um, other than that, it's just micronutrients. If you wanna know what's in the vitamin, this is what's in it. Um, if you look at most of the vitamins, it's 200% of the US RD A. And so if you're in a pinch, you can just tell a patient just to, hey, take, take just a regular adult multivitamin, just double up the dose, take two adult doses a day and that's pretty darn close. Um, it's got a lot of thymine. Now, thymine deficiency, your body can't really store thymine. And if you're vomiting for like two weeks straight, you could become thymine deficient. Um, we don't see that hardly ever except a rare patient who's struggling, like right after surgery, like in the first two or three weeks. Um, that's pretty rare. There's also a ton of B 12 in these vitamins. I'll tell you, uh, I'd be curious, I've never seen a case of B 12 deficiency in a bariatric patient. I wonder if you have, like, if you have, let me know because I'm just curious but it's something that all the textbooks say, but I've never actually seen it. So, um, here's our team and um, we, uh, really wanna work with you and, uh, partner with you in taking care of your patients with obesity. And please let me know any ways that we can help you take care of this um patient population.