The Cancer Doctors Keep Missing in Young Adults - Dr. Michelle Pearlman

Colorectal cancer is very common, and it's now becoming the leading cause of cancer under the age of 50. And we're seeing it at earlier ages, so in most other cancers, we are making progress when it comes to prevention and lowering prevalence, but we're seeing more metastatic disease in younger individuals. Most people don't go to a gastroenterologist thinking I'm going to do nutritional work. They're thinking I'm bloated, I'm having reflux. Most gastroenterologists would say you're too young for colorectal cancer, it's probably just hemorrhoids. And then we realized it's not just hemorrhoids in a lot of people, even if it's just rectal bleeding with wiping, I recommend to colonoscopy. What are some of those alarm signs? It would be unintentional weight loss. Medicine isn't about disease prevention, it's about fixing a problem. We need to stop telling people to just do it on their own, they're going to be doing it on their own, but why not use tools in the toolbox to do two things, make it a little bit easier and a little bit less painful, why not? You realize that we are at the precipice of an entirely new landscape of medicine. I would say this has completely revolutionized healthcare. These medications are going to infiltrate every single field in medicine. So the first medication I have here is Dr. Michelle Perlman, welcome to the show. Thank you so much for having me. You know, as I was thinking about today's episode, we are going to talk about a gastro-metabolic approach to health and wellness because you are a gastroenterologist. For those individuals who don't know what that is and that field of medicine, how would you describe that? In simplistic terms, I take care of everything from the mouth all the way down to the anus. So what does that mean? Well, it's understanding digestion, absorption, the things that we put in our mouth, how that affects the cellular health of our body, and the gut microbiome, which oddly enough, I never learned about in 14 years' worth of medical training. Not surprising, it's kind of this evolving field. When we were talking before the camera started rolling, you had said that you were doing a ton of endoscopies, the little cameras that you swallow, and that's a routine procedure done by gastroenterologists. Also, you do colonoscopies, so you do both ends. Not at the same time. That would be impressive and very convenient because it would really minimize the amount of time that one was in the operating suite or whatever it is. You had said something that I thought was really interesting from a medical perspective. Number one, typically medicine isn't about disease prevention. It's about fixing a problem. And when you were scoping these people, they would finish their scope and say, I'm still not feeling well. It's interesting. I went into gastroenterology because I've always been fascinated with nutrition. And I figured, okay, out of all the specialties available, which one would you assume would learn the most about nutrition? Well, a gastroenterologist came to my mind because the gut and its food and our mouth and everything and absorption and digestion. And I'll tell you throughout all that training in three years worth of gastroenterology and hepatology fellowship training, I learned pathology. I did not learn nutrition. I learned about ciliac disease. I learned about ulcerative colitis and Crohn's disease and steatohepatitis and reflux disease. But none of that training actually covered nutrition. And it was actually one of my attendings, one of my bosses in my training program told me when I was about to graduate, he said, Michelle, there's no business in nutrition. I think you should just be a general gastroenterologist and do endoscopies and colonoscopies. And I said, I don't buy it. Okay. And now you, in your own clinical practice, so you have a private practice, you combine both nutritional sciences with gastroenterology. Oh, absolutely. Because they are one in the same. Just like the mind and body, people often say that they are two different things. The whole gut brain access is such a powerful connection that we have. And so when I would do, you know, let's say 15 procedures in a day, I would have people that have been struggling with acid reflux and abdominal pain and bloating, diarrhea, constipation for decades. And they would wake up after the procedure and they'd say, doc, what's wrong with me? I'm miserable. And I learned a powerful lesson. I once, you know, I trained at the VA and my patient woke up and I said, Billy, great news. Everything was normal. And he said, Oh, doc, so you're telling me I'm bat X crazy. And I learned don't tell someone who's suffering that everything's normal. I think the phrasing is very important. And so endoscopies and colonoscopies are looking for structural things. But oftentimes when people are suffering from acid reflux and all these other symptoms, it's more of a functional process or a motility issue. And you're not going to find that during a procedure. When you are seeing patients now, your practice is a little bit skewed, people are really coming to your prevention. But for the general population, what is the most common symptom that people are seeking to solve for? And so my practice has definitely evolved. Initially, I was seeing people mostly for weight management. So people who wanted to be able to lose a good amount of weight for overall health, not to see a six pack and walk around on South Beach, although I do have a couple of those. But most of my patients wanted to lose, let's say 10 to 15% of their body weight and be able to keep it off. And so that's the initial practice was weight management. How things evolved is, you know, a lot of my patients were middle age women. And a big part of my practice is using GLP one medications to improve cardiometabolic health and help with the weight loss process. Because most of the patients come to see me, it's not their first rodeo, they've struggled for decades. The last thing they want is to go to a doctor and be told by just another person to eat less and move more, because they're really struggling. So I use all the tools in the toolbox to help optimize someone's health when they come to see me, which is counterative because most people don't go to a gastroenterologist thinking I'm going to do nutritional work. They're thinking I'm bloated, I'm having reflux, maybe I need my scope, which is now 45 is when they recommend. For colonoscopy. But what's interesting is so many gastro related issues, heartburn, bloating, pelvic floor dysfunction, constipation are weight related. And that's one of the other reasons why I pivoted in my practice is because a lot of my patients were struggling with their weight. So they would have acid reflux. And I would do the endoscopy and the endoscopy was normal. And I'd say, okay, go on protonics or nexium or, you know, pick a random antacid where there's a million on the market. Why don't we shut down your acid production? We would give out as gastroenterologist, PPI's, another antacids like candy. But is that fixing the underlying problem? If someone is struggling with obesity and they have a lot of visceral fat, that extra fat around the midsection is just acting like an external corset. It's increasing intradominal pressure and they're going to reflux. So no amount of antacid is going to fix the mechanical issue. So that was one of the main reasons for my pivot. The other main reason is the place I was working was not ready for a culture shift when it came to nutrition. So it's fascinating within medicine. We talk about things at such a high level. When we talk about innovation and technology and all these high level concepts. But I don't know if you've seen it and I'm sure you have. We are missing the low hanging fruit pun intended. One of the worst places that you can find ultra processed food is the hospital. I would have patients wake up from their endoscopy. They would literally still be half asleep, lying almost flat. And the nurse would give them orange juice or they'd give them a very high sodium turkey sandwich or a cookie or a muffin. And I would tell them I literally just spent an hour with this patient talking about optimal nutrition. It really sends them a very confusing message to give them everything I told them to limit. And I was told by the staff that I was too aggressive for asking for hummus and carrots and healthier snacks when my patients woke up from their procedure. That is shifting. Now we have the new dietary guidelines that are really targeting towards whole healthy foods. What percentage of individuals if the majority of individuals are struggling with obesity or are overweight. But also a huge percentage of the population has reflux. What percentage would you consider or do you think is the reflux related to say something like H. pylori or some kind of pathology or maybe not pathology but a parasite or something like that versus weight. Yeah, I think it's really hard to say. I would say the new normal is being overweight or obese. Where if you see a normal appearing individual oftentimes we assume there's something wrong with them. I mean that's how scary it's become with just even on a global perspective when it comes to weight when it comes to being overweight. So I'm not sure I can give you that exact percentage because if the majority of patients we're seeing are overweight or obese and I'm a gastroenterologist I'm seeing a very skewed population because most of those patients are coming in to see me for gastrorelated issues. Do you use PPI's. I do. A lot of my patients come in because they've been on them for years but my goal is attack the nutrition part and not just what they're eating but the dietary habits are equally as important. How late they're eating, how much they're eating, how quickly they're eating, you know what is the volume at which they're eating. Are they sucking down tons of fluids with a straw during their meals. So those dietary habits are equally as important. So I tackle those. Obviously I want to try to help them get to a healthier weight. If they need a PPI or another antacid in the interim by all means I'll use them but my goal is not to just shut down someone's acid long term because we're seeing longer term effects from these right. It is a survival mechanism or it's evolutionary you know based that we produce acid because acid helps us break down food which then allows for proper absorption. So it only makes intuitive sense that if I were to shut down all your acid production could I be affecting bone density? Probably. I think there's some pretty good data. Yeah. Yeah and this is actually. Because that affects vitamin D and calcium and all these things. That is exactly where I wanted to get to with this component of the show about PPI. So proton pump inhibitors, things like Pepsid or antacids. One of the things very I remember I used to live in New York City by the way and a very fit more mature woman came in and she fractured her femur and this was close to 15 years ago and based on everything that we looked at because I was you know utilizing nutrition in my practice I was like listen this PPI use that you've been on chronic PPI's this is affected your calcium your vitamin mineral status and man her coach her trainer was furious at me because they were like I can't believe that you told them that their PPI is affecting their bone density. Subsequently years later we're starting to see a lot more data that these are even while they are available over the counter these medications are available over the counter it doesn't mean that they're safe. Oh when I would say some of the over counter medications like ibuprofen they get gastroenterologist job security when it comes to peptic ulcers the number of patients that would come in hemorrhaging to death because they took a bunch of NSAIDs for let's say orthopedic issues more than I want to say so oftentimes people quite over the counter was safe and that's not necessarily the truth. If you were to tell them people listening what's up guys three things never to do what would you tell them please don't say carbonation and I know your sister is here Dr. Amy Perlman we're not talking about sex toys just yet but would it be for example I love carbonation please don't tell me to stop drinking carbonated things are there just a handful of things that you're like you know when it comes to acid reflux in particular or how about gut health just in general okay the first thing would be you have to be able to identify the food right so if it's something like baloney it's a hodgepodge of the odds and ends of who knows what that is so even though it's high protein it's very ultra process so that can definitely lead to dysbiosis of the gut so I would say try to minimize the number of ingredients so calories are important macronutrients are important but the quality of our food and the ingredients really really matter when it comes to overall gut health and how people feel. How do we how do we know do we know that to be true so we have randomized control trials that'll elicit the information that if something is ultra processed there so there's a cause a mechanism of action and an outcome. So for instance like deli meat is considered a class one carcinogen increased risk of things like colorectal cancer and gastric cancer so you would mention kind of the new screening guidelines for colorectal cancer so really since the beginning of time it was age 50 but we are seeing metastatic colorectal cancer in 20 year olds. Why do you think that is? It's our environmental exposures these are people without genetic predisposition and the the interesting thing is our genetics haven't changed within the past couple of decades our environmental our environmental exposures have and that changes the way our genes are expressed or epigenetics. Do you think that it is the say for example the nitrites nitrates or do you think that it's this constant exposure to chemicals from maybe fruits and vegetables or just you know why colorectal cancer? I think it's all of those things right when I say environmental exposures it's whether it's microplastics whether it's pesticides whether it's you know pollutants in the air it's so hard to say because you can't do randomized control trials in that regard I don't know what people are being exposed to in their home let's say with mold. Colorectal cancer is very common and it's now becoming the leading cause of cancer under the age of 50 for individuals and and we're seeing it at earlier ages so in most other cancers we are making progress when it comes to prevention and lowering prevalence but we're seeing more metastatic disease in younger individuals and and why is that it's because the stuff we're eating right has direct contact with our gastrointestinal tract versus let's say you know our skin you know that's different our hair is different our eyes are different what we're eating and our gut microbiome our gut is our largest immune organ so if what if we're putting in chemicals into our body and we're stimulating this underlying cytokine cascade that has huge implications on just overall health and disease but also direct contact with that gut lining. And is it because the colon is where if someone is constipated that that you know waste byproduct sits there? Oh yeah I think that's I think that's definitely playing a role now does constipation increase risk of colorectal cancer I don't think we have the data to support that but I'm sure you know if those feces which are you know basically waste matter are sitting there I imagine that probably can't be good for the lining of the gut. Yeah I just I think do we have you know the the carcinogen classification has been a real challenge for me because you know there was that annals of internal medicine Bradley Johnston came out with you know basically he looked at red meat and he looked at the risk factors and he used the grade analysis for you guys listening and we'll link these papers I think they're available to everybody but basically the grade analysis of how you know the quality of the evidence and there if you know basically if it's whole red meat he didn't find a relationship between cancer or heart disease which makes me think is it a weight problem is it for example if we've got 20 year olds that are coming in with metastatic cancer I mean it's got to be pretty complex and it's probably also from what I understand one of the risk factors for colorectal cancer if I'm not mistaken is obesity. Oh yeah no absolutely but what's interesting about that is that hasn't made it into the screening guidelines so if let's say I have a patient who has metabolic disease and obesity I'm not screening them any earlier based on guidelines I'm still waiting until I'm 45 I think that's where the guidelines probably need significant improvement if we know that you know diabetes or insulin resistance or fatty liver if these things may play a role in development of polyps then that should make it into the screening guidelines to the point where let's say you have someone who's very healthy and they have a colonoscopy at 45 do they need to repeat colonoscopy in 10 years maybe maybe not versus someone who let's say is diabetic and has other metabolic issues maybe we shouldn't wait 10 years even with a normal colonoscopy at 45 I think that's where there's a lot of unknowns. When do you think would be appropriate to screen for colonoscopy? I think 45 is appropriate because if we were to lower that age the question is are people going to have access to the procedures we already have depending on where you live there aren't many gastroenterologists in smaller towns so if we end up lowering the screening age are these people actually going to have access to get colonoscopies and colonoscopies do have risk because you get sedation versus screening a larger population there's now a blood test that's come out you can do coligar which is do you mean testing of the skulls? I just want to pause for this is really important I believe in early cancer detection are you talking about the grail test or the gallery test that looks at methylated DNA for various types of cancers or coligar or something like that? So it's actually a different company it's a different company that recently came out so it's separate from like the gallery test and specifically is looking for like higher risk polyps in the blood so that's a separate test yeah yeah that's how you get more people screened right a screening test is only effective if you're doing it in a large population and how specific like how sensitive are those tests? Yeah you're still going to have false negatives and false positives um but if someone is willing to do a colonoscopy with a positive blood test versus they'd say I'm never doing a colonoscopy which I have patients like that and I'm sure at least they're going to get screened now would you offer the blood test if they said even if it's positive and not getting a colonoscopy not sure in that regard it's going to be helpful but sometimes it will lead someone to get a colonoscopy if they say okay you know I need to take this more seriously because it was a you know a positive test but yeah you can still have false negatives and false positives colonoscopy is technically the gold standard but not everyone has access to colonoscopies and not everyone is willing to do that as their first step. Three things that you would tell your patients to never do for gut health. Okay um I never say never but the first one is to avoid or try to at least limit ultra processed food. Number two? Number two is never well I guess I do say never almost never never ignore warning signs. I think that that's a really good never do because as physicians I think that we're also focused on the nuance and it's very difficult to say okay this is black and white but that is something that I would say people should never ignore warning signs I think that's really important. Yeah and I think we're seeing it you know in the celebrity realm where people are coming out um James Vanderbeek with Colorectal Cancer. That's what I was thinking yeah and how by the way didn't have a weight problem. Yeah no but he had some symptoms that he probably said oh it's probably nothing and there's been several celebrities and professional athletes that have died from colorectal cancer over the past few years and so it used to be that if a 25 year old person came into my clinic and said I've had rectal bleeding most gastroenterologists would say you're too young for colorectal cancer it's probably just hemorrhoids and then we realized it's not just hemorrhoids in a lot of people and so anyone with any sort of rectal bleeding even if it's just rectal bleeding with wiping I recommend a colonoscopy so we don't want to avoid those warning signs what are some of those alarm signs it would be unintentional weight loss nausea how much weight loss 5% 10% there's no percentage it's just it would be unintentional so because it depends on what your starting weight is if someone's 200 pounds and they lose 5 pounds I probably wouldn't be so concerned if I have a patient who's 120 and they lose 5 pounds that could be a big deal if there is no other explanation so unintentional weight loss nausea vomiting abdominal pain if it's getting worse or if it's not improving so not just a run-of-the-mill gastroenteritis if something is prolonged or getting worse that would be a warning sign and then rectal bleeding or blood in the stool so never ignore warning signs yeah avoid ultra processed foods yeah the third one I would say is we can't skip the foundation with all the hype with peptides and glp ones and glp ones are a big part of my practice and all the technologies and innovation that are coming out within the medical and the wellness industry we cannot skip the foundation which is optimal nutrition getting our protein as you know moving our bodies on a daily basis no amount of medication will replace those things sleep stress management that social network all those things are incredibly important for overall health and wellness okay the worst is going to buy sheets and they look pretty 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exposure actually to these medications so I was a gi fellow at the time and I actually got exposure to this medication outside of my own training program so I was already very fascinated with weight management and cardiometabolic health so I asked someone who ran the weight management program at UT southwestern he's an endocrinologist and I said I'm a gastroenterology fellow but I would love to rotate through your endocrine who was that Dr. Jamie Almond does he is phenomenal he is the man who changed the trajectory of my career not even within my own training specialty so I rotated through his clinic and that was my first exposure to watching a dietician talk to a patient it was my first exposure to see a doctor talk to a patient about what does their family unit look like what does their budget look like you know what are their health and wellness goals what is their nutrition intake what is their movement and then give them a realistic plan on all the foundations of health and wellness nutrition movement but then also introduce medications when they were appropriate and to the point that he inspired me I kind of created my own little weight management clinic as a trainee and I was actually teaching my attendings at the time which was fascinating you bring up a really good point the misconception about GLP ones is that they are new medications but they have been around and have been FDA approved for type 2 diabetes then 2018 they are then available to be used for weight management and I think that that's probably the biggest shift would you agree because the medications were around yeah so the initial medications uh victoza was initially uh FDA approved for type 2 diabetics they started seeing that people were losing weight they did additional clinical trials and that's when succenda came out so these are daily injections and that's loraglotide is kind of the the generic name now loraglotide or succenda for weight loss only gave you about five to six percent weight loss so it's something but for overall cardiomathabolic health we typically want to hit around seven to ten percent of weight loss it's not a hundred or two hundred pounds it's seven to ten percent so it was helping the good thing also about it is a lot of the other diabetic drugs on the market like insulin which we used to use a lot were weight promoting so it wouldn't be fair to the patients if we said you know hey sally you got to lose a bunch of weight we have to start insulin for you because of your diabetes my goodness we just made it a lot harder for sally to lose weight because we're giving her insulin which is a fat storage hormone so at least we had medications that were targeting both the diabetes management but also helped them lose weight and then ozempit came out in 2018 so that is a once per week injection so the other name for that is somagotide but actually wegovi which is the same medication but different dosing came out in 2021 so it actually wasn't until 2021 that we had medication FDA approved for weight management and people with a bmi of 27 or above with a comorbid condition weight related or 30 and above and they didn't need a comorbid condition and then more recently is tersepatide so tersepatide we have set bound for non-diabetics and we have manjaro for diabetic so a lot of people think ozempic is the only medication out in the world and that's not true there's really the two kind of main ones which is uh somagotide and tersepatide it's just there's a lot of other names because of FDA approvals and indications but it goes way beyond weight loss and diabetes control i actually went to a recent longevity conference locally in miami and one of the cardiometabolic specialists he's a lipidologist he was speaking on glp ones and longevity so glp ones are now actually entering the whole longevity space which i think is amazing he made a very interesting phrase he said we need to stop saying these are weight loss drugs and diabetes drugs these are metabolic reprogrammers and i love that the siksanda would give an individual daily injection five percent or so arguably could be good for liver but not necessarily effective for cardiometabolic health in terms of reasons why someone wouldn't try these medications what are those reasons i think there's a lot of fear mongering out there so with social media and the digital age obviously it's an incredible resource for information but when it comes to glp one medications it is very stigmatizing you have people who are pro and you have people who are anti and there's not many people in the middle ground which is kind of fascinating to me it's also a big stigma for patients themselves i have many patients who will not tell anyone even their husbands or their wives that they're on the medication because oftentimes they think it's a failure on their part because they couldn't lose the weight quote unquote on their own which i think is really awful you know these medications act in probably 50 different mechanisms most of which we don't quite yet understand i think a lot of people have this thought that they just shut down your appetite which is not the only mechanism yes they delay gastric emptying so they slow down the rate at which your stomach empties it takes a normal stomach about four hours to empty a standard meal like an egg sandwich these medications slow down that process so that maybe the meal stays in your stomach for five hours or six hours so it helps in particular for people who eat a meal and they don't feel satisfied or they feel satisfied and then they have hunger one or two hours later that's where it can be very helpful it also you know our body naturally makes this hormone glp1 right people talk oh i want to go into peptide i go listen you're already on one glucagon like one peptide right um so this hormone when food goes down into our intestine our body releases this glp1 hormone it sends signals back to our brain and it says brain i'm full but our body also has an enzyme that breaks that down pretty quickly so for people who say oh just take berberan or take all these other supplements that enhance your natural glp1 well they may but they're not preventing the quick breakdown of it so these medications like somaglotide or terzepotide they are synthetic versions of that hormone so they stay in the body longer they help get you fuller sooner they keep you fuller longer we also have glp1 receptors in the brain so it works on the cravings and the pleasure pathway now what i tell people all the time my goal is not to shut down your your hunger it's not to create food aversions i want you to feel hungry because when you work out if i were to shut down your hunger and you don't eat after your workout is that a good thing for muscle growth i mean i feel like i'm gonna throw up but i imagine you probably eat something to fuel within a certain period within the day yeah within the day not necessarily post training but definitely within the day yeah but fuel is very important for muscle protein synthesis so what i tell people all the time is my goal is not to shut down your hunger i want you to get that hunger cue so that you eat something but you eat your protein you eat your fiber and then you feel satisfied and you kind of get rid of that the food noise in between meals what about the nausea there's a lot of discussion around nausea vomiting reflux people are afraid i also before we get to what happened side effects i really appreciate what you said about there's a lot of stigma yeah we've only i would argue we've only seen that with one other group of medications hormones that's it and i do both and so it's very interesting although i have people who they're much more likely to open up about hormones so i have you know a lot of patients who are on both hrt or menopausal hormone replacement therapy um with glp ones and they will tell their friends they're on hormones and they change their lives and they won't necessarily disclose if they're on a glp one they don't need to disclose it but oftentimes i will find that people are more likely to disclose they're on hormones rather than the glp ones i think it's still you know there's this thought that it's a failure on their part and i see that in both men and women it's you know it can be hard for them to talk about yeah nowhere else in medicine i you know what i shouldn't say that because ssri's lithium some of the other psychiatric drugs there's been a long time stigma with that but no one cares about cough medicine or something like that or even a sleep medication these medications that seem to really affect arguably body composition end up really being so polarizing and i think because people put it in like this aesthetic category where they're like oh you just want to lose weight to look better and i would argue i'm sorry what's wrong with that what is wrong with looking good and feeling well because confidence is so incredibly important if you wake up in the morning and you hate what you see in the mirror that will set the tone for the day right and so there's absolutely nothing wrong with wanting to feel confident in liking what you see in the mirror now these medications are not developed to lose you know five pounds um so people need to talk to me about the percentage of weight loss that someone should expect yeah so depends on the medication right so if it's something like loragliti which is succenda that's about five to six percent if we're talking about no one's people don't use that anymore do they some depending on insurance coverage some will if that's the only one they can get covered then they will still use that one we found that um and again everyone practices medicine in different ways when we started prescribing succenda which we don't really prescribe anymore it was patients didn't like giving themselves a shot every day and we didn't find it incredibly effective yeah again i'm sure that this is nothing against succenda or whatever the company is you know i i feel like it's almost obsolete yeah and now that we have a lot more medication the cash pay rates are going down i think it's definitely less common it just it really depends on the person though i would say one niche population would be if someone is really worried about side effects and they're worried if they do something like somaglite and the side effects are going to last a little bit longer because the half life is longer then that may arguably be a reason to kind of do a test dose with something like loragliti because it's you know quicker out of the body type of thing and what is the mechanism of action of succenda the same thing yeah that's also a glp one yep okay yeah five percent with succenda yes so somaglite you're going to get around 12 to 14 percent and these are looking at max doses typically at the 72 week mark so 12 to 14 percent and then terzepetide is roughly 16 to 22 percent and then retitru tide we're looking at 22 percent so as these medications become more and more effective for weight management what does that mean well that means the risk of malnutrition can definitely go up because now we're looking at percentages that are equating to bariatric surgery what's interesting about bariatric surgery is there is a barrier to entry right you have to call someone you have to schedule an appointment you see the bariatric surgeon and then often for you to actually go through the process a couple things have to happen typically you have to be cleared by a psychologist you have to see a dietitian typically like on a monthly basis for a six month period and then you get the surgery and then you have post op care you may not see the bariatric surgeon post op but you're going to have some sort of care where they're making sure you're getting your supplements post bariatric you know you're still making progress there is a barrier to entry because you have to call someone pick up the phone make the appointment and have the follow-up versus now weight management has become weight loss commerce you have on weight loss weight loss commerce maybe i'll maybe i'll trademark that so when it comes to weight loss commerce everyone's selling weight loss so you have all these virtual platforms that are popping up which are basically script mills i'll tell you the easiest part of my job is writing a script what is the hard part it's counseling people on what matters on how to not only get them to lose weight in the short term i don't care about six months from now i care about six decades from now and that's where you can never replace the foundation these drugs are becoming extremely powerful the hard part is not losing the weight it's keeping the weight off long term because as you and i know neither of us are getting any younger we have metabolic adaptation we have anabolic resistance we have hormonal changes we have higher risk of frailty and fractures we get older we have to take all these things into consideration and so these virtual platforms they don't care they're just writing the script and saying i'll follow up with you in six months and so that's what we need to be careful about basically what you're saying is people are they used to be overfed and undernourished and now they are underfed arguably if they're on these medications and undernourished yeah and they're not getting guidance so that's where kind of the press and the media is really pushing this out is people are sharing their stories when they've had bad experiences and there there are bad experiences out there i mean the poison control hotlines have gone up like a million percent because people aren't being guided they're getting either compounded formulations or they're using let's say ozempic pens and they're tight trading the dose based on the number of clicks but if they're not being guided on how to do the dosing and with compounded formulations it's kind of all over the map with some of these drugs and each batch could be vastly different which is why if someone uses a compound pharmacy they should go to a compound pharmacy with a really good reputation exactly so there's just so many unknowns even though these drugs aren't new there are a lot of unknowns and there's not enough supervision there's two things that i definitely want to touch on number one is the effect on muscle and then number two we were talking about delaying gastric emptying and symptoms if someone is on these medications are there ways to mitigate things like reflux nausea vomiting you also hear about pancreatitis i haven't seen that clinically also i would love for you to touch on i don't know if it still carries a black box warning for thyroid cancer so yeah so the black box warning that's easiest to tackle first it was actually only seen in rat models so that it's not all thyroid cancer it's medullary thyroid cancer which is actually a rare type of cancer so i have a patient who had a history of papillary thyroid cancer and his uh thyroid oncologist said no worries he can still go on the medication because it's not medullary so medullary thyroid cancer is a contraindication and then the only other contraindication is a family or personal history of multiple endocrine neoplasia type two most of my patients have never heard that term before so those are the two reasons why we shouldn't prescribe the medication mainly because it's on the black box but again it was only seen in rat studies but those you know otherwise it's fair game okay now one would also say well what if i already have a lot of gastrointestinal symptoms right i'm a gastro so a lot of people with gastro issues come and see me a lot of people are worried that would be weird they came to see you for knee pain yes oh i have plenty of patients that see me for knee pain a lot of times it's weight related so i help them target that um but you know a lot of people like we mentioned gi issues like acid reflux and dyspepsia are related to obesity so they're concerned that if over 60 percent of people on a glp one will have a gi side effect am i only making their problems worse um potentially yes in the beginning right as people are trying to understand how their body is going to react to the medication acid reflux oftentimes gets worse before it will get better but if we're getting rid of the ultimate trigger which is the visceral fat then as they lose weight and they lose inches around their midsection their reflex will often get better do you have tips or tricks to deal with reflux if someone is on the medication yeah is it baking soda do you say for a short period of time take in an acid take mastic gum or any number of natural type supplements yeah so if they're already on let's say an antacid let's say they're not they're not okay yeah um one of these medications yeah and their first symptom is reflux or they're burping something up or you name it but it's kind of that refluxy symptom yeah so very common and i tell people this is not out of the the norm where it's when we start a medication typically if we increase the dose they're going to feel it or within the first one to two days post injection those would be the three most common your body will often adjust to the medication and as you lose weight and you lose the visceral fat those symptoms will get um better okay um but some people will still have reflux so we got to say okay one thing we want to treat it okay what we know from the data is if you have let's say a lot of reflux or nausea and you're not eating as much that doesn't mean you're going to be more successful with weight loss so we we want to treat you my goal is what do you mean what do you mean oh so like i would let's say start you on an antacid i wouldn't say okay suffer through it you're not going to eat as much and then i think you're going to lose more weight so we don't want people to suffer through it we know those people if they're having more symptoms are not necessarily more successful with losing weight so i always want to treat them to i see so the symptom severity doesn't correlate with more weight loss so if someone has significant nausea that doesn't necessarily mean they're going to lose more weight right so we don't want people to be miserable but again my other goal is not to give one someone one medication and have to give them five others to treat all the side effects i'm causing so we always want to go back to the drawing board and say okay are there triggers that have caused this um we have to go back to normal physiology right if someone is eating too late and we know that this medication delays the rate at which the stomach empties if they're eating at eight o'clock at night and it's a fatty meal and we know out of all the macronutrients fat has the biggest influence on delayed gastric emptying so if they're eating you know a 16-ounce steak at eight o'clock at night then they're lying down at 10 to watch Netflix on or off the medication they're probably going to have reflex so if they have reflex with that off the medication i tell them it's only going to get worse on the medication right so we got to figure out how can we change that i tend to tell people to front load their calories earlier in the day right when you're more active you're upright you're moving around your stomach is going to empty faster than eating a heavier meal at night is that when you also recommend they take the injection so the time of the injection actually doesn't matter so much because the half-life is a week so you still have some of the medication in your body the day the injection should be fairly consistent the time of the day doesn't matter so much because it is a long-acting medication but eating habits are very important so we want to eat earlier in the day if we're going to have a fattier heavier meal we want to have that also earlier in the day which is very important we also need to chew our food so i don't know about you but i am really guilty of inhaling my food and so if we're not chewing properly we're not going to digest properly we're not going to absorb properly and we're more likely to swallow a lot of air and cause more reflex and bloating symptoms so those are really two powerful tips to mitigate a lot of the side effects that we see but no are there any natural supplements that use and the reason i ask is because i swear when i was pregnant i had the world's worst reflex it was terrible i also had hyperexamestas gravinum oh it was awful because then you also can't take a lot of medications yeah yes but one of the things that really helped me was dgl it's you know this licorice type extract i don't know if there's things and also i don't know if there's evidence behind that yeah are there any kind of natural type supplements or say aloe something like that some people will take aloe supplements i'm a big fan of like decaf tea ginger tea is like a smooth muscle relaxer so i'm all for ginger tea as far as supplements i'll use like peppermint capsules there's things like ibogard or fdgaard that have like menthol and peppermint in them but they're delayed release so if someone's having intestinal spasms that can help kind of with the smooth muscle relaxant effect in the gut but if you have a bunch of mint like mint gum that actually can worsen reflex mint can relax the lower esophageal sphincter so it depends on what the symptom is there are natural remedies but a big part of it is if you're eating pizza at 10 o'clock at night they're probably not going to feel well on this medication so the lifestyle again the foundation we cannot skip if you want to lose weight maintain your weight loss and and more importantly feel well doing so the nutritional changes are absolutely essential what about constipation very common more so with semaglutide i see it less with chur's appetite so if you were to ask me how do i pick one medication from another obviously it depends on the person it also depends on what their budget is some of the medications are more expensive than others you know nowadays at least the cash pay rates are going down insurance i honestly have lost a lot of faith in insurance coverage a lot of my patients meet all the fda criteria available and still get denied because it's not under their benefit plan so it's a problem when it comes to coverage and that's very frustrating for people because they say doc like i have diabetes or i've been struggling with weight my whole life why is my insurance company covering bariatric surgery and won't cover wagovi i mean it's so backwards why we'd go to a more aggressive method when we can try medication first but that's you know the healthcare system for you these days hopefully is changing hopefully hopefully is changing soon thank you to timeline for sponsoring this episode time isn't just about how long you live it is about the quality of those years it's having the energy you need to move through your day without fatigue the strength to pick up your kids your grandkids who knows someone else's kids and the clarity to show up as your best now that kind of strength does go deeper than muscle it starts with your mitochondria the energy producing engines inside your cells we've learned about mitochondria i don't know in our fifth grade science class and here's the reality as we age those mitochondria decline in fact it's one of the key hallmarks of aging and it directly impacts strength recovery and overall how we feel one of the ways your body protects itself is through mitophagy which helps clear out damaged mitochondria and replace them with healthier ones and you're thinking okay so why is she talking about this well i use timeline powered by mitopure because it contains urolithin a which is a molecule backed by over 18 years of research and multiple human trials it works at the cellular level to support mitochondrial renewal it's not a quick fix or a stimulant it does support your body from the inside out over time and if you've been considering trying it is a great time timeline has just lowered their price and you can get an additional 20 off your first month when you go to timeline.com slash lion and use the code lion lower price same science bigger biceps hey living longer doesn't mean living less vital. Are you concerned about so for constipation for example in our clinic we might give people a regimen of senicott merilax if we start them on a glp1 yeah do you have protocols like that to help with constipation when it happens? Yes absolutely so part of the way these medications work is they also have a diuretic effect so sometimes dehydration can contribute to the constipation if i'm lowering your appetite and i'm telling people to focus on protein oftentimes they're not getting enough fiber so that's really important is targeting 25 to 35 grams of dietary fiber a day and that also just helps with the gut microbiome and the health of the of the colonic cells and then obviously using things like supplements or medications big fan of merilax all that does is it's an osmotic laxative it just helps pull water into the colon then you can also use like stimulant laxatives like sena or dolcolax and those will stimulate the bowel to move some people just they have bulky stool and it gets trapped in the rectum and so that's where suppositories or enemas can be helpful so not all bowel regimens are created equal it really just depends on what the person's going through what i also see so much of is pelvic floor dysfunction in both men and women so you could be on the latest and greatest bowel regimen in the world if you have pelvic floor dysfunction where you're trying to push and you're not able to generate enough pressure to get it out of your rectum no amount of colonic stimulation is going to help you with that so i send a lot of patients to pelvic floor physical therapy for specifically for constipation yes absolutely we had dr sue mcjohn hold on the podcast which she was on dr Amy Perlman you might know her they're 20 cents dark and Larry Lipscholtz they did a an episode i believe both Larry and dr Amy did an episode dr sue mcjohn if you guys did not hear that episode yet please listen she covers pelvic floor dysfunction in women of course but in men yeah yeah which we often like i was told in gastro that it's typically women who have had foreset vaginal deliveries that get pelvic floor dysfunction those are not the only people that struggle with that a lot of people do so anyone with constipation or this feeling of incomplete evacuation that can definitely be a problem and and starting a g lp1 medication can oftentimes just exacerbate the problem so we want to make sure we are tackling it from all different points of view but yes amalgam is definitely more likely to cause constipation than newer medications like tersepati so there are many medications on the market there are many different pen delivery systems and there are injections and there are pills so i want to kind of simplify it for the viewers because even in someone who practices in this space it can be quite confusing and i'll tell you this it's only getting more confusing because we're going to have different generations yeah because there's more medications coming out on the market so patients need to understand what are the different options out there and why is their provider choosing one or the other that's really important so the first medication i have here is ozempic ozempic comes in a multi dose delivery pen so this is fda proof for diabetes but you know i will actually use it off label in non-diabetics because they can kind of multi dose it and it kind of saves them money and when you say multi yes what do you mean so what i mean by that so you can use the clicks here and kind of adjust the dose okay now this is not necessarily what the manufacturer is telling you to do but a lot of providers are doing it because it will save cost so you'll still deliver a standard dose but it's just a highly concentrated pen if that makes sense this is different from what are the starting dose so the starting dose is always 0.25 milligrams per week of somatotype now this is the same medication as wagovi why would i choose this one instead of this one and if you guys are just listening in one hand she has the ozempic pen and in the other hand she has the wagovi pen yes so these are the exact same medication they are both by novo they're both somatotype this one is just a different pen delivery system this one you can adjust the dose this one is a single dose auto injector is the first one is the ozempic pen on auto injector um so it's not necessarily you attach a needle here this one the needle is built in and you adjust the dose here and then you would click it and then inject the medication this auto injector i'm literally not doing anything i pull off the cap when i'm ready to inject i push this little plunger in here the needle pops out and so it's a one and done thing so it's one exactly it's one pen per week um on this you can adjust the dose on the pen okay but again it's the same exact medication but technically if you want to go kind of by the guidelines ozempic is FDA approved for diabetics wagovi is FDA approved for non-diabetics for weight loss okay so this came out in 2018 wagovi 2021 and these medications can be also used off label yes for off yeah so a lot of people would say oh i'm only using the FDA indication but the reality is when they do drug studies they're not trying to get every indication covered because those studies would take literally a million years what we're seeing nowadays is we'd be really old by that we would be really old so initially developed for diabetes then weight management now next kid on the block is zephyl which is terzepotide and then you have the same delivery system manjaro so those there's no delivery system changes it's just this single dose pen here so this is zephbound so now zephbound is actually FDA approved for moderate to severe sleep apnea so that's the added indication here and wagovi is now approved for f2f3 fatty liver so f2f3 means the degree of fibrosis so more indications are expanding they are doing active clinical trials in Alzheimer's alcohol PCOS near and dear to my heart is inflammatory bowel disease so as a gastroenterologist it used to be when these medications first came out i wouldn't touch a patient with Crohn's or ulcerative colitis with a 10-foot pole with these medications now we're actually doing clinical trials in IBD patients because of the anti-inflammatory effects so that's where you have this pliotropic effect with these with these medications way beyond weight management and insulin control now we're looking at the anti-inflammatory effects and there's clinical trials in autoimmune conditions what is the dose is the dosing different so the dosing for zephbound and manjaro are the exact same the dosing for anti-inflammatory oh different yeah it's different so i'm hearing that it's it's more like the micro dosing versus these other doses which are different yeah so it depends on what the target is but at least for sleep apnea and for fatty liver those doses are the same that we would see in diabetes and weight management because the mechanism is in part weight loss exactly yeah and the insulin pathway versus the anti-inflammatory pathway it's so fascinating do you think it's too good to be true i think there's a lot of things that are too good to be true i would say this has completely revolutionized healthcare where even if you as a prescriber or a doctor are not prescribing these medications i will tell you your patients are on them whether or not they're telling you these medications are going to infiltrate every single field in medicine we need to stop telling people to just do it on their own they're going to be doing on their own but why not use tools in the toolbox to do two things make it a little bit easier and a little bit less painful why not it's fascinating that we are i mean you realize that we are at the precipice of an entirely new landscape of medicine it's you know i used to run a weight management clinic in my fellowship we didn't have access and these were morbid people struggled with morbid obesity and we were not using these medications because it wasn't indicated and it was heart breaking to watch two years later you know they come to the program they fall off so many comorbid conditions it's amazing well we're also using it in post bariatric patients because you know these these tools these medications bariatric surgery they're not cures for obesity they are treatments and what we even see in the bariatric population is weight regain let's say five years later so a lot of those patients are actually going back to their bariatric surgeons and they may get you know a revision surgery but many of them are actually going on glp ones to help combat some of the weight regain that we see the uh you also had the pill form oh yes show me the pill form oh here we go okay so um novo just came out with the pill form so the pill form has actually been out for a couple years now that was named ribelsis but that was FDA approved for diabetes and they were at lower doses um they are daily pills um the past couple of months one day once a day yeah the past couple of months a couple months ago novo came out with wagovi which is the pill version now um the pill version of ribelsis the highest dose of that um didn't get you anywhere close when it came to the weight loss that the injections of ozepic did and so you didn't get the degree of weight loss that you got with the injection so if people needed to lose more weight we would typically put them on injections instead of the pill um but they've actually changed the delivery device or the vehicle so that our body doesn't break down this medication so now we're seeing that the wagovi pills are equally as effective as the injections available now you may say or a lot of people would think that oh why would someone want to you know jab right do the jab i don't know if you've heard that phrase never people are using it all the time now for these medications why would you do the jab if you could take a daily pill now i'll tell you from experience and i've talked to a lot of my patients i've asked them do you want to change to the pill or do you want to stay with the injection and oddly enough i don't have a single patient that said they wanted to change to a pill because they're used to the injection it's once a week or i now have some patients who are in their maintenance phase who are injecting every two weeks and they're like honestly it's a one and done thing i'd rather not have to take a daily pill people also need to realize that they're not really that easy to take this medication in particular it has to be on an empty stomach you can't take it with other pills you can only take it with four ounces of water then you have to eat 30 minutes later if you're kind of someone who's traveling kind of on the go and and things like that it can realistically be a little bit of a challenge to take what about drug-drug interactions with these medications so we don't really know you know it's interesting when i used to do a lot of endoscopies i would see undigested pills still in the stomach you got to wonder like are we telling people oh you're not taking your medication or the medication is not effective what if that person just doesn't have the ability to even break down the capsule they're not absorbing the medication i mean it's really crazy we haven't done clinical trials to say okay you're on wagovi how is that going to affect your blood pressure medication because technically um that medication is going to sit in your stomach longer than it otherwise would have but i would argue you know in let's say poorly controlled diabetics if they have a higher propensity for gastroparesis which is delayed gastric emptying are we doing drug trials in them to say okay if you're a diabetic you need to take this blood pressure medication instead of this one because you're going to digest it differently we're not we assume everyone digested the same but that's not true so gastric and intestinal motility do play a role in drug absorption we don't have the studies to actually show what happens and we don't know for example if someone was on oral birth control how would these medications make it less effective do we yeah so birth control is one that we have to be careful with because it can definitely affect the efficacy where i don't know if you've heard of like ozepic babies right where because i have but i actually thought it was because of increased fertility well so yeah there's a couple things right so if people are more likely of infertility because of let's say pc os and they're losing weight and we're improving their insulin resistance they are more likely to get fertile and so some of them may or may not be practicing safe sex but now that they're more fertile they can't get away with that anymore so that's one reason the other thing is it can it can affect the efficacy of birth control um so typically what we tell people is when you're starting the medication or you go up on the dose you should be on two forms of birth control but i don't think we honestly know enough about it but better safe than sorry after even though these medications have been around for 20 years do you think that that is research in women we're we're just too complicated i mean my husband says that but i don't know so it makes sense that we should do clinical trials but i think you know it's really hard to do clinical trials in you know well in women it's just it's not that it's hard it's just not done that often but um but yeah we just don't have the data we don't know unfortunately from a personal perspective not evidence-based but just evidence informed are you seeing that perhaps it affects antibiotic use are there other things that an individual would want to think about as they're on these medications um i do see hair loss and that is a big concern in my patients now i think it's multifactorial one is a lot of these patients are mid-age so are they also perimenopausal absolutely i think that's contributing the second thing is they're eating less and they tend to be eating less protein and as we know protein is really important for hair so i want to obviously optimize protein intake um how do you end up recommending people do that i actually aim on the higher end of protein recommendations so i really tell people well my ultimate goal is like one gram of protein per pound of ideal body weight but if i'm starting someone on a glp one that's like that's not going to be that's not going to be happening it's not realistic so i'll tell people in general to try to hit at least you know 100 to 120 grams of protein per day to start and i knew you you know tell people at least 100 grams a day so i have to be realistic if i tell someone 200 grams they're going to say you are crazy that's never going to happen i have to meet the patient where they're at and it also depends on how much protein they're getting at baseline if they're used to getting 30 and i start them on a glp one i cannot realistically recommend oh hit 150 you know by tomorrow that's ridiculous so if someone's hitting 40 i say please track your protein let's try to get you to 80 and then next month let's try to get you to 100 it has to be a step-rise approach thank you to one of the new sponsors of the show if you are someone who is intentional about what you put in your body and how you use it this is something i've been experimenting with in a very specific and particular way it's called a lucy and i use the 2 milligram nicotine gum for me it's not something i use passively like i'm chewing bubblegum i use it as a tool at specific times when i want to stay focused and locked in the science here is actually quite compelling nicotine mimics acetylcholine and that's a primary neurotransmitter involved in learning and focus there's data that can support that it improves visual attention working memory motor processing speed all of these things that i need when i have long writing sessions travel days high stakes projects i need sustained attention what i love is that lucy is a tobacco-free product it's clear in its dosing you're isolating the compounds to leverage 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nicotine and nicotine is an addictive chemical for hair loss in our clinic we typically look at ferritin stores iron stores we look at copper are there certain markers that you look at in the blood when just as it relates to hair loss so i do a whole gamut of labs to get their nutritional status and what a lot of people don't realize is just because someone is overweight a lot of overweight or obese individuals are malnourished so we should be checking baseline labs baseline labs i would check now not having to do with hair but it's you know an advanced lipid panel it's their insulin level their complete metabolic planal um their blood count but i also check their b12 their vitamin d and then depending you know their iron labs i have a lot of people who have normal hemoglobins but are very iron deficient and a lot of people are missing that so i want to check yes their baseline nutritional status do you find obviously you say for hair loss one of the recommendations that you have is protein uh another thing that we use in the clinic are essential amino acids which especially if someone is starting on a glp one that can be so helpful because it just is providing amino acids with none of the bulk yeah um we've just found that that's really easy to tolerate do you see any labs get worse meaning do you see obviously hsrp improves but do you see things like ferritin getting worse or do you see various markers i haven't but i you know i'm just curious yeah i haven't either um and i and i do trend these things um you know i wouldn't do it every month it really depends on the person um i'm all for supplements i'm all for food is first but supplements can be very helpful especially when it comes to b12 iron vitamin d those key players i'm a big proponent of creatine people are plus or minus on collagen i've had a lot of patients that report better skin hair and nails on collagen so i'm all for it there's little very little harm but i think we also have to be careful with a lot of the other supplements out there i've had liver enzyme abnormalities with things like neutrophile so it does depend on the quality of the supplement i'm not one for giving someone a supplement that has everything in the kitchen sink right i'm all for okay your b12 is low let's optimize your b12 your iron's low let's optimize your b12 because a lot of these all in one type supplements they are containing so many things in there that actually interfere with the absorption of another like multivitamins if we know that calcium interferes with iron why would i give you a supplement that has calcium and iron because you want to cause constipation obviously the metformin craze there was a whole metformin craze we actually had um dr eisenberg on the show he's a urologist and he was talking about how metformin can potentially affect birth defects the reason i bring this up is because metformin again used ubiquitously affected b vitamin metabolism b12 makes sense do you think that there is something like that with glp ones well a lot of my patients are already starting with low b12 and so i obviously want to optimize that so i can obviously blame the glp one on that a lot of my patients because we're delaying gastric emptying and affecting digestion red meat is just less appetizing or it tends to really just stain their stomach like a brick so they tend to be getting less b12 through their nutrition on the glp one medications um so oftentimes i will supplement those folks as well if they're having trouble taking in dietary vitamin b12 sources that makes sense and basically what i'm trying to get to the underbelly is is there something potentially we're missing because again these medications are they too good to be true i i mean i don't know look at hormones one could also argue that hormones estrogen progesterone testosterone are too good to be true but our body makes them and our body does make glp one yeah the overdose situation with the new medications the half life is long do we have a solution if someone by accident takes the wrong dose they take a much higher dose are they going to be stuck with nausea vomiting i mean i can only imagine that would be terrible yeah there's no antidote for these medications so if someone takes too much of a dose or they're just having a side effect if we up tie traded or they're initiating the medication there's no medication i can give you something like a benzo or a morphine where i can reverse the effect so a big part of it you know it's all about supportive care it's maybe i've never had a vision to that i have actually yeah they got mixed up they were doing it in the car they weren't paying attention they called me a day after and they said i am just so miserable and i said walk me through what happened and i'm like okay all right now luckily they did not go to the hospital they were fine they were just pretty miserable for about a week right because the half life is a week oh absolutely yeah so it's all about supportive care hydration is key right so like they don't people can survive without food for a week we can't survive without fluid so my go-to is it's actually not slamming down a bunch of water it's making sure we have oral rehydration solution so simple things like pd light or i have you know recipes of homemade solutions if people don't like gatorade gatorade is fine but it's not technically a hydrate hydration solution there's not enough salt in there so you have to actually add salt to maintain hydration um so it's maintaining hydration is the key and then using medications as supportive care to help prevent the vomiting the diarrhea so it can happen i would say are we missing something are these too good to be true as access improves which is great um you still are going to have these weight loss companies that are just writing scripts for people so we want to make sure we have an appropriate candidate we want to make sure how do we define appropriate candidate well someone who is ready to invest in their health and make the other foundational changes along with the medication i want people to have realistic expectations that the goal is not just to lose 50 pounds stop the medication because what do we see in the data we see the weight regain and people may gain with the weight gain gain a little bit of muscle but the majority is regaining a lot of that fat and then ends up causing this vicious cycle so we have to really look at how do we optimize long-term health outcomes improve cardiometabolic health so yes improving access is important but making sure the patient understands how do these medications work and how can i be successful long-term is really important now the typical indications though we're all weight related i have plenty of people that come to me who have a normal bmi who i think are candidates for glp1 medications maybe they're struggling with alcohol i live in miami that's a big problem maybe they're perimenopausal and they have a normal bmi but they've gained a bunch of fat around their midsection and they're struggling and now they're you know insulin resistant i use those medications off label in those individuals so that's where there's really the art to the medicine piece compounding pharmacies we didn't mention that as you're showing the pills and the injectables we do use compounding pharmacies i think that they're great as long as they're reputable yeah the other thing that i wanted to ask you about was you talked about the foundational plan fiber i know that you have some show more show and tell which i appreciate them being empty fiber the microbiome yes fiber is so important but what's interesting about kind of social media is you have people again yeah that or you know you have people who are pro and who are against like people who are all about keto and and plans are trying to kill us type of thing there is overwhelming evidence to support the optimal effects of fiber on the gut microbiome so we use a lot of different terms like prebiotic and probiotic and it can get a little bit complicated for people so let me break it down prebiotic is dietary fiber so nuts seeds whole grains all of those things when we eat dietary fiber those molecules are broken down by the bacteria in our gut and then produce other molecules that have more downstream effects things like short chain fatty acids that then hit our colon and help optimize the health of our colonic cells so that's one of the reasons why dietary fiber is really important but also our bacteria in our gut really like the dietary fiber so it helps promote a healthy gut microbiome when we eat whole food when we eat dietary fiber our bacteria like it and then we grow the good bacteria when we have good bacteria those bacteria take care of us so when we eat ultra processed food and you and i may define that a little bit differently but i would define ultra processed i mean technically let me grab my little show and tell here technically all these things are processed right they're in a bag this did not so she has for you that are not watching this which you should because her outfit is fat we've got what do we have i have my plain greek yogurt i have my good culture cottage cheese roasted chickpeas peanut butter powder roasted lentils a chia seed bar and almonds wait peanut butter powder yes let me see that so it's literally just pulverized peanuts that is super easy that you can kind of mix in with like a greek yogurt or cottage cheese and it adds typically about eight grams of protein or you could add it to a shake but that's fake news fake protein because it's flour so if it says eight grounds it's probably closer to four that's my little peanut butter powder here um so yeah so fiber is very important um protein is very important these are all things that are travel friendly except for at the airport these are a little bit too big unfortunately to get through so yes these are technically all processed because they're not coming from that naturally but they are healthier alternatives to most of the stuff you're going to find at the nearest 7-eleven gas station or at the airport and and many of these also contain fiber now these are not high protein sources you're not going to get your protein you know requirement for the day but they will give you at least some protein towards your daily goal the fiber component insoluble versus soluble fiber you said 25 to 30 grams do you believe is that enough should it be higher depends on someone where someone is starting from i think we should we could probably benefit from more but to put things into perspective like one cup of broccoli gets you about four grams of fiber so that's a lot of broccoli to eat in a day um a lot of people are eating like 10 grams of fiber and fiber is one of those things where as a gastroenterologist i see people either too little or too much if you overdo fiber like anything else too much of a good thing can be a bad thing there's a lot of diet food products like these keto tortillas or breads that in one serving will get you like 25 grams of sorry no i thought i was doing so great i used to eat um do you remember they still have them they're just these they're fiber wafers this was in college and i just thought this is such a great idea i can eat this have some peanut butter yeah but it really i just felt terrible oh yeah people yeah the bloating is a real thing because fiber a lot of it is indigestible by the human body so we care the percentage of soluble versus it depends on the person um if you know soluble fiber is going to help kind of bulk up the stool so if someone over does that you can bulk up the stool so much that it can actually worsen the constipation in general any high fiber food is going to have a good mixture of both yeah whole food yes whole food again now we're talking about the food matrix yeah would have an appropriate proportion of soluble versus insoluble yes broccoli is insoluble fiber mostly lentils nuts is there should someone say if they have small intestinal bacteria overgrowth are there certain fibers that people with gut dysbiosis should use versus other fibers honestly in my perspective it depends on what the person likes right so if someone tells me they have a food aversion to lentils i'm not going to tell them to eat lentils a big part of it is what are they currently eating what are they willing to eat just to really reintroduce fiber into their diet and i start there i mean we can either make it simple or overly complicated in general people just need to eat more whole food and more fiber we start there and kind of go over the nuances as we go would you consider short chain fatty acids to be a post biotic then we don't have much data taking short chain fatty acid supplements as far as having like better outcomes we want to make the short chain fatty acids by the food that we're eating so taking things like butyric acid people used to use it for certain conditions like butyric acid kind of enemas that may be helpful in things like proctitis for some individuals but taking a short chain fatty acid supplement you're not going to see the same results that you do from actually getting dietary fiber through food and the way someone would get short chain fatty acids would be through just the consumption of exactly dietary fiber and our microbiome takes care of it for us that's a beautiful thing about the human body how do we define microbiome it's trillions of bacteria and fungi that live in our gut and and really the microbiome it's in our vaginal canal it's on our skin it's in every organ when we talk about the microbiome most of us are really talking specifically for the gut microbiome I know you're bringing to muscle we were going to do push-ups and it was already trained the gut muscle access yeah we talked about the glp ones which some of the weight that is lost is also muscle the other part of the gut microbiome is what it produces and like you said short chain fatty acids do you think that there are specific foods that are helpful for the mitochondria for the myocytes beyond protein and I am truly curious because I haven't really other than urolithin A I haven't thought so much about the interplay between the post biotic after we eat and what we make and its effect on muscle and as someone who's very clearly by the way if you guys are not seeing this she is jacked are there foods that you think okay this is my muscle plan for muscle sparing on a glp one I don't think we know you know it's interesting when we look at the clinical trials the dietary guidelines are very general in the glp one studies so they're telling people to eat protein you know to eat anti-inflammatory foods but beyond that they're not given specific dietary plans so I couldn't tell you whether someone's eating more plant-based versus animal based on a glp one that's not how they created the clinical trials a lot of nutrition studies also they're just really hard to interpret because they're relying on dietary recall a lot of epidemiology exactly so we don't know when it comes to nutrition they may get general guidance but we don't quite know what they're eating on a day-to-day basis so no supplements that you think okay aside from creatine yeah yeah creatine for sure yeah nothing that is kind of you're interested in right now or on the top of your mind when it comes to mitochondrial health I don't think anything is going to replace the foundation which is whole food fiber protein we got to just keep it simple and focus on those things thanks to one of the sponsors of the show amp because I can walk two doors down and get a great workout and if you've ever walked into a workout and thought am I lifting too heavy am I not lifting enough where is the weights I can't find anything and is this even working you are not alone seriously the uncertainty is one of the biggest reasons why people do not see results and they stop strength training is an essential daily routine and amp was founded to introduce it into everyone's life home and ambition that's exactly why I've been using amp what makes it different is it removes the mental noise amp ai uses your resistance to adjust sets and reps in real time so you are always training at the level that your body needs no second guessing no wasted time and by the way it has everything that you need your body responds to progressive stimulus and you need to do that correctly you don't want just random workouts that you find out online or you find online it mounts to your wall takes up almost no space and gives me access to hundreds of movements from strength training to high intensity work I am telling you I love this technology it is beautiful it is on my wall and it is a system that meets me where I'm at regardless of the day if I need some recovery it's there if your goal is to build muscle get stronger no more guesswork and be consistent go to amp.ai check it out that's amp.ai training should be effective and it doesn't have to be complicated hormones how do you think about the interplay and I suppose not the direct interplay between the glp ones but ultimately people and patients they want outcomes yeah they want to physically transform you have been utilizing studying and prescribing hormones for a long time fair to say actually not that long so you had initially asked me what is my kind of day to day look like or what sort of patients are seeing me and the initial practice was set up for weight management it actually wasn't until about a year and a half in where so my sister and I are in practice together and what were we noticing we were noticing that our most successful happiest patient was our middle-aged man who I was working on his nutrition his exercise programming he was on a glp one medication my sister was managing his testosterone this guy was hitting prs and marathons he had five pounds more muscle now 40 pounds lighter and we sat down and we said if we can do this for women I'm sorry for men why can't we do this for women so we actually tried to find gynecologists and specialists in the Miami area to send our women patients to to optimize their hormones and a couple things we found one is the really good ones we're already so busy they weren't accepting new patients or if they were accepting patients my patients were going to have to wait three to six months to see them the third was some of these providers were still not on the bandwagon of hormone replacement therapy to the point that they were telling my patients my 45 year old patient that I see you have osteopenia but hormones have nothing to do with bone health and I said okay it's one thing for a provider not to prescribe HRT it's one thing to gaslight my patient and give them misinformation so my sister and I said okay if we can't find the providers in the area to see our patients soon and optimize their hormones we're going to take care of it ourselves so we took a course with Dr. Rachel Rubin she taught us everything we needed to know about hormones she's absolutely amazing whenever I have a question about anything I just use one text away and then now those are my happiest and healthiest patients because we're not only helping them improve their cardiometabolic health getting them and maintaining a healthier weight we're treating their sleep disturbances we're treating their hot flashes their night sweats all these things are incredibly important for optimal quality of life but we found it serendipitously with our middle-aged male patient who was killing it those guys from a body composition perspective there isn't a ton of data with hormones actually changing body composition what have you seen in your clinic it's interesting because you know as women reach middle age and that's you know mid to late 30s right in early 40s we start to see body composition changes as you know where maybe the BMI or the weight is pretty similar five pounds up but people often you know my women come in and they say I have a belly I've never had before right my my body has changed my skin has changed this is just very different for me but my lifestyle hasn't changed why is this happening to me now if I'm doing everything I did when I was 20 and 30 right and I say the problem is your physiology is vastly different even though you didn't change your body has changed underneath the hood so that you know is a big thing what do we see with hormone replacement therapy well a lot of people would argue well if I gained weight during perimenopause if you just give me back some of the hormones won't I lose the weight we just don't see it HRT is not a weight loss strategy now if someone's gaining weight because they can't sleep and you fix their sleep then maybe it will help in that regard but in many of my patients I may actually see a little bit of weight gain why because we're helping with bone and muscle especially if they're on testosterone they may actually gain a little bit of weight even though their body composition is changing their BMI or that number on the scale may not be going down but what we're seeing actually more and more in retrospective studies currently is the secret sauce is the combination of HRT and GLP1 therapy and you had asked me earlier what are we seeing with lean tissue or muscle changes and I'll tell you I can tell exactly the point that I started patient on a GLP1 on hormone replacement therapy because their lean mass losses start to kind of go straight and then they start to gain muscle when I'm optimizing specifically my my women on testosterone so that's really cool to see when you're actually tracking the data that matters do you have a number in mind if someone is coming in because again there is still surprisingly no aside from hyposexual desire disorder no other FDA approval Dr. Amy Perlman is sitting in here for testosterone do you think about okay so the patient comes in they're on a GLP1 we know that they don't do anything magic for muscle loss and I've just been reviewing some of the data so I'm excited to hear kind of what you were seeing when it comes to muscle health from my perspective it helps with improved muscle health not decrease muscle health because people will say individuals are losing more muscle mass it's perhaps the rate of weight loss is accelerated with the GLP1 but the quality of muscle seems to improve yeah absolutely I mean people will blame everything and anything on GLP1 therapy but what do we actually see in the data so when you compare diet and exercise GLP1 therapy and bariatric surgery the absolute percentage of lean tissue loss is the same across all 25 to 40 percent of losses you're going to see across all three modalities but people are losing more weight now on GLP1 than they've ever been able to lose before with diet and exercise so of course the absolute number is going to be more than just diet and exercise but like you mentioned is muscle mass is that the holy grail I would argue it's not because I'm tracking that right but if I have a patient that says okay I've lost 30 pounds yes I've lost five pounds of muscle but I feel stronger now than I did when I started how many clinics do you think are testing hand grip strength six minute walk tests I get up and go test because ultimately that's what matters is performance is strength not how much muscle mass you have but the actual contractile forces you're able to to you know have right frailty and fracture what matters that's my issue actually with dexas scans we're looking at bone mineralization we're not looking at how strong are your bones in actuality so I think that's where we're missing the boat when it comes to you know talking about frailty fracture muscle mass metabolic health is not just what are you made of but you know how strong is your muscle and how productive can you be to reduce your risk of frailty and fracture you are highlighting the diagnostic gap that as healthcare providers this should be standard someone goes to their provider and they get blood pressure checked they get weight checked but they don't get hand grip strength which we know is a great one of the greatest indications of longevity and it literally takes 30 seconds or less even it might even be I don't want to say that it's more important than blood pressure but the indications when we think about strength and survivability muscle is underutilized underdiagnosed it's not part of the normal conversation yeah and I'm really glad to hear you say that we don't even have well okay I will say we have a blood pressure cuff at our clinic only because my sister does procedures so we need it if someone feels faint or if someone says I have a headache I will check their blood pressure other than that I never check blood pressure in patients why because I live in Miami and people are driving in Miami traffic so I would much rather a patient check their blood pressure at home send me their wearable information which is more realistic to how they live on their daily basis not a one data point from when they're here in clinic but yet in the typical healthcare scenario the number of profound medical decisions we make on one data point in clinic is absolutely insane to me amen to that amen to that when you think and start to see a decline in lean tissue from the perspective of patient care how do you decide is it going to be estrogen is it going to be progesterone is it going to be testosterone let's say they are perimenopause so not totally in menopause maybe their estrogen numbers are lower maybe all their hormones are low how from a clinical decision making standpoint do you report on yeah so one thing is we can't you know we have to track in order to see someone's progression so for instance people who see me in clinic I see them on a monthly basis and I use a medical grade bioimpedance scale called the seca and I'm tracking every month now I will have patients who see me let's say out of state they'll send me their data from let's say a withing scale or the Hume scale so I have you know the body fat and the muscle the trends are important the absolute numbers not so much but the trends are really important so if someone's let's say on a glp1 medication even though I previously mentioned like that mass is not the end all be all it gives me data to say okay you lost two pounds of muscle this month how much protein are you taking in and I know you're telling me you're having chicken breast for lunch but can you please weigh it out I need to know if it's if it's two ounces or six because there's a big difference there so it gives me a platform to better inform myself and the patient to say okay are you getting enough protein before I even delve into the hormone piece the exercise key says you know like exercise is so incredibly important for longevity if we could package that up in a pill you and I would never have to work another day in our life right exercise is so important but I have so many patients that let's say see trainers or they're on this orange theory bandwagon or a berry's boot camp and they're doing endless kind of circuit training moderate intensity and they're not making gains and so I will actually talk to a lot of trainers I'll have a phone call I'll have a zoom yeah I'm like you know it's like but I need to understand because not all trainers are created equal like not all doctors are created equal what is your exercise programming look like because if I'm not seeing the results that I anticipate in my patient by what they're telling me I need to truly understand what is their exercise program look like and I have so many patients that will get a trainer for 45 minutes they're rushing from exercise to exercise they're doing like 15 exercises and I'm like how much are you how much time are you resting in between exercise and they're like two minutes and I'm like no no that math doesn't math you're doing 15 exercises four sets of each like in 45 minutes you know where you're doing cardio exactly like where do we where do we build muscle not in the gym we build muscle outside of the gym but you know with recovery and fuel but you need to actually make sure you're resting in between sets you're doing progressive overload and my patients kind of just follow whatever the program is if they don't have the knowledge to start talking to their trainer about it so I kind of fill that gap and have that conversation and I've had patients that switch trainers and all of a sudden they start gaining muscle so that's really key when it comes to the hormones it depends on what their symptoms are right if they're having hot flashes and night sweats we're going to start with the estradiol and then progression if they still have a uterus if you know a lot of my patients don't necessarily realize the importance of testosterone as you know we as women have more testosterone than we do estrogen in all phases of our life so they'll say oh I don't want to look like a bodybuilder and I say do you understand that it is to look like a bodybuilder right my goal is not to give you male doses of testosterone but if someone is worried about bone health if they're worried about muscle health if they want to improve their cognition their libido right testosterone can be very very beneficial in that regard but we have to start terming just like GLP ones are not just weight loss drugs we have to stop calling hormone replacement therapy as or testosterone as just libido enhancers they are brain hormones they are heart hormones they are muscle and bone hormones so it depends on what the person's ultimate goals are but I look under the hood and if they're eating the protein they're doing the resistance training but they're struggling with bone and muscle health I will say I really think we should give testosterone a try how do you think about dosing for testosterone um so I do use a compounding pharmacy for testosterone I aim on the lower side instead of the higher side because I've had patients come in with significant hair loss with acne with mood changes with you know clitoral enlargement which can sometimes need surgery to correct um so I usually start them low because a lot of my female patients are already worried about hair loss the last thing I want to do is convert more of that into DHT so I will typically do a daily cream that's compounded or I will use oral testosterone like chyzotrex which is a little bit higher doses you are the first physician I think that we've had on that is maybe a year ago I think chyzotrex is a great yeah a great I'm on it myself okay yeah talk to me about chyzotrex the oral testosterone so you know a lot of people are worried about taking oral hormones and I get it because same thing like oral estrogen that can increase even though it's a small increase risk of clotting and the old oral testosterone formulations caused liver issues now the nice thing about chyzotrex because of first pass me on exactly yeah so the nice thing about chyzotrex is we absorb it through our small intestine right now we do have to take it with fat in order to optimize absorption but it's a very easy pill to take now we don't have the you know the doses approved for women so I will start the lowest dose possible and it is a little bit higher than what we're going to get with the cream but it yeah it depends on the person and what sort of formulation they want or they're willing to take I really think revolutionizing the ability to take hormones because a lot of guys whether they are traveling or they don't like injections really struggle also women from a perspective with testosterone and just any kind of hormone people have kids you know it's it might be too much of a risk for transference yeah yeah the oral chyzotrex what is the starting dose that you guys think about for women so the lowest dose is 100 milligrams and that's once a day with food yeah yeah versus for men it's typically they'll do four pills like 400 milligrams twice per day so they don't yet have a lower version it will be nice I think once they have maybe lower versions most of my patients are on the compounded cream mainly because I don't want to drive up their levels too much so it depends because the chyzotrex is going to be a higher dose than what you're going to get on typical top and the women do a lot better on that I only have actually probably two patients on the the chyzotrex actually most of my patients are on the lotion more so because yeah yeah I think they're some of them are just worried about higher doses and so I typically will start most patients on the cream yeah do you find that the blood levels look different for example if someone is on the cream do they have a higher conversion to DHT versus if someone is using an oral agent um I think it's hard to say because I don't have most of my patients are on the topical so I'm not sure if I can answer that question but I'm mostly looking at you know side effects and I will see that more so in my patients who were on pellets or injections so I get those patients that come in and they weren't given any other option they were literally said you know um you should be started on hormones here are pellets they didn't realize there were other modes of administration so I see more virilizing effects in those patients and so I will definitely start them on the topicals just because it's it's quick it's lower doses and they're already worried about side effects I aim more on the lower end yeah do you have an expectation of how much muscle you want them to gain we're talking about just the paramount apostle woman where you're like okay we're on a glp one you've changed your body composition you're going through recomp you've lost 10 pounds of fat I want to see you put on or do you have an expectation of the amount of muscle mass that you want them to gain I would say my goal for each and every one of my patients is when they hit their weight loss goal and they're in maintenance mode um that's when the actually that's when the hard part begins is is gaining muscle because the easier part is losing the weight the hard part is regaining some of the lean tissue that was lost I want each and every one of my patients to have more muscle than when they started and that's doable but it requires obviously that daily consistent effort protein protein protein not just exercising but progressive overload consistent resistance training when we go on vacation our muscles don't care that's a really hard thing for people to realize is I have people businessmen and women who travel for three months out of the year during the summer I hear only poor people stay in Miami over the summer my sister and I are always here uh over the summer in Miami but um people will travel for a couple of months and they may go on cruises or they're walking around in Europe and they literally stop resistance training for three months and they assume they're going to be able to maintain all of their muscle mass and that's just not the way the body works so I want people to be feel strong you know a lot of my patients they have the financial means they have a great family support they retire they want to travel the world and do whatever they want I know you ask you know a lot of your um guests on here what is forever strong mean to them and to me it means being able to do whatever whenever you want you know and to have nothing hold you back whether that's mentally physically it doesn't matter it is freedom it is independence and people work their butts off their whole life for what they retire at 65 and then they can't travel because they're too frail that is awful to me one at a two postmen a pause a women develop osteoporosis that doesn't have to happen once they fall in fracture and they break a hip at the age of 70 their one-year mortality is outrageously high these things are preventable if we talk to people in their 20s and 30s when they're still able to build bone and when building muscle is easier these are the times the conversations should start not when we get their first dexa scan at the age of 65 we have missed the boat in another realm when it comes to that and i'm sure you saw that you know when you were doing geriatrics as well we are missing so many things that can be prevented you mentioned something about the maintenance that you have patients that are in maintenance now glp ones there is no guide there there just are no guidelines for a maintenance strategy take me through your maintenance strategy yeah so i always ask people how do they define success as far as their health and wellness and oftentimes they'll tell me a number on the scale like oh i want to hit 130 and the reality is there's nothing magical about 130 130 they were happier because they were 22 years old without a husband and without kids and had less responsibility so i really want to figure out like what is really their ultimate goal right sometimes it is weight based once they get to their goal then i tell them okay before we start tapering out or tapering off the glp one medication the majority of my patients honestly they've done so well and they're thrilled and they're happy and healthy they say doc if i need to continue this medication weekly for the rest of my life i will absolutely do that to help prevent the yo-yos of the weight up and down for the rest of my life so for a lot of my patients they're basically still on the weekly dosing for weight loss maintenance but i do have some patients that say okay i don't want to inject myself every week can we try to at least space it out so my weight man uh maintenance strategy for those folks is i start to space it out let's say they are initially doing weekly dosing i'll say let's space it out to every 10 days or let's space it out to every 14 days it's typically going to be the dose that they reach their goal on so if they're on zephoun 15 milligrams a week i'll say let's keep you on 15 let's space it out to every two weeks because at least at higher doses some of the medication is still in your body at that point and then i'll tell them tell me when you start to feel more hunger and cravings and they'll say oh you know at day 14 i feel fine so i'll keep them every two weeks on that if they say well around day 10 i really start to struggle with portion control then i'll say okay then why don't we do injections every 10 days so it's a very dynamic thing just because someone reached their goal at one dose doesn't mean that's going to be the dose the frequency the regimen that they're going to be on for the next couple of years and beyond okay and you found that that way of doing a dosing strategy is really successful yeah but it will vary because i have some people that you know they're in maintenance they're on injections every two weeks then the holidays come around and they're traveling and they're less consistent with their protein and they aren't working with their trainer then we have to say okay you gain 10 pounds over the holidays let's get you back to every week so i think that can be frustrating for people because people really worry obviously about that weight regain there's a lot of anxiety that's invoked with that but the reality is our bodies we're only you know for most of us not you but for most of us we are getting older that i really have to work harder actually in the weight maintenance phase now when it comes to exercise recommendations we recommend 150 minutes of moderate exercise per week for weight loss but for weight maintenance it's 300 minutes a week so we shouldn't actually get more lax in the maintenance phase that's actually when we have to work harder to maintain which people need to realize whether without glp1 medications the dosing is like you said it's different for everybody do you ever find that if a patient is like okay i want to come off this because the two-year recidivism rate is i think 73 percent of people end up going off the the medication is there a place where instead of say staying on the 15 milligrams do you have them in essence microdose ever or it's not just a really great strategy for you um not necessarily microdose where people are injecting every day but i have some people that are on the minimal doses like 0.25 milligrams of ozempic once a week or once every two weeks typically though those are going to be the patients that were always on low doses that they were able to minimize their their dose to 0.25 weekly lose 10 20 pounds and then we just maintain them at that typically you're not going to go from someone on 2.4 milligrams of wagovi to 0.25 in their maintenance i have also found yeah i've also found that if a patient does really well uh that people do well on various doses which is why compounding is so great and uh to do a maintenance dose they you can't just go back down to this small microdose i found it does yeah and it's not gender specific and it's not age specific and i have some people who are my larger patients who are men that you would think would need higher doses and they are actually more sensitive to the medication than some of my more petite women so you just cannot predict it in advance it makes me it begs the question are there things that people can do i don't think we know this answer to make these medications more effective well i think it comes down to well how do we also harness our natural glp one in addition to the synthetic medication that we're giving ourselves we know that fiber and protein are very satiating so if we focus on those two things then we're really throwing everything at those satiety hormones to help with hunger and reduce cravings you feel very passionately about this did something happen did you witness someone get sick so i kind of went through it myself actually now i've been a bodybuilder on and off since i was 18 and undergrad and i did it the unhealthy way in the healthy way so my first show i lost 30 pounds in three months i was doing two hours of cardio every single day they had to kick my butt out of the gym when they were closing because i was very ocd about it um i had female athlete triad i would miss periods i kind of took that as you know like a medal like oh i'm so lean i'm missing my period right that's a good thing um so i kind of went through that on and off for a couple of years i did bodybuilding shows in medical school it's kind of like my badge of honor i am 39 years old i went to my gynecologist a year ago and i said i want to get a bone density scan my mom has osteoporosis i kind of had to convince her to order one for me so i went in to get my bone density scan and the technologist said your bones look great i walk out i text my mom i said mom my bones are strong as hell i pull up the report in my portal shell pearlman osteoporosis of lumbar spine i was devastated i said this can't happen i'm a bodybuilder i've been lifting heavy shit since i was 13 years old i ate 160 grams of protein a day i'm super active i counsel my patients i'm reducing risk of frailty and fracture that this has to be wrong right so my gynecologist said oh they make mistakes all the time let's get another dexa scan so i ordered another bone density scan i went to the hospital this time went to the hospital got my bone density scan same damn thing osteoporosis of the lumbar spine osteopenia the hip so not only is this something i see in my patients every single day this is personal because i thought i could do i did everything to minimize my risk now i went to see an endocrinologist and i said i thought i was doing everything i could to help prevent this what should i be doing differently clearly i'm missing something should i be doing x y and z for exercise and he looked at me and he said i don't know what to tell you and i said well hell i didn't say this verbally but in my brain i'm thinking if you as the bone specialist don't know what to tell me as far as nutrition guidelines as far as exercise then what are people who aren't doing what i'm doing who are struggling where are they going for help i think we need more research when it comes to how to optimize our bones and and muscle health and everything really it starts in our teens and twenties and i think that's you know a big population we need to target because those are born our bone forming years and if you know what i see and you had mentioned the term earlier we are over training and under fueling and again we take that as a badge of honor that we're not eating that much that we're training really hard we're getting away we're getting away with five hours of sleep at night and our body tells us at some point uh that's not going to work for you and that was my wake-up call and what are you doing about it so i had to actually beg my gynecologist to start me on hormones i said listen i've had the iud for years i have no clue what my obvulatory status is but i want to start on estradiol i need to throw everything in the kitchen sink at my bones because i'm 39 years old and she's like okay well yeah i guess we can do that okay so we started you know on estradiol and i said and i would also like to be started on testosterone because there is data to support that that will also help with bone density and obviously it's a musculoskeletal unit the stronger our muscles the stronger our bones and she said well that's just not part of the guidelines i said f the guidelines so i got the testosterone elsewhere you know but it's crazy that myself in healthcare as what i would consider myself an expert in hormone replacement therapy and in bone and muscle health that not even i could advocate for myself to get what i thought i needed because the guidelines didn't say it and you and i know the guidelines are often 10 20 30 years behind what we're actually seeing in clinical practice what do you want people to know what do you want to see for example yeah to protect your bones we need and i know that we don't have this number estrogen to you know to be 75 in the blood you know and there's various this is just an example there's various ways that someone could measure it in terms of the metric units but what as a physician who is an expert and obviously your sister is an expert you didn't have answers and this one thing can change the trajectory of of your life yeah your survivability where do you where do we go what do you want i think one of the biggest things is education right we have to educate ourselves and this is where podcasts and platforms like yours are extremely helpful right because you are educating the larger population on the metrics that matter on muscle centric medicine you always say muscle is the longevity organ and i was never taught that in medical training or in fellowship or in the first four years of my career i learned it because in my clinical practice i was looking at the data and i was saying something doesn't make sense and things are not lining up right and what are we missing why are all these women at the age of 40 coming in with osteopenia right it's because no one had that foundational conversation when they were in their teens right these conversations weren't coming up in pediatrics and they weren't coming up in their 20s or 30s so we're picking it up and we're being more reactive than proactive the nice thing is these things don't have to be super complicated or expensive but it requires education you know through platforms like yours it's talking about what what are the metrics that matter muscle and bone they are longevity organs right we know that patients with osteoporosis have worsening brain function and cognitive ability so it's not just about having that six-pack or being able to you know do a heavy bicep curl or 20 push-ups it literally affects our health span and lifespan so it's i think it's um reforming or rephrasing the conversation on what matters not just getting people on an old school scale right i don't care when people say what is my ideal body weight i tell them i don't really know what that is right but if you lose 10 pounds and it's eight pounds of muscle you nor i are going to be happy 10 pounds less right so it really goes back to what are you made of um and how are we going to improve your quality of life six 10 20 40 years from now and a big part of that is the musco skeletal system do you think we are going to get to a place where it's equal opportunity for muscle as an organ system from the healthcare provider standpoint i'm not sure it's going to enter the typical healthcare scenario i think where we're going to see it is in in providers who are kind of going outside of the typical box and and thinking more outside of the box practices like my sister and i and yours where we're able to practice medicine the way we think it should be done we are evidence based but we're not bounded by guidelines right and we're having these conversations both in our clinic and our sterile white walls but also out on these social media platforms where people are hearing about it now the fascinating yet scary part is what we're seeing especially in the hormone and the glp1 space is now that the the population the public is getting more educated they are now advocating for themselves and they're more aggressive at advocating for themselves the people who need to be watching your podcast are not only the patients they are the providers and the problem is the providers who are against these things are never going to watch your podcast because they've been in practice for decades and they are not willing to change their practice because whatever they're doing is kind of still working for them that's the problem so now we have this big mismatch where we have patients advocating for themselves they go to their provider their provider is not up to date and now they're being gaslit and then patients are like well why am I going to go to a doctor because no one's listening to me anyways that's where we I think can also improve the evolution has to come yeah because what's going to happen is we're going to go from an epidemic of obesity to one of sarcopenia and we're going to accelerate the age sarcopenia osteoporosis we're going to accelerate that earlier because these medications are available and then it begs the question beyond hormones uh and I'll say it this way beyond estrogen progesterone and testosterone are there other anabolic agents that we can use to treat muscle and I think there are because they are doing clinical trials looking at you know myostatin antagonists and things like that where I think those medications can be very powerful my argument though would be if you're not doing the resistance training just stimulate those contractile forces I imagine you can have very large beefy muscles whether or not those muscles actually can have the contractile forces you need to help prevent a fall is a whole nother story you make a really you bring up a really a point with obesity you don't necessarily have to work for that meaning in order to build strong muscles there's only one way to get it anabolic agents various other hormones various other selective androgen receptor modulators are not going to take away the fact that work has to be done and within that process of doing the work the body systemically becomes healthier yeah that is a really good point that it is medications they have to be there I mean it would be the same as saying well you're going to go lose weight and the way that you're going to do it is through diet and exercise and then people struggle and then people struggle and it affects their confidence affects all of these things and then on the same hand if we think about building muscle the foundation is critical they have you're not going to get away from doing the hard work yeah and no drug is going to change that and no drug is going to change that yeah if we can get people to do meaningful practices meaningful ways to lean into the harder thing and then they have access to other anabolic agents just as they would have access to something to help them lose weight this is what is going to have to happen otherwise right before our eyes as healthcare providers as fellowship trained healthcare providers we are watching the world trade one epidemic for another yeah yeah and it's a it's a multi system approach right we can't just do one without the other it's kind of throwing everything at it I think you know a big way that we can harness technology because a lot of providers right who don't have their own practice they get 15 minutes so how the hell am I going to have a nuanced conversation on what are you eating in a typical day what do your portions look like what does your budget look like your family unit what are your baseline gastro symptoms okay let me educate you all about nutrition now let's start a glp one how am I going to educate you on minimizing all these GI symptoms in a 15 minute visit right that is very overwhelming and then you know one of the reasons why I left my prior practice and I would have patients say I'll see you next month and I'd say I'll see I'll see you back in six because I didn't have the access so where technology I think can be very helpful is integrating wearable data right the metrics that matter whether that's at home bio impedance testing heart rate blood pressure all those different sensors sleep I use the order ring all the time looking at step count how can we integrate that data into other platforms so I'm actually I'm also a tech entrepreneur I'm building out a nutrition platform called bite MD where it's actually going to harness all the things about GI health nutritional intake and glp one so you're able to actually talk to an avatar it's going to pick up what you're eating without you having to track okay I'm eating chicken it's going to see you're eating chicken it's going to see how fast you're eating the chicken it's going to look at your emotional state while you're eating the chicken holy cow and then you're going to say okay I just did my set bound injection 12.5 milligrams I'm feeling kind of nauseous it's going to start to pull up these patterns and it's going to say okay it looks like you're nauseated because you ate you know barbecue chicken at eight o'clock at night then you went to bed at 10 so how about the next time you do your injection why don't we have a lighter dinner and eat it at six instead of 10 so I think it's using technology to fill in the gap of that nutritional coach where we know we're not going to find that in most healthcare systems. Dr. Michelle Perlman not only are you an extraordinary physician but now tech entrepreneur it is physicians like you that really can help shift the way our cultures he's medicine thank you so much thank you so much for having me