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When is Weight Loss Surgery the Right Answer?
Most people are told to “try harder” while fighting a disease their biology is trying to keep. We sit down with bariatric surgeon Dr. Joshua Alley to cut through stigma and explain how modern metabolic care actually works: minimally invasive procedures, powerful new medications, and a full-circle support system that treats obesity as the chronic condition it is. The goal isn’t a number on a scale; it’s better health, more energy and more years with the people you love.
We break down the options in plain language. You’ll hear what distinguishes sleeve gastrectomy, gastric bypass, and the SADI procedure, why today’s surgical risks are similar to gallbladder surgery and where GLP-1 medications like semaglutide and tirzepatide fit. We talk criteria beyond raw pounds, including BMI and conditions like sleep apnea, diabetes and hypertension. If you’ve wondered whether surgery is “the easy way out,” you’ll get the uncomfortable truth: patients work hard before and after, and long-term success depends on nutrition, sleep, movement and consistent follow-up.
Ready to explore your path? Start with your primary care clinician or self-refer to the bariatric or medical weight management team. If this conversation helps reframe your thinking, follow the show, share with someone who needs hopeful facts, and leave a review to tell us what you want to hear next.
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Hi and welcome to And So Much More. I am here with Dr. Joshua Alley, who is a bariatric surgeon here at Centra. And there have been a lot of misconceptions, I think, out there about bariatric surgery. And we thought, why don't we have this conversation about like putting to rest, which just isn't true, and shining a light on like what it is important for you to know, whether you're considering this or someone you love is going through this, how can you better support them? So much information we're gonna cover today. But first, Joshua Alley, why don't you tell us a little bit about yourself, how you came to Centra?
SPEAKER_01:Sure. I grew up here in Lynchburg. I worked for Centra back in the 90s when I was a hospital orderly at Lynchburg General. Oh wow. And then uh went away to college, med school, residency, military service, practiced up in uh the Northeast for a while, and then was able to come back to Lynchburg 10 years ago.
SPEAKER_00:Okay, wow, Lynchburg native. You don't hear that a lot.
SPEAKER_01:Yep.
SPEAKER_00:Um, so what made you choose bariatric surgery?
SPEAKER_01:Um I started doing it first uh in residency because I um uh you have to you know have to do it as a resident. And then when I finished residency, one of my mentors said, uh you're you're pretty good at this. You should come and join us and and um do the training and do this full time. And I thought, well, why not? And then started um learning a lot more about obesity and then really got passionate about helping patients who have obesity to to work on this disease because it's uh more complex than a lot of people think.
SPEAKER_00:Yeah, I believe it. And we're gonna talk about some of that as well. Um, so just to kind of start really plainly um for myself, but also for those who are listening, um, you know, bariatric surgery, if you have not heard that term, you have not interacted with it, you're kind of wondering what are we talking about? So, what is bariatric surgery?
SPEAKER_01:Well, some people call it weight loss surgery, uh, bariatric surgery, metabolic surgery is another term that's come into um uh more popularity lately. And it's basically uh surgery and lifestyle change to help with sustained weight loss. And um uh it's there's a number of surgeries that are done as part of bariatric surgery, and we use dietary intervention and we use medications. So a lot of patients um I tell, you know, we do about this much surgery and about this much lifestyle change work.
SPEAKER_00:Oh wow. See, I think that's important to know because I don't think as I would have thought about bariatric surgery, like your mind just goes to surgery. But the fact that there is um so much lifestyle change that's in encompassed with that, I think that's actually pretty pretty cool that you're looking at the whole person here and really their whole life outside of the surgery, outside of the operating room. Um, so why do you think there are so many misconceptions about this?
SPEAKER_01:Uh well, I think a lot of it comes down to there's a fair amount of obesity bias in our society.
SPEAKER_00:Yeah.
SPEAKER_01:Um, there is a tendency to think of obesity as a character flaw, a willpower failing when it's really a complex chronic disease that is quite difficult to treat. Um, a lot of do-it-yourself methods have very limited success. And so um, because of that, a lot of people are very reticent to talk about the things they've done to work on weight loss. In fact, a lot of patients who have had bariatric surgery, their friends don't know it. They think, oh, you know, that person, they've been, they they told me they were working on their eating habits, they were working with a doctor, they lost a lot of weight and kept it off. What's wrong with me that I can't do this? And oftentimes that person doesn't want to speak up about the interventions they've had, whether it's medication or surgery, because there's a lot of bias and they're expecting to be judged by you know uh people in society for making choices to deal with their weight.
SPEAKER_00:Yeah, and that kind of leads me to my next question is like, why do you think people consider this an easy way out? You think it just comes back to that bias?
SPEAKER_01:Yeah, um obesity is um it's like a lot of other diseases. There are things that we do to contribute to it. There are a lot of things that we have no control over that contribute to this disease. And um, but uh the the um perception in society is that this is just that person's fault. And so for that reason, you have some employers that don't provide any coverage for obesity treatment, which is a shame. Um you have people that think that it's the easy way out or that you should suffer and work harder when these uh patients of ours are working very hard and they've tried a lot of different things often before they come to have bariatric surgery. Um so it's not the easy way out. There's a lot of hard work involved in this.
SPEAKER_00:Yeah. So when you say obesity, I think that um some of our some of our minds go to an extreme place. But um bariatric surgery is not for someone, from what I understand, who is extremely overweight, or is that not true? So can you what are like the parameters when you think about that? Is it only for someone who uh maybe is well past a certain number on the scale? Great question.
SPEAKER_01:I think my 600-pound life is the is the uh the elephant in the room that we have to address, that there's this TV show, and what makes good TV is extreme cases, yeah, right? And so um that show is about the the extreme cases, and and those patients are appropriate for bariatric surgery, but a lot of our patients uh aren't that large. Um, probably 250 to 500 pounds is the is the the normal range that a lot of our patients are in, and even some shorter patients may be smaller than that. Oftentimes they've had family or friends say, Well, you're not big enough to have that surgery. And it turns out it's not based on a certain number of pounds or what your relatives or friends think, it's based on pretty set criteria, uh things like body mass index, whether you have health conditions like diabetes, sleep apnea, high blood pressure. Um, and so um it you don't have to be extreme, you know, five, six hundred pounds to have bariatric surgery.
SPEAKER_00:Yeah.
SPEAKER_01:Um and then you get down to um what are the different uh treatment options for obesity? Um and so there uh there's a whole class of medications that are really popular right now. A lot of people are trying them called GLP1 receptor agonists or GLP1s. Um you may have heard of the diabetes versions like um semaglutide, osymphic, um uh manjaro, trzepatide, but there's an obesity version of all those because they also help with um weight loss. Okay, and so those are great for people that want to lose 30, 40, 50, sometimes 60 um pounds. Oftentimes our patients that come to us need to lose 100 or more pounds. Okay, and so um uh and in some cases we combine surgery and medications to get that weight loss result that people need because some of our patients need not just one or the other, but both.
SPEAKER_00:Yeah, oh wow. So this is a very personal, and I think that this is important anytime we have a podcast about um I would say procedures like this or services that we offer, it is about having a conversation with your doctor because it's going to be different for everyone. One thing is not gonna work for someone else. I think it just how we're made and um and having that open dialogue with a physician is so important. Um, and I think back to this bias, that's gotta be a hard conversation to start.
SPEAKER_01:It's very difficult. And your doctor oftentimes is um very maybe reticent to have that conversation. So definitely bring it up with them. Uh, our patients with obesity often that that um disease, it's like a it's like an infected wound that's very tender, and they have been judged so many times that it's almost a place they want to close off and not address. And so, um, and your doctor is sensitive to that. They don't want to bring up things that are causing you pain or discomfort or make you upset. But um uh very often um you know your your your doctor's willing to have that conversation with you, and and many of them do bring it up. Um we we love to um talk to our medical colleagues about how to do that in a in a um in a careful way, yeah. Um but um realize that your doctor wants to talk to you about your weight and it affects so many other health conditions that you have.
SPEAKER_00:Yeah, and it's not a shaming conversation, it is a support conversation.
SPEAKER_01:It should be conversation.
SPEAKER_00:Yeah, it should not be that.
SPEAKER_01:You know, our clinic works really hard to um, you know, we're we're we like to think of ourselves as the friendliest place to talk about your weight and your struggles and your failures and your successes. Um we we don't beat up on people, it's uh it's a um it's an encouraging thing and it's a um a sensitive thing when you're not doing well.
SPEAKER_00:Yeah. So let's talk about the actual procedure. Um, I mean, I think most people get a little apprehensive when it comes to surgery, yeah, as it is. So um, can you talk about like the safety of it, the preparation for it, um, what parameters are put in place so that um this is done really well?
SPEAKER_01:Yeah. Well, um, the good news is that bariatric surgery, there are a number of procedures and they're all done minimally invasive, and it's about as safe as gallbladder surgery now.
SPEAKER_00:Oh wow.
SPEAKER_01:Which is a pretty common thing that's done in our hospitals. Um, I think the key thing that you brought up is that this is not the first thing to you know to try, but believe me, our patients that come in to see us, they have tried a lot of things.
SPEAKER_00:I believe it.
SPEAKER_01:They've tried a lot of do-it-yourself diet programs, they've tried a lot working with a dietitian or their doctor, and sometimes tried medications, and that's appropriate. Um, but many times um uh patients say, I wish I had you know done this sooner, instead of continuing to work at the same things that were not giving them results that they needed. Um bariatric surgery is um uh, like I said, about the same level of risk as gallbladder surgery. It's an overnight stay in the hospital. It's done through small incisions with robotic-assisted laparoscopic surgery.
SPEAKER_00:Oh wow.
SPEAKER_01:There are three procedures that are commonly done or that are done in our medical center right now. There's an older one called the gastric bypass, it's been around a very long time and it's still very good operation. There's a newer one that's very popular in the US in the US right now called sleeve gastrectomy. And um, and then there's a third one for patients maybe that are larger or have um uh more difficult insulin-dependent diabetes called the SADI procedure. So we talk to patients about each one of those. Uh, people watch a video to come into our clinic and learn a bit more about each one of those procedures before they see us.
SPEAKER_00:Okay. So long-term outcomes, because I imagine as if you've tried everything and it's not working, um, and you get a surgery that feels very like final, like, okay, this is going to change things for me. Can you talk about like long-term outcomes? I know some people say either you can't gain the weight back or it's very dangerous if you don't follow certain protocols and you do gain the weight back. What does all of that look like?
SPEAKER_01:Yeah, great question. Um, so it's important to recognize that obesity is a chronic disease. It's we call it, it's defined as a chronic relapsing uh metabolic disease. And which means that it's um going to try to claw its way back into your life no matter what you do, whether you take medications, whether you do diet plans, or whether you have surgery. So long term, it's not like surgery takes away the need to do healthy things with regard to our weight. Surgery makes it possible to do some of those healthy things, and then we gotta stick with them long term.
SPEAKER_00:Okay.
SPEAKER_01:And we plan to see our patients long term uh after the surgery, at uh, you know, frequently during the first year, and then we space out those visits more. Uh, is it possible to regain weight after surgery? Sure. Yeah. Uh ultimately what it comes down to though, you brought up long-term health outcomes. They've studied patients that have had bariatric surgery, and the studies have gone on for 10, 20, or more years.
SPEAKER_00:That's encouraging, though.
SPEAKER_01:There's a big one out of Sweden. Um, there was a large one out of Utah several years ago, and there are multiple ongoing ones. Cleveland Clinic has been big in this, and they've shown that patients who had bariatric surgery compared to patients who were otherwise uh the same as them who didn't go through surgery, they were more likely to be alive in 10 or 20 years, mainly due to reductions in death from cardiac disease, diabetes, and cancer.
SPEAKER_00:Okay, can we just highlight that for a second? Because not just in 10 years they were able to keep the weight off, which is I think where our brains go. They were still alive. Like this is, I think that changes the perspective from oh, you're doing this just because you want to lose weight, it's it's a vanity thing, to like, no, like this is life-saving surgery.
SPEAKER_01:This is not what patients do to look good. Most of our patients come in, they're like, I don't, you know, the looks is the last thing in my mind. They want their health to be improved, they want to be around for their children and grandchildren to see those milestones and not be chronically ill or even not around with us anymore.
SPEAKER_00:Yeah, I mean it will change your life completely.
SPEAKER_01:Absolutely.
SPEAKER_00:So, someone who is either watching this or you know, how do you start this conversation? Like, do you start with your primary care provider? What is how does the journey begin?
SPEAKER_01:Yeah, I think that um uh starting with your primary care provider is a great option no matter what. Um, some patients self-refer and come right directly into our clinic, and that's another way to come into. Some patients come in and see our medical weight loss team. So we have uh a number of providers in our clinic that do non-surgical weight loss using a combination of medications and uh dietary interventions and things like that. So uh I don't know that it matters how you get into us, just that you take action and get in and see someone in our clinic.
SPEAKER_00:Okay.
SPEAKER_01:And uh very often patients work through that medical process, and if there's they get to where they want to be, great. They just kind of stay in maintenance mode there. If they try and see if they can maximize the medical therapy, but they're not quite where they want to be, they'll often get referred over to see us for bariatric surgery.
SPEAKER_00:Okay. So since there are so many options, which I think is really great for those who are coming in and maybe feeling like, where do I go? What do I do? How do they decide between surgery or non-surgical approach?
SPEAKER_01:Yeah, it's often a patient choice. No one has to have bariatric surgery, um, but um often it's it's based on what their goals are. You know, if if they need to lose about 150 pounds to be at a healthy weight, not a skinny weight, but a healthy weight, um they um often are not going to get there with um with just medication or just dietary intervention. If they can, if they're that 1% that can do it, great, that's that's a that's a win. Um but uh you know, like I said, um medications and medical therapy are great for 30 to 60 pounds of weight loss. And then above that, we're often talking about bariatric surgery or surgery plus medications.
SPEAKER_00:Okay. I imagine there has to be some type of support system in place for these types of, I would say, approaches to be successful. I mean, it's just really difficult to sustain something by yourself. I think that level of willpower exists to your point in that 1%. Um, I'm not in that 1%. I need a support system and accountability, even just to make healthy choices, to get out and be active. And so, how do you ensure some of that is in place for your patients?
SPEAKER_01:So uh there are a number of um parts to that question. One is that every patient has a pre-surgery uh mental health and kind of social evaluation by one of our mental health providers. Okay. Do you have the support you need? Are you gonna be able to make these changes? Uh are there any things that are gonna trip you off, like substance abuse or mental health issues that need to be addressed better before you can go through the surgery? Uh secondly, is is your um and and sorry, I should also say that mental health support is also available after surgery. Oh, because sometimes things come up as you're losing weight or life happens and it's knocked you down, you're working, you're struggling with your weight because these other things are going on. Yeah. Secondly, is that your family uh support system, right? If you have a spouse, they they really need to be supportive or a significant other because they can make or break your success in this area. And then your extended family also. And then uh third, we have in our clinic our support system. So we see patients long-term, I mentioned. We also have support groups that meet monthly. Um all-commerce support group, and then a just post-op patient support group. And those are we have a combination of virtual and in-person groups, um, and that's that's uh a way to kind of stay motivated, stay inspired, um, and and kind of um build each other up in that way.
SPEAKER_00:Yeah. I love that this is such a, and I kind of already said it earlier, but this is it feels it's not holistic, but it feels like a holistic approach because you are really serving every part of this person. You're making sure mentally they're prepared, you're making sure emotionally they have the support system, you're following them after the fact with all of those same components. This really is not just about fitting into the right pair of jeans, which is, I think, the misconception out there. I think a lot of people um there's some shame associated with it. I think there's just um a complete misunderstanding when you think about the work that it takes for this surgery to be successful on the front end and then afterwards.
SPEAKER_01:Um I think a lot of people underestimate that amount of work. Yes. I think um, you know, people that want to lose, you know, 50 pounds uh feel like I just need a little bit of something, and you often need a lot of work to do that. Yeah. People that need to lose 100 or 150 pounds really need pretty dramatic intervention to get to that. But uh you're right, it's a it's a global um it's a disease that has so many contributing factors, it affects so many parts of our lives. And so it's no surprise that we really need to work on it from a lot of angles, from both the mental health, the nutrition, the you know, the metabolics, so with surgery and medications. Um, and and we talk a lot about sleep and how important that is for for good health and for maintaining a good healthy weight. Uh, we talk a lot about exercise. Exercise is a misunderstood thing, it doesn't cause much weight loss by itself, but it is important at keeping the weight off, and it's so important for living a long, healthy life.
SPEAKER_00:Yeah.
SPEAKER_01:And so we are we are um we are bullish on exercise.
SPEAKER_00:Yeah. So it seems like um we've covered a lot. So for those of you who are watching, maybe taking notes furiously, this is a lot of information. Where can they go to learn more? Like you said, they can just walk right in if they needed to, which I think is great. I don't think the average person, including myself, would have known that you don't have to get a referral for something like this to be able to come right in. I think that is really encouraging. Um, but like, is there anywhere they can get more information? I know you guys have like an informational video.
SPEAKER_01:We do, yeah. You can you could just Google Central Weight Loss, and um that's probably the easiest way to find us. Um you'll find the link there. Uh, there's an informational video that you can watch there. In fact, um, to come into the surgical program, you you need to watch that and then submit some information, and you'll get scheduled for an appointment with us. Um, you can also um submit um uh requests to get seen in the medical weight loss team there. So either medical or surgical, whichever way you want to go, you can go to Central Weight Loss and um and find that out. I do recommend talking to your primary care provider about it. That's so important. Other things that people can do as they prepare for this, one key thing that um uh everyone that does it knows they need to quit is is quitting smoking. Um and uh it's a hard thing. Uh nobody says it's easy for sure, but um to have the good outcomes that we talk about, that's because um we make sure patients have quit before they before they go through surgery. Okay, so that's an important thing too.
SPEAKER_00:Which is so interesting because I feel like um that's a misconception right there. I I know this was a very long time ago, but when I was in high school, you know, all my friends were smoking because they thought it suppressed their appetite, so they wanted to lose weight, and it was like something that they wanted to do, which is ridiculous. But I think when you when you open your mind and you open yourself up to kind of changing some of those beliefs you have in your head, there's a lot waiting for you on the other side of it. Absolutely. Um, so if there was anything I didn't ask you, or anything you really think that would it would be important for someone to know about bariatric surgery, about this whole process, non-surgical weight loss, is there anything you'd like to add?
SPEAKER_01:Yeah, I think that um uh weight loss as portrayed in the media is a huge influence on how people think about obesity. Right? And so that you know, think about the biggest loser where people um you know can work out um with trainers for hours a day and have a personal chef that prepares, you know, these high-quality meals for them and they're sequestered from all of the rest of life for weeks and weeks, and they lose a huge amount of weight. Um, it makes it seem like, well, this is just something that anyone could do. And that is not something that anyone can do, right? Uh it's an artificial environment. And that's that is shown to be the truth by the fact that they've studied um the biggest loser participants after the show, and they showed that invariably almost all of them regain to within about 10% of their starting weight, and at the end of that journey, their metabolism, their metabolic rate is slower. So there's some there are some changes that your body makes to try to regain weight, which is why, one, it's important to um to keep up with it, all right, continuing to work at it with uh with a you know with someone or uh however works for you for the long term. But two, this is not just an issue of willpower. And I think that's the unfortunate thing about some shows like The Biggest Loser, it makes it seem like, well, anyone could just do this if they put their mind to it. And um that's exactly what the biggest loser shows is that you it's not just a willpower thing that um people regain that weight if they don't have some other uh there's one participant, the biggest loser, who then went on to have bariatric surgery, and they were the only one of their cohort that kept the weight off to a significant amount.
SPEAKER_00:Well, there's the data right there for you. Yeah, wow. Well, thank you so much for sharing all of this information. Um, we're gonna put some links in the description um to our page on centerhealth.com that has bariatric surgery represented with a lot of great resources. Um, and then anything else, we'll throw some of the video link in there if that would work. Um and I encourage you guys to check it out. Start having these questions, bring them to your provider, or just I guess walk right in and set yourself up. So thank you for joining us.
SPEAKER_01:Thanks, Kami.
SPEAKER_00:Yes, and thank you all for joining us on and so much more.
