With obesity affecting more than a third of U.S. adults – and disproportionately impacting communities of color – PCPs need to identify patients and offer practical therapies. Weight management specialist Diana Thiara, MD, presents an update on obesity care, with guidance on using screening tools, having sensitive discussions, and selecting treatments – from dietary modifications to surgery. Includes a helpful medication chart, with contraindications and side effects.
Hi everyone. I'm diana. And today I will be talking to you about office assessment and treatment of adult obesity. So, in addition to primary care at UCSF, I'm also the medical director of our weight management clinic. And I look forward to talking to you all today. Just a quick outline will briefly touch upon epidemiology of obesity. We'll go through diagnosis and we'll spend the bulk of today's talk discussing treatment options, focusing mostly on lifestyle change interventions, but also going through medications for weight loss. So, in terms of epidemiology, more than one third of us, adult people have obesity with the highest rate of obesity being between Uh those who are aged 40-59. As you can see on this map, um the obesity epidemic disproportionately affects certain parts of the country, California is somewhat scared when you look at overall demographics, but when you look at more race specific maps like this one, we see that minority groups are disproportionately affected by obesity with non latin. It's black, adults Having obesity rates at almost 50% in Latin. X patients having obesity rates at about 43%. The other thing to note is that we'll talk about this a little bit later. Uh some of these epidemiology slides are not super accurate because obesity cutoffs or asian and asian american patients are actually lower. However, these epidemiology maps don't take that into account. So places like California may actually be under representing there obesity metrics. So, in terms of diagnosing obesity will go through the three main ways to diagnose obesity. BME waist circumference and percent body fat. So BME is the main thing that clinicians used to diagnose diagnose obesity and we should remember that BME correlates with metabolic risk for most people and at the population level it's actually quite accurate. However, we do see limitations in B. M. I. Predicting body composition with for people who have extremes of muscle. So for athletes, B. M. I often overestimates cardio metabolic risk. And for older sarka Penick patients, BME can oftentimes underestimate risk. So it's super important to remember that again. This is a population level metric. So it's a really good screening tool. But like with all screening tools, we definitely over identify people. So you have to look at the picture more broadly than just being my alone. But in a busy clinical world, this is the fastest and easiest way to screen patients for obesity. So in terms of being my cutoffs, normal Bmi ranges 18-24.9 overweight is 25 to 29.9. And then obesity is considered a B. M. I. Of 30 or greater. And then we separate uh we segment B. M. I. And obesity range based on three classes Class one, Class two and class three. It's really important to note that we do not use terms like morbid obesity anymore. Those are very stigmatizing to patients. So instead use these class cutoffs for obesity categorization rather than saying things like severely obese or morbidly obese. In addition to BME limitations around extremes of muscle mass, there also raised specific limitations. So the BMI was developed for white men and that's not really our entire patient population. So there's a specific BMI cut offs for our asian and asian american patients. Because we know that at lower BMI s asian and asian american patients have higher metabolic risk. This is very important with our patient population in California and you should remember that this is pan asia. So this does also include the sub the indian subcontinent. So for our Asian and Asian American patients, a b. m. i of 27 or greater is considered obese And overweight is 23-26.9, so slightly lower than the other bme cutoffs that we normally use and this won't always screen positive. If you're not actually looking for this metric, your EMR system won't necessarily flag this as being in the obese category, but you should just try and commit this one to memory. Another way you can diagnose diagnose obesity is through waist circumference. So waist circumference is really helpful for individuals with the BIM less than 35. However, if someone's BMI is over 35 waist circumference does not correlate with metabolic risk as well as BME does. So this is a good tool for those patients who are in that overweight to Class one obesity range where the where you want to further risk stratify. So maybe somebody doesn't look like they're carrying excess body weight in their trunk region, which is where you know that more visceral fat, the dangerous fat can be. This is where we can use something like waist circumference to further characterize somebody's cardio metabolic risk. So the american Health Association classifies obesity using waist circumference for and has different cutoffs for men and women. So for men with the waist circumference of greater than 40, it's considered obesity. And for women with a waist circumference over 35, it's considered obesity. The main limitation to using waist circumference is that there is a lot of uh, there's a lot of differences between the person who's taking the measurement. So you want to make sure you train your staff to do this correctly and that everybody's doing it consistently in the same place. You don't want the measuring tape to be too tight pulling at the skin and you don't want it to be too loose where it's hanging off of the skin. And you want to make sure you're doing it right at the level of the top of the hips, basically where the iliac crest falls. The third way to diagnose obesity is by percent body fat. This can be a reasonable measure for patients with either an increase or decrease in muscle mass where we don't think BME would be accurate. You can do a texas scan in order to get this information that's the probably the cheapest and most accurate way to do it. It still isn't that cheap and it isn't super easy to screen patients using a texas scan for body for percent body fat. But for patients who are really interested in knowing what their percent body fat is, There are places around San Francisco that do it for around $60-70. Now, moving on to management in primary care according to the U. S. P. S. T. F. Which really drives all of our screening guidelines. They recommend that every patient is screened for obesity annually and if someone screens positive for obesity then they give a grade B recommendation to an intensive multi component behavioral intervention. And it's important to note that what's defined as an intensive multi component behavioral intervention is providing 12-26 sessions per year. Talking about nutrition and lifestyle. So that's a lot. But it can be uh an interdisciplinary team of providers. So that can be a team of physicians, therapists and dietitians providing those 12-26 sessions per year. So once you have a patient who screen positive for obesity, you want to get labs to assess for comorbidities associated with obesity. So you want to screen for something like prediabetes or diabetes with a hemoglobin a one C and remember for our asian and asian american patients fasting blood glucose is a more accurate measure for glucose intolerance. So for an asian or asian american patient who screen positive for obesity, you want to also get a fasting blood glucose and then just generally for everybody else you want to get a lipid panel. TSH LFTs as well as vitamin D. Individuals with obesity are often times vitamin D deficient. The other big important thing in primary care is to understand weight bias. Uh The obesity action coalition does a lot of work in the space to help providers understand their own bias and work to improve patient care. But just to start, what is weight bias to weight bias is defined as negative stereotypes directed towards individuals affected by excess weight or obesity, which often leads to prejudice and discrimination. And this very unfortunately leads to decreased utilization of health care services. So just one brief study that I found looking at actually a large cohort of women, 2400 women, 69% reported that their doctors were a source of weight bias and over half reported being stigmatized by their doctor on multiple occasions. Another large study of MDS reported that MDS had a lower desire to help patients as their BME went up and they self identified as saying treating obesity is a waste of time and that they have less respect for their patients with obesity, which is really alarming to hear. Uh and and this sort of perspective and the feeling of stigmatization by patients is problematic. Not just for treating their obesity but patients with obesity because of these these uh this weight bias oftentimes do not have as high adherence with general health maintenance things. So they're not getting pap smears, mammograms, colon cancer screening, lung cancer training as regularly as lean individuals. So it's important for us to note that this bias actually impacts patients care holistically and we should really try to work on that. So what can we do focusing on patient centric care is really important. So there's really three key things from a sort of structural standpoint that you should try to do in your clinic space. So one thing is having some chairs that do not have arm rests in the waiting room or the chairs that are very large to accommodate all body types. Another important thing to do is have large exam tables as well as large gowns. That same study of the 2400 women, a large portion of women reported that their doctors only had gowns in size small and extra small and after going into a clinic like that, they never returned. And then another super important thing is to have scales in private areas. Uh we sometimes have trouble trouble with that, but you don't want patients to be weighed in front of other people. So if you can have a scale either in a back corner of the clinic or ideally in each clinic room, that is that is best and you want to have scales that can go up to at least £500 patient centric language is another very important thing to reduce weight bias. And the key thing for us to do with our patients is to ask permission to discuss. Wait. So you have a patient who screen positive for obesity and now what? So you ask, can we talk about your weight today? If that feels too intrusive or awkward, you can be even more vague. So what I say to patients who I'm first meeting, I would say I counsel all my patients on nutrition and lifestyle. Is that something we can talk about today? If a patient says no, that's a hard stop. You don't try to understand why or further explore that. You just respect what their wishes are and leave it alone at that visit. It's still important to address at subsequent visits in a similar manner, but you have to respect somebody's choice to not want to talk about their weight or their nutrition and lifestyle. Other important patient centric language things are by saying individual with obesity rather than obese individual. And using terminology such as High BMI or saying something like excess body weight puts you at an increased risk for dot dot dot rather than saying some other sort of stigmatizing and problematic phrases. Um, in the arab open notes. It's also important in your documentation to use these similar phrases because patients do read our notes and we don't want them to feel hurt by our language. So moving on to treatment, this is the basic treatment pyramid for obesity. It's uh very important to note that the bottom of the pyramid which is lifestyle modification is the key part of anything that we do up further on the pyramid. So for every patient with obesity who are trying to treat we should really focus the beginning parts of our work together on lifestyle modification and with intensive lifestyle modification focusing on diet and exercise. Individuals average about 5-10% body weight loss. And then moving up the pyramid something like meal replacement that would need to be medically supervised. We see about 15% weight loss medications that will go through more in depth in a minute. You can see up to 15% weight loss as well with meds. And then obviously surgery has the highest weight loss and we can see about 20-40% of excess body weight loss with bariatric surgery. So in terms of lifestyle modification, diet is really the main uh main focus for initial weight loss. And the key takeaway is that macro nutrient composition does not predict weight loss. So over the past two decades there have been multiple R. C. T. S. And multiple meta analyses that compare different diets things like low fat versus low carb comparing name brand diets like keto versus Ornish versus med. And the results have all been the same that at but one year time mark there's really no difference in the various macro nutrient diets at six months. We do see that very low carb diets like the keto diet can have marginally more weight loss. But at the one year mark that kind of evens out. And we think that marginal difference at the six month time period is mostly due to water water weight. So here's just one of the big R. C. T. S. That was published in the new England Journal of Medicine in 2000 and nine comparing different macro nutrient diet. And it really just supports what I just said. So if you look at six months there is no difference. All the confidence intervals overlap and at every time period there's no difference between the various macro nutrients. Uh So whether it was six months or two years out macro nutrient composition does not impact weight loss. And this was a very large R. C. T. done with 800 patients. So this is a pretty pretty solid study from a scientific standpoint. So what do we recommend for diet creating a calorie deficit of about 500 calories per day for the average patient is all that really matters. Uh And the key takeaway is that a diet that a patient can adhere to the longest is the best diet for that patient. So this is where we get more into the that person specific medical care. You want to understand what works for that patient in the confines of their life and really progress with that. And so what should we recommend when we look at big research studies looking at successful weight loss and maintenance of weight loss. Self monitoring is very, very important part of that. And people can do self monitoring many different ways. So tracking with an app like my fitness pal or lose. It is probably one of the more popular things now, but doing something like a pen and paper food journal, an Excel spreadsheet. Those work and then for patients who are lower literacy taking photos of your meals is also a fine option for self monitoring. We also want to make sure we're eliminating liquid calories. That that's a really big thing, especially in the pediatric population. We don't see as much of that in san Francisco for adults. But it's definitely something you want to screen patients with obesity for. And then you want to advise on portion control, which we'll talk about in the next two slides. I just list intermittent fasting here. Not because I recommend it to a patient, but because it's one of the more hot diets that patients will ask about. The main thing to know about intermittent fasting is that when you compare intermittent fasting to any type of calorie deficit, there's no difference in weight loss. So there's nothing magical about intermittent fasting when it comes to weight loss. However, if you have a patient who eats a lot at night. Uh They are just really struggled to set that end of the day boundary with eating. This is sometimes helpful. So you set a boundary around what time patients are eating and that can be helpful but when it comes to weight loss there's really no there's no need to do intermittent fasting unless the patient wants to for their own personal reasons. So portion control is a really important part of dietary counseling for uh weight loss. And so a really a good resource that we can all use for our patients is the harvard healthy eating plate. This helps patients visualize what each of their meals should look like. And the website is quite interactive so you can click on each of these sections of the plate and patients can get examples. So they'll get examples of non starchy vegetables, lean proteins and whole grains. And it's also been translated into many different languages and there's also a lower literacy version that has a lot of graphics. So it's very helpful for patients. Another option is providing the plate method which was initially developed for patients who have diabetes but general is is pretty effectively across the board and it's very similar in that half the plate should be vegetables and then the other half of the plate can be divided into lean proteins and whole grains. Teaching patients about what portions look like is another big part of lifestyle modification and counseling. And so in the ideal world patients are measuring what they're eating either with measuring cups or sort of the most intense version would be with a food scale but that's not realistic for most patients. So this graphic from the C. D. C. Is also very helpful and it shows patients based on the size of their hand what a serving size looks like. So one serving of protein should be about the size of your palm or deck of cards and then something that's reported in ounces. Mostly cheese is the big one should be about the size of your thumb or two dice. That's approximately one ounce. The other thing that I use is the one cup or one medium fruit is the size of your fist. So when patients are having grains like rice or pasta or whatnot, you can tell them that the size of their fist is about the same as a cup. I personally don't think the tablespoon or teaspoon graphics are that helpful, patients should really just be measuring those out for things like oil, nut, butter, us, things like that. And then the same for the cupped hand, The cupped hand reference. I don't think that's that useful for patients. So what I encourage you to do is tell patients to get out there measuring cups and actually learn to see what portions look like. But if they can't do it or they're eating out then to use this this hand graphic to help them through that process. The next part of lifestyle modification is exercise. The main takeaway here is that exercise has minimal impact on initial weight loss. It's about 1-2 kg, but it's super, super important for maintenance of weight loss and it's also very important for metabolic health. So exercise is great and it's a key part of lifestyle modification. But at the beginning of the weight loss process where we're really teaching patients a lot about new skills around nutrition. You don't want to overwhelm a patient by setting up too much with exercise and nutrition. So you kind of pick what the patient prefers to discuss more as the first line option. And we try to nudge them towards focusing on nutrition first for some people, activity is super motivating. So we also still encourage that. It's important for patients to know that it's not going to have a huge impact on weight loss. Uh and the the guidelines for exercise are 150- 300 minutes a week of moderate intensity activity, or 75, minutes of vigorous activity per week. Plus, strength training twice a week. So, modern intensity activity is your active, your heart rate's a little up, you can hold a conversation, you're a little bit sweaty, vigorous activity is, you know, you're super, your heart rate's up, you're sweating a lot, you can't really hold a conversation only able to speak one or two words at a time. So that's important to note. And then the strength training piece was added about two years ago. So it is really key for patients to be doing some type of muscle muscle exercises. So the next part of the treatment pyramid that will discuss our medications used for weight loss, medications for weight loss that are FDA approved are only FDA approved for individuals with a BMI greater than or equal to 30 or if you have a BMI greater than or equal to 27 with a co morbidity associated with obesity. So that's things like sleep apnea, diabetes, hypertension, Hyperloop anemia, L. A. Those are all comorbidities that would be included. And what you can expect for weight loss is 3-15% of initial body weight loss for someone who is using medications. So, just briefly to understand medications, we need to understand the biology of obesity. I'm not going to go through this in depth, but it's just key to remember the energy homeostasis is regulated at the level of the hypothalamus and it's a really complex set of feedback loops that involve peripheral hormones as well as hormones from the brain. And that is where most of our medications work. So most medications work at the level of the hypothalamus, with some also working at the level of the GI system. But this is this is why our meds for weight loss work. But then the big caveat is that we eat for reasons other than energy homeostasis. Uh, and that's why medications for weight loss don't really work for everybody. So, before we get into the different medications, I think these takeaways are really important to know. So one thing is to stop or change any weight promoting medications if you can. That's really, really, really important. And then the other main takeaway is that intensive lifestyle changes, key for weight loss and weight loss medications are an adjunctive tool for select patients. So you should not be using medications for weight loss without somebody also being in an intensive lifestyle change program. We'll talk about it more in the next slides. But every FDA approved medication uh in the in the studies, the patients who were receiving medications were also on a 500 calorie deficit per day diet. So that's important to know that we? Re create that when we're actually prescribing these medications to patients. Another big takeaway is that medications for weight loss do not have reduction in morbidity and mortality related to cardiovascular disease or malignancy. They may reduce risk of diabetes. However, that reduction in risk is no more so than lifestyle change programs. Most notably something like the diabetes prevention program, medications may have a marginal improvement in quality of life though. So that is an important thing for us to remember medications have adverse side effects, whereas most lifestyle change programs do not. So that's another thing to remember. And if you do start a patient on a medication for weight loss, you should evaluate weight loss at 12 weeks after getting to the maximum effective dose. If somebody has not lost at least 3% of their body weight, then you need to stop the medication because it is not it is considered ineffective. Here's just an overview uh that if you wanted to take a screenshot of something, this would be a great medication overview. I'll go through each of these one at a time. But just so you just for a preview we'll go through the GLP one receptor agonist will go through QC. Mia contrary and then we'll briefly touch upon orlistat. So the two GLP one receptor agonists are long Raglan tide brand name six agenda and cemig Lutai brand name Logo V. Only. The brand names are FDA FDA approved for weight loss. So that's why include them. So you can only prescribe six. Agenda And logo V. If it's just for weight loss. If you can somehow get insurance to cover it for something like diabetes, obviously you can prescribe the generics but for weight loss alone right now it's only six and a and what gov. So in terms of mechanism of action, it really works peripherally and centrally to help with weight loss. So the main thing peripherally is to decrease gastric emptying at the level of the stomach to keep people full for longer and then centrally. The medication promotes society via the palm sea cart neurons and then separately as we all know from diabetes, It increases insulin secretion via the pancreas and improves insulin sensitivity via the liver. So all of that goes hand in hand to help promote weight loss. Yeah, so in terms of side effects, everybody is going to have nausea when they start the medication. Some people will also have vomiting. I I honestly see that more with my patients who are diabetic and who are not really adhering to healthy lifestyle. If people are eating heavier fattier foods, they oftentimes experience MSs. Whereas my patients and weight management clinic who are focusing on lifestyle change oftentimes just have the nausea. We also see dizziness, diarrhea. Some people have constipation, headache and fatigue. Those are the common ones. They usually go away. So the way we prescribe both of these medications as you start at a very low dose and you increase slowly over time. And so you want the side effects to be gone before you up, titrate to the next dose. And most people don't have side effects after one or two weeks. One concerning side effect to know about is pancreatitis, it is rare, but it is possible. So if somebody, so you need to counsel patient before starting this medication that if they have severe abdominal pain with eating, they need to stop and get labs done right away, absolute contraindications for these medications are a personal or family history of medullary thyroid cancer uh history of pancreatitis is not a contra indication. But it's just important to be extra vigilant in patients who have that history. And then in terms of the study around the studies around these meds. So uh you're ugly tide or the six agenda has had five studies And it shows about 5-10% body weight loss at around a year with 6% body weight loss at three years. So there are long term outcome data that they're calling. Long term maintenance of weight loss is three years and that weight loss is at about 6%. And like I said before, all of the the studies included lifestyle change. We'll go V came out very recently. The beginning of this year. There's only one study to date and it is only a short term study. So one year of weight loss, there's no long term weight loss data, but it was pretty impressive at nearly 15% body weight loss. And again, this study included lifestyle change. So I would say the limitation to Agovv is one that it's probably not on most insurance formularies yet. Insurance companies have told me we can expect either December 2021 or January 2022 to see it on the formulary for weight loss. But the downside is there's no uh there's no long term data to see how people are able to maintain weight loss with this medication. Another thing some of you may be noticing is these doses for both this agenda and the logo v are much higher than what we use for our diabetic patients. And so the side effects are a little bit more significant than what we see. Normally. Another great medication option is casa mia. Uh And this is a combination of phentermine and two pyramid. Both have pretty complex mechanisms of action. I'm not really going to go through them too much but they do both work centrally to promote satiety and infantrymen is also a stimulate stimulant which can reduce appetite. The side effects for this medication include constipation, dizziness, insomnia paris. These asia's dyskinesia not as much as if you are on the effective dose for venture mean by itself. But some of these side effects still occur, absolute contraindications or hyperthyroidism, glaucoma and use of an M. A. L. I. In the last 14 days. Uh This has been pretty well studied for studies. One included life in one study for the long term weight loss. They all included lifestyle change. And you can see about 9 to 14% body weight loss at one year and then about 10% body weight loss at the two year mark. Which is what they're calling maintenance phase of weight loss. And then the other medication we use is contrary, which is a combination of the appropriate and they'll check sound so be appropriate, increases that reward sensation associated with eating. There are FmRI studies showing that individuals with obesity do not. They don't have as much dopamine release when they're shown food queues as lean individuals so the thought is the appropriate increases that reward experience. And patients with obesity feel the need to eat less. They feel less drawn to carbs and drawn to sugar. And then we add on naltrexone with this naltrexone, as many of, you know, as an opioid antagonist. It works centrally for opiate addiction and alcohol use disorder, but it also works to promote satiety at the same mu receptors work to promote satiety. The main side effects for this. Uh They're pretty similar to the magnetite some level of nausea. Most patients don't have it that severely constipation, diarrhea can happen. And then a lot just like the normal side effects for the appropriate. We do see some insomnia and we can see headache, dizziness, and dry mouth. Uh You should be think be thoughtful before you prescribe this with somebody who has anxiety. It's not a contra indication, but sometimes the appropriate and can worsen anxiety. And if someone has insomnia can worsen that. So you want to be thoughtful about patients who have those comorbidities before starting this medication, absolute contraindications are uncontrolled hypertension and then just like the contraindications would be programmed. So not not appropriate for people seizure disorder restrictive eating disorders and then somebody and alcohol withdrawal or opiate abuse, you don't want to use this if somebody had a recent surgery and he's using opiates for pain control. You also would not want to use this because the medications wouldn't work In terms of results. We see 8-11% body weight loss at 56 weeks. And then when we see people who And that that's for all comers. Sorry, that's for people who completed the study. If we were to look at all comers, that weight loss is actually lost at 5-8%. So you have to suspect it might be closer to that 8% because some patients aren't going to be able to continue the medication because of side effects. And then orlistat it's a light pace inhibitor. The side effects are really, really tough. Uh phlebitis with discharge and fecal incontinence to the point where patients are wearing diapers. So I I almost never prescribe this. It's only when I use it for when the insurance as we have to before we can try something else. But for some patients who have uh who just want to something when they're going out to eat or having a high fatty meal, you can use this as an option. But it's really not that great of a medication and it doesn't really have that significant of body weight loss. So it's not something we use that much in terms of medications that promote weight gain will go through this pretty quickly. It's important to know the time course. So a lot of medications are listed as promoting weight gain, but you need to understand if there actually was weight gain when the medication was started. We honestly don't have a choice with a lot of meds. But the things that we do have choice on is when we're starting patients on diabetes medications and when we're starting medications for things like depression and anxiety. So if you're starting a Patient who has diabetes on meds, you want to focus on metformin first line and then if you can get them on a GLP one agonist, that would be the best second line option. You really want to avoid things like insulin. Obviously sometimes we don't have a choice. You really shouldn't be prescribing things like blip aside anymore with all of these newer agents available antidepressants be appropriate. It's a great first line option. But again, some people have insomnia and worsening of anxiety so we can't use that for everybody. So the SSR ES and S and R. S. That are considered weight neutral are sertraline. Del oxytocin and flew oxytocin. Uh Murtaza peon is definitely wait promoting. So you want to avoid that as much as you can. And paroxetine also is weight promoting in terms of anti seizure and anti migraine meds oftentimes these are started by specialists. So if you see someone who's on gap of Pentonville provoke acid carBAMazepine, you want to reach out to the specialist to understand why that was started. And not something like two pyramid or remote. Try gene to pyramid is definitely wait negative and the other two are weight neutral. So if you can get a patient there neurologists to be comfortable switching, that would be great. But obviously seizure control trump's the weight loss effects. Anti psychotics are tough psychiatrists know which ones are weight neutral in which our weight promoting and oftentimes patients can't come off of there certain meds and that's why they're on them. But it's still important to make sure their psychiatrist has thought about it at some point. And then the last part of the treatment. Pyramid is bariatric surgery. And I think someone had put this as a question. So when can you refer someone to bariatric surgery? So insurances cover bariatric surgery if you have a Bmi greater than or equal to 40 Or if you have a B. A. My greater than or equal to 35 with a co morbidity. And again, it's the same core member comorbidities I mentioned last time. So things like diabetes, hypertension, Hyperloop academia away. And then other things I didn't mention. So, something like snaffled would definitely count. Uh and and some of the reproductive cancers you could probably get insurance is to cover as well. Most insurances require the primary care provider or whoever referred to bariatric surgery to write a letter saying that the patient has been involved in six months of lifestyle change before they'll cover it. So it's again important to remember that the base of this pyramid is lifestyle modification for any part of the treatment period, Even treatment, even something like surgery. And we do know that patients who lose weight before surgery have better weight loss in the six months after surgery. And they have better maintenance of weight loss at the five year mark. Which is what surgeons look at for their long term weight loss data in terms of procedures. The two most common ones are ruined. Why? And gastrectomy. We don't really see many people doing the band anymore because the side effects are not well, first of all the weight loss isn't that great at five years and then second of all those can be a lot of adverse effects. There's a lot of movement of the band or erosion of the band and a lot of people have reversal of that procedure. So that's not really something to counsel patients on very much anymore. And then the B. P. D. D. S. Is very surgically complex procedure that has the highest rate of weight loss but it also has the highest rate of complications. So not many surgeons do that. So if a patient asks about surgery, you can just tell them the sleeve and ruin why are the two most common and just put in a referral to the bariatric team. And they can explain more. It's good to get patients in early. Um Most bariatric programs have intro meeting. So they have information sessions. It's just an information sharing environment. It's not like you're committing to surgery type of thing. But that way patients can start thinking about it on the earlier side and start working on some of the lifestyle change pieces before before going down that path.