Today on Healthcare Pittstop, I welcome Dr. Kevin Potter. Kevin and I work together in Arizona. Kevin specializes in obesity. He’s trained in general surgery but has focused his practice on obesity, and I thought he could talk to us today about obesity in America, some of the surgical options, and how we got to where we are. Kevin, welcome.
Dr. Kevin Potter: Thank you, Alan.
AP: So Kevin, you started your training in general surgery but then elected to kind of move over to looking at surgical options for obesity. How did that happen?
KP: Yeah, it’s an interesting story. I originally did my surgical training, general surgery, I did a fellowship in surgical oncology, specifically focusing on cancers of the liver and biliary tract and pancreas. And we kept finding more and more links between obesity and abdominal cancers. We were finding that patients who used to be cachectic and wasting with these diseases were no longer appearing that way; they were remaining obese despite having these terrible abdominal cancers. So it piqued my interest. I kind of stumbled into an obesity and bariatric surgery practice and I completely fell in love with it. It’s a rare opportunity in medicine to treat so many diseases for a potential cure in one operation. And it was the power of those single operations that drew my attention. It spoke against what I had learned in treating cancers of the pancreas where, at best, maybe 15% of the patients would see some sort of benefit. So it piqued my interest and that’s how I got into obesity.
AP: How does this surgery work? I know you take part of the stomach out, but I don’t think it’s just that you have a small stomach anymore.
KP: Yeah. Well, there’s two ways to achieve weight loss with surgery. One is by limiting the capacity to eat. So several different ways to limit how much your stomach will hold, whether it’s by surgically stapling and dividing the stomach into smaller parts, or by placing a medical device like a lap band onto the stomach. Those techniques provide restriction alone. And then the second way is by creating malabsorption, or shortening the functional length of the intestine so that despite what you eat, less of it gets absorbed. And it turns out that in combination, those two things produce the best weight loss results.
The question is always, “Well, how does it work?” In the end, it’s just about less calories. Inside of that less calories, there’s a whole host of physiologic games going on with the body when we limit the amount of calories you can take in. There’s a whole host of hormones that we’ve discovered that are involved in part of the stomach, the top of the stomach called the fundus, that we pretend like we understand, but I’m not so certain we understand it. But what’s clear is the most effective way of helping patients lose weight is by limiting how much they can eat.
AP: Interesting. And the average patient you’re taking care of—I want to be clear—is it someone who’s like, 50 pounds overweight? One hundred pounds overweight? What does that average person look like that you’re operating on?
KP: The average person is somewhere between 75 and 100 pounds overweight. And we usually do that by their body mass index (BMI). BMI is our best way of understanding your disease risk for your weight against your height. That’s a number that’s easy to calculate, just type in “BMI” in your Google search bar and you can put in your basic facts—your age and your height and your weight, and boom, you get a BMI. Whether or not you’re a candidate for surgery is really determined by your insurance, unfortunately. So those patients who have a BMI greater than 35 but less than 40 have to have some sort of comorbid condition that is considered by the NIH to be a major comorbid condition, like coronary artery disease, type 2 diabetes, severe gastroesophageal reflux disease, normal pressure hydrocephalus… These are all major issues of obesity that if your BMI is under 40 but greater than 35 would make you a candidate for surgery. And those patients who have a BMI of 40 or greater, just based on their BMI alone, are automatically a candidate for surgery.
AP: I work here at this major neuro institute and I’m waiting for the controlled study that compares back surgery to stomach surgery. I think you probably would do a better job than some of my back surgeons would. These patients have all sorts of problems, don’t they, because of their weight?
KP: They really do. You have to remember that you only get one set of joints, and the effect that gravity has on you is based on your body mass, so the higher your body mass is, the more strain placed on your joints. As you know, the spine is a complex organ, and when you load it in unnatural ways with abdominal obesity, that puts unnecessary or improper strain on those connections and can cause the spine to break down very quickly. It turns out that when you lose weight, we can stabilize or even improve the degenerative processes that are going on in all the joints. Losing weight should be the top priority for anybody who has either degenerative spine or degenerative joint disease.
AP: Interesting. Part of the reason I wanted to interview you was that I started doing some research and I found some articles saying that over the last 40 years, the average American seems to have gained 25 pounds, and though some of us think that it’s because we’re working with computers all the time, you mentioned that you don’t think that’s the case. Why do you think Americans have gained so much weight over the last few decades?
KP: Let’s face it, we are less active than we used to be as a people in general. But what we know about the contribution of activity to your overall body calorie balance and weight loss is that activity or exercise contributes only to about 15% or 20% of the work. It turns out that the remainder is just about how much you eat. And the reason that we all lean away from that and start focusing on food is because the food supply has changed so drastically in the United States. In fact, if you look at the products that we export, like fast food, if you compare the rural Chinese to the urban Chinese, the urban Chinese have a very similar diet to Americans, and they have all the same diseases we have. If you look at the rural Chinese, it’s actually quite the opposite. They don’t have any of the diseases that we have because their diets are completely different. And so, it helps us focus our attention on the food supply as well. And it turns out that we may have a public health crisis on our hands just based on the food that we eat alone.
AP: Do you think that the people who make our food have changed in the way that they make our food over the last few decades? Or are our habits just different than the way they were before? What do you think about that?
KP: I’m not so sure our habits have changed a lot. But what’s clear is that the food has changed. When you look around, some of the cheapest food that’s available for patients to buy is calorie-dense, it’s nutrient-poor, it’s cheap, and it stimulates a part of the brain that makes you want to have more of it. And this is a common theme that’s been played around in the United States with other products like tobacco. It used to be cheap, and they added things to make sure that people kept coming back for more. And some of the largest processed food suppliers in the country are former tobacco companies. And so, all of this together has led to, in my opinion, a change in what we are eating in this country, that’s making it very difficult for us to lose weight.
One of the first things that we do in our program is we ask patients to, number one, eliminate processed food. All processed foods have to go. Turns out the convenience is more dangerous than anything. It’s the foods that are easy to make, that are simple, that are very quick to do, those are the foods that turn out to be the most dangerous. In order to maintain something that resembles a tasty meal that can sit on the shelf for a decade or more and still be safe to eat, has to be preserved. The two most common preservatives used are salt and sugar. And you know as well as I do that if you put too much salt on something, it’s pretty terrible. So that typically gets balanced with sugar. So a lot of extra sugar is added to foods that normally wouldn’t be there. For instance, there’s more sugar in a cup of processed pasta sauce than there is in a Twinkie.
AP: Wow. You don’t usually think of that. I think you’re kind of alluding to this book you were mentioning that some of our food producers kind of use the similar things to tobacco. There was a book, Salt Sugar Fat: How the Food Giants Hooked Us, by Michael Moss, that came out a while ago, suggesting that the industry was using similar tactics from tobacco with the food supply.
KP: It’s a very interesting book. It’s kind of a dry read, but if you’re into the idea of informing yourself about your food supply, this is a must-read.
This book, Salt Sugar Fat, was a series of exposes written by a New York Times columnist, who wanted to dive into the processed food industry and how things are made. In fact, one of the foods that he says that, after his research, everyone should get away from are Lunchables, which is like everyone’s favorite food to send their children to school with, and it turns out that there isn’t a worse food on the planet you could feed your child. It’s full of salt. It’s full of sugar. It’s all fat. It has very little nutrient density. It’s essentially just calories. And when you eat this way, while it may satisfy your mouth, it does very little to satisfy your body. So even though you’ve just eaten, your body remains hungry.
These are ways that we produce “artificial appetite.” And this book is interesting because it dives into all the different ways that processed foods are made, the tactics used, and the terminology that they use, I mean, it blew my mind when I read it. And in our program for patients who are readers, it’s a must-read, because I think it’s more powerful than anything else you have to inform yourself when you’re trying to make dietary changes.
AP: Interesting. I’ve gone to the supermarket sometimes, and I know that sugar and salt are bad for me, but trying to buy a diet, if you will, in the American grocery store is super difficult, given how food is displayed and brought to you. Do you have suggestions for your patients, for parents who are trying to deal with their children? What do you suggest in terms of how we interact with the grocery store, if you will, to try to avoid this epidemic?
KP: It’s always a challenge because number one is cost. Everyone is at a pinch for how much it costs to feed your family. To eat healthy, unfortunately, is more expensive. So most of the foods that are available at a fair price, typically, are not good for you. So step one that I ask patients to do to start to change is to stay away from the center of the grocery store. If they stay to the edge of the grocery store, you typically stay away from the processed foods. Most of the butcher shops are in the back, the dairy case is in the back, the produce is on the end, the delis are on the end. These are places where the healthy, fresh food is. The center is where all the stuff that can sit on the shelf for the next 10 years and not go bad is, and those are the foods I ask patients to stay away from.
Foods that are readily prepared, like frozen foods, are typically probably more heavily preserved than any of them. There’s a process that happens, that’s initiated when you cook any protein, so any meat, fish, beef, pork, anything, and they try to suspend it in space by freezing it, but it turns out freezing it isn’t enough. So in order to hold that process, several chemicals have to be added to these meats in order to preserve them, to preserve taste, to preserve texture, and without them, frozen food would be impossible to sell. It would be unpalatable. These are the first foods that I ask people to stay away from. Stay away from the frozen foods section.
AP: So go to the margins of the grocery store, as opposed to the center.
KP: That’s right, the margins of the store, where the fresh fruits and vegetables are, where the produce is. I encourage people to get back into the bulk food bins, where you can purchase large volumes of whole grains, like whole grain rice or oatmeal. Quinoa is a good example of a healthy grain. And unfortunately, these are foods that are not convenient, they take 45 minutes to cook. It takes a real time commitment to prepare them. And this is where meal planning can be very helpful. If patients can commit to meal planning, say, on Sunday before the week starts, you can prepare several meals and have them in the refrigerator ready to go, create your own convenience, as opposed to relying on some processed food company to provide you with convenience. These are some little tricks and strategies you can do to help set yourself up for success.
AP: We, as Americans, I hate to say this, tend to be a little… We have a little fat racism, almost. We see a heavy person and we kind of tend to judge them. But I guess what I am hearing from you is that heavy folks—it’s not that they’re not exercising, it’s that they may not be able to afford the kinds of foods one needs to stay thin. Would you say that that’s true?
KP: I would definitely say that’s true. In fact, I’m glad you bring this up because I think this is an important thing. It’s sort of the last area in humanity where it’s okay to continue to shame people and to treat them differently for their weight. And it’s unfortunate, because a lot of these people have a disease process that is very difficult to control. Your body is uniquely suited to do two things: to concentrate calories and to concentrate sodium, and it’ll hang on to them at all costs, as you know. This is standard human physiology, and it turns out the more weight you gain, the harder it is to lose. If you have little financial means, and you have a tendency for high-calorie foods, those high-calorie foods tend to produce this desire or need to come back and eat more of them, and it starts to build a very vicious cycle.
One of the things I love about treating patients with obesity, is that this is a whole-patient disease. It isn’t just one thing; it isn’t just your genetics, it isn’t just your food supply, it isn’t just any mental issues like depression or prior history of abuse that can lead to obesity. Obesity is a whole-body disease. So it forces the opportunity to start treating the entire patient, which is something, I think as physicians, we all want to strive toward. But in the end, I think that if we can begin to see obese patients as human beings, as people who need help, if we can begin to see obesity as a disease that requires treatment, not shaming, then we can start to make a significant change. We can start to see the need for changes in public policy that can address the issues that surround the public health crisis, that can be something simple, like high-calorie sodas being available in large volumes. If we don’t address it from a public health standpoint, it’s going to be very difficult to get control of and manage.
AP: Interesting. As always, business interests tend to trump what’s right for us. Kevin, I want to thank you very much for the time today. I’ll include some information on you and your group, for those who have additional questions. But I appreciate this overview. Thank you so much.
KP: My pleasure, Alan. Thanks
Dr. Potter can be reached at