Struggles with Obesity

People who are obese face a number of physical, emotional, social, and even professional challenges. In this podcast, we speak with Subhash Kini, MD, who is the Director of the Institute of Bariatric and Minimally Invasive Surgery at Mount Sinai Morningside Hospital. 

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Transcript

[00:00:00] Stephen Calabria: From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm your host, Stephen Calabria, Mount Sinai's Director of Podcasting. On this episode, we welcome Subhash Kini, MD

[00:00:16] Dr. Kini is the Director of the Institute for Bariatric and Minimally Invasive Surgery at Mount Sinai Morningside Hospital and served as an Associate Professor of Surgery at the Icahn School of Medicine at Mount Sinai.

[00:00:28] in this interview, Dr. Kini discusses the myriad challenges for patients facing obesity, particularly those who choose to undergo surgery to assist in their recovery.

[00:00:38] The physical, psychological, and emotional challenges for those battling obesity requires substantial levels of resilience, and their trials hold many lessons for those who are not. We're honored to have Dr. Subhash Kini on the show.

[00:00:53] Dr. Subhash Kini, welcome to Road to Resilience. 

[00:00:56] Dr. Subhash Kini: Thank you so much, Stephen, for having me on this show. 

[00:00:59] Stephen Calabria: Could you share a bit about your background and what led you to specialize in bariatric surgery?

[00:01:04] Dr. Subhash Kini: I trained in general surgery and was very happy with the training I received and the fact that I would be performing general surgery. However, I came across laparoscopic surgery during the early part of my training and fell in love with laparoscopic surgery, since I was able to do the same operations that I was trained in the first few years, but in a minimally invasive manner.

[00:01:29] And when I came to Mount Sinai to do a year's research in bariatric surgery, I knew that what I wanted to do for the rest of my life, and that was to do laparoscopic bariatric surgery. 

[00:01:40] Stephen Calabria: What are the most common types of bariatric surgeries and how do they differ? 

[00:01:46] Dr. Subhash Kini: The two commonest operations that are being performed now are a sleeve gastrectomy and a gastric bypass.

[00:01:53] The gastric bypass has been around for 50 years and involves division of the stomach into two parts and bringing a loop of bowel up to the pouch, whereas a sleeve gastrectomy involves in removal of a portion of the stomach only. 

[00:02:11] Stephen Calabria: How important is a holistic approach to treating obesity, incorporating physical, psychological, and lifestyle changes?

[00:02:20] Dr. Subhash Kini: That is a very good question. It is extremely important to have a holistic approach to any form of weight loss, because this is a chronic condition and there are no magic bullets that will take care of the problem.

[00:02:33] Therefore, one needs to use all the modalities that are available at our disposal to help counter this so that the patient loses weight and keeps that weight off for the rest of their life. And that includes diet, exercise, medications, surgery. Psychological and social changes that the patient needs to do.

[00:02:58] Stephen Calabria: So you screen for new patients when folks come to see you. What does that screening process typically look like? 

[00:03:05] Dr. Subhash Kini: When a person is overweight, they tend to have many conditions that are worsened because of the increased weight. Some of them are diabetes, high blood pressure, high cholesterol. 

[00:03:18] And for a person to qualify for bariatric surgery, their body mass index must be above 35 with one of these conditions or at least about 40 if they have none of these comorbidities, as they are called.

[00:03:32] Stephen Calabria: Is there a common tipping point at which people decide they want to get help and perhaps even get the surgery? 

[00:03:40] Dr. Subhash Kini: This varies from patient to patient, but you are right. At some point in time, a person will feel that they have tried enough and not succeeded, and they want to proceed with weight loss surgery. Unfortunately, not everyone realizes this when their body mass index is 35 or 40. 

[00:04:02] Many of them only realize when the body mass index is 50 or 60 even more, by which time, certain conditions are beyond repair. 

[00:04:14] For example, if they wait too long and the cartilage in the knee has worn down and requires knee replacement, unfortunately, weight loss at that moment in time will not prevent them from having a knee replacement. 

[00:04:30] Stephen Calabria: What kinds of social and psychological problems often accompany people wanting to get the surgery?

[00:04:36] Dr. Subhash Kini: So, they have the same psychological problems as general population. In addition to the same psychological problems that the general population faces, a small percentage of our patient tend to have reactive depression due to the condition. 

[00:04:52] And that is because of how they feel about themselves, i.e. the body image, self-image they have about how they look, the discrimination that they feel at work and at home and with friends.

[00:05:08] The social aspects are quite a lot in that people who are obese tend to face discrimination at work, with friends, and that's why they tend to have a much smaller network of friends.

[00:05:24] And it may surprise some people that most of our patients do not drink even socially because, most people drink alcohol when they are with friends and not alone. And since their network of friends is very small, they tend to not drink at all.

[00:05:45] The psychosocial problems they have with family members also include having strained relations with the spouse. And this can be from many reasons.

[00:05:58] One of them is that they sometimes face spousal abuse because the spouse feels that the person who's overweight is not up to, in quotes, their standard. Many obese people face difficulties in their relationship with their spouse. 

[00:06:19] This can start as a small problem and then snowball into a major problem where the spouse looks down at the person who is obese and there is actual spousal abuse in these relationships.

[00:06:37] Sometimes spouses feel that they are doing the obese person a favor by staying in the relationship, and this dynamic leads to a lot of problems for the obese patient, and many times the obese person may feel that they cannot get out of the relationship, as they may not find another person who may find them attractive.

[00:07:02] This leads to the person staying in the marriage, however, not being happy in that marriage. Weight loss after, say, weight loss surgery, dramatically changes this, as the person loses a significant amount of weight, say, a hundred pounds, and their body image improves. 

[00:07:25] This can result in both positive and negative changes in the relationship. The positive could be that the spouse is now very happy with the body image of the person who has lost weight and therefore has much more respect and shows this in their interactions. 

[00:07:44] And the negative thing could be when a spouse now is jealous of the way the person who has lost weight looks like and is now not happy with the change in dynamics that occurs in their relationship.

[00:08:01] Stephen Calabria: What is the typical profile of your average patient? 

[00:08:06] Dr. Subhash Kini: Eighty-five percent of our patients are women and, though they range from 18 to maybe 65 or even 70, most of them are between the ages of 30 to 40. 

[00:08:20] Stephen Calabria: Why is it that your patients, do you think, are predominantly women? 

[00:08:25] Dr. Subhash Kini: That is a tough one to answer. Women are more acutely aware of the body image more so than men and definitely women find it more socially acceptable to undergo surgery for weight loss. Whereas more men tend to think of this as an easy way out or something that they don't need.

[00:08:48] Stephen Calabria: Why do you think that men will tend to see this as something that is unnecessary?

[00:08:55] Dr. Subhash Kini: Many patients recognize that they need to lose weight to overcome medical problems that they have. However, many patients want to do this either on their own, using diet and exercise, or will go to medical weight loss, more so recently with the newer drugs, but are not willing to undergo surgery 

[00:09:20] And this is mostly because people don't know enough about surgical weight loss and how easy it is from a patient's perspective to undergo surgery.

[00:09:34] Many people think that this involves a prolonged post operative period where they will not be able to do things. There'll be a lot of pain involved. And therefore the best advocate for this is by patients who have already undergone bariatric surgery. 

[00:09:53] Therefore, when a person comes across a close family member or a friend who has undergone bariatric surgery and has done well and can put this across to the person, about how little pain they had, that is the single most important factor in galvanizing many patients from just sticking to diet and exercise and making that jump to undergo surgery. 

[00:10:18] Stephen Calabria: What is it about this condition that makes people feel as though discrimination is appropriate or warranted, as opposed to other things for which people may face discrimination in life?

[00:10:30] Dr. Subhash Kini: Over the years, race, gender, sexual orientation and certain medical conditions have now been found to be socially unacceptable to be discriminated against. However, obesity is not one of those.

[00:10:47] People still find it's okay to discriminate against those who are overweight or obese even in 2024. 

[00:10:54] Stephen Calabria: Why is 

[00:10:55] Dr. Subhash Kini: It's a stereotype. The stereotype is they're lazy and not, not motivated. Just eat less and exercise, No, I've been told this by doctors, you know, by an endocrinologist. Come on, all they have to do is just keep them out, that's all. 

[00:11:09] Stephen Calabria: Just not eat. 

[00:11:10] Dr. Subhash Kini: Just not eat. You know, just eat less, you know, just stop, stop it. And, and this was an endocrinologist who says this to me, and I said, you just don't get it, you just don't get it.

[00:11:19] You know, I'm not obese, agreed, but I mean, I can lose some. And I try, I work out nine hours a week. I do yoga. I do work out with trainers, three hours. I play three hours of tennis. I do yoga is two hours a week. 

[00:11:31] Every day, 15 minutes with my cousin and his wife in Boston. I go to the gym twice a week and I do some boxing. There's unbelievable amount of this thing. So I'm fit, but I understand, you know, it's not just, eat less, man. You know, it's not that easy, you know. 

[00:11:46] The stereotype that is woven around an obese or overweight patient is that they are lazy and not motivated.

[00:11:54] They have tried everything under the sun before they come to a surgeon. Many people feel that all you need to do to not gain weight or lose weight is just to eat less. This is as far as possible from the truth, because most people do try it. 

[00:12:14] This is a very interesting thing. This, I read in a book and he put it very nice. He said, if there's a famous chef coming, and we've got two tickets to go and eat tomorrow night. What are you going to do tomorrow? 

[00:12:26] You'll say, you know what? I'll probably miss lunch. And maybe if I'm so inclined, I'll go for a three mile run. We've just said that I'm going to do those things to eat more at his dinner, right? Because he's a chef who has come. And what do we tell our patients? Eat less and exercise.

[00:12:45] We advise our patients to eat less and exercise. But say we were going to a special dinner where we expect to have really high quality food and we want to eat a good meal, we may prepare ourselves by missing the previous meal.

[00:13:05] And maybe if you are so inclined, go for a three mile jog. Both these are exact things we tell our patients to do to lose weight. And here we are doing those things so that we'll eat more. So, when we tell patients eat less and exercise, we are also causing them to develop increased appetite, which they'll eat more.

[00:13:25] Stephen Calabria: And because it is something that can be physically seen and it traces back in part to behavior, I imagine it's far easier for people to cast judgment because it's like, if only you changed your behavior, and this is harming your health, so it's all on you. It's your responsibility. 

[00:13:44] Dr. Subhash Kini: That is correct. Yeah, it's all on you and it's your responsibility. Whereas you would say if it's race or age or socioeconomic status, it may not be all up to them to change it. Whereas here, it just seems like a very quick fix. You just eat less and you'll be done.

[00:14:01] Stephen Calabria: Right. And even with other medical conditions that are brought about in part by behaviors, lung cancer for example, we wouldn't tell the patient, just stop smoking and then that takes care of everything. 

[00:14:17] Dr. Subhash Kini: Yeah, or putting it another way, we would say that, please stop smoking, but then we don't discriminate that you got lung cancer and therefore you are, 

[00:14:27] Stephen Calabria: Lazy, you can't handle stress very well. There's something wrong with you. 

[00:14:31] Dr. Subhash Kini: Yes, sir. We realize that you are smoking and we will help you try to stop smoking, but we don't judge that person and say that, well, the lung cancer developed because you're smoking and therefore you're totally responsible for it, etc. 

[00:14:46] Stephen Calabria: And all of this discrimination, both on an individual and a societal level, has a compound effect that oftentimes results the patient's condition only being exacerbated. Because they are perhaps eating to deal, or not deal, with the problems that they're encountering. 

[00:15:06] Dr. Subhash Kini: That is correct. So, many patients who face these discriminatory attitudes of people around them leads them to sometimes eat more because that's how they find solace and unfortunately that exacerbates their problem.

[00:15:23] Stephen Calabria: What kind of mental health support then do you recommend for patients before and after they receive surgery?

[00:15:29] Dr. Subhash Kini: Every patient who undergoes bariatric surgery is evaluated by one of a small group of mental health professionals. And only if, after a long consultation, they feel that the person is mentally okay to proceed with surgery are they cleared for surgery.

[00:15:48] Patients who may have mental health issues, which may be exacerbated with the stress of surgery may have to undergo behavioral counseling and other forms of mental health support before they're cleared for surgery. 

[00:16:04] And after surgery, those who where provisionally cleared but needed mental health support in the form of behavioral therapy may have to continue this after surgery too. 

[00:16:17] Stephen Calabria: What kinds of preparations are made for a patient as they are heading into surgery and how long does the surgery typically take? 

[00:16:25] Dr. Subhash Kini: The process before surgery depends on the medical condition and the psychological condition the patient. If the person needs behavioral therapy before surgery, they will have to undergo that. 

[00:16:42] And if they have to be optimized from a heart lung point of view, they would meet with a cardiologist and a pulmonologist who would then get them ready for surgery.

[00:16:53] In addition to these two, the patient has to try to lose as much weight as they can before surgery. And sometimes we do give them target weights of losing maybe 10, 15, 20 pounds. 

[00:17:05] And other people who have a relatively lower body mass index of around 40, we may not give them a number, but ask them to lose as much weight as they can before surgery.

[00:17:18] The preparation just before surgery is to remain on a clear liquid diet for 48 hours. And that includes, just prior to surgery, a patient is told to remain on clear liquid and a protein shake diet for two days before surgery. The operation typically lasts between an hour and two hours.

[00:17:40] Stephen Calabria: What is the typical recovery process? And what should patients expect in the weeks and months following their surgery?

[00:17:48] Dr. Subhash Kini: Since these operations are done laparoscopically, there is not much pain after surgery except for some discomfort in the first three or five days. The diet progression, however, goes on for about two, two and a half months where they go through clear liquids, followed by period diet, followed by soft cooked food, and finally normal consistency food thereafter.

[00:18:16] Patients are able to get up and walk around a few hours after surgery, and we encourage them to do so more and more after they are discharged, typically a day after surgery.

[00:18:27] Stephen Calabria: After the surgery, what kinds of behavioral health changes do patients need to adopt to ensure long term success?

[00:18:35] Dr. Subhash Kini: After surgery, patients are surprised by the lack of hunger, which they're not used to since most of my patients before surgery, wake up hungry and are always hungry well before the time for a meal. This changes dramatically after surgery. They wake up in the morning and are not hungry at all.

[00:18:59] And they remind themselves to have a breakfast as directed by our nutritionist. Subsequently, during the day, they sometimes look at the watch and are surprised that it's more than an hour later than when they would have eaten normally and they are not hungry. 

[00:19:17] Also, when they eat a small portion of food, they feel full. However, this lack of hunger and feeling full earlier sometimes can be difficult to adjust to because, it's a lifetime's habits that have to be changed in a few days. 

[00:19:35] And, whereas some people find it very easy to do so, others find that it's a change that they have to work on for a few days or a few weeks before they get used to. However, in the end, patients are really happy because they can eat a small portion and be happy with that.

[00:19:56] Stephen Calabria: In keeping with that point about breaking lifelong habits, how do you help patients develop a healthy relationship with food, post-surgery? 

[00:20:07] Dr. Subhash Kini: We tell patients that they should be selecting from only two main food groups, and that is, white meats, which is chicken, fish, shrimp, turkey, egg white, and tofu. And non- starchy vegetables. 

[00:20:25] With this two food groups, literally thousands of recipes can be created, provided it's a healthy cooking style, such as boiling or roasting as opposed to frying. 

[00:20:41] And I encourage my patients to consider increasing their cooking styles in a way to incorporate these changes and to really embrace these changes and to enjoy food, provided it's a healthy option, and to add variety to their diet. 

[00:21:01] Stephen Calabria: How important are support systems, family, friends, even support groups, in a patient's journey?

[00:21:09] Dr. Subhash Kini: Many of the problems that patients face are seemingly trivial, but are very specific and probably best understood by a person who's either undergone surgery, i. e. other patients, or a support group leader who has been doing this for a long time and truly understands the problems that post op patients undergo.

[00:21:28] This could be as simple as cutting down dress size, and what do you do with a dress that no longer fits you, to food choices, to types of exercises that one can do as one loses weight. 

[00:21:43] Stephen Calabria: You touched upon those new drugs. Insofar as we can even speak with any authority on these drugs because they're so new. How do we feel about Ozempic? 

[00:21:54] Dr. Subhash Kini: Definitely the advent of the newer drugs has dramatically changed the landscape of weight loss. We have a new, exciting dimension to the modalities that we can offer to patients. 

[00:22:14] In the past, patients were limited to diet and exercise on their own or with the help from a nutritionist or an exercise physiologist or trainer, but the medications were not very effective. 

[00:22:28] The current medications are significantly more potent than what we had in the past. However, they do have the limitations, in that about 20 percent of people do not respond to the newer weight loss medications. 

[00:22:43] And even those who do, a great majority of them will not lose enough weight if the body mass index is about 40 or 45, and even of those who do lose weight, they will not keep it off without continued use of the medication.

[00:23:03] Stephen Calabria: What common traits or habits have you observed in patients who achieve longterm success?

[00:23:09] Dr. Subhash Kini: Those patients who look upon surgery as the equivalent of having won the lottery really do well, because they know that there's almost no chance that they will win the lottery a second time. 

[00:23:23] And therefore, they will embrace all the changes that they need to have after surgery and have often said to me that, I will never go back to that weight that I was prior to surgery. 

[00:23:36] On the other hand, some patients look upon surgery as just another modality of weight loss and do not take it as seriously, and therefore do not incorporate all the changes that they should after surgery. And this group of patients tend to have a partial or a significant amount of weight regain. 

[00:23:59] Stephen Calabria: What are some of your favorite success stories as far as the patients you've treated?

[00:24:05] Dr. Subhash Kini: Many come to mind, but the two that stand out are, the first one is a lady who represented United States in Olympics and unfortunately gained a lot of weight subsequently and was unable to lose the weight. 

[00:24:21] She came to me and told me that I will be your best patient. And three months after surgery, she had lost all the extra weight and was torn in half. And had been exercising and her muscular tone was just tremendous. 

[00:24:36] She moved away from New York and was planning to represent the United States in the senior version of the Olympics. 

[00:24:48] The second patient who comes to mind is someone who was four hundred and fifty pounds and underwent two operations, first a sleeve and then a bypass, and she lost over 300 pounds and now weighs only 150 pounds and she keeps herself busy and works full time. 

[00:25:08] She also is a pastor and is able to help people in a congregation, in many other ways. And, she had a history of abuse as a child and the changes that have occurred over the last few years, which include this significant weight loss, has made her a different person.

[00:25:30] Stephen Calabria: So based on your answers, it sounds a lot like, Obesity is not just a physical problem. It is very much also a mindset slash psychological problem that with the appropriate reset could absolutely be tackled and people often go on to live a healthy and happy life. 

[00:25:55] Dr. Subhash Kini: That is exactly right. I'm glad that you bring the point reset, because bariatric surgery actually helps lower a person's body weight set point . 

[00:26:08] The set point is a term used where a person will tend to remain at that weight, and if he gains a little weight, he may easily able to lose that extra weight. Or if he loses some weight, he will easily get back to that set point.

[00:26:22] Bariatric surgery changes the set point and puts it at a much lower level, such that when the weight fluctuate, it fluctuates at a much lower level. So, for example, if a person weighs 280 pounds and loses a hundred pounds and is now at 180 pounds, they will fluctuate around 180 now, as opposed to fluctuating around 280. 

[00:26:45] Stephen Calabria: Last question. If a patient is struggling with obesity, what should they do? 

[00:26:50] Dr. Subhash Kini: The first step is to acknowledge that they have a weight problem. Until one person acknowledges this, they will never think of it as a problem and will continue to do all the things that they've been doing. 

[00:27:09] And unfortunately, this leads to a very slow weight or much faster weight regain for rest of their lives. The moment they acknowledge that they have a weight problem, they themselves will find solutions to this. 

[00:27:22] And this includes diet and exercise on their own, going to a doctor and a nutritionist to help with this, incorporating medications. And if none of these work, seeking out a surgeon to undergo bariatric surgery.

[00:27:40] Stephen Calabria: Well, sir, that was it for my questions. Was there anything else you wanted to say?

[00:27:44] Dr. Subhash Kini: This is very important. Clearly, being overweight is a very large problem in the United States and rest of the world. I wish more people would look towards losing weight on their own with medications or seek surgical help if the other modalities don't work. 

[00:28:04] Stephen Calabria: Dr. Subhash Kini, thank you so much for your time, sir.

[00:28:08] Dr. Subhash Kini: Thank you.

[00:28:10] Stephen Calabria: Thanks again to Dr. Subhash Kini for his time and expertise. That's all for this episode of Road to Resilience. If you enjoyed it, please rate, review, and subscribe to our podcast on your favorite podcast platform. 

[00:28:21] Want to submit feedback or an idea for a future episode? Email us at podcasts at mountsinai. org. 

[00:28:28] Road to Resilience is a production of the Mount Sinai Health System. It's produced by me, Stephen Calabria, and our executive producer, Lucia Lee. From all of us here at Mount Sinai, thanks for listening, and we'll catch you next time.