Chapters Transcript Video Treating Cardiovascular Disease Through Weight Loss Dr Anjali Gresens discusses weight loss and metabolic wellness in relation to cardiovascular health. Thank you for the invitation. So we're gonna spend some time this morning talking about treating cardiovascular disease through weight loss, um, or the fastest way to fix the heart is through the stomach, um, hopefully this will be some new information for you all, um. You know, go here. Here we go, uh, first of all, I don't have any disclosures. um, Christina Cradeville is our bariatrician over at the weight loss Center, and she helped me out with a lot of the medication slides, so I wanna thank her. But my objectives for today, uh, we're gonna define the disease of obesity and the population, especially in relation to cardiovascular health. We'll introduce some of the medications that are now revolutionizing the field of obesity. We'll talk about metabolic and bariatric surgical options, and then we'll spend some time answering questions. So this stuff is everywhere, uh, people all over social media, the news, they're talking about obesity treatment, and in particular these GLP one medications. Um, I don't know if any of you watched the Oprah special a year or so ago about shame, blame, and the weight loss revolution, um, but it's prompting many of our patients to come in and ask about anti-obesity meds. We define obesity as a chronic, progressive, relapsing and treatable, multifactorial neurobehavioral disease where an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces resulting in adverse metabolic, biomechanical, and psychosocial health consequences. That's a lot of words, um, at the end of the day, we're reframing the discussion about obesity being a disease, and it's not just eat less and move more. And now that we're treating it as a disease, we're seeing medications and more treatment options. So when we diagnose obesity, there are a couple of ways to do that. BMI is the easiest, body mass index, ratio of your height to your weight. Why is this important? Because this is the way that we can code for it and diagnose it in our notes. But coming of more importance is also waist circumference, um, it is shown to be a predictor of cardio metabolic risk, and then you can also look at body fat percentage or visceral adipose tissue. So in order to quantify this stuff, um, BMI is the easiest, you know, a normal BMI is about 18 to 25. We start getting into pre-obesity around 25. And then class one obesity starts at 30 to 35, and we go up every 5. Unfortunately, we don't have a good classification for those BMI's of 50, 60, and 70. You know, this is not perfect, um, it doesn't stratify men versus women, um, different races or individuals, but it's kind of the best and easiest that we have. Waist circumference, like I said, is becoming more talked about, um, basically, these are kind of the cutoffs, so, you know, Caucasian males with a waist circumference higher than 40 show increased risk. Um, this is just showing how to measure that. It's not as practical, you know, most of us don't have tape measures in our office, and we don't necessarily trust the patients to take that measurement themselves. I'm a surgeon, I like these maps, um, but this is showing the prevalence of obesity, uh, it's up to date, it's 2023. You can see most of these states are orange and red, which shows that 30% or more of the population struggles with a BMI of over 30. When we look at age over 20 with obesity, it's about 42%. And then when you include pre-obesity and obesity, it's almost 74%, and these numbers were pre-pandemic. So before COVID, 3 out of 4 people in the United States were eligible for obesity interventions. So very few people that don't meet criteria. 23 states have more than 1 in 3 adults living with obesity, and Virginia is one of them. So this is looking at our data, you know, Centerra Medical Group, here's our South side and here's our peninsula, um, when we're looking at BMI over 30 on the south side, like 111,000 patients and about 44% of who we're treating. Up on the peninsula, again, about 43% or 46,000 patients. 22% of our patients have BMIs over 35. And you all know that there's a chronic or a significant overlap between diabetes, hypertension, hyperlipidemia, cardiovascular disease, etc. It affects all parts of our body. Uh, the one that I like to point out is that people don't realize obesity increases our risk for several cancers, um, but this I'm sure you've seen before. When we focus in on cardiovascular health, you know, we know that cardiovascular disease is a leading cause of death. And this was jarring to me that obesity related cardiovascular disease deaths tripled between 99 and 2020. 42% of the population suffer, and that's up 10% in the past decade. Uh, we know that especially central obesity increases cardiovascular disease mortality. An excess adiposity increases carotid entema thickness, carotid atherosclerosis, and remodeling, arterial stiffness, fat deposition within and outside the pericardial sac. I'm gonna try really hard to not try to teach cardiology to cardiologists, um, so bear with me, um, but these are looking at your patients, so Sentera cardiology patients by BMI and about 44,000 patients fall into the category of having obesity, um, class 12 or 3. When we look at the impact, um, we know that it's an independent risk factor for ventricular tachy arrhythmias and sudden cardiac death. But these were some interesting statistics to me that 2 decades of obesity is an independent risk factor for CAD. And our 20 year prevalence of heart failure grows by 70%. And then just a 10 kg rise in body weight increases coronary artery disease by 12%. So that's every 25 pounds-ish, we go up by 12%. An increase of BMI by just one unit increases our ischemic stroke rate of 4%, hemorrhagic stroke rates of 6%, heart failure 5 to 7%, and new onset Afib by 4%. So you think about these patients with BMI's of 50, 60, 70, they are very high risk. This is actually an AHA scientific statement, um, and so, you know, why do you guys care about this also is you're doing procedures and patients with obesity have greater mortality, contrast-induced nephropathy, dialysis, vascular complications. When you start talking about surgical revascularization, again, higher short term and long-term mortality. Increased superficial wound infections, but this one was interesting to me that waist circumference in and of itself was associated with higher post-op afib, reintubation, renal failure, um, and longer ICU in hospital length of stays, and that was independent of BMI. So that's why we see this waist circumference starting to become important. So what do we do to mitigate these risks? Um, from a lifestyle standpoint, there was the lookahead trial that showed that participants who lost more than 10% of their body weight had significant reductions in cardiovascular events. We also saw that exercise reduces visceral adipose tissue, independent of weight loss and does act as a risk reducer. Medications. These GOP ones reduce major adverse cardiac events and cardiovascular death. Um, the GLP-1s and SGLT2 inhibitors, uh, reduce hospitalization for heart failure and cardiovascular death. And then we know that bariatric surgery also decreases cardiovascular death, improves left ventricular function, myocardial mechanics, and heart failure, and has been shown to reduce hospitalizations. So that's the foundation, um, so talking management, you know, we have to look at it as a pyramid. So the foundation of the pyramid is lifestyle changes, and honestly, typically people only get between 2 and 5% total body weight loss, just by trying to eat better and exercise. When we add in some of these prescriptive diets, um, we'll get maybe up to a 10% total body weight loss. Uh, pharmacotherapy, so that's anywhere from phentermine to simaglotide, uh, 5 to 20%. And then surgery is at the top, uh, with 20 to 40% total body weight loss. Now, traditionally, you know, you see this treatment intensity over here, and it kind of looks like things stop at the top. But what we're seeing now in our practice is that patients are going up and down this pyramid that if they've had surgery and experienced weight regain or inadequate weight loss, then we go back to the foundations and can reintroduce medications, and it's a continuous cycle. So we have to talk about nutrition, um, you know, this is what Christie told me when she talks to a patient, you know, she's looking at their habits, behaviors, comorbid conditions, um, personal history of metabolic disease, and then also social, cultural influences, and access to resources. Most of us don't have that kind of time. Um, the basics that you can teach people is that regardless of the plan they go on, you need a caloric deficit to achieve weight reduction. We teach our patients a for protein 1st, 60 to 80 g a day over 3 meals. Increase your fiber And limit your sugars to less than 9 g per serving. Now what we do struggle with is a lot of our patients don't really understand what a protein is, um, and that takes some additional counseling. There are several medically recommended and evidence-based uh diet plans that can be supervised by a physician, you know, the Mediterranean diet, DASH diet, low fat, the Ornish. Um, intermittent fasting shows some benefit in cardiovascular disease and glycemic control while you're practicing the diet, but there don't seem to be lasting effects, and there's no necessarily increase in weight loss. And then these are more popular diets that don't have data or evidence behind them, um, but keto, low carb, anti-inflammatory, you know, a lot of these over here will overlap with some of these medically recommended diets. This one, I'm sure you're familiar with the DASH diet, um, dietary approaches to stop hypertension. Honestly, this looks a little confusing to me, um to try to keep track of all of it, um, but 6 portions of meat, fish and chicken is a lot for a day. But it has been shown to improve blood pressure and lower our risk of cardiovascular disease. I actually reached out to some of the dietitians that work with the AHF clinic, and one of the things they teach your patients is something called the plate method, which is actually what we use for our bariatric patients, and it's based on the diabetic diet recommended by the ADA. And so if you only have 3 minutes to talk to a patient about nutrition, this is a good way to start. Tell them to get a 9-inch plate, fill half of it with non-starchy vegetables, quarter of it with protein, and quarter of it with the carbohydrate, and then don't drink your calories. And if they can set this up, you know, they will end up following more of the guidelines. Um, it looks kind of complicated, but I'll tell you what, taco can follow the plate method, so it doesn't have to be hard. Like I said before though, diet, exercise, and behavior intervention alone result in about 4% or less of body weight loss at 12 months for the average person. So this is from the American College of Lifestyle Medicine. And basically it says that a comprehensive lifestyle approach prevents and treats other comorbidities, uh, like hypertension, high cholesterol, heart disease, diabetes, and arthritis. But lifestyle medicine must become the foundation of comprehensive treatment, with or without surgery and or medications as adjunctive therapies. So again, it's not just eat less, move more. So what do we do when diet's not enough? So there are several anti-obesity medications or AOMs that are considered to be on label and can be prescribed for obesity. You know, phentermine is the classic one, and diethylpropion's been around for a long time. Unfortunately, probably a lot of your patients don't qualify because their cardiac issues, um, but it is available. We have a couple of the GLP one RAs like Laraglotide and simaglotide that are able to be prescribed for weight loss. The GLP1 GIP trazepaide can be prescribed for weight loss. And then there's a naltrexone bupropion combination pill and Oralstat. But these are our weight loss, anti-obesity medications. There are a couple others for specific circumstances that is beyond the scope of this talk. But what we're seeing more is these medications being used off-label, you know, they're prescribed for something else, um, but we get the effect of weight loss. Now phentermine and diethylpropion should only be used for 3 months at a time, but we are seeing them used for longer, quote, off-label, uh, to achieve more weight loss. These GLP ones are prescribed to treat diabetes. With the side effect of weight loss. Uh, riceidide can also be used to treat diabetes and also achieve weight loss. And then you'll often see buproprion, naltrexone, topiramate and metformin used, um, mostly because they're more available. In an attempt to achieve some weight loss. So how do you know which one to pick? You have to know if they've tried them before, and if so, what happened? What's their biggest challenge, you know, are they bingers? Do they not eat all day? What's worked for them in the past? What comorbidities do they have? And this is the big one is what insurance do they have and who do they work for? This is way more than you need to know, um, but like I said, phentermine is cheap, turns off the food noise. Pyramate, also very affordable, and it's good for binge eating and people with migraines. Buproprion, also very affordable, good for people who have depression. Naltrexone, affordable and can help decrease alcohol use. And then this is the big one that everybody's talking about are the GLP ones um they can be used to treat diabetes, heart disease, liver disease, sleep apnea, but this is where we see the most robust weight loss. They work by slowing everything down, you know, food enters the small intestine and triggers GLP one, which tells the brain, I'm not hungry. It goes down to the gut and decreases gastric emptying and slows everything down, so patients are full longer. In the pancreas we're increasing insulin and decreasing glucagon, which then also feeds back. So there's a couple of them out here right now, um, some magnetide 2.4 is being looked at in patients with heart failure with preserved ejection fraction, um, and the FDA is looking for approve or looking to approve it sometime this year. Trezepatide has been FDA approved for the treatment of sleep apnea. Servotidide is in trials right now looking to treat um steatosis and fibrosis. Do not say this word, retratide, um, I think they're calling it Triple G, it's being looked at as an additional anti-obesity medication. And then this is the one that you guys care about is simaglotide 2.4, which has been approved by the FDA to reduce cardiovascular risk. And so right now, if you're looking to prescribe these not for weight loss, these are the two big indications, it's cardiovascular disease and sleep apnea. So if you're thinking about getting into the GLP one game, there's a couple of things you need to know, um, you have to be prepared to counsel on diet changes. Many of the insurance companies for their prior authorization require documentation of lifestyle changes and dietary counseling. That's where the plate method can come into play. Patients also have to be counseled that they're not going to eat as much, especially on days 1 and 2. And if they continue to eat like they're used to, they are not going to feel good. A lot of the intolerances that we see with these medications are because people aren't changing their diet. You know, people don't tolerate fatty foods, greasy foods, oily, sugary, rich foods on the GLP ones. And then like I said, sometimes you need actual um documentation of diet visits with dietitians, but every insurance is different. Things we need to keep an eye out for, uh, we need to monitor the GFR uh we can see a decreased GFR very commonly, you know, when patients aren't hungry, they also forget to drink and so dehydration can be very common, um, typically when we see this, we can. Increase their hydration and it will get better, um, that can be hard in the heart failure patients um and if you see that it's not improving with modifications in behavior, then they might have to come off the GLP one. We also need to keep track of the A1C um and counsel patients on hypoglycemia, you know, when they're not eating, we can see blood sugars drop. Patients need to know what to look out for and how to treat it. And I hate to say it, but these patients require a lot of communication. Some of it is because of shortages of the medications, and they're gonna want you to try to send it to different pharmacies, they're gonna have an issue getting it, they're gonna want a new prescription, and then you do have to titrate these medications and typically see patients every 1 to 2 months. So if you're thinking about trying to prescribe and dose these, typically, you increase the dose on a monthly titration. So for imagnotide, you start at 0.25 and you can work up to 2.4, takes about 5 months. Or ricepatide, you start at 2.5, and you can work your way up to 15/6 months. As long as patients feel OK and have minimal side effects, you can go on this monthly trajectory. However, if they have side effects, you know, they're having GI issues or something, you could stay on a dose for an extra month before increasing. And then some patients just don't respond, um, they typically should lose about 5% of their body weight over 3 months, and if you're not seeing that weight loss by 3 or 6 months, it might be time to switch to something else. So what are the side effects? I mean, surely, you all know people that have been on these medications. Um, the big two to talk about first is if they have a history of medullary thyroid cancer, um, they probably shouldn't be on one of these medications, and if they have a history of pancreatitis, they should not be on one of these medications. We touched on hypoglycemia a little bit. Um, most of the side effects are GI related. We can see gastroparesis, we see abdominal pain, nausea, cramping, um, constipation is a big one, but we can also see diarrhea. With rapid weight loss, we see an increase in gallstones and gallbladder disease. And then we can see kidney failure, AKI's um so that's why we need to keep track of that GFR. The other thing that's not on this list is when we do stop the medication, we tend to see rebound weight gain and so really we're treating these medications as being lifelong, um, so patients have to be prepared to think about that. I like this little graph, um, this shows some of the older anti-obesity medications and some of the newer ones, you know, as far as weight loss with diet and exercise, it's like 4% or less. With the traditional anti-obesity medications like phentermine and um naltrexone, you know, we can get 5 to 10%. Bariatric surgeries down here at almost 30. And that's it, the 1 year point. So magnetide was the first one to really show promising results, um, and we typically see about 15% total body weight loss. And then with trazepatide at 72 weeks, um, it's approaching 18 to 20%. So that's been a game changer for a lot of patients. Um, you know, this is similar to the last pyramid, but you can see kind of the same thing. As we add in bariatric surgical procedures, we do see increasing weight loss, and again, this is where our practice is starting to evolve into, is using medications as adjuncts to bariatric surgery, especially for our high BMI patients, we'll put them on a GLP one, get them to lose some weight, then we'll operate. And sometimes restart the medication afterwards, and we can approach almost 50% weight loss. So we have to talk about bariatric surgery, you know, I'm the surgeon, um, so a a sleeve that I did, I always blow it up and take a picture for them so they can see how big it was. I'm not in all of them. Um, but bariatric surgery has been around a long time. Uh, we know that it's the only approach that provides consistent and permanent weight loss for patients with class 3 obesity. This is probably what you guys are familiar with, are these guidelines from 1991, which are now ancient, um, but those said BMI of over 40 or BMI of over 35 with comorbidity. Those are now out of date. In 2022, our national organizations revamped the guidelines and now recommend that patients be considered for surgery with BMI's greater than or equal to 35, regardless of comorbidity. And then patients with BMI's greater than 30 with type 2 diabetes or metabolic syndrome, should qualify. They also state that if patients have failed to achieve durable weight loss with non-surgical means and have BMIs over 30, they should be considered. And then there are some special populations, you know, a lower BMI in the Asian population, and appropriately selected adolescents, and we can go down to age 15, um, typically we've gone down to 16. So these are the current bariatric procedures, um, I'll tell you that the lap band was really popular 20 years ago, and now we're taking them all out, um, they don't work, people are having complications and not losing weight. I've been doing bariatric surgery just since 2014 and I've never put one in. I'm good at taking him out. Typically, the sleeve and the bypass are the two operations that we offer. Um, the sleeve is the most common operation, and it's about 75% of our practice. It's not a thing that we put in, but it means we're taking out 80 or 85% of the stomach, and making the stomach into a skinny banana. Um, we've actually done a handful of LVAD patients and done sleeves on them, uh, as bridge to heart transplant, um, so this is very safe even in a high risk population. The bypass has been around since 1967, you know, it's considered the gold standard, um, there's no taking anything out, but we're rearranging things, and we create a small pouch. Bypass the rest of the stomach and the duodenum and then bring up a ru limb to connect here. So there is a component of malabsorption, um, but not as bad as I used to think. And you know, this is still a very popular operation. I put these two on here more just as an FYI because they're being talked about more in our world, um, down at the bottom, the bilial pancreatic diversion and duodenal switch, it's been around for decades, uh, but it was always like 0.5% of bariatric procedures. It's kind of a a combination of a sleeve and a super mega gastric bypass, and all of the absorption happens down at this common channel, which was traditionally 100 to 200 centimeters. So lots of malabsorption, I've seen stinky farts and diarrhea, um, but it does work well for patients, but they have to be very compliant, and they have to be able to afford the nutritious food and vitamins. This CAI procedure though is becoming more and more common. It's kind of the same thing as this, but in a loop form instead of a ruin why. And so we may start to see more CAD patients out there, um, we'll probably get into this um procedure over the next 5 years, um, so stay tuned. Uh, we know that we can get about 20 to 40% total body weight loss in these patients. It's cost effective over time. We have better long-term glycemic control than with uh medical management of diabetes. There's a cardio protective effect. And then bariatric surgery has shown the lower all cause mortality by 40%. For heart-related mortality, we see a decrease of 40%. Cancer related by 60%. And diabetes related mortality by 92%. Those are big numbers. And then we do see that the metabolic effects, especially on diabetes, are independent of weight loss. So even if a patient doesn't lose a lot of weight after a gastric bypass, we still see better glycemic control and cardio protective effects. You know, I like this. I'm sure you guys have seen this before, um, but after surgery, all of these things improve, you know, we have an 83% resolution rate for type 2 diabetes. 82% risk reduction in cardiovascular disease, hypertension, there's like a 50 to 90% chance that we can resolve it. We improve sleep apnea, fatty liver disease, joint disease, fertility. Um, there's an 89% reduction in 5-year mortality. And 95% of patients cite an improved quality of life. So then we had to look at some of the cardiovascular things, um, so this was an interesting article that randomized 100 patients, uh, to either bariatric surgery or medical management, you know, 76% were female, mid-40s, BMI around 37%, and they had to be on at least 2 anti-hypertensive medications at maximum doses. After 5 years in the surgical group, 80% of patients reduced at least 30% of their medications, compared to only 13.7% of the medical therapy group. 47% in the surgical group reached remission for their hypertension, versus only 2.4% in the medical group. And then we do see a reduction in BMI with the surgery group, whereas down here, it really didn't change more than 0.5. And so when you have these hypertensive patients with obesity, I mean, think about bariatric surgery because it's an effective and durable strategy to treat hypertension. This was also an interesting article that I found, um, it shows a decreased risk of ED visits and hospitalizations due to heart failure. And they looked at almost 900 patients who underwent bariatric surgery. Pre-surgery, patients have like an 11.5% rate of ED visits or hospitalizations for heart failure. Post-surgery in the first year, that dropped to 3.7% for any heart failure related visits. And it dropped even further in the 2nd year. You know, over here you see the overall with surgery, you know, the band is not as good uh but hospitalizations, ED visits, and related visits all dropped significantly. Now I like to think bariatric surgery is amazing and everybody should have it, um, but it is more invasive, it's not without risk, it's not reversible. It can be expensive, you know, just in Virginia, a gastric bypass costs somebody about $27,000 if they don't have insurance coverage. It's also not magic, it requires long term lifestyle changes, and it's not a cure. This was an interesting comparison of the medications to surgery though. Um, when you look at gastric bypass, which is more expensive than a sleeve on, um, imagnotide. By 11 months, bariatric surgery is more cost effective. With some of these others, Manjaro and Ozempic, um, you see that at about 1516 months, so before a year and a half. Bariatric surgery is more cost effective. So something to think about. Uh, we know that bariatric surgery has better outcomes with weight loss, control of diabetes, reduction in major adverse cardiovascular events. Um, this article showed that if you're on a GLP1, you needed 20% weight loss to reduce your risk of cardiovascular events, um, and we saw that most patients with medication don't achieve that. They saw a reduction in cardiovascular events with only 10% weight loss with surgery. And then unfortunately, with the GLP ones, when you stop the medication, you tend to lose the benefits, whereas with surgery, they are more um durable. That being said, surgery does have more risks and complications, despite being very safe, so it's not for everybody, you know, usually when you see complications and side effects from the medications, you stop the medication and the complications and side effects go away. It doesn't necessarily happen with surgery. Um, we also know that with surgery, we can often see transfer addiction, um, and people will turn to alcohol or other substances. There's a huge mental health component and an increase in fractures. Then we have to talk about insurance requirements, which is again more than you need to know. But at the base level, federal insurances, Tricare and Medicaid tend to all cover the anti-obesity medications and surgery. But, you know, they have their own hoops that people have to jump through, you know, you have to do 3 months of diet visits, you have to do 6. We have to try this medicine before we can try that medicine, um. It's complicated. When we look at some of the commercial insurances, um, it makes you want your head to explode, um, it's so much to think about, uh, Centera Health Plan employees do have coverage for both medications and surgery, um, but you have to be in a program. These commercial insurances down here also do cover both. Medicare will not cover anti-obesity medications, but they will cover surgery. They will cover Wagovi for cardiovascular risk reduction though. So this is important probably for a lot of your patients. The cities of Portsmouth, Norfolk, Virginia Beach don't cover anything. State of Virginia covers um both medication and surgery, but the Centerra Health plan, Partner and Tidewater covers neither. State of Virginia doesn't cover, excuse me, North Carolina doesn't cover either. And then Medicaid of North Carolina just started their coverage about 6 months ago. And so I'll tell you, it's a lot of work on the part of our MA's and our office staff to try to figure out what every patient's insurance will cover. Now there is a prior authorization team through Centera that you might be familiar with, um. If you're thinking about trying to prescribe some of these GLP ones for cardiovascular risk reduction, um, I will say that just the Sentra health plan one is about 3 pages long, um, there are some if then situations that you have to pay attention to, and then it only gives approval for about 12 months at a time. So if you're thinking about prescribing one of these, um, your MA can reach out to the prior off team to help you figure and navigate uh the requirements. But if you wanna try to support us or the primary cares to get coverage for the GLP ones to reduce cardiovascular risk, um, the patient needs to have a history of stroke, MI or peripheral vascular disease. And then we need to ensure the patient is on background guideline directed therapy. And then these are some of the things you can help us document, is we have to document counseling on lifestyle changes, which is both diet and exercise. You have to say what the patient's intolerance or contraindications are to other medications like statins and SGLT-2s. And then even if they're on statins or SGLT-2s, you have to document why those are not producing sufficient cardiac risk reduction and why you need uh someaglotide instead. And so, if you can think about those things when you're documenting their your note, that can sometimes help us get the medication covered, um, it sounds like for Medicare and some of these other insurance companies, the prescriptions do need to be through a cardiologist, um, but we can partner with you on the diet part. So if we can help, you know, we now have 3 offices. Uh, we have an office up at Carelex in Hampton, we have our Norfolk office, which is over by Centarily. And then we have an office in Suffolk at Ose. We offer obesity medicine and surgery at both of them. We have dietitians on site. We have a gym at our Norfolk office with an exercise specialist. We have an on-site retail store in Norfolk, which is not just for patients, so you're welcome to stop by. And then we have a partnership with a mental health team to help support our patients with emotional eating and binge eating. We have onsite support groups, and we offer in-person and virtual options. So I just wanna recap, you know, obesity is a multifactorial disease that's intimately involved in cardiovascular health. Treatment has to be multi-disciplinary and consists of lifestyle medications, medication, and surgery. And then these GLP ones have shown really promising results, um, but don't work for everyone. And then bariatric surgery has superior outcomes, but again it's not without risk. So with that, I'll say thank you, I'll stop and here's my information if I can help answer questions or provide patient care along with you guys, please let me know. Published March 5, 2025 Created by Related Presenters Anjali Gresens, MD Surgery, Surgery – Bariatric View full profile
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