157: The Role of Surgery in Diabetes and Obesity

In this episode, we are joined by Dr. Mitchell Roslin to discuss the complexities of obesity.

We explore the role of GLP-1 medications in weight management, the evolution of bariatric surgery, and the innovative SIPS procedure.  

Dr. Roslin emphasizes that obesity is not merely a result of poor lifestyle choices but involves intricate biological and hormonal mechanisms. 

He also highlights the importance of functional assessments in determining appropriate treatment for obesity, advocating for a more systematic approach to obesity management.

Learn more about Dr. Mitchell Roslin: https://faculty.medicine.hofstra.edu/4990-mitchell-roslin

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Transcript

Disclaimer: This transcript was generated by AI and may not be 100% accurate. If you notice any errors or corrections, please email us at phil@longevityroadmap.com.

  I've seen really severe type two diabetics and get reasonably good results is that when we resect portion of the stomach and we deviate the biliary stream, we're changing the absorption of glucose as well.

Welcome everybody. This is Buck Joffrey with the Longevity Roadmap and, uh, today interesting conversation. Dr. Mitchell Roslin is a bariatric surgeon. And why is this, um, why is bariatric surgery or basically, you know, surgery for obesity, uh, why is it, uh, relevant to longevity? Well, as you'll hear Dr. Roslin talk about obesity is essentially.

Accelerated aging. And so it's a big problem. And um, if you're listening to this show, there's a good chance you're in pretty good shape or you are at least trying. Um, but you know, it, it's such a major problem. And you may have people in your family, people, you know, and it may be worth something to learn about these ideas.

Um, the big picture here is that it's not, you know, bariatric surgery when we're talking about. You may have heard of stapling the stomach or all the, that kind of stuff that you, you hear in the popular, uh, news and that kind of thing. The types of procedures that are being done now is by people like Dr.

Rosalyn. They are not only, uh, to help with obesity, but also to help with severely resistant diabetes. And so it's interesting. It's not just. You are changing the mechanics of the, uh, gastrointestinal system. But for example, uh, the, you know, absorption of glucose, which we know we, a lot of us use glucose monitors.

That kind of thing is most significant. And the first part of the intestine, part of the, uh, duodenum and some of these procedures. They essentially, you know, bypass that, remove that part of the intestine. And so it significantly decreases the amount of volatility in blood sugar. And, and also, uh, it's another interesting thing that, you know, the stomach, uh, it used to be that, you know, you'd remove most of the stomach, whatever, but leaving the last part of the stomach, the pylorus.

Is important because if you don't, um, food goes to the intestine very, very quickly and then you get that massive amount of volatility, uh, into, uh, that first part of the intestine. So it's an interesting thing. It's a, if you're a surgeon, especially, this will be very interesting to you, you or a physician, and you know the anatomy.

If you don't know the anatomy, you might wanna pick up a. Just, uh, pull up an, an anatomy book while you're listening to him speak about the anatomical part of this, the surgical part of this, because I think you'll find it really fascinating, even if you don't. Um, there's a lot of interesting information in here just about obesity, uh, and his, um, uh, you know, his findings on that, you know.

What causes recalcitrant obesity, that kind of thing. Anyway, hope you enjoy it and, uh, you know, again, think about the people in your life who may actually require this, uh, despite all their efforts. And, uh, we'll have that interview right after these messages. Hey, longevity enthusiast. It's time to take it to the next level.

I've been fine tuning my longevity regimen for years, and I look better and feel better than I did a decade ago. In fact, my blood work is even better than it was back then. And it's all because of my data-driven regimen. And it's inspired me to create a course and community just for you. It's called the Longevity Roadmap, and I urge you to check it out.

If you're tired of your belly fat, tired of being tired, or just wanna optimize yourself for the next 50 years, visit longevity roadmap.com. That's longevity roadmap.com. Welcome back to the show everyone. Today I am joined by Dr. Mitchell Roslin. He's the chief of bariatric Surgery At. Lennox Hill Hospital, New York.

Uh, I'm professor of surgery at the Zucker. School of Medicine, uh, at Hofstra Northwell. Uh, he trained, um, at my mount, this is a always a, a mouthful for me, but Maimonide Medical Center in Mount Sinai, which is obviously, uh, much easier for me and he's helped it pioneer procedures, uh, like hips, which is a safer, safer version of, uh, the Duan switch.

We'll get into all that, uh, holds multiple patents in the. Field, some of which he was telling me about, involve, uh, vagus nerve stimulators, uh, as we've had Kevin Tracy on the, uh, program in the past. Um, Dr. Roslinn, thank you so much for, uh, being on the show. Thank you for having me. Really look forward to speaking to you.

'cause I think it's a, a fascinating area. Yeah, for sure. I mean, you know, it's, uh, let's start out with this. Let's just set up, you know, for people to get a little bit of a foundation here. It's pretty clear. That obesity isn't just about eating too much and moving too little and being lazy. Um, I mean, maybe for some people it is, you know, but, but there are, there are others.

That have a real problem here, that that is sort of outta control in many cases. So from your perspective, I guess as a metabolic surgeon, uh, what are the key biological and hormonal mechanisms that drive that kind of obesity, which is not easily controlled? So you began to talk about it and it, it truly is multifactorial.

So what, what I would look at is. What everybody who's interested in longevity could potentially learn from what we do in bariatric, in metabolic surgery. And the aria of that question is what makes people different? Okay? What makes people different? So the first thing that I would say is that really anybody who's interested in the longevity space.

Should pay very close attention to the obesity space because obesity is a model of accelerated aging. Think about it as the furnace in the house is on too high temperature set too high, sympathetic turns sent too high, and every part is more likely to burn out early. And where it's sym symptomatic is where we see it.

Then the next question people have. Is one of the funniest things that I always hear is like a calorie is not a calorie. It's like me saying like, you know, an inch is not an inch. And you know, with being five eight, I was never gonna play for the Knicks or the Lakers. Okay. I'm not mugsy bogs. Um, so an inch or a calorie is a unit of heat.

So where people are different, which I think is really fascinating. Really, again, really pertinent to the longevity space is the fuels that they burn and what happens when people have an obesity problem. A diabetic is, our people who are listening in longevity will know this better, is they begin to lose or they lose their zone two of exercise.

So at a very, very low heart rate, they convert over. To burning their glycogen and their, their, their glycogen stores. And that begins to explain that once you become obese, and I think really looking at evolution's really important, the body drives you to eat more. Another way of saying this is that intake and outtake are linked.

So when an obese person increases their level of activity, the body forces them to eat more. Because they're always burning their glycogen stores. They basically have a, you know, a lock placed on their fat. And that probably is mostly, you know, derived from insulin levels and having higher fasting insulin levels and things like that.

Interesting. So, yeah. So let's, I mean, along that line we've got, um, we've got the GLP one revolution, right? Um. Semaglutide Tirzepatide really have, I mean in many cases, really changed the landscape, right? I mean, for some people they have truly, they are like truly a miracle drug. I've seen it in my own neighborhood and you know, parents at school that I stuff were, you know, grossly overweight and all of a sudden they look great.

So I guess the question is, you know, how are there people, there must be people who are resistant to this and. How do they become sort of resistant to these kinds of things? If, you know, going back to your comment that this is, this is sort of, this is largely in many, in most cases, it's, it's a metabolic, it's a metabolic syndrome, right?

It's a derangement of, uh, you know, what, what you should burn, what order you should burn, that kind of thing. And these kinds of drugs seem to do a really good job with sort of helping with that. Why, why are some people not, uh, responsive to them? So again, you've been a doctor for a long time. Um, Ozempic was first approved by the F-D-A-F-D-A in 2017, right?

Did anybody come on your show and say diabetes was cured? And the answer is the more insulin resistant you are. The larger you are, the lower your weight loss. So diabetics lose about half as much weight, which makes sense because there's still incretins and in the insulin pathway. So, you know, recently you've seen more articles about Ozempic trying to macro dose, but again, with people who have very high body mass indexes or who are truly diabetic or truly insulin resistance, they're going to have less weight loss.

Um, and I think you're getting at another really fascinating question, which is, you know, what causes us to kind of lose the ability to retain fat? And, you know, how does that happen? And it, it's fascinating that, you know, it's through the insulin pathway and. Again in medical school because Banting, you'd have discovered insulin from, and I, I know Mo many of your people will be familiar with that.

And insulin was first discovered when, when people were dying of diabetes and the only treatment was a ketogenic diet. Um, back in the day, we tend to think of insulin only in glucose metabolism. Insulin is as important in fat metabolism as it is in glucose metabolism, and. I mean, we, we don't realize it, you know, again, at the extremes we talk about gestational diabetes, but normal pregnancy, women deliberately become slightly insulin resistant and their third trimester because it tries to encourage them to store fat, especially in certain areas so that they have enough fat to maintain lactation.

So the same type of thing, fat is not the enemy. Fat is very, very important. You know, we, we published an article during COVID that showed that basically there was a phase change in people with high BMI. They were likely to expire, but every time you'd hear the, the story about the young person who ran marathons and had no fat mass, and if you have no fat mass, you have no reserve if you get septic and get infected.

So we wanna have the right amount of fat. We certainly don't want excess fat. We certainly don't want profound insulin resistance, but women need about 15% body fat in order to lactate, menstruate, and, and reproduce properly. And men need a certain fat reserve in case they become stressed or infected of stuff like that.

So fat's not the enemy, but obviously excess fat is so GLP are fantastic drugs, but it also tells you that. The weekly derivative that penetrated the blood-brain barrier has been far more successful than the daily derivatives, which that tells you that all energy balanced is centrally regulated. And we know that women, you know, their, their, their metabolism increases in p pregnancy, the estrogen and progesterone increased, their appetite increases to meet that increased metabolic need.

You know, that's completely central and that tells you how. The brain and the body regulate our weight and energy distribution. Now the question is, is why does Western society and what happens here that the brain loses that degree of regulation? Yeah. And what do you think, obviously you have a theory on that, I'm sure.

Well, I think there's a lot of it that we do know. I mean, I think there's a lot of it that we do know and, and this is kind of. I actually, you know, again, to many of your listeners, they might've heard that I was a bariatric surgeon and turned off because they say I don't need that. You know, the health is of the healthy, but the answer is bariatric surgery is the greatest model.

In fact, how we kind of understood GLP and in certain, and you alluded to the work that we've done on SIPS or Sadie, which is a single anastomosis duodenal switch. So what do we do when we do that? And then I'm gonna go back to an answering the question that we make. The stomach small, like a tube. Stomach is very important in sensing mechanical things so it understands stretch.

So a smaller stomach, you're going to eat less sleeve gastrectomy, and people think they're going to be eat less forever. What's the downside of small stomach? Similar to the downside of a small tank of gas, can't get very far. But if you fill it up enough, you can get from New York to your studio in California where we're talking regularly.

So a small stomach will empty fast and the stomach is very important in hunger and fullness. But what it's not in in very important in is what's called satiety. What is satiety? Satiety is the time that you feel full after you eat. And satiety signals come from the bottom portion of the intestine. So again, what happens when you eat processed food or high sugar things?

You get an insulin response, okay? All of the food gets absorbed. There's no residue that goes to the bottom portion of the intestine. That's where most of your endocrine cells see GLP come from the gut. The science that Novan Natis masked it and then Lilly was taking these things called increments that had very short half-life and stabilizing it.

These are all naturally found compounds and they're mainly, you know, nothing in the body as you know, of being a surgeon has a monopoly, but there are more L cells in the bottom portion of the in. So in bariatric surgery, when I take a sleeve and then I detour the food, so it's only going to the bottom half of the intestine, so it's not going to the approximately half of the intestine.

Our GLP goes up about 12 fold. What's interesting is, is that right? Wow. In 80, our GIP goes down, which makes me believe that the difference between ozempic and Manjaro or ze bound and the GIP component mainly just reduces the GI side effects. Did I lose everybody there? Well, you know, I wanna make sure we kind of go back, which I spent a little bit, I wanna spend a little bit of time talking about the surgical innovations because, and this is gonna be a tough one because not everybody who's listening is a physician, but I, I sort of wanna try to make, make people kind of understand, you know, they might have heard of gastric bypasses or stomach stapling, but they don't know exactly what it means.

Maybe if you would, can you. In layout in some of the main types of weight loss surgeries. It might be helpful if we just stop, uh, start with anatomy 1 0 1, stomach pylorus and all that, and then, and then connect it. We got a smart group here. Uh, and so e essentially, essentially the way food starts, we start, you know, in our mouth and.

Our mouth is actually digestive. Actually, you know, sugars are broken down by salivary amylase that's there, and then the food goes into a tube that connects the mouth to the stomach where it travels through your chest and you're going to get into your abdomen where the stomach is. Status store food.

Stomach is a very, very interesting organ, has a fair amount of functions. It functions as a defense organ. So for years we thought it was sterile because it's high acidic. Do you ever realize why phyto can go in the backyard, eat something on the ground, not get sick, but if you do that, you know you'll be very, very sick because their stomachs are still very, very acidic.

First thing the stomach does when you eat is actually it receptively relaxes, so you don't get full after one one gulp of food. Okay? The stomach then kind of breaks the food down. Into a chime and then it's passed to the first portion of the intestine or the duodenum, and that's where the juices from the pancreas and the liver and probably stimulates the greatest degree of insulin production are in the proximal caution of the intestine.

What's very, very interesting, and we don't talk about it mo a lot, is that most glucose absorption actually is active. Meaning that it requires antigen and it requires sodium and it takes place in the first portion of the intestine. So the simplest, the real first operation hit mainstream, not, wasn't the first weight loss operation.

So the hall node of bariatric surgery is when people had their stomach resected, mainly for ulcer disease. They lost weight. So that became started. A thought process. Could the stomach be altered in people who were really, really severely obese to get them to lose weight in the first operation? That kind of was done in widespread.

It wasn't the first, it was called a vertical banded gastroplasty. So if you're my age, and I'll be 63 in December, you'll remember like, you know, the old. Television shows like St. Elsewhere, and they always had a gastric stapling on. They were alluding to what they called the stomach stapling, and it was exactly that.

You would staple the stomach, put a ring around it, and it would make it hard for it to eat. Okay. Okay. Yeah. I guess the best way to say it, every coop. The Surgeon General in the Reagan administration. Probably the last surgeon general I can name too, like actually Me too. It used to be like a real position, right?

Yeah, it did. Yeah, you're right. Okay. See, ever coup? Yep. Mm-hmm. Okay. Comes out with the fact that aids, which was the big medical thing, wasn't, was the biggest health problem. Obesity and a sedentary lifestyle. Whole obesity epidemic happens, and then kind of really at the beginning of my career. Amazing things happen.

You know, and I, I just wrote something about this. 1996. I first kind of became, because the first people were using laparoscopic surgery to do minimally invasive surgery. I went to the first Bariatric Surgical Society meeting that I went to in 1996. There was six exhibits slammed into a room that was smaller than my office five years later.

Walter of East Carolina wrote an article that surgery could be the best treatment for diabetes. And we now had, we're able to do these procedures through small holes laparoscopically. We had endoscopic staplers and powered instruments. There are now 1700 people in Washington DC bariatric surgery. Later around that year, our group operated on.

Al Roker, Debra Voight, who was a famous soprano, had surgery at Lennox Hill Hospital for diabetes. That was on 60 minutes and bariatric surgery moves into the mainstream and the operation at that time was gastric bypass. Grew up with it, thought it was fantastic, and then I really started to study obesity and gastric bypass is still one of the most common.

Operations done. What happens when you make a DUA gastric bypass is you make the stomach the size of a golf ball, and then you bypass the first portion of the intestine and you bring one loop up where food goes and another loop down so that you basically have a loop of intestine where there's only food, a loop of intestine, where there's only digestive enzymes and a loop with a two mix.

Call the down. So people thought gas bypass great operation and when. Then a few years later I started seeing patients whose weight was coming back from bypass and any operation or any treatment of your recidivism. But they all gave me the same history that they would, you know, be relatively satisfied during the day they come home, they eat something.

Um, and usually it wouldn't be some, you know, it would be more likely a processed food. They'd feel empty jolt, and all of a sudden then they'd feel crashing and they'd go through this loop. And what I realized is that gastric bypass promotes, what your listeners would understand is glucose variability.

So it does cure diabetes, but the way it does so is by having a lot of high sugars and a lot of low sugars. So they average and you're getting a high insulin level after you eat. Which then crashes you. So what do you do later? You eat and you're always on this rollercoaster it to me, I began to say this doesn't make sense.

Like if I go see any dietician in the country or any obesity expert in the country, what they're asking me to do is eat protein and fiber so that my insulin levels don't go up and down. So how could the gold standard surgical operation have the most glucose variability? And we did a lot of research on that.

So it started the quest to try to find a way of doing bariatric surgery in a way where we didn't have the tails up and down in bariatric surgery and have less glucose variability, which is why I know that every bariatric surgeons go, oh, it's too much this, too much that, or He only does it for weight.

No hogwash. I did it because there's too much glucose variability and that if you actually do. Sadie or sips, right? You see much less glucose variability. Now, again, you alluded so, so Dr. Dr. Rolin, one thing is just for clarity for the audience, why, why the glucose variability? Like why, what was causing the glucose variability?

'cause what happens is, what does the intestine do? The intestine absorbs food. It's the same thing that can give gastric bypass patients potentially. ETOH. So if you eat something, the mouth breaks it down, go straight into the intestine, the intestines where we absorb. So the speed to it, getting to the bloodstream increases.

Got it. So you, you were reducing the amount of food, but you weren't taking away the the metabolic issue. To some extent. I mean, there's no one factor, but there was a lot of glu, there's a lot of glucose variability in hyperinsulinemic hypoglycemia, so we postulated because we're mechanics. We were surgeons, you were a surgeon.

You know, like you know everything at ever mechanical solution back in that day. But if we preserved the pyloric valve, which is what controls the empty of stomach, we would, you know, solve the problem. Because you would slow it down. You would slow down the, uh, the food actually going into the intestines, which was the speed was probably what was creating all the variability, right?

Correct. And that was a great hypothesis, except then we studied sleeve gastrectomy, duodenal switch, and gastric bypass. And we found that gastric bypass had the most glucose variability. Duodenal switch had the, had the leaves and sleeve was intermediary. Which made us take a step back and realize there's a lot more going on.

And what I think really happens to some extent, which is why I've seen really severe type two diabetics and get reasonably good results, is that when we resect portion of the stomach and we deviate the Billary stream. We're changing the absorption of glucose as well, so it's interesting. We get less insulin, but we get a lower curve of glucose absorption, and it really tells you that the glucose absorption is occurring in the proximal portion of the intestine.

And when food goes straight down and you have less sodium in it, and the sodium comes from bile and removing the stomach, you're getting a slower up slope as well. So it's not. Not just one reason. So just a along that lines, um, take us through that. 'cause you we're talking about a few things here in terms, but we wanna make sure that we kind of, sort of evolve into the procedure that you ultimately are doing now that seems to work better.

So you had the gastric bypass and then describe the sleeve. The idea of a sleeve is you're making the stomach, which kind of looks like a kidney shaped beam into looking like a tube or a banana so that it will hold less food and you're preserving the pyloric valve. So food will go through the normal course of the entire intestine.

So one of the reasons that's appealing to patients is that it doesn't change the way they theoretically would absorb food. The downside of that is that the small stomach at times will empty quicker and you don't get the same hormonal results that when you add. Right. So it wasn't solving the, it wasn't solving the insulin, uh, variability.

Well, it does to, well, not the insulin variability. Again, any weight loss will work. For insulin resistance in diabetes, but it, it's not going to have a strong effect. One of the issues with Arab business is teasing out how much is due to the weight loss or eating differently and how much is due because of the, an anatomical rearrangement, if that makes sense.

'cause everyone eats differently, which is why there's such a big Hawthorne or placebo effect with any procedure. So the one that, that you ended up on, um. This is the sips. Describe exactly how that works. Okay, so what we do, and again, this is a procedure I use, you know, if you're really kind of, you know, body mass index is more than 45 to 50.

I find that most people, you know, what I tell them is the stomach gets weighed off. In other words, if you make the stomach small, you lose weight. But manipulating the intestine is what keeps it off. So for people who have a really. Significant. So in other words, normal BMI is 25 and they're of 50, so we call class four, or people who were on insulin, you know, for their type two diabetes, meaning they make, uh, too much insulin, but they're so insulin resistant that they're on insulin.

I think it's best to combine a stomach and intestinal approach in rather than the gastric bypass. What I like to do is do a sleeve gastrectomy that's slightly bigger, preserve the valve. Then the first portion of the intestine is called the duodenum, and just slightly past there, I divide the duodenum and then the intestine is about a curvy structure that people know the intestine in the human beings probably about 22 to 24 feet, and that what we'll do is we'll plug the food in, so it's halfway down.

So it's about 12 feet from the bottom, so-called into the ileum or distal juju. And that's the part where, think about how the body's designed, okay? When residue, people always say processed food is bad, and you ask them why is processed food is bad? And they go, well, I give you insulin resistance and diabetes, but explain the physiology to me.

What happens when people eat processed food? When people eat processed food, basically you're taking out the undigestible contents and making everything digestible. So what happens is there's no residue hitting the bottom portion of the intestine. When there's no residue hitting the bottom portion of the intestine, you are always going to be hungry.

So that's what, why you eat these foods and they're not filling and understanding. This is, I think, really important to your audience. 'cause it, it, it clarifies some of the diet mysteries. So what we do is we take advantage, so we detour the food so it goes to the bottom portion of the intestine. Another way of explaining this to give some idea to this, is that if you have montezuma's revenge and things are passing through you, no one's hungry.

Right? Same process when full food, it's the bottom portion of the intestine. You're far, you, you remain satiated, and satiety is really the holy grail. So going back to glp, okay, there's only one way for anybody to lose weight loss to a weight loss, and that's a sustained deprivation in calories. What surgery and GLP at different levels.

For different patients do is they eliminate the food noise so that you can maintain that caloric deprivation for a long period of time. And then it kind of duplicates what happened in nature years ago where we become insulin resistant before the drought. So we'd store fat and then we kind of have eat much less and have caloric deprivation and get rid of our insulin resistance.

So what medications and surgery do? They allow you to maintain a caloric deprivation without food noise and being miserable. Um, can you explain the difference between what you are doing compared to like a traditional duodenal switch? So the traditional duodenal switch was pretty much the same as Arun y gastric bypass, and again, and I always love.

You know, I think that understanding surgery and understanding obesity, evolution and history is so really, really, really important. So the original duodenal switch was an operation, did a sleeve gastrectomy, okay? And then you divided the intestine and you basically had an elementary limb where there was only food, and that was usually about one and a half meters.

Then a very, very small area that they called the common channel that was anywhere from 50 to a hundred centimeters. Okay. And the rest of the bowel just had digestive juices in it and they didn't mix. And the idea of having the very short common channel is that the food wouldn't mix with the digestive juices, but realized that the body can absorb carbohydrates to some degree protein, what the body can't absorb with digestive contents.

Without bile and lipase is fat. Okay, so the original DO Isal switch came from a kind when the number one consensus. You know, I, I, I know how your listeners will be amazed, but the number one consensus back when these operations started in the 1980s and nineties was that fat caused obesity. Okay, that fat was the leading cause of obesity.

So having a short common channel and the inability to absorb fat made sense. So again, when we came along, we said, you don't need a short common channel. We don't need people pooping six times a day to get them to lose weight. We can take advantage of the physiology bypass less of the intestine. We didn't need to do a RU and y, and then there are other technical things to do it, and we can make this operation less malabsorbed because the issue with obesity, okay, again, no matter how you do it, is on one hand you wanna lose excess fat without losing bone muscle and lean tissue mass, even with ozempic.

People are losing about 40% of their lean muscle mix. So really, really, really important for people listening to this with weight loss. They have to have adequate protein intake. And again, just having the Brix isn't enough. They actually have to do something with the bricks resistance training and things like that.

Um, let's talk about, just in terms of your algorithm for who, who would qualify for this? Do you, do you do? You know, GLP one trials, do you, how, how do you, how do you get to the point where you decide somebody's appropriate for surgery? So the, it's so a great, great question and I think it's really kind of, uh, an amazing question and I think it's something that we really need to tackle.

So right now, unfortunately, the way. Obesity and weight management is practice is basically based on patient interest and who's interested in getting things. And that's really sad because when you have, we just recently did a study where we looked at, you know, the different cohorts of different ages. If you're a man with A BMI of 50 and you're in your thirties, you're very unlikely to see your 60th correctly.

Women maybe get five to 10 years yet. If you look at 68% of the prescriptions that are given for weight loss medications, they go to females. I think that may be awesome, but it just goes to show that we're really treating the people who are mostly weight concerned. And the same thing happens with treatment of PE people.

People are asked, well, you know, do you want your obesity treated? Yes or no? Well, how would you like it treated? And they may say, well, I'm willing to have medicines, but I'm not willing to have surgery. And it's completely different. Imagine, God forbid somebody has cancer or they have heart disease. It's based on the anatomy or the stage that you're given the most appropriate treatment.

And I think that people have to realize, and then there's no relationship again between the people who need to be treated. Because we're not doing objective testing as far as I'm concerned. In a perfect world, which we are far from, that every single person with a high BMI should have some form of a functional assessment.

Your leaders would say, CPA testing, when my patients are tested on A CPA. Generally their VO two max is less than 20, and you'll know that if VO two max in less than 20, their mortality is four to five times higher. So based on BMI and VO O2 max or proxies for TO two max, we should be stratifying therapy.

Now, if that means giving people three to four months of LPs to see if they have a response, that's fine, but we really need to understand that severe obesity. Especially with metabolic type derangement is a life-threatening disease, you know, riskier than, or as risky as anything else that we stage, and yet we don't do that.

You know, again, you come into the hospital with, and somebody's severely obese and, and they come in because they have respiratory or they have cellulitis. No one tracks that data. It goes down as an exacerbation of COPD or somebody who's really had, who comes in with heart failure, goes down as heart failure.

We need to kind of start keeping that and we'll realize just how deadly Class four obesity is. You know, you don't have to agree or disagree, but just go outside. You'll see a lot of young people who are double in normal weight, who are 25 to 45. You don't see too many who are 55 to 70. Yeah, those numbers are going up, aren't they?

Uh, do you have any statistics on that? Yeah, so, um, you know, again, when I, we, I, I used to quote that maybe five to 6% of the population had a body mass index of 40. That number is comfortably 10%, and the amount of people that have a body mass index of 50 is comfortably at least 2% of the population. Yet, very few of those people are getting treated and certainly the number of people with A BMI greater than 50, I don't think it's likely that they would do well with just medications alone long term.

And again, one of the reasons bariatric surgical numbers have declined is because there's just been an expansion and a transfer of the people who await concerned. But we really have to do a better job of staging obesity as a disease itself. Yeah, interesting stuff. Um, where can we learn more? I mean, people might have, you know, questions for their family members, some ideas, stuff like that.

What, what are some good resources for people to check out? So I think I really, really been really, truly impressed by the work of Aria Sharma, who it was a Canadian researcher, Dr. Sharma. You know what I loved about Dr. Sharma's work? I think this is really the most important thing, and I think we have to give a lot of credit from the longevity place people like yourself and and podcast, is that Dr.

Sharma put obesity into a staging system with functional impairment and trying to get treatment based on that. So the Edmonton Obesity staging system. So I think looking at where you stand is really, really kind of important. I think that. Podcasters like yourself have done a remarkable job. I mean, I think, you know.

Bringing to light so much of the education and the reason why I am on this show is that because I said obesity is accelerated aging, all of the things with longevity that people are like, you know, Peter att talk about on a regular basis and their, their podcasts. Well what are they mostly, I mean, we can talk and argue about caloric restriction, whether that really is beneficial.

Okay. Metformin was certainly a diabetes drug and I know whether it's really a longevity agent, controversial. The best treatment we've ever had from a large gerontologic effect has been bariatric surgery. You know it. It's the only thing that's been shown to increase CPA reduce. You know, reduce the Framingham risk score, especially for, for appropriate people to do that.

I think that, so the podcasts out there yourself, Gabrielle Lyons, Peter, unfortunately, they're more up to, you guys, are more up to date than the medical literature is, is, you know, I can say this, I've learned more from exercise physiologist or as much as I have in new, in new fields. I think understanding.

The work of people like Gary TAs and I don't think there's is really, really important. I think there's Richard Johnson reading his books, fantastic books that, that explain from an evolutionary standpoint, insulin Sensitivity, who's a nephrologist from University of Colorado. Outstanding. I loved reading that stuff.

I think reading Michael Pollan's books, you know, on the Omnivores dilemma. Absolutely. Absolutely fantastic stuff. Um, you know, Marian Nestle's basic book on, you know, I forgot, uh, on nutrition, I'm blanking on the name. Fantastic, uh, resource and I think, um, um, from Cleveland Clinic, you know, functional medicine, great, but food, what the heck to eat?

Food, what the heck to eat, I think is a great resource. Then I also think that what the job of people like myself is to kind of simplify the message. So what should be the message and what, what is some of the risk issues with some of the people out there is that the people who are doing many of the PO podcasts and surgery, you'd say there are certain surgeons that put belt on suspenders on everything.

Maybe it was a little bit over the top for most people. So let's bring it back to real life number one, you can't be healthy if you're not active. So function function's, really, really important. Diet, really, you know, it should be protein and foods that have a lot of fiber. Some of the rules that I tell my patients is if it doesn't go into a refrigerator, don't eat it.

There is nothing in a package that you absolutely need. Okay. There's nothing in package. With all due respect to everybody, maybe you and I will create our own protein bar by the end of podcast. 'cause that seems to be like where whatever it was, the soup, protein, uh, you know, protein bar, but there's nothing you need that doesn't spoil.

Okay? Minimize getting any of your calories from liquids. After all, Starbucks is a sugar factory, so be very careful when you work in this. I hope I don't get sued for that, but that's what it really, truly is. Okay. You do not need a frappuccino. You know, if you look at behavioral health studies, it's reducing your sugary beverages.

You know, again, if you want to make yourself a smoothie with protein powder and grind up, you know, vegetables or fruit, that's fine, but you don't need orange juice. You can get plenty of vitamin C from an orange. You know, God, Robert Lustig said, God gave us the antidote for sugar. It's called fiber, and there's no place.

World with sugar and fiber aren't together. Okay. So I think those are some of now obviously relationships and sleep as well. But I can leave that for people who, who know more about that than me. Well, I, we do, I do appreciate you being on the show today, uh, Dr. Roslin, uh, and, um, and, uh, you know, I'm sure people learned a lot and, uh, uh, thank you again for being on.

Thank you. Thanks for listening. A quick reminder that while I am in fact a surgeon, nothing I say should be construed as medical advice. Now, make sure to include your physician in any medical decisions you make, and also, if you're enjoying the show, please make sure to show your support with the like, share, or subscribe.