Medically Speaking #13

Welcome to today's episode of Medically Speaking. Today we have a very interesting topic. We're going to be talking about weight loss. We have two of our experts in this area here with us today. We have Dr. Santosh Swaminathan and Dr. Kat Johnson. And I thought maybe we could just start with introductions so we can get to know each other and then we're going to have some conversations. So Santosh, why don't you tell us about yourself a little bit, where you're from and your training and what you do. Yeah, hello everyone. This is Santosh Swaminathan. I'm a fellowship trained metabolic and bariatric surgeon, trained in residency from Connecticut and did my fellowship at Jefferson Health, Abington, Pennsylvania. And now with bariatric services here at Self Regional Healthcare and extremely happy to be here. and providing these services for our wonderful community. Awesome. Great. Kat, tell us a little bit about your training and background. Well, I'm Kat Johnson and I'm a family practice doctor trained here at our wonderful residency. Graduated several years ago and now I work with the residents to teach them and I also help direct the full circle care diabetes and metabolic clinic where we do obesity medicine treatment. Awesome. Very good. So when we think about like obesity treatments, what comes immediately? What comes immediately to my mind is like, how do you decide between the different treatment options? I know traditionally, like when I was coming through medical school, you're always taught, well, it's all about diet and exercise, but there's been a ton of change and I guess so the thinking around obesity and weight loss and metabolic management. I think since, at least since once I went to medical school. Maybe Kat, we could start with you a little bit and maybe tell us a little bit about some of the background of like, I don't have such a hard time losing weight to start with and maybe some of the I guess current thinking on that. Yeah. Well, I agree. I don't think for a long time the medical community had a great grasp on the science behind weight regulation and certainly not why people have trouble losing weight. And so and I felt that lack of knowledge. So when I was post graduation, I went ahead and did an obesity medicine fellowship and that was very, or obesity medicine certification rather, I apologize, very helpful for establishing more of the science behind weight regulation in humans. Because if you don't understand what's happening, I don't think you can really pick the right treatment. And it does kind of get reduced down to this lifestyle, personal willpower, self control, kind of attitude, where it's just, you know, we'll work harder, do better and you'll succeed. And I think people all over the world could say, man, they're trying real hard, but they're not really finding success. So why is that? And very briefly, without getting into like the nitty gritty, cellular stuff that no one wants to talk about, you know, the current thought is probably all of us have a set point weight range, right? Some of those genetic like you kind of look like your family. If your family are taller and kind of bigger people, then you're probably not going to be. Right. You're probably not going to be able to do a lot. You're probably not going to be real thin and vice versa. So there's kind of a genetic set point. And then as you're kind of go through your life, things may adjust your set point up and down, you know, pregnancy, adolescence, right? Nobody tells an adolescent boy to eat more. They will just eat more and grow. So hormones, medications, different things will adjust where your body kind of sets its fat tissue amount. And then what will happen to some people, not all people, but some people is that that set point keeps going up and up, right? And despite their best efforts, their body kind of wants to hold on to the certain amount of fat tissue. And so you start to eat less and exercise more. And sometimes that does work initially, but then your body kind of wants to bring you back up to that set point. And so people have this yo-yo dieting experience. And a lot of that is, is blamed on self-control. And what they don't realize is while you're losing weight, you're losing weight. You're is while you're losing weight, your body is going to make adjustments to regain the weight. And so, you know, it's pretty hard to find a system that you don't have any frontal lobe control over. And so I think that's where lifestyle interventions play a role, but also tagging on medications and then even bariatric and metabolic surgery makes a lot of sense, because sometimes those lifestyle changes just aren't going to overcome the body's compensation. Does that make sense? Yeah, absolutely. Okay, so let's say that someone has or is in a situation where they find themselves with, they're obese, they're overweight, they need to lose weight, they've been trying. They've been trying diet and exercise, and they just can't seem to get the weight off for whatever reason. And, like, how do you make the decision on what to do first? Like, as far as, like, I know there's a lot of medicines. There's the stuff that you see on the news with, like, Wegovi and the different, different shots are available, and then some pills and different things. Like, how do you decide? Like, how do you decide where to start? I mean, Santos, you want to start with that? Yeah, I mean, I completely agree with what Dr. Johnson had to say with the etiology or the cause for all this. I mean, before we begin into this, I think just to spell it out and say it out loud, I think we should recognize obesity is a disease, and basically patients with obesity are suffering from obesity. I mean, it's just like. It's like having diabetes, high blood pressure, or any other disease that they may have, and that should be something we need to make sure patients are comfortable speaking about, sharing, as well as same goes with health care providers, recognizing this, as well as speaking about it freely, and sort of break that stigma. Now, that being said, I think what is the right way to manage this? I think it's not a one-way highway situation. This is a multi-modality, or what we say, basically, attacking it from different angles, just like how we would treat any other disease. That being said, the whole concept of treatment of obesity or, you know, the holistic aspect of it is not essentially to make you skinny. It is to make you healthier, make sure, like, you know, you are able to perform activities of daily living without difficulty and get to your goals that you have. So, typically, it's not like, you know, getting to a BMI of 20, 18. Those numbers even don't mean anything overall. Nobody knows what BMI means because that's just an indicator that we came up with. Is it waist, hip circumference? Is it BMI? Nobody knows. So, it's very hard to pinpoint exactly what your goal should be. As I said, the goal should be to be healthier, get off your high blood pressure medications or diabetes medications. So, typically, the first question that we need to know from the patient is, what is their expectation? What are they here for? Or what is their expectations from their treatment? Are they looking to get rid of their medical problems? Are they looking for short-term weight loss? Is it like sometimes even, you know, we may see patients who have a wedding in six months and they want to lose weight for that wedding? Or are they trying to lose weight for, like I said, getting rid of their diabetes or getting rid of their high blood pressure? Or are they losing weight to go to a particular surgery that they need? For example, if they need spine surgery, or knee surgery, sometimes their weight may not allow them to have the surgery safely. So, typically, just understand what their expectation is, what their expectation in terms of how much weight loss they're looking for, is it temporary or permanent that they're looking for? So, a lot of discussion based on that. And how much are they looking for? Like I said, typically, medications, lifestyle and diet are integral to everything. So, it's not like lifestyle. Medication, surgery, I think all three go well along with each other. I think lifestyle is integral to medication as well as surgery. So, typically, it just depends on how much are they looking for and what is their goal. Do you guys find that, maybe Kat, I'm going to ask you this, that some patients will have tried the diet and exercise stuff, the lifestyle modification stuff, and yet they need something to help them a little bit more. How do you decide someone should get on one of these newer, newer medicines to help lose weight? So, there are some FDA qualifications. The FDA would say to qualify for a weight loss medication, you would need to have a BMI greater than 30 with or without any medical problems associated with your weight. Maybe explain what BMI is just for the audience too. I would say most of us who are in metabolic circles hate BMI. It's just, it's really a population. Number, it takes somebody's weight, I mean, it takes somebody's height and it calculates this thing called BMI. You know, but probably you can imagine that you have 10 friends who are all 150 pounds and they're all 5'5" and they still may have wildly different body compositions. They may look very different, some might be athletic, some may not, and BMI doesn't extrapolate to any of that. So, it's a horrible indicator of health. The FDA, because it's what we have, has said a BMI of above 30 qualifies as having obesity and so they would qualify as having, being able to obtain obesity medications. Or, a BMI above 27 if you have a weight-related condition. And so, if you are lower than that, per the FDA recommendations, an anti-obesity medication is not necessarily indicated. So, that's the science-y answer. Okay. That's the science-y answer. Okay. I would say, most people who are coming to the doctor to talk about weight-loss medicines are going to meet those parameters, and at that point, patient preference makes a huge, huge impact on what we choose. So, if a patient comes and says, "I don't want to do medications, let's focus on lifestyle." Well, then let's dig into lifestyle, right? And lifestyle we talk about is sleep, stress, food, or nutrition. And so, when we talk about exercise, we talk about exercise as being a movement. And I don't even say exercise, because movement and exercise may not be the same thing for someone. And they, but they may come and say, "Look, my lifestyle is as good as it's going to get right now, it just is what it is." Or, "I've optimized it to the point that I can optimize it, let's talk about my next option." And that may be medications, and then I have patients who, they're interested in going right to bariatric or metabolic surgery. And there's really not, you tell me if you agree, Santosh, but there's really not a, "You must do this step, and then this step, and then this step." I think it, patient preference is so important here in the conversation. Okay, yeah, I mean, I think, well, if we come to indications of metabolic and bariatric surgery, there are some hard indications. And I have the same views and feelings about BMI as an indicator, as I've even mentioned before, these guidelines were actually, made in 1991 in a consensus conference by the NIH, so you can imagine how archaic or how behind it is in terms of doing these. Our society did come up with 2022 guidelines, but we are still waiting for insurances to catch up. But overall, anyone with a BMI 40 or greater without any medical problems would easily qualify for metabolic and bariatric surgery. Or someone with a BMI 35 and greater with one comorbidity, could even potentially be obstructive sleep apnea, high blood pressure. And then there is a special allowance for patients who have diabetes, if their BMI is 30 and above even, they could potentially, with some insurances, be able to avail the benefit of bariatric and metabolic surgery. There is a special population, ethnicity-wise, for example, in South Asian population, they have even lowered it further to a 27.5 cutoff. Again, insurances are catching up to all these. I'm just even glad insurances have considered obesity as a disease because 10, 15 years ago, even that wasn't a part of coverage in general. So overall, those would be just, again, indications as to what we currently are following. Okay. All right. So, well, I guess, Kat, let me go back to you for a second. In the patients that you care for in our community, what do you find is, I guess, like some of the common comorbidities that patients have when they have obesity? And why is it important, just at a high level, why is it important to address the obesity in context of all their other medical problems? That's a good question, especially since the treatment paradigm has shifted, I think, for a lot of these chronic diseases. So a lot of the times when people are struggling with overweight, or obesity, they may also be struggling with diabetes or pre-diabetes. They often are going to have risk factors or active cardiovascular disease, so heart disease, strokes, heart attacks are at much higher risk. And then you have the just weight-related problems, such as arthritis, right? Everybody knows, you know, they say, "Hey, I lost 10 pounds and my knees felt better," right? So if you are holding on to 50 extra pounds, then your knees are going to feel an impact. And then you have the metabolic effects, those are the diabetes, cardiovascular disease, risk of stroke, heart attack. And then you also have the musculoskeletal effects, and those are the big things that I look at. The other more nuanced things that I think people do occasionally hear about, but are not as well known, would be cancer. There are multiple cancers that are absolutely related to having excess weight. So people who have a history of cancer in their family or personal history, they're likely to have a history of having excess weight. So the weight loss can be a very, very big thing with prevention. And I like to always put that out there, because that's not always talked about. Yeah, no, that's a good point. So the weight loss itself actually can have a dramatic effect on all of these other things that cause chronic conditions and cancers and heart disease and heart attacks and strokes, and all of that can be related. And by addressing this, it's almost like trying to get to the root cause of this, that a patient has that you're addressing, whether it be through medications or, again, lifestyle changes or surgery that can have a dramatic impact on someone's life. Absolutely. I'm really glad we're addressing that in our community, and I appreciate both of you guys for the work that y'all are doing. So let's talk a minute about some of the medication options that are out there. Again, I think we definitely should talk about it, because it's all over the news, and a lot of people are using the Wegovis and the Mongeros and all those type. Let's dive into those for just a minute, and what are the benefits of those? Just at a high level, how do they work? Do they just make you not hungry, or do they make you eat less? Just give us an overview of the meds. I mean, I could talk about this for hours, but I won't do that to you. And I'm assuming you probably want to talk specifically about those more high-talked-about medicines? Yes, absolutely. So I'm going to throw out some name brands, not because we are perpetuating any medicine here. Sure. The brand names for that would be Ozempic, which is branded for diabetes. It is the exact same medicine as Wegovi, which is brand named for weight loss. How interesting. We can have its own discussion about that, but we won't. The same thing is Mongero and Zepbound. The generic for that is Terzepatide, but the Mongero is approved for diabetes, and the Zepbound is approved for weight loss. They're great drugs, and I think the reason they've gotten so much attention, is because they work so well for the vast amount of people who take them. You know, go back 10 years, we had some weight loss medicines. I still use those medicines, but they are not as universally effective. So it was hard to get excited about medicines that you're like, well, this might work for you, right? It's kind of like, well, I hope your aspirin works for you. Nobody really gets excited about a medicine that might work for them. These newer medicines work so incredibly well that it's now not, they might work for you, they probably will work for you. And they'll probably work for you in a pretty intense, life-changing way, right? We're not talking 5% weight loss. We're talking 10, 15, 20, 25% weight loss with a lot of the people in the studies having incredible effect. So these are really effective. That's why we're excited about them. The issues with them. Number one, expensive. They are so expensive. Shortages have been an issue. And I would say from a medical perspective, people who can't or shouldn't, should kind of talk to their doctor about it. There are some contraindications for them. People have something called gastroparesis, or if you have a history of pancreatitis, or this very rare syndrome called MEN syndrome. Those are contraindications. You don't want to give those out to people. Most people don't have those contraindications. So it's kind of accessible for a large amount of people. Now, how do they work? You did ask that, right? How do they work? How do they work? All right. One thing they do is they tell the brain, "Hey, you're not as hungry." So I don't know if you all have ever been on a diet, but if you drop your calories down, suddenly food tastes better. And suddenly you're like, "Oh, I see that food over there. You're very interested in food." So this medicine cuts that because it tells your brain, "You're okay. You lost some weight. We're not that hungry. It's okay." So that obviously helps, right? The other thing it does is it works all over the rest of the body, and so it kind of opens up the cells to be more metabolically healthy. So it's not just appetite suppression. And I, again, won't get into the cellular stuff, but it's really kind of cool in that I think it helps your body be less inflamed. It helps the body accept a lower fat mass so that the person's lifestyle efforts are better. It helps the body accept a lower fat mass so that the person's lifestyle efforts are suddenly more effective. They're cool drugs. They're really cool. They're not right for everybody. That's a good explanation. So do you have to take them for your whole life if you get started? Okay, the unsatisfactory answer to that is we're not sure. We're really not sure. At this time, I think people should plan on taking them chronically. We call it a chronic disease. So even if you've lost that 20%—and you think about it, that's a huge number. Yeah. If someone weighs 300 pounds, that's like, wow. Is that 60 pounds? Right. 70 pounds? Right. Something crazy. That's a huge amount of weight to lose. But once you've reached that, keep taking it. Probably. And keep paying that over $1,000 a month. Probably. Forever. Right. Man. I mean, that can be hard. That's a commitment. I want to sign up for that. Mm-hmm. And so it's interesting. They're studying this. Yeah. We wonder if there are people who can probably come off of it and maybe keep their weight down. Maybe if your lifestyle has changed, right? If you lose 60 pounds, suddenly you can do sports, right? Right. Suddenly you can go to the gym and not be uncomfortable. Perhaps those people can come off the medicine or lower the medicine. They're definitely being studied. This question is being studied. I don't think we really have the full answer as a medical community yet. So I tell people, "Probably you need to plan on being on this drug long-term. We can always pull you off and see what your weight does." But I wouldn't want people to go into it thinking, "I'll take it for granted." I'll take it for six months and then stop. Because they'll likely have weight regain over one to three years is what they see in the studies. Sure, sure. Another common question might be like, "Okay, well, I want to give this a try. What are some common side effects of weight loss medicines?" Also a good question. Typically mild to moderate GI upset. So nausea, heartburn. I've seen diarrhea. I've seen constipation. I can't tell who's going to have what. And I tell people mild to moderate. That should pass. Severe, I see occasionally. Not commonly, but occasionally. And, you know, that would be a reason to say don't take it again. That's just not for you. It's not your drug. So I do think when people use these medicines, it should be after a really frank conversation with their physician and a planned follow-up. I'm not personally a huge fan of these medicines being used in, say, like med spas. You know, that could be up for debate. That could be up for debate. But I think there really are risks and benefits, and they have to be weighed out individually. So on the surgery side, so again, thanks. Very good explanation, Dr. Johnson. On the surgery side, at least in my head, I'm like, "Okay, if I'm in this position and I'm trying to decide, well, there's still some unknowns about the medicines, and I may have to take this really expensive medicine, like, for the rest of my life, or I could have surgery one time and not have to wait." And not have to worry about it anymore. Why don't you talk to us a little bit about the surgery piece of it and kind of, like, how when you're seeing a patient for the first time, like, how do you go through your thought process with the patient on, like, does this patient — should we really do this surgery? Should we try some other options first? Yeah. No, I think it's obviously in this day and age, this is a common question to occur. That being said, surgery has been around for more than two, three decades. In fact, the hormones or the drugs that were created really changed. And the drugs that were created were created from studying the downstream signaling that happens after surgery. So, you know, it's almost like it's one gave birth to another in terms of the thought process or the hormonal signaling. So, obviously, the same benefits or the same logic applies when you have surgery, basically triggering this incretin pathway, the GLP-1 pathway, and sort of keeping it going, essentially. So, you know, the patient, like I said, I still go over the fact that if they are seeing me, they are considering weight loss as a serious, you know, barrier in their life. And so we discuss how it's affecting them, what is their initiating event or motivating point for surgery, and what is their expectation out of this. And then we talk about how they can resolve their issues, that is, diabetes, high blood pressure, and which surgery would suit them. One of the things I will ask them is how bad they are. How bad is their reflux if they have it, and if they have had endoscopies recently because that alters the kind of surgery. Typically, we are offering three types of surgery here at Greenwood. It would be the sleeve gastrectomy, the gastric bypass, and the duodenal switch with varying expected weight loss after surgery. And typically, we calculate our weight loss at the end of one year after surgery, and it can be anywhere between 50% to 70% based on — of excess weight loss, which is basically their weight minus their ideal body weight and see how many pounds that is. And then it will be 50% to 70% of that. So some of the mechanisms from surgery are even still not completely understood because it's just not the incretin pathway. It's more that happens. So that being said, we do like to make sure patients are actually understanding of what their expectations are post-surgery as well. And as well as their economics, are they going to be able to afford vitamins? And are they going to be able to consume that amount of protein that they are expected to and social support? So I look at it in a holistic way, not just as a patient who wants like surgery like this. This is not like having a gallbladder removed or a hernia repaired. This is a lifetime, life-changing experience that you want to go through only once and you want to do it right. And so we try to prepare them for the best outcome. And there is an extensive program where they see our nutritionists. They see psychology and you get evaluated. They get all our consultants that they need to be seen to be completely in tune for this operation. Like I said, it's a once-in-a-lifetime opportunity and you want to do it right. So that's what I'm evaluating when I'm seeing a new patient. Gotcha. You know, we were talking earlier a little bit about some of the techniques. I guess that are used in bariatric surgery. I know that's changed over the years. And one of the things that I think is really cool that you're bringing to our community is the ability to do some of these surgeries robotically, which I think is a relatively new technique. Can you talk to us a little bit about that? Yeah, and I would say thanks to Self Regional, we do have the opportunity to offer robotic bariatric surgeries, whether it be primary surgeries or revisional surgeries on the Da Vinci surgical platform. And I think that has revolutionized care in general in surgery. It's a form of advanced laparoscopy, giving the ability to the surgeon to have in-depth views of their anatomy and being able to do things consistently and in a very sure manner with utmost care and gentleness. So I think we offer it in all the procedures that I mentioned just now, the sleeve gastrectomy, the adjuvantal switch, as well as the gastric bypass. And I'm extremely happy that we have that ability here in Greenwood at our very own backyard. So again, touching on some of the same things like side effects, what are the risks of having a bariatric surgery? So first and foremost, bariatric surgery is actually one of the flag bearers in terms of quality in surgery overall. Our complication rates are less than 1% across the board for any complication you might pick, some being even in the decimals. We are so nitpicky about every complication at this point that even other specialties are trying to follow our model because we have a big oversight and we get routinely checked for how our performance is. And it's technically safer at this point than even a cholecystectomy, which is basically gallbladder removal. So that being said, the main side effects that remain because we are triggering these same very hormones that the medication triggers is that initial bout of maybe some nausea postoperatively. Whenever we handle the stomach, any bowel or stomach doesn't really like to be handled, so they get a little touchy-feely about it and they don't like to give that nausea feeling to the patient first week or two, which usually they get over very quickly. And otherwise, the main thing like I just mentioned is vitamin or nutritional deficiencies, which is why we put impetus on understanding what the patient can do. So it can be B-complex vitamin deficiencies and in some procedures, fat-soluble vitamin deficiencies. So we see our patients very so often and we also encourage them to see us every year after. So there is a very thorough follow-up schedule, which may be, you know, initially every three months and then annually every year where we check their blood work. Gotcha. Well, guys, I kind of see this as like multiple different options, right? So if I'm a patient and you kind of have to weigh, I guess, the surgery options versus like, you know, diet, exercise, traditional things maybe to try, as well as the current medication. So there's a lot of things to think about. If I'm a patient who's, say, moderately overweight, and I say moderately for our community, it's hard to know what that is exactly. Let's just pretend that I have a BMI of, say, 35 or close to 40. And I'm trying to decide, like, I recognize that I need to do something. You know, I've got high blood pressure, maybe type 2 diabetes. I've got some issues going on. I need to do something about my weight. What would be the first place I would start or how do I go about making a decision like this? I think start with your primary care doctor. I think that's, I mean, you know, your primary care doctor typically knows their patient better than anyone and can kind of guide them through their options or direct them to a specialty clinic. And the specialty clinics are not competitive with primary care. It's not taking over. But it can be an augmentation, I think, of that relationship. So that's where I would suggest people start is talk to their doctor. I think I would say, like I said, what are they looking for? What are they looking for? Are we looking for weight loss only? Are we looking for what kind of weight loss? I would say look at what they can do from a diet and, you know, lifestyle manner. Have they addressed that? Potentially look into medications if you're looking at a 35, 40 BMI. I mean, realistically speaking, these are domains like, you know, if you have a patient about 50 BMI and you're only going to use medications, you just have to know that you can get to a certain point with it, not maybe get lower than, I mean, there might be a reason or there might be some goal in their mind. So it just depends. Are you looking for a 15, 20%, 30% goal? Are you looking for complete resolution of diabetes? Like some surgeries that we have can offer that ability to completely resolve your diabetes, completely get rid of blood pressure medications, completely get rid of that sleep apnea machine that you're having struggles with. Or are you looking for, you know, I want to see how I'm going to do on this, you know, try the medication. I tell Dr. Johnson the same thing. We are trying to attack this from every angle possible. And you could be on medication and think of surgery and go through the process for surgery at the same time. So none of this is prohibitive. Like you choosing surgery as an option or choosing medication as an option doesn't prohibit you from thinking about the other. So someone with a 35, 40, I would encourage them, they can look into medications, see how they are doing, because that also gives the surgeon an ability or a peek into how they might behave after surgery. Are they able to comply with the rules of the medication, the diet? Because that gives me a portal into understanding. Because the surgery, like I said, is a once-in-a-lifetime opportunity. And that gives me that idea that, okay, this patient might even do well with surgery when they decide to choose to do that. I would just say, I don't really care about BMI a ton. I really want to know a patient's happy weight and healthy weight and where you can put them together. Because if they have a BMI that's 35 but they can do everything they want and they're happy and they love their body and they're empirically healthy, fabulous, who cares? Who cares what the BMI is? What's happy and healthy for you? And I agree. I think that can direct you to either both modalities of treatment, on top of the lifestyle intervention. Lifestyle is the foundation for everything. But it's not that medications and metabolic surgery are competitive or prohibitive. I love that. Yeah. Well, gosh, this has been a great discussion. Do you guys have anything else that you think that, like, our community might want to know about this topic? Anything at all? Well, if I can start. I mean, I personally would like to first put it out. Like, again, just reiterating, obesity is a disease. We have to tackle it in a multidimensional format. It's not — and I would tell everyone, basically, you're not alone in this fight. This is something as common as your blood pressure issues, your diabetes issues. So I encourage everyone who is, you know, having that stigma within them to approach a healthcare provider regarding this, to feel free regarding discussing it. This could be something that could lead on in future to worse things that, you know, then you have to seek care. And, you know, things could be really worse when before we can — you know, this is preventative. We can prevent. This is something we can help you earlier on. Earlier the better. Like we say, prevention is better than cure. So that's my first point. Second point, I think just from bariatric surgery standpoint, it is a safe operation. It is, you know, this is a sustainable option. And people should recognize this as — this is not cosmetic surgery. The other thing I want to reiterate, this is not cosmetic surgery. This is not like I'm removing fat. Like this is not liposuction or any kind of plastic surgery. This is life-altering metabolic surgery where you can get rid of these problems that are accompanying you along with, of course, the great added benefit of weight loss. My fight is against diabetes, high blood pressure, and all these other things that are plaguing me. All these other things that are plaguing the community. And weight loss is one of the other benefits that happen. So it's a safe option. And whatever you choose, just, you know, give it 100%. Commitment is the most important thing. I think it never can undermine anything. We can do the best operations, give the best medications, but I think us as a team fighting obesity and the commitment to it is far more important. And so, yeah, I just wanted to reiterate these two things. You know, I'm going to take a slightly touchy-feely bent here, but I would say for anyone who has interacted with the medical community and has struggled with excess weight and has not felt like they were treated with the most dignity and respect that they should expect, I would apologize to them. I think traditionally speaking, we have received very little education on obesity. Again, 20 years ago, 30 years ago, it wasn't even considered a disease. And so people have had a lot of negative experiences. And I just think they kind of deserve an apology and also a, you know, give it another try. I think people will take — physicians and nurse practitioners and PAs in the medical community, I think, will do a better job going forward. And I think the education is out there, and I hope that people can feel like they can come to their practitioners asking for help and be met with respect. Yeah, that's great, Kat. So I totally agree. There is — it is a big problem in general. It's really hard as an individual struggling with weight loss. I've had members of my family that have struggled with weight problems, and I know it's not for lack of trying to get healthier. And so, yeah, I agree with everything you both said. It does need to be thought of as a disease, and there is help for you. Yes. There is help, whether it be through medication or through the surgical options, there is help that can be had that can help you get on a healthier life to be happy, to be happy with your body and where you are. And that's a very individual thing for everyone where that is. And, again, wow, this has been awesome. I tell you, our community is so fortunate to have you two here to help in fighting the disease of obesity. And all the things that go with that. And super, super happy you're both here and excited about the initiation of the bariatric program that we're just starting here to try to help our community with this and all the work that you guys do, Kat, at the Full Circle Clinic. So thank you both so much for being with us today on "Medically Speaking," and we will wrap up today. Thank you all for joining us, and we look forward to the next episode. Thank you. ♪ ♪ Thank you.