Weight Loss & Weight Management

Young african american women running in downtown Chicago

Achieve & Maintain Your Weight Loss Goals

The University of Chicago Medicine offers a full spectrum of services for weight management and obesity treatment. Our physicians and care teams work with patients to help them decide which approaches are best, taking into account many variables, including lifestyle, genetic makeup, other medical conditions and more. Our individualized care plans are designed to meet and maintain weight loss goals — ensuring each patient gets the most beneficial outcome.

Bariatric Surgery

The decision to have weight loss surgery is an important and often difficult one. We have been a leader in obesity treatment and bariatrics for nearly 20 years, and our team is the most experienced in the Chicago area.

Weight Loss (Bariatric) Surgery

Chicago Weight

This medical weight loss program helps adults manage their weight and any medical conditions associated with excess weight. Our obesity medicine experts create personalized weight management plans for each patient.

Chicago Weight Program

Nonsurgical Options

We offer patients the latest treatments in nonsurgical weight loss. Our experts use endoscopic therapies to treat obesity and achieve sustained weight loss. Endoscopic weight loss procedures are incision-free.

Endoscopic Procedures for Weight Loss

Which Weight Loss Approach is Right for You?

Whether you are looking for medical management options, such as medication and behavioral therapy, or are considering a variety of surgical or endoscopic weight loss aids, our teams will provide the education and support necessary to achieve your goals.

Weight Management Q&A

What are the main reasons people struggle to lose and maintain weight? We spoke with weight management experts Silvana Pannain, MD, obesity specialist and endocrinologist, and Andrea Busby, PhD, health psychologist answering viewer questions.

Watch Video

[MUSIC PLAYING] Hello, and welcome to the University of Chicago Medicine At the Forefront live. The purpose of our program is to allow you to interact with our doctors live on Facebook. So get your questions ready, and we'll answer as many as we possibly can over the next half hour. Now, we want to remind our viewers that our program today is not designed to take the place of a medical consultation with your physician. Joining us today is Dr. Edwin McDonald and Dr. Christopher Chapman. They'll be speaking with us about healthy weight loss options available here at UChicago Medicine. I'll start off with the two of you introducing yourselves. Kind of tell us a little bit about your areas of specialty.

Absolutely. So I'm one of the advanced endoscopists here at the University of Chicago. There's three of us here. So I do a lot of procedures that deal with pancreatic cancer, other diseases like that. And one of my focuses is on endoscopic treatments for obesity. And that's what I like to do.

Great. Dr. McDonald?

So I'm also one of the gastroenterologists here. I specialize in nutrition. So that means I basically see people who suffer from malnutrition. So people with short bowel syndrome who need alternative ways to get nutrients in. And I also do weight management. So I also do some of the procedures that Chris mentioned, but also focus on medical weight loss, which is essentially talking about diet, exercise, and then people who qualify maybe even using medications.

And you're also a chef. We're going to talk a little bit more about that later.

I'm also a trained chef.

That's pretty exciting. That's great stuff.

It is. I love doing it.

I haven't had his food yet, though.


Well, I should have you over sometime.

I think so. I think so.

I think that's an official invitation.

Yeah, that was an invite.

We have a witness here, so that's great.

You heard it here now.

Absolutely. Well, many people have had their lives changed the healthy weight loss options available at UChicago Medicine. Let's hear from one of our patients, who had a wonderful outcome.

I walked from my apartment to the lake and back. And that was something like 6,000 steps. And you know, it's not something I could have done a year ago. So I'm really happy about that. I'm happy. My wife's happy. Everybody's happy.

Gregory Fulham is doing things he hasn't been able to do in years.

The success has been dramatic.

Gregory had a procedure performed by Dr. Christopher Chapman called endoscopic sleeve gastroplasty. The procedure is quick, and the results can change lives dramatically.

The advantages of the endoscopic sleeve gastroplasty are that it's an outpatient procedure. There are no incisions, so there is no scarring. And the healing time is drastically reduced.

The endoscopic sleeve gastroplasty is a noninvasive procedure designed to reduce gastric volume. Sutures are put in the stomach, reducing the size of the stomach. Stomach volume is reduced by 50% or more. Patients eat less, because they become full more quickly, and are satisfied with smaller portions.

You feel full sooner. And that's a good thing.

The University of Chicago Medicine provides a full range of bariatric services. For some patients, this is the perfect solution. Others, though, will require surgical procedures, also available at the University of Chicago Medicine.

We're happy to see any patient who would be interested in procedures or other methods for weight loss. However, for this particular endoscopic sleeve gastroplasty procedure, we're looking for patients who are really in need for that jump start to lose about 30 to 60 pounds of weight.

Patients go through a process before the procedure to make sure they're ready for this step. After the procedure, they will be expected to change their lifestyle, eating less and exercising more.

At University of Chicago Medicine, we pride ourselves on our multi-disciplinary evaluation. That includes seeing a psychologist, an endocrinologist, a dietitian, as well as a gastroenterologist. We have the patients see all these providers before we even do the procedure.

Gregory says the procedure went very well, and the changes to his lifestyle have been surprisingly easy to make.

I eat the same stuff that I have been eating forever. I just eat less.

The procedure had Gregory in and out of the hospital in a day. He says the care has been great.

It's really a privilege to be in a neighborhood that has an institution like this so handy and so ready to assist. It's wonderful.

See, that was I think pretty interesting, because it really showed what a difference that made in Gregory's life. I mean, he was talking about these changes, and the fact that he can walk and get around now. Which is really neat to see.

Absolutely. He's had a remarkable journey. And you know, he keeps telling me-- I see him where he is employed-- and he tells me how much of a difference it's made for him.

Great. And Dr. McDonald, I imagine you see a lot of patients that are in the same situation, where their lives are literally transformed.

Oh, definitely. I mean, I've seen people-- I think the most weight loss I've seen in our clinic so far maybe went probably close to 150 pounds or so. So that makes a huge difference in people's lives, as far as mobility, as far as happiness, as far as just day-to-day, everyday interactions.

So I know both of you are-- what you preach to your patients is healthy weight loss, and healthy is the important aspect of that. Let's just start off talking about what exactly that means. What's the difference between healthy weight loss versus non-healthy weight loss?

So for me, I think it's better to define what unhealthy weight loss is. And that's a good place to start. So unhealthy weight loss-- you know, I see a lot of people who try these starvation diets. So these different fasts, where people are just drinking water for days on end. And a lot of those diets, it's really just not sustainable.

So I think healthy weight loss is something that is going to have a sustained effect over time. And it is a pattern of eating that someone can actually stick to and continue with, as opposed to something that is going to lead to issues over a certain period of time. So there's a lot of different very, very low calorie diets out there that for the most part will lead to weight loss.

But you can really only do those for about a month or so. And eventually, most people, all the weight is going to come back. So what we tend to focus on is really a way of eating that people can carry out throughout their entire life, as opposed to just one month or just a couple of months. Because again, like I said, we want the weight loss to be sustainable.

It's a lifestyle change.

Yeah. I agree. And as Ed and I were talking together-- we work very closely together-- that this is not just a single moment of change. This is a lifestyle change that we want to do. And that's why the multi-disciplinary approach that we see with Ed working on some of the medications and the procedures that we do together, where the focus is more about providing durability for those patients that yo-yo up and down with their weights. Because they do a fad diet. They crash. And they get down, but then it's ultimately unsustainable. And then they end up having these problems again. So we're trying to find these ways to build not only a medical relationship, but a personal relationship that allows us to make long term changes.

And when people yo-yo like that, it's not only hard on them physically, but emotionally as well, I would imagine.

Yeah. And it's actually harder to maintain the weight loss when you go up and down. Primarily, every time you go up and down, that's associated with hormonal changes. And that can impact your long term weight loss overall. So the way I view weight loss, it's almost like a pyramid. And you have to have the foundation.

Without the foundation, the whole pyramid is going to fall apart. But there will be maybe multiple rungs on the pyramid or rungs on the ladder. So lifestyle modification is really the foundation. But for a lot of people-- for most people-- studies show that lifestyle modification on its own may not be as effective. And that's why we provide these adjuncts. And so you have medications. You have bariatric and endoscopic therapy. Then we also have bariatric surgery. And each of them can play an important role, depending on what the individual patient is going through.

Full continuum of care here.

A full continuum of care.

Great. I do want to remind our viewers that if you have questions for either one of our physicians, just type him in on Facebook, and we'll get to him as quickly as we can. We have our first question from a viewer. And that is, is BMI the best way to gauge a healthy weight?

So BMI is the way that we use commonly primarily because for research purposes, we do have to have some sort of classification, and also to decide whether or not people would benefit from bariatric surgery or medications. We need some sort of marker to make those decisions, and BMI based upon studies has become that marker.

But there are a lot of limitations when it comes to BMI. So BMI is not a reflection of your muscle mass, nor is it a reflection on differences in terms of ethnicity. So certain ethnicities may just in general carry a higher BMI or a lower BMI. So for instance, according to research studies, people of Asian descent may have a lower BMI to begin with. But that does not necessarily mean that they don't have obesity. So someone may not have a BMI that puts them in overweight category. But if you actually look at their fat mass, technically they're functionally over weight. And BMI is not capturing that population. So BMI is just one metric that we use. But it's not the sole metric, by no means.

We look at other things, like waist circumference. Things like that. Or also we really look for like kind of visceral adiposity, or fat volume we're talking about. So I agree with Ed that BMI in itself is not the only tool that we use and should be using to assess someone's weight status.

Great. We have another question from a viewer that asks, how do you know if you should be considering bariatric surgery or endoscopic procedure or something else like medical weight loss? And I'm going to throw that one to you first.

Sure. So since we have the wide spectrum of care here going all the way from lifestyle management to medications to bariatric endoscopy all the way up to bariatric surgery, what we try to do is work very closely with the whole group to decide what's the best for the patient individualized. And so our general guidelines are based on a BMI. So if you have a BMI between 30 and 40, that might make you a good candidate for endoscopic bariatric therapy.

However, if you have a BMI greater than 40, oftentimes bariatric surgery is the most effective option to treat your obesity issue, as well some of the complications that arise from the weight issues. And so either a BMI greater than 40 or a BMI of greater than 35 with co-morbidities should be considered for surgery.

However, if you look at medications, even a BMI of 27 would be an indication to consider medical management to help with weight. So we can use the BMI as a starting point. But then we do tailor it to individuals. So if someone has a BMI in a higher class that is more interested in endoscopic procedure, that may be better than nothing at all. it really depends on the patient. But we kind of use the BMI as a first starting point. And Ed, how do you feel?

Yeah, I totally agree And what Dr. Chapman here means by co-morbidities is really the other conditions that may be associated with gaining extra weight, or just other conditions in general. So say someone has severe lung disease. That may put them at risk for complications from bariatric surgery. We may have to consider alternate options that aren't as invasive. Or if someone has severe diabetes and we know they need to lose weight immediately, bariatric surgery may be the better option, just because we know it's a little bit more effective, especially with a BMI over 40.

And I think Ed brings up a great point about the timing and the need. So we deal at University of Chicago with a lot of patients with significant health problems in addition to weight issues. And so we're in constant communication with our transplant surgeons, our orthopedic surgeons, our OBGYNs. We deal with fertility issues. These are patients who, if they're struggling with these conditions, sometimes helping them lose a little bit body weight-- even 10%-- can make a significant difference for their outcomes for other procedures or their plans for their families.

I've got to get to a couple of things, because we have some props here that you brought that I'm fascinated by. And so if you could kind of explain to us what we're seeing here. And we were talking a little bit during the video that aired a few moments ago, and there was an animation that showed one of the procedures you do. And you brought in some things.

Right. So currently, there are about three procedures that are FDA-approved, or the device is FDA-approved for use. And these are endoscopic procedures, meaning that we use a flexible tube with a camera on it to go down through the mouth and do interventions on the stomach. So there's no cuts or no incisions. The wound healing is not really there, because it's all internal. It's very discreet.

And so these are the options that we're kind of employing from the endoscopic side. And there's the intragastric balloon here. You see it's a silicone balloon. There are about three that are FDA-approved on the market. They're fluid-filled or gas-filled. They're about the size of a grapefruit. They stay in your stomach for a period about six months, and then we take it out. So this is a very nice option for those patients who are looking for a very reversible option. Because once you remove the balloon, you're completely back to yourself.

The other option that we do is the endoscopic sleeve gastroplasty. This is a where we use a suturing device here that allows us to actually take full thickness bites through and through the stomach wall to tighten the stomach. And we kind of call this the accordion procedure, because you're basically folding it and closing it on itself. And this is the one that Gregory had and had such a great response. So you can see that you use this device and a handle that allows you to close and basically pass a suture and take bites of tissue. And then I'll let Ed here finish and talk about aspiration therapy. Because we both do this therapy here.

Yeah. So there is aspiration therapy, which is basically where we place a small tube in the stomach. And the tube allows people to empty out at least 30% of their calories that they take in a given meal. So you know, it's actually just a variation of a common procedure that we do all the time as gastroenterologists, which is a Percutaneous Endoscopic Gastrostomy tube, also known as a PEG tube.

So typically historically, we do the PEG tube for people who can't eat. They have swallowing issues or issues with their esophagus, and we have to feed them directly in the stomach. But with this tube, It's a little bit different. So this allows people to basically empty out their stomach just a little bit. But one, you have to chew your food very carefully.

So you just can't empty out everything you're eating. Two, it's always done in a context of lifestyle change. So it's not a tool that people can use and just eat whatever they want and empty whatever they want. Doesn't work exactly like that. So people are seen by myself and our dietitians, and even we have psychologists involved that help us out with the whole process.

You know, that to me is I think critical. Because this isn't just a procedure. When you both do your work, you involve a lot of folks in the process. And it is about a lifestyle change. It's really from beginning to end with them.

Right. You need a full evaluation for this. Because it is such a drastic change. A lot of time, people are battling 30-40 years of habit that they've built up that they're trying to suddenly change. And kudos to them for coming in and starting that process. But because it is so challenging, we acknowledge that we have to ask our patients to meet with a dietitian and a psychologist to make sure that we're moving in the right direction and it's going to be safe.

Great. Now we have a question from one of our viewers. Stephanie is asking, she sees every one or two years there's a new fad diet that comes out. I think keto, Whole30, paleo, there's a bunch of them. Are these realistic for patients to do diets like this? Does it help? Is this more of a hindrance? What are your thoughts?

I mean, everyone's a little bit different. And I think whenever we see someone in clinic, we don't automatically tell them just to do Keto, or tell them just to do x diet. We really have to take an individual approach to understand what people's taste preferences are, what their ability to afford certain foods, where they live at. So access is an issue. So we take all these different things in consideration. But what a lot of these diets have in common, ultimately you're avoiding ultra-processed foods. So there's no diet that really tells you to eat a whole bunch of potato chips.

Or other foods.

Or other ultra-processed foods. And then most of the diets really involve some sort of calorie restriction. So there's a lot of debate out there in terms of where we should place those calories. Should those calories be mostly protein? Should those calories be less fat or less carbohydrates? But when you look at a lot of different studies, ultimately when people decrease their caloric intake-- their calorie intake-- people tend to lose weight. And if you add exercise to the mix, you're even going to lose even more weight. So fundamentally, just eating less and eating more healthier foods that aren't processed is going to be the foundation to any of these diet programs.

Now, there are some diets out there that are just unsafe. And most of those diets are really where you're doing like 800 calories or less for extended periods of time, where you're putting yourself at risk for starvation and also protein loss. So you know, I tend to tell people to be careful with those, and also be careful with things that sound like it's too miraculous to be true.

So if there's a diet that says the miracle diet, the miracle diet really does not exist. And if the diets really just focus on supplements, typically a lot of supplements don't really lead to a lot of weight loss. So case in point, there's like the HCG diet out there, where people are taking a lot of HCG, which is a hormone associated with pregnancy.

You know, that diet has been-- it's out there in the literature. But the diet has been studied, and it's not as effective as what people claim to be. So ultimately, what I tell people with these diets, you really have to do your research. And a lot of research should include talking to a registered dietitian. Not necessarily a nutritionist. If they are a nutritionist, you really have to find someone who's certified, as opposed to someone who is online claiming to be a nutritionist. Which that happens.

We have another viewer who-- there's a procedure that they had done called the roux-en-Y. Is that correct?

Roux-en-Y. Gastric bypass.

Yeah, it didn't maintain. But they want a new beginning. What would you tell someone like that?

Right. We see a lot of patients who have had bariatric surgery, and then unfortunately have regained weight. So I think when we bring them into our clinic to discuss, we actually just try to find the underlying reason why they've had weight regain. Is it something behavioral? Or is it something mechanical? And if it's mechanical, sometimes we can actually try to repair those things.

The repair could be surgical. So bariatric surgery definitely has a role, like a revision bariatric surgery. But also we're using this endoscopic suturing device to do certain things as well. So a lot of times, we find that the opening of the stomach to the small intestine is dilated. So it's stretched out in size over time. And this typically happens anywhere from five to eight years post-operative. And you can actually use this device to suture down that opening to make it tight again to provide that level of restriction.

So one of the key questions I ask my patients when they come in with this problem is, do you feel any restriction? Or can you eat more food than you could before? And so those are different things that we want to try to get at to try to see if maybe there's a mechanical component that can be doing this. And even sometimes people may form what we call a gastrogastric fistula, where there's actually an abnormal connection from their pouch into their old excluded stomach. Because with a bypass, your old stomach is still there. So there's a chance, actually, when you eat, the food you're going is back down the original path. And so we kind of do a full range of evaluation to see is there's something mechanical, or is there something behavioral? And we go from there.

Dr. McDonald, can we talk about coffee a minute? I'm pointing at your UChicago Medicine mug. I've got to get the plug in there. But talk a little bit about coffee, because we were discussing this a little bit before the program began, and some of the benefits of black coffee. So lead us down that path, if you will.

I mean, for me, I'm probably a coffee addict since years ago when I became a resident and had my first kid-- my wife and I first kid-- when I was an intern. So coffee became mandatory. And since then, I just have not stopped. Overall, coffee is pretty healthy. So there's a lot of concerns. A lot of times people come in to me and in my clinic and say things like, I stopped coffee, I stop spicy foods.

And I'm like, wait a minute, where did all this negative connotation come from when it comes to coffee and spicy foods and stuff like that? Because ultimately, a lot of these foods are healthy. So black coffee by itself has been associated with decreased risk of liver cancer, and maybe even decreased risk of heart disease. Now, when you add a lot of sugar and a lot of cream some of the fancy lattes and everything that have a lot of calories, that can be associated with weight loss.

And also, those aren't very healthy, because it's again simple sugars. And that's probably more along the lines of the processed food category. So there are some recent concerns about coffee and cancer. Specifically in the state of California, at least at Starbucks and other coffee stores, they have to put a label explaining the risk of cancer with certain types of coffee.

So a lot of that risk or a lot of those concerns comes from studies on mice, but not necessarily studies in humans. So most of the studies in humans, again, show that coffee decreases the risk of cancers. But the concern really comes from the fact that coffee, especially when it's roasted-- so like our darker roast coffee-- may have higher amounts of a carcinogen-- a cancer causing agent-- called [? acro ?] aromatase. But that's also found in potatoes. It's also found in bread. It's also found in a lot of foods that we roast in the oven.

Now ultimately, how much does it take? You know, how much exposure to [? acro ?] aromatase does it take to cause cancer? I don't think anyone really knows that, because to set that up to answer that question, you'd have to do an unethical study, where you're just giving people [? acro ?] aromatase for many years and then seeing what happens. So we don't know. But ultimately, I drink coffee. I probably drink maybe a little bit less dark roast. But I don't really have any concerns about it, for my own well-being.

One of the questions too that's coming in kind of along the same lines, and it deals with cancer. But the link between obesity and cancer. Would either one of you care to comment there?

Right. I mean, so there's definitely a link between obesity and cancer as well as outcomes related to cancer therapies. If you look at breast cancer, for example, that there have been plenty of literature published and well-done studies suggesting that if you have obesity and are undergoing treatment for breast cancer, that your outcomes are less favorable. So we know that there is definitely a link not only to the development of cancer, but also to the outcomes related to therapy. So this is another reason why I think some of these options should be on the table for patients, even when they're battling some of those very strenuous conditions.

Interesting. So another question. Many of these popular diets or high protein diets. And the concern is, is there a correlation between all that protein and possibly having kidney stones?

Not necessarily. So it depends on one, someone's personal history with kidney stones. Because there's multiple different types of kidney stones. Most of the stones are really based upon calcium, not necessarily protein intake. Now in the past, especially like in the '90s, everyone was concerned about eating too much protein and that causing kidney failure.

So I remember years ago when I was playing football and sports, and people were trying to do protein shakes. And all the coaches were like, don't do too much, or else you're going to get kidney failure. That is not true. So that has all been debunked. And a lot of people-- even people with kidney disease-- actually need protein, up until a certain point where they need dialysis. Then you really just need to talk to a dietitian and make sure you're not overdoing it. But for the most part, the protein concerns and kidney disease, you really don't have to be concerned too much. Because most people aren't going super crazy with the protein.

Another one of our viewers says, I have a PCOS and a slightly high A1C. Would an endoscopic weight management procedure be beneficial to helping me lower my A1C?

Yeah, I think that's a great question. Unfortunately, one of the common presentations of PCOS is weight-related challenges in addition to menstrual cycle irregularities or having irregular periods. And so the treatment of PCOS or using an endoscopic management, it really gets to the bottom line is, does it also help with treatment of those conditions that are associated with weight, such as diabetes or high blood pressure?

And there are literature out there that suggests that these endoscopic procedures, when they're capable to lose that 10% to 20% of your weight, can improve hemoglobin A1C, can improve people with fatty liver disease, can improve people with blood pressure or cholesterol problems. So yes, for that person out there, I would say that if you do have PCOS and you're struggling with weight, this could be a viable option to help you get over that hump and get you out of that.

We see a lot of patients who are in that pre-diabetes phase, and they say their numbers are borderline. If they're trying to correct that issue, weight loss will help try to get them back down out of that range. So people with that borderline diabetes, that's a signal. That's an alarm sign that's just going off saying that we need probably to do something more aggressive. Whether that's lifestyle, whether that's endoscopic, whether that surgery is very tailored to the person. But that's an alarm sign for people. Because these things can help.

Can I answer that?

Yeah, absolutely.

So also, PCOS can be very complicated. And it's something that really requires a multi-disciplinary team to manage. So here at the University of Chicago, we have people seeing endocrinologists. We work with the gynecologists. And then we also work with ourselves as weight loss specialist and endoscopist. So I think that approach is going to be individualized. But it's probably going to take input from a lot of different doctors to decide what's the best overall approach.

Absolutely. Because there are medications that are great treatments for PCOS too. Like a lot of patients are on metformin, which also is an a blood sugar control medicine. So that may be enough to help this person get out of that range with a mildly elevated A1C. So as Ed mentioned, we work very closely with the endocrinologist to make sure that they're in the right approach. We don't just offer one thing and say that this is what we do. But you have to look at the whole picture. And sometimes, procedures aren't the right option. Sometimes medications are. But we do tailor it individually, I would say.

Another viewer question. I've heard that women's hormones make it more difficult to lose weight. Would you approach a woman's weight loss treatment differently than you would a man?

No. I mean, for the most part, yes. So women can have a harder time to lose weight. But at the end of the day, really, lifestyle modification is the foundation. And those changes are the same. Reducing calories, trying to exercise, sleeping, not trying to sleep too little, not sleeping too much. And then from there, we decide based upon other conditions people may have whether or not they're a candidate for bariatric surgery, medications, or endoscopy. But ultimately, the equation, if you will, is relatively similar. It just so happens to be a little bit more difficult, especially in women who are post-menopausal.

Yeah. We see a lot of women patients actually come in who are interested in endoscopic therapies. And in fact, our most frequent patient are really those patients that have had their second child, and they just can't shake the weight after their second or third child. And so there is definitely a gender difference that I've seen in my practice in terms of how people do.

But men do well with the procedures and with lifestyle changes as well. But I think it is something that we do try to tailor. And we look at other things that they're going through. Women may be more likely to have thyroid disease than a man. So we have to ask those kinds of questions and make sure those conditions are ascertained or assessed as well. And so there are other things that we look at same time.

Another question from a viewer. Vegan diet, yes or no?

Yeah. I mean, it depends on your taste preferences and what you're really into. So if you want to do fruits and vegetables and be a vegan, you can do that in a healthy way. But you really have to be a healthy vegan. So I've seen unhealthy vegans where, they're just eating potato chips, and they're calling themselves a vegan. And technically, you can be on a potato chip diet and be a vegan. But that is an unhealthy diet. Or you could just eat pasta all day and be a vegan, but you're not eating fruits and vegetables.

So I remember I was giving a community lecture, and someone came up to me and said they're a vegan. And I asked them like, oh, what's your favorite fruits and vegetables? And they said, they hate fruits and vegetables. And I'm like, how can you be a vegan and you hate fruits and vegetables? So that is an example of being an unhealthy began.

But vegan as a whole, a lot of studies show that people may live a little bit longer, if you look at some of the Seventh Day Adventist studies. They may potentially have a decreased risk of cancer. So for some people, that is a very viable option. People who are interested in becoming a vegan, you have to be aware of the possibility of B12 deficiency. So that's something that definitely occurs in the vegan population. But outside of that, you really just have to make sure you're a healthy, which applies to any diet.

And I would imagine you just have to watch your intake of--

Yeah, the macronutrients. Making sure you get a protein. What are the protein sources that are vegan-compatible. Those are why you see a registered dietitian or someone like Dr. McDonald who can help you understand what those macronutrients--

What is a good protein source for a vegan, just out of curiosity?

So you'd have to have multiple protein sources. Primarily because there are a few plant-based proteins that have all your essential amino acids. So the only ones I can think of offhand, quinoa is a complete protein that's plant-based. And I believe amaranth is also. But everything else, you're going to have a combination of different seeds, different nuts, and different beans. And using that combination will get you all those essential amino acids, which are kind of the building blocks of protein.

We're about out of time, but we do have one more question from one of our viewers. Keto diet, good or bad?

It can be good if done appropriately. So a lot of studies show that the keto died for people who have seizures can decrease the risk of seizures. It plays a role in it, especially in people who have epilepsy. It may help out with people who have migraines. And people can lose weight with a ketogenic diet. Now, the ketogenic diet is still a relatively recent phenomenon, so in terms of long term effects, I think we need to do a little bit further studies.

In terms of how it affects our gut bacteria, those studies also need to be done and are actively being done. And I think some of our researchers, specifically Jane Chang is looking at some of those, trying to answer some of those questions. But from a weight loss perspective purely, people can lose weight with a ketogenic diet. But at the end of the day, most of these diets are really restricting your calories, and really cutting back on some of these ultra-processed foods.

Dr. Chapman, any parting words for us?

No. I think this was fantastic. I hope everyone learned a lot. And you know, I hope you got a taste of how Ed and I work very closely together, and that we are here to help people. And if you have any questions, we're always happy to reach out.


Perfect. And we want to stress the continuum of care. Because there are a lot of services that are available here at UChicago Medicine for folks that want to lose weight and change your lifestyle in a safe manner.

Yeah, absolutely.

So I see people with a bariatric surgeons. For people who are candidates for bariatric surgery, I tend to at least recommend they have a conversation with a bariatric surgeon, just so they can see what their options are.


Great. If you want more information about UChicago Medicine's weight management program, please visit our website site at UChicagoMedicine.org/weight-management. It's there at the bottom of the screen. Or you can call 888-824-0200. Thanks for watching At the Forefront live, and have a great week.

Coming up on At the Forefront Live, obesity is a very challenging condition. People struggle with weight, and are often frustrated with a lack of results. Today on At The Forefront Live, we'll look at bariatric surgery options, and how this can change lives. 

Here at UChicago Medicine, bariatric surgery programs are tailored for each individual to get the maximum outcome and benefit. Also today, we'll meet one patient who lost over 80 pounds and gained control over her diabetes. Lynn Yanow has quite a story to tell, and is a different person today because of bariatric surgery. That's next, on At the Forefront Live. 


And welcome to UChicago Medicine, At the Forefront Live. This is your chance to ask our experts your questions by typing in the comments section. We'll get to as many as possible over the next half hour. Remember, this program does not take the place of an actual visit with your physician. 

Joining us today, we have two experts in bariatric surgery, Dr. Vivek Prachand and Dr. Mustafa Hussain. Welcome to the program. 

Thank you. 

First of all, just tell us a little bit about bariatric surgery, in general, what exactly that entails. I think a lot of people, when they think of bariatric surgery, they think, you're just cheating, you're not dieting, you're taking the easy way out. But that's really not the case. 

Thank you for the question. Bariatric surgery is basically surgery-- which means manipulation of your organs and your stomach and your intestine-- to really change the way your body perceives hunger and when it feels full. It works by changing your anatomy, but also your physiology, which is the chemical nature of your body's relationship and understanding to food. 

And it works by mechanisms that we partially understand, but not fully. And we're definitely working on that. But it's definitely not cheating. It is for people who have tried several things before, but really need additional help from us, in terms of losing weight. 

And it's really for people who are looking to lose 75 or 100 pounds. So, Dr. Prachand, why is it called obesity or metabolic surgery, instead of weight loss surgery? 

I think that that's a really good question, and I think it's something that's really changed in the field over the last 5 to 10 years. So the emphasis used to really be about weight loss in the past, and so we would really be emphasizing how many pounds people lost, and so forth. 

But the American Medical Association, about five years ago, recognized obesity as a disease. And one of the things that we've always recognized with these operations is that, in addition to achieving the weight loss, which is pretty substantial and sustainable, is the impact on the medical problems related to obesity. 

And so the importance of thinking about obesity and metabolic surgery is to really keep in mind and emphasize the fact that these operations also have the opportunity to impact all the different medical conditions that come along with obesity, such as diabetes, high blood pressure, high cholesterol, sleep apnea, severe joint problems. 

We even see patients who might benefit from transplantation, but are too heavy to qualify to undergo a transplant. 

Bariatric surgery can really make a difference. We spoke to one patient who had bariatric surgery here at UChicago Medicine, and here's her story. 

And that has drastically changed my life, not to have to take insulin shots. I feel significantly better. 

Lynn Yanow was taking four insulin shots a day. It was the only way she could control her diabetes. 

I feel better emotionally, physically, and I'm very, very pleased. 

Now, Lynn is much lighter, and off most of her medications, including those four insulin shots. 

As of today, I've lost 80 pounds in six months. And I'm very excited about that. I would maybe like to lose another 10, but everyone tells me that I should leave it be. 

Lynn chose the bariatric program at the University of Chicago Medicine, one of the leading programs in the country. She had the gastric bypass procedure, and is very happy with the results. 

The reason that I chose University of Chicago Medicine is because they had a program, Dr. Hussein had a program to go along with the bypass. You had to go to classes, you had to follow up, there was a whole plan. 

What differentiates us from everybody else is, I think, our experience, our judgment, and our comprehensive evaluation of patients. 

UChicago Medicine offers many options for weight loss. Some of those options include surgery. There's sleeve gastrectomy, gastric bypass, and a procedure for extremely heavy patients-- that is only done at about 1% of the centers in the country-- that's called the duodenal switch. 

As an institution, we are providing a wide array of options for patients who are trying to lose weight, whether it's that 10 pounds you need to lose after Christmas, or it's that 200 pounds that you've accumulated over years. 

Each of these procedures requires a team approach. The patient will work with several caregivers to assess their challenges and provide solutions. There is also follow-up after the procedure, to make sure the patient has the right support to keep the weight off. 

So at a single hospital visit, they will see the surgical team, they will see our bariatric dieticians, as well as our psychologist. And so it's a one-stop shop, if you will. 

Weight loss isn't easy, and the patients who participate in the surgical program have struggled with their situations for years prior. But the positive news is there is hope, and it can be a lasting change. 

Despite all of our biases, we don't know why people are overweight. It's easy to say they eat more food than they actually burn off. And while that may be true, we don't understand why some patients are more efficient at burning off food than others. 

Obesity is a complex issue. It has to do with your genes, what you're eating, what your habits are, what your social behavior is, what your psychological situation is. So it's a complex issue, so it doesn't have just one solution. 

Surgery happens to be the most effective way to help people lose weight, but we realize it doesn't function in a vacuum. 

Lynn's family is happy with her outcome, as well. It has changed her life, and helped her to a healthier existence. 

Since I did the surgery, I feel much better about myself. I am much more confident, I do a lot more things. I do double-takes in the mirror every time I walk a window, every time. I absolutely do not believe that I look like this. And I feel very, very good about it. 

It's an interesting story. And it's fascinating to hear the difference in her life, particularly with her diabetes. So to your point just a moment ago, it really does make a significant health difference. 

And one thing that you touched upon in the video, Dr. Prachand-- I wanted you to talk maybe a little bit more about this-- is that overall plan. It's not just surgery, but there are many different aspects and different things that people go through before the surgery and after. Talk to us a little bit about how that works, if you will. 

Sure. So as was alluded to in the video, we really have a true multidisciplinary program. And what I mean by true, as opposed to virtual, is that we literally have our dieticians and psychologists in the clinic with us. 

And we take turns seeing the patients while they're in the clinic office. And then we discuss and confer amongst ourselves to really formulate a good game plan. 

So this takes place when patients come in for their initial evaluation. So we identify if there's some particular behaviors or education that we can work on to really get people ready to be successful with surgery. And we also have the same approach in the aftercare. 

And all of this is really focused on selecting the patients that we think will have the best chance of success with surgery, and getting the best outcomes that we can have after surgery. So really having that team approach is I think what sets us quite a bit apart. 

And it really sets the patients up for success in the future. 


So we want to remind our viewers that we are taking your questions, so type them in the comments section. We'll try to get to as many as possible. 

Let's start off talking about the different types of bariatric surgery available. They were mentioned in the video, but if you could tell us a little bit about what they are, and what they entail. 

Sure. So there are currently four approved bariatric surgeries that are performed nationwide. We are one of the only centers that actually offers all four types of surgeries. 

The most common one being performed these days is something called the sleeve gastrectomy, or vertical sleeve gastrectomy. Some people call it VSG. This is a procedure that's done laparoscopically, which means surgery through very small incisions. 

So most of the incisions are about 1/4 of an inch or so. And this can be done with general anesthesia, and most people actually wind up leaving the next day. So the sleeve gastrectomy is a procedure which reduces the size of your stomach by permanently removing a portion of it. 

So I like to tell people, if you think of your stomach like a big handbag that you can stuff lots of things into, if you were going somewhere over the weekend. By removing a portion of it, you basically are trimming it down to where just the essentials fit in. 

So some people say it's a banana shape, or I like to say from the big handbag, to maybe just like a small purse you would take to a party, or something like that. 

And so that reduces the space where you can fit food, but also we've learned that actually impacts some hormones in your body that affect hunger and how full you feel. So it's not that you feel hungry but can't eat, but it actually changes the relationship that you have with food. So that's why it's one of the reasons that it actually works better than restricting yourself on a diet. 

So that's currently the most common procedure. Another procedure that's performed, also laparoscopically, or using the small incisions, is called the gastric bypass. Sometimes call it people call it the Roux-en-Y. 

This is a procedure that's been performed actually the longest for weight loss, since like the '60s or something like that. And it has a really excellent track record. Because it's been around, there are some stories out there maybe that it was not safe in the past, et cetera. 

But this is actually is not true. It's a very safe procedure, likely as safe as all the other procedures. And it has certain advantages over the sleeve. And sometimes we recommended for people with severe heartburn or reflux. 

We may also recommend it if you have diabetes on insulin, such as the patient that was highlighted earlier. And it can be quite effective in getting people off the insulin that they're on. 

The other procedure is a procedure called the duodenal switch, which is the procedure that we specialize in here at the University of Chicago. Dr. Prachand was actually the person to perform it first, using the minimally invasive techniques here in the Midwest. 

And very few centers around the country perform it. It is a little bit more complex procedure, but also has more rewards. The duodenal switch is a procedure that affords you the most weight loss, particularly if you're in the category of people who may need to lose around 200 pounds. And that's people whose BMI-- which is body mass index-- is over 50. 

And also, it's very effective for people who have very severe diabetes, that have been diabetic for greater than 10 years on insulin. And can be a very powerful way to treat that metabolic disease, that combination of obesity and diabetes. 

The last procedure is something called the laparoscopic adjustable gastric band. Technically we do offer it, but it is a procedure that is becoming sort of less popular these days, mainly because it is a device. It is subject to moving and breaking. 

And also we've seen over the last few years that the weight loss is not as effective as some of the other procedures. And so it is a procedure that is approved, but we are actually performing it less frequently, these days. 

Now, we are getting questions from viewers. I want to get to those, and try to answer as many as we possibly can during the program. First question, which you pretty much just answered but we'll go ahead and throw it at you again, anyway, when you were talking about the duodenal switch. 

This is somebody who says, do you think a person whose BMI is over 50 should think about surgery? And I guess, the question would be, then, what types of surgery should they should they first consider? And either one of you can field that one. 

So you mentioned BMI of greater than 50. So again, BMI stands for body mass index. And we get that number by combining height and weight into a formula, and it gives a pretty good estimate of how much extra fat a person has for their height. 

It's not a perfect number, and you'll see a lot of news stories and a lot of complaining about BMI. But the reality is that, unless you're an NFL linebacker or a professional athlete, it actually does a pretty decent job of estimating this. 

So just to quickly review, a normal BMI is between 20 and 25. And a person is considered obese if their BMI is greater than 30. And so we talk about surgery for obesity when the BMI is 40 or higher, or if it's between 35 and 40 and the person has other significant medical problems related to their obesity, as we mentioned earlier. 

So when we're talking about BMI of greater than 50, that's typically somebody who's 150 to 200 pounds overweight. And typically, and frequently associated with that are those other obesity-related medical conditions like diabetes, high blood pressure, and so forth. 

So in the past, when gastric bypass was the most common operation performed, say 15, 20 years ago, what was seen quite frequently is that patients who had BMIs greater than 50 or 60, they frequently failed to lose enough weight after they had gastric bypass, or they would regain a significant amount of weight. 

And that's really what prompted our interest in performing the duodenal switch, because historically, it seemed to be associated with a greater amount of weight loss. But there really had not been any head to head studies comparing the two operations to determine which is actually more effective for this very difficult-to-treat group of patients with a higher BMI. 

So we did the first study comparing not only the weight loss, but the impact on diabetes, high blood pressure, and high cholesterol. And we were the first to find that there was, in fact, a significant advantage for patients with greater than a BMI of 50. 

Now, that doesn't mean that every patient with the BMI of greater than 50 should have a duodenal switch. And I think that one of the key things that we really try to convey to our patients when they come for an evaluation, and what we really take most of their time in our conversations and discussions with patients, is figuring out what the right tool is for you, as an individual. 

Because there's not one operation that's the best for everyone in all circumstances. And so it's really about finding the right match between the operation and the patient, taking to account the fact that each person has a different amount of weight that they need to lose, each person has different medical conditions that are related to their obesity, different side effects of the operations, and different effectiveness, in terms of weight loss and impact on these medical conditions. 

And so that conversation that we have as the surgeon with the patient is really the key. 

So we've talked about people with the higher BMI. So we have a question from a viewer, somebody without that level of BMI. And the question is, for someone struggling to lose 25 pounds, would surgery be an option? 

Generally, probably not. Again, we don't necessarily go by how much weight you're overweight, but the BMI. So you would have to calculate your BMI. But the minimum BMI is basically 40, which correlates to roughly around 100 pounds for people who are normal height. Or an average height, I should say. 

Or if you're a BMI is over 35 and you have a medical condition closely related to obesity, such as diabetes, high blood pressure, high cholesterol, or sleep apnea. 

Generally, if you're about 25 pounds overweight, you're probably around a BMI of 30, again, if you're an average height individual. And around that BMI, generally, the first recommendation would be intensive lifestyle modification, which is also the first step for anyone who's trying to lose weight. 

So that's, generally, meaning working with a professional, such as a dietician or a medical specialist that works with obesity medicine. Or maybe even a therapist or a psychologist that can help you lose weight. But having those regular visits with professionals really been shown to affect success with people trying to lose weight. 

And that's one of the nice things about UChicago Medicine. We do offer services like that, as well, so we can cover the whole range. How safe is bariatric surgery? 

So I think that there is a lot of myths and concerns, when it comes to surgical safety with these operations. And again, this, I think, dates back to 20 years ago, when these operations really were considered to be risky. And frankly, there as a lot of high-profile cases in the newspapers, and so forth, as the operations initially started to become more popular. 

But over the years, with modifications and techniques and the management of these patients, using laparoscopic approaches, instead of the traditional open incision, which required a pretty large incision extending from the breastbone down to the belly button. 

By using these approaches, and really the management of the team, the safety today in centers of excellence, such as ours, is very similar to patients who have gallbladder surgery. Which is to say that it's a very safe operation. 

We have more questions coming from our viewers. I've heard hair loss can be a common side effect of bariatric surgery. Is there a way to avoid this, and does it taper off on its own? 

This can happen after bariatric surgery, but it can happen also if you're losing weight with any other means. When you do lose a significant amount of weight, particularly quickly, it is the body's natural response to sort of make sure it's not wasting resources, if you will. 

And not that hair is a waste of a resource, but basically, it does require protein from your body to make hair. So when you're in that initial period of rapid weight loss, your body may say, let's just see what's going on. Make sure we have enough nutrients for essential functions. 

So it may shut down new hair growth for a little bit, and that may come off as seeing that you're losing hair. Generally, this is temporary and fully recoverable. And it generally is not significant to a point where others would notice, but you may notice that your hair is thinning. 

Our dieticians, who are nutritional specialists that we work with, are very good at counseling our patients through this period, and making sure that they keep up with the appropriate protein and vitamin recommendations that can really limit the amount of hair loss that they experience, and certainly help with the hair regrow period. 

We've got a follow-up question to that. Let's talk a little bit about the vitamins and supplements and things that people will take after a surgery like this. How long does that go on, and how significant is that? 

So with all of the operations that we do, taking vitamins is something that's necessary after surgery forever. Each of the operations is slightly different, in terms of the way that the body absorbs and handles different nutrients and vitamins, but in all cases, because of that reduction in appetite and because there's less food being taken in, if you don't get enough in and if your body's not absorbing in the way that it had been previously, you're at risk of developing deficiencies. 

So taking vitamins every day is an important part of being as successful as you can be after surgery. I like to tell patients, you wouldn't want to get a transplant operation and then not take your immune suppression medication afterwards. And you have to almost look at vitamins in the same way, after you have these operations. 

One of the common criticisms that people will make when they talk about bariatric surgery is, oh, people will just gain the weight back. Is that true? Or what do we do now to try to prevent that? 

So if you look at, let's say 100 people who've had bariatric surgery, the majority of those patients-- let's say 5, 10 years afterwards-- will be down from the initial point that they had surgery. 

So let's say, if they had 100 pounds to lose, the majority of them-- that's over 50% of those patients-- will be down 60, 70, 80 pounds. It is very normal, though, after the first year or two after the surgery, to regain a little bit of weight. 

I tell my patients it's kind of like setting your thermostat. You should think of surgery as resetting your body's thermostat of where the normal weight will be. So initially, you will lose a lot of weight, and your body will then find its new steady state. 

And then everybody regains just a little bit of weight back. And then it's our job working with the patients to make sure that that little bit of weight we gain, which is normal, stays at that level, and doesn't you know skyrocket back so people are getting excessive amounts of weight back. 

There are some patients that do gain a significant amount of weight back, usually not to the point where they start off at. But if you if they've lost like 80 pounds, they may regain back 30, 40 pounds, which is not a result that we wanted. And we definitely work with them to limit that. 

A major way to prevent that from happening is close follow-up with us, close follow-up with our dieticians, and a continued understanding that surgery, as we talked about earlier, is not the easy way out. It is basically a tool to help you continue to do what you know you should have been doing, which is modifying your diet, increasing your physical activity, and the everything else that we normally talk about with weight loss. 

So here's another question right along those lines from a viewer. For those of us who have had gastric sleeve surgery-- this person was June of 2014-- they've gained some weight back. They want some motivation or suggestions to kind of get back on track. What would you tell somebody to jumpstart that process again, and how would you help? 

Sure. So the way that I would begin with that patient is make sure that they go in to see their surgeon, and re-engage with the program. Oftentimes, patients will sort of drift away because of job changes, or they move and so forth. And if they can come back and see their team, that first step can help substantially. 

Typically, what we would do in that sort of circumstance is make sure that there's not any sort of anatomic problem that might be contributing to the weight re-gain. And at the same time, we would have a full assessment by our dieticians and our psychologists to make sure that the diet hasn't drifted or shifted in a negative direction. 

And really kind of re-educating and just getting back on track. And to be honest, I think that that's really where the value of the long-term follow-up comes in. Because the reality is that nobody can be perfect every single day, multiple times a day for the rest of their lives. 

We kind of use a ratio of, if you do the right thing 80%, 85% of the time, you're going to be fine. And life happens. And there's things that happen with regards to employment, relationships, and so forth, and stresses that can lead to people kind of getting off the track a little bit. 

And we're here for our patients to really get them redirected and re-engaged and moving forward again. 

Here's another viewer question. Not sure why this one is being asked, but I'm going to go go ahead and throw it out anyway. They want to know what form of vitamins would they take. Chewable, gummy, or pills? 

That's actually a great question. After bariatric surgery, we are, generally, altering the anatomy. So the way some things are absorbed or taken up by your body is a little different. And that's partially how the surgeries work. 

So after certain procedures, we do counsel our patients to take vitamins that are absorbed better. Sometimes the gummy vitamins, those are vitamins that can basically dissolve in water. You chew them in your saliva or spit, and they dissolve and you can swallow them. And that's adequate for some of the vitamins. 

But some vitamins actually are not well absorbed in that format, and we may then recommend different combinations or formulations of vitamins that are better absorbed. Some vitamins, you may notice, come in a little droplet of oil, and those may not be good after certain procedures. 

So we and our dieticians come up with an individualized plan for each patient based upon the surgery they had, and also, actually, their pre-vitamin levels. 

You may have noticed in Chicago that it's actually pretty cloudy today, so that means vitamin D levels are low. And actually, most people, actually even before surgery, come in with some low vitamin levels. 

And what we do is we actually, before your surgery, check all those levels, come up with an individualized plan about what your vitamin regimen should be based on that and the surgery you've had. 

So each patient will vary somewhat in what they'll have to take, and how they'll have to take it. So here's an interesting question. How do you make sure that people don't lose too much weight? I don't know if that's ever a concern with patients, but how would you handle that? 

Well, I think that it is a realistic concern. I think patients all have in their minds sort of what they would consider to be a target or a goal weight, if you will. And I would say that the first step is you have the write operation to begin with. 

As I said earlier, there's not one operation that's best for everyone in all circumstances. And it's really that initial determination and decision that we come together with the patient about the surgery a choice that will significantly determine, not only the risk of losing too much weight or also not losing enough weight. So really finding that sweet spot in between. 

So are there certain foods or drinks that will be off limits after the surgery? 

That's a great question. So again, it sort of depends on the type of procedure you've had. In general, many people come in thinking that, oh, gosh, I'm going to have to eat baby food for the rest of my life, or just drink liquids. 

That's actually not true at all. Our goal is to get you to eat normal, healthy food again. And about three months after the surgery, consistency-wise, there's really no restriction. So you can eat vegetables again, you can eat meat again, all those things. 

But we do counsel you on the types of foods you should be avoiding, and foods that work against the weight loss. So a high-carbohydrate diet, that's, again, a lot of starches, flour rice, pasta, potatoes. Anything that has that sort of white color and consistency is generally to be avoided, mainly for weight loss. 

Sugars, sugary things, sweet things. Again, works against weight loss, but sometimes can make you feel ill after certain types of surgery. So if you eat something that's very sweet or high concentrated in sugar, that, again, may not agree with you, and also is not good for weight loss. 

Generally, we tell people to avoid carbonated beverages. That's things like soda, beer, pop. Again, because as that gas expands in the stomach that maybe a little smaller, or in your intestine, that can be uncomfortable and not make you feel well. 

So I would say things to be avoided are carbonated beverages, high sugars, and then high-carbohydrate foods. 

We're about out of time, but I do want to ask this one last question, and it's concerning insurance. Obviously, if you're going to have a procedure done, there's always some concern from the patient's standpoint on whether or not something like this would be covered by insurance. Can you speak to that a little bit? 

Yeah. So I think that there's a perception out there that these operations are cosmetic, and in many cases, cosmetic operations are not covered by insurance. But I think it's really important to understand that these obesity and metabolic operations are not cosmetic. 

As Dr. Hussain alluded to, these things actually change the physiology of the body and contribute to the weight loss, as well as to the improvement in the medical conditions related to obesity. 

And because of that medical aspect, most insurance companies actually do cover obesity surgery. Although the individual patient has to look at their plan to see if it's a covered benefit. 

It turns out that, with the reduction in medications and the overall gain and health that takes place after these operations in the long run, it's actually a cost savings to the health care system for individuals to undergo these operations. 

That makes perfect sense. Well, gentlemen, thank you very much. That was great. 

Thank you. 

Appreciate it. That's all the time we have for At the Forefront Live. Thanks to our guests for their participation in today's program, and thanks to you for watching and submitting questions. 

If you want more information about bariatric surgery, please visit our website site at uchicagomedicine.org, or you can call 888-824-0200. 

Join us for our next At the Forefront Live, where we learn about minimally invasive robotic cardiac surgery. That's Monday, February 4th. Also check out our Facebook page for future At the Forefront Live dates and subjects. 

Thanks for watching, and have a great week.

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